Adhesive Versus Spatial Anatomical Distortion Determines Energy Device Performance in Complex Total Laparoscopic Hysterectomy

Study Objective To evaluate whether the type of anatomical distortion—spatial or adhesive—determines the relative performance of the energy device in complex total laparoscopic hysterectomy (TLH). Design Retrospective cohort study. Setting Single tertiary referral center. Patients A total of 167 women who underwent complex TLH between 2018 and 2025 were included. Cases were classified according to intraoperatively confirmed distortion type as spatial (uterine enlargement), adhesive (previous cesarean delivery or endometriosis), or combined. Interventions TLH performed with conventional bipolar electrosurgery (CBP, n = 94) or LigaSure (LG, n = 73). Device selection was based on real‐time availability. Measurements and Main Results Primary outcome was operative time. Overall operative time (136 ± 18 vs. 140 ± 17 min, p = 0.761), hemoglobin change, and length of hospital stay were comparable between groups. Subgroup analysis revealed a significant interaction between device type and distortion subgroup (F (1,90) = 18.0, p < 0.001). In the spatial distortion subgroup, LG was associated with shorter operative time (90 ± 23 vs. 110 ± 17 min, p = 0.004). In the adhesive distortion subgroup, CBP outperformed LG (140 ± 23 vs. 155 ± 19 min, p = 0.003). Multivariable regression confirmed that the device–distortion interaction remained significant after adjustment for potential confounders (B = 18.9, p < 0.001). Bladder injury was more frequent in the LG group (8.2% vs. 1.1%, p = 0.031), exclusively in patients with prior cesarean delivery. All conversions to laparotomy occurred in the spatial distortion subgroup, with no significant difference between devices (4.3% vs. 4.1%, p = 0.961).

Device efficiency in complex TLH is determined by the type of anatomical distortion. LG offers operative advantages when complexity is defined by uterine enlargement, whereas CBP electrosurgery is superior in the presence of adhesive disease. These findings support anatomy‐driven device selection in complex TLH.

anatomical distortion, conventional bipolar electrosurgery, energy devices, LigaSure, total laparoscopic hysterectomy 1. Introduction Total laparoscopic hysterectomy (TLH) has become the preferred surgical approach for benign uterine conditions, with population‐based analyses confirming a transition to endoscopic route in more than 55% of cases by 2020 [1, 2]. However, with this shift, gynecologists have been increasingly faced with more complex operative fields resulting from large uteri, previous cesarean delivery, and endometriosis, each of which can distort pelvic anatomy with increased perioperative risk. Anatomical distortion may arise from two main mechanisms and may result in distinct presentations. Spatial distortion can be defined as a condition caused by excessive uterine volume, leading to displacement of pelvic organs, narrowing of the operative field, and disruption of tissue planes between adjacent anatomical structures. In contrast, adhesive distortion, resulting from scarring after prior cesarean delivery or fibrotic infiltration in endometriosis, alters tissue planes and obscures key anatomical landmarks. Electrosurgical energy devices, by providing effective hemostasis and tissue transection, constitute a critical component of a safe surgery. Conventional bipolar (CBP) devices limit electrical current to the instrument tips, whereas advanced bipolar vessel‐sealing systems such as LigaSure (LG) employ a feedback‐controlled mechanism that terminates current once sealing is achieved, enabling vessel sealing up to 7 mm with reduced thermal spread [3, 4, 5]. This controlled tissue effect may offer an advantage in surgical scenarios characterized by distorted anatomy. Although some authors have compared the surgical outcomes of CBP and LG during hysterectomy [6, 7, 8], there is a lack of studies examining their effects in complex cases, particularly those involving anatomically distorted surgical fields. In this study, we aimed to compare perioperative outcomes between CBP electrosurgery and LG in patients undergoing complex TLH, and to determine whether intraoperatively confirmed anatomical distortion (adhesive or spatial) affects device performance. 