Laparoscopic Surgery For Endometriosis Research Articles

Endometriosis of the appendix: prevalence, associated lesions, and proposal of pathogenetic hypotheses. A retrospective cohort study with prospectively collected data.

To assess the prevalence of endometriosis of the appendix and the association with other pelvic localizations of the disease and to provide pathogenesis hypotheses. Monocentric, observational, retrospective, cohort study. Patients undergoing laparoscopic endometriosis surgery in our tertiary referral center were consecutively enrolled. The prevalence of the different localizations of pelvic endometriosis including appendix involvement detected during surgery was collected. Included patients were divided into two groups based on the presence of appendiceal endometriosis. Women with a history of appendectomy were excluded. Four hundred-sixty patients were included for data analysis. The prevalence of appendiceal endometriosis was 2.8%. In patients affected by endometriosis of the appendix, concomitant ovarian and/or bladder endometriosis were more frequently encountered, with prevalence of 53.9% (vs 21.0% in non-appendiceal endometriosis group, p = 0.005) and 38.4% (vs 11.4%, p = 0.003), respectively. Isolated ovarian endometriosis was significantly associated to appendiceal disease compared to isolated uterosacral ligament (USL) endometriosis or USL and ovarian endometriosis combined (46.2% vs 15.4% vs 7.7%, p < 0.001). Poisson regression analysis revealed a 4.1-fold and 4.4-fold higher risk of ovarian and bladder endometriosis, respectively, and a 0.1-fold risk of concomitant USL endometriosis in patients with appendiceal involvement. Involvement of the appendix is not uncommon among patients undergoing endometriosis surgery. Significant association was detected between appendiceal, ovarian, and bladder endometriosis that may be explained by disease dissemination coming from endometrioma fluid shedding. Given the prevalence of appendiceal involvement, counseling regarding the potential need for appendectomy during endometriosis surgery should be considered.

Comparison of ovarian preservation versus oophorectomy on fertility outcomes in patients with endometriosis post-laparoscopic surgery: A prospective study.

Endometriosis is a chronic inflammatory condition affecting a significant proportion of women of reproductive age. Although laparoscopic surgery is commonly the preferred treatment, the decision to preserve or remove the ovaries remains controversial. Previous studies have yielded inconsistent results regarding the impact of ovarian preservation vs oophorectomy on fertility outcomes and disease recurrence. This prospective study aimed to address this knowledge gap by comparing the effects of these surgical approaches on spontaneous pregnancy rates, time to pregnancy, recurrence rates, and postoperative pain in patients with endometriosis. To compare the reproductive outcomes and recurrence rates between ovarian preservation and oophorectomy in women undergoing laparoscopic surgery for endometriosis. This study was conducted at a tertiary care hospital between January 2019 and December 2023. A total of 312 women aged 18 to 40 years, diagnosed with endometriosis and undergoing laparoscopic surgery, were included. The patients were categorized into the ovarian preservation group (n = 204) and the oophorectomy group (n = 108). The primary outcome measure was the achievement of spontaneous pregnancy within 24 months post-surgery. Secondary outcomes included time to spontaneous pregnancy, recurrence rates, and postoperative pain scores. The ovarian preservation group exhibited a significantly higher spontaneous pregnancy rate than that in the oophorectomy group (43.6% vs 28.7%, P = 0.006). Moreover, the median time to spontaneous pregnancy was shorter in the ovarian preservation group (8.2 months vs 11.4 months, P = 0.018). Nonetheless, endometriosis recurrence was more prevalent in the ovarian preservation group (22.1% vs 11.1%, P = 0.014). The postoperative pain scores demonstrated similar improvements in both groups, with no significant differences observed. Subgroup analyses indicated that the benefit of ovarian preservation on spontaneous pregnancy rates was more evident among younger women (≤ 35 years) and those with advanced-stage endometriosis. Ovarian preservation is associated with a high spontaneous pregnancy rate and a short time to pregnancy. However, because of the increased risk of recurrence, the decision should be based on age, fertility aspirations, and disease severity.

