The Role of Ovarian Suspension in Endometriosis Surgery: A Randomized Controlled Trial

Safety, Efficacy, and Cost-effectiveness of Organ Suspension in Laparoscopic Gynecologic Surgery: A Retrospective Cohort Study to Validate an Innovative Technique: Laparoscopic Organ Suspension sec. Angioni

OBJECTIVES

This study aims to evaluate the safety, efficacy, and cost-effectiveness of the Laparoscopic Organ Suspension (OS) sec. Angioni, an innovative approach to transient OS in laparoscopic gynecological procedures. Recognizing the need to enhance surgical site access and overcome limitations of existing organ retraction methods, the study investigates a novel, in-theater constructed OS device.

DESIGN

This retrospective observational study was conducted from March 2019 to May 2021 and included 330 patients who underwent multiport or single-site-port laparoscopic surgery employing Angioni's technique for transient pelvic OS.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants included individuals undergoing surgery for conditions such as endometriosis, ovarian cancer, endometrial cancer, pelvic prolapse, and benign ovarian cysts. The Laparoscopic OS sec. Angioni utilizes a segment of a Foley catheter connected to a Polyglactin suture to provide adjustable tension, minimizing the need for reconfiguration during surgery.

RESULTS

The application of this OS technique resulted in an average suspension time of 1.9 min, with no significant difference between senior and junior surgeons. The method proved more time-efficient for posterior peritoneum suspension than other published methods and showed no additional risks of organ damage, bleeding, conversion to laparotomy, or OS-related complications. The secondary outcomes revealed reduced hospital stays and minimal blood loss, highlighting the procedure's overall efficiency.

LIMITATIONS

Given its retrospective and single-center nature, the study's results may not be widely generalizable. Prospective multicentric comparative studies are recommended to further validate Angioni's technique.

CONCLUSIONS

Laparoscopic OS sec. Angioni is introduced as a straightforward, safe, and cost-effective method that significantly streamlines the surgical process. Its adaptability and ease of use suggest that it could be a valuable addition to current gynecological surgical practices, with potential implications for increasing efficiency and reducing procedural costs. Future studies are required to confirm these results across diverse clinical environments.

Ovariopexy-Before and after Endometriosis Surgery

Endometriosis surgery is often very challenging. Key to complete resection of endometriosis is access to the retroperitoneum. Endometriosis can involve the ureter and uterine vessels, and ovary on the lateral pelvic wall makes retroperitoneal access difficult. Primary and post-surgical adhesions prevalence in endometriosis is very high. Ovariopexy, transposition of ovaries temporarily, is done for better surgical access and to reduce postoperative adhesions. We concluded that although limited evidence, ovariopexy is an excellent tool to aid endometriosis surgery and prevent postoperative adhesions. It is cost effective, simple and complication rate almost nil. More robust trials are required to substantiate evidence for its impact on preventing postoperative adhesions and its effect on fertility. In this review, we describe our technique of ovariopexy supplemented with a video, with the aim to put light on this useful and important technique, which is beneficial both for surgeons and patients.

Role of Ovarian Suspension in Preventing Postsurgical Ovarian Adhesions in Patients with Stage III-IV Pelvic Endometriosis: A Systematic Review

