Inflammation of adhesions after surgery. Methods for the treatment of adhesions. Adhesions after appendicitis surgery

Adhesions are "strings" of connective tissues that are formed as a result of surgery, inflammation or injury. Any surgical intervention in the pelvis or abdominal cavity leads to adhesion formation. Protection of a living organism from the spread of purulent-inflammatory processes along abdominal cavity is the main function of adhesions.

Postoperative adhesions.

Adhesions after surgery are formed due to:

Rough tissue manipulation;

The presence of blood;

Ischemia or hypoxia of tissues (this is an insufficient supply of blood and oxygen to tissues);

Drying tissue during surgery.

To foreign bodies, causing appearance adhesions include particles of adhesions from doctor's gloves, fibers from tampons or gauze. also formed in endometriosis. This is when a small amount of blood containing cells of the uterine mucosa enters the abdominal cavity during menstruation. These cells can be removed with the help of their own immunity; in case of any malfunction, they live in functioning islands that are secreted into the abdominal cavity. Adhesions are formed near these islets.

Adhesions after surgery: symptoms.

Adhesions can begin as a gradual or sudden increase in pain, increased bowel movement (peristalsis), which may be accompanied by a rise in temperature, severe vomiting, weakness and decrease blood pressure.

Adhesions after surgery: diagnosis.

The presence of scars and various adhesions in the abdominal cavity can be suspected in patients who have had pelvic disease, in women who suffer from endometriosis or have undergone surgery in the abdominal cavity.

Allows you to assume the presence of adhesions in the abdominal cavity of a woman with a probability of 75% using ultrasound, but the patency of the fallopian tubes will not allow to exclude the presence of these adhesions, which seriously interferes with pregnancy. Promising diagnostics are methods of magnetic resonance imaging (MRI) or nuclear magnetic resonance (NMR). This method takes pictures that show general state organism and the course of the disease.

Laparoscopy is one of the main methods for diagnosing adhesions, which allows you to assess the severity and treat adhesions on early stages their manifestations. There are three stages of adhesion formation:

stage I, adhesions are around fallopian tube or ovaries.

Stage II, adhesions are located between the fallopian tube and the ovaries.

III stage, there is a dense blockade of the egg.

Adhesions after surgery: treatment

main way Treatment of adhesions after surgery is laparoscopy. Special micromanipulators produce adhesiolysis - this is a dissection and removal adhesive process. The method of separation of adhesions includes aquadissection, electrosurgery, laser therapy. For the prevention of new formations after laparoscopy use following methods:

Wrapping the ovaries and fallopian tubes with a special absorbable polymer film;

The introduction of a barrier fluid (povidine, dextran) between the anatomical structures.

Prevention

Among preventive measures The most important thing is to stop the process of adhesion formation, or reduce their number, density and distribution in the abdominal cavity, while maintaining normal process healing.

All methods of prevention can be divided into groups:

1. Surgical methods and their use;

2. Usage medicines and mechanical barriers - the so-called additives;

3. Physiotherapeutic procedures.

Whatever the disease, it is much easier to prevent than to treat later. Be healthy!

Adhesions after hysterectomy are frequent complication and occur in 90% of operated women. it dangerous consequence surgical intervention, since as a result various functional disorders in the work of internal organs, up to symptoms intestinal obstruction.

What are spikes

Extensive adhesions of internal organs are also called adhesive disease by doctors. However, it is important to distinguish physiological process formation of adhesions from pathological.

Removal of the uterus (hysterectomy) is always accompanied by the formation of connective tissue scars at the sites of scars and incisions. The resulting scars are physiological adhesions. The scarring of the wound gradually stops, due to which the normal functioning of the organs is restored, and the symptoms of inflammation disappear.

Important! The process of formation of adhesions (or scarring) after removal of the uterus is normal physiological state which has nothing to do with pathology. If education connective tissue does not stop, and fibrous cords grow and grow into other internal organs - this is a pathology called adhesive disease. It has its own symptoms and requires serious medical intervention.

These pathological fibrous bands have a whitish hue. They look like fibrous formations that connect the internal organs. The strength of the strands is high, which is why it is necessary to resort to reoperation for their removal.

