{"paper_id":"85879f85-815e-434b-bfa9-cd3d3ce0c041","body_text":"40 \n DOI: https://doi.org/10.4038/sljm.v35i1.683  Sri Lanka Journal of Medicine Vol. 35 No.1,2026 \nSri Lanka Journal of Medicine SLJM\nOriginal \nResearch \nCitation: Gnanarathna S, Subasinghe H, Isurindi UA, 2026 Clinical Determinants and Operative Impact of Adhesions in Women \nUndergoing Laparoscopic Gynaecological Surgery: A Retrospective Analysis . Sri Lanka Journal of Medicine, pp. 40-46. \nDOI: https://doi.org/10.4038/sljm.v35i1.683 \nClinical Determinants and Operative Impact of Adhesions in Women \nUndergoing Laparoscopic Gynaecological Surgery: A Retrospective \nAnalysis \nS Gnanarathne1, H Subasinghe1, U.A Isurindi2 \n \n \nABSTRACT \nBackground: Adhesions are abnormal fibrous bands that join two normally separate anatomical structures \nand remain one of the most frequent sequelae of gynecological surgery.    They contribute to chronic pelvic \npain, infertility, and bowel obstruction, making their recognition clinically important. Objectives: To determine \nthe prevalence, severity, anatomical distribution, associated factors, and operative consequences of \nadhesions in women undergoing laparoscopic gynecological surgery at Teaching Hospital Peradeniya (THP). \nMethods: A retrospective analysis of operative notes and patient records was conducted for all women who \nunderwent laparoscopic gynecological surgery at THP. Data collected included patient demographics, prior \nsurgical history, presence and severity of adhesions, and intraoperative outcomes. Results: Of the 391 \nprocedures reviewed, adhesions were present in 46.5% of patients. Pelvic adhesions were most common \n(54.4%), followed by abdominal (22.5%) and mixed abdominal-pelvic adhesions (20.3%). Thin/filmy adhesions \naccounted for 56%, while thick/fibrous bands comprised 43.4%. Severe adhesions were found in 42.62%.  \nPrevious abdominal or pelvic surgery (χ2=79.331, p < 0.001), endometriosis (χ2=15.424, p < 0.001), and \nsubfertility (χ2=6.149, p = 0.013) we re significantly associated with adhesion development. Intraoperative \ndifficulties occurred in 30.6% of patients with adhesions, including increased bleeding, prolonged duration, \nand entry injuries. Conversion to open surgery occurred in 1.3% of cases, pre dominantly among those with \nmoderate or severe adhesions. Conclusions: Adhesions are common among women undergoing laparoscopic \ngynecological surgery and are strongly associated with previous abdominopelvic surgery, endometriosis, and \nsubfertility. Adhesion severity correlates with increased operative difficulty and conversi on to open surgery. \nUnderstanding associated risk factors can help optimize surgical strategies to reduce adhesion -related \nmorbidity. \n Keywords: Adhesions, Laparoscopic gynecological surgery, Operative complications, Abdominopelvic surgery \nINTRODUCTION \n Adhesions are fibrous bands that connect \nnormally distinct anatomical structures (1). They \nare among the most frequent findings \nencountered during gynaecological laparoscopic \nsurgery and remain a major cause of operative \ndifficulty, risk, and morbidity worldwide.  In \ngynaecological surgeries, the adhesions \nencountered are a result of previous abdominal or \npelvic surgeries, inflammatory conditions, \n1Department of Obstetrics and Gynaecology, Faculty of Medicine, \nUniversity of Peradeniya, Sri Lanka \n2Department of Anaesthesiology and Critical Care, Faculty of Medicine, \nUniversity of Peradeniya, Sri Lanka \nThis work is licensed under a Creative Commons Attribution 4.0 International License (CC BY) \nReceived: 2025-12-09   Accepted revised version: 2026-04-08   Published: 2026-04-22 \nCorrespondence:  \nS. Gnanarathne \nE mail:  sgresearchuop@gmail.com \nhttps://orcid.org/0009-0007-6023-502X\n\n Adhesions in laparoscopic gynaecological surgery                        Sri Lanka Journal of Medicine Vol. 35 No.1,2026 \n41 \n \nendometriosis, pelvic infections, or any peritoneal \ninsult (2,3).  \n \nThe SCAR study has studied a wide variety of \nlaparoscopic surgeries in relation to adhesion \nformation. As a conclusion, the study group has \nsuggested using laparoscopic surgeries in order to \nminimize adhesions (4). Presence of adhesions \nsignificantly influences the safety and complexity \nof laparoscopic procedures. Laparoscopy, with its \nsuperior magnification and illumination, improves \nthe detection of pelvic pathologies like adhesions. \nHowever, the initial entry into the abdominal \ncavity is usually performe d blindly using a Veress \nneedle or trocar, making undiagnosed adhesions a \ncritical intraoperative concern. \n \nThe reported incidence of intraperitoneal \nadhesions after general abdominal operations \nranges from 67% - 93% (5). When adhesions \nassociated with laparoscopic gynaecological \nsurgeries are considered, depending on the type \nand number of previous procedures, they are \nstrongly associated with conditions such as \nendometriosis, pelvic inflammatory disease, and \nrepeated caesarean sections (6). The presence of \nadhesions, particularly those involving the \numbilicus or anterior abdominal wall, markedly \nincreases the r isk of entry -related complications, \nleading to unnecessary conversion to open \nsurgeries and prolonged surgical procedures. \n \nDespite their clinical significance, the true \nprevalence, anatomical distribution, and severity \nof adhesions in women undergoing gynaecological \nlaparoscopy in Sri Lanka remain largely \nundocumented, and limited local data exist to \nguide surgeons in risk str atification and selection \nof the safest abdominal entry techniques. \nUnderstanding the patterns and predictors of \nadhesions in the local population is essential for \noptimising surgical planning, preventing avoidable \ninjuries, and improving overall patient outcomes. \n \nThis study aims to address this gap by \nsystematically analysing the prevalence, severity, \nassociated factors, and complications of \nadhesions encountered in gynaecological \nlaparoscopic surgeries at Teaching Hospital \nPeradeniya. \n \nMETHODOLOGY \n \nThis retrospective descriptive cross-sectional study \nwas conducted at the Professorial Obstetrics and \nGynaecology Unit of the Teaching Hospital \nPeradeniya, Sri Lanka. Ethical approval for the study \nwas obtained from the Ethics Review Committee of \nthe Facul ty of Medicine, University of Peradeniya \n(2025/EC/106). As the study involved a \nretrospective review of existing records, there was \nno direct patient involvement and no associated \nrisk. The study covered procedures performed \nbetween January 2022 and July 2 025, with data \ncollection carried out over a period of 2 months. \nThe study population consisted of all women who \nwere above 18 years old and who underwent \ndiagnostic or operative gynaecological laparoscopy \nduring the specified period. Women with complete \ndocumentation regarding the presence or absence \nof adhesions were included, while those with \nmissing or incomplete bed head tickets (BHTs), \nlaparoscopies performed for non -gynaecological \nindications were excluded from the study. \nData were extracted from BHTs, operative notes, \nanaesthetic charts, and theatre registers using a \nstructured data extraction sheet. Variables \ncollected included demographic details, clinical \nhistory, and operative details. Adhesions were \nassessed and graded using the Modified American \nFertility Society classification, with severity \ncategorised as mild, moderate, or severe based on \ndensity and involvement of critical structures (7). \nAdhesion locations documented included \nabdominal, pelvic and visceral organs . \nIntraoperative and postoperative complications, \nincluding entry-related bowel, bladder, or vascular \ninjuries, bleeding during adhesiolysis, and duration \nof surgery, were also recorded. \nStatistical analysis \nData were analysed using SPSS. Descriptive \nstatistics summarised baseline characteristics and \nthe prevalence of adhesions. Chi -square tests and \nt-tests/ANOVA