What causes persistent abdominal pain since a laparoscopic myomectomy?
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I'm a 43 years old women from Norway, suffering from abdominal (pelvic) pain since a laparoscopic myomectomy in April 2012. The pain is around the area of the lower cross incision, with a width of about 4 cm and located 4 cm above the symphysis. No history of pain or disease before this surgery. MRI has not detected any patology or lesions. However: Four weeks ago I went through a diagnostic laparoscopy. Two small lesions where removed on peritoneum just below the incision site, respectively the size of 1 mm and 2 mm. (The lower cross incision were not opened during this surgery.) But I still have suffered pain after the surgery. The report from the pathologist (who analysed the removed tissue) was as follow: "Abdominal wall tissue with foci of foreign objects and foreign objects reaction. The foreign objects are glass clear, `birefringent` (?), and vary in size. It is unclear however what they represent. They are located in well-defined areas. Modest amount of multinucleated giant cells are present. Striking inflammation outside this are not present." Because I still have pain I'm wondering if this foreign cells and/or inflammation might be present in the abdominal wall and/or other pelvic areas. My gynecologist expresses concern with respect to do another suregy and I do share this concer; things might get worse. My question to the doctor is: Do you have any suggestion for any radiological modality that possible could give me an answer of remaining lesions in my abdomen? I'm pretty sure I at least got a nerve problem in the region, but as I understand this can't be detected by means of any images. The pain is triggered by normal physical activity, like housework, bending my back and prolonged sitting (but the pudental region is not affected). Thank you so much in advance!
Posted Wed, 19 Mar 2014 in X-ray, Lab tests and Scans
Answered by Dr. Vivek Chail 34 minutes later
Brief Answer: Please find detailed answer below Detailed Answer: Hi XXXX Thanks for writing in to us. I have read through your query in detail. In summary, 1.Initial laproscopic myomectomy done in April 2012. 2.Pain in area 4 cm about 4 cm above symphysis pubis. 3.MRI done showed no lesion. 4.Diagnostic laproscopy done in February 2014 shows small 1 mm and 2 mm lesions on the peritoneal surface of the incision. 5.Pathological report mentions it as multinucleated giant cells - probably due to foreign body reaction. With the above information I would first choose to repeat an ultrasound scan of the area under the incision using a high frequency linear probe. This will give me greater insight to any pathology in the incision site with considerable magnification. To see the pelvic organs better, I recommend a transvaginal ultrasound scan as the entire area might be screened in greater detail and also any focal area of pain can be assessed. Further any specific pain confined to movements of the lower back and pelvis needs a basic X ray examination and MRI if necessary may help in assessment of nerve roots supplying the area. Concerning the multinucleated giant cells, it might be a minimal reaction at the surgical site to biomedical materials used. This is induced by certain triggers and may be an extension of the healing process in tissues. Keeping this in mind it is less likely that you may have similar areas in any other part of the abdomen. However, if your gynecologist still feels that there may be other areas which need to be assessed for inflammatory lesions a MRI scan is still among the best using a 3 T MRI machine. I would request you to have a discussion with your hospital regarding the availability of a 3 T MRI scanner that may be able to scan your complete abdomen and pelvis in much greater detail should you wish to have it done. Hope your query is answered. Do write back if you have any doubts. Regards, Dr.Vivek
Follow-up: What causes persistent abdominal pain since a laparoscopic myomectomy? 3 hours later
Thank you. I appreciate your answer, and will discusse further with my gynecologist. What's bothering me is that all the medical assessments done previously provide no explanation, including "internal" and "external" ultrasounds, conventional pelvic/abdominal MRI as well as diagnostic laparascopy. It seem to me that if there is any available solution this would involve taken into intellectual account (also) unlikely possibilities and special radiological modalities. Please let me present some additional following up questions even though some of them might transcend your medical speciality: 1. Is it normaly hard to identify small foreign bodies and "modest" amount of giant cells in the abdomen with means of conventional MRI, and easier with a 3 T MRI machine? Is the 3 T MRI more accurate and detailed concerning small lesions in the soft tissue and abdominal wall? 2. If it is the suture material that has provoked an inflammatoric reaction, it seems likely (?) that the same lesion may be found in the other layers of the abdominal wall tissue right above, i.e the suture has two layers. (Maybe the pain isn't related to any suture material subject at all: I should mention that I had an unproblematic caesarean section in 2002, without any suture reaction. In addition: The type of suture thread in my case were self dissolveable, and should - I suppose - have dissolved almost two years later?Besides: see below) 3. The pathological report stresses occurrence of both foreign bodies (wich are "glass-clear" etc.) and giant cells (foreign giant cells?) - as I understand this report. Could the referal to the "foreign bodies" mean some sort of self produced (epidermoid) cyst in the skin? Could it mean real "foreign bodies", i.e. retained substances after surgery? - Do you have an opinion of which radiological modality should be prefered in either of the cases? (I guess this would depend on the actual material of the foreign body in question ...) Let me add as background information in case it's of any medical relevance: With the finger I can feel areas with small, hard lumps beneath my skin, and are able to provoke the pain by repeating pressing my finger on those areas. The pain is worse when the pressure is released. I also have pain after urination a full bladder in the morning - as with ordinary physical activity and prolonged sitting as mentioned. A gastro surgeon said he felt "a cleft-formed defect" in the laparascopic cross scar, when he touched me. But no hernia were seen during last surgery. Injections of local anaesthetic have given some pain relief immediately, but have reinforced the pain after a few hours (by irritating the tissue?). The hole area of the lower abdomen feels very hard and stiff to touch. Thank You for any considerations you might have. Please feel free. I understand of course that your answer would be in principle and can not substitute physical examination and consulting.
Answered by Dr. Vivek Chail 10 hours later
Brief Answer: Please find detailed answer below Detailed Answer: Hi XXXX Thanks for writing back with an update. A higher machine will give better quality of images due to increased resolution between structures. However, it is difficult to characterize any area less than 5 mm in diameter using MRI machine. It is very small to specifically say what it can be. Even saying that it is a foreign body reaction would be considered an extreme opinion. Suture materials are made of many materials and thickness. The foreign body reaction depends on the nature of suture material as well as tissues present locally along the suture. Other discrete lesions may or may not be found depending on the tissue content surrounding the suture. The pathological report details about microscopic observations which may go unnoticed by the naked eye. These are materials very small to be seen on any kind of imaging used at present. These foreign bodies in question are degradable biomedical substances used. Small molecules can form a focus which then draws calcification and giant cells. The small bumps felt by running the finger might be the healed tissue. It is important to know if you are speaking of the findings following recent diagnostic laproscopy or it is in the area of previous surgery. If it is the recent one then we must allow sufficient time to heal. If these are for the earlier surgery then there might have been due to changes during surgical incision and subsequent healing. The pain is probably due to stimulation of nerve endings by pressure. The cleft type defect may be visualized better on a superficial ultrasound scan of the area using a high frequency probe. The urination related and pain after minimal physical activity may be due to the same reasons ie stimulation of nerve endings below the skin in that area. Hope your query is answered. Do write back if you have any doubts. Regards, Dr.Vivek