O-267 Extracellular vesicles as biomarkers of endometriosis

Abstract Study question Can extracellular vesicles serve as biomarkers of endometriosis, particularly for stages I and II, which are difficult to detect by ultrasound? Summary answer Our findings suggest the feasibility of defining a protein signature of endometriosis based on EV cargoes. What is known already Endometriosis is characterised by intraperitoneal lesions of endometrial tissue. Although ultrasound detection of severe endometriosis is possible, the diagnosis of peritoneal lesions currently relies on invasive laparoscopy, which leads to a delay of 8-10 years. We have previously shown that peritoneal fluid (PF) of women with endometriosis contains endometriosis specific EVs. Traced in peripheral blood (PB), EVs could serve as biomarkers of endometriosis, particularly for stages I and II, which are difficult to detect by ultrasound. Study design, size, duration Women 18-45 years of age undergoing laparoscopic surgery for endometriosis or unrelated conditions were invited to participate in our study (HREC 20-159A/HREC 20-882A). Following informed consent, we collected PF and PB samples from n = 101 participants (n = 47 controls, n = 54 cases). Exclusion criteria were pregnancy, malignancy, and menopause. Participants/materials, setting, methods We processed PF and PB samples by differential ultracentrifugation and validated the presence of EVs by nanoparticle tracking analysis (NTA), Western blotting and transmission electron microscopy (TEM). EVs were analysed by untargeted, label-based quantitative proteomics using Tandem Mass Tags (TMT). Data analysis was performed using Proteome Discoverer v2.4 (Thermo Fisher) followed by statistical analysis using R. Candidate biomarker proteins were tested by traditional and automated Western blotting (WES, ProteinSimple). Main results and the role of chance We ascertained the identity of EVs by TEM and NTA (mode size 121.8 ± 18.0 nm (blood, n = 5) and 155.9 ± 37.2 (PF, n = 6)), and signals for syntenin and ALIX in immunoblots as well as expression of CD9, CD63 and CD81 in capture bead-flow cytometry. Proteomic analysis identified 9145 protein groups across all sample groups, with 602 significantly regulated between comparisons (adjusted P-value &amp;lt;0.05). In PF, 533 proteins changed significantly in abundance (245 up/288 down), while in blood, only four proteins changed in abundance. We tested the presence/absence of two of these as candidate markers on PB EV protein preparations from n = 32 samples to date; our best marker showed a sensitivity of 67% and a specificity of 90%; upon exclusion of severe endometriosis cases, sensitivity improved to 80%. Limitations, reasons for caution Because of the changes in vesicle composition and amounts with the menstrual cycle, we have to group the samples by menstrual cycle phase and disease severity. This leaves relatively small numbers per group per condition. Another limitation concerns the relatively small amount of sample liquid and thus, EVs available for analysis. Wider implications of the findings Our findings suggest the feasibility of defining a protein signature of endometriosis based on EV cargoes. A non-invasive clinical test would allow for earlier diagnosis and thus treatment of endometriosis. It would also allow patients to initiate fertility treatment early. Trial registration number not applicable

Transvaginal Sonography for the Preoperative Assessment of Parametrial Deep Infiltrating Endometriosis: A Diagnostic Accuracy Study

Objective: The aim of the study was to evaluate the diagnostic accuracy for parametria endometriosis (PE) of transvaginal sonography (TVS) performed following a systematic approach for the assessment of the lateral parametria. Design: A diagnostic accuracy study was employed based on a prospective observational design. Participants: All consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020 were considered. Setting: The study was conducted at endometriosis referral hospitals. Methods: We prospectively collected clinical, imaging, and surgical data of all consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020. A standardized technique with a systematic approach for the assessment of the lateral parametria following specific anatomic landmarks was used for the TVS. The diagnostic accuracy for PE in TVS was assessed using the intraoperative and pathologic diagnosis of PE as the gold standard. Results: In 476 patients who underwent surgery, PE was identified in 114 out of 476 patients (23.95%): 91 left and 54 right PE out of 476 surgical procedures were identified (19.12% vs. 11.34%; p = 0.001); bilateral involvement in 27.19% (31/114 patients) cases. The sensitivity of TVS for PE was 90.74% (79.70–96.92%, 95% CI) for the right side and 87.91% (79.40–93.81%, 95% CI) for the left side. The specificity was almost identical for both sides (98.58% vs. 98.18%). For the right parametrium, the positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 63.82 (28.70–141.90, 95% CI) and 0.09 (0.04–0.22, 95% CI), respectively. On the left parametrium, the PLR and NLR were 48.35 (23.12–101.4, 95% CI) and 0.12 (0.07–0.21, 95% CI), respectively. The diagnostic accuracy for right and left PE was 97.69% (95.90–98.84%, 95% CI) and 96.22% (94.04–97.74%, 95% CI), respectively. Limitations: The principal limit is the high dependence of TVS on the operator experience. Therefore, although a standardized approach following precise definitions of anatomical landmarks was used, we cannot conclude that the observed accuracy of TVS for PE is the same for all sonographers. In this regard, the learning curve was not assessed. In the case of negative TVS for parametrial involvement with an absent intraoperative suspect, a complete dissection of the parametrium was not performed to avoid surgical complications; therefore, cases of minor PE may be missed, underestimating false negatives. Conclusions: TVS performed following a systematic approach for assessing the lateral parametria seems to have good diagnostic accuracy for PE with large changes in the posttest probability of parametrial involvement based on the TVS evaluation. Considering the clinical and surgical implications of PE, further studies implementing a standardized approach for assessing the parametrium by TVS are recommended to confirm our observations and implement a standardized protocol in clinical practice.

