Laparoscopic Surgical Techniques Endometriosis and Adenomyosis · Diagnostic andTherapeutic...

Diagnostic and Therapeutic Endoscopy, Vol. 6, pp. 153-168Reprints available directly from the publisherPhotocopying permitted by license only

(C) 2000 OPA (Overseas Publishers Association) N.V.Published by license under

the Harwood Academic Publishers imprint,part of The Gordon and Breach Publishing Group.

Printed in Malaysia.

Laparoscopic Surgical Techniques for Endometriosisand Adenomyosis

C. WOODa’*, P. MAHERb and R. WOODS

aEndometriosis Care Centre of Australia, Monash IVF, Monash University, Cliveden Hill Private Hospital, Victoria, Australia;bMercy Hospitalfor Women, Victoria, Australia; CBox Hill Hospital, Melbourne, Victoria, Australia

(Received 25 January 2000; Revised 10 March 2000; In finalform 10 May 2000)

The details ofsurgical techniques for laparoscopic removal ofendometriosis and adenomyosisare described briefly in textbooks and gynaecological journal articles. We have described awide variety of techniques for the various procedures required in the treatment of endo-metriosis and adenomyosis, excluding hysterectomy. The principles are based upon those usedin removal of primary cancer lesions. The limitations of thermal ablation are discussed, andevidence of improved results after excision of lesions have been submitted for publication.

Keywords: Adenomyoma, Endometriosis, Laparoscopy, Surgical techniques

INTRODUCTION

A review of surgical treatment of endometriosis ispresented because of the difficulty expressed bygynaecologists in removing endometriosis when it isextensive or involving vital structures such as theureter, bladder, rectum, ovary or major vessels. Thishas been exemplified by a study of 198 patients withrecurrent endometriosis referred to the Endometri-osis Clinic with an average of 5.7 previous medicaland surgical treatments who underwent furtherlaparoscopy assessment [1]. Two-thirds of thesepatients had disease mainly located over the courseof the ureter, or on the rectum, the vagina, or thebladder. This suggests that the previous surgery,

which involved CO2 laser or diathermy and wasperformed on an average 2.7 times, may haveavoided vital structures to avoid the risk of traumato them.Our previous articles concerning the use of

laparoscopy surgery have not detailed the surgicaltechniques. The difficulty in learning laparoscopictechniques is illustrated by a review of journalarticles and books describing techniques used forthe laparoscopic removal of an ovary. The numberof steps described was always 6 or less and thedetailed pieces of information which make this asafe procedure were always less than 20. In our ownestimation there were 19 important steps and over100 pieces of relevant information (see text).

* Corresponding author. 19 Simpson Street, Melbourne, Victoria 3002, Australia. Tel.: +61 3 9415 7722. Fax: -+-61 3 9415 8461.E-mail: [email protected].

153

154 C. WOOD et al.

Endometriosis is the most frequent reason forgynaecologic operative laparoscopy in the UnitedStates and probably also in Australia [2]. It istherefore important for the laparoscopist to bethoroughly familiar with the current standards ofmanagement.

TeLinde and Scott defined the objectives of surgi-cal treatment of endometriosis in 1952: "one shouldexcise or fulgurate all evident endometriosis." Thesurgical objectives of laparoscopic treatment aresimilar, i.e. to remove all evident endometriosis byexcising large superficial and deep lesions and onlyvaporizing smaller deposits. The limited hormonalresponsiveness of ectopic endometrium has deter-mined the need to perform surgery [3].The technical advantages of a laparoscopic

approach to endometriosis surgery include: easyintraoperative access to the rectum, vagina, andureter, magnification which is easier to manipulatethan an operative microscope, and the ability toperform an underwater examination at the end ofthe procedure during which all blood clot is evacu-ated and complete haemostasis obtained. Thegeneral advantages of laparoscopy include: sameday diagnosis and treatment, short hospitalization,rapid recuperation, superior scar cosmetics, excel-lent patient acceptance, cost effectiveness, andresults at least equal to laparotomy [2].The advanced laparoscopic surgeon may use a

variety of techniques and requires equipment formechanical cutting, electrosurgery, aquadissection,suturing and stapling. Electrosurgery and laserhave equivalent results in the relief of pain andinfertility [4].

LAPAROSCOPIC TECHNIQUES

Bleeding

Bleeding problems are common and difficult toresolve. Coagulation current is rarely used. The tipof a spoon electrode is used to cut and, the roundbody of the electrode is used to tamponade arteri-olar bleeding vessels after which cutting current isapplied to coagulate the vessel wall. The Kleppinger

bipolar forceps (Richard Wolf) are most effectivefor large vessel haemostasis. A number of bipolarforceps are not robust and do not tamponadelarger vessels so that the application of current isineffective.

Suturing

Suturing with large curved needles using 5 mm lowerquadrant incisions requires a special technique toput them into the peritoneal cavity [5]. Lowerabdominal incisions placed lateral to the rectusmuscle make a path that is very easy to re-enter onremoving the trocar sleeve. To suture with a needle,the trocar sleeve is taken out of the abdomen andloaded by introducing a grasping forceps throughthe cannula. The forceps grasps the distal end of thesuture, and pulls the suture through the trocarsleeve. The forceps is reinserted through the can-nula, and grasps the suture 2 cm from the needle.The needle and forceps is inserted into the peritonealcavity through the original tract as visualized on themonitor; the needle follows through the soft tissueand the trocar sleeve is pushed downward over thedriver to reinsert it at its original position in theperitoneal cavity.The needle is grasped by the forceps and sutur-

ing achieved. Arter this the needle is placed in theanterior abdominal wall parietal peritoneum forremoval after the suture is tied. The suture is cutadjacent to the needle, and the cut end of the sutureis pulled out of the peritoneal cavity; the knot thenis tied with a knotpusher without loss of pneumo-peritoneum because of the tight seal of the trocarsleeve. The surgeon holding both strands makes asimple half-hitch. The knot-pusher is placed on onestrand ofthe suturejust above the knot, the suture isheld firmly across the index finger and the throw ispushed down to the tissue defect. The second throwis made in the same direction (i.e. a slip knot) whileexerting tension from above to further secure thetissue. The knot is secured with the third and fourththrows by pushing half-hitches, made in the oppo-site way, down to the knot to secure it firmly. Toretrieve the needle the trocar sleeve is pulled out

LAPAROSCOPY FOR ENDOMETRIOSIS 155

and the needle holder inside it drags the needlethrough the soft tissue. The trocar sleeve is replacedeasily with or without another suture.

Suturing may be easier using the Endo Stitch(R).It enables a suture to be placed with a 10 mm diam-eter instrument containing the needle and suturewithin the caliber of the instrument. Placement ofthe suture and the resultant tie are controlled fromthe handle avoiding the complexity of several sepa-rate steps using separate needle holding, sutureneedle and knot pushing equipment.

Equipment

High flow CO2 insuffiation to 15 L/min or more isnecessary to compensate for the rapid loss of CO2during suctioning. The ability to maintain a rela-tively constant intra-abdominal pressure between10 and 15mmHg during laparoscopic surgery isessential. Operating room tables capable of a 30Trendelenburg’s position are extremely valuable forlaparoscopic deep pelvic dissection.

Extracorporeal tying is facilitated by using atrocar sleeve without a trap to avoid difficulty inslipping knots down to the tissue. The AppleTrocar(R) (Apple Medical, Boston, MA) has a tightseal preventing loss of pneumoperitoneum whenpushing the knot down.

