Laparoscopic adhesiolysis for adhesion-related chronic abdominal and pelvic pain after gynaecological and general surgery: an updated meta-analysis and systematic review

A total of 30 studies were included, with 1,450 patients (Fig.  1 ). The main characteristics of the included studies are summarized in Table  1 . Most studies were observational in design, predominantly involved female patients. Fig. 1 PRISMA flowchart demonstrating the selection of publications identified in the systematic review and meta-analysis. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-analyses Table 1 Characteristics of included studies Study Country Patients Location of adhesions Surgical history ✝ Diagnostic work-up Intervention Follow-up Outcome measures Laparoscopic adhesiolysis with anti-adhesion barrier Steege and Stout 1991 [ 5 ] USA 30 patients (gynaecology) 100% female Pelvic 100% gynaecology Diagnostic laparoscopy Carbon dioxide laser, blunt anatomical dissolution and adhesion placement interceed 6 − 12 months Improvement of pain Nezhat et al. 2000 [ 18 ] Not reported 48 patients (gynaecology) 100% female Pelvic Mixed, majority gynecological History taking, physklical examination, diagnostic laparoscopy Carbon dioxide laser cracking, place Interced TC7 and rinse with lactated Ringer’s solution 2 − 8 weeks, 6 − 12 months and 2 − 5 years Improvement of pain Complications Relapse Khaitan et al. 2003 [ 19 ] USA 19 patients (general surgery) 89.47% female Abdominal and pelvic 15.79% gynaecology 5.26% general surgery 78.95% mixed History taking, physical examination, diagnostic laparoscopy Lysis and placement of hyaluronic acid-carboxy methylcellulose membrane 9.6 months (range 1 − 32) Improvement of pain Complications Using painkillers Swank et al. 2003 [ 20 ] Netherlands 200 patients(general surgery) 74% female Abdominal 37.5% gynaecology 62.5% general surgery History taking, physical examination, Diagnostic laparoscopy, ultrasound, radiography, colonoscopy Argon laser, ultrasonic knife lysed, Seprafilm placed 3 months Improvement of pain Complications Neagoe et al. 2018 [ 21 ] Romania 20 patients (general surgery) 65% female Abdominal Not reported History taking, physical examination, diagnostic laparoscopy Open surgery, 50 ml methylene blue (1%)50 mL 28.5 months Pain scores Joergensen and Settnes 2019 [ 22 ] Denmark 3 patients (gynaecology) 100% female Pelvic 66.67% gynaecology 33.33% mixed History taking, physical examination, diagnostic laparoscopy, ultrasound Sharp dissection of adhesions, Placing anti adhesion adhesive 3 − 12 weeks Improvement of pain Cheong et al. 2014 [ 12 ] UK 50 patients (gynaecology) 100% female Pelvic Not reported History taking, physical examination, diagnostic laparoscopy RCT: adhesiolysis vs. diagnostic laparoscopy, Icodextrin 4% solution 0, 3 and 6 months Improvement of pain QOL (SF-12 EHP-30) Complications van den Beukel et al. 2023 [ 23 ] Netherlands 122 patients (general surgery) 76.23% female Abdominal Not reported History taking, physical examination, diagnostic laparoscopy, CineMRI non-invasive diagnosis Icodextrin 4% solution, hyaluronic acid-carboxy methylcellulose membrane 70 months Relapse Consult a surgeon Laparoscopic adhesiolysis without anti-adhesion barrier Arndt and Creutzfeldt 1976 [ 24 ] Germany 7 patients (general surgery) 100% female Abdominal 71.43% general surgery 28.57% mixed History taking, physical examination, diagnostic laparoscopy Sharp dissection of adhesions 6 − 18 months Improvement of pain Goldstein et al. 1979 [ 25 ] USA 26 patients (gynaecology) 100% female Pelvic 26.92% gynaecology 65.38% general surgery History taking, physical examination, diagnostic laparoscopy Lysis with scissors and fixation of uterus 1 − 51 months Improvement of pain Negative laparoscopies Kleinhaus 1984 [ 26 ] USA 2 patients (general surgery) 100% female Abdominal 50% general surgery 50% mixed Diagnostic laparoscopy Lysis of adhesions 6 and 12 months Improvement of pain Sutton and MacDonald 1990 [ 27 ] UK 65 patients (gynaecology) 100% female Abdominal 55.38% gynaecology 23.08% general surgery 10.77% mixed Diagnostic laparoscopy CO 2 laser relaxation 1 − 5 years Improvement of pain Negative laparoscopies Tschudi et al. 1993 [ 28 ] Not reported 19 patients (general surgery) unclear Not reported Not reported Diagnostic laparoscopy Not reported 18.3 months (range 5 − 36) Improvement of pain Fayez and Clark 1994 [ 29 ] USA 156 patients (gynaecology) 100% female Abdominal and pelvic Majority