Author information
Manamita Niphadkar*, Parulekar SV**, Mirchandani A***
(*Second year resident, **Professor and head of the department, ***
Assistant Professor Department of
Obstetrics and Gynecology, Seth GS Medical College and KEM
Hospital Mumbai , India
Abstract
Pelvic and intra abdominal adhesions are known post-operative
complications in patients who have undergone cesarean section or any other
abdominal surgery.[1,2] We report a case of an unusual adhesion of
the uterus to the anterior abdominal wall in a 44 year old woman with history
of previous 2 cesarean deliveries undergoing total abdominal hysterectomy.
Introduction
Intraperitoneal adhesions is a known complication of any abdominal
surgery.[1,2] Most of the adhesions are between the uterus and
omentum.[3] Sometimes bowel may get adherent to the uterus.[1,2,4]
Development of adhesions between the uterus and the anterior abdominal wall in
not very common. However this complication is on the rise with increase in the
rate of multiple cesarean sections.[4] Such adhesion may lead to
difficulty in future abdominopelvic operations by limiting access. We report a
case of an unusual adhesion of the uterus to the anterior abdominal wall.
Case report
A 44 year old woman, married for 30 years, with previous 2 cesarean
sections, presented with complaints of menorrhagia for 3-4 years. Her menses
occurred every 28-30 days, lasting for 6-8 days, soaking 4 pads/day, associated
with passage of clots and dysmenorrhea. She had undergone a hysteroscopy with
dilatation and curettage for the same 10 months ago. Endometrial histopathology
report showed proliferative changes. She had mild pelvic inflammatory disease
clinically, and was cured of it with a course of doxycycline and metronidazole.
She was a known case of ulcerative colitis on treatment with sulfasalazine.
Colonoscopy was done in 2008 which showed grade 3 changes up to 25 cm from anal
verge.
There was no history of any other major medical or surgical illness. Her
uterus was mildly enlarged, high in position and fixed. Traction on the cervix
vaginally produced retraction of the anterior abdominal wall midway between the
umbilicus and pubis. There was a Pfannensteil scar. General and systemic
examination revealed no abnormality. Her hemogram, blood sugar, liver function
tests, renal function tests, chest radiograph and electrocardiogram were
normal.
An abdominal hysterectomy was scheduled. The abdomen was opened in
layers by infraumbilical vertical midline incision till the rectus sheath.
Rectus sheath was found to be firmly adherent to the anterior wall of the
uterus and the uterus was pulled up due to adhesions. There were omental
adhesions to the uterus, which were dissected free. The left round ligament was
identified, while the right one could not be seen. The left round ligament was
divided and ligated with No. 1 polyglactin transfixion suture. Then the lower limit of the adhesion to the anterior
uterine wall could be reached, and a finger could be passed between the
uterovesical pouch of peritoneum and the lower limit of the adhesion, which was
below the level of the isthmus. The uterus was dissected sharply from the
abdominal wall from the left to the right, and the freed portion was swung
backwards as the separation progressed. Finally the left round ligament could
be clamped, cut, and ligated. The subsequent steps of hysterectomy were as in
the conventional technique.
Figure 1. The uterus is adherent to the anterior abdominal wall. A.
Inability to insert the C-shaped retractor between the uterus and the anterior
abdominal wall on the right side indicates total occlusion of that area; B.
Finger in the cavity of the rectus sheath.
Figure 2. Omental adhesion with the uterus elevated with an index finger
(shown by the black arrow).
Figure 3. Application of straight clamps to the cornual structures.
Figure 4. Omentum dissection from the right side of the uterus.
Figure 5. Separation of the bowel adherent to the right side of the
uterus.
Figure 6. Division of the left round ligament. The part of the anterior
peritoneal pouch between the utero-vesical fold of peritoneum and lower limit
of the adhesion is shown by the white arrow.
Figure 7. Separation of the right side of the abdomino-uterine adhesion
after swinging the left part of the uterus backwards.
Figure 8. The adhesion has been dissected. The right round ligament is
shown by a white arrow.
Figure 9. The right round ligament has been divided (black hollow
arrows). The raw area on the anterior uterine surface is shown by white arrows.
The free part of the anterior peritoneal pouch lies at the level of the solid
black arrow.
Figure 10. The anterior surface of the specimen after hysterectomy.
Discussion
The incidence of adhesions between the posterior surface of the anterior
abdominal wall and the anterior surface of the uterus has been rising owing to
the increased rates of caesarean sections in the last few decades.[1,2]
It is further increased proportional to the number of cesarean sections a woman
undergoes.[4] If the area of the adhesion is long and wide, the
lower part of the anterior surface of the uterus cannot be approached. Since
the location the urinary bladder in these adhesions cannot be predicted, it is
at risk of injury during separation of the adhesions. We dissected the adhesion
on one side, divided the round ligament on that side, and reached the lower
lateral limit of the adhesion. After ascertaining the location of the bladder,
dissection was continued to the other side. This technique is safer than starting
the dissection at the upper part of the adhesion and progressing downwards
towards the bladder.
From the study of a single case, one cannot conclude about closure or
non closure of the uterovesical fold of the peritoneum and its effect on such
adhesions. The operation notes of the cesarean section of this patient were not
available to help decide the cause of the adhesion. It was not an inverted
T-shaped incision on the lower segment, as the part above the uterovesical fold
was free. It is possible that the anterior surface of the uterus was injured
while a deep incision was made on the anterior abdominal wall. The vertical
suture line on the uterus and the closed abdominal wall incision might have
resulted in this adhesion, as would occur in the case of an upper segment
cesarean section.
References
1.
El-Shawarby S, Salim R, Lavery S, Saridogan
E. Uterine adherence to anterior abdominal wall after caesarean section. BJOG 2011;118:1133–1135.
2.
Stark M, Hoyme UB, Stubert B, Kieback
D, di Renzo GC. Post-cesarean adhesions - are they a unique entity? J Matern
Fetal Neonatal Med 2008;21:513–6.
3.
Awonuga AO, Fletcher NM, Saed GM, Diamond
MP. Postoperative Adhesion Development Following Cesarean and Open Intra-Abdominal
Gynecological Operations. Reproductive Sci. 2011 December; 18(12): 1166–1185.
4.
Z Shi, L Ma, Y Yang, H Wang, A Schreiber, X Li, et al. Adhesion formation after previous
caesarean section-a meta-analysis and
systematic review. BJOG 2011;118:410–22.
Citation
Niphadkar M, Parulekar SV, Mirchandani A. Abdomino-Uterine Adhesion. JPGO 2014 Volume 1 Number 7 Available from: http://www.jpgo.org/2014/07/abdomino-uterine-adhesion.html