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Surgical treatment of Endometriosis

During the diagnostic laparoscopy

Treatment of endometriosis : surgery

The decision to perform a diagnostic laparoscopy

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Preoperative exams

  • No suspicion of deep endometriosis - or severe adhesions: surgery can be planned as day surgery without additional exams.
  • deep Endometriosis or severe adhesions are suspected and surgery can be unexpectedly difficult including bowel surgery and suturing of the ureter and the bladder and occasionally a nerve dissection
  • IVP or other exams to check for hydronefrosis.
  • Contrast enema to ascertain less than 50% sigmoid occlusion over less than 2-3 cm
  • Ultrasound may have suspected a bladder nodule

Medical therapy before surgery ?

  • medical therapy can be given for a short time to help with the diagnosis
  • has no place before surgery
  • can be given after surgery if surgery was incomplete ;

Surgical treatment of endometriosis during the diagnostic laparoscopy

Technical decisions on equipment

Is CO2 laser surgery an advantage ?

  •  CO2 laser was frequently used during the pioneering period of endoscopic surgery. Today however the place of CO2 laser surgery has become controversial.
  • Contra : The quality of the image is less for technical reasons.
  • Pro : Theoretically tissue damage is minimal i.e. of 100 micron only with probably less adhesion formation.
  • Today we use CO2 laser for superficial endometriosis which is the most frequent fertility surgery. For deep endometriosis however CO2 laser surgery is no longer recommended.

Surgical treatment of Subtle Endometriosis

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Subtle endometriosis is not a pathology
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Subtle endometriosis is not progressive
  • Subtle endometriosis should not be considered a pathology since there is no (proven) association with pain or infertility.
  • Since CO2 laser vaporization takes a few seconds; without risks, we prefer to treat.
  • Aggressive coagulation of large areas is avoided because of the risk of adhesion
  • Common mistake : subtle endometriosis is treated aggressively causing unnecessary adhesions.

Surgical Treatment of Typical Endometriosis takes 15-30 min only

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Beginning CO2 laser excision
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Typical endometriosis

Indication for surgical treatment

  • Typical endometriosis can cause pain albeit mild and not in all women (50%) ;
  • Women with infertility have more typical endometriosis, and typical endometriosis is associated with the LUF syndrome.

Which surgical treatment ?

  • Typical endometriosis should be vaporized or excised. For this the CO2 laser has specific advantages. Coagulation only should be avoided since the depth of invasion cannot be judged superficially.

Results of surgical treatment

  • Fertility : some 30 to 50% of women will conceive, but it is still unclear whether the increased fertility is because of the removal of the typical endometriosis, or whether the incidence of LUF syndrome decreases
  • Pain : pain will be less
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Diaphragma
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Typical endometriosis
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Typical endometriosis
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Atypical endometriosis

 

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Surgical treatment of cystic Ovarian endometriosis

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Cystic Ovarian endometriosis

Indication for surgical treatment

  • All endometriosis cysts larger than 3-4 cm  that causes pain
  • Surgery on a cystic corpus luteum should be avoided.
  • If IVF is indicated, and the cyst is small  it is unclear whether it is preferable to do surgery first

How should surgery be done ?

  • If less than 5 cm in Diameter
    • Very small lesions can be vaporized.
    • A cystic corpus luteum should not be operated.
    • The method of choice is excision of cyst since the recurrence rate is 5% only. Superficial coagulation has a recurrence rate of more than 20%. For this reason I stopped vaporization in 1996
  • If more than 5 cm in Diameter :
    • either a 2 step surgery to preserve the ovary or an adnexectomy should be done since excision will generally cause destruction of the ovary
    • The first surgery is a 10 min day surgery with aspiration and rinsing of the endometrioma. After 3 months of GNRH therapy the cyst has become small and can be excised

Complications of surgery

  • Ovarian damage a decreased ovarian reserve
    • Only video-registration can demonstrate that a plane was missed, or that excessive coagulation, especially of the hilus damaged the blood supply.
    • Surgery for ovarian cysts is erroneously considered ‘easy’. Reality is that many women will have a decreased ovarian reserve after surgery, whereas reports from excellent surgical groups do not show any decrease. Surgery for cystic ovarian endometriosis therefore is delicate, with superficial coagulation of bleeding vessels only.
  • Since coagulation is done minimally , this carries the risk of some 3-4 % haematoma’s after surgery.

Results of surgery

Recurrence rate of 5%

Pain : disappears in over 90%

Fertility : 70% spontaneous pregnancy rate within 1 year

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Small endometrioma
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Incision of endometrioma
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cyst and ovary
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after surgery :a normal ovary

Deep endometriosis is difficult surgery

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Our experience in 2010
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resection or excision or debulking

We were the first to describe deep endometriosis and its excision back in 1989
Surgically 4 Localizations and types should be distinguished
Recto-vaginal
Sigmoid
Bladder
rare presentation : ovarian remnant
As indicated on the left slide I performed over 2500 deep endometriosis resections in Leuven, some 300 in Oxford and some 250 in Rome

What is the problem of Deep endometriosis Surgery
It can be technically very demanding surgery because of distorted anatomy and occasionally surgery of the bowel, the ureter, and the bladder. Especially larger lesions can be technically difficult.Therefore this surgery needs a thorough preoperative preparation.  Occasionally a deep endometriosis can be an unsuspected finding. In this rare case it is important not to operate because of the absence of a bowel preparation. This surgery requires a surgeon with the necessary expertise, the right equipment, and a good team (assistant, nurses) to have adequate assistance to deal with any problem of bowel, bladder, or ureter during surgery. Also close supervision during the postoperative period is equally important .

