Gynecologic Adnexal Tumors and Tumor-Like Lesions in Children and Adolescents: Experience at a Cancer Center.

Introduction. Tumors and tumor-like lesions of the uterine adnexa in children and adolescents are uncommon but may carry devastating consequences. Methods. We conducted an observational retrospective cohort study, to describe patients aged 0 to 19 years diagnosed with tumors and tumor-like lesions of the uterine adnexa at our institution between 2000 and 2018. Results. Eighty-nine patients with 105 adnexal lesions were included. Thirty-seven (42%) patients presented with benign tumors, 13 (15%) with borderline tumors, 25 (28%) with malignant tumors and 14 (16%) with tumor-like lesions. Germ cell tumors (n = 45|43%) were the most frequent, followed by epithelial tumors (n = 30|29%). No significant differences were found in the age distribution of the lesions by malignant potential or histologic group. Most patients (n = 80|90%) were treated primarily with conservative surgery, including cystectomy (n = 25|28%) and unilateral oophorectomy/adnexectomy (n = 54|61%). Thirty-four (38%) underwent surgical staging (partial omentectomy and peritoneal biopsies). Twenty (23%) patients with borderline and malignant tumors were submitted to chemotherapy. Four (5%) patients with borderline or malignant tumors relapsed, one of whom died from disease. Conclusion. Gynecological lesions in children and adolescents encompass a wide range of rare histological tumor subtypes, requiring evaluation by experienced pathologists. Most tumors were diagnosed at early stages, with low relapse and mortality rates. Conservative management, with fertility sparing surgery and limited use of adjuvant chemotherapy, is of utmost importance.

Minimally invasive adnexa-sparing surgery for benign ovarian and paratubal masses in children.

BACKGROUND: The precision of minimally invasive surgery (MIS) to resect benign ovarian and paratubal masses while preserving adnexa in children is unclear. This study evaluated the integrity of laparoscopy to spare adnexa while resecting benign pathologies in children. METHODS: The institutional pathology database was queried to identify patients aged 18 years and younger having any ovarian or tubal lesion resected at a comprehensive children's hospital between 2006 and 2021. Adnexa-sparing surgery was defined as preserving both the ovary and tube from which the lesion was resected. Postoperative ultrasounds were reviewed to document ovarian follicles, blood flow, volumes, and lesion recurrence. RESULTS: Adnexal preservation was implemented in 168 of 328 pathological resections. MIS approach was used in 149 cases. Median age was 13.4 [11.0-15.3]. Among sparing surgeries, MIS associated with benign pathology, shorter operative time (median minutes: 78 MIS [59-111.5]; 130 open [92.8-149.8]; 174 MIS-to-open [132.8-199.5]; p = 0.010), and reduced hospital stay (median days: 1 MIS (Lindfors, 1971; Lovvorn III et al., 1998) [1-2]; 2 open [2-2.9], 2 MIS-to-open [1-3.3]; p = 0.001). Postoperative ovarian volume ipsilateral to the MIS procedure (median, 7.6 ml [4.3-12.1]) was relatively smaller than the contralateral ovary (median, 9.1 ml [5.5-15.0]). Blood flow was documented to the ovary in 70/94 (74.4%) of patients after MIS adnexal-sparing surgery. Distinct follicles were detected in 48/74 (64.8%) of post-menarchal patients after MIS adnexal-sparing surgery. Five ovarian cysts recurred. CONCLUSIONS: MIS preserves adnexa reliably, with postoperative ovarian follicles and blood flow detected in most patients, and maintains ∼80% of contralateral volume, while achieving definitive tumor resection. LEVEL OF EVIDENCE: III.

Adnexal torsion in pregnancy: A systematic review of case reports and case series.