Association between pathological positivity rate of endometriosis, demographics, and concomitant gynecological conditions.

To date, there remains a paucity of present-day literature on the topic of demographics and the biopsy-proven pathological positivity rate of endometriosis. The goal of this study was to explore the association between patients' demographics and other concomitant gynecological conditions or procedures and the pathological positivity rate of excision of endometriosis. Retrospective cohort study. All women >18 years old who underwent laparoscopic surgery for endometriosis at a tertiary care hospital from October 2011 to October 2020. Women were classified into two groups: (1) Study group: women with >80% pathological positivity rate of endometriosis and (2) Control group: women with <80% pathological positivity rate. A total of 401 women were included in the analysis. No difference was noted in the 80% pathological positivity rate based on body mass index [BMI; 68.7% in normal BMI versus 80% in underweight, versus 74.5% in overweight, and 74.1% in obese patients (p = 0.72)]. The percentage of patients reaching 80% pathological positivity of endometriosis was lower in women who had undergone previous laparoscopy for endometriosis compared to surgery naïve women (66.5% versus 76.5%, p = 0.03). In addition, a higher percentage of women who underwent concomitant hysterectomy (83.5% versus 68.8% for non-hysterectomy, p = 0.005) or bilateral oophorectomy (92.7% versus 70.0% for non-oophorectomy, p = 0.002) reached 80% pathological positivity. Women with an associated diagnosis of fibroids (79.7% versus 70.5%) or adenomyosis (76.4% versus 71.7%) were more likely to reach 80% pathological positivity compared to women without any other coexisting pathology; however, the observed differences were not statistically significant. After applying a log-binomial regression model, compared to White non-Hispanics, Hispanic patients were 30% less likely to reach 80% positivity (RR: 0.70, 95% CI: 0.49-1.02), although not statistically significant. No significant racial difference was found when comparing the rates of 80% pathological positivity of suspected endometriosis lesions among groups. Endometriosis pathological positivity rate was unaffected by patients' BMI and the presence of concomitant pathologies. In addition, prior laparoscopic surgery for endometriosis might cause tissue changes that result in a decrease in the observed pathological positivity rate of endometriosis lesions during subsequent surgeries.

Assessing the role of robotic surgery versus laparoscopic surgery in patients with a diagnosis of endometriosis: A meta-analysis.

Surgical management of endometriosis can be carried out with the traditional standard laparoscopic technique or the robotic surgery technique; however, it is not clear if there is a significant difference between techniques. This meta-analysis aims to evaluate and compare the impact of robotic and standard laparoscopic techniques in endometriosis regarding the clinical outcome. Studies comparing robotic surgery to laparoscopic surgery for endometriosis were among the studies from various languages that met the inclusion criteria. Using dichotomous and continuous random-effect models, the results of these investigations (surgery time, hospitalization time, blood loss, complications, and conversion rate) were examined, and the mean difference with 95% confidence intervals was computed. Eight studies from 2013 to 2022 were selected for the current analysis including 1741 patients with endometriosis. The studied data revealed a statistically significant (P = .01) lower operation time related to laparoscopic surgery compared with the robotic technique. In addition, the hospitalization time of laparoscopic surgery is significantly (P = .03) lower than that of robotic surgery. On the other hand, blood loss, rehospitalization, postoperative and intraoperative complications, and conversion rates were not significantly different between both techniques. Heterogeneity values were variable according to the analysis factor, from 0% to 91%. Both robotic and standard laparoscopic techniques have similar outcomes regarding blood loss, rehospitalization, conversion rate, and rate of complication. However, the substantial difference between techniques was in favor of standard laparoscopic surgery regarding operation and hospitalization time.

A Prospective Study of Bladder Function Following Endometriosis Surgery With Up to Eight Years Follow-Up