were used to explore associations \nbetween adhesions and clinical or surgical \nvariables. Complicati on rates were compared \nacross different adhesion severity categories. A p -\n\n Adhesions in laparoscopic gynaecological surgery                        Sri Lanka Journal of Medicine Vol. 35 No.1,2026 \n42 \n \nvalue of <0.05 was considered statistically \nsignificant. \nRESULTS \nA total of 391 ASA I and II patients were included in \nthe study. The mean age of the participants was \n44.49 ± 4.86 years, with an age range of 30 to 60 \nyears. The mean haemoglobin concentration was \n11.28 ± 1.54 g/dL (range 7.1 -14.5 g/dL). The \ndistribution of comorbid diseases and the type of \nsurgeries are summarized in Table 1. \nTable 1. Baseline comorbidities and types of \nsurgeries in the study population \nCharacteristics  N (%) \nComorbid \ndisease \nHypertension 73 \n(18.67%) \n Bronchial \nasthma/ COPD \n19 \n(4.85%) \n Diabetes Mellitus 65 \n(16.2%) \n Hypothyroidism  10 \n(2.55%) \n Ischaemic heart \ndisease \n4 \n(1.02%) \n Dyslipidaemia  34 \n(8.6%) \n Deep vein \nthrombosis  \n3 \n(0.76%) \n Neurological \ndisorders  \n1 \n(0.25%) \n CKD/ Any other \nrenal problems  \n2 \n(0.51%) \nType of \nsurgery \nTotal \nlaparoscopic \nhysterectomy \n106 \n(27.12%) \n Laparoscopic \ncystectomy \n102 \n(26.08%) \n Laparoscopic \nmyomectomy  \n52 \n(13.29%) \nCharacteristics  N (%) \n Diagnostic \nlaparoscopy \n73 \n(18.67%) \n Lap and dye test  50 \n(12.78%) \n \nThe commonest indication to undergo laparoscopic \nsurgery in the cohort was heavy menstrual \nbleeding, followed by dysmenorrhoea. Figure 1 \nshows the distribution of indications to undergo \nlaparoscopic surgery in this cohort. \n \n \n \n \n \n \n \n \n \n \nFigure 1. The horizontal bar graph illustrates the \ndistribution of presenting complaints among \npatients who underwent laparoscopic surgery. \nPrevalence, severity, and characteristics of \nadhesions \nAdhesions were identified in 182 patients (46.5%), \nwhile 208 patients (53.2%) had no adhesions. \nAmong those with adhesions, pelvic adhesions \nwere the most common (54.4%), followed by \nabdominal (22.5%) and mixed abdomino -pelvic \nadhesions (20.3%) o f the identified adhesions, \nthin/filmy adhesions accounted for 56%, while \nthick/fibrous bands accounted for 43.4%. Severity \n0 50 100 150 200\nOther\nLower abdominal pain\nSecondary subfertility\nPrimary subfertility\nUSS detection of cyst\nDysmenorrhoea\nHeavy menstrual bleeding\nPresenting complaints among \nstudy participants (n= 391) \nNumber of patients\n\n Adhesions in laparoscopic gynaecological surgery                        Sri Lanka Journal of Medicine Vol. 35 No.1,2026 \n43 \n \ngrading demonstrated mild adhesions in 15.94%, \nmoderate in 41.44 %, and severe in 42.62% of \ncases. A strong and statistically significant \nassociation was observed between adhesion type \nand severity (χ² = 22.523, p < 0.001). Thin adhesions \nwere largely mild  or moderate, whereas thick \nadhesions were predominantly severe. \nDemographic and Clinical Factors Associated with \nAdhesions \nAge and BMI showed non -normal distribution. No \nsignificant association was observed between age \n(MWU z =-1.654, p = 0.098) or BMI (MWU z =-0.291, \np = 0.771) and the presence of adhesions. \nComorbidities such as diabetes, hypertension, \ndyslipidaemia, asthma/COPD, hypothyroidism, and \ncardiovascular disease showed no significant \nassociations with the presence of adhesions or \ntheir severity. However, previous abdominal or \npelvic surgery (73.1% among adhesion -positive \npatients; χ2=79.331, p < 0.001) and endometri osis \n(15.4%; χ2=15.424, p < 0.001) were significantly \nassociated with adhesions. Subfertility showed a \nweaker but significant association (χ2=6.149, p = \n0.013). Table 2 highlights the association of \ndemographic and clinical factors with the formation \nof ad hesions.  