Intra-Abdominal Adhesions and Endometriosis: Insights From a Prospective Cohort Study

INTRODUCTION: Endometriosis is a chronic inflammatory condition. Both endometriosis and its surgical treatment contribute to surgically challenging intra-abdominal adhesions. OBJECTIVE: To identify risk factors for intra-abdominal adhesions in the setting of endometriosis for patient counseling and surgical planning. METHODS: This is a multisite observational prospective cohort study including two tertiary referral practices for endometriosis. Benign gynecologic laparoscopy cases in adult patients were collected from 2019 until 2021. Patient characteristics, including surgical history and characteristics of intra-abdominal adhesions such as location, type of adhesions (filmy, dense, cohesive/attached surfaces), entry technique, and operative complications, were recorded. Patients with a history of endometriosis surgery or undergoing surgery for endometriosis at the time of collection were compared to patients with other surgical indications. Comparisons between groups were made using chi-square analysis. Multivariable logistic regression analysis was conducted, controlling for type and location of prior surgery. RESULTS: A total of 1,071 patients underwent gynecologic laparoscopy, 374 (34.9%) with endometriosis. Compared to other gynecologic patients, patients with endometriosis had more prior surgeries (67.6% vs. 54.8%, p<0.001), including prior laparotomy. Of those with endometriosis, 47.3% had undergone a prior surgery for endometriosis, and 1.6% had undergone more than five. More patients with endometriosis had adhesions at the time of laparoscopy (68.5% vs. 46.1%, aOR 2.12, p<0.001), controlling for history of prior laparoscopy, laparotomy, or any inflammatory event. In patients with no surgical history, 62.4% of patients with endometriosis had adhesions, including 37.1% with dense adhesions and 24.4% with cohesive/attached surfaces. Patients with endometriosis were more likely to have cohesive/attached surfaces (30.1% vs 19.9%, p<0.001) primarily located in the lower abdomen. More patients with endometriosis had any adhesions to bowel (45.1% vs. 35.8%, p=0.001), especially to large bowel. Only 5.4% of patients with endometriosis had adhesions at the umbilicus. The presence of adhesions in patients with endometriosis did not change the planned course of the procedure, or contribute to difficulty with entry more often than in other gynecologic laparoscopy, although these outcomes were rare. Intraoperative complications were uncommon in both groups (7.5% vs. 5.3%, p=0.15). Risk factors for dense or cohesive/attached adhesions included endometriosis and a history of lysis of adhesions (p<0.001). Risk factors for lysis of adhesions included endometriosis, ovarian cystectomy or adnexal surgery for endometriosis, and prior laparotomy for endometriosis (p<0.05). Risk of adhesions after excision of endometriosis was less than after fulguration of endometriosis (65.2% vs. 88.9%, p=0.26) (Figure 1). CONCLUSIONS: The majority of patients with endometriosis have intra-abdominal adhesions at laparoscopy, especially those with prior fulguration of endometriosis, ovarian cystectomy, or laparotomy for endometriosis. Adhesions did not impact the planned procedure, difficulty with entry, or intraoperative complications at tertiary referral practices (Tables 1 and 2).