Diagnostic Accuracy and Reproducibility of Predicting Cul-de-Sac Obliteration by General Gynaecologists and Minimally Invasive Gynaecologic Surgeons

Authors Organisations
  • Mathew Leonardi(Author)
    University of Sydney
  • Shannon Reid(Author)
    Liverpool Hospital, Sydney
  • Chuan Lu(Author)
  • Bassem Gerges(Author)
    Blacktown Hospital, Sydney
  • Tim Chang(Author)
    Blacktown Hospital, Sydney
    Campbelltown Private Hospital
  • Luk Rombauts(Author)
    Monash IVF Australia
    Monash Health
    Monash University
  • Martin Healey(Author)
    Monash IVF Australia
  • Danny Chou(Author)
    The Sydney Women's Endosurgery Centre
  • Sarah Choi(Author)
    The Sydney Women's Endosurgery Centre
  • Dheya Al-Mashat(Author)
    University of Sydney Nepean Hospital
  • Robert Magotti(Author)
    University of Sydney Nepean Hospital
  • Ralph Nader(Author)
    Hawkesbury Hospital
Type Article
Original languageEnglish
Pages (from-to)443-449.e2
JournalJournal of Obstetrics and Gynaecology Canada
Issue number4
Early online date22 Oct 2018
Publication statusPublished - 01 Apr 2019
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Knowledge of rectouterine cul-de-sac state and consistent classification among surgeons are important in the surgical management of women with endometriosis. The objective of this study was to determine the diagnostic accuracy and interobserver and intraobserver agreement among general gynaecologists (GGs) and minimally invasive gynaecologic surgeons (MIGSs) in the prediction of cul-de-sac obliteration at off-line analysis of laparoscopic videos.

Five GGs and five MIGSs viewed 33 prerecorded laparoscopic video sets off-line to determine cul-de-sac obliteration state (non-obliterated, partially obliterated, or completely obliterated) on two occasions (at least 7 days apart). Diagnostic accuracy and interobserver and intraobserver agreement were evaluated.

The interobserver agreements for all 10 observers for the description of cul-de-sac state ranged from fair to substantial agreement, with moderate overall agreement. MIGSs had slightly higher within-group interobserver agreement compared with GGs. MIGSs achieved overall almost perfect intraobserver agreement compared with substantial agreement for GGs. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for MIGSs classifying the cul-de-sac state were 83.9%, 88.5%, 88.5%, 89.2%, 92.0%, and 84.7%, respectively, whereas for GGs, they were 79.1%, 79.4%, 88.1%, 89.9%, and 76.1%, respectively.

Diagnostic accuracy and interobserver and intraobserver agreement for cul-de-sac obliteration state classification is acceptable in both groups. MIGSs had greater diagnostic accuracy and exhibited high interobserver and intraobserver agreement, a finding suggesting that their advanced training makes them more reliable in cul-de-sac obliteration assessment. Partial cul-de-sac obliteration was the most commonly incorrectly diagnosed state, thus implying that partial obliteration is not well understood.


  • rectouterine pouch, diagnostic accuracy, interobserver agreement, intraobserver agreement, reproducibility study