Preoperative Preparation

Preoperative ovarian suppression is not often usedfor therapy as only mild endometriosis reductionoccurs and that which does prevents the removal ofresidual microscopic lesions [3].

Preoperative oral Fleet(R) is given in 1-2 bottlesif deep pelvic endometriosis is expected whichrapidly clears the bowel. Alternatively, a Durolax(R)

or Fleet(R) enema may be given to clear the lowerbowel.

PERITONEAL EXCISION

Our preference for excision is based upon the fallacyof vaporizing or burning lesions and then claimingendometriosis has been treated. The diagnosis of

endometriosis is histological, not visual. Endomet-riosis is found in only 47% ofyellow brown defects,67% of glandular blister lesions and 81% of whiteopaque and red flame lesions [6,7]. Even in the mostexperienced hands visual identification is only 81%accurate, and in less experienced hands, 41% [8].Biopsy studies show that at least 7% of lesions aremissed and the extent ofdisease is underestimated in50%, histology showing disease at the border of theexcised tissue which was intended to be complete [9].It is unfair and unethical to label a patient as havingendometriosis when they may not, as unnecessaryanxiety, possible drug therapy, and misdiagnosis isto their disadvantage. If this argument is acceptedthere is no point in taking a biopsy of part of thelesion, and burning the remainder, as biopsy neces-sitates complete excision. When multiple lesionswith macroscopic features ofendometriosis are pre-sent, only 2 of 3 lesions excised from 30 patientswere histologically proven to be endometriosis. Theremainder were granulomas, scar or vascular tissue[10]. The presence and extent ofthe disease can onlybe assessed by excising all suspicious lesions.A controlled trial to compare peritoneal excision

to thermal ablation is difficult to design as the diag-nosis of endometriosis when all suspicious lesionsare excised will be more accurate than vaporizationor thermal ablation, when most of the tissue is notexamined, and women without endometriosis willbe included in the latter group.

Surgical considerations also favour excision.While most endometriosis is not penetrating, a sig-nificant number of women with persistent diseasehave lesions infiltrating beyond 5 mm, 21% (41 of198) and 8% (16 of 198) infiltrating the rectal muscleand 8% (16 of 198) infiltrating the wall of thebladder [1]. The reason for the persistence or recur-rence is most likely the use ofthermal ablation whenthe depth of ablation may be limited because ofeither the false assumption that lesions are super-ficial and deeper treatment is unnecessary, or thatharm may result to the bladder, bowel, ureter, arter-ies or veins.The average number of previous surgical treat-

ments by laser or electrocoagulation, was 2.7, so it

156 C. WOOD et al.

is reasonable to assume that some of the 16 patientsrequiring resection of the rectum or excision of asegment of the bladder may have avoided this byearlier excision defining and removing the infiltrat-ing lesion. Ten of these patients had symptomsrecurring within 6 months of the previous laparo-scopic treatment.

Occult microscopic endometriosis has been foundin 13% of normal looking peritoneum next to thevisible lesion [11]. This finding and the histologicallyproven frequent incomplete removal in 50% ofcases when the edge of excised lesions were exam-ined suggests that peritoneal excision or thermalablation need to include or 2 cm of tissue beyondthe visible lesion [9].Another limitation of thermal ablation is that if

the pathology is coagulated it may be replaced bywhite scar which obscures assessment of the extentof pathology. Vaporization by laser or sparkingpoint diathermy avoids this. This is achieved byusing 80W cutting current with a fine needle held1-3 mm from the surface of the lesion. The use ofthermal ablation may increase the risk ofdamagingthe ureter, uterine artery, bladder or rectal musclewhen the lesions are sited over the surface of thesestructures. The most common sites ofendometriosisin the 198 patients with recurrent endometriosiswas on the lateral pelvic wall over the course of theureter and on the surface of the bladder, rectum,vagina and pararectum, accounting for 67% ofcases. Excision allows safe removal ofendometriosisover or attached to the ureter and precise excision ofinfiltrating lesions in the wall of the bladder, vaginaand rectum.Other reasons for using excision is the cost

reduction as laser is not required, and the absenceof necrotic areas which may form scar tissue whichresults from extensive electrocoagulation.Although studies of excisional surgery are un-

controlled the lower recurrence rates reported after1-3 years than after ablation suggests that it is equalor better [12-14]. The unsatisfactory diagnosticbasis of a controlled trial of the 2 methods (seep. 7) limits proof that excision may be better thanthermal ablation.

LATERAL PELVIC WALL

Lateral pelvic wall peritoneum is mobilized beforeexcision. Fine toothed grasping forceps are used tograsp the endometriotic lesion and retract the peri-toneum medially from the lateral pelvic wall. If thelesion is friable, opaque or adherent to underlyingtissue, normal peritoneum above the lesion isretracted and the dissection commenced in normaltissue enabling the size and depth of lesion to bedefined. Surrounding anatomy such as the ureter,internal iliac artery and its branches becomes moreobvious after peritoneal mobilization. The laparo-scope is placed close to the lesion to magnify theanatomy. Blunt ended scissors or spoon electrodeare used to open a small hole in the peritoneum. It isimportant to reflect any tissue adherent to the innersurface of the peritoneum as it may contain anadherent ureter or uterine artery, before extendingthe peritoneal excision. If the peritoneum is vas-cular, cutting or coagulation diathermy is used asrequired.An elliptical incision is made in normal perito-

neum surrounding the fibrotic portion ofthe lesion,its edge lifted outwards, and the lesion underminedusing scissors or pressurized irrigant from a suction-irrigation device (aquadissector) to push the fibroticendometriosis from the underlying pelvic side wall,rectum, or bladder. Gentle aquadissection openslow resistance tissue planes avoiding trauma to ves-sels on the ureter and is particularly useful if scartissue prevents identification of normal anatomy.Suction should not be applied when the instrumentis in contact with the ureter or blood vessels. Thismakes undercutting of the lesion with scissors orelectrosurgery safer.

In the presence of peritoneal thickening it maybe difficult to visualize the course of the ureter;the peritoneum is cut from the upper pelvic wall in2-5 mm steps and the course of the ureter is iden-tified as the peritoneum is retracted. Small bloodvessels close to the ureter are avoided where possibleas they may affect ureteric integrity. If the perito-neum is adherent to the ureter then the ureter is iso-lated proximal to the adherence where it is mobile,


and retracted. This allows more control and accu-rate dissection between the ureter and peritoneumover the adherent area as the dissection proceedsforward.

If the ureter cannot be seen even after peritonealdissection because of extreme fibrosis, uretericcatheters can be used, or the ureter is dissected fromthe level of the pelvic brim. Catheters enableidentification of the ureter by moving the catheteror by feeling the solid consistency of the catheterwith a forcep.

Small pinpoint endometriotic lesions can bevaporized using the CO2 laser or unipolar cutting-current held 1-3 mm from the surface of the lesionwith resultant drainage of hemosiderin-filled fluidin cases where deposits have progressed to justbeneath the peritoneum. The base of the lesion isthen vaporized until normal tissue is seen.The peritoneum tends to be more adherent on the

posterior wall of the broad ligament close to theuterus. In this situation knowledge of the courseof the ureter and uterine arteries is mandatory. Ifthe lesions are superficial, the peritoneum may bestripped without harming the uterine vessels orureter.

