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The abdominal (and pelvic) cavity is lined with a thin layer of mesothelium (a single layer of flattened cells that lines serous body cavities like the abdomen) that also covers most of the contained viscera (organs of the digestive, urogenital, respiratory, endocrine systems). This thin layer of (abdominal and pelvic) mesothelium is called the “peritoneum.”
Peritoneal scarring (adhesion formation) is a result of abnormal healing. Normally, peritoneal trauma results in formation of proteinaceous (protein rich) serosanguinous fluid (discharge composed primarily of serum and blood) that is resorbed locally and allows healing to occur without scar formation. Abnormal absorption of this fluid results in local tissue invasion by (the body’s) inflammatory cells and fibroblasts which then results in the buildup of scar (adhesions).
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Conditions that predispose a woman to create scar tissue along the peritoneum include
(1) infection
Any pelvic or abdominal infection can result in an intense inflammatory reaction and abundant pelvic adhesion formation. Tubo ovarian infections are particularly destructive to the reproductive organs. Prior appendicitis may have been unrecognized (as in the “not so uncommon” case of a 10 year old girl approaching her mother with lower abdominal discomfort, being told to wait until tomorrow and if the pain persists then they will go to the doctor, having a potential appendicitis “cool down” spontaneously so that no diagnosis is confirmed, and then 20 years later this female finds she has “unexplained” infertility until a laparoscopy is performed and pelvic adhesions are identified). The presence of pelvic adhesions may occasionally be suggested on hysterosalpingography (if the dye collects within loculations around the outside of the fallopian tube) but need to be confirmed by direct visualization. It is certainly possible to have a normal hysterosalpingogram with bilateral tubal patency in the presence of abundant pelvic adhesions causing subfertility (or infertility).
(2) endometriosis
Endometriosis causes an inflammatory reaction in the pelvis since the endometriotic lesions (foci) respond to the sex steroids of the ovary (just as the uterine lining = endometrium responds to these hormones) but at the time of menses the uterine lining is released through the cervix into the vaginal vault while the tissue in the pelvis has no outlet. These cells then create an acute inflammatory reaction during menses that can result in pain (dysmenorrhea) and/or local pelvic adhesions. Since the most common sites for endometriosis are around the outside of the fallopian tube, these adhesions can distort the normal relationship between the fallopian tubes and the ovaries.
(3) blood
Blood appears to be highly irritating to the peritoneal lining and free blood in the abdomen or pelvis often results in a rigid highly tender (surgical) abdomen. Ovarian follicular cysts (cysts containing the maturing egg) occasionally rupture in such a way as to bleed locally, which may cause a sudden tremendous amount of pelvic pain lasting a few days. These ruptured hemorrhagic cysts may also cause pelvic adhesions to develop, which might impact on fertility.
(4) other traumatic events
Localized trauma to the pelvic organs, devascularization (interruption of the normal blood supply), desiccation (drying of the tissues), thermal injury (intraoperatively), or foreign material in the pelvis can all cause adhesion formation and are (should be) meticulously avoided during pelvic fertility surgery.
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