Study ObjectiveTo assess long-term urinary function for women having laparoscopic surgery for endometriosis. DesignInstitutional Review Board-approved nested cohort study within a larger randomized controlled trial (RCT) assessing urinary function following any benign laparoscopy for gynecological presentations SettingTwo tertiary level university-affiliated hospitals PatientsWomen with histologically confirmed endometriosis within the RCT between April 2012 and November 2019 where baseline urinary function was determined InterventionsWomen with histologically confirmed endometriosis were contacted between February and October 2020 and urinary function was re-assessed MeasurementsUrinary function was assessed using validated questionnaires across the domains of filling, voiding, incontinence and quality of life determined distant from surgery. Higher scores correlated with a greater severity of symptoms Main ResultsFrom 518/711 (72.9%) women with histologically confirmed endometriosis, 289/518 (55.8%) consented to the nested study. At a mean of 50 months (range 12-103 months) post-operatively, 35 participants (12.1%) had sought treatment for bladder symptoms and 81 participants (28.0%) reported at least one urinary tract infection (UTI) since their index surgery. There was a significant worsening of symptoms for filling, voiding, incontinence and quality of life pre-operative to post-operatively (2.27 vs 3.32, 0.93 vs 2.02, 1.06 vs 2.32, 0.83 vs 2.13 respectively, p<.001). There was no statistically significant difference in urinary questionnaire scores in participants with and without uterovesical endometriosis. There was no statistically significant difference in any parameter when comparing any rASM stage of endometriosis. Participants who had post-operative urinary retention reported a higher mean voiding score than those who did not (3.24 vs 1.94, p=.017), while participants with post-operative UTI reported a higher mean frequency score than those who did not (5.17 vs 3.24, p=.016). ConclusionThis study suggests a decline in urinary function over time following laparoscopic surgery for endometriosis, that is not dependent on severity or location of disease.

Postoperative Peritoneal Granulomatous Inflammation After the Application of Potato Starch-Based Anti-Adhesive Agent in Laparoscopic Endometriosis Surgery.

Endometriosis is a chronic inflammatory oestrogen-dependent disease. It is characterised by elevated inflammatory markers in the peritoneal milieu with subsequent adhesiogenesis. Nowadays, excisional, and ablative surgeries are considered the main treatment of endometriosis, and adhesiolysis is being performed almost routinely during these procedures. Postoperative adhesion formation is a significant concern for many surgeons, especially as endometriosis patients are assumed to be predisposed to adhesiogenesis. In order to minimise adhesiogenesis after endometriosis surgery, the usage of different barrier methods have been discussed in the literature. Recent studies aim to investigate the effect of potato starch preparations on adhesion formation in endometriosis patients. We aim to describe the findings of a second-look laparoscopy on patients who received a starch-based anti-adhesive agent. We present a retrospective case series that included the medical, surgical, and histopathologic data of three patients. Intraperitoneal adhesion formation and peritoneal inflammation. All three patients had de-novo adhesions during the second-look laparoscopy. Pathological examination revealed noncaseating granulomatosis of the peritoneum in all patients. The use of potato starch-based agents as a peritoneal adhesion prophylaxis in laparoscopic endometriosis surgery could lead to granulomatous peritoneal inflammation. Correct application by avoiding powder remnants through complete rinsing and transformation to gel seems to be an important factor to avoid this adverse effect. We aim to highlight that potato starch-based anti-adhesive agents similar to the one used in this study could be a cause of adhesiogenesis and peritoneal inflammation.

Rare case of of Enlargment dextro Inguinal Endometriosis TissueLump : Case Report and Literature review

Background : Endometriosis is usually found in intrapelvic structures such as the ovaries, peritoneum, gynecological organs and the pouch of Douglas. We report an unusual case of endometriosis in the right inguinal region. Cases : A 36-year-old woman with a history of laparoscopic surgery for endometriosis 4 years ago complained of catamenial pain and a mass in the right inguinal region, and her symptoms fluctuated with the menstrual cycle. An indistinct firm mass palpable in the right inguinal region. Ultrasound examination revealed a 2 × 1 cm mass in front of the pubic area on the lower edge of the rectus abdominis muscle. In a patient with an inguinal subcutaneous mass who complains of periodic changes in symptoms, endometriosis should be considered in the differential diagnosis. Conclusion : The low incidence of inguinal endometriosis is one of the considerations in the different diagnosis of painful inguinal hernias in the inguinal area in women with childbearing age. The diagnosis of endometriosis can be demonstrated clearly on High-Definition Ultrasound by trained personnel. Surgery is the optional treatment and is curative in this case.

Evaluation of the effect of previous endometriosis surgery on clinical and surgical outcomes of subsequent endometriosis surgery

PurposePatients often undergo repeat surgery for endometriosis, due to recurrent or residual disease. Previous surgery is often considered a risk factor for worse surgical outcome. However, data are scarce concerning the influence of subsequent endometriosis surgery.MethodsA retrospective study in a centre of expertise for endometriosis was conducted. All endometriosis subtypes and intra-operative steps were included. Detailed information regarding surgical history of patients was collected. Surgical time, intra-operative steps and major post-operative complications were obtained as outcome measures.Results595 patients were included, of which 45.9% had previous endometriosis surgery. 7.9% had major post-operative complications and 4.4% intra-operative complications. The patient journey showed a median of 3 years between previous endometriosis surgeries. Each previous therapeutic laparotomic surgery resulted on average in 13 additional minutes (p = 0.013) of surgical time. Additionally, it resulted in more frequent performance of adhesiolysis (OR 2.96, p < 0.001) and in a higher risk for intra-operative complications (OR 1.81, p = 0.045), however no higher risk for major post-operative complications (OR 1.29, p = 0.418). Previous therapeutic laparoscopic endometriosis surgery, laparotomic and laparoscopic non-endometriosis surgery showed no association with surgical outcomes. Regardless of previous surgery, disc and segmental bowel resection showed a higher risk for major post-operative complications (OR 3.64, p = 0.017 respectively OR 3.50, p < 0.001).ConclusionPrevious therapeutic laparotomic endometriosis surgery shows an association with longer surgical time, the need to perform adhesiolysis, and more intra-operative complications in the subsequent surgery for endometriosis. However, in a centre of expertise with experienced surgeons, no increased risk of major post-operative complications was observed.