2. Material and Methods 2.1. Study Design and Study Group This retrospective cohort study was conducted at Private İzmir Can Hospital, İzmir, Türkiye. The study protocol was approved by the Ethics Committee of Kâtip Çelebi University Atatürk Training and Research Hospital, İzmir, Türkiye (May 26, 2022; IRB No. 0251), and conducted in accordance with the Declaration of Helsinki. Informed consent was waived by the Ethics Committee due to the retrospective study design. The initial cohort comprised 327 patients who underwent TLH for benign indications by a single laparoscopic surgeon (C.M.G.) at Private İzmir Can Hospital between January 2018 and November 2025. Exclusion criteria were: antithrombotic prophylaxis (n = 11); mobile uterus smaller than 12 weeks with no anatomical distortion on laparoscopic inspection (n = 37); histopathologically confirmed gynecologic malignancy (n = 9); concomitant urogynecologic procedures (n = 49); additional surgical procedures beyond hysterectomy, including bowel or urinary tract procedures (n = 13); history of previous non‐obstetric pelvic surgery (n = 32); uterine specimen weight > 1000 g (n = 9). After these exclusions, 167 patients were included in the study (Figure 1). Complex TLH was defined by the presence of at least one form of intraoperatively confirmed anatomical distortion—spatial or adhesive—consistent with the most frequently reported contributors to operative difficulty in the literature. Patients were divided into two groups according to the primary energy device used: the CBP group (n = 94) and the LG group (n = 73). Device selection was determined primarily by real‐time instrument availability; the institution maintained a limited number of both devices shared across surgical specialties, and either could be in use by other teams or temporarily unavailable. Surgeon preference, case complexity, and anticipated operative difficulty were not considered. All procedures were performed by a single surgeon (C.M.G.) with over 10 years of experience in TLH at the time the study period commenced (2018), including extensive experience with both CBP electrosurgery and LG. The proportion of cases performed with each device remained stable throughout the study period, with no temporal shift in device utilization. 2.2. Data Collection Data on age, body mass index (BMI), uterine weight, mode of delivery, gravidity, parity, operative duration, perioperative hemoglobin drop, major complications, conversion to laparotomy, postoperative inpatient time (hours), and presence of anatomical distortion were obtained from electronic medical records, pathology reports, and operative video recordings. Anatomical distortion was classified intraoperatively as adhesive or spatial based on laparoscopic inspection. Spatial distortion was defined as uterine enlargement corresponding to ≥ 12 gestational weeks on preoperative assessment, with intraoperative confirmation of pelvic organ displacement, narrowing of the operative field, and disruption of tissue planes between adjacent structures (Figure 2). Adhesive distortion was defined by the presence of fibrotic scarring, obliteration of tissue planes, or obscured anatomical landmarks confirmed on intraoperative inspection in patients with a clinical history of previous cesarean delivery (Figure 3) or endometriosis (Figure 4). The primary outcome was operative duration, defined as the interval from skin incision to removal of the final umbilical trocar; morcellation time was excluded when applicable. Secondary outcomes included hemoglobin drop (preoperative minus 24‐h postoperative value), conversion to laparotomy, postoperative inpatient time, and major intraoperative complications (urinary tract injury, bowel injury, major vascular injury, or reoperation). 2.3. Surgical Procedure All procedures were performed under general anesthesia in the dorsal lithotomy position with a uterine manipulator in place. Pneumoperitoneum was established via Veress needle, followed by enlargement of the umbilical incision and placement of a 10‐mm laparoscope. After routine abdominopelvic inspection, 5‐mm trocar sheaths were inserted bilaterally in the lower quadrants, approximately 3–4 cm medial to the anterior superior iliac spine. An additional 5‐mm trocar was placed in the midline, approximately 6–8 cm above the symphysis pubis. In cases of a large uterus, trocar positions were shifted approximately 6–8 cm cephalad. In the CBP group, a bipolar forceps (RoBi, Karl