OBJECTIVES: This study aimed to investigate clinical presentations, surgical procedures and findings, complications, and predisposing factors of adnexal torsion in pregnant women. METHODS: We searched PubMed/Medline, Embase, and Web of Science from January 2000 to March 2022. All case reports and case series with full-text English language reporting adnexal torsion in pregnant women were included. Medical history, clinical presentations, surgical procedures and findings, complications related to adnexal torsion, and predisposing factors were independently extracted by two investigators. RESULTS: A total of 182 articles reporting 662 pregnant women with adnexal torsion were included. Most of the adnexal torsions occurred during the first trimester (54.63%), while others occurred during the second (26.36%) and third (19.00%) trimesters. The most common symptom of adnexal torsion was sudden-onset pain (80.60%). Enlargement of the adnexa was the most prevalent ultrasound finding in a twisted adnexa (95.20%). Additionally, about half of the patients had decreased blood flow in Doppler ultrasound (53.80%). Laparoscopic surgery was the favorite option (56.88%), while cystectomy and detorsion were the most commonly performed procedure (29.06%). Expectant management was reported in only 2.99% of the patients. In addition, the most common complications were preterm labor (27.58%) and emergent cesarean sections (25.28%). CONCLUSIONS: Clinicians should think of adnexal torsion when pregnant women complain of sudden-onset pain. Then, using ultrasound, adnexal enlargement or masses should be explored seriously. They should take invasive and urgent therapy to preserve ovaries and prevent complications.

Standardised step by step approach to adnexectomy by Vaginal Natural Orifice Transluminal Endoscopic Surgery.

Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) combines the advantages of vaginal surgery with those of laparoscopic surgery. Feasibility of vNOTES for other indications such as hysterectomy, ovarian cystectomy and myomectomy has been established. In this article, we describe a standardised step by step process to perform adnexal surgery by vNOTES.

Application of Single-Hole Laparoscopy and Sentinel Lymph Node Imaging in Early Endometrial Carcinoma in Special Population.

AIM: To explore the clinical efficacy of single-hole laparoscopy combined with sentinel lymph node imaging in the treatment of early endometrial carcinoma in a special population. METHOD: A retrospective analysis was made on the clinicopathological data of 8 patients with early endometrial carcinoma who underwent extra fascial total hysterectomy plus double adnexal resection and pelvic sentinel lymphadenectomy by transumbilical single-hole laparoscopy in Jiaxing Maternal and Child Health Hospital from Apr. 2019 to Apr. 2021. RESULT: Single-hole laparoscopy and sentinel lymph node imaging were successfully performed in 8 patients with early endometrial carcinoma, and none of them was converted to porous or laparotomy. At the same time, all 8 patients have a high demand for body shape. All FIGO pathological grades were grade I before operation. Operation time is 160.87 ± 40.61 min, amount of bleeding is 68.75 ± 12.31 ml, the catheter was removed for 2 days, anal exhaust time is 30.13 ± 10.99 h, and postoperative hospital stay is 4.00 ± 1.07 d. There was no related organ injury during the operation, no case of blood transfusion, or case of poor wound healing. The evaluation of postoperative satisfaction was very satisfactory. CONCLUSION: The application of single-hole laparoscopy and sentinel lymph node imaging in the treatment of early endometrial carcinoma in the special population should be safe and feasible with high satisfaction.

Adnexectomy by vaginal Natural Orifice Transluminal Endoscopic Surgery versus laparoscopy: results of a first randomised controlled trial (NOTABLE trial).

