Laparoscopy-assisted versus open surgery for reconstruction of abdominal wall defects following endometriosis resection: a retrospective cohort study

A retrospective cohort study was conducted on consecutive female patients who underwent radical resection for histologically confirmed AWE and subsequent abdominal wall reconstruction at our institution between July 2023 and June 2025. Patients were allocated to the Open Group or the Laparoscopy-assisted Group based on the surgical approach employed, which was determined by preoperative imaging classification (Type II or III AWE) and shared decision-making between the surgeon and patient, taking into account simultaneous treatment of abdominal/pelvic diseases (uterine fibroids, ovarian cyst, abdominal adhesion, etc.) and patient’s willingness. Inclusion criteria were: (1) Based on preoperative imaging (CT MRI or ultrasonography) the abdominal wall endometriotic lesions are classified as Type II or III as per the anatomical system in Wu et al. ( 2023 ) (Type I: invasion of skin/subcutaneous tissue; Type II: invasion of fascia/rectus abdominis; Type III: invasion of peritoneum) [ 18 ]; (2) Undergoing either open or laparoscopy-assisted surgical resection and reconstruction; (3) Placement of a synthetic mesh for abdominal wall defect repair. Exclusion criteria were: postoperative pathology confirming that the resected abdominal wall mass was non-endometriotic tissue. As the study was a retrospective cohort study, the informed consent for the use of the remaining medical specimens and data was signed before the operation, so the ethical review was exempted by the institutional review committee. All procedures were performed by a dedicated surgical team consisting of hernia and abdominal wall surgeons and gynecologists with expertise in both open and minimally invasive techniques, ensuring consistency and reliability in surgical quality across both groups. In the open surgery group, patients were placed in the supine position under general anesthesia. A midline or transverse incision was made over the palpable mass. The abdominal wall endometriosis was identified and visualized both intraoperatively and correlated with preoperative axial and sagittal CT images ( Fig.  1 A and B ) . Complete excision of the lesion was performed with a 1 cm circumferential margin ( Fig.  1 C ) . Following resection, the Retzius space was carefully separated to facilitate mesh placement (Fig.  1 D)[ 15 ]. A synthetic mesh was then positioned in the retrorectus plane to reinforce the abdominal wall (Fig.  1 E) [ 6 ]. Finally the abdominal wall was reconstructed using the component separation technique (CST)n [ 5 ], which involved bilateral release of the external oblique aponeurosis to allow medial advancement of the rectus muscles and tension-free closure (Fig.  1 F). Fig. 1 Surgical techniques for abdominal wall reconstruction following resection of endometriosis: laparoscopy-assisted versus open approach. ( A ) Axial CT image demonstrating an abdominal wall endometrioma in open surgery group. ( B ) Sagittal CT image of the same lesion in open surgery group. ( C ) Complete excision of the lesion with a 1 cm circumferential margin. ( D ) Separation of the Retzius space. ( E ) Placement of mesh in the retrorectus plane. ( F ) Abdominal wall reconstruction using the component separation technique (CST). ( G ) Axial CT image demonstrating an abdominal wall endometrioma in laparoscopy-assisted surgery group. ( H ) Sagittal CT image of the same lesion in laparoscopy-assisted surgery group. ( I ) Wide local excision of the lesion with a 1 cm margin. ( J ) Release of the bilateral anterior rectus sheaths using the CST. ( K ) Separation of the Retzius space. ( L ) Repair of the lower abdominal wall defect using the transabdominal partial extraperitoneal (TAPE) method Surgical techniques for abdominal wall reconstruction following resection of endometriosis: laparoscopy-assisted versus open approach. ( A ) Axial CT image demonstrating an abdominal wall