Storz, Tuttlingen, Germany; or Powergrip, Bissinger, Teningen, Germany) and monopolar scissors used as a cold knife (Karl Storz) were employed for dissection and hemostasis, alternating through the trocars as needed. A blunt‐tip grasper was used by the assistant. In the LG group, a LG Blunt Tip Open Sealer/Divider (5 mm, 23 cm; Covidien, Mansfield, MA, USA) connected to a Valleylab FT10 generator (Medtronic, Minneapolis, MN, USA) was used, with blunt‐tip graspers by both the surgeon and assistant. In both groups, the surgeon handled two instruments simultaneously with either hand. Adhesiolysis and blunt or sharp dissection to restore pelvic anatomy and identify safe dissection planes were performed as needed according to intraoperative findings. Dissection was performed using either CBP with monopolar scissors in the bipolar group or LG with a blunt‐tip grasper in the LG group. The remainder of the procedure followed a standardized TLH technique based on the Clermont‐Ferrand school principles [9]. Vaginal cuff closure was performed with interrupted 0 polyglactin 910 sutures (Vicryl; Ethicon, Somerville, NJ, USA) using an extracorporeal knot‐tying technique. 2.4. Statistical Analysis Normality was assessed using the Shapiro–Wilk test. Normally distributed variables were compared using Student's t‐test and reported as mean ± SD; non‐normally distributed variables were analyzed using the Mann–Whitney U test and reported as median (IQR). Categorical variables were compared using chi‐square or Fisher's exact test. To evaluate whether device effect on operative duration differed by distortion subtype, a two‐way ANOVA was performed with device type and distortion subgroup as fixed factors, including an interaction term. To ensure nonoverlapping comparisons, the interaction analysis included only patients with isolated spatial or isolated adhesive distortion. The combined distortion subgroup was analyzed separately and reported descriptively, as the co‐presence of both distortion mechanisms precludes attribution of device effect to a single distortion type. To adjust for potential confounders, a multivariable linear regression model was constructed with operative time as the dependent variable. Independent variables included device type, distortion subgroup, the device–distortion interaction term, age, BMI, uterine weight, and number of prior cesarean deliveries. Multicollinearity was assessed using variance inflation factors (VIF). All analyses were performed using SPSS v24.0 (IBM Corp., Armonk, NY, USA); p < 0.05 was considered statistically significant. 3. Results A total of 167 patients were included (CBP n = 94, LG n = 73). Baseline demographic and clinical characteristics, including age, BMI, gravidity, parity, preoperative hemoglobin, mode of delivery, uterine weight, and indication for hysterectomy, were comparable between groups. The distribution of anatomical distortion subtypes was also similar (Table 1). TABLE 1. | Variables | CBP (n = 94), mean ± SD | LG (n = 73), mean ± SD | p | |---|---|---|---| | Age | 41.75 ± 3.24 | 42.34 ± 4.17 | 0.741 | | Uterine weight (g) | 405 ± 55 | 417 ± 49 | 0.471 | | Variables | Median [IQR] | Median [IQR] | p | |---|---|---|---| | BMI (kg/m2) | 21.9 [19.7–26.1] | 22.55 [19.2–25.98] | 0.437 | | Gravida | 3 [0–5] | 3 [0–5] | 0.601 | | Parity | 2 [0–4] | 2 [0–4] | 0.356 | | Preoperative hemoglobin level (g/dL) | 12.4 [10.3–13.0] | 11.9 [10.4–12.87] | 0.598 | | Variables | n (%) | n (%) | p | |---|---|---|---| | Indication of hysterectomy | ||| | Uterine leiomyoma | 45 (47.8) | 36 (49.3) | NA | | Abnormal uterine bleeding | 24 (25.5) | 18 (24.6) | NA | | Endometriosis | 17 (18.0) | 12 (16.4) | NA | | Other benign pathologies | 8 (8.5) | 7 (9.5) | NA | | Type of delivery | ||| | Cesarean 1 or more | 64 (68) | 51 (69.8) | NA | | Vaginal | 27 (28.7) | 19 (26) | NA | | Nullipara | 3 (3.2) | 3 (4.1) | NA | | Anatomic distortion subtype | ||| | Spatial (large uteri) | 54 (57.4) | 43 (58.9) | 0.850 | | Adhesive | 80 (85.1) | 63 (86.3) | 0.827 | | Combined | 40 (42.6) | 33 (45.2) | 0.732 | Note: p values reflect between‐group comparisons. p < 0.05 considered statistically significant. Spatial and adhesive distortion subtypes are not mutually exclusive; the combined category denotes patients presenting both subtypes concurrently, who are also counted within the individual spatial and adhesive rows. Percentages are calculated over the group