OBJECTIVE: To compare adnexectomy by vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) versus laparoscopy. DESIGN: Parallel group, 1:1 single-centre single-blinded randomised trial, designed as non-inferiority study with a margin of 15%. SETTING: Belgian teaching hospital. POPULATION: Non-pregnant non-virgin women with an intact uterus and without obliteration of the pouch of Douglas scheduled to undergo removal of an adnexal mass assessed to be benign on ultrasound by IOTA criteria. METHODS: Randomisation to laparoscopy (control group) or vNOTES (experimental group). Stratification according to adnexal size. Blinding of participants and outcome assessors by sham incisions. MAIN OUTCOME MEASURES: The primary outcome measure was adnexectomy by the allocated technique. Secondary outcomes included duration of surgery, pain scores and analgesics used, quality of life and adverse events. RESULTS: We randomly assigned 67 participants (34 to the vNOTES group and 33 to the laparoscopy group). The primary end point was always reached in both groups: there were no conversions. We performed a sensitivity analysis for the primary outcome, assuming one conversion in the vNOTES group and no conversions in the laparoscopy group: the one-sided 95% upper limit for the differences in proportions of conversion was estimated as 13%, which is below the predefined non-inferiority margin of 15%. The secondary outcomes demonstrated a shorter duration of surgery, lower pain scores, lower total dose of analgesics and a trend for more adverse events in the vNOTES group. CONCLUSIONS: vNOTES is non-inferior to laparoscopy for a successful adnexectomy without conversion. vNOTES allowed shorter operating times and less postoperative pain but there was a trend for more adverse events.

Pregnancy Outcomes Following Laparoscopic and Open Surgery in Pelvis during Pregnancy: a Nationwide Population-based Study in Korea.

BACKGROUND: Non-obstetric surgery during pregnancy is associated with adverse obstetric and fetal outcomes. The aim of this study was to investigate the risk of adverse pregnancy outcomes for women who underwent non-obstetric pelvic surgery during pregnancy compared with that of women that did not undergo surgery. METHODS: Study data from women who gave birth in Korea were collected from the Korea National Health Insurance claims database between 2006 and 2016. We identified pregnant women who underwent abdominal non-obstetric pelvic surgery by laparoscopy or laparotomy from the database. Pregnancy outcomes including preterm birth, low birth weight (LBW), cesarean section (C/S), gestational hypertension, gestational diabetes, and postpartum hemorrhage were identified. The adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the pregnancy outcomes were estimated by multivariate regression models. RESULTS: Data from 4,439,778 women were collected for this study. From 2006-2016, 9,417 women from the initial cohort underwent non-obstetric pelvic surgery (adnexal mass resection, appendectomy) during pregnancy. Multivariate logistic regression analysis indicated that preterm birth (HR, 2.01; 95% CI, 1.81-2.23), LBW (HR, 1.62; 95% CI, 1.46-1.79), C/S (HR, 1.13; 95% CI, 1.08-1.18), and gestational hypertension (HR, 1.35; 95% CI, 1.18-1.55) were significantly more frequent in women who underwent non-obstetric surgery during pregnancy compared to pregnant women who did not undergo surgery. When the laparoscopic and laparotomy groups were compared for risk of fetal outcomes, the risk of LBW was significantly decreased in laparoscopic adnexal resection during pregnancy compared to laparotomy (odds ratio, 0.62; 95% CI, 0.40-0.95). CONCLUSION: Non-obstetric pelvic surgery during pregnancy was associated with a higher risk of preterm birth, LBW, gestational hypertension, placenta previa, placental abruption, and C/S. Although the benefits and safety of laparoscopy during pregnancy appear similar to those of laparotomy in regard to pregnancy outcomes, laparoscopic adnexal mass resection was associated with a lower risk of LBW.

vNOTES for adnexal procedures.

This work aims to describe the technique and review all transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for adnexal procedures performed and to acknowledge vNOTES as an alternative to conventional laparoscopy. The procedure consisted of an incision in the Pouch of Douglas, insertion of a single port device, laparoscopic surgery through the device, extraction of specimens through the vagina and closure of the vaginal apex with a direct suture. Eighteen procedures have been successfully completed, 1 patient required conversion to conventional abdominal surgery due to intolerance to pneumoperitoneum. Surgeries' length range was 45-210 minutes. The estimated blood loss was less than 100 mL. The patients required minimal analgesia, were discharged the day after and had no postoperative complications. No patients complained of dyspareunia. Two patients conceived after surgery. vNOTES is a safe and desirable approach to the adnexa and a reasonable alternative to conventional laparoscopy or vaginal surgery.Impact statementWhat is already known on this subject? Natural Orifice Transluminal Surgery (NOTES) is a technique used to access the abdominal cavity through natural orifice. Compared to conventional laparoscopy, it's expected to have fewer complications.What do the results of this study add? This is one of the few works addressing vNOTES adnexal surgery, which appears to be a good alternative to conventional laparoscopy.What are the implications of these findings for clinical practice and/or further research? vNOTES may be a desirable approach to the adnexa. This work opens a door to new research regarding vNOTES in more complex gynaecologic procedures.