If the lesion is infiltrative then ureteric dissectionfrom the posterior to anterior lateral pelvic walldetermines the position of the uterine artery andvein, crossing the ureter which are then ligated bybipolar electrocoagulation, or clip ligation.

This is an important technique as dissection onthe posterior leaf of broad ligament or anterior onthe lateral pelvic wall may result in uterine arterybleeding which is difficult to control without risk ofdamaging the ureter.When an endometriotic nodule has infiltrated

deeply, the anatomy is distorted and the uterineartery or anterior branch of the internal iliac arteryis safely ligated close to the pelvic wall. The uterineartery can be found by following the obliteratedhypogastric artery posteriorally into the triangleformed by the round ligament, the lateral pelvic walland the infundibulo-pelvic ligaments. The obli-terated hypogastric artery joins the uterine arterydeep in the triangle. Using this technique the whole

of the peritoneum and lateral pelvic wall can beremoved when necessary.The ovary and/or sigmoid colon may have to be

mobilized from the left lateral pelvic wall prior toexcision of the peritoneum. If the sigmoid colon isadherent to the pelvic wall and adnexae it is best firstmobilized posteriorly close to the junction with thedescending colon as correct tissue planes are easierto determine moving from normal to pathologic tis-sue. Traction of the sigmoid colon (ovary or bowel)should be made with bowel holding forceps, whichare flat and a traumatic late bowel perforations haveresulted from using tooth forceps holding the bowelwall (not the fat tags on the bowel).The area ofperitoneum excised is also important.

Occult (microscopic) endometriosis has been in nor-mal appearing peritoneum in 13-50% of patients[9,11]. Removal of 1-2cm margin of peritoneumaround the lesion may eliminate microscopic foci.

BLADDER LESIONS

It is difficult to determine the depth of a peritonealendometriotic lesion on the bladder by inspection.Elevation of the bladder peritoneum is essential.A small incision is made in the normal peritoneumclose to the lesion and blunt and sharp dissectionused to determine the area and depth of infiltrationofthe disease process. Aquadissection may facilitateperitoneal separation from the bladder. A metalcatheter is helpful in determining the edge of thebladder muscle when excising peritoneal lesionsadherent to the bladder. If the lesion extends intomuscle of the bladder, cystoscopy is performed todetermine the extent and site of bladder involve-ment. This determines the extent and depth of dis-section required and its proximity to the uretericorifices. The vascularity of the bladder muscle maymake it.difficult to determine the periphery of thedisease process. The edge of the specimen removedrequires careful examination to ensure the edge is5 mm clear ofthe endometriotic tissue. Ifthe bladderis entered, the hole is closed in 2 layers, with sizePDS or monocryla and a catheter is placed in situ

158 C. WOOD et al.

for 7 days. A cystogram can be performed after6 days to confirm healing ofthe bladder prior to thecatheter being removed.

If the bladder lesion is close to a ureteric orificeureteric catheters are inserted so that the proximityof the endometriosis to the ureteric orifices can bedetermined. If the disease is close to a ureteric ori-fice, a urological consultation is sought as reim-plantation of the ureter may be necessary.

ENDOMETRIOMA

There are 4 treatments described:

(1) Drug therapy using GnRH analogues orDanazol(R).

(2) Aspiration of the endometrioma with addi-tional anti-endometriosis drug therapy, usuallya GnRH analogue or Danazol(R).

(3) A three step procedure, laparoscopy to diagnoseand aspirate the endometrioma, followed bydrug therapy for 3-6 months, followed by re-laparoscopy and removal ofthe endometrioma.

(4) A one step surgical procedure, excision of theendometrioma.

Removal of the endometrioma is preferable tomedical therapy or simple drainage. The short termdrug therapy cure rate has ranged from 12% to45% and the surgical cure rate after 1-3 years from70% to 90% [15,16]. The best result followed care-ful excision of endometriomas, 90% of patientsbeing pain free at year and 50% conceived [17].

Aspiration of the contents does not remove theactive endometriotic tissue in the wall of the ovary.Drugs may prevent further growth or reduce

the size of the endometrioma. Shrinkage does notindicate shrinkage of the endometriotic tissue, astemporary inactivity in the absence of estrogenstimulation will allow reabsorption ofthe chocolatefluid in the endometrioma cavity over a period oftime. The action of drugs in shrinking the endo-metriotic lining is limited by 2 things, the difficultaccess as the lesions are usually surrounded by

extensive scar tissue, and the nature of the brownor black lesions, which usually have a low estrogenreceptor count, in contrast to red or clear blisterlesions seen elsewhere in the pelvis [18].The 3-step procedure has not proven to be more

effective than a single step surgical procedure, thelatter having a 90% cure rate after one year followup [17]. The 3-step procedure assumes that bothdrainage and drug treatment have lasting benefits,which is very unlikely. In a study of drainage anddrug therapy alone, the majority of lesions, 87%,had recurred within one year [15,16]. The only otherreason to use the 3-step system is that it may makesurgery easier. There is a small advantage in startingthe operation with a small ovary, but this advan-tage no longer exists once the large endometriomashave been drained, which takes only several minutesand reduces the ovary to near normal size. The first2 steps of the 3-step procedure, drainage by lapa-roscopy and drug therapy involves unnecessarycosts, one unnecessary operation and unnecessaryside effects from drug therapy.The one step procedure has been used successfully

in endometriomas up to 16 cm diameter.

TECHNIQUE OF REMOVAL

The operation is achieved using three accessoryincisions: two being used to hold the ovary or theedges of the endometrioma and one for the instru-ment used to excise the endometrioma. Ports onboth sides of the abdomen allow sufficiently wideangles to retract the ovary medially away fromthe lateral pelvic wall or bowel and to open theendometrioma.The endometrioma is incised over the point of

maximum curvature using electrocautery, laser orscissors. Electrocautery has the advantage of con-taining bleeding over the line of the incision, whilescissors facilitate an excellent view of the ovarianwall and endometrioma capsule adherent to theinner ovarian wall. In a minority ofendometriomasan initial incision for drainage is not required, as theendometrioma has formed between the pelvic wall


and ovary or between the irregular surfaces of theovary; the endometrioma drains naturally aftermobilization of the ovary.

Drainage is achieved by suction irrigation toreduce spillage of the chocolate-like material foundinside the endometrioma. A suction irrigator isplaced inside the abdomen at the time of ovarianmobilization, to reduce spillage. Dilution of thickmaterial may be required before the suction iseffective.The cyst cavity is rinsed clean with lactated

Ringer’s solution and the endometrioma thenexcised using 5 mm grasping forceps, and a spoonelectrode or scissors [2]. To create an initial planebetween the ovarian wall and the wall of the endo-metrioma grasping forceps are placed in 2 parts ofthe ovarian wall thus opening the cavity of theendometrioma, and a third grasping forceps is usedto grasp the capsule of the endometrioma. If thisis difficult cutting current (70-100 W), through ascissor or spoon electrode tip is applied at the junc-tion of the cyst wall and ovary to develop a plane ofdissection. This step avoids excessive bleeding.The laparoscope is brought close to the area of

dissection, magnifying the wall of the endometrio-ma clearly. Two grasping forceps to stabilize theovarian cortex while traction is exerted on thecapsule of the endometrioma by a third graspingforceps to peel it from inside the ovary. Sometimesthe wall of the endometrioma will not peel awayfrom the ovary, so that scissor, laser or electro-cautery excision is required. Thermal injury to theovary is reduced by using the scissors, with back-updiathermy used only to control bleeding. If thesurgical plane for excision is not clear because ofexcessive scar or bleeding, the wall of the endome-trioma may be vaporized by electrocautery or laser.The obvious disadvantage is that thermal injurymay occur to adjacent ovarian tissue, reducing thefollicle population in the ovary.

