QB-2022-000824 - [2025] EWHC 1610 (KB)

Following cross-examination there appeared to be agreement between the experts that in the Claimant’s case the surgery required was very complex because of the severity of the adhesions adhering her rectum to her uterus. Accordingly, there was a high risk of iatrogenic damage particularly to the bowel, which would likely be permanent, leading to a stoma.

There also was agreement between Mr Raine-Fenning and Mr Slack at least (the point not being explored with Mr Magos) that any such surgery would likely need to be carried out in a tertiary endometriosis centre, not because she has endometriosis (which there is no good evidence before me that she has), but because, as Mr Raine-Fenning explained, this meant it would be carried out by a team of experts including bowel surgeons, urologists and specialist radiographers as well as gynaecologists with advanced specialism in such complex surgeries. I am satisfied that is why the Claimant’s treating gynaecologist, Mr Chan, referred her to such an endometriosis centre in September 2024. The Claimant’s appointment there has had to be postponed as it fell during the trial. Mr Raine-Fenning told the Court that half his list on a Tuesday consisted of adhesiolysis surgery, but despite that expertise said “Few people would do this surgery. I wouldn’t.” I accept Mr Slack’s evidence in cross-examination that the fact that Mr Chan had referred her for another opinion from a specialist centre does not mean that he himself considers the surgery to be appropriate and safe.

Mr Slack does not consider that adhesiolysis is recommended, as in his opinion there is no good evidence for benefit and it carries significant risk. In cross-examination by Mr Dufficy he describes it as being “historically carried out a lot”. Mr Magos agrees and also would advise against such surgery on the grounds that it is unlikely to be effective and yet carries significant risk of organ injury. He said in oral evidence that if the Claimant was his patient he would not advise her to undergo it. Both Mr Slack and Mr Magos made the point in oral evidence that having more surgery to remove adhesions may well cause new adhesions to form and so poses a risk that it causes no improvement, or even a deterioration, in pain symptoms.

Mr Slack relies on a paper Surgical interventions for the management of chronic pelvic pain in women (Review) Leonardi, Armour, Gibbons, Cave, et al: Cochrane Database of Systematic Reviews 2021, Issue 12) to support his opinion that there is no good evidence for benefit of adhesiolysis surgery, Mr Raine-Fenning said he was extremely familiar with the paper and its authors and had spoken at conferences about it, but it had limited relevance because the review team had excluded from the review studies with participants with “pain due to active chronic PID”. I accept that they did. However, on reading the paper this appears to be for the reason set out in the plain language summary on internal page 2: “When identifiable causes of chronic pelvic pain are present, …there may be different treatment strategies necessary than when there are no obvious problems. When no disease is identified at the time of a diagnostic surgery despite chronic pelvic pain, we may consider various surgical procedures to treat the chronic pelvic pain, including removing scar tissue originating from infection or previous operation (called adhesiolysis)…”. This seems to be for the reason that Mr Magos explained to the court as summarised in paragraph 16 above: because of the difficulties in assessing benefit of treating only one of several potential causes of chronic pelvic pain. However it still has value to this case, in my judgment, in its review of the benefit of adhesiolysis in treating pain arising from adhesions. The authors were left uncertain of the effect on pelvic pain scores post operatively at 3, 6 and 12 months post-operatively; they were uncertain of the safety of adhesiolysis compared to comparator groups due to low certainty evidence and lack of structured event reporting; they considered it may improve emotional wellbeing and social support but the evidence for this was also low-certainty; and there were no studies reported on psychological outcomes. Their conclusion was that “there is currently little to support these interventions” for patients with chronic pelvic pain.

Mr Raine-Fenning in the joint statement generally agrees with the view of Mr Magos and Mr Slack, accepting that the evidence for adhesiolysis is unclear and that there is a high risk that adhesions will reform, but he notes that: (i) some women do experience a reduction in pain, even if this is temporary; and (ii) the formation of new adhesions can be reduced by meticulous surgery and the use of anti-adhesion agents. In oral evidence he said that he would not carry out so many adhesiolysis surgeries if there was no benefit to them, but of course each case will have its own risk/reward profile for each patient to consider and decide whether to consent to surgery. Mr Raine-Fenning also sees potential value in such surgery providing an opportunity to assess her right fallopian tube and divide any adhesions that impact it, which could improve her chances of natural conception and reduce the risk of ectopic surgery. Mr Magos accepted that could improve her chances, but noted his view that she had a reasonable chance as she is, having conceived twice previously.