Retrospective analysis of urgent gynecological laparoscopic surgery in patients of reproductive age

Gynecological emergencies requiring urgent surgery, are life-threatening conditions, and the term “acute abdomen” includes several major nosological forms [1–5].

The result of urgent surgery is elimination of the etiological factor that led to surgical intervention and preservation of reproductive potential [2–5].  There are three major nosological forms in emergency gynecology, that require hospitalization: ruptured ovarian cyst, apoplexy, external genital endometriosis, ectopic pregnancy and a combination of several causes [1–7]. Some studies analyzed the structure of surgical interventions in emergency gynecology. The study by Malyshkina A.I. et al. compared the age of patients, the etiological factors, the surgical access, the volume of interventions; however, but blood loss volume, duration of surgical intervention, the severity of adhesions and the length of postoperative hospital stay were not assessed [5]. The study by Miklyaeva I.A. et al. analyzed the etiological factors, the surgical access and volume, but other data were not analyzed [6]. Analysis of the etiological factors, assessment of the proportion of each factor as the cause for surgery, the age of patients, duration of surgical interventions, blood loss volume, the prevalence of adhesions requires further exploration and comparison of various nosologies in emergency gynecology [5–10]. Attention should be paid to timely diagnosis of external genital endometriosis, which is considered to be a risk factor of surgical and postoperative complications [11]. Taking into account the era of delayed motherhood, urgent surgical interventions require research to improve surgical techniques aimed to reduce negative factors resulting from surgical intervention and improve postoperative rehabilitation techniques.

Aim of the study was to perform a retrospective analysis to identify relationship between various nosological forms and blood volume loss, the severity of the adhesive process, duration of surgery and postoperative rehabilitation period in emergency gynecology.

Materials and methods

A retrospective analysis of 371 medical histories of patients of reproductive age, who were urgently hospitalized in Gynecological Emergency Department of   Simferopol clinical maternity hospital No. 2 (in Simferopol) and underwent surgery in the period from 2019 to 2022, was conducted.

 Surgical interventions were performed using standard videoendoscopic techniques.

Exclusion criteria were the age of patients below 19 years and over 49 years; elective surgical treatment; malignant neoplasms in female reproductive system.

To investigate and analyze the cases of surgical treatment, the women were divided into 4 groups. Group 1 comprised 158/371 (42.6%) women with records of surgical intervention due to ovarian apoplexy or ruptured ovarian cysts in medical history. Group 2 included   92/371 (24.8%) women with interrupted ectopic pregnancy. Group 3 included 65/371 (17.5%) women with various complicated forms of external genital endometriosis. Group 4 consisted of 56/371 (15.1%) women, who previously underwent surgery because of non-gynecological indications, or due to combination of factors, which potentially led to adhesions (including appendectomy, salpingo-oophoritis, pathological processes of neighboring pelvic and abdominal organs, as well as various traumas).

The following data were investigated:

1) the age of patients (years);

2) duration of surgery;

3) intraoperative blood loss (ml);

4) intraoperative determination of the severity grading of adhesions (grade 1–4);

5) the length of postoperative hospital stay (bed-days).

Assessment of the prevalence of the adhesive process was done according to the American Fertility Society classification (1988), that takes into account the prevalence, localization and nature of the adhesive process, as well as obliteration of the fallopian tubes [12].

Statistical analysis

For quantitative parameters, the Shapiro–Wilk test was used to compare how close the empirical distribution fit to the normal distribution [13]. 

Since at least in one sample there were statistically significant differences between the empirical and normal distribution with critical values at p<0.05 for each parameter, further statistical analysis was performed using nonparametric rank-based methods.  The median (Me) and interquartile range (Q1; Q3) were calculated as the indicators of descriptive statistics of the analyzed quantitative data.

The nonparametric rank-based Kruskal–Wallis test was used to verify the hypothesis of the equality of medians in the analyzed four samples [14]. The Dunn’s post-hoc test was used for pairwise comparison for the equality of medians of parameters in the analyzed samples [15]. Holm–Bonferroni p-value adjustments were made to account for multiple pairwise comparisons [16].  For interpretation of the results of statistical analysis, the critical value of the level of statistical significance was at p<0.05.