is gynaecology History taking, physical examination, imaging on indication, diagnostic laparoscopy Laser relaxation, Lactic acid Ringer’s solution rinse 12 years Improvement of pain Return to daily activity Complications Relapse Freys et al. 1994 [ 30 ] Germany 58 patients (general surgery) 68.97% female Abdominal 15 appendicitis, 4 single major surgeries, 39 multiple major surgeries History taking, physical examination, diagnostic laparoscopy, Ultrasound, NMR, CT, gas sleeve tube (GIT) intracavity endoscopic examination Sharp dissection of adhesions 2.5 years Improvement of pain Complications Mueller et al. 1995 [ 31 ] Switzerland 51 patients (gynaecology) 76.47% female Abdominal 35.29% gynaecology 64.71% general surgery History taking, physical examination, diagnostic laparoscopy, Ultrasound, abdominal X-ray, colonoscopy, contrast imaging, CT Sharp dissection of adhesions 6 − 36 months Improvement of pain Hallfedt et al. 1995 [ 32 ] Not reported 16 patients (general surgery) 93.75% female Abdominal 12.5% gynaecology 62.5% general surgery 12.5% mixed History taking, physical examination and imaging on indication, diagnostic laparoscopy Scissors with diathermia 9 months (range 4 − 18) Improvement of pain Recommendation Complications Chen et al. 1997 [ 33 ] China 10 patients (general surgery) 100%female Pelvic 100% gynaecology Diagnostic laparoscopy Electrocauterization dissolution 3 months Improvement of pain Bremers et al. 2000 [ 34 ] Netherlands 12 patients (general surgery) 91.67% female Abdominal Not reported History taking, physical examination, diagnostic laparoscopy Sharp or diathermic dissection 3, 6 and 12 months Improvement of pain QOL (GIQLI MOS-SF36) Complications Negative laparoscopies Malik et al. 2000 [ 35 ] Germany 101 patients(gynaecology) 100% female Pelvic 89.11% have a history of surgery Diagnostic laparoscopy Electrocauterization dissolution, Lactic acid Ringer’s solution rinse 6 − 18 months Improvement of pain Return to daily activity Schenk et al. 2000 [ 36 ] Not reported 56 patients (general surgery) 66.07% female Abdominal 46.43% gynaecology 51.79% general surgery 1.79% mixed History taking, physical examination, diagnostic laparoscopy Sharp tools are lysed, washed with heated lactic acid Ringer’s solution 31.5 month Improvement of pain Relapse Shayani et al. 2002 [ 37 ] Not reported 18 patients (general surgery) 94.44% female Abdominal and pelvic Majority is general surgery History taking, CT angiography, colonoscopy Not reported 11 months Improvement of pain Relapse Using painkillers Dunker et al. 2004 [ 38 ] Netherlands 23 patients (general surgery) 95.65% female Abdominal 21.74% gynaecology 4.35% general surgery 73.91% mixed History taking, physical examination, diagnostic laparoscopy Not reported 3, 6, 12, 24 months with second-look laparoscopy Improvement of pain QOL (GIQLI MOS-SF36) Complications Relapse McClain et al. 2011 [ 39 ] USA 31 patients(general surgery) 93.55% female Abdominal and pelvic 100% have undergone surgery History taking, physical examination, diagnostic laparoscopy Sharp dissection of adhesions 3, 6, 9 and 12 months Pain scores Complications Paajanen, Paavo et al. 2018 [ 40 ] Finland 68 patients (general surgery) 86.76% female Abdominal Majority is mixed History taking, physical examination, diagnostic laparoscopy Sharp dissection of adhesions 3.6 years Improvement of pain Hardy and Rousseau 2019 [ 41 ] Canada 10 patients (gynaecology) 100% female Pelvic 100% gynaecology History taking, physical examination, diagnostic laparoscopy Loose adhesion, hysterectomy 5 years Improvement of pain Steege 1994 [ 42 ] USA 8 patients (gynaecology) 100% female Pelvic 75% gynaecology History taking, physical examination, diagnostic laparoscopy 4 × Lysis using laser through Tecnkhoff catheter Ringer’s Lactate 7 − 11 months Improvement of pain Peters et al. 1992 [ 43 ] Netherlands 48 patients (gynaecology) 100% female Abdominal and pelvic 54.17% previous laparotomies Diagnostic laparoscopy RCT: Sharp dissection of adhesions vs. diagnostic laparoscopy 9 − 12 months Improvement of pain QOL (GIQLI MOS-SF36) Return to daily activity RCT randomized control trial, GIQLI Gastro-intestinal Quality of Life Index, QOL Quality of Life ✝ Summary of surgical history includes: type of previous interventions i.e. percentage of patients with history of gynaecology or general surgery, or mixed (both gynaecology and general) surgery PRISMA flowchart demonstrating the selection of publications identified in the systematic review and meta-analysis. