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
Hospital .) Mumbai, India
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.
Intraperitoneal adhesions is a known complication of any abdominal surgery.[1,2] Most of the adhesions are between the uterus and omentum. 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. 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.
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.
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. 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.
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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.
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