endometrioma in open surgery group. ( B ) Sagittal CT image of the same lesion in open surgery group. ( C ) Complete excision of the lesion with a 1 cm circumferential margin. ( D ) Separation of the Retzius space. ( E ) Placement of mesh in the retrorectus plane. ( F ) Abdominal wall reconstruction using the component separation technique (CST). ( G ) Axial CT image demonstrating an abdominal wall endometrioma in laparoscopy-assisted surgery group. ( H ) Sagittal CT image of the same lesion in laparoscopy-assisted surgery group. ( I ) Wide local excision of the lesion with a 1 cm margin. ( J ) Release of the bilateral anterior rectus sheaths using the CST. ( K ) Separation of the Retzius space. ( L ) Repair of the lower abdominal wall defect using the transabdominal partial extraperitoneal (TAPE) method In the laparoscopy-assisted group, patients were similarly placed supine under general anesthesia. Initial laparoscopy ports were placed away from the suspected lesion site. The abdominal wall endometriosis was localized using intraoperative laparoscopy visualization and confirmed with preoperative CT imaging (Fig.  1 G and H). Wide local excision of the lesion was performed through a small abdominal incision with a 1 cm margin (Fig.  1 I). The bilateral anterior rectus sheaths were then released using the component separation technique (CST) under laparoscopy guidance to minimize tissue trauma (Fig.  1 J)[ 5 ]. Subsequently, the Retzius space was separated laparoscopyally to prepare for mesh placement (Fig.  1 K)[ 15 ]. The lower abdominal wall defect was repaired using the transabdominal partial extraperitoneal (TAPE) method [ 16 ], in which a synthetic mesh was introduced through a port, positioned in the preperitoneal space, and secured laparoscopyally (Fig.  1 L)[ 6 ]. Data were extracted from HIS Medical Management System of the Third Affiliated Hospital of Sun Yat-sen University. Primary outcomes included operative time intraoperative blood loss incision length drainage parameters postoperative pain scores (Visual Analog Scale VAS) and inflammatory markers (hypersensitive C-reactive protein neutrophil percentage white blood cell count etc.). Secondary outcomes included time to first flatus diet ambulation hospital stay and complication rates (surgical site infection hematoma seroma recurrence incisional hernia) during a 6-month follow-up. Complications were classified according to the Clavien-Dindo Classification (CDC) [ 4 ]. Data were analyzed using SPSS version 27.0. Continuous variables are presented as mean ± standard deviation and compared using the independent Student’s t-test or Mann-Whitney U test as appropriate. Categorical variables are expressed as frequencies (percentages) and compared using the Chi-square test or Fisher’s exact test. A two-tailed p-value < 0.05 was considered statistically significant.

A total of 32 patients were enrolled in this study, with 18 undergoing open abdominal wall reconstruction (Open group) and 14 receiving laparoscopy-assisted reconstruction (Laparoscopy-assisted group). The baseline demographic and clinical characteristics of the two groups are summarized in Table  1 . Both groups were well-matched in terms of age (Open group: 33.22 ± 5.76 vs. Laparoscopy-assisted group: 30.14 ± 6.53 years, P  = 0.175), body mass index (BMI) (19.59 ± 1.99 vs. 19.18 ± 1.69 kg/m², P  = 0.534), and history of cesarean Sect. (100% in both groups). All patients presented with periodic pain and a palpable abdominal mass, consistent with typical AWE symptomatology. No significant differences were observed in ASA grade ( P  = 0.898), AWE type ( P  = 0.721), lesion location ( P  = 0.798), number of masses ( P  = 0.492), preoperative imaging-measured lesion diameter (Open group: 5.42 ± 1.52 cm vs. Laparoscopy-assisted group: 5.09 ± 1.67, P  = 0.568), preoperative CA-125 levels ( P  = 0.438), prior treatments, or concurrent abdominal/pelvic diseases ( P  = 0.087). This demographic and clinical homogeneity between groups supports the validity of