In our cohort, previous abdomino -\npelvic surgery and endometriosis are the strongest \npredictors of the formation of adhesions. \nTable 2 . Demographic and Clinical Factors \nAssociated with Adhesions \nVariable Total N \n(%) \nAdhesio\nn + N \n(%) \np-value \nAge (Mean ± \nSD) \n38.19 ± \n9.76 \n— MWU z =-\n1.654, p = \n0.098 \nBMI (Mean ± \nSD) \n24.10 ± \n3.81 \n— MWU z =-\n0.291, p = \n0.771 \nPast \nabdominal/ \npelvic surgery \n191 (48.8) 133 \n(73.1) \nχ2=79.331\n, p<0.001 \nEndometriosis 36 (9.2) 28 \n(15.4) \nχ2=15.424\n, p <0.001 \nVariable Total N \n(%) \nAdhesio\nn + N \n(%) \np-value \nSubfertility 62 (15.9) 40 (11) χ2=6.149, \np= 0.013 \nComorbidities DM 39 \n(10) \n40 (11) χ2=0.371, \np= 0.543 \n HTN 73 \n(11.3) \n42 \n(11.5) \nχ2=0.022, \np= 0.881 \n DL 15 \n(3.8) \n14 (3.8) χ2=0.000, \np= 1.000 \n BA/COPD \n18 (4.6) \n 14 (3.8) χ2=0.459, \np= 0.498 \n Hypothyr\noidism 17 \n(4.3) \n9 (4.9) χ2=0.281, \np= 0.596 \n CVS \ndisease \n10 (2.6) \n8 (2.2) χ2=0.183, \np= 0.669 \n \nIntraoperative Complications Associated with \nAdhesions \nConversion to open surgery occurred in 1.3% (n = 5) \nof all cases, with 4 occurring in adhesion -positive \npatients. Although the finding is clinically \nsignificant, it was not found to be statistically \nsignificant. (χ2=2.261, p = 0.133). Adhesion-positive \npatients experienced higher rates of increased \nbleeding (11%) and longer surgery duration \n(20.2%). These findings are clinically significant in \nour context. However, statistical significance was \nnot reached. Entry injuries (0.8%) and solid organ \ninjuries (0.3 %) were rare and occurred only in \nadhesion-positive patients. \nRelationship Between Adhesion Severity and \nOperative Outcomes \nConversion to open surgery occurred in 1 patient \nwith moderate adhesions and 2 patients with \nsevere adhesions, while no conversions were \nobserved in patients with mild adhesions. \n \n\n Adhesions in laparoscopic gynaecological surgery                        Sri Lanka Journal of Medicine Vol. 35 No.1,2026 \n44 \n \nDISCUSSION \nOur findings demonstrate that adhesions were a \ncommon intraoperative finding in this cohort. In \nglobal literature, similar values were reported. The \nrisk of abdominopelvic adhesions following open \nsurgeries ranges from 35 to 60%. (1,8,9,10). \nSimilarly, the distribution and anatomical patterns \nobserved in our cohort closely resemble findings \nfrom global literature, indicating that adhesion \nformation remains a widespread challenge across \ndiverse surgical settings. \nIn our population, previous pelvic or abdominal \nsurgery and endometriosis were found to be the \nmajor clinical determinants of adhesions. Both of \nthese factors are well -established contributors to \nperitoneal inflammation and fibrosis. Previous \nstudies also reported that previous pelvic surgeries \nare known to be associated with findings of \nadhesions (9,11,12). Most studies have shown that \ncaesarean sections are common among surgeries \nleading to adhesions. In contrast, a study done in \nNigeria has shown that open myomectomy has the \nhighest risk of adhesions (13). Few studies support \nthis finding, highlighting the possibility of high \nchances of re -surgery in this cohort for the same \nindication or fertility alterations. \nIn our study, the presence of endometriosis was \nalso found to be a predictor for the development of \nadhesions. A randomised controlled study \nperformed by Parker et al confirmed that not only \nendometriosis, but any surgery performed for \nendometriosis will l ead to the formation of new \nadhesions (14). \nAdhesions were also associated with increased \noperative time, higher blood loss, and an increased \nlikelihood of conversion to open surgery. Although \nnot statistically significant, there are clinically \nsignificant findings that will alter the patient \noutcome, length of stay, and hospital cost.  