Acute abdomen or life-threatening heterotopic pregnancy with tubal rupture: where does imaging play a role?

Heterotopic pregnancy (HP) is a rare, potentially life-threatening complication of an intrauterine pregnancy with a simultaneous ectopic pregnancy. There is a higher incidence with assisted reproduction techniques (ART) and radiology can be pivotal in its diagnosis. A 28-year-old woman underwent ART and at 7 weeks' gestation presented with acute right iliac fossa pain. Transvaginal ultrasound (US) imaging confirmed a viable intrauterine pregnancy. The patients' pain persisted however, and transabdominal US demonstrated a complex, heterogeneous right adnexal mass. Subsequent magnetic resonance imaging (MRI) confirmed an HP with a ruptured ectopic and haemoperitoneum. Emergency laparoscopic surgery and right salpingo-oopherectomy were performed without complication. We highlight the importance of considering HP as a diagnosis in the acute gravid abdomen, especially when initial investigations have confirmed a viable intrauterine pregnancy. Furthermore, this case highlights MRI as a useful modality in complex cases due to its high soft tissue contrast resolution using non-ionising radiation.

Applicability of minimally invasive surgery for clinically T4 colorectal cancer.

The role of minimally invasive surgery (MIS) to treat clinically T4 (cT4) colorectal cancer (CRC) remains uncertain and deserves further investigation. A retrospective cohort study was conducted between September 2006 and March 2019 recruiting patients diagnosed as cT4 CRC and undergoing MIS at a university hospital and its branch. Patients' demography, clinicopathology, surgical and oncological outcomes, and radicality were analyzed. A total of 128 patients were recruited with an average follow-up period of 33.8 months. The median time to soft diet was 6 days, and the median postoperative hospitalization periods was 11 days. The conversion and complication (Clavien-Dindo classification ≥ II) rates were 7.8% and 27.3%, respectively. The 30-day mortality was 0.78%. R0 resection rate was 92.2% for cT4M0 and 88.6% for pT4M0 patients. For cT4 CRC patients, the disease-free survival and 3-year overall survival were 86.1% and 86.8% for stage II, 54.1% and 57.9% for stage III, and 10.8% and 17.8% for stage IV. With acceptable conversion, complication and mortality rate, MIS may achieve satisfactory R0 resection rate and thus lead to good oncological outcomes for selected patients with cT4 CRC.

Learning curve analysis of applying Seprafilm hyaluronic acid/carboxymethylcellulose membrane during laparoscopic hysterectomy.

This study was designed to evaluate the learning curve of applying Seprafilm (modified hyaluronic acid and carboxymethylcellulose; Genzyme, Cambridge, MA, USA) during laparoscopic hysterectomy or subtotal hysterectomy with or without adnexectomy. In this retrospective cohort study, 35 patients who underwent laparoscopic hysterectomy or subtotal hysterectomy with or without adnexectomy were enrolled. The Seprafilm was cut into 4 pieces, rolled up with a trimmed plastic sleeve and delivered through an incision wound made for the 5-mm ancillary trocar. The membrane was unrolled and placed on the rough surface after hysterectomy or subtotal hysterectomy with or without adnexectomy. The time from the insertion of the first piece of membrane into the abdominal cavity to the complete removal of the trimmed plastic sleeve was recorded. The median time for Seprafilm placement was 3 min. The learning curve was analyzed using the power-law method and suggested that 10 cases were required to achieve proficiency in the procedure. The presence of adnexectomy was significantly associated with the time required for Seprafilm placement (P < 0.001). Although Seprafilm placement is more complicated compared to the liquid and gel forms of anti-adhesion barriers, surgical proficiency seemed to be attained after 10 cases for an experienced surgeon.

