Video-Based Assessment of Operative Complexity in Endometriosis: Associations of AAGL 2021, #Enzian, and rASRM Classifications with Operative Time and Advanced Surgical Procedures

Study objective: To evaluate how the AAGL 2021, #Enzian, and revised American Society for Reproductive Medicine (rASRM) classifications reflect operative time, advanced surgical procedures, and blood-loss-related perioperative outcomes in a video-reassessed cohort of laparoscopic endometriosis surgeries.

Design: Retrospective cohort study using systematic postoperative operative-video review.

Setting: Tertiary referral center for minimally invasive endometriosis surgery.

Participants: Women undergoing laparoscopic surgery for endometriosis between January 2023 and May 2026. A total of 86 cases with complete operative time data constituted the primary analytic cohort.

Interventions: Operative videos were independently reassessed using the AAGL 2021, #Enzian, and rASRM classifications. Advanced surgical procedures were defined as ureterolysis, rectal shaving, discoid bowel resection, segmental bowel resection, or vaginal excision. Blood-loss-related perioperative outcomes included hemoglobin drop and blood transfusion.

Measurements and main results: Median age was 39.0 years (IQR, 34.2-41.0), and median operative time was 115.0 minutes (IQR, 77.2-160.0). The AAGL 2021 total score showed the strongest correlation with operative time (Spearman ρ=0.619; P<.001), followed by the rASRM total score (ρ=0.572; P<.001). Among #Enzian compartments, C, FU, B, and A were significantly associated with operative duration. In multivariable linear regression, the AAGL 2021 total score remained independently associated with operative time after adjustment for age and hemoglobin drop (β=1.44 minutes per point; 95% CI, 0.97-1.92; P<.001). Each 10-point increase in AAGL score was associated with increased odds of undergoing any advanced surgical procedure (adjusted OR, 2.54; 95% CI, 1.69-3.81; P<.001). For postoperative discrimination of any advanced procedure, the AUC was 0.875 (95% CI, 0.799-0.939) for AAGL 2021 and 0.803 (95% CI, 0.708-0.887) for rASRM (DeLong P=.022). For bowel procedures, the corresponding AUCs were 0.877 and 0.843, respectively; for ureterolysis, 0.837 and 0.792. Interobserver agreement was excellent for both AAGL 2021 and rASRM total scores (ICC=0.998 for each). For #Enzian, compartment-level agreement was substantial to almost perfect, with weighted kappa values ranging from 0.662 to 1.000.

Conclusion: In this video-reassessed cohort of complex laparoscopic endometriosis surgery, the AAGL 2021 total score showed the strongest association with observed operative complexity and the highest postoperative discrimination for advanced surgical procedures, whereas #Enzian provided complementary anatomic characterization of disease extent. These findings support the complementary use of AAGL 2021 for standardized assessment of surgical complexity and #Enzian for detailed anatomic mapping, while rASRM remains useful as a widely recognized global staging system.