total and therefore do not sum to 100%. Abbreviations: BMI, body mass index; CBP, conventional bipolar; IQR, interquartile range; LG, LigaSure; NA, not applicable. Overall operative time, hemoglobin drop, and postoperative inpatient time were comparable between groups (Table 2). Only bladder injury was encountered in the urinary tract. Bladder injury was significantly more frequent in the LG group (8.2% vs. 1.1%, p = 0.031); all injuries occurred in patients with previous cesarean delivery and were identified and repaired intraoperatively without long‐term sequelae. No ureteral, bowel, or major vascular injuries were observed. TABLE 2. | Variables | CBP, (n = 94), mean ± SD | LG, (n = 73), mean ± SD | p | |---|---|---|---| | Duration of the operation (min) | 136 ± 18 | 140 ± 17 | 0.761 | | Hemoglobin drop (g/dL) | 2.1 ± 0.7 | 2.3 ± 0.6 | 0.480 | | Total postoperative inpatient time (hours) | 26 ± 3 | 25 ± 6 | 0.607 | | Variables | n (%) | n (%) | p | |---|---|---|---| | Major perioperative complications | ||| | Bladder injury | 1 (1.1) | 6 (8.2) | 0.031 | | Bowel injury | 0 | 0 | NA | | Ureteral injury | 0 | 0 | NA | | Major vascular injury | 0 | 0 | NA | | Conversion to laparotomy | 4 (4.3) | 3 (4.1) | 0.961 | Note: p values reflect between‐group comparisons; p < 0.05 considered statistically significant. Bold values denote statistically significant p‐values. Abbreviations: CBP, conventional bipolar; LG, LigaSure; NA, not applicable; SD, standard deviation. Conversion to laparotomy occurred in seven patients (CBP: 4 [4.3%], LG: 3 [4.1%], p = 0.961), all in the spatial distortion subgroup. No patient required reoperation. A significant interaction between device type and anatomical distortion was observed (F(1,90) = 18.0, p < 0.001), suggesting that device effect varied according to distortion subtype. In the spatial distortion subgroup, operative time was shorter with LG than CBP (90 ± 23 vs. 110 ± 17 min, p = 0.004). In the adhesive distortion subgroup, CBP outperformed LG (140 ± 23 vs. 155 ± 19 min, p = 0.003). Subgroup results are presented in Table 3. TABLE 3. | Distortion subgroup | CBP, mean ± SD (min) | LG, mean ± SD (min) | Difference (CBP − LG) | p | |---|---|---|---|---| | Spatial (CBP n = 54, LG n = 43) | 110 ± 17 | 90 ± 23 | +20 | 0.004 | | Adhesive (CBP n = 80, LG n = 63) | 140 ± 23 | 155 ± 19 | −15 | 0.003 | | Interaction (device × subgroup) | F (1,90) = 18.0 | < 0.001 | Note: Difference = CBP mean − LG mean; positive values indicate CBP was longer. Interaction term assessed using two‐way ANOVA (Type II). Combined distortion subgroup results reported in text. Bold values denote statistically significant p‐values. Abbreviations: CBP, conventional bipolar; LG, LigaSure; SD, standard deviation. The combined distortion subgroup (CBP n = 40, LG n = 33) was excluded from the interaction model due to subgroup overlap. In this subgroup, operative time was longer in the LG group than the CBP group (176 ± 20 vs. 163 ± 31 min, p = 0.004), consistent with the adhesive distortion pattern. Multivariable linear regression confirmed that the device–distortion interaction remained significant after adjustment for potential confounders (B = 18.9, 95% CI 8.2–29.6, p < 0.001). LG was independently associated with shorter operative time in the spatial distortion subgroup (B = −14.3, 95% CI −22.1 to −6.5, p < 0.001), whereas adhesive distortion was associated with longer operative time (B = 11.7, 95% CI 3.9–19.5, p = 0.004). Uterine weight was also an independent predictor of operative time (B = 0.04, 95% CI 0.02–0.06, p < 0.001). Age, BMI, and number of prior cesarean deliveries were not significant predictors. All VIF values were below 2.5, indicating no multicollinearity (Table 4). TABLE 4. | Variable | B | 95% CI | p | VIF | |---|---|---|---|---| | Constant | 48.2 | 18.1–78.3 | 0.002 | — | | Device type (LigaSure = 1) | −14.3 | −22.1 to −6.5 | < 0.001 | 1.8 | | Distortion subgroup (adhesive = 1) | 11.7 | 3.9–19.5 | 0.004 | 1.6 | | Device × distortion interaction | 18.9 | 8.2–29.6 | < 0.001 | 2.1 | | Age (years) | 0.3 | −0.2 to 0.8 | 0.241 | 1.1 | | BMI (kg/m2) | 0.8 | −0.1 to 1.7 | 0.082 | 1.3 | | Uterine weight (g) | 0.04 | 0.02–0.06 | < 0.001 | 1.4 | | Number of prior cesarean deliveries | 3.1 | −1.2 to 7.4 | 0.156 | 1.5 | Note: Dependent variable: operative time (min). Reference categories: device type = conventional bipolar; distortion subgroup = spatial. Bold p values indicate statistical significance (p < 0.05). Model summary: R 2 = 0.375, adjusted R 2 = 0.347, F = 13.6, p < 0.001. Abbreviations: B, unstandardized regression coefficient; BMI, body mass index; CI, confidence interval; VIF, variance inflation factor. 