subsequent comparative analyses regarding surgical outcomes. Table 1 Baseline characteristics of the study cohort Variables Open Group ( n  = 18) Laparoscopy-assisted Group ( n  = 14) P -value Age (years) 33.22 ± 5.76 30.14 ± 6.53 0.175 BMI (kg/m²) 19.59 ± 1.99 19.18 ± 1.69 0.534 Previous cesarean 1.000  Yes 18 (100.0%) 14 (100.0%)  No 0 (0.0%) 0 (0.0%) ASA grade 0.898  I/II 17 (94.4%) 14 (100.0%)  III 1 (5.6%) 0 (0.0%) Type of AWE 0.721  I 0 (0.0%) 0 (0.0%)  II 7 (38.9%) 7 (50.0%)  III 11 (61.1%) 7 (50.0%) Preoperative imaging-measured lesion diameter (cm) 5.42 ± 1.52 5.09 ± 1.67 0.568 Preoperative symptoms  Periodic pain 18 (100.0%) 14 (100.0%) 1.000  Palpable mass 18 (100.0%) 14 (100.0%) 1.000  Skin ulceration 1 (5.6%) 0 (0.0%) 0.898  Dysmenorrhea 13 (72.2%) 10 (71.4%) 0.728 Location of AWE mass 0.798  Left lower abdomen 5 (27.8%) 3 (21.4%)  Median lower abdomen 10 (55.6%) 7 (50.0%)  Right lower abdomen 3 (16.7%) 4 (28.6%) Number of AWE mass 0.492  1 16 (88.9%) 14 (100.0%)  2 2 (11.1%) 0 (0.0%) CA-125 level 0.438  ≤ 35 U/mL 18 (100.0%) 13 (92.9%)  > 35 U/mL 0 (0.0%) 1 (7.1%) Previous treatment 0.872  Surgery 1 (5.6%) 0 (0.0%)  Pharmaceutical treatment 1 (5.6%) 2 (14.3%)  HIFU 1 (5.6%) 0 (0.0%)  None 15 (83.3%) 12 (85.7%) Simultaneous treatment of abdominal/pelvic diseases 0.087  Uterine fibroids 0 (0.0%) 2 (14.3%)  Ovarian cyst 0 (0.0%) 1 (7.1%)  Abdominal adhesion 1 (5.6%) 2 (14.3%)  None 17 (94.4%) 9 (64.3%) Baseline characteristics of the study cohort The intraoperative and early postoperative recovery outcomes were detailed in Table  2 . Specifically, operative time (Open group: 108.80 ± 54.02 vs. Laparoscopy-assisted group: 123.60 ± 45.87 min, P  = 0.411) and intraoperative blood loss (Open group: 13.33 ± 9.39 vs. Laparoscopy-assisted group: 11.29 ± 5.72 mL, P  = 0.453) did not differ significantly between the groups, suggesting comparable procedural complexity and hemostatic efficacy for both techniques. Table 2 Comparison of operative and postoperative recovery outcomes between the two groups Variables Open Group ( n  = 18) Laparoscopy-assisted Group ( n  = 14) P -value Total operative time (min) 108.80 ± 54.02 123.60 ± 45.87 0.411 Intraoperative blood loss (mL) 13.33 ± 9.39 11.29 ± 5.72 0.453 Length of surgical incision (cm) 10.17 ± 1.60 6.46 ± 0.89 < 0.001 Total hospital stay (days) 7.61 ± 2.40 5.86 ± 1.83 0.026 Number of drainage tube 2.56 ± 0.51 0.79 ± 0.43 < 0.001 Drainage tube indwelling time (days) 4.78 ± 2.60 2.79 ± 1.85 0.017 Postoperative specimen diameter (cm) 6.56 ± 1.37 6.64 ± 1.68 0.876 Time to first flatus (days) 2.44 ± 1.82 1.86 ± 1.46 0.320 Time to first diet (days) 1.33 ± 0.69 1.14 ± 0.95 0.533 Time to first ambulation (days) 2.28 ± 2.19 1.79 ± 1.37 0.443 hsCRP (mg/L)  Day 1 postoperatively 34.43 ± 58.42 29.23 ± 46.30 0.781  Day 3 postoperatively 25.58 ± 35.36 21.24 ± 27.43 0.699  Day 5 postoperatively 25.31 ± 41.67 17.13 ± 18.78 0.465 Absolute neutrophil count (*10⁹/L)  Day 1 postoperatively 4.51 ± 2.18 6.64 ± 1.75 0.005  Day 3 postoperatively 7.06 ± 2.40 6.54 ± 1.06 0.415  Day 5 postoperatively 5.82 ± 2.01 6.85 ± 0.90 0.063 WBC count (*10⁹/L)  Day 1 postoperatively 6.85 ± 2.10 6.54 ± 1.58 0.643  Day 3 postoperatively 9.07 ± 2.74 6.76 ± 1.03 0.003  Day 5 postoperatively 7.05 ± 1.93 6.22 ± 1.32 0.158 Pain score (points)  Day 1 postoperatively 4.28 ± 0.89 3.86 ± 0.95 0.213  Day 3 postoperatively 2.61 ± 0.78 1.71 ± 0.61 < 0.001  Day 5 postoperatively 1.72 ± 0.46 0.79 ± 0.43 < 0.001 Application of CST technique 0.818  Yes 16 (88.9%) 13 (92.9%)  No 2 (11.1%) 1 (7.1%) Complications  Major hemorrhage 0 (0.0%) 0 (0.0%) 1.000  Adjacent organ/tissue injury 0 (0.0%) 0 (0.0%) 1.000  Cardiovascular complications 0 (0.0%) 0 (0.0%) 1.000  Respiratory complications 0 (0.0%) 0 (0.0%) 1.000  Incision-related infection 0 (0.0%) 0 (0.0%) 1.000  Abdominal infection 0 (0.0%) 0 (0.0%) 1.000 Comparison of operative and postoperative recovery outcomes between the two groups Notably, the laparoscopy-assisted group demonstrated several tangible advantages pertaining to