Adhesiolysis is a surgical method used to remove adhesions. Adhesions are bands of scar tissue that connect normally separated pelvic structures. Pelvic adhesions (scars) develop as a normal tissue response to inflammation, which occurs whenever the tissue is damaged. Postoperative adhesions occur in 60% to 90% of patients undergoing major gynecologic surgery. 

Both microsurgical and laparoscopic techniques are used to treat pelvic adhesions. The basic principles for carrying out adhesiolysis are followed: If the adhesion is thin and avascular, it is easily lysed and the chances of recurrence are not much. If adhesion is thick and highly vascular it is difficult to separate. The lysis (removal) of adhesions requires use of energy (Unipolar or Bipolar, Ultrasonic dissector). After achieving haemostasis (preventing hemorrhage by occluding blood vessels) sharp dissection with scissors are necessary. After adhesiolysis some fluid can be left inside to prevent recurrence, or high molecular weight dextran can be used to prevent re-adhesion. 

Additional studies also indicate the benefit of adhesiolysis in treating infertility. Adhesiolysis is essential to restore normal tubo-ovarian anatomical relationships. Pelvic adhesions impair fertility by disrupting normal tubal-ovarian relationships. 

With an optimal surgical technique intending to minimize mesothelial injury, peritoneal trauma is inevitable. Laparoscopy leads to less adhesion formation compared to open surgery. The fertility results after adhesiolysis are correlated with the state of the adhesions.

The success of the surgery in removing adhesions without any more new adhesions being formed depends on various factors. 

The most important factors which suppress fibrinolytic activity (natural decomposition of fibrin, the protein promoting adhesion formation) and promote adhesion formation are: location of the port wound just above the target of dissection, tissue ischemia (reduced blood supply), prolonged operation, visceral injury (injury of the internal organs), drying of serosal surfaces (surfaces covered by thin transparent membranes, such as he peritoneum), blood clots, traction (stretching) of peritoneum, history of infection in the abdominal cavity, endometriosis, previous intra-abdominal trauma or bleeding, surgical glove powder, and delayed postoperative mobilization of the patient. 

On the other hand, adhesion prevention techniques include gentle tissue handling, use of barrier agents, precise treatment of the surgical area, minimal blood loss, copious pelvic irrigation, no glove powder exposure, antibiotics, barriers (either solid membranes or liquids) and use antihistamines and inflammation supressing hormones.

The most common intraoperative complication is injury to the bowel. With dense adhesions, this risk increases. Other intraoperative complications may include bleeding and injury to adjacent organs such as the gallbladder, spleen, ovaries, especially when working next to these organs. The surgery also has the risk of reforming adhesions and worsening of the pain.

Despite over twenty years of debate over the role of surgical adhesiolysis in women with CPP (chronic pelvic pain) there is no clear clinical consensus as to whether surgically removing adhesions in women with pelvic adhesions and pain is beneficial. A statistically significant improvement of VAS score (visual acuity score, a scoring system of the intensity of pain) was shown in women with adhesiolysis compared to those without. Women who underwent adhesiolysis also demonstrated an improvement in physical and emotional well-being. Operative adhesiolysis is, however, known to be associated with a high rate of adhesion reformation as well as the risk of inadvertent enterotomy (surgical injury to the bowel). 

The recent advances in minimal invasive surgery with miniaturization of instruments have made it possible for many of the operative procedures to be carried out laparoscopically both in infants and children. This is including laparoscopic adhesiolysis which was shown to be feasible and safe in experienced hands. Not only this but laparoscopy being less invasive and with its widespread use, it is expected to decrease the incidence of adhesive intestinal obstruction. This, however, needs to be substantiated by future studies.

Hysteroscopic adhesiolysis has been documented to have significant beneficial effect on fertility in women with infertility and recurrent pregnancy loss due to pelvic adhesions. The pregnancy rate in patients treated by adhesiolysis is up to 80%, depending on the severity of the adhesions. Women with mild or moderate pelvic adhesions have the best pregnancy outcomes and the lowest rate of adhesions re-formation. In women with severe adhesions, the rate of adhesions re-formation was almost six times higher than in women with mild adhesions, and pregnancy rate was significantly lower.

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The role of Endoscopy in Management of Infertility ―by Daru and Kereszturi licensed under CC BY 3.0
Adhesions ―by Hic et nunc licensed under CC BY-SA 3.0
Blausen 0602 Laparoscopy 02 ―by BruceBlaus licensed under CC BY 3.0
Diagnosis Hystroscopy & Laparoscopic Adhesiolysis ―sourced from Youtube licensed under CC BY 3.0
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