Surgery for endometriosis

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 Normal cells in abnormal location.

Sampson’s theory

Sampson’s theory says that the endometriosis is the implantation of the retrograde menstrual cells.
Endometrial cells usually implant on the peritoneum progressing to typical cystic ovarian endometriosis or sometimes deep infiltrating lesions.
Severe endometriosis can be considered as benign tumour whereas subtle endometriosis is a physiological phenomenon occurring intermittently in all women.
To differentiate between the two conditions they are named as ” endometriosis ” which is subtle ”  ”endometriotic disease ” which is cystic , typical and deep.

Diagnosis

It is a surgical diagnosis.
Symptoms may be infertility, chronic abdominal pain, secondary dysmenorrhoea and dyspareunia.

Differential diagnosis

Irritable bowel syndrome and PID also present similarly.

Treatment

It depends upon the woman’s age , her fertility , previous treatment , the nature and severity of symptoms, location and severity of disease.
Medical management is not a permanent cure.
Majority of women who desire to maintain their fertility , treatment should be minimally invasive .
Surgical treatment is to remove ectopic endometrial tissue and to restore the normal pelvic anatomy.

Surgical techniques :

Laparoscopy

CO2-laser has the disadvantage of smoke production and blooming of the laparoscope.
Another difference between CO2 -laser and electrocautery is the angle of access to the tissues.
Laser beam will have almost horizontal access to rectovaginal septum .
Energy used through secondary ports will have a more vertical line of access.

Pathophysiology of  cystic ovarian endometriosis

When the ovary becomes adherent to the pelvic wall by endometriotic implants , it appears as a pseudocyst .
In this there is accumulation of old blood and debris thus stretching the ovarian capsule over the cyst.
This could explain why inside of the cyst wall is not always covered by endometriosis, which may be locaised as focal spots.these focal spots should be destroyed logically because removal of cyst wall is equivalent to removing the ovarian surface.Careful observation and histology reveals that endometriotic glands can be present in so called cyst wall up to a depth of 5-6 mm.

Surgical management depending upon the size of cyst

For smaller cysts < 5 mm , cyst wall can generally be stripped easily from the ovary.The process follows a
bloodless natural plain of cleavage.
For cysts > 5 mm in diameter , the decision whether the cyst wall should be removed or destroyed or whether the focal treatment will be sufficient is purely academic.
Indeed in women with large cysts , remaining rim is so thin that resection becomes impossible and practically unrealistic since minimal or no tissue will be left.

Method of treatment

Aspiration of the cyst under ultrasound guide have been attempted but recurrence rate was high.The fluid in the pelvis may result into pelvic infections and abscess formation.
For smaller cysts , plane of cleavage is found and cyst wall can be easily stripped from the ovary.By coagulation of the inner wall of the endometriotic cystic cavity we can get excellent results.
For larger cysts excision or vaporisation is the treatment.It can be performed in two stages.In the first operation a large window is made in the cyst wall , followed by rinsing , no adhesilolysis is done followed by GnRh agonist treatment for 3 months.Then ultrasound is done , if cyst persists or reforms , this small cyst is treated by operation and that is excision.If no cyst is found second operation may not be required in the absence of pain or infertility.

Deep endometriosis :

Endometriois can infiltrate surrounding tissues leading to sclerotic changes leading to ureteral and bowel obstrution.This is known as rectovaginal endometriosis.It becomes cone shaped , becoming smaller as it grows deeper.In some cases it can not be seen on laparoscopic examination and bowel retraction is the only sign.In more advanced type three cases , a careful vaginal examination reveals dark black nodules in the posterior fornix.They are the most severe form and can lead to sclerosis around ureter. Type four is rare but it is 10 cm above the rectovaginal septum .Type three are in the pouch of douglas apposite the vaginal wall.Type two are situated higher up , between the back of uterus and rectosigmoid and occasionally under infundibulopelvic ligament.
Ultrasound and MRI are done to diagnose the deep endometriosis.
For type four lesions , a contrast enema and rectoscopy is done.

Surgical treatment

Full preoperative bowel preparations , IVP , contrast enema are necessary before operation .
Surgery should be carefully planned.
It often requires colorectal surgeon and urologist in the team.Preoperative ureteric stenting may be required.
Resection of sigmoid and rectum and resuturing may be required.
CO2 laser ( Sharplan ) with high flow insufflator is required.( Thermoflator , Storz AG ). It is mandatory for smoke evacuation and cooling the laser beam.
The lesion is circumscribed to mark it’s limits.
The lateral edges of the nodule are dissected to free it from ureter , uterine and sacrospinous ligament.This is the most difficult part of the surgery because of the presence of large vessels and nerves.
Pararectal spaces are identified.Finally the posterior part of nodule is dissected from the rectum.It remains attached to the uterus and vagina so by elevating it rectum falls down with gravity.In 20% part of vaginal fornix has to be removed and in 20% rectum has to be opened.

Other techniques are :

Sharp dissection with electrosurgery through laparoscope and through secondary ports.
A partial rectum resection followed by reanastomosis with a circular stapler.

Complications :

Transection of uterine artery
Ureteric lesion
Late bowel perforation
So surgery should involve a multi disciplinary team including a rectovaginal surgeon and a urologist.
It requires extensive preoperative investigations and planning including IVP , MRI and barium enemas.

Adhesions between left ovary and pelvic side wall
Endometriosis in the left ovary
Dense adhesions with advanced endometriosis
Chocolate cyst
Powder-burn lesion
pictures courtesy–
Fatty tissue between the rectum and left uterosacral ligament.
Incision parallel to right uterosacral , ureter pulled upwards[2]MRGADIR@AOL.COM

 

Rectum stuck to left uterosacral ligament and back to the cervix

 

Images..courtesy

Contact person: Ms. Bina Chander RGN at             020 8347 5081      , E mail: MRGADIR@AOL.COM

References

  1. http://www.gynaecology.spotmysite.com/page/649/
  2. Recent advances in ObGyn…23…John Bonnar and William Dunlop.
  3. http://www.endo-resolved.com/picture.htm

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