Deep endometriosis : recto-vaginal and rectosigmoid

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When is will be difficult
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clinical diagnosis is inadequate

Most important is to have made or suspected the diagnosis before surgery. Clinically a recto-vaginal endometriosis is palpable in 30 to 50% only ; smaller ones can only be detected during menstruation

In our experience complete discoid excision is almost always possible since we only performed a low bowel resection in 3/2000 women only. . For a more thorough discussion on bowel resections see a recent systematic review discussing this
Difficulty increases exponentially with size. When bigger than 3 cm and when fixed to the spine a lot of experience is necessary.
“Shaving” is often used to indicate incomplete resection, ie leaving some endometriosis on the bowel if necessary. Although not evidence based proven, we believe that incomplete surgery should be avoided although some fibrosis can be left.
Deep Endometriosis invades the muscle of the bowel in 50% whereas 20% are transmural. Complete resection of deep endometriosis thus requires a muscularis resection with one layer suture in some 50% and/or a full thickness resection in some 20% with a double layer suture. When these deep endometriosis nodules are big especially with a low lateral extension, or when attached to the spine the parasympaticus nerve is involved in the endometriosis with a 10-15% risk of temporary bladder retention

A low bowel resection is rarely necessary even not for the large ones. A low bowel resection should be avoided because of the high complication rate, the 30% live long bowel, 30% bladder and 40% sexual problems. Moreover there is no demonstrated advantage

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recto-vaginal
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after resection
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uterosacral
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after resection
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Important is a manipulator
as the rotator of eSaturnus
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parasympaticus nerve
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muscularis lesion and suture
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better no bowel resection

Deep endometriosis of the sigmoid

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A contrast enema is the best diagnostic method to diagnose sigmoid endometriosis and to judge the degree of bowel stenosis.

I the stenosis is less than 50% over less than 2-3 cm we always begin with a discoid resection. Only in 5 % a sigmoid resection will be necessary. It is important always to start with a discoid resection since otherwise a lot of unnecessary bowel resections will be performed because of artefacts.

I the stenosis is more than 50% over more than 2-3 cm we do an elective sigmoid resection since we consider this technically too difficult for a discoid resection.
Sigmoid endometriosis almost always is invasive. in 90% invasion of the muscularis , in more than 50% transmural
We can be more liberal to do a sigmoid resection than for a rectum resection because of the much lower complication rate for a sigmoid resection. In addition a discoid resection of the sigmoid is technically very difficult surgery and should be avoided unless very experienced.
A colonoscopy or NMR is not very useful since it does not change surgery.

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RX contrast enema
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30% occlusion
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Big lesion
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5o% occlusion
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macroscopically it looks
a small lesion
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Artifact :a spasm
thus NO resection
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Artifact : a spasm
thus NO resection

Deep endometriosis : Bladder

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Cystoscopy
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Laparoscopic image

Diagnosis should be suspected clinically but sometimes an experienced ultrasonographist can make the diagnosis If the lesion is big, it is wise to do a cystoscopy to check the position of the ureters. In doubt we insert a double J stent in the ureter Excision can be radical without hesitation since the bladder heals well The bladder is my friend since she heals well

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laparoscopic image
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a big nodule
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full thickness
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A bladder heals well

Deep endometriosis : Ureter involvement and ureter surgery

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Deep endometriosis surgery can involve the ureter and cause hydronefrosis. Although rather frequent for larger lesions this can even occur in smaller deep endometriosis
Therefore the surgeon should know beforehand whether ureter surgery can be anticipated and he should have the skills to do so.
If hydronefrosis : a preoperative stent is mandatory since associated with an 18% risk for ureter lesion
If no hydronefrosis : a systematic stent is over-treatment and should not be used. First it is not necessary (risk of lesion less than 0.5%), second it causes pain and fibrosis .Most importantly all ureter lesions can be treated by laparoscopy with excellent outcome as we demonstrated in 2 recent reviews a review of the literature in 2007 and personal data 2009

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deep endometriosis
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after excision
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hydronefrosis
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no indication for reimplantation

Deep endometriosis : ovarian remnant Syndrome

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endometriosis surgery
looks like an ovary
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beginning of excision

Fortunately rare
the ureter is always at the middle of the ovary
always very difficult surgery
fortunately rare

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ureter
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through
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the lesion
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suture of ureter

Peritoneal Pockets

Peritoneal pockets are not that well known and often not easy to diagnose. Generally an endometriosis spider is present. As shown in the images below they can be very deep. Excision is the therapy of choice. When infiltrating up to the nerves this can be technically challenging