Reasons for the formation of adhesions after removal of the uterus

In the body, adhesions occur mainly only after extensive operations that require the removal of one or two organs at once. The reasons for their occurrence are diverse and depend on a number of factors:

How long was the operation.
The amount of surgery.
The volume of blood loss.
Internal bleeding in the postoperative period. In this case, there is an active resorption of blood accumulated in the abdominal cavity, and this predisposes to the occurrence of adhesions.
Infection of wounds in the postoperative period.
genetic predisposition. This is due to the fact that a special enzyme is not formed in a genetically predisposed organism that can dissolve fibrin overlays, which ultimately leads to the onset of symptoms. adhesive disease.
People of asthenic physique.
In addition, the occurrence of adhesions depends on the actions of the surgeon himself. What is important here is how correctly the incision was made, what suture materials were used, how professionally the suture itself was applied.
There are cases when surgeons left foreign objects in the abdominal cavity. It also predisposes to the development of adhesions after hysterectomy and the onset of symptoms of adhesive disease.

Symptoms of adhesions after surgery

You can suspect adhesive disease in a woman who has recently had a uterus removed by the following symptoms:

Aching or drawing pains in the lower abdomen, forcing to take an antalgic (forced) position. Pain can be permanent or intermittent, reaching a high intensity.
Delay and other disorders of urination and defecation, up to the absence of urine and feces.
Symptoms dyspeptic disorders: pain all over the abdomen, flatulence and gas formation, " sheep feces', feeling increased peristalsis intestines and others.
Subfebrile or febrile temperature body (increase to 38-40 C).
Feeling of severe pain when probing the postoperative scar, its redness and swelling.
Pain during intercourse. Discharge from the vagina is bloody.
If several weeks have passed since the removal of the uterus, then when these symptoms appear, you should immediately contact your doctor (gynecologist).

Important! Symptoms of adhesive disease are nonspecific. This means that if a woman makes such complaints, then no qualified doctor can say with full confidence that she has formed adhesions in the small pelvis. To confirm the diagnosis, instrumental and laboratory methods examinations.

Diagnosis of adhesive process in the postoperative period

A preliminary diagnosis is made after a thorough history taking, patient complaints and symptoms of the disease. To confirm the presence of adhesions, the doctor prescribes an additional examination:

General blood analysis. Needed to check if you have inflammation in the body. Also evaluate the activity of the fibrinolytic system of the blood.
Ultrasound of the abdominal cavity and the pelvic cavity. The visual method of examination helps with a 100% guarantee to say whether there is an adhesive process in the small pelvis after the operation of removing the uterus.
X-ray examination of the intestines with the help of contrast (coloring) substances. Helper method, which allows to judge the patency of the intestine and the degree of narrowing of its lumen.
Laparoscopic diagnostics is also used, during which individual adhesive formations are dissected and removed, and the issue of repeated surgical intervention is also resolved.

Surgical treatment of adhesions

Mostly adhesive disease is treated surgically. This is related to the fact that conservative treatment not effective, it is used only as a prophylaxis in the postoperative period and to relieve symptoms of the disease.

There are 2 types of operation:

Laparoscopic surgery. It is carried out using special fiber optic equipment. At the same time, 2-3 small incisions are made on the skin of the anterior abdominal wall, and then in these places abdominal wall pierce. These incisions provide access to the abdominal cavity. The advantage of this operation is that the dissection of adhesions is carried out under control optical system, with minimal trauma to internal organs. With the help of special laparoscopic instruments, fibrous cords are cut, followed by hemostasis. Pain and complications after such surgery are extremely rare. Recovery period takes several days, the symptoms of the adhesive process disappear almost immediately, physical activity possible the next day after the operation.
Laparotomy. Shown in two situations:
- There is no possibility of laparoscopic surgery.
- The presence of symptoms of an extensive adhesive process in the abdominal cavity.
In this case, the lower middle access is used first, and then it is expanded upwards to 15-20 cm. This is done in order to carefully examine all organs and remove overgrown adhesions. Such an operation is highly traumatic, has the risk of postoperative complications or relapse of the disease. The recovery period takes about two weeks.

After the operation of dissection of adhesions, it is necessary to constantly visit the attending physician in order to observe the processes occurring in the small pelvis

Important! No doctor can give a full guarantee that adhesive disease will not return to you again. Removal of adhesions is the same operation as removal of the uterus, which means that fibrous bands between organs can form again. To prevent this from happening, follow the doctor's recommendations in the postoperative period and prevent the recurrence of the disease.