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-analyses Characteristics of included studies Improvement of pain Complications Relapse 15.79% gynaecology 5.26% general surgery 78.95% mixed Improvement of pain Complications Using painkillers 37.5% gynaecology 62.5% general surgery Improvement of pain Complications 66.67% gynaecology 33.33% mixed Improvement of pain QOL (SF-12 EHP-30) Complications Relapse Consult a surgeon 71.43% general surgery 28.57% mixed 26.92% gynaecology 65.38% general surgery Improvement of pain Negative laparoscopies 50% general surgery 50% mixed 55.38% gynaecology 23.08% general surgery 10.77% mixed Improvement of pain Negative laparoscopies Improvement of pain Return to daily activity Complications Relapse 15 appendicitis, 4 single major surgeries, 39 multiple major surgeries Improvement of pain Complications 35.29% gynaecology 64.71% general surgery 12.5% gynaecology 62.5% general surgery 12.5% mixed Improvement of pain Recommendation Complications Improvement of pain QOL (GIQLI MOS-SF36) Complications Negative laparoscopies Improvement of pain Return to daily activity 46.43% gynaecology 51.79% general surgery 1.79% mixed Improvement of pain Relapse Improvement of pain Relapse Using painkillers 21.74% gynaecology 4.35% general surgery 73.91% mixed 3, 6, 12, 24 months with second-look laparoscopy Improvement of pain QOL (GIQLI MOS-SF36) Complications Relapse Pain scores Complications Hardy and Rousseau 2019 [ 41 ] 4 × Lysis using laser through Tecnkhoff catheter Ringer’s Lactate Improvement of pain QOL (GIQLI MOS-SF36) Return to daily activity RCT randomized control trial, GIQLI Gastro-intestinal Quality of Life Index, QOL Quality of Life ✝ Summary of surgical history includes: type of previous interventions i.e. percentage of patients with history of gynaecology or general surgery, or mixed (both gynaecology and general) surgery Four RCTs were included, one with an adhesion barrier and the rest without an adhesion barrier. In all studies, the vast majority of adhesions were adhesiolysis through laparoscopy. Adhesion barriers were used in eight studies. Alternative adhesion-reduction techniques were implemented in seven of the 22 studies that did not use adhesion barriers. These other techniques included the use of uterine prolapse suspension in one study and the use of lactated Ringe’s solution irrigation in four studies. In one study, the uterus was removed, and in another, a Tenckhoff catheter was placed in the laxity for intermittent outpatient laparoscopy and irrigated with lactated Ringer’s solution (Table  1 ). Pre-treatment diagnosis is based primarily on a history of prior surgery followed by physical examination and occasionally imaging studies to rule out other diagnoses. One study used noninvasive diagnostic techniques to diagnose adhesions, such as cine-MRI, a technique that utilizes magnetic resonance imaging to diagnose adhesions by taking consecutive moving images of the abdominal organs (Table  1 ). In 14 papers, all patients included were female, with a greater proportion of females in studies with mixed populations, with all females accounting for more than 60%. The majority of pain and adhesion sites were abdominal, and some studies had a mix of abdominal and pelvic patients. In addition, in the gynecologic and general surgical studies, most patients had a mixed history of gynecologic and general surgical procedures (Table  1 ). A review of the RCTs conducted revealed that the majority of studies exhibited a low risk of bias, with the exception of one study. Of the studies included, two were deemed to be at high risk, 12 at moderate risk, and 16 at low risk (Results for the risk of bias assessment are presented in Supplementary Table S2). Common methodological limitations included unclear blinding and incomplete follow-up. A total of 27 studies with 1,150 participants were eligible for calculation of pain improvement rates, and the pooled rate was 67.3% (95% CI: 57.7 − 76.2%, I 2  = 91% (Fig.  2 ). The pain improvement rate of the group with adhesion barrier was 54.5%, while the pain improvement rate of the group without adhesion barrier was 70.5%, with no statistical difference between the two groups ( P  = 0.16). Fig. 2 Forest plot of pain improvement in patients undergoing laparoscopic adhesiolysis Forest plot of pain improvement in patients undergoing laparoscopic adhesiolysis Of the six studies of adhesiolysis with