Significant bleeding requires the use of bipolarforceps, which reduces the spread ofcurrent into theadjacent ovary. Suture ofthe ovary may also be usedto control bleeding, using a 3/0 absorbable suturewith a needle large enough to compact the ovarian

tissue. If there is a large raw area of ovary, suturemay reduce the risk of extensive bowel adherenceto the ovary, although controlled trials of routinesuture closure ofthe ovary have shown no reductionof postoperative adhesions compared to leaving anopen ovarian wound [19].Oophorectomy is preferable ifno normal ovarian

tissue is found after removal of a large endome-trioma. Oophorectomy may also be considered ifthe endometrioma has been recurrent or the ovaryis causing pain as a result of being adhered to thelateral pelvic wall by very rigid scar tissue and theovary fragments when dissected.

OVARIAN REMOVAL

A preliminary ultrasound is helpful to detail theposition of the ovary, its size, associated pathology,and fixity or otherwise to neighbouring structure.MRI, especially with special coils, is also useful

in analyzing details of pelvic organs, including theovary, to determine the site, size, fixity and asso-ciated pathology. In several countries it is moreexpensive than vaginal ultrasound and is restrictedin its use to the diagnosis of the pelvic mass whichcannot be assessed by other techniques.

Incisions are made through the umbilicus, 10 mm,and left and right iliac fossa lateral to the rectusmuscle, 5 mm. The lateral incisions may be placedhigher if the ovary is enlarged above the pelvic brim.Another 5 mm midline incision in the suprapubicarea is an advantage in all but the most simpleoperations. Appropriate trocars are placed throughthe incisions.A 10mm laparoscope is inserted through the

umbilicus, and 5mm grasping forceps, spoonshaped monopolar electrosurgical forceps, bipolarelectrosurgical forceps, scissors and a suction irri-gator may be placed through the 5 mm incisions.An intrauterine manipulator is placed inside the

uterine cavity.If the ovary is adherent to the deep pelvis, a rectal

probe is placed inside the rectum.

160 C. WOOD et al.

Inspection of the lower abdomen assesses the sizeand pathology ofthe ovary, the position ofthe ovaryin relation to the uterus, lateral pelvic wall, andbowel and its fixity or mobility.

If the ovary is mobile it is rotated upwards out ofthe pelvis by grasping with a tooth or Allis forceps,and the uterus is moved to the side opposite fromthe ovary being removed, so that the whole of thelateral pelvic wall is visualized, in particular therelationship of the ovary to the ureter [20].Movement of the ureter confirms its position. If

it appears not to move gentle massage or flushingfluid on the ureter may initiate movement. Once theposition ofthe ureter has been established, a furthercheck on its position is made before each step of theoperation to avoid possible damage. If the uretercannot be identified it is visualized at the pelvicbrim and its subsequent course determined by free-ing the ureter from the peritoneum until it haspassed beyond the ovary. If the ureter still cannotbe seen, usually due to scarring of the peritoneumfrom previous endometriosis, the danger ofdamageto the ureter is increased as its course may beabnormal and the ureter may be stuck on the lowersurface of the ovary. The course of the ureter isdetermined by inserting a ureteric catheter andvisualizing the catheter as it is moved up and down.If it still cannot be seen it can be felt by runninga blunt instrument across the lateral pelvic wall tofeel the catheter.

If the ureter is seen close to or passing over thelower part of the ovary it requires dissection andmobilization. This can be performed by elevatingthe peritoneum close to but several millimetersabove or below the ureter and making a small 5-10 mm incision in the peritoneum (see Lateral PelvicWall Dissection).

If the ovary is fixed to the pelvic wall, it may bemobilized by stretching it away from the point offixity, which allows visualization of adhesions orscar tissue. These are cut after making sure of thecourse of the ureter. If the ovary if fixed firmly tothe pelvic wall, the edge ofthe ovary may be difficultto determine. A small incision at the edge of thewhite scar on the retracted ovary, away from the

ureter, ovarian blood vessels and the iliac vesselshigh on the lateral pelvic wall, usually identifies thecorrect plane for dissection. Once in this plane thedissection usually proceeds rapidly.

Sometimes the ovary is completely retroperito-neal. In this case incision and mobilization of theperitoneum over the ovary will enable definitionof the size and position of the ovary. Mobilizationof the ovary proceeds quickly with traction andshort incisions close to the ovary to avoid the ureterand blood vessels on the lateral pelvic wall. If theovary cannot be identified incision of the perito-neum lateral to the ovarian vessels and subsequentmobilization of these vessels will lead to the ovaryand ureter.

If the ovary is enlarged reducing its size may behelpful prior to removal. Before doing so it isimportant to make sure the enlargement is not dueto cancer or a dermoid cyst. The former may beexcluded by vaginal ultrasound, blood tumourmarkers, such as CA125, CEA and inhibin, and byinspection of the ovary for neoplastic characteris-tics. If malignancy cannot be excluded it is betterto remove the ovary intact even if this can only beachieved by laparotomy. A dermoid cyst is usuallydiagnosed by characteristic features on ultrasound.If a large dermoid cyst is accidentally rupturedduring removal, repeated peritoneal washings withsaline or Hartmann’s solution, until the peritonealfluid is clear, will prevent the rare occurrence ofchemical peritonitis or implantation of live tissue,e.g. thyroid tissue.The most common large cysts contain clear

fluid, blood, or chocolate coloured thick fluid.These cysts are aspirated by suction irrigation aftermaking a small hole in the ovarian wall. Flushingthe inside of the cyst ensures emptying and preventsfurther spillage during ovarian removal which mayslow dissection. Proper deflation of large ovariesenables removal of ovaries as large as a 24 weekpregnancy by laparoscopy.

Further mobilization of the ovary may assistremoval. This can be done by cutting the ligamentattaching the ovary to the uterus using scissors,bipolar, diathermy, or spoon electrode, or laser.


The major ovarian blood supply in theinfundibulo-pelvic ligament may be dealt with in5 ways.

(1) The cheapest method is by suture ligation. Therelation of the blood vessels to the ureter ischecked. A small hole is made with scissorsin the peritoneum below the blood vessels withthe ovary stretched away from the pelvic wallto best display the blood vessels. A curvedforceps is placed through the hole with a sizeabsorbable stitch, passing lateral to medialbelow the blood vessels. The end of the sutureis grasped by the same forceps placed abovethe blood vessels, aided by the assistant hold-ing the end of the stitch while the angled for-ceps takes up the new position above the bloodvessels. Two ends of the suture are now outsidethe abdomen and a knot tied by sliding singleknots repeatedly down to the blood vessels,the last two in the opposite loop to lock theknot. Two ligatures are made, each ligature isseparated by about 2 cm. The blood vessels arecut between the ligatures.