4. Discussion This study demonstrates that the type of anatomical distortion is a key determinant of energy device efficiency in complex TLH. To our knowledge, this is the first study to evaluate energy device performance in relation to the type of anatomical distortion in complex TLH. In the present study, overall perioperative outcomes—including operative time, intraoperative blood loss, and length of hospital stay—were comparable between the two device groups, consistent with previous reports using the same devices [6, 7, 10]. Despite the anatomical complexity of our cohort, operative times were within the range reported in unselected populations [7, 10], though this should be interpreted in light of our operative time definition, which excluded morcellation time. This exclusion was deliberate, as morcellation is a mechanical step unrelated to energy device performance and its duration is determined primarily by specimen size rather than surgical technique or device type. Including morcellation time would have introduced a systematic bias favoring the CBP group in the spatial distortion subgroup, where larger uteri require longer morcellation. Although the definition of complex TLH remains unclear [11], large uterine size and pelvic adhesion from prior cesarean delivery or endometriosis represent the most consistently identified contributors to operative difficulty [12, 13, 14]. In the present study, surgical complexity was defined by the presence of anatomical distortion, which was further divided into two categories: spatial distortion characterized by significant uterine enlargement and adhesive distortion defined by intraoperative adhesions from prior cesarean delivery or endometriosis. Both have been previously identified as predictors of operative difficulty [12, 13, 14, 15]. This classification enabled a systematic evaluation of energy device performance across anatomically distinct surgical contexts. Previous studies comparing CBP electrosurgery and LG in TLH have reported comparable perioperative outcomes in general patient populations [6, 10]. The absence of significant differences in these studies may reflect the population heterogeneity, whereby the opposing effects of device performance across different distortion subtypes offset each other when analyzed collectively. This finding was further supported by multivariable regression analysis, in which the device–distortion interaction remained significant (B = 18.9, p < 0.001) after adjustment for age, BMI, uterine weight, and prior cesarean delivery history, confirming that the differential device effect is independent of these potential confounders. In the spatial distortion subgroup, LG was associated with significantly shorter operative time than CBP (90 ± 23 vs. 110 ± 17 min, p = 0.004). Large uterine size has been identified as an independent predictor of operative difficulty and less favorable surgical outcomes in TLH [12, 14]. In our experience, the technical design of LG may offer a potential advantage; the broad jaws of LG enable en bloc sealing with fewer applications, and its sealing‐and‐transection capability eliminates the need for instrument switching. In addition, the use of a blunt‐tip grasper in the surgeon's assisting hand may provide improved uterine manipulation, thereby enhancing operative efficiency. These findings are consistent with a report by Biçer et al. demonstrating the effective use of LG in TLH with enlarged uteri [16]. Notably, all conversions to laparotomy occurred in the spatial distortion subgroup, with no significant difference between device groups (CBP 4.3% vs. LG 4.1%, p = 0.961). This suggests that, in cases of significant uterine enlargement, the risk of conversion is more closely related to anatomical factors than the choice of energy device. In the adhesive distortion subgroup, CBP was associated with shorter operative time than LG (140 ± 23 vs. 155 ± 19 min, p = 0.003). Previous cesarean delivery and endometriosis alter the normal anatomical relationships between the bladder, ureter, and uterine vessels [13, 14, 17]. Consistent with previous reports [18], all bladder injuries