Risk Factors for Major Complications Following Minimally Invasive Surgeries for Endometriosis in the United States

To study the rate and risk factors for short-term postoperative complications of patients undergoing minimally invasive surgery (MIS) for endometriosis in the United States. Retrospective cohort study. American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2020. Patients with endometriosis diagnosis. Laparoscopic surgery for endometriosis. We compared women with and without 30-day postoperative major complications, defined according to the Clavien-Dindo classification. A total of 28 697 women underwent MIS during the study period, of which 2.6% had major postoperative complications. Organ space surgical site infection and reoperation were the most common complications (47.0% and 39.8%, respectively). In multivariable regression analysis, African American race (adjusted odds ratio [aOR] 95% confidence interval [CI] 1.61 [1.29-2.01], p <.001), hypertension (aOR 95% CI 1.23 [1.01-1.50], p=.036), bleeding disorders (aOR 95% CI 1.96 [1.03-3.74], p=.041), bowel procedures (aOR 95% CI 1.93 [1.37-2.72], p <.001) and hysterectomy (aOR 95% CI 2.09 [1.67-2.63], p <.001) were independently associated with increased risk of major complications. In multivariable regression analysis of laparoscopies without bowel procedures, African American race, bleeding disorders, and hysterectomy were independently associated with increased major complication risk. Among cases with bowel procedures, African American race and colectomy were independently associated with increased major complication risk. In multivariable regression analysis of women who underwent hysterectomy, African American race, bleeding disorders, and lysis of adhesions were independently associated with increased major complications risk. Among women who underwent uterine-sparing surgery, African American race, hypertension, preoperative blood transfusion, and bowel procedures were independently associated with increased major complications risk. Among women undergoing MIS for endometriosis, African American race, hypertension, bleeding disorders, and bowel surgery or hysterectomy are risk factors for major complications. African American race is a risk factor for major complications among women undergoing surgeries with and without bowel procedures or hysterectomy.

The procoagulant potential before and after surgery for endometriosis and its association with disease severity.

Previous studies have suggested that endometriosis is associated with increased hypercoagulable state. We aimed to determine the procoagulant potential among women with endometriosis before and after surgery. A prospective longitudinal study performed during 2020-2021 at a university hospital. Women undergoing laparoscopic surgery for endometriosis served as the study group. Blood samples were taken preoperatively and 3 months after surgery. The degree of hypercoagulability was assessed by thrombin generation, a global marker of the activation of the coagulation system, expressed as the endogenous thrombin potential (ETP). Healthy volunteers, without any medical condition or medications use, matched for age and weight of the study group, served as a control group. Thirty women with histologically-proven endometriosis and thirty healthy control subjects were enrolled in this study. Median preoperative ETP was significantly higher in women with moderate-to-severe endometriosis (3313 [interquartile range, IQR 3067-3632] nM) as compared to those with minimal-to-mild disease (2368 [IQR 1850-2621] nM) and the control group (2451 [2096-2617] nM) ( P < 0.001 for both comparisons). Following surgery, the ETP significantly decreased in those with moderate-to-severe endometriosis (postoperative: 2368 vs. preoperative: 3313 nM, P < 0.001) and was comparable to the ETP in the control group ( P = 0.35). In multivariate analysis, moderate-to-severe endometriosis was the only independent predictor of the preoperative ETP level ( P < 0.001), with a direct positive correlation between disease revised American Society for Reproductive Medicine severity score and the preoperative ETP level ( rs = 0.67; P < 0.0001). Moderate-to-severe endometriosis is associated with enhanced hypercoagulable state, which decreases significantly after surgery. Disease severity was independently associated with the degree of hypercoagulability.

Pregnancy after laparoscopic surgery for endometriosis: How long should we wait? A retrospective study involving a long-term follow up at a university endometriosis center.