surgical invasiveness and recovery. The incision length was significantly shorter in this group (Laparoscopy-assisted group: 6.46 ± 0.89 cm vs. Open group: 10.17 ± 1.60 cm, P  < 0.001). Although the surgical procedures for lesion resection were largely similar between the two groups, open surgical repair of the abdominal wall defect required a larger incision for exposure of the operative area, dissection of the preperitoneal space, and placement of the mesh. This reduction in incision size and minor injury to the surgical area contributed to the observed decrease in both the number of drainage tubes placed (Laparoscopy-assisted group: 0.79 ± 0.43 vs. Open group: 2.56 ± 0.51, P  < 0.001), the duration of drainage (Laparoscopy-assisted group: 2.79 ± 1.85 days vs. Open group: 4.78 ± 2.60 days, P  = 0.017), and shorter total hospital stay (Laparoscopy-assisted group: 5.86 ± 1.83 vs. Open group: 7.61 ± 2.40 days, P  = 0.026). These findings may be attributed to reduced tissue dissection and potentially less seroma formation associated with the laparoscopic-assisted approach. Postoperative pain, assessed using the Visual Analog Scale (VAS), was significantly lower in the laparoscopy-assisted group on both postoperative day 3 (1.71 ± 0.61 vs. 2.61 ± 0.78, P  < 0.001) and day 5 (0.79 ± 0.43 vs. 1.72 ± 0.46, P  < 0.001). This aligns with established evidence that minimally invasive techniques reduce soft tissue trauma and consequently postoperative pain. Inflammatory markers, including hypersensitive C-reactive protein (hsCRP), neutrophil count, and white blood cell (WBC) count, generally followed similar trends. However, some intergroup variations were noted, such as a higher absolute neutrophil count in the laparoscopy-assisted group on postoperative day 1 (6.64 ± 1.75 vs. 4.51 ± 2.18 *10⁹/L, P  = 0.005). These differences may reflect nuanced variations in the immune response or tissue handling between the two surgical modalities. Times to first flatus (Open group: 2.44 ± 1.82 days vs. Laparoscopy-assisted group: 1.86 ± 1.46 days, P  = 0.320), first diet resumption (Open group: 1.33 ± 0.69 days vs. Laparoscopy-assisted group: 1.14 ± 0.95 days, P  = 0.533), and first ambulation (Open group: 2.28 ± 2.19 days vs. Laparoscopy-assisted group: 1.79 ± 1.37 days, p  = 0.443) did not differ significantly, indicating comparable early gastrointestinal and functional recovery in laparoscopy-assisted group. The component separation technique (CST) was utilized in the vast majority of cases in both groups (Open group: 88.9% vs. Laparoscopy-assisted group: 92.9%, P  = 0.818), underscoring its central role in achieving tension-free closure irrespective of the surgical access method. The laparoscopy-assisted approach demonstrated clear benefits in reducing surgical trauma, postoperative pain, and drainage dependency—advantages intrinsically linked to its minimally invasive nature. While it exhibited a non-significant trend toward longer operative times, its superior performance in key recovery metrics supports its role as a viable alternative to open surgery in appropriately selected patients. The postoperative complications and the outcomes of 6-month follow-up after discharge were shown in Table  3 . According to the Clavien-Dindo Classification all observed complications were Grade I (incisional numbness and transient pain). No Grade II or higher complications occurred [ 4 ]. Reassuringly, no major intraoperative complications—such as significant hemorrhage, adjacent organ injury, or cardiopulmonary events—occurred in either group. Minor complications, including incisional numbness (Open group: 11.1% vs. Laparoscopy-assisted group: 7.1%, P  = 0.818) and chronic pain persisting beyond 3 months (Open group: 5.6% vs. Laparoscopy-assisted group: 0%, P  = 0.898), were infrequent and statistically comparable between the groups. Table 3 Postoperative complications and follow-up outcomes between the two groups Variables Open Group ( n  = 18) laparoscopy-assisted Group ( n  = 14) P -value Incisional