Endometriosis is a benign complex gynecologic condition with high morbidity that affects women of reproductive age. Pelvic adhesion formation represents a serious clinical challenge in the management of patients with endometriosis. Several interventions aimed at reducing postoperative ovarian adhesion formation have been proposed in recent years. Here we summarize the published evidence on the efficacy of ovarian suspension in preventing postoperative ovarian adhesion formation in women undergoing laparoscopic surgery for stage III-IV endometriosis. The research was conducted using electronic databases. A review of the abstracts of all references retrieved from the search was conducted. Selection criteria for the systematic review included all randomized controlled trials (RCTs) and nonrandomized studies (NRSs) of premenopausal women diagnosed with stage III-IV pelvic endometriosis who underwent ovarian suspension or no ovarian suspension (control group). The RCTs were eligible for meta-analysis. Eight studies, 2 RCTs and 6 NRSs, were included in the systematic review. In all 8 studies, ovarian suspension was performed during surgery for stage III-IV endometriosis. The site of the suspension was the anterior abdominal wall in 76.8% of the cases. Five studies reported the use of polypropylene as suture for the suspension. Removal of the suspension suture in the postoperative period was reported in 6 studies. Pooled data from a meta-analysis of the RCTs show that women who underwent ovarian suspension had a significantly lower incidence of postoperative adhesion formation, particularly of moderate to severe adhesions. Ovarian suspension may reduce the rate and severity of postoperative adhesions formation in women undergoing laparoscopy for the treatment of stage III-IV endometriosis; however, RCTs with larger sample sizes are needed.

Role of the peritoneal cavity in the prevention of postoperative adhesions, pain, and fatigue

A surgical trauma results within minutes in exudation, platelets, and fibrin deposition. Within hours, the denuded area is covered by tissue repair cells/macrophages, starting a cascade of events. Epithelial repair starts on day 1 and is terminated by day 3. If repair is delayed by decreased fibrinolysis, local inflammation, or factors in peritoneal fluid, fibroblast growth starting on day 3 and angiogenesis starting on day 5 results in adhesion formation. For adhesion formation, quantitatively more important are factors released into the peritoneal fluid after retraction of the fragile mesothelial cells and acute inflammation of the entire peritoneal cavity. This is caused by mechanical trauma, hypoxia (e.g., CO₂ pneumoperitoneum), reactive oxygen species (ROS; e.g., open surgery), desiccation, or presence of blood, and this is more severe at higher temperatures. The inflammation at trauma sites is delayed by necrotic tissue, resorbable sutures, vascularization damage, and oxidative stress. Prevention of adhesion formation therefore consists of the prevention of acute inflammation in the peritoneal cavity by means of gentle tissue handling, the addition of more than 5% N₂O to the CO₂ pneumoperitoneum, cooling the abdomen to 30°C, prevention of desiccation, a short duration of surgery, and, at the end of surgery, meticulous hemostasis, thorough lavage, application of a barrier to injury sites, and administration of dexamethasone. With this combined therapy, nearly adhesion-free surgery can be performed today. Conditioning alone results in some 85% adhesion prevention, barriers alone in 40%-50%.

Cesarean wound scar characteristics for the prediction of pelvic adhesions: a meta-analysis of observational studies

OBJECTIVE

The pathophysiologic processes that result in wound healing are the same regardless of the tissue involved. The purpose of the present meta-analysis is to evaluate whether cesarean scar characteristics may predict the presence of pelvic adhesions.

MATERIALS AND METHODS

We conducted a systematic review searching the Medline (1966-2016), Scopus (2004-2016), ClinicalTrials.gov (2008-2016), Cochrane Central Register of Controlled Trials CENTRAL (1999-2016) and Google Scholar (2004-2016) databases together with reference lists from included studies. All prospective and retrospective observational cohort studies were included. Statistical meta-analysis was performed using the RevMan 5.1 software.

RESULTS

Current evidence suggests that depressed scars are positively associated with intra-abdominal adhesions (ΟR 2.79, 95%CI 1.74-4.46). Elevated scars might also correlate with the presence of adhesions, however, this association did not reach statistical significance (OR 1.61, 95%CI 0.91-2.85, p = 0.10). The same was reported in the case of scar pigmentation (REM, OR 1.68, 95%CI 0.86-3.26, p = 0.13). Flat scars were predictive of the absence of adhesions (899 patients, REM, OR 0.33, 95%CI 0.23-0.54, p < 0.00001).

CONCLUSION

According to our meta-analysis, abdominal wound characteristics following cesarean section can predict the presence of adhesions. However, given the small number of published studies, further research is needed to corroborate our findings.