To find the factors that influence the time until pregnancy after laparoscopic intervention and to evaluate the proper time to start assisted reproductive therapy (ART). This is a retrospective analysis that includes a prospective evaluation of patients with infertility and with a diagnosis of endometriosis. A subgroup of patients who desired to be pregnant after laparoscopic intervention (102 patients) was followed up for 36-197 months after the surgery. In this study, 71 (69.9%) and 60 (58.8%) of the patients achieved pregnancy and live birth, respectively. In the group of patients who became pregnant, the duration of infertility was significantly lower (2.7 ± 2.1 years vs. 4.7 ± 3.2 years). The median time until pregnancy after laparoscopic intervention was 8 months (the average was 10 months). After 38 months, no pregnancy occurred. In the group of patients with endometriosis and infertility, the first 12 months were the optimal time for pregnancy. For women with revised American Society for Reproductive Medicine classification of endometriosis (rASRM) stages I and II, spontaneous pregnancy can probably be delayed for up to 24 months, but in patients with rASRM stages III and IV, ART may be considered after 12 months. The gynecologist must be careful about the timing of further interventions after the operation.

Microwave Thermal Ablation of Uterine Fibroids during Laparoscopic Surgery for Endometriosis

Endometriosis is defined as the presence of endometrial glands or stroma outside the uterus, commonly diagnosed in women of childbearing age frequently with subfertility. Endometriosis is associated with the presence of uterine fibroids, which are benign tumors of the smooth muscle cells of the uterus, in 20-25% of cases. It is unclear whether fibroids interfere with fertility and pregnancy. The association of the two pathologies makes us ask the question of which is the best therapy to use. Sometimes medical therapy is not effective or has contraindications, surgery can be burdened with secondary effects that can impair fertility. In recent years, new techniques have been introduced to integrate conventional therapies, which involve the use of different forms of energy. Among these energies, an important place is occupied by microwaves (MW). MW creates an electromagnetic field that transforms kinetic energy into heat that induces cell death by coagulation necrosis. We have chosen to use MW thermal ablation to treat fibroids during laparoscopic surgery for endometriosis due to the fact that laparoscopic removal of myomas significantly lengthens the surgical time and increases possible complications.

Cost-effectiveness Analysis of Dienogest Compared with Combined Oral Contraceptives after Surgery for Endometriosis

To assess the cost-effectiveness of different strategies, including the dienogest (DNG) and combined oral contraceptives (COC) therapy, for the prevention of endometriosis recurrence after surgery. A decision tree model was created. The analysis was based on data from a healthcare provider in China. Model inputs were derived from published data. The end points included incremental cost effectiveness ratio, net monetary benefit (NMB), and incremental NMB associated with prevention of recurrence. The uncertainty was assessed through one way and probabilistic sensitivity analysis. The Consolidated Health Economic Evaluation Reporting Standards 2022 checklist was used to assess quality of the reporting. China healthcare system. Individuals undergoing laparoscopic surgery for endometriosis. DNG vs COC. The base case analysis showed that hormone supression via DNG resulted in 0.7493 quality-adjusted life years (QALYs) at a cost of $1625.49 compared with COC, which resulted in 0.7346 QALYs at a cost of $343.61. The incremental cost effectiveness ratio was $87 679.89 per additional QALY gained and the DNG treatment was associated with an incremental NMB of -$731.39. Probabilistic sensitivity analysis indicated that DNG is not cost-effective in most cases at a threshold consistent with World Health Organisation recommendations of $37 653/QALY. The result of our present analysis suggests that the DNG might not be cost-effective for the prevention of endometriosis recurrence after surgery in China.

Surgical Treatment of Catamenial Chest Pain: Excision of diaphragmatic endometriosis during robot-assisted laparoscopic surgery.

10% of women of reproductive age are affected by endometriosis, and diaphragmatic endometriosis represents 1-1.5% of these cases. Diaphragmatic endometriotic lesions often require surgical treatment. This video aims to demonstrate the appearance of diaphragmatic endometriosis and describe our experience with robot-assisted laparoscopic excision of full thickness diaphragmatic endometriosis. The patient was a 37-year-old female with the complaint of cyclical right shoulder pain (for 1 year). She previously had caesarean section scar and umbilical endometriosis excision procedures. The magnetic resonance imaging (MRI) of the abdomen highlighted three endometriotic nodules, one of which was described as full thickness on the right hemi-diaphragm. The patient underwent a robot-assisted laparoscopic endometriosis surgery as a joint procedure between the gynaecology and general surgery teams. The falciform ligament was completely divided to obtain full views of the endometriotic lesions on the diaphragm. Superficial diaphragmatic lesions were first excised. The larger deep nodule, which was described on the MRI, was then excised with the full thickness of diaphragm. Pleural cavity was entered intentionally to achieve complete excision of the nodule. Laparoscopic assessment of the right lower pleural cavity through this opening did not show any endometriotic lesions. After the excision, the diaphragm was repaired with a barbed suture. Negative pressure suction of the pleural cavity was performed at the end of this repair instead of using a chest tube. The patient was discharged on the 3rd day with no complications encountered. Histopathological examination confirmed endometriosis. The patient was asymptomatic three months after surgery. Robotic-assisted surgery is an easy and safe choice especially in such challenging dual compartment surgeries by providing a 3D view that abolishes sensory loss and increases depth perception, providing better manoeuvrability with tremor absence.