The degree of adhesion can be expressed by ordinal or categorical scales of measurement. Consequently, the analysis of this indicator a priori cannot be performed using parametric statistical methods. In our study, based on clinical assumptions, this indicator was considered to be categorical (where the stages of the adhesive process from 1 to 4 were denoted as categories). Therefore, the absolute and relative frequency was used in descriptive statistics, and the chi-square goodness-of-fit test was used to compare distribution in four analyzed groups [17].

Statistical data processing was performed using software program PAST, version 4.03, that was used for free for scientific purposes conditional upon reference for the first publication of the authors’ program [18].

Results and discussion

Table 1 presents descriptive statistics and the results of comparison of quantitative parameters with indication of precise values of the statistical significance level p according to the Kruskal–Wallis test.

The results of pairwise comparisons of quantitative parameters that were obtained using the Dunn’s post-hoc test and Holm–Bonferroni correction are shown in Table 2.

In addition, the initial numerical values of the parameters are shown in Table 1.

Table 3 shows the descriptive statistics for the stage of adhesion in absolute and relative frequency (in percentage).

Chi-square test showed that there are differences between frequency distribution of the stages of the adhesive process in 4 groups at the level of significance p<0.001 (χ²=51.8, the number of the degrees of freedom k=9).

The analysis demonstrated that ruptured ovarian cyst or ovarian apoplexy is a nosological form that most often was the reason for urgent hospitalization (158 patients in group 1; 92 patients in group 2; 65 patients in group 3, and 56 patients in group 4) and was accompanied by higher blood loss – 290.0 (285.0;300.0) ml in group 1 versus minimal blood loss – 100.00 (50.0;150.0) ml in group 2. The obtained results differ from the results of retrospective analysis done by other authors. According to analysis of urgent interventions performed by Malyshkina et a. in 2018–202 in V.N. Gorodkov Research Institute of Maternity and Childhood, the Ministry of Health of Russia, the most common reason for hospitalization was ectopic pregnancy –in 67.4% of cases, while ovarian apoplexy – only in 25.2% of cases [5]. However, Miklyaeva I.A. et al., who did the analysis of urgent care in V.N. Gorodkov Research Institute of Maternity and Childhood, the Ministry of Health of Russia, reported that the most common reason for hospitalization was ectopic pregnancy – in 44% of cases, and ovarian apoplexy ranked second – in 42% of cases, that was only 2% less [6]. 

Given the data in Table 1, maximum time of surgery duration was in group 3 and 4, where the results were almost identical: 64.0 (62.0; 65.8) minutes in group 4 and 63.0 (62.0; 65.0) minutes in group 3 versus 35.0 (30.0; 50.0) minutes in group 1, 30.0 (20.0;45.0) minutes in group 2. Longer lasting surgery in group 3 and 4 was due to external genital endometriosis, and combination of various etiological factors that led to surgical intervention in women in group 4. The maximum length of postoperative rehabilitation period was 6.0 (5.0; 6.0) and 5.0 (4.0; 5.0) bed-days in group 3 and 4, respectively. Therefore, the diagnosis of external genital endometriosis or the presence of combination of factors that led to urgent intervention, even at the stage of hospitalization suggested necessity to get ready for a longer surgical intervention and a longer postoperative rehabilitation period.

The analysis of the severity grade of the adhesive process in 4 groups showed, that grade 4 was most often in group 3 that included the patients with external genital endometriosis – in 5/65 (7.7%) women. Minimal prevalence of the adhesive process was most often in group 1 – in 138/158 (87.3%) women.

Conclusion

1. In the structure of urgent gynecological pathology, ovarian apoplexy or ruptured ovarian cysts were predominant – 158/371 (42.6%) cases. The second most common nosological form was ectopic pregnancy – 92/371 (24,8%) cases.
2. With ruptured ovarian cysts and ovarian apoplexy, clinical and statistical blood volume loos was significantly higher.
3. With anamnestic and clinical diagnosis of external genital endometriosis, postoperative rehabilitation period is longer.
4. Common forms of external genital endometriosis lead to severe grade of adhesion – stage 4 according to the American Fertility Society classification (1988).
5. Duration of surgical intervention was longer in the group of patients with external genital endometriosis and combination of several etiological factors.