(2) Bipolar diathermy may be used to close theblood vessels. With large veins or arteries it maybe difficult to achieve closure of the vessels withshort ended bipolar forceps. Blood flow hasto be occluded by the forceps to obtain effectivecoagulation, so the forceps have to closeeffectively Kleppinger’s corrugated forceps aremost effective.

(3) The Harmonic Scalpel(R) can also be used toclose ovarian blood vessels. It has the advantageof the absence of risks of electrosurgery and theabsence ofsmoke. Although the reusable equip-ment is inexpensive, the basic unit costs AUS$50,000 and about US $32,000.

(4) Vascular clips may be used to close the vessels.They are more expensive and may not be longenough to close large dilated veins.

(5) Staples are the quickest method ofclosing bloodvessels but they are the most expensive. They areeasy to use but require either a second 10 mmincision in the lateral part ofthe abdomen or the

use of a 5 mm laparoscope laterally to view theovary and the placement of the 10-12mmstaple gun through the umbilical incision. Thelatter is preferable and only requires short ex-perience oflooking at the ovary from a differentangle.

After the blood vessels are cut the mesovariumattaching the ovary to the lateral pelvic wall requiresseparation from the ovary. Large veins are presentso bipolar forceps or a spoon electrosurgical forcepsmay be required before the whole ovary is free fromits attachments.The ovary may be removed through the abdomen

or vagina.

The AbdomenThe ovary may be removed through the 10mmumbilical port using a 5 mm laparoscope from oneof the lateral sites to view the removal. This isimportant as if a small piece of ovary drops backinto the abdomen it may implant and cause sub-sequent pain. This technique may be aided by:

(a) reducing the size of the ovary using scissorsor diathermy to make 2 or 3 separate pieces;

(b) the passage of the ovary through the umbilicusmay be aided by placing it in a plastic bagto reduce friction between the ovary and exitduring withdrawal, and to allow a strong grasp-ing forceps to be passed into the neck ofthe bagas it appears in the umbilicus to compress theovary and increase the force of withdrawal, or;

(c) placing a curved blunt ended scissors into theincision, guided by one finger, and enlarging theumbilical incision by 1-3cm in a downwarddirection.

The VaginaIf the ovary is too large to remove through theumbilicus or requires to be removed intact (der-moid cyst or possible malignancy) it may beremoved through the posterior vaginal vault (pos-terior colpotomy) [21] or by a transverse supra-pubic incision enlarged to the size enabling easyremoval.

162 C. WOOD et al.

Removal through the vagina may be done in2 ways:

(a) by distending the vaginal vault behind theuterus with a sponge forceps, and opening thevagina by laparoscopic diathermy or a laserprobe, passing a grasping forceps from thevagina into the pelvis, and extracting the ovary.

(b) by passing a 10 mm trocar and cannula throughthe vaginal vault, removing the trocar andplacing a strong toothed grasping forceps intothe low pelvis and withdrawing the ovary. Thevagina is more elastic than the abdominal walland the hole can be easily dilated, and repairedlater.

The final step in removal of the ovary is to checkhaemostasis. Bleeding may be controlled by bipolarforceps near vital structures, or by a spoon mono-polar electrode.Any 10mm incision requires careful suture ofthe

rectus sheath.

DEEP PELVIC ENDOMETRIOSIS

In contrast to mild endometriosis, laparoscopy isoften unnecessary to diagnose endometriosis in thedeep pelvis. It can usually be diagnosed by clinicalexamination.

These patients need not be subjected to diagnosticlaparoscopy, and can be referred to surgeons capa-ble of treating rectal endometriosis [2].

Rectovaginal examination is diagnostic of endo-metriosis in the pouch of Douglas when nodularityin the rectovaginal septum can be felt and most oftenpelvic tenderness elicited.At laparoscopy careful inspection of the pouch

of Douglas is necessary to evaluate the extent ofadherence of the rectum to the vagina, cervix anduterus [22]. A sponge forceps is inserted into theposterior vaginal fornix and a rectal probe in therectum. The normal posterior fornix shows a por-tion of vaginal wall between the cervix and rectumas a distinct and separate bulge. The uterosacralligaments are normal in calibre, lateral and mobile.

Complete obliteration of the pouch of Douglas isdiagnosed when the outline of the posterior fornixcannot be visualized initially through the laparo-scope; the rectum or fibrotic endometriotic nodulescompletely obscure the vaginal vault.

Surgical Technique

Deep pelvic endometriosis involving the pouch ofDouglas requires excision of nodular fibrotic tissuefrom the uterosacral ligaments, posterior cervix,posterior vagina, and the anterior and lateral rectalsurface [22,23].Drug therapy has been less successful in deep

pelvic disease, because ofthe association with exten-sive scar tissue and the predominance of lesions,brown or black with low levels ofestrogen receptors.The patient is placed in deep Trendelenburg

position to allow the small intestines to fall out ofthe pelvis.

There are 2 main techniques, initial rectal mobil-ization, or initial lateral dissection of the pararectalspace or uterosacral ligaments.The distinction between vagina and rectal wall

may be difficult as the rectum may obscure thevagina and be adherent to it. The vaginal and rectalprobes may assist recognition and dissection of thetwo structures. I prefer to have one finger in therectum and one finger in the vagina using the lefthand and use the right hand to dissect with scissors.Palpation assists visualization both in distinguish-ing the structures and guiding the dissection anddepth of dissection.The Harmonic Scalpel(R) may be preferred

because of the absence of smoke working deep inthe pelvis. If rectovaginal palpation is assisting thedissection, round ended scissors are preferable.

(1) The anterior rectum is dissected from the uterusand vagina until loose areolar tissue in therectovaginal space is reached. Using the rectalprobe or finger in the rectum as a guide to rectallocation, the rectal serosa is opened at its junc-tion with the adherent uterus using scissors.Careful sharp and blunt dissection then ensues


until the rectum, normal or with containedfibrotic endometriosis is separated from theposterior uterus, cervix, upper vagina, andrectum until surrounding loose areolar tissue isidentifiable below the lesion. The fibrotic endo-metriosis is removed from the posterior vagina,uterosacral ligaments, and rectum only afteranterior rectal mobilization is completed.The ureter is visualized prior to excising the

lesion. If it is not seen, dissection at the pelvicbrim or lower in the pelvis is required to deter-mine its course. Sometimes the ureter is attachedto or surrounded by the endometriotic tissue.An aberrant ureter has been seen medial to theuterosacral ligament. The ureter lies lateral tomost cul-de-sac lesions, especially when they areplaced on medial traction. With the uterosacralligament pulled medially, there is less risk ofureteral damage. When the ureter is close to thelesion, its course is traced starting at the pelvicbrim, and when necessary, the peritoneum over-lying the ureter is opened to confirm ureteralposition deep in the pelvis. Uterosacral fibroticendometriosis may envelop the ureter, necessi-tating its dissection and excision.

(2) (a) If the uterosacral ligaments are infiltratedwith endometriosis, they are removed early inthe operation before rectal mobilization. Theymay make up a large portion of the rectalnodule. Part ofthe ligament which has a normalcalibre is identified on the pelvic side wall,divided and put on traction. The peritoneum isincised on both sides of the ligament, and thethickened portion of the ligament is excised,and including its insertion into the cervix. Nor-mal appearing, soft loose areolar tissue, adiposetissue, uterine vessels, and ureter are foundbelow and lateral to the ligament.(b) If the lesion is large, fibrotic and planes ofdissection are difficult to determine, dissectionof the pararectal space may provide a safer andeasier approach to defining the anatomy andpathology of rectovaginal endometriosis. Therectovaginal septum often can be defined moreeasily by a lateral approach to the septum. The

fibrotic, often nodular, endometriotic lesionsare excised from the uterosacral ligaments, theupper posterior vagina (the location of which iscontinually confirmed by the sponge in theposterior fornix or finger), and the posteriorcervix. The dissection of the fibrotic endome-triosis from the vaginal wall proceeds usingtraction with a biopsy forceps to pull the lesionfrom one side to the other; electrosurgery orscissors are used.