7690 Association between Prior Surgery and Concomitant Conditions and Positive Pathological Confirmation of Endometriosis Lesions

<h3>Study Objective</h3> To compare the association between prior surgical intervention and concomitant conditions and pathologically confirmed positivity rate of endometriosis lesions. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> University teaching hospital. <h3>Patients or Participants</h3> All women above 18 years-old who underwent laparoscopic surgery for endometriosis at a tertiary care hospital from October 2011 to October 2020 were screened for inclusion. Patients who underwent open surgery or whose primary indication for surgery was not endometriosis were excluded. Procedures performed by non-gynecologic surgeons were also excluded. A total of 401 cases were included in this study. Patients were classified according to whether prior surgery for endometriosis or prior hysterectomy was done, concurrent hysterectomy or bilateral oophorectomy were performed, and whether fibroids and adenomyosis were diagnosed. To examine differences in positivity rates of endometriosis lesions, patients were classified as having reached or not having reached 80% positivity in pathological confirmation. Chi-square and Fisher's exact tests were used to assess statistically significant differences. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> The percentage of patients reaching 80% positivity on pathological confirmed endometriosis was lower in women who had undergone previous laparoscopy for endometriosis compared to surgery naïve women, 66.5% vs 76.5% respectively, (p=0.03). Additionally, a higher percentage of women who underwent concomitant hysterectomy (83.5% vs 68.8% for non-hysterectomy, p=0.005) or bilateral oophorectomy (92.7% vs 70.0% for non-oophorectomy, p=0.002) achieved 80% positivity. Although women who had an associated diagnosis of fibroids (79.7% vs 70.5%) or adenomyosis (76.4% vs 71.7%) were more likely to reach 80% positivity compared to undiagnosed women, these differences were not statistically significant (p>0.05). <h3>Conclusion</h3> Prior laparoscopic surgery for endometriosis might cause tissue changes that decrease the pathological positivity rate of endometriosis lesions. This is beneficial when discussing post-operative findings and pathological results with patients.

Laser Assisted Appendectomy

<h3>Study Objective</h3> Appendiceal endometriosis is commonly encountered by gynecologists during laparoscopy for endometriosis or chronic pelvic pain. This video reviews appendiceal endometriosis, highlights important anatomical landmarks for appendectomy and demonstrates a novel technique for laparoscopic appendectomy using a CO2 Laser at the time of surgical management of endometriosis. <h3>Design</h3> This video uses still images, video footage and narration to review appendiceal endometriosis and laser-assisted appendectomy. The laser appendectomy approach is reviewed in four steps, addressing preoperative and intraoperative considerations. <h3>Setting</h3> Patient positioned in Trendelenburg position with left lateral tilt. <h3>Patients or Participants</h3> Patients undergoing gynecologic laser laparoscopic surgery for endometriosis or chronic pelvic pain. <h3>Interventions</h3> Laser assisted laparoscopic appendectomy. <h3>Measurements and Main Results</h3> When performing a laparoscopy for endometriosis or chronic pelvic pain assess the appendix for signs of endometriosis. The four key steps when planning a laser appendectomy are (1) patient preparation, (2) isolate the appendix, (3) secure blood supply, and (4) remove appendix. <h3>Conclusion</h3> Appendiceal endometriosis is common and pre-operative diagnosis is challenging. Appendectomy should be considered at the time of gynecologic surgery for endometriosis or chronic pelvic pain. This video can be used as a reference for gynecologists when performing appendectomy at the time of hysterectomy or laparoscopy for endometriosis or chronic pelvic pain.

