The Effect of Temporary Ovarian Suspension to the Anterior Abdominal Wall During Laparoscopic Endometriosis Surgery for Adhesion Prevention -A Comparative and Prospective Study

Endometriosis is a chronic condition characterized by growth of endometrial tissue in sites other than the uterine cavity, most commonly in the pelvic cavity, including the ovaries, the uterosacral ligaments, and the pouch of Douglas. Laparoscopic excision of endometriosis lesions has become the gold standard treatment. At follow-up, relief of pain and quality of life after endometriosis surgical treatment ranges between 50% and 95%. However, pelvic surgery for endometriosis has been associated with a high rate of postoperative adhesion formation. The incidence of pelvic adhesions at second-look laparoscopy in the initial few weeks after surgery has been reported to be between 50% and 100%. The ovaries are the most common site involved by adhesions because of their anatomic localization (close to the pelvic sidewall and the homolateral tube) and the fragility of the coelomic epithelium that covers the ovarian surface [7,8]. In addition, when the posterior pelvic compartment is involved, obliteration of the pouch of Douglas is often observed as a result of a post-inflammatory process causing ovarian adhesions [9]. Women with higher risk for postoperative ovarian adhesions include those who have preoperative ovarian adhesions or patients undergoing ovarian cystectomy, peritonectomy of the ovarian fossa or extensive pelvic adhesiolysis. Postoperative retained free fluid with blood and postoperative infections may also increase the risk for adhesions. Postoperative adhesions are a source of major concern because of their potential consequences including persistent pelvic pain, dyspareunia (difficult or painful sexual intercourse), infertility, intestinal obstruction, and complications at subsequent surgery.

A wide range of interventions has been tried in the past in order to reduce postoperative pelvic adhesions. This includes intra-peritoneal administration of anti-adhesive solutions such as icodextrin and hyaluronic acid. Various drugs including steroids and heparin have also been tried in the past but none of them have gained wide acceptance (Metwally et al., 2006; Kamel, 2010). Oxidized regenerated cellulose was found to reduce postoperative adhesion in two very small RCTs (Ahmad et al., 2008).

Intra-operative suspension of the ovaries to the anterior abdominal wall is sometimes used to facilitate ovarian retraction and improve exposure of the pelvis during surgery for severe endometriosis (Cutner et al., 2004). Temporary ovarian suspension can be achieved using a straight needle and absorbable suture to suspend the ovary to the abdominal wall with an external knot tie that can be easily removed at any time after surgery. Two small observational studies suggested that temporary ovarian suspension for 4-7 days following surgery for severe endometriosis may reduce the frequency of postoperative pelvic adhesions (Abuzeid et al., 2002; Ouahba et al., 2004).

The Objective of the Study The primary objective of the study is to examine adhesion formation following laparoscopic surgery with temporary ovarian suspension removed a week after surgery.

The secondary objective is the analyze patient symptoms and adherence to the ovarian suspension as well as request to remove the suture before one week post operative.