numbness 2 (11.1%) 1 (7.1%) 0.818 Chronic pain (> 3 months) 1 (5.6%) 0 (0.0%) 0.898 AWE recurrence 0 (0.0%) 0 (0.0%) 1.000 Incisional hernia 0 (0.0%) 0 (0.0%) 1.000 Postoperative pharmaceutical adjuvant therapy 0.898  Yes 17 (94.4%) 14 (100.0%)  No 1 (5.6%) 0 (0.0%) Postoperative complications and follow-up outcomes between the two groups Most importantly, no cases of AWE recurrence or incisional hernia were observed in either group at the 6-month follow-up. This indicates that both techniques, when performed with radical intent and appropriate mesh reinforcement, provide effective short-term disease control and durable restoration of abdominal wall integrity. Adjuvant pharmacotherapy was administered to nearly all patients (Open group: 94.4% vs. Laparoscopy-assisted group: 100%, P  = 0.898), reflecting a standardized, multidisciplinary approach aimed at suppressing residual microscopic disease and preventing symptom recurrence. The absence of significant differences in complication rates, recurrence, or hernia formation between the two groups underscores their comparable short-term safety and efficacy profiles. The laparoscopy-assisted technique did not compromise oncological completeness or structural durability, providing crucial evidence for its clinical adoption as a minimally invasive option that maintains therapeutic standards.

This comparative study demonstrates that laparoscopy-assisted abdominal wall reconstruction following radical resection of abdominal wall endometriosis (AWE) is both feasible and safe, offering distinct advantages in postoperative recovery compared to the conventional open approach. While achieving comparable radical resection margins and operative safety profiles, the laparoscopy-assisted technique resulted in significantly reduced incision length, decreased dependency on surgical drains, shorter drainage duration, and markedly lower postoperative pain scores during the early recovery period. The benefits of the laparoscopy-assisted approach can be summarized as follows. First it aligns with the principles of Enhanced Recovery After Surgery (ERAS) [ 13 , 14 , 17 ], facilitating expedited recovery through minimized tissue trauma, reduced postoperative pain, and earlier mobilization. Second, the laparoscopic view provides magnified and clear visualization of anatomical planes, allowing precise dissection and complete development of the Retzius space, which is crucial for accurate mesh placement and fixation. Third, this approach offers comprehensive surgical management, enabling concurrent diagnosis and treatment of concomitant pelvic pathologies—such as uterine fibroids or ovarian cysts—as well as lysis of abdominal adhesions during the same procedure. Fourth, the minimally invasive nature translates to smaller incisions, reduced tissue dissection, and potentially less postoperative seroma formation, thereby diminishing the need for prolonged drainage. Nevertheless it is important to acknowledge the limitations associated with the laparoscopy-assisted technique. It demands a higher level of surgical skill and carries a steeper learning curve [ 2 ]. Although not statistically significant in this cohort, the trend toward longer operative times may reflect increased technical complexity, which could prolong anesthesia duration and pose additional perioperative risks, particularly during the initial phase of adoption. Furthermore, the higher proportion of concurrent procedures (e.g., uterine fibroid resection, ovarian cystectomy) in the laparoscopy-assisted group may have contributed to longer operative time and recovery parameters, potentially underestimating the true benefits of the minimally invasive approach. Future studies should control for this variable. Conversely, open surgery remains a valuable and reliable option, with its own set of advantages. It offers direct visualization and tactile feedback, which can simplify dissection and mesh placement, especially in cases with large or complex defects. The technique is generally more