Laparoscopy for bowel adhesions

Laparoscopy is keyhole surgery of the abdomen in which a camera and instruments are inserted through holes in the skin, into the abdomen to see the structures within (diagnostic laparoscopy) and to correct pathology where possible (therapeutic laparoscopy). In patients that have had previous pathology or surgery to the abdomen, adhesions can develop whereby loops of bowel can get caught up in scar tissue. If this causes an obstruction of the bowel, it can be very serious, but often people just have abdominal pain that coexists with adhesions.

Adhesions are common, and so is abdominal pain. Many doctors think that the adhesions cause pain ( the recurrent problem of association-equals-causation), and recommend laparoscopic surgery to look around the abdomen and to ‘divide’ or unpick the scarred down loops of bowel (the adhesions). Sounds reasonable enough, and some case series have shown improvement in over 80% of patients undergoing laparoscopic division of adhesions.

Some doctors from the Netherlands suspected that the benefit may lie in the placebo effect, and the reassurance that the diagnostic part of the laparoscopy provided (if nothing serious was found), and that the adhesions (in the absence of a bowel obstruction) might not be the cause of the pain.

They conducted a study (here) of 100 patients with adhesions and abdominal pain who underwent a diagnostic laparoscopy in which they excluded any other causes of pain. They then randomised them to having the adhesions divided (laparoscopically, at the same time) or doing nothing (only the diagnostic laparoscopy, leaving the adhesions alone). They followed the patients for 12 months and noted that there was no difference in the improvements in pain or quality of life between the groups. In other words, having the adhesions divided made no difference to whether or not the patients’ symptoms improved.

If you are a regular reader, you can probably guess the difference that they did find. The group that had the adhesions divided were more likely to have a serious complication, including perforation of the bowel, an abscess, bleeding, and a fistula (look it up - nasty). None of the patients in the diagnostic group developed complications.

What this means is that well-intentioned, honest surgeons who do this procedure because they have seen previous patients improve afterwards, because it is a recognised procedure, because they believe it might help and is at least worth a try, and because they want to offer the patient ‘active’ treatment rather than reassurance, are, on average, harming patients and providing no benefit.