Video-Based Assessment of Operative Complexity in Endometriosis: Associations of AAGL 2021, #Enzian, and rASRM Classifications with Operative Time and Advanced Surgical Procedures

Aslan K, Kiper Aslan, Işıl Kasapoğlu, Isil Kasapoglu, Kasapoglu I, Bahadır Kosan, Bahadir Kosan, Kosan B, Uncu G, Gürkan Uncu
Journal of Minimally Invasive Gynecology · 2026 · doi:10.1016/j.jmig.2026.08.001 · PMID:42567476 · W7201889422
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The AAGL 2021 classification strongly correlated with operative time and predicted advanced surgical procedures in laparoscopic endometriosis cases, with #Enzian providing complementary anatomical detail.

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Abstract

STUDY OBJECTIVE: To evaluate how the AAGL 2021, #Enzian, and revised American Society for Reproductive Medicine (rASRM) classifications reflect operative time, advanced surgical procedures, and blood-loss-related perioperative outcomes in a video-reassessed cohort of laparoscopic endometriosis surgeries. DESIGN: Retrospective cohort study using systematic postoperative operative-video review. SETTING: Tertiary referral center for minimally invasive endometriosis surgery. PARTICIPANTS: Women undergoing laparoscopic surgery for endometriosis between January 2023 and May 2026. A total of 86 cases with complete operative time data constituted the primary analytic cohort. INTERVENTIONS: Operative videos were independently reassessed using the AAGL 2021, #Enzian, and rASRM classifications. Advanced surgical procedures were defined as ureterolysis, rectal shaving, discoid bowel resection, segmental bowel resection, or vaginal excision. Blood-loss-related perioperative outcomes included hemoglobin drop and blood transfusion. MEASUREMENTS AND MAIN RESULTS: Median age was 39.0 years (IQR, 34.2-41.0), and median operative time was 115.0 minutes (IQR, 77.2-160.0). The AAGL 2021 total score showed the strongest correlation with operative time (Spearman ρ = 0.619; p <.001), followed by the rASRM total score (ρ = 0.572; p <.001). Among #Enzian compartments, C, FU, B, and A were significantly associated with operative duration. In multivariable linear regression, the AAGL 2021 total score remained independently associated with operative time after adjustment for age and hemoglobin drop (β=1.44 minutes per point; 95% CI, 0.97-1.92; p <.001). Each 10-point increase in AAGL score was associated with increased odds of undergoing any advanced surgical procedure (adjusted OR, 2.54; 95% CI, 1.69-3.81; p <.001). For postoperative discrimination of any advanced procedure, the AUC was 0.875 (95% CI, 0.799-0.939) for AAGL 2021 and 0.803 (95% CI, 0.708-0.887) for rASRM (DeLong p = .022). For bowel procedures, the corresponding AUCs were 0.877 and 0.843, respectively; for ureterolysis, 0.837 and 0.792. Interobserver agreement was excellent for both AAGL 2021 and rASRM total scores (ICC=0.998 for each). For #Enzian, compartment-level agreement was substantial to almost perfect, with weighted kappa values ranging from 0.662 to 1.000. CONCLUSION: In this video-reassessed cohort of complex laparoscopic endometriosis surgery, the AAGL 2021 total score showed the strongest association with observed operative complexity and the highest postoperative discrimination for advanced surgical procedures, whereas #Enzian provided complementary anatomic characterization of disease extent. These findings support the complementary use of AAGL 2021 for standardized assessment of surgical complexity and #Enzian for detailed anatomic mapping, while rASRM remains useful as a widely recognized global staging system.

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