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What Lies Beneath: Adhesion and Injury Risk in Laparoscopy after Abdominopelvic Surgery
Samantha S Mooney1, Hannah Gordon2, Debjyoti Karmakar1
1Department of Obstetrics Gynaecology and Newborn Health, University of Melbourne (Drs. Mooney, Gordon, Karmakar, Hicks, Readman), Parkville, Victoria, Australia; Department of Gynaecology, Mercy Hospital for Women (Drs. Mooney, Karmakar, Wong, Harlow, McNamara, Readman, Ellett, MIG Group), Heidelberg, Victoria, Australia.
Objective:
Adhesions following prior abdominopelvic surgery increase visceral injury risk at laparoscopic entry, but contemporary risk estimates are limited. We aimed to (1) quantify umbilical adhesion risk by prior surgical number and type; (2) assess visceral injury risk during umbilical entry; and (3) develop predictive adhesion and injury risk models.
Design:
Pragmatic prospective cohort study conducted between January 2018 and December 2023.
Setting:
Australian tertiary gynecological teaching hospital with regional recruiting site.
Participants:
Consecutive patients undergoing elective gynecologic laparoscopy (n = 823): Cases with prior laparotomy/laparoscopy (n = 534) and controls with no prior abdominopelvic surgery (n = 289).
Interventions:
Observational; entry technique determined by surgeon.
Measurements:
Surgeons documented anterior abdominal wall adhesions, distance from the umbilicus, and omental/visceral involvement. Adhesions ≤2 cm from the umbilicus were classified as "high umbilical-risk." Logistic models evaluated associations with surgical history and entry approach; weighted regression and cross-validation supported model robustness.
Results:
Adhesions were significantly more common in patients with prior surgery (33.7% for ≤2 and 50.3% for ≥3) than in those without prior surgery (7.6%, p < .001). A similar gradient was observed for umbilical-risk adhesions, increasing from 0.7% with no prior surgery to 14.7% with ≤2 and 29.7% with ≥3 prior surgeries. Adhesion risk increased further with laparotomy burden, reaching 69.0% overall and 40.5% umbilical-risk after ≥3 laparotomies. Midline laparotomies carried the greatest burden, with overall adhesions in 60.0% after one and 100% after ≥2 procedures, and umbilical-risk adhesions in 36.0% and 60.0%, respectively. Low transverse incisions were associated with intermediate risk, increasing to 64.3% overall and 35.7% umbilical-risk after ≥3 procedures. Visceral injury was rare overall (0.49%) but increased in patients with higher laparotomy and midline exposure. The umbilical-risk model demonstrated good discrimination (area under the curve 0.807; sensitivity 71.8%; specificity 81.1%; negative predictive value 96.1%).
Conclusion:
Increasing number of prior abdominopelvic surgeries, particularly multiple and midline laparotomies, markedly elevates umbilical adhesion risk. History-based prediction models may support safer, individualized laparoscopic entry planning.