adhesion barriers, two studies reported pain improvement at long-term follow-up and four studies reported pain improvement at mid-term follow-up. The rate of pain improvement at any follow-up was 54.5% (95% CI: 34.3−74.0%, I 2 = 81%) in 326 patients, with a pooled incidence of long-term improvement of 49.8% (95% CI: 25.4−74.3%, I 2 = 80%) in 78 patients; and a pooled incidence of interim improvement of 61.3% (95% CI: 25.3−91.3%, I 2 = 85%) in 248 patients. Although pooled pain improvement rates were numerically higher at mid-term follow-up than at long-term follow-up, the difference was not statistically significant (Supplementary Figure S6, Table 2 ). Table 2 Main outcomes measures, for total calculation and subgroups All studies With adhesion barrier Without adhesion barrier Studies (n) Participants (n) Rate (%) I 2 (%) *P-val Studies (n) Participants (n) Rate (%) I 2 (%) *P-val Studies (n) Participants (n) Rate (%) I 2 (%) *P-val All studies 27 1150 67.3 (57.7 − 76.2) 91 6 326 54.5 (34.3 − 74.0) 81 21 824 70.5 (60.3 − 79.9) 89 Follow-up time  Long-term 20 868 66.9 (56.0 − 76.9) 90 0.8836 2 78 49.8 (25.4 − 74.3) 80 0.7254 18 790 68.8 (57.2 − 79.3) 90 0.3387  Intermediate 7 282 69.5 (46.8 − 88.2) 87 Ref 4 248 61.3 (25.3 − 91.3) 85 Ref 3 34 83 (68.7 − 93.5) 0 Ref Department  gynaecology 12 548 67.9 (51.5 − 82.4) 91 0.0148 4 107 57.7(24.5 − 87.5) 81 0.9474 8 441 72.8 (54.5 − 87.7) 92 0.7600  general surgery 15 602 67.0 (54.8 − 78.2) 90 Ref 2 219 54.7 (20.7 − 86.3) 89 Ref 13 383 69.2 (56.0 − 80.9) 86 Ref Year of publication  2000 − 2023 14 678 61.7 (45.7 − 76.6) 91 0.1488 5 296 54.3(28.2 − 79.2) 80 0.7764 9 382 65.4 (45.2 − 83.1) 96 0.3216  1976 − 1999 13 472 73.4 (64.2 − 81.7) 75 Ref 1 30 63.3(43.9 − 80.1)  −  Ref 12 442 74.4 (64.5 − 83.1) 76 Ref Area  North America 7 251 82.7 (66.3 − 94.4) 78 0.6028 2 49 67.5(53.8 − 79.7) 0 0.6520 5 202 89 (68.3 − 99.4) 78 0.4216  Unknown 5 157 67.7 (49.4 − 83.6) 82 0.9429 1 48 37.5(24.0 − 52.6)  −  0.6389 4 109 74.7 (66.1 − 82.4) 3 0.8238  Europe 14 732 59.1 (45.3 − 72.1) 92 0.6829 3 229 59.4(10.6 − 98.0) 81 Ref 11 503 60.8 (46.4 − 74.3) 91 0.7226  Asia 1 10 70.0 (34.8 − 93.3)  −  Ref  −   −   −   −  1 10 70.0 (34.8 − 93.3)  −  Ref Proportion of Females  Equal to 100% 14 516 71.9 (56.4 − 85.1) 90 0.4495 4 107 57.7 (24.5 − 87.5) 81 0.9474 10 409 77.2 (61.1 − 90.0) 89 0.2787  Unknown 1 19 63.2 (38.4 − 83.7)  −  0.9841  −   −   −   −  1 19 63.2 (38.4 − 83.7)  −  0.9288  Less than 100% 12 615 63.6 (50.2 − 76.1) 92 Ref 2 219 54.7 (20.7 − 86.3) 89 Ref 10 396 65.5 (50.6 − 79.0) 89 Ref Adhesive site  Pelvic 9 238 68.4 (47.4–86.1) 82 0.8364 3 59 68.0 (19.5 − 99.2) 85 0.3280 6 179 70.0 (45.0 − 89.9) 84 0.9327  Abdominal and pelvic 3 193 83.1 (72.9 − 91.3) 36 0.2929 1 19 73.7 (48.8 − 90.9)  −  0.3049 2 174 86.4 (79.1 − 92.3) 14 0.4190  Unknown 2 31 61.3 (43.8 − 77.4)  −  0.8403  −   −   −   −   −  2 31 61.3 (43.8 − 77.4) 0 0.6351  Abdominal 13 688 65.0 (50.5 − 78.3) 93 Ref 2 248 37.9 (32.0 − 44.0) 0 Ref 11 440 70.3 (55.1 − 83.5) 89 Ref Anti-adhesion barrier  liquid 1 26 30.8 (14.3 − 51.8)  −  0.4101 1 26 30.8 (14.3 − 51.8)  −  0.3130  −   −   −   −   Gel 1 3 100. 0 (29.2 − 100.0)  −  *0.0445 1 3 100.0 (29.2 − 100.0)  −  *0.0246  −   −   −   −   Unknown 21 824 70.5 (60.3 − 79.9) 89 0.1401  −   −   −   −   −   −   −   −   −   Absorbable film agent 4 297 51.4 (34.0 − 68.7) 80 Ref 4 297 51.4 (34.0 − 68.7) 80 Ref  −   −   −   −  Rate: rate of pain improvement Main outcomes measures, for total calculation and subgroups Rate: rate of pain improvement Of the 21 studies of adhesiolysis without adhesion barriers, 18 studies reported pain improvement at long-term follow-up and three studies reported pain improvement at mid-term follow-up. The rate of pain improvement at any follow-up was 70.5% (95% CI: 60.3 − 79.9%, I 2  = 89%) in 824 patients, the pooled incidence of long-term improvement was 68.8% (95% CI: 57.2 − 79.3%, I 2  = 90%) in 790 patients, and the pooled incidence of mid-term improvement was 83% (95% CI: 68.7 − 93.5%, I 2  = 0%) in 34 patients, and the rate of pain improvement at mid-term follow-up was higher than the rate of pain improvement at long-term follow-up, but the difference was not significant (Supplementary Figure S7, Table  2 ). In all studies, the pain improvement rate during mid-term follow-up was higher than that during long-term follow-up (69.5% [95% CI: 46.8 − 88.2%, I 2  = 87%] vs. 66.9% [95% CI: 56.0 − 76.9%, I 2  = 90%]), but the difference was not significant (Supplementary