These \noutcomes align with previous studies, which show \na significant association which is observed in non -\ngynecological surgeries as well (15). In routine \nsurgery, unplanned adhesiolysis will increase the \nrisk of unin tended organ injury, prolonged \npneumoperitoneum, hypothermia, and increased \npostoperative pain, all of which may further impact \nsurgical morbidity. The clinical impact is particularly \nrelevant in the context of minimally invasive \nsurgery, where conversion to laparotomy carries \nimplications for recovery, wound complications, \nand patient satisfaction. Therefore, the presence of \nadhesions raises the question of whether open \nsurgery for ben ign indications is justifiable, \nespecially when minimally invasive alter natives \nmay still be feasible with appropriate expertise and \npreoperative planning. \nOverall, this study highlights the importance of \nidentifying women at risk of adhesions and \nadopting intraoperative strategies that minimise \ntissue injury, inflammation, and ischemia. Even \nthough our statistically non -significant findings \nlimit definitive causal conclusions, the clinical \nrelevance is clear: adhesions not only complicate \nlaparoscopic procedures but may affect patient \noutcomes, health -care resources, and long -term \nreproductive and pain-related morbidity. This study \nhas several limitations. It s retrospective design \nlimits causal inference, and some operative \nvariables, such as detailed operative time and \nblood loss, were incompletely recorded. In \naddition, this was a single-center study, which may \nlimit generalizability. A key strength of this study is \nthe relatively large sample size and inclusion of a \nwide range of laparoscopic procedures, providing \nuseful insight into adhesion patterns in a local \npopulation. Future prospective studies with larger \nsample sizes and standardised adhesion scoring  \nsystems are warranted to better characterise these \nassociations and evaluate preventive strategies in \nthe Sri Lankan surgical context. \nCONCLUSION \nThis retrospective study demonstrates that \nadhesions are a common finding among women \nundergoing laparoscopic gynaecological surgery, \nwith patterns and prevalence comparable to \ninternational data. Previous pelvic surgery and \nendometriosis were the most imp ortant clinical \ndeterminants, and although associations with \nincreased operative time, blood loss, and \nconversion to open surgery were not statistically \nsignificant, they remain clinically meaningful. \nAdhesions continue to pose a substantial challenge \nto minimally invasive surgery, increasing operative \ncomplexity and the risk of complications. Further \nprospective research is needed to better quantify \n\n Adhesions in laparoscopic gynaecological surgery                        Sri Lanka Journal of Medicine Vol. 35 No.1,2026 \n45 \n \nthese risks and evaluate the effectiveness of \nprevention methods in our local setting.  \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nREFERENCES \n1. Al-Husban N, Elayyan Y, El -Qudah M, Aloran B, Batayneh \nR. Surgical adhesions among women undergoing \nlaparoscopic gynecological surgery with or without \nadhesiolysis – prevalence, severity, and implications: \nretrospective cohort study at a University Hospita l. \nTherapeutic Advances in Reproductive Health. 2020;14. \ndoi:10.1177/2633494120906010 \n2. Hirschelmann A, Wallwiener CW, Wallwiener M, et al. Is \nPatient Education About Adhesions a Requirement in \nAbdominopelvic Surgery?. Geburtshilfe Frauenheilkd. \n2012;72(4):299-304. doi:10.1055/s-0031-1298425 \n3. De Wilde RL, Bakkum EA, Brölmann  H, et al. Consensus \nrecommendations on adhesions (version 2014) for the \nESGE Adhesions Research Working Group (European \nSociety for Gynecological Endoscopy): an expert opinion. \nArch Gynecol Obstet. 