in our study occurred in patients with prior cesarean delivery, and the rate was higher in the LG group. The overall bladder injury rate of 8.2% in the LG group should be interpreted in the context of the exclusively complex nature of the cohort; when calculated among cesarean‐scarred patients only (6 of 51), the rate was 11.8%, which is within the range reported for TLH in women with prior cesarean delivery [18]. Furthermore, comparable baseline characteristics between device groups, including distribution of prior cesarean delivery (CBP 68% vs. LG 69.8%), suggest that the higher injury rate reflects a device‐related factor in the adhesive field rather than case selection bias. Although a multivariable analysis adjusting for potential confounders would be desirable, the low absolute number of events (n = 7) precluded a reliable logistic regression model. Nevertheless, the exclusive occurrence of bladder injuries in patients with prior cesarean delivery, combined with the comparable distribution of cesarean history between device groups, supports a device–anatomy interaction rather than a confounding effect. The fine‐tipped design of CBP forceps and monopolar scissors allows more precise tissue handling and safer dissection, particularly in the vesicovaginal space. In contrast, the broader jaws of LG may be more difficult to position precisely in narrow spaces without inadvertently grasping the adjacent viscera. This was most apparent during vesicouterine dissection in patients with dense cesarean scar adhesions and during parametrial dissection in deep infiltrating endometriosis, where precise instrument control is essential to avoid urological injury. In the combined distortion subgroup, operative time followed a pattern consistent with adhesive distortion, with LG associated with longer operative time than CBP (176 ± 20 vs. 163 ± 31 min, p = 0.004). These findings suggest that the adhesive component may be the dominant determinant of device efficiency when both distortion types coexist, indicating that surgical complexity is driven primarily by the adhesive component and may diminish the potential advantages of device‐related sealing efficiency. This pattern further supports the validity of analyzing spatial and adhesive distortion as separate entities in the interaction model. Importantly, despite the observed differences in operative time, overall complication rates, hemoglobin drop, and length of hospital stay remained comparable between device groups, suggesting that both devices can be used safely in complex TLH regardless of distortion type. These findings have important implications for preoperative surgical planning. The type of anatomical distortion anticipated—based on uterine size on imaging and clinical history of prior cesarean delivery or endometriosis—may guide energy device selection before surgery. In cases where spatial distortion predominates without adhesive disease, LG may offer an advantage in operative time. Conversely, in cases with high risk of adhesive distortion, CBP electrosurgery should be considered as the primary instrument. Given that both device types may be required within the same procedure—particularly in combined distortion cases—surgeons should avoid relying solely on a single energy device in complex TLH. Preoperative imaging and clinical history—uterine size, prior cesarean delivery, and endometriosis—provide sufficient information to guide device selection before the first incision. This study has several limitations. First, its retrospective, single‐surgeon design limits generalizability, though it eliminates inter‐operator variability and ensures consistent proficiency with both devices throughout the study period. Second, device selection based on real‐time availability rather than randomization introduces potential selection bias. Although baseline characteristics were comparable between groups and multivariable analysis was performed to adjust for key clinical variables, residual confounding from unmeasured factors cannot be entirely excluded. Third, adhesive distortion was defined exclusively by prior cesarean delivery and endometriosis; other etiologies were not systematically captured. Moreover, a standardized adhesion scoring system (e.g., r‐ASRM) was not applied; as the cohort included both cesarean‐related and endometriosis‐related adhesions, no single validated grading tool was universally