straightforward to master, often resulting in shorter operative times. In our study, open surgery demonstrated comparable outcomes in terms of return of bowel function, ambulation, and overall complication rates, underscoring its continued relevance as an effective and safe alternative, particularly in settings with limited laparoscopic expertise or resources. This study has several limitations including its retrospective design modest sample size (inherent to the rarity of AWE) and relatively short follow-up period. As a preliminary study our finding s should be interpreted with caution and larger multicenter studies are needed to validate the results. Potential selection bias cannot be ruled out despite balanced baseline characteristics [ 10 , 12 ]. Additionally, the lack of blinding in outcome assessment may introduce detection bias. Long-term outcomes such as hernia recurrence, chronic pain, and patient-reported satisfaction warrant further investigation through prospective, larger-scale studies. The laparoscopy-assisted technique demonstrates significant minimally invasive advantages in this procedure, markedly reducing incision length, decreasing the use of drainage tubes, shortening drainage duration, shortening hospital stay, alleviating early postoperative pain. Additionally, when necessary, abdominal or pelvic diseases can be treated simultaneously. While remaining comparable to the conventional open technique in key metrics such as operative time, intraoperative blood loss, length of hospital stay, and complication rates. Long-term follow-up reveals no differences between the two groups in terms of incisional numbness, chronic pain, or disease recurrence rates. In summary, the laparoscopy-assisted technique is a safe and effective minimally invasive option that promotes postoperative recovery while ensuring surgical safety and AWE radical treatment.

Abdominal wall endometriosis (AWE) is an uncommon but clinically significant condition often occurring in women with a history of cesarean section presenting as a painful cyclical abdominal mass [ 1 , 3 , 8 ]. Radical full-thickness resection remains the cornerstone of treatment, which inevitably creates substantial abdominal wall defects. Reconstructive surgery is essential to restore abdominal integrity and prevent hernia formation. Currently open surgery is widely regarded as the standard approach for AWE resection and reconstruction offering direct visualization reliable mesh placement and applicability to large or complex defects. However it is associated with considerable surgical trauma longer incisions increased postoperative pain and slower recovery [ 7 , 9 ]. In recent years minimally invasive techniques have gained traction in abdominal wall surgery [ 19 , 20 ]. Totally laparoscopic excision and reconstruction for AWE have been described and demonstrate the potential of endoscopic techniques in this field [ 11 ]. However, laparoscopy-assisted combined techniques—which integrate laparoscopic guidance and component separation with a limited open incision for lesion excision and mesh handling—are less commonly reported, and their specific perioperative profile compared to conventional open surgery remains poorly characterized. Comparative data on these two approaches specifically for AWE-related reconstructions are limited. Most existing studies focus on hernia repair or general abdominal wall surgery, with few addressing the unique challenges posed by endometriotic lesions, such as cyclical pain, inflammatory adhesion, and the need for radical excision. Furthermore, the relative safety, efficacy, and recovery benefits of the laparoscopy-assisted combined approach versus the standard open technique have not been well elucidated. This study retrospectively evaluates the perioperative outcomes and short-term efficacy of laparoscopy-assisted versus open abdominal wall reconstruction following radical AWE resection, aiming to provide evidence to guide surgical strategy selection in this specific patient population.