Prevention of adhesion formation

If you are scheduled for surgery to remove the uterus, carefully approach the choice of a surgeon. The course of the postoperative period largely depends on it.

What will the doctor do

For wound closure, use only absorbable surgical suture material. This is necessary as a hysterectomy is an extensive and highly traumatic operation. Threads are a foreign body that will become overgrown with connective tissue and subsequently form adhesions.

Professionally sutures when the edges of the wound are in contact throughout with each other.

Drug prevention of adhesive disease in the postoperative period. Doctor prescribes antibiotics a wide range actions (to prevent infection, suppress inflammation), anticoagulants.

Early appointment of physiotherapy with electrophoresis of enzymes that destroy fibrin (lidase, hyaluronidase and others). They destroy dense adhesive formations, which contributes to the rapid extinction of the symptoms of the disease.

Dynamic observation after surgery, careful monitoring of the state of the pelvic organs using ultrasound.

What should you do

Early physical activity after hysterectomy is important for the prevention of adhesions. The fact is that while walking improves intestinal motility, which prevents the development of adhesions.

The second point is diet. Eliminate salty, spicy, fried, alcohol, carbonated drinks. They disrupt digestion, and intestinal motility weakens. It is necessary to eat up to 6-8 times a day in fractional small portions. This will not overload the intestines, which means it will not be constricted by fibrous overlays.

What about folk methods treatment, they can be used as an adjunct to drug therapy and only after consultation with the attending physician. For the prevention and treatment of adhesions in traditional medicine apply infusions and decoctions of plantain, dill, flax seeds, St. John's wort, aloe leaves.

Summing up

Adhesive disease disrupts the physiological functioning of all organs of the abdominal cavity. It is a consequence of highly traumatic operations. Advanced forms of adhesive disease can only be treated by surgery, but this also harms the body. To prevent this from happening, it is necessary to follow the recommendations of the attending physician in the postoperative period and to prevent the recurrence of the disease. When the first symptoms appear, indicating the presence of adhesions in the body, you should immediately consult a doctor for consultation and subsequent diagnosis.

Video: When to be afraid of adhesions? The main symptoms of impending problems

Connective tissue strands (adhesions) in the abdominal or pelvic cavity are formed as a consequence of surgical interventions or as a response to inflammatory processes in this area.

The body builds up additional tissue, releases sticky fibrin, and sticks adjacent surfaces together in an attempt to support a diseased organ or stop inflammation from spreading.

Adhesions may take the form of scars, threads or films connecting neighboring organs and intestinal loops.

Reasons for the formation of adhesive strands:

tissue damage as a result of surgical interventions (laparoscopy, laparotomy);
inflammation of the appendix and surgery to remove it (appendectomy), diverticulitis;
abortion, uterine curettage, C-section;
long-term use intrauterine contraceptives;
hemorrhage in the body cavity;
endometriosis;
inflammatory diseases abdominal organs and pelvic cavities, including venereal ones.

Postoperative adhesive disease is caused by tissue damage, their hypoxia, ischemia or drying, as well as entry into the body cavity foreign objects, some chemical substances(particles of talc, gauze fibers).

Many women are subjected to various kinds operations, but not everyone knows that the consequences of surgery can greatly affect women's health.

This applies to adhesions that form on female organs and can become a serious hindrance to motherhood. Adhesions in the uterus appear due to infectious diseases, operations on the pelvic organs, abortion and inflammatory diseases.

What are adhesions (synechia)?

Causes

More often, the adhesive process is provoked by operations, but other reasons for their appearance are also possible. Adhesions in the peritoneal cavity may remain after bruises or closed injuries of the abdomen, as a result of which the outflow of blood is disturbed, the lining surface of the abdominal cavity "dries up" and the internal organs in the process of rubbing against each other without a protective "lubrication" "overgrown" with adhesions.

Much less common are cases where adhesions are formed as a result of aseptic inflammation in the abdominal cavity, caused by the ingestion of certain substances into it, such as alcohol, iodine or a solution of rivanol.

By the way, these fluids can enter the peritoneum only during the operation.

all sorts of inflammatory diseases;
Operations;
endometriosis;
Thickened blood in the abdomen.

Adhesions due to inflammation

Most common cause the process of formation of adhesions are operations on the organs of the abdominal cavity. Almost all patients (about 95%) develop adhesive disease after surgical interventions on the abdominal organs.