Figure S5, Table  2 ). In the subgroup analysis of factors influencing pain relief, we initially categorized patients according to whether they utilized an adhesion barrier following adhesiolysis surgery. Thereafter, we proceeded to examine these two subgroups in more granular subgroups based on a multitude of factors that may influence the efficacy of pain relief. Subgroup analyses showed that the pain improvement rates between subgroups in the without adhesion barriers group were all higher than the pain improvement rates between subgroups with adhesion barriers (Supplementary Figure S8−Figure S22, Table 2 ). In particular, the pain improvement rate in the abdominal group of the adhesion site subgroup of the without adhesion barrier group was 70.3% (95% CI: 55.1−83.5%, I 2 = 89%) (Supplementary Figure S22, Table 2 ), which was numerically higher than the rate reported in the group with adhesion barriers, which was 37.9% (95% CI: 32.0−44.0%, I 2 = 0%) (Supplementary Figure S21, Table 2 ). A total of 13 studies with 739 participants were eligible for calculation of postoperative complications rates, and the pooled rate was 5.2% (95% CI: 1.9−10.1%, I 2 = 80%). And one study reported no mortality. The incidence of postoperative complications was 7.8% (95% CI: 0.7−21.5%, I 2 = 83%) in the four studies with an adhesion barrier, and the combined rate in the nine studies without an adhesion barrier was 4.2% (95% CI: 1.0−9.6%, I 2 = 79%),two groups have no statistical significance (P = 0.51) (Supplementary Figure S1). Four RCTs were conducted to compare the outcomes between adhesiolysis (adhesiolysis group, n = 144) and diagnostic laparoscopy (control group, n = 127). Pain improvement was reported by 38.9% of patients in the adhesiolysis group and 36.2% of patients in the control group, with no statistically significant difference between the two groups (RR = 1.05; 95% CI: 0.61−1.83, I 2 = 60%, P = 0.28). In a RCT using an adhesion barrier, the rate of pain improvement in the adhesiolysis group was slightly higher at 30.8% than in the control group at 16.7%, but the difference was not significant (RR = 1.85; 95% CI: 0.64−5.35, I 2 = NA). In three other RCTs without an adhesion barrier, the rate of pain improvement was 40.7% in the adhesiolysis group and 40.8% in the control group. There was no difference in pain improvement rates between the two groups (RR = 0.94; 95% CI: 0.49−1.79, I 2 = 70%) (Figures 2 and 3 ). Fig. 3 Forest plot of relative risk of pain improvement with laparoscopic adhesiolysis vs. diagnostic laparoscopy in RCTs Forest plot of relative risk of pain improvement with laparoscopic adhesiolysis vs. diagnostic laparoscopy in RCTs Three randomized controlled trials were eligible for analysis of postoperative complications. When pooled as incidence estimates within the adhesiolysis groups, the overall postoperative complication rate was 4.2% (95% CI: 0.0–14.4%; I 2  = 73%). Two trials without adhesion barriers reported a pooled complication rate of 8.5% (95% CI: 3.7–14.9%; I 2  = 0%), whereas one trial using an adhesion barrier reported no postoperative complications. In contrast, comparative analysis between the adhesiolysis group and the diagnostic laparoscopy control group showed no statistically significant difference in postoperative morbidity. Complications occurred in 6.7% of patients in the adhesiolysis group and in 0% of controls, yielding a pooled relative risk of 4.66 (95% CI: 0.76–28.52; I 2  = 0%; P  = 0.36). No perioperative mortality was reported in any randomized trial. We conducted a sensitivity analysis by sequentially excluding each study to evaluate the robustness of the pooled pain improvement rate. The results showed that after excluding any single study, the overall pain improvement rate no significant deviation compared to the original pooled rate, indicating good robustness of the results (Supplementary Figure S24). The sensitivity analysis results further support the reliability of the meta-analysis conclusions. The funnel plot was symmetrically for the meta-analysis of the pain improvement rate of patients who underwent adhesiolysis surgery (Supplementary Figure S2). The “Arcsine” test showed a pain improvement rate of p = 0.333, indicating no evidence of publication bias.