The extent of vaginal surgery is determined byremoving all scarred tissue which is localised bycombined vaginal palpation and laparoscopy in-spection and instrument palpation. Frequent palpa-tion using rectovaginal examinations helps identifyoccult lesions. The lesion may penetrate the vaginalwall when dissection removes all visible and palpa-ble fibrotic endometriosis in the vagina.

If the vagina is opened visualization may bemaintained by performing gasless laparoscopyusing the Maher elevator or by packing the vagina.The gasless technique allows vaginal surgery tobe carried out in association with laparoscopicdissection [24].

RECTAL ENDOMETRIOSIS(R. WOODS !51)

Endometriosis in the pouch of Douglas (POD)can range from simple peritoneal changes tosevere infiltrating dense tissue mandating a rectalresection.Symptoms vary although they are not necessarily

proportional to the severity of the pathology. Pre-operative assessment should include vaginal andrectal examinations. If able to be performed simul-taneously this allows forward placement of anyPOD lesions and this mobility gives a guide topossible rectal involvement. Diagnosis may requirean anaesthetic. A colonoscopy is not routinely per-formed. Informed consent is crucial and involvesdiscussion ofpossible bowel resection and potentialcomplications including anastomotic leak and thepossibility of temporary stromas.

164 C. WOOD et al.

Cyclical rectal pain, cyclical bleeding and rectalwall involvement seen and/or felt at rectal exam-ination suggests rectal involvement. Preoperativeassessment can be difficult and sometimes the fullextent is only determined at surgery. If the circum-stances are not favourable for complete excision ofthe endometriosis partial excision should not beattempted as it makes the "definitive" operationmore difficult. The patient should be rescheduled.

In difficult POD dissection the dissection iscommenced laterally with ureteric dissection and/or stenting as the uterosacral ligaments are ofteninvolved and need excision. Early excision or releaseof the ligaments allows for maximal anterior-posterior retraction of the uterus/cervix/vaginaaway from the rectum. Rectal and posterior for-nix probes help delineate the rectovaginal planeand demonstrate any fibrosis by placing tissues ontraction.

Rectal involvement may be diffuse, localised orin close apposition in increasing order offrequency.The degree of rectal involvement with endometri-osis is assessed with a rectal probe and movementof the nodule with a grasper after mobilization ofthe rectum as described above. If clear of rectalmuscle wall it can be easily excised. If the disease islocalised over a small area a trial dissection is per-formed resulting in either total excision or at leastdebulking of the nodule.A localised nodule can be managed by laparo-

scopic excision with suture, transvaginal excisionwith suture or anterior rectal wall disc excision witha circular stapler. This last option is our preferredapproach. This involves debulking the lesion andthen placing the circular stapler eccentrically so thatthe anterior rectal wall with the nodule is containedwithin the stapler. This is achieved by posteriorpressure on the nodule with a suture grasped oneither side of the rectum pushing it within thestapler which is applying counter pressure ante-riorly. A disc of anterior rectum extending to themidlateral extent is excised.

If diffuse involvement is encountered resectionis required. This can be performed laparoscop-ically with mobilization of the rectum below the

endometriosis in the presacral plane and thenmobilization of the sigmoid to the midline withidentification of the left ureter. The posterior meso-rectum (containing the superior rectal vessels) istransected with an endo GIA stapler (vascular) asis the rectum at this level. The sigmoid mesentery isalso transected with an endo GIA. The proximalbowel is then delivered through a minilaparotomyand a pursestring suture is inserted into the proximalbowel after transection. The Permian EEA is thenfired intracorporeally. Any bowel resection or dis-section can also be performed using open lapa-rotomy approach and similar techniques as outlinedabove.

ADENOMYOSIS (C. WOOD 1261)

Conservative surgery involving endomyometrialablation, laparoscopic myometrial electrocoagula-tion or excision has cured symptoms in 32 of 54patients (81.5%) followed for3 years [26].

Technical Difficulty

Laparoscopic surgery may be limited by the needto excise ill-defined tough adenomyotic tissue andto use robust suturing equipment to obtain woundclosure after excising significant areas of myo-metrium. The easier removal of adenomyosis bylaparotomy is a less attractive alternative to laparo-scopy, particularly as cure cannot be guaranteed.Unless the adenomyosis is well defined, as in anadenomyoma, it is not possible to be certain of curefollowing excision or electrocoagulation.The choice of a suitable surgical procedure

depends upon the site and extent of disease, theage of the patient, the desire for future pregnancy,the patient’s desire for certain cure or not, and thesurgical skill of the gynaecologist.

Endo-myometrial Ablation/Resection

The levonorgestrel IUD may be used to controlmenorrhagia and dysmenorrhoea. If this fails endo-metrial ablation may be used.


Endomyometrial resection is most suited topatients with disease limited to the endomyometrialjunction as menstrual symptoms may be reducedand the pathology may be removed. It may also beuseful when adenomyosis is present in the outermyometrium as laparoscopic myometrial excisionalone may not cure menstrual symptoms, eitherbecause excision may be incomplete or the mens-trual symptoms are not caused by the outer my0-metrial adenomyosis.

Technique

The technique of endometrial ablation has beenwell described. If MRI or ultrasound shows theextent and site of endomyometrial distortion theprocedure can be modified to include 2-3 mm ofmyometrium in the affected areas. The whole of theendometrium should be removed as menorrhagiamay be due to factors other than the adenomyosis.Deeper myometrial removal or ablation carries therisk of causing increased bleeding as significantarteries are situated about 5 mm deep to the myo-metrial surface.

Laparoscopic Myometrial Electrocoagulation

Electrocoagulation has the capability of shrinkingadenomyosis by causing necrosis. The techniquehas been applied to localized or extensive disease.The adenomyosis can be detected by MRI, vaginalultrasound, inspection ofthe uterus at laparoscopy,myometrial needling, or manual palpation duringgasless laparoscopy to detect differences in consis-tency between normal and abnormal tissue. Elec-trocoagulation may reduce the strength of themyometrium by replacing abnormal myometriumwith scar tissue. The width of the scar is moreextensive than after surgical excision when closeapposition of normal myometrium is achieved.

Electrocoagulation is best suited to women over40 years of age, who do not wish to conceive, andwho wish to avoid more extensive surgery such asexcision or hysterectomy. Even if recurrence occursthe procedure may be repeated until the onset ofthe menopause when symptoms cease.

Technique

Uterine manipulation with a Valtchev manipulatorimproves access to the diseased areas by facilitat-ing antero-posterior and lateral movement of theuterus.

Vasoconstricting agents such as adrenaline andvasopressin are not used routinely as excessivebleeding has not been experienced and the blanch-ing of the myometrium after vasoconstrictionmakes it difficult to determine the devascularizingeffect ofelectrocoagulation or uterine vessel closure.