Adhesions can thicken and increase in size over time, creating certain problems many years after surgery.

AT rare cases are caused by the process of inflammation, the appearance of which is not associated with the operation.

These reasons include:

Performance radiotherapy for the treatment of oncological diseases.
Appendicitis.
infectious diseases internal organs of the abdominal cavity.
Gynecological diseases, for example, adhesions after removal of the uterus.
Adhesions after laparoscopy.

In rare cases, adhesive disease appears for no apparent reason.

One of the dangerous and unpleasant complications after surgery to remove the uterus is the activation of the adhesive process, or more simply, adhesions.

Clinical picture

The danger is the fact that adhesions that form in the abdominal cavity can lead to the development of severe diseases, the most important of which is adhesive fecal obstruction.

Adhesions are strings of connective tissue resulting from surgical interventions or any kind of inflammation, stretching from organ to organ. Sometimes there are cases that adhesions are formed in the abdominal cavity and in the small pelvis, such adhesions can block the path to conception, therefore it is necessary to be constantly examined, and if they are found, it is necessary to eliminate them.

Adhesions after surgery - what is it?

The organs of the small pelvis and abdominal cavity (fallopian tubes, uterus itself, bladder, ovaries, rectum) are usually covered on the outside with a thin bright membrane - the peritoneum. A small amount of fluid and smoothness of the peritoneum provides a fairly good displacement of the loops of the uterus, fallopian tubes. AT normal operation intestines, there are no problems with the capture of the fallopian tube by the egg, the growth of the uterus does not interfere with good work Bladder and intestines.

Peritonitis - inflammation of the peritoneum is a very dangerous disease. The more inflammation more dangerous disease. The body has a mechanism that limits the spread of this disease, this is the formation of adhesions.

Fabrics at inflammatory process become edematous, the peritoneum is covered with a sticky coating that contains fibrin - this is a protein, the basis blood clot. Touching this thin film of fibrin in the focus of inflammation, it can be said that it glues the surfaces together, the result of this action is a mechanical obstacle to the inflammatory process. After the inflammatory process has ended, adhesions (transparent - whitish) films may form in the places of gluing. They are called spikes. The main function of adhesions is to protect the body from pus and inflammation in the peritoneum.

But we want to note that adhesions are not always formed during the inflammatory process. In the event that the treatment began on time, and all procedures were carried out correctly, the likelihood that adhesions form in the body decreases. But nevertheless, adhesions are formed when the disease passes into chronic process and extends over time.

These spikes upon completion gynecological surgery interfere normal functioning internal organs. If the mobility of the intestinal loops is disturbed, this can lead to intestinal obstruction. Adhesions that affect the fallopian tubes, ovaries, uterus, disrupt the body (the egg enters the fallopian tube, movement, advancement of the embryo into the uterine cavity). Adhesions can be a major cause of infertility.

All kinds of inflammatory diseases;
Operations;
endometriosis;
Thickened blood in the abdomen.

Adhesions due to inflammation

The ovaries, uterus, and fallopian tubes may be involved in adhesions, which may result from organ inflammation (eg, appendicitis), in some cases, damage to the colon and small intestine. In such cases, the genitals are not severely damaged - the process of adhesion formation does not violate internal structure. In the case when inflammation occurs in the genital organs, there is a process of formation of adhesions that disrupt the functioning of the genital organs.

The most unprotected is the fallopian tube - this is the most delicate organ. plays leading role in conception and in the maintenance of pregnancy.

Spermatozoa that enter the vagina are in turn filtered in the mucus of the cervix, pass first into the uterine cavity, and then penetrate into the fallopian tube. Speaking about the fallopian tube, we can say that it provides transportation of the embryo and germ cells, creates an environment for the development of the embryo. A change in the composition of the mucus that appears in the fallopian tube can kill the embryo. Immunity in the fallopian tube is minimal, there are practically no mechanisms that would reject foreign substances, excessive immunity activity is unfavorable for pregnancy. The fallopian tubes are very delicate and easily fall prey to infections ( diagnostic curettage abortion, hysteroscopy).