The full review protocol was registered with PROSPERO under registration number CRD42023478049. This study was conducted and reported in strict accordance with the PRISMA 2020 guidelines [ 16 ]. This study is a systematic review and meta-analysis based exclusively on previously published literature. No human participants or animals were directly involved, and therefore, ethical approval and patient consent were not required. This statement is consistent with the journal’s editorial policies. In this systematic review and meta-analysis, we searched PubMed, Embase, and Web of Science up to August 2025, with no start date and language restrictions. Searches included the following MeSH descriptors: ‘abdominal pain’, ‘chronic pain’, ‘pelvic pain’, ‘laparotomy’, ‘laparoscopy’, ‘abdomen/surgery’, ‘tissue adhesions’. The search strategy for each database is provided in the Appendix (Table S1). We manually checked the reference lists of relevant articles to identify additional potentially relevant papers. We included cohorts or RCTs of studies that (1) patients with chronic pain due to postoperative adhesions (pain duration ≥ 3 months).; (2) were treated with laparoscopic adhesiolysis surgery; (3) reported outcomes of pain improvement or outcomes of complications; (4) diagnostic laparoscopy alone or no intervention (for RCTs). We excluded studies: (1) where adhesions were not the primary suspected cause of pain (patients with pain due to endometriosis or inflammatory disease); (2) that had data that overlapped with other studies; (3) that were abstracts, letters or reviews. The definition of ‘pain improvement’ was not standardized across the included studies. The definition of “pain improvement” was not standardized across the included studies. We accepted the outcomes as defined by the original authors. The specific measurement tools and criteria varied considerably, including, for example, a ≥ 50% reduction in visual analog scale (VAS) or numerical rating scale (NRS) scores (e.g., Swank et al., 2003), patient-reported global impression of “improvement” (e.g., Cheong et al., 2014), or a substantial reduction in analgesic use. This heterogeneity in outcome assessment is a recognized limitation. For the purpose of the meta-analysis, These heterogeneous definitions were harmonized into binary outcomes (improved vs. not improved) for statistical pooling; however, such harmonization does not imply clinical equivalence across studies and may introduce interpretive imprecision. Two reviewers (MDW and YG) independently extracted and checked the data. For relevant articles, we extracted information on study design, including the first author’s name, year of publication, title, study country, study type, use of non-invasive techniques for diagnosis of adhesions, use of adhesion barriers, characteristics, number of participants and outcomes reported. When outcome measures were registered during several time intervals within the same study, we used the data from the longest follow-up period. We assessed the quality of all studies using the revised Joanna Briggs Institute Critical Appraisal Tools of eight items. The tool categorizes assessment results into four levels: “Yes”, “No”, “Unclear” and “Not Applicable”. Among them, “Yes” represents one point, and the other options are not scored. The total score is out of eight points. The risk of bias was then categorized into three levels based on the score: low risk (six to eight points), medium risk (three to five points), and high risk (zero to two points). The methodological quality of the studies was independently assessed by two investigators (MDW and YG). Additionally, a third investigator (GZZ) independently reviewed these assessments. In cases of any disagreements, a consensus was reached through discussion and agreement among the investigators. Pooled estimates of pain improvement rates with corresponding 95% confidence intervals (CIs) were computed using a random-effects model. I2 statistic was used to assess heterogeneity of included studies, with I2 > 50% suggesting significant heterogeneity [ 17 ]. Prespecified subgroup analyses were conducted to explore potential sources of heterogeneity, stratified by the use of adhesion barriers, follow-up duration (mid-term ≤ 12 months vs. long-term > 12 months), surgical specialty (gynecology vs. general surgery), geographical region, and primary adhesion site (abdominal vs. pelvic). Sensitivity analyses were performed by sequentially excluding individual studies to evaluate the robustness of the pooled results. Univariate meta-regression was applied to assess the statistical significance of subgroup differences. “Acsine” test was set as a parameter in publication bias detection. All p -values were two sided. A p -value < 0.05 was considered statistically significant. This meta-analysis was conducted using the “meta” package in R statistical software version 4.2.