8918 Relationship between Brainwave Biomarker and Endometriosis Pain Symptoms before and after Laparoscopic Surgery

Study Objective The purpose of this study was to explore the relationship between peak alpha frequency (PAF), an electroencephalogram (EEG)-based biomarker for pain sensitivity, and pain symptoms for patients undergoing laparoscopic surgery for endometriosis. Design Prospective observational pilot study. Setting Large academic hospital. Patients or Participants Patients (n=18) undergoing laparoscopic endometriosis excision surgery were invited to participate. Participants enrolled before surgery and were followed up to 6 weeks postoperatively. Interventions N/A. Measurements and Main Results Participants completed a physical exam, quantitative EEG, and symptom questionnaires before and after surgery (2-weeks and/or 6-weeks post-op). We hypothesized that PAF would increase after surgery indicating an improvement in pain symptoms. To measure PAF, EEG data was collected using a BrainBit dry electrode headset. Patient-reported outcome measures for pain and endometriosis symptoms were collected using Modified Brief Pain Inventory (BPI), Short-form McGill Pain Questionnaire 2, Endometriosis Health Profile 30, and Patient Health Questionnaire 9. Descriptive statistics and Spearman correlation coefficients were calculated for each measure before and after surgery. Overall, we observed an increase in PAF following surgery, where median values shifted from 9.88 Hz preoperatively (IQR 9.84 - 9.99 Hz) to 10.01 Hz postoperatively (IQR 9.84 - 10.06 Hz). Preliminary results suggest that preoperative PAF is moderately inversely correlated with average preoperative pain reported using BPI (rho = -0.52) but is not strongly correlated with other measures. Conclusion While the reported results are underpowered to determine statistical significance, PAF was found to increase six weeks after endometriosis surgery. Furthermore, preoperative PAF appears to be inversely correlated with preoperative pain symptoms, suggesting that PAF is a useful measure for tracking pain in patients with endometriosis. Additional investigation and follow-up is needed to determine how PAF relates to long-term surgical outcomes for patients with chronic pelvic pain. The purpose of this study was to explore the relationship between peak alpha frequency (PAF), an electroencephalogram (EEG)-based biomarker for pain sensitivity, and pain symptoms for patients undergoing laparoscopic surgery for endometriosis. Prospective observational pilot study. Large academic hospital. Patients (n=18) undergoing laparoscopic endometriosis excision surgery were invited to participate. Participants enrolled before surgery and were followed up to 6 weeks postoperatively. N/A. Participants completed a physical exam, quantitative EEG, and symptom questionnaires before and after surgery (2-weeks and/or 6-weeks post-op). We hypothesized that PAF would increase after surgery indicating an improvement in pain symptoms. To measure PAF, EEG data was collected using a BrainBit dry electrode headset. Patient-reported outcome measures for pain and endometriosis symptoms were collected using Modified Brief Pain Inventory (BPI), Short-form McGill Pain Questionnaire 2, Endometriosis Health Profile 30, and Patient Health Questionnaire 9. Descriptive statistics and Spearman correlation coefficients were calculated for each measure before and after surgery. Overall, we observed an increase in PAF following surgery, where median values shifted from 9.88 Hz preoperatively (IQR 9.84 - 9.99 Hz) to 10.01 Hz postoperatively (IQR 9.84 - 10.06 Hz). Preliminary results suggest that preoperative PAF is moderately inversely correlated with average preoperative pain reported using BPI (rho = -0.52) but is not strongly correlated with other measures. While the reported results are underpowered to determine statistical significance, PAF was found to increase six weeks after endometriosis surgery. Furthermore, preoperative PAF appears to be inversely correlated with preoperative pain symptoms, suggesting that PAF is a useful measure for tracking pain in patients with endometriosis. Additional investigation and follow-up is needed to determine how PAF relates to long-term surgical outcomes for patients with chronic pelvic pain.

7676 Association between BMI and Race and Positive Pathological Confirmation of Endometriosis Lesions

<h3>Study Objective</h3> To compare the association between BMI and race and the pathologically confirmed positivity rate of endometriosis lesions. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> University teaching hospital. <h3>Patients or Participants</h3> All women above 18 years-old who underwent laparoscopic surgery for endometriosis at tertiary care hospital from October 2011 to October 2020 were screened for inclusion. Patients who underwent open surgery or whose primary indication for surgery was not endometriosis were excluded. Procedures performed by non-gynecologic surgeons were also excluded. A total of 401 patients were included in the study. BMI was defined by WHO standards with race categorization obtained from previously available demographic data. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> Patients were classified as having reached or not having reached 80% positivity in pathological confirmation of endometriosis lesions. Chi-square and Fisher's exact tests were used to assess statistically significant differences. Among patients of white race (n=266), 74.1% reached an 80% positivity rate, compared to 70.9% and 50% in the African American and Hispanic patient groups, respectively (p=0.04). A total of 147 (36.7%) patients comprised the normal BMI subgroup, of which 68.7% reached 80% positivity rate. In comparison, the percentage of overweight and obese women who reached 80% positivity rate were 74.5% and 74.1% respectively (p=0.72). Among patients with preoperative diagnosis of adenomyosis, 68.2% had 80% or more pathological positivity rate compared 72.8% of patients without adenomyosis. (p=0.52). <h3>Conclusion</h3> In this retrospective study, statistically significant racial disparities were still found in regards to pathological positivity rate for endometriosis. Future prospective studies are needed to further investigate this finding. BMI subgroups or adenomyosis diagnosis did not show any significant differences in positivity rate.