From the very beginning, the infection affects the mucous membrane, then the muscle layer, on last step the outer layer of the fallopian tube is involved and conditions arise for the occurrence of so-called intestinal adhesions. If the treatment of these adhesions is not carried out on time, it forms scar tissue. The fallopian tube turns into a connecting sac, loses its ability to promote the egg. With such severe violations elimination of adhesions does not restore the function of the fallopian tube, the presence of this focus of inflammation leads to infertility. In these cases, for pregnancy, the entire tube is removed entirely.

Postoperative intestinal adhesions

After the operation has been performed, adhesions are formed in such cases:

Tissue ischemia or hypoxia;
Drying of tissues;
Rough actions with the fabric;
Foreign bodies;
Blood;
Separation of early adhesions.

Those foreign bodies that cause the formation of adhesions include particles from the doctor's gloves, cotton fibers from tampons and gauze, and suture material. Intestinal adhesions after gynecological surgery dangerous problem, also such adhesions can appear with endometritis. During menstrual cycle blood containing living cells of the membrane - the mucous membrane (endometrium) can enter the abdominal cavity. The immune system must itself remove these cells, but if there are malfunctions in the immune system, the cells take root and form islands of the endometrium, adhesions usually form around these foci.

Adhesion treatment

Only under the control of the vision of an experienced surgeon is it worthwhile to isolate the tumor and separate the adhesions. The intestine is retracted by the finger of the surgeon's assistant or by the anatomical patient from behind and to the top. If the tumor is located behind the belly, then in this case the peritoneum is dissected where the intestine is not observed above the upper pole of the tumor, and then the tumor is carefully and slowly isolated. In order not to damage the intestine in any way, professional surgeons leave capsules or part benign tumor on the wall of the intestine with dense adhesions. In some cases, it will even be better if you first cut the fibromyoma capsule in an accessible place, then enucleate it, and then carefully separate the intestine from the capsule or excise the capsule as carefully as possible without damaging the rectum.

Unpleasant consequences of operations, injuries, certain infectious diseases are adhesions. They are formed due to excessive production of fibrin by the body - a substance that promotes the fusion of internal organs with the abdominal cavity.

Reveal this pathology possible according to severe symptoms: the patient has complaints about frequent vomiting, abdominal pain, stool disorder.

Treatment of adhesive disease requires integrated approach, but to achieve positive result it may take more than one year.

Adhesions of the abdominal cavity - a schematic representation

Postoperative prevention of adhesive disease of the abdominal cavity

The main cause of the disease under consideration is the consequences of surgical intervention.

That's why preventive actions should begin at the stage of initial manipulation, as well as in postoperative period:

Surgical access to the abdominal cavity should be gentle. Ideally, a laparoscopic technique should be used. However, if it is impossible to carry out this procedure, the surgeon should perform the resection as carefully as possible.
Compliance with the rules of antisepsis during the operation reduce the likelihood of developing inflammatory phenomena in the future, which may lead to the formation of adhesions.
Purpose preventive treatment for patients who need it (according to the results of the survey). In the postoperative period, 5 times with a certain time interval, the state of the abdominal cavity is examined by means of ultrasonography. In the presence of pathologies, therapy is prescribed, which includes injections (prodigiazone), ultraphonophoresis, vitamin E intake. The dosage is determined by the age of the patient.
Little patients who survived surgical intervention on the abdominal cavity, put on dispensary registration. The level of control over patients will be determined by the quality of the manipulation, as well as the state of health before the operation.

Indications for surgery for adhesive disease of the abdominal cavity - the main types of operations for adhesions

Schematic representation of intestinal adhesions

In the treatment of the pathology in question, doctors try to avoid surgical procedures, or are limited to minilaparotomy .

In the case of children, they try to eliminate the disease through comprehensive conservative therapy , which often does not give the desired effect.

The most optimal treatment strategy for similar situations is timely detection adhesions and their further elimination with the help of

Surgical treatment of adhesive disease is indicated in such cases:

Malfunctions in the work of the intestines(gas, vomiting, impaired stool), which are accompanied by severe pain of a paroxysmal nature.
Regular pain in the abdomen that appear at the time of execution sudden movements(playing tennis, badminton, long jump, etc.).
Complaints about severe pain in the stomach when overeating. This phenomenon is often accompanied by vomiting.
Complete obstruction of the intestine.

Minimally invasive methods of treating adhesive disease include laparoscopy.

The algorithm of this procedure is as follows:

1. The operator makes 3 small incisions in the navel area. If this is not the first operation for the patient, and there are scars on the abdomen, the resection is done a few centimeters from the scars.