In conclusion, laparoscopic adhesiolysis should not be considered a first-line intervention for most patients with adhesion-related chronic pain. However, in carefully selected cases and within a shared decision-making framework, it may still have a role. Current randomized evidence does not support its superiority over diagnostic laparoscopy alone.

This updated meta-analysis, incorporating 30 studies and 1,450 patients, represents the most comprehensive synthesis to date evaluating laparoscopic adhesiolysis for adhesion-related chronic abdominal and pelvic pain. Three principal findings emerge, all of which require cautious interpretation in light of study design and methodological limitations. Although single-arm and other non-randomised studies reported a pooled pain improvement rate of 67.3% (95% CI: 57.5–76.2%), randomised controlled trials demonstrated no significant difference between adhesiolysis and diagnostic laparoscopy alone (38.9% vs. 36.2%; RR = 1.05, 95% CI: 0.61–1.83). This discrepancy highlights the critical influence of study design on outcome interpretation. Higher improvement rates observed in non-randomised studies are likely influenced by selection bias, placebo effects inherent to surgical interventions, and regression to the mean in chronic pain conditions characterised by symptom fluctuation. Accordingly, these observational findings should be regarded as hypothesis-generating rather than evidence of causal effectiveness. Our findings align with yet refine previous systematic reviews. Van den Beukel et al. reported a similar improvement rate of 72.0% but with wider confidence intervals (95% CI: 61.0–83.0%) based on only 13 studies [ 14 ]. Our expanded sample ( n  = 30 studies) provides more precise estimates (95% CI: 57.5–76.2%) and enhances the reliability of the pooled results. Whereas non-randomized studies report relatively high rates of pain improvement, all available randomized trials consistently demonstrate no significant advantage of adhesiolysis over diagnostic laparoscopy alone [ 44 , 45 ]. A counterintuitive observation was that studies reporting the use of adhesion barriers demonstrated lower pain improvement rates (54.5%) compared with studies without barrier use (70.5%). This finding must not be interpreted as evidence that adhesion barriers worsen outcomes. Confounding by indication is highly probable, as barriers are typically applied in patients with more extensive, dense, or vascularized adhesions, who may inherently have a poorer pain prognosis. Confounding by indication is likely, as barriers may have been preferentially used in patients with more extensive or complex adhesions who inherently have a poorer pain prognosis. In addition, substantial clinical heterogeneity exists with respect to barrier materials and application techniques, and the limited number of studies and patients reporting barrier use precludes meaningful stratified analyses. These results are therefore best considered exploratory and hypothesis-generating.​ The pooled complication rate of 4.7% (95% CI: 1.4–9.8%), with no reported perioperative mortality, suggests an acceptable short-term safety profile. However, major evidence gaps remain. Data on re-adhesion rates, long-term adverse outcomes, and negative laparoscopy rates were largely absent, substantially limiting comprehensive safety assessment. The formation of new adhesions following adhesiolysis remains a particular concern, as it may offset initial symptom relief and lead to more complex subsequent management. Standardised reporting of both short- and long-term safety outcomes is therefore essential in future studies. Substantial statistical heterogeneity was observed across included studies (I 2  = 91%). Despite prespecified subgroup analyses and univariable meta-regression, this heterogeneity could not be adequately explained. A major contributor is the wide variability in the definition of “pain improvement,” which was frequently based on non-standardised or author-defined criteria rather than validated pain assessment tools [ 44 ]. Because heterogeneous and often non-standardized definitions were dichotomized for analysis, pooled improvement rates should not be interpreted as uniform clinical benefit. Rather, they