Laparoscopic surgery for benign adnexal conditions under spinal anaesthesia: Towards a multidisciplinary minimally invasive approach.

BACKGROUND: Laparoscopic gynaecological surgery is commonly performed under general anaesthesia with endotracheal intubation. In general surgery, locoregional anaesthesia was applied to laparoscopic procedures, increasing minimally invasive surgery advantages. AIMS: To assess and compare postoperative pain after laparoscopic adnexal procedures for benign conditions under spinal anaesthesia (SA) versus general anaesthesia (GA). Furthermore, anaesthesiologic, surgical and clinical data were evaluated in both groups. MATERIALS AND METHODS: This is a prospective cohort study performed in a tertiary level referral centre for minimally invasive gynaecological surgery (Gynaecology and Human Reproduction Physiopathology, University of Bologna). Women scheduled for adnexal laparoscopic surgery for benign conditions between February and May 2019 were assigned to receive either SA or GA with endotracheal intubation. A sample size of 13 women per group was needed to detect a 2-point difference in pain scores. MAIN FINDINGS: 13 women were enrolled in the SA arm, 15 in the GA arm. In the SA cohort, the most common intraoperative adverse event was shoulder pain, reported by 3/12 women. At 1, 8, 12, 24 and 48 h after surgery pain was significantly lower in the SA arm (p < .05). Patients submitted to SA experienced no need for opioid drugs administration, unlike those receiving GA. Patients' mobilization and return of bowel function were noted significantly earlier in the SA group (p < .05). CONCLUSIONS: SA is a feasible, safe and effective anaesthesiologic technique for laparoscopic gynaecological procedures for benign conditions, allowing a better control of postoperative pain. Women undergoing SA achieve earlier mobilization and bowel canalization. During the Covid-19 pandemics, SA could be useful in reducing the need for invasive procedures on respiratory tract.

Laparoscopic adnexectomy under regional anaesthesia: It is possible!

At present, the majority of laparoscopic operations are performed under general anaesthesia, as it controls surgical pain and improves patient comfort using pneumoperitoneum and the Trendelenburg position. However, some laparoscopic procedures, such as adnexectomies, can potentially be performed under epidural anaesthesia with a purposefully selected and motivated patient managed by prepared surgical and anaesthesia care teams working together effectively. This study reports the case of a 63-year-old female patient with major respiratory failure who underwent laparoscopic bilateral adnexectomies under epidural anaesthesia.

Extraperitoneal Uterosacral Ligament Hysteropexy: A Novel Treatment for Apical Compartment Prolapse.

OBJECTIVE: To treat mild-to-moderate apical compartment prolapse while preserving the uterus, our extraperitoneal uterosacral ligament hysteropexy repair technique was developed. Hysterectomy for prolapse accounted for 13% of all benign hysterectomies, which is the third most common reason.1 Although concomitant hysterectomy risks at time of prolapse surgery are not well defined, risks associated with hysterectomy have been well described in the literature. Additionally, it is well known that anterior compartment prolapse often has an apical component.2 Benefits of hysteropexy in prolapse surgery consistently cited in the literature include reduced surgical time, blood loss, and morbidity.3 A study by Frick et al, reported more than 60% of women would decline a concomitant hysterectomy if offered an equally efficacious surgical option.4 Our primary aim was to achieve anatomical success as defined as apical POP-Q less than or equal to Stage 1, resolution of subjective bulge and no reoperation for recurrent prolapse. METHODS: We performed a retrospective case series of extraperitoneal uterosacral ligament hysteropexy (EPUSLH) procedures from 2017 to 2019. RESULTS: In our case series, the objective cure rate (POP-Q apical prolapse stage ≤1) and the subjective cure rate at 5 months follow up was 100%, refer to Table 1. The mean length lost in total vaginal length compared to baseline was 0.5 cm, refer to Table 2. Mean surgical time for EPUSLH with combined procedures was 110 minutes. The mean EBL was 101 mL. CONCLUSION: EPUSLH demonstrated good short-term success with a low rate of complications in this small cohort. Being a tertiary referral center with many patients traveling long distances or internationally has limited follow-up. Although larger numbers and long-term follow-up are needed to better understand the success of this procedure, the early results are encouraging that this technique could be a simple alternative hysteropexy method.