2. Insertion of an optical trocar for examining internal organs. When the abdominal cavity is cut, the operator checks whether there are adhesions there: the presence of these defects is confirmed by gases.

3. Detection and dissection of adhesions. Several methods can be used here:

elimination of adhesions ( laser therapy ).
Use of water supplied under high pressure to separate splices ( aquadissection ).
Application electric knife to remove adhesions. This method is most popular in the treatment of adhesive disease, but the operator must be careful: the slightest touch with an electroknife to internal organs can cause them to burn or lead to extensive bleeding.

The operated area after resection of adhesions is thoroughly washed with saline, which contains disinfectants(dioxidine).

4. Repeated examination of the abdominal cavity by means of a trocar. In the process of revision, the surgeon checks the quality of the work performed, controls hemostasis, and makes sure that the internal organs are intact.

5. Introduction to the abdominal cavity of the drug which prevents the formation of adhesions.

Laparotomy is far from a sparing method of treating the ailment in question.

But you can't do without it if:

Adhesions spread to the entire abdominal cavity.
Diagnosis confirmed the presence purulent sacs in the intestine.
There are doubts about the qualitative dissection of all adhesions with laparoscopic access.
There is intestinal paresis.
In the shell of the abdominal cavity revealed inflammation.

This procedure requires a large incision (about 15 cm) in the abdomen.

The surgeon performs several manipulations:

Cuts through adhesions.
Eliminates dead tissue from the intestine that has been pinched.
Fixes intestinal loops in a certain position, which will protect them from infringement in the future.

Guarantees that the recurrence of this pathology after surgical treatment will not, the doctor will not be able to give.

Adhesive disease requires a whole range of preventive measures in the postoperative period, as well as proper nutrition.

Folk methods in the treatment of abdominal adhesions

Folk remedies in the fight against this disease should be used after consulting a doctor.

Phytotherapy can help if there are single adhesions. If the pathology has acquired chronic form, medicinal herbs won't give any results.

There are several traditional medicine recipes:

Douching with a decoction of bergenia leaves. For this procedure, you need to mix 200 gr. boiling water and 50 gr. dry grass. The resulting mixture is placed in a thermos for 6-7 hours. After that, the infusion is filtered. For one douching, half a glass of decoction is enough. The rest should be stored in the refrigerator. You can also use tampons soaked in this mixture.
The use of a mixture of lingonberries (15 berries), wild rose (5-6 berries), dry nettle leaves (30 gr.). These ingredients are poured with boiling water (1 liter) and placed in a thermos overnight. You need to drink a decoction of half a glass 2 times a day: before breakfast and before bedtime.
Hypericum tincture. It is prepared by mixing medicinal plant(1 tbsp. l) with a glass of boiling water with further insisting on steam bath(about 20 min.). An hour later, the broth is filtered and drunk in small portions throughout the day.
Usage gauze swabs , soaked in aloe juice and honey. They are set at 6 o'clock.

Treatment and prevention of adhesive disease - diet, gymnastics and proper organization of the regime

On the full recovery after surgical treatment of the ailment in question, it may take several years.

During this period, it is important to maintain an adequate diet:

You should not overload your stomach with food and arrange snacks with fast food. It is better to eat about 5-6 times a day. Hunger strike is strictly prohibited in case of adhesive disease: this can aggravate the situation.
From products that provoke gas formation ( homemade milk, peas, corn, cabbage, etc.) should be avoided for 3-6 months (although in some cases it may be necessary to refrain from these products for several years). The same goes for soda, hot spices.
You should regularly monitor your stool. The presence of constipation should be reported to the attending physician, who will help with the help of diet and laxatives to solve this problem.

From heavy physical activity in the postoperative period must be abandoned, but physiotherapy will help speed up recovery.

Need to start with simple exercises, limited to 10 minutes a day .

Gradually increase the load. When pain, discomfort, classes should be stopped, and seek the advice of a doctor!

There are several effective exercises:

On the back

In this position, “scissors”, “bike”, rolls from left to right are performed alternately. The abdominal muscles will help strengthen the raises from the back to the legs without the help of hands.

Don't forget the importance correct breathing during exercise.

On the side (first on one, then on the other)

The main active element here will be upper leg. They draw circles in the air for her, sway back in front, bend / unbend parallel to the floor.