Diagnostic Accuracy of the Sonographic Sliding Sign for Predicting Pelvic Organ Adhesions in Gynecologic Endoscopic Surgery

Abstract

Background: Pelvic adhesions are a common consequence of prior abdominal surgery, endometriosis, malignancy, or infection, often leading to infertility, chronic pelvic pain, and surgical complications. Reliable preoperative prediction of these adhesions can guide surgical planning and minimize risks. The sonographic sliding sign has shown promise in detecting intra-abdominal adhesions, yet its routine use remains limited. This study aims to evaluate the diagnostic accuracy of both transvaginal and transabdominal ultrasonographic assessments of the sliding sign in predicting intra-abdominal adhesions prior to gynecologic endoscopic surgery. Methods: This retrospective cohort study included 262 women who underwent gynecologic endoscopic surgery at a tertiary care center in 2024. Patients with body mass index (BMI) > 35 were excluded. Both transabdominal and transvaginal ultrasonographic evaluations of the sliding sign were performed preoperatively by a single experienced physician, while operative outcomes were recorded by a blinded observer. Adhesion status, operative time, hospital stay, and surgical complications were analyzed. Statistical methods included Chi-square, Fisher's Exact test, Mann-Whitney U test, and receiver operating characteristic (ROC) curve analysis. Results: Intra-abdominal adhesions were confirmed in 56 patients (21.4%). Absence of the sliding sign was significantly associated with the presence of adhesions (p < 0.001). Transvaginal sonography yielded a sensitivity of 77%, specificity of 100%, and area under curve (AUC) of 0.884. Transabdominal sonography demonstrated higher accuracy, with a sensitivity of 96%, specificity of 100%, and AUC of 0.982. The combination of both methods matched the diagnostic performance of transabdominal ultrasound alone. Adhesions were significantly associated with previous abdominal surgery (p < 0.001), endometriosis (p = 0.01), hypotrophic or keloid scars (p < 0.001), obliteration of the Douglas pouch (p < 0.001), longer hospital stay (p = 0.006), and increased rates of hemorrhage (p = 0.003) and bladder injury (p = 0.03). Conclusion: Preoperative ultrasonographic evaluation of the sliding sign is a highly accurate, non-invasive, and practical tool for predicting intra-abdominal adhesions. Both transabdominal and transvaginal sonography offers superior sensitivity and should be considered in routine preoperative assessments. Integration of this method into standard preoperative protocols may help reduce complications, optimize surgical planning, and improve patient outcomes in gynecologic endoscopic procedures.