[Borderline Ovarian Tumours: CNGOF Guidelines for Clinical Practice - Therapeutic Management of Early Stages]. / Tumeurs frontières de l'ovaire. Recommandations pour la pratique clinique du CNGOF ­ Prise en charge thérapeutique des stades précoces.

OBJECTIVES: To provide guidelines for clinical practice from the French College of Obstetrics and Gynecology (CNGOF), based on the best evidence available, concerning early stage borderline ovarian tumors (BOT). METHODS: Bibliographical search in French and English languages by consultation of Pubmed, Cochrane, Embase, and international databases. RESULTS: Considering management of early stage BOT, if surgery is possible without a risk of tumor rupture, the laparoscopic approach is recommended compared to laparotomy (Grade C). In BOT, it is recommended to take all the measures to avoid tumor rupture, including the peroperative decision of laparoconversion (Grade C). In BOT, extraction of the surgical specimen using an endoscopic bag is recommended (Grade C). In case of early stage, uni or bilateral BOT, suspected in preoperative imaging in a postmenopausal patient, bilateral adnexectomy is recommended (Grade B). In cases of bilateral BOT and desire of fertility preservation, a bilateral cystectomy is recommended (Grade B). In case of mucinous BOT and desire of fertility preservation, it is recommended to perform a unilateral adnexectomy (Grade C). In case of endometrioid BOT and desire of fertility preservation, it is not possible to establish a recommendation of treatment choice between cystectomy and unilateral adnexectomy. In case of mucinous BOT at definitive histological analysis in a woman of childbearing age who had an initial cystectomy, surgical revision for unilateral adnexectomy is recommended (Grade C). In the case of serous BOT with definitive histological analysis in a woman of childbearing age who has had an initial cystectomy, it is not recommended to repeat surgery for adnexectomy in the absence of residual suspicious lesion during initial surgery and/or on postoperative imaging (referent ultrasound or pelvic MRI) (Grade C). An omentectomy is recommended for complete initial surgical staging when BOT is diagnosed on extemporaneous analysis or suspected on preoperative radiological elements (Grade B). There is no data in the literature to recommend the type of omentectomy to be performed. If restaging surgery is decided for a presumed early stage BOT, an omentectomy is recommended (Grade B). Multiple peritoneal biopsies are recommended for complete initial surgical staging when BOT is diagnosed on extemporaneous or suspected on preoperative radiological elements (Grade C). In case of restaging surgery for a presumed early stage BOT, exploration of the abdominal cavity should be complete and peritoneal biopsies should be performed on suspicious areas or systematically (Grade C). A primary peritoneal cytology is recommended in order to achieve complete initial surgical staging when BOT is suspected on preoperative radiological elements (Grade C). In case of restaging surgery for presumed early stage BOT, a first peritoneal cytology is recommended (Grade C). For early serous or mucinous BOT, it is not recommended to perform a systematic hysterectomy (Grade C). For early stage endometrioid BOT, and in the absence of a desire to maintain fertility, hysterectomy is recommended for initial surgery or if restaging surgery is indicated (Grade C). For endometrioid-type early stage BOT, if there is a desire for fertility preservation, the uterus may be retained subject to good evaluation of the endometrium by imaging and endometrial sampling (Grade C). In case of surgery (initial or restaging if indicated) for early stage BOT, it is recommended to evaluate the macroscopic appearance of the appendix (Grade B). In case of surgery (initial or restaging if indicated) for early stage BOT, appendectomy is recommended only in case of macroscopically pathological appearance of the appendix (Grade C). Pelvic and lumbar aortic lymphadenectomy is not recommended for initial surgery or restaging surgery for early stage BOT regardless of histologic type (Grade C). In case of BOT diagnosed on definitive histology, the indication of restaging surgery should be discussed in Multidisciplinary Collaborative Meeting. For presumed early stage BOT, it is recommended to use the laparoscopic approach to perform restaging surgery (Grade C). Restaging surgery is recommended for serous BOT with micropapillary appearance and unsatisfactory abdominal cavity inspection during initial surgery (Grade C). Restaging surgery is recommended in case of mucinous BOT if only a cystectomy has been performed or the appendix has not been visualized, then a unilateral adnexectomy will be performed (Grade C). If a restaging surgery is decided in the management of a presumed early stage BOT, the actions to be carried out are as follows: a peritoneal cytology (Grade C), an omentectomy (there is no data in the literature recommending the type of omentectomy to be performed) (Grade B), a complete exploration of the abdominal cavity with peritoneal biopsies on suspect areas or systematically (Grade C), visualization of the appendix± the appendectomy in case of pathological macroscopic appearance (Grade C), unilateral adnexectomy in case of mucinous TFO (Grade C).