2014;290(3):581 -582. \ndoi:10.1007/s00404-014-3312-7 \n4. Pepijn Krielen, Martijn W J Stommel, Pille Pargmae, Nicole \nD Bouvy, Erica A Bakkum, Harold Ellis, Michael C Parker, \nEwen A Griffiths, Harry van Goor, Richard P G ten Broek, \nAdhesion-related readmissions after open and \nlaparoscopic surgery: a retrospective cohort study (SCAR \nupdate), The Lancet, Volume 395, Issue 10217,2020, \nPages 33 -41, ISSN 0140 -6736, \nhttps://doi.org/10.1016/S0140-6736(19)32636-4. \n5. Liakakos TThomakos NFine PMDervenis CYoung RL. \nPeritoneal Adhesions: Etiology, Pathophysiology, and \nClinical Significance. Recent Advances in Prevention and \nManagement. Dig Surg (2001) 18:260 –73. \nDoi:10.1159/000050149 \n6. Ten Broek RP, Issa Y, van Santbrink EJ, et al. Burden of \nadhesions in abdominal and pelvic surgery: systematic \nreview and met-analysis. BMJ. 2013;347:f5588. Published \n2013 Oct 3. doi:10.1136/bmj.f5588 \n7. International working group of AAGL, ESGE, ESHRE and \nWES, Nathalie Vermeulen, Mauricio S Abrao, Jon I \nEinarsson, Andrew W Horne, Neil P Johnson, Ted T M Lee, \nStacey Missmer, John Petrozza, Carla Tomassetti, Krina T \nZondervan, Grigoris Grimbizis, Rudy Leon De Wilde, \nEndometriosis classification, staging and reporting \nsystems: a review on the road to a universally accepted \nendometriosis classification,, Human Reproduction Open, \nVolume 2021, Issue 4, 2021, hoab025, \n8. Kubinova K, Mara M, Horak P, et al. Reproduction after \nmyomectomy: comparison of patients with and without \nsecond-look laparoscopy. Minim Invasive Ther Allied \nTechnol 2012; 21: 118 –124. \nhttps://doi.org/10.3109/13645706.2011.573797 \n9. Ikechebelu JI, Eleje GU, Eke NO, et al. Prevalence and \npattern of intra -abdominal adhesion seen at diagnostic \nlaparoscopy among infertile women with prior open \nappendicectomy in Nnewi, South -east Nigeria. J Med Sci \n2010; 1: 391 –394.  doi: 10.4103/njcp.njcp_39_17. PMID: \n30417838. \n10. Conforti A, Krishnamurthy GB, Dragamestianos C, et al. \nIntrauterine adhesions after open myomectomy: an audit. \nEur J Obstet Gynecol Reprod Biol 2014; 179: 42 –45. \nhttps://doi.org/10.1016/j.ejogrb.2014.04.034 \n11. Tinelli A, Malvasi A, Guido M, Tsin D, Hudelist G, Hurst B, \net al Adhesion formation after intracapsular \nmyomectomy with or withoutadhesion barrier Fertil \nSteril. 2011;95:1780 –5  \nhttps://doi.org/10.1016/j.fertnstert.2010.12.049 \n12. Nzau-Ngoma E, Mbuyi -Muamba J, Mboloko E, Lebwaze \nM. Abdominal and pelvic adhesions: Possible role of \nleiomyomas and skin scar anomaly in profiling high risk \npatients Open J Obstet Gynecol. 2014;4:16 –22 \n10.4236/ojog.2014.41004 \n13. Imaralu, John Osaigbovoh; Ani, Franklin Inyang; Ayegbusi, \nEkundayo Oluwole1; Oguntade, Florence Adebisi2; \nNwankpa, Chimaobi Chukwuemeka; Olaleye, Bukunmi \nDeborah. Peritoneal Adhesion Findings during \nLaparoscopy: Determinants of Occurrence and Effect of \nSeverity on Operative Outcomes in a Nigerian Hospital. \nAnnals of African Medicine 22(2):p 145 -152, Apr –Jun \n2023. | DOI: 10.4103/aam.aam_43_22 \n14. J.D. Parker, N. Sinaii, J.H. Segars, H. Godoy, C. Winkel, P. \nStratton Adhesion formation after laparoscopic excision \nof endometriosis and lysis of adhesions. Fertil Steril, 84 \n(2005), pp. 1457 -1461 \nhttps://doi.org/10.1016/j.fertnstert.2005.04.057 \n15. M. Ouaïssi, S. Gaujoux, N. Veyrie, E. Denève, C. Brigand, B. \nCastel, J.J. Duron, A. Rault, K. Slim, D. Nocca, Post -\noperative adhesions after digestive surgery: Their \nincidence and prevention: Review of the literature, \nJournal of Visceral Surgery, Volume 14 9, Issue \n2,2012,Pages e104 -e114,ISSN 1878 -7886, \nhttps://doi.org/10.1016/j.jviscsurg.2011.11.006. \n \nAuthor declaration   \n \nAcknowledgement \nNone.  \n \nAuthors' contributions:  \nSG: Conceptualization, providing clinical oversight, \nreviewing the final manuscript.  HS: Data collection, \ndata analysis, writing the manuscript; UAI: Data \ncollection, data analysis, writing the manuscript. \n \nConflicts of interest:  \nThe authors declare that there is no financial or non-\nfinancial conflict of interest.   \n \nFunding statement:  \nSelf-funded. \n \nEthics statement:  \nEthical clearance was obtained from the Ethics \nReview Committee of the Faculty of Medicine, \nUniversity of Peradeniya (2025/EC/106). \n \nStatement on data availability:  \nData will be available on request from the \ncorresponding author.","source_license":"CC0","license_restricted":false}