Closure of the ascending uterine artery may beperformed if future pregnancy is not wanted, andthe site of the adenomyosis is in the upper uterinebody. Bipolar forceps, clips or suture ligation maybe used to close the uterine vessels. Laparoscopicuterine artery ligation may also be achieved lateralin the pelvis after dissection of the ureter.

Electrocoagulation of the adenomyosis may becarried out with unipolar or bipolar needles, using50W coagulation current. Bipolar needles have atheoretical advantage of concentrating currentbetween the two needles, but their effectiveness isdiminished by the tendency of the two needles tomove close together as they penetrate the myome-trium. Additionally, the area of coagulation mayspread outwards from each needle, simulating theeffect of monopolar electrocoagulation.The extent of coagulation can be controlled by

reducing the current strength and changing thetime the needle(s) are held in position. In order toreduce the possibility of severe surface necrosisand carbonization, either of which may encouragefuture adhesion formation, the insulated part oftheneedle is buried a few millimetres below the uterinesurface before electrocoagulation is commenced.The insulation on the bipolar needle can be ex-tended so that the active part of the electrode isshortened in order to avoid surface coagulation andnecrosis. Needle punctures are made at 1-2cmintervals, depending on the spread of the coagula-tive effect. The depth of needle puncture mayvary, depending on the thickness of the adenomyo-tic myometrium. This varies from 3-25mm.

166 C. WOOD et al.

If hysteroscopic endomyometrial ablation hasalso been carried out, the depth of laparoscopicneedle electrocoagulation may be reduced. Laserhas been used to shrink fibroids but its use has notbeen reported in the laparoscopic treatment ofadenomyosis.

Electrocoagulation is best suited to women over40 years of age, who do not wish to conceive, andwho wish to avoid more extensive surgery such asexcision or hysterectomy. Even if recurrence occursthe procedure may be repeated until the onset ofthe menopause when symptoms cease.

Myometrial Excision

Adenomyosis may be excised if it does not involvethe major portion of the uterus. The technique ismost suitable for adenomyomas where the marginsof the pathology are more easily defined. It maybe useful in women wishing to become pregnant,providing sufficient myometrium remains to allowuterine expansion and term pregnancy and the scarformed after excision is not wide or shallow. MRIor colour doppler ultrasound after surgery shouldbe used to check both for cure, the width and depthof scar, and the possible association of residualadenomyosis close to the scar, before attempts atconception are advised.

Technique

Preoperative GnRH analogues or Danazol(R) mayreduce uterine vascularity, correct anaemia if thepatient has severe menorrhagia, and reduce opera-tive bleeding which facilitates surgery by laparo-scopy rather than laparotomy. Vasoconstrictordrugs may also reduce bleeding at the time ofsurgery.

Prior to myometrial excision, as with electro-surgical coagulation, the uterine blood supply maybe reduced by suture or clip ligation or bipolardiathermy of the uterine vessels in women not con-cerned with fertility. Apart from reducing bleed-ing during surgery the reduction in blood flowmay reduce future growth or development ofadenomyosis.

Two associated surgical procedures may beoffered, sterilization to prevent conception andhysteroscopic endomyometrial ablation if menor-rhagia is present, and fertility is not required.

Laparoscopy, and gasless laparoscopy, with orwithout minilaparotomy, facilitate myometrialexcision avoiding the need to perform laparotomy.Gasless laparoscopy is done with an abdominalelevator, the Maher elevator forming an S-shapedloop, being effective and cheap [24]. A finger orlaparotomy instruments can gain entry to theabdomen through a 2-4 cm incision which may besufficient to remove and repair areas of myome-trium up to 6 x 8 cm.A Valtchev uterine manipulator is used to posi-

tion the adenomyotic areas as close as possible toa laparoscopic or minilaparotomy incision. Some-times a myoma screw may stabilize the diseasedarea and aid excision. A diathermy spoon using100W monopolar current, or scalpel, are suitablefor excision. The spoon has the advantage ofcuttingeffectively with the sharp end close to the tissue, andcoagulating vessels when the convex curve of thespoon compresses the vessel. When the tissue is veryfirm the scalpel may be preferable, providing moreeffective and rapid excision. The scalpel can be usedsafely through a 2 cm accessory laparoscopy inci-sion or a minilaparotomy incision. The margin ofthe adenomyosis may be determined by change inappearance, vascularity or consistency; finger pal-pation may be an advantage.A myometrial morcellator may also be used to

remove adenomyotic tissue coring pieces up to 15-20mm in diameter. The difficulty in definition ofthe margin of adenomyotic tissue make morcella-tion less precise than scissor or knife dissection. Themorcellator hides the tissue as it is cored out. Therisk of trauma to other organs is prevented bythe myometrium being drawn outwards or the in-strument not being inserted beyond the surface ofthe uterus. The morcellator may be hand or elec-trical driven. It costs AUS $7000-12,000. Lateralinsertion in the abdominal wall is essential for safety.A 10mm laparoscope gives a better view ofthe pro-cedure. Laparoscopic or gasless laparoscopy, using


a large scalpel blade and/or large heavy scissorstomorcellate adenomyosis as it is withdrawn from asmall 2-4 cm incision in the umbilicus, the supra-pubic area, or vagina, may be a better technique [26].This technique is cheaper than a morcellator, is justas quick, and may be safer as the surgery is doneunder vision in the abdominal wound.

Closure of uterine incisions longer than 5-6 cmmay require laparotomy instruments as excision ofa significant volume of myometrium increases thetension at the myometrial edges which may have tobe stretched to close the defect. If the uterine woundis brought into a minilaparotomy incision, the defectcan be closed more easily and quickly. Absorbablesutures (No. 1) are used in one ormore layers. Ifthereis a large defect a single layer through and throughsuture may best approximate the wound, acting as atension suture, and because of the increased thick-ness ofthe whole myometrium, it is less likely to tearas tension is increased to attain closure. In 2 patients,30% and 50% of the posterior myometrium hasbeen removed and allowed successful completion ofpregnancy at 34 and 36 weeks [26].

Anti-adhesives such as Interceed(R) and Goretex(R)

membrane may be used [27-30].Interceed may be used if perfect haemostasis is

obtained. Application of Surgicel(R) prior to Inter-ceed may improve haemostasis and allow the useof Interceed. If bleeding persists Goretex can bestapled over the wound. This need not be removedunless pregnancy is planned. Uterine enlargementmay displace the membrane from the uterus whichmay attach to other organs.

CONCLUSIONS

The techniques described have been proven to besafe and effective over 5 years, involving 650 (CW)patients with endometriosis and adenomyosis. Noserious complications such as ureteric trauma orundiagnosed opening of the bowel or bladder haveoccurred. Entry into the bowel or bladder has onlyoccurred when excising endometriosis in theseorgans.

The one year cure of symptoms for the varioustypes of endometriosis are between 75% and 90%.In a smaller sample of 56 women with recurrentendometriosis, the 2-3 year cure rate has been 78%.The limitations of thermal ablation are evident: thedestruction oflesions without biopsy involves a falsepositive diagnosis in 20-50% of lesions diagnosedvisually and the limitation of removing infiltratinglesions over the bladder, bowel and ureter.The current surgical techniques are based upon

the proper identification of all macroscopic disease,consideration of the presence of microscopic dis-ease, and excision in a manner which copies theprinciples involved in removal ofmalignant disease.