represent aggregated reporting patterns across studies with varying outcome constructs. Within the current evidence base, laparoscopic adhesiolysis should not be regarded as a first-line intervention for most patients with adhesion-related chronic pain. Nevertheless, in carefully selected individuals—particularly those with dense, vascularized adhesions involving bowel structures and evaluated within a multidisciplinary framework—the procedure may still be considered. Clinical decision-making should integrate adhesion characteristics, symptom severity, prior treatment response, psychosocial context, and surgical expertise [ 46 ]. Furthermore, given the fluctuating course of chronic pain and the well-recognized placebo response associated with surgical interventions, thorough patient counseling and a structured shared decision-making process are essential components of optimal care. Surgical technique and tissue handling may influence both adhesion formation and long-term pain outcomes. Factors such as suture strategy, access platform, and minimally invasive optimization may affect postoperative healing and adhesion burden. Recent analyses in minimally invasive gynecologic surgery have demonstrated that refined vaginal cuff closure strategies and optimized access platforms may influence postoperative recovery and complication profiles [ 47 , 48 ]. Although these studies focus primarily on prevention rather than ment of established adhesions, they highlight the broader importance of surgical quality and technique in adhesion-related outcomes. Taken together, this meta-analysis provides a comprehensive descriptive synthesis of the existing literature but does not establish causal evidence for the effectiveness of laparoscopic adhesiolysis in adhesion-related chronic pain. Well-designed, adequately powered randomised trials with standardised pain outcomes and long-term follow-up are required to better define the role of adhesiolysis within multidisciplinary management strategies for chronic abdominal and pelvic pain.

Chronic pelvic and abdominal pain severely affects millions of people, particularly women. In low- and middle-income countries, chronic pelvic pain affects 11% of the general adult population and 7% of the elderly [ 1 ]. In women, prevalence ranges from 5% to 25% [ 2 , 3 ]. In the United State [ 4 ], approximately $881.5 million is spent annually on outpatient treatment, while the UK spends an estimated £158 million on similar care [ 5 ]. Surgery-induced adhesions are the primary cause of chronic abdominal or pelvic pain [ 6 ]. Adhesions develop in 90% of patients after open abdominal surgery and 70% after laparoscopy [ 7 , 8 ]. They can lead to chronic abdominal pain and adhesive small bowel obstruction [ 9 , 10 ]. Postoperative adhesions are a common cause of chronic pain [ 11 ]. A study of 198 patients who underwent lower gastrointestinal surgery found that 40% reported chronic abdominal pain [ 12 ]. Additionally, a meta-analysis by ten Broek et al. indicated that adhesions were identified as the likely cause of pain in 57% of patients who underwent diagnostic laparoscopy following prior surgery [ 10 ]. Laparoscopic adhesiolysis is a common treatment [ 13 ], though its efficacy and safety remain debated, particularly regarding the use of barriers. In 2017, van den Beukel et al. evaluated the efficacy and risks of laparoscopic adhesiolysis for chronic pain caused by post-surgical adhesions in a meta-analysis [ 14 ]. The study was limited by a small number of included studies, with only two RCTs, and short follow-up periods (6–12 months) in most non-randomized studies, hindering long-term assessment. However, advances in non-invasive diagnostic techniques have improved detection of adhesion-related pain [ 15 ]. Chronic pain caused by postoperative adhesions is an important and challenging clinical problem, but the evidence regarding the therapeutic benefit of adhesiolysis remains inconsistent. A clear gap exists in the lack of systematic comparisons between laparoscopic adhesiolysis and diagnostic laparoscopy alone for pain relief, as well as limited high-quality evidence on the role of adhesion barriers.​ This study aims to evaluate the effectiveness of laparoscopic adhesiolysis in relieving adhesion-related chronic postoperative pain through a systematic review and meta-analysis, and to further explore the impact of adhesion barriers on treatment outcomes.

Supplementary Material 1. Supplementary Material 1.