Laparoscopic peritoneal adhesion formation follows a pathway similar to laparotomy, both of which are only partially understood. Laparoscopic adhesion formation is complicated and influenced by pressure, dry gas desiccation, and hypoxia caused and superimposed by the pneumoperitoneum. It may further be affected by products of tissue combustion and inappropriate irrigation. Adjuvants are a poor substitute for attention to surgical detail and offer little help for the problem. The best defenses to reduce adhesion formation are maintenance of a normal physiologic peritoneal state that is wet and warm, gentle tissue handling, low intra-abdominal pressure, appropriate irrigation, and evacuation of smoke. Continued research into peritoneal cell response to the provocative circumstances of laparoscopic surgery will hopefully offer assistance to diminish the potential for laparoscopic adhesion formation.