Further consideration of laparoscopic surgicalanatomy, and functional histopathology of theendometriosis and the behaviour of various typesof endometriosis can be expected to modify currentsurgical techniques.

Acknowledgements

H. Reich and D. Redwine have developed someof the techniques described and assisted myselfand Peter Maher copy their techniques. The scriptconcerning endometriosis was written by C. Woodand resulted from a large experience of endomet-riosis surgery performed by P. Maher and myselfworking together and separately which facilitatedboth collaboration, constructive criticism and shar-ing of experience and ideas. A wide variety of tech-niques are described, which we have used, andenable surgeons to choose techniques to suit theirown skills, available equipment and cost restraints.The rectal surgery was described and performedby R. Woods, bowel surgeon, who has a largeexperience of rectal endometriosis. The adenomyo-sis surgery was described and performed byC. Wood.

References

[1] Wood, C. Radical laparoscopic surgery for treatment ofendometriosis. In: Minaguchi, H. and Sugimoto, O. (Eds.).Endometriosis today, advances in research and practice.Proceedings of the Vth Worm Congress of Endometriosis,Yokohama, Japan, 1996: pp. 289-296.

168 C. WOOD et al.

[2] Reich, H. Laparoscopic surgery for advanced endometri-osis. Internet article, http:/www.womensurgerygroup.com/Laparoscopic Surgery for Adv. Htm.

[3] Metzgar, D.A., Olive, D.L. and Haney, A.F. Limitedhormonal responsiveness of ectopc endometrium. Histol-ogic correlation with intrauterine endometrium. Hum. Path.1988; 19:1417-1424.

[4] Wood, C. Endoscopy in the management of endometriosis.In: Wood, C. (Ed.) Gynaecological Operative Laparoscopy:Current Statues andFuture Development, Clinical Obstetricsand Gynaecology 1994, Baillere Tindall, London, pp. 735-757.

[5] Reich, H., Clarke, C. and Sekel, L. A simple method forligating with straight and curved needles in operativelaparoscopy. Obstet. Gynecol. 1992; 79: 143-147.

[6] Jansen, R.P.S. and Russell, P. Non pigmental endometri-osis: clinical, laparoscopic and pathological distribution.Am. J. Obstet. Gynecol. 1986; 155:1154-1159.

[7] Cook, A.S. and Rock, J.A. Diagnosis of endometriosis:laparoscopic appearances. In: Sutton, C. and Diamond, M.(Eds.). Endoscopic Surgery for Gynaecologists. London:Saunders, 1993: p. 202.

[8] Martin, D.C., Hubert, C.P., Vander Zwaag, R. et al.Laparoscopic appearances of peritoneal endometriosis.Fert. Steril. 1989; 51: 63067.

[9] Martin, D.C., Armic, R. and E1 Sehg, F.A. Histologicdiagnosis of endometriosis. J. Gynecol. Surg. 1990; 6: 275-279.

[10] Wood, C. Histology of multiple lesions present in 30consecutive patients having laparoscopic peritoneal exci-sion, 1999 (Unpublished data).

[11] Nissole, M., Caspanas-Roux, F. and Donnez, J. Histologicstudy of occult endometriosis after hormonal therapy.Fert. Steril. 1988; 49: 423-426.

[12] Redwine, D.B. Conservative laparoscopic excision ofendometriosis by sharp dissection: life table analysis ofreoperation and persistent or recurrent disease. Fert.Steril. 1991; 56(4): 628-634.

[13] Wheeler, J.M. and Malseak, L.R. Recurrent endometriosis:incidence, management and prognosis. Am. J. Obstet.Gynecol. 1983; 146: 247-253.

[14] Winkel, C.A. and Bray, M. Use of leuprolide acetate incombination with surgical treatment for women withendometriosis. In: Minaguchi H. and Sugimoto O. (eds.).Endometriosis Today Advances in Research and Practice1996; pp. 365-369.

[15] Canis, M. Surgery of the ovary. Presented at the 3rdMeeting of the International Society for GynaecologicEndoscopy, Washington June 24-26, 1993.

[16] Dequesne, J. CO laser laparoscopy for peritoneal andovarian endometriosis. Abstracts of 3rd World Congresson Endometriosis (018), Brussels, Belgium 1-3 June 1992.

[17] Wood, C., Maher, P. and Hill, D. Diagnosis and surgicalmanagement of endometriomas, Aust. NZ J. Obstet.Gynaecol. 1992; 32(2): 161-163.

[18] Nissole, M., Donnez, J. and Casanas-Roux, F. Expressionof steroid receptors, vimentin and cytokeratin expression inendometriotic tissue. In: Minaguchi, H. and Sugimoto, O.(eds.) Proceedings of the Vth Worm Congress on Endo-metriosis. Yokohama, Japan: 1996; p. 165.

[19] Nezhat, C. and Nezhat, F. Postoperative adhesion forma-tion after ovarian cystectomy with and without ovarianreconstruction. 47th Annual Meeting of the AmericanFertility Society, Orlando, F1, October 21-24, 1991.

[20] Reich, H. and McGlynn. Laparoscopic oophorectomyand salpingo-oophorectomy in the treatment of benigntubo-ovarian disease. J. Reprod. Med. 1986; 31:609-611.

[21] Wood, C., Hill, D. and Maher, P. Laparoscopic culdotomy.Aust. NZ J. Obstet. Gynaecol. 1993; 33(1): 67-70.

[22] Reich, H., McGlynn, F. and Salvat, J. Laparoscopictreatment of cul-de-sac obliteration secondary to retro-cervical deep fibrotic endometriosis. J. Reprod. Med. 1991;36: 516-522.

[23] Wood, C., Maher, P. and Hill, D. Laparoscopic Removalof Endometriosis in the Pouch of Douglas. Aust. NZJ. Obstet. Gynaecol. 1993; 33(3): 295-299.

[24] Maher, P., Wood, C. and Hill, D. Excision of endome-triosis in the pouch of Douglas by combined laparovaginalsurgery using the Maher abdominal elevator. J. AAGL 1995;2(2): 199-202.

[25] Woods, R. Surgical management of rectal endometriosis:prepared for this article.

[26] Wood, C. Surgical and medical treatment of adenomyosis.Hum. Reprod. Update 1998; 4(4): 323-336.

[27] Diamond, M.P., Daniell, J.F., Feste, J. et al., Adhesionreformation and de novo adhesion formation after repro-ductive pelvic surgery. Fertil. Steril. 1987; 47(5): 864-66.

[28] Operative Laparoscopy Study Group. Postoperative adhe-sion development after operative laparoscopy: evaluation atearly second-look procedures. Fertil. Steril. 1991; 55(4):700-4.

[29] Jansen, R.P.S. Prevention of pelvic peritoneal adhesions.Current Opinion in Obstet. Gynecol. 1991; 3: 369-74.

[30] Bulletti, C., Polli, V., Negrini, V. et al., Adhesion formationafter laparoscopy myomectomy. JAAGL 1996; 3(4): 533-6.

Submit your manuscripts athttp://www.hindawi.com

Stem CellsInternational

Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014


MEDIATORSINFLAMMATION

of


Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014

Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinson’s Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

Laparoscopic Surgical Techniques Endometriosis and Adenomyosis · Diagnostic andTherapeutic...

Documents

Transcript of Laparoscopic Surgical Techniques Endometriosis and Adenomyosis · Diagnostic andTherapeutic...