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Small hole
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excision
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end of excision

Deep endometriosis : Complications and Postoperative management

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Deep endometriosis surgery requires experience and a team Not only the surgeon should be experienced, but also the assistant, and preferentially the second assistant, as occurs in the Gruppo Italo Belga. This permits to discuss during surgery when in doubt. Such a team know the following rules

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incomplete excision is a
severe complication

- complete surgery. Indeed incomplete surgery is a serious complication. The surgery not only will have to be repeated, but most importantly the second surgery will be more difficult. Sometimes it is a difficult decision when the lesion is not very clear : without experience the surgeon will refrain because of the risk of bowel perforation, and thus will leave endometriosis behind. To highlight this we did present case reports at several meetings.
- that complete excision is especially important at the level of the vagina since this is the most frequent localisation of recurrences
- that a layer of fibrosis can be left on the bowel.
- that the bladder heals well and that surgery thus can be radical.
- that all ureter lesions can be treated by laparoscopy and that a re-implantation of the ureter no longer is the first line treatment
- that unnecessary bowel resections should be avoided : indeed in some series up to 14% of women with a bowel resection for endometriosis did not have endometriosis
- that the difficulty increases exponentially with size of the lesion, and when attached to the spine or the sigmoid

- the risk that of an accidental hysterectomy is zero
- the risk of an accidental ovariecomy also is non-existent
- hydronefrosis is associated with a risk of 18% ureter lesions ; with a normal ureter this risk is less than 0.5%.
- a 2cm nodule in the rectum carries a risk of a muscularis resection and a 1 layer suture of 50% ; for the sigmoid the risk would be 90%
- a 3 cm nodule is associated with a full thickness resection en a double suture of 40 and 95% respectively.

- Other potential complications and fatigue Complications are those of severe surgery and the risk is mainly dependent on the expertise of the surgeon and his team. We consider it important to implement a risk management system. We published as recognizable risk factors an inexperienced assistant, inadequate equipment, and fatigue. Clearly all 3 factors relate to the duration of surgery. As a rule of thumb I consider that for surgeons get tired after 5 hours and that attention and precision decreases. Since severe deep endometriosis surgery can require 4-5 hours, I consider it important not to add an extra 1-2 hours because of the absence of a CO2 laser, or to add 1-2 hours because of equipment or assistance..
POSTOPERATIVE MANAGEMENT.
a 1 layer prophylactic suture requires an hospitalization of 4 days; a double layer suture requires an hospitalization of 7 days.
an hydronefrosis with ureter wall resection and suture requires a double J stent for 6 weeks.  A bladder deep endometriosis with a full thickness bladder wall resection, and suture requires a bladder catheter for 7 days.

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a late bowel perforation

Risk management and video-registration Since video-registration of entire procedures is systematically used we do analyse each complication of surgery. Moreover we discuss and publish this analysis as a training of the team and in order to help others not to repeat the mistake.

POSTOPERATIVE COMPLICATIONS

A late bowel perforation occurred in some 5% - since we introduced massive lavage this risk has fallen below 0.5% We recognized and published this as early as 1996 This complication is severe and requires a close supervision of the patient for 5 days since the symptoms are vague and since a late perforation is easily missed if not experienced. The importance of immediate recognition is that a late perforation can be treated by a repeat laparoscopy and a suture of the perforation. If however the perforation exists for more than 24 hours a colostomy is necessary because of a 4 quadrant peritonitis
1-2% recto-vaginal fistulas In order to avoid this we prefer not to associate an hysterectomy with surgery of deep endometriosis
Bleeding and infection
Bladder retention occurs in some 10-15 % especially in big nodules with lateral extension. This complication rarely last longer than 3 months.
Provided early repeat laparoscopy all complications can be managed by laparoscopy.

Results of endometriosis surgery

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cumulative pregnancy rates

Subtle endometriosis
No effect upon pain or infertility since it is not a cause of pain nor of infertility. Endometriosis surgery is probably not useful and will not prevent recurrences. Since, endometriosis surgery takes a few minutes without risks, superficial vaporization with a CO2 laser is performed
Typical endometriosis
Pain : After excision , a significant reduction in pain occurs in 50% of the women only as demonstrated in the RCT of Sutton.
infertility : Endometriosis surgery is believed to increase fertility rate during 6-12 months. The data however are not clear.
Recurrences : 20% over 10 years.
Cystic ovarian endometriosis
pain severe pain will decrease by 90%
infertility the cumulative fertility should be around 60% after 12 months.
Recurrences : less than 5% after complete excision.
The biggest risk is (partial) destruction of the ovary. This occurs rather frequently if the surgeon is not sufficiently experienced. Therefore quality control should be introduced
Deep endometriosis
Pain Endometriosis surgery will cure pain in over 85%. In the remaining 15% the difficult question whether surgery was incomplete cannot be answered without video-registration
infertility is still unclear whether deep endometriosis causes infertility, since some 50% of the women with deep endometriosis have children. Anyway the cumulative fertility should be around 60% after 12 months
Recurrences is some 1% if completely excised. There is no advantage when a bowel resection is performed

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