applicable across both etiologies. Additionally, the degree of anatomical distortion was not quantitatively graded; therefore, the present findings pertain to the type rather than the severity of distortion, and future studies incorporating validated severity scales are warranted. Fourth, cases with atypically located myomas without significant uterine enlargement were not included, as these may represent a distinct form of spatial complexity. Additionally, non‐cesarean and non‐endometriosis causes of adhesions, such as pelvic inflammatory disease, were not specifically evaluated. Finally, the non‐mutually exclusive nature of distortion subgroups necessitated exclusion of the combined subgroup from the interaction model. Although this approach reduces sample size, it ensures that device effects can be attributed to a single distortion mechanism. The consistency of combined subgroup results with the adhesive distortion pattern provides indirect support for the robustness of the primary findings. CBP electrosurgery should be considered an essential instrument in complex TLH; advanced bipolar devices alone may not provide adequate versatility in adhesive conditions (e.g., previous cesarean delivery and endometriosis). LG may be preferable in cases where surgical complexity is primarily driven by uterine enlargement in the absence of adhesive disease. Author Contributions Şebnem Özgür: methodology, formal analysis, writing – original draft, writing – review and editing, visualization. Cenk Mustafa Güven: conceptualization, methodology, software, data curation, investigation, validation, formal analysis, supervision, writing – review and editing, writing – original draft, resources, visualization. Dilek Uysal: methodology, conceptualization, validation, writing – review and editing, project administration, writing – original draft. Ethics Statement This study was approved by the Ethics Committee of Kâtip Çelebi University Atatürk Training and Research Hospital, İzmir, Türkiye (approval date: May 26, 2022; IRB No. 0251), and was conducted in accordance with the principles of the Declaration of Helsinki. Consent Informed consent was waived by the Ethics Committee owing to the retrospective design of the study. No patient‐identifiable data are included in this article. Conflicts of Interest The authors declare no conflicts of interest. Acknowledgments AI‐assisted language editing tools based on large language models were used for manuscript preparation assistance. All scientific content, data analysis, and intellectual contributions were performed solely by the authors, who take full responsibility for the integrity and accuracy of the work. Data Availability Statement The data that support the findings of this study consist of retrospectively collected patient records from Private İzmir Can Hospital, İzmir, Türkiye. Sharing of individual patient‐level data is not permitted under the institutional ethics approval granted by the Ethics Committee of Kâtip Çelebi University Atatürk Training and Research Hospital, İzmir, Türkiye (May 26, 2022; IRB No. 0251), as data sharing was not included in the scope of the original ethics application, and disclosure of identifiable clinical records could compromise patient confidentiality in accordance with applicable Turkish personal data protection legislation (KVKK No. 6698). Anonymized aggregate data may be made available upon reasonable request to the corresponding author, subject to a formal data sharing agreement and ethical review.

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Data Availability Statement The data that support the findings of this study consist of retrospectively collected patient records from Private İzmir Can Hospital, İzmir, Türkiye. Sharing of individual patient‐level data is not permitted under the institutional ethics approval granted by the Ethics Committee of Kâtip Çelebi University Atatürk Training and Research Hospital, İzmir, Türkiye (May 26, 2022; IRB No. 0251), as data sharing was not included in the scope of the original ethics application, and disclosure of identifiable clinical records could compromise patient confidentiality in accordance with applicable Turkish personal data protection legislation (KVKK No. 6698). Anonymized aggregate data may be made available upon reasonable request to the corresponding author, subject to a formal data sharing agreement and ethical review.