Impact of prior hysterectomy on surgical outcomes for laparoscopic adnexal surgery.

BACKGROUND: Adnexal surgery is believed to be more complex in patients with prior hysterectomy; however, there is little data regarding surgical outcomes. Understanding of individualized risks improves counseling, informed consent, and preoperative planning. METHODS: We performed a retrospective cohort study with a control group; we evaluated 744 patients undergoing laparoscopic adnexal surgery at an academic tertiary care center from 2011 to 2015. Comparisons were made using Chi square, Fisher's exact, or Wilcoxon-rank sum tests. We used log-binomial regression to calculate risk ratio and 95% confidence interval. RESULTS: Patients with prior hysterectomy were more likely to have intraoperative or postoperative complications at the time of laparoscopic adnexal surgery when compared to patients without prior hysterectomy [17.7% vs. 10.2%, p = 0.02, risk ratio (RR) 1.7, 95% confidence interval (CI) 1.1-2.7]. Patients with prior hysterectomy were four times more likely to have intraoperative complications (3.2% vs. 0.8%, p = 0.047, RR 4.0, 95% CI 1.1-14.7), and five times more likely to have conversion to laparotomy (5.6% vs. 1.1%, p = 0.004, RR 5.0, 95% CI 1.8-14.0). Patients with prior hysterectomy were more likely to need additional procedures, including lysis of adhesions (69.4% vs. 26.0%, p < 0.001), ureterolysis (15.3% vs. 4.8%, p < 0.001), and cystoscopy (28.2% vs. 8.1%, p < 0.001). They had longer operative time [101.5 min (IQR 59.5-135.0) vs. 78.0 min (IQR 53.0-109.0, p < 0.001)], and were less likely to have outpatient surgery (56.5% vs. 84.8%, p < 0.01). Postoperative complications were also more common (15.3% vs. 9.4%, p = 0.046). CONCLUSIONS: Patients with prior hysterectomy were 70% more likely to have a complication at the time of laparoscopic adnexal surgery than patients without hysterectomy. Increased risk of complications in subsequent adnexal surgery may influence the informed consent process or decisions regarding ovarian conservation. Awareness of potential need for additional surgical procedures may guide availability of equipment, choice of operating site, or referral to an advanced pelvic surgeon.