Surgery for Endometriosis
Surgery is the therapy of choice ; medical therapy is secondary.
first a correct diagnosis
then informed consent about the intervention
preoperative exams and bowel preparation if necessary
Laser surgery is an advantage :(for a more complete discussion see “Laser Surgery for endometriosis.pdf”)
First a diagnosis which is based upon
Clinical symptoms
Ultrasound
Contrast enema and IVP whenever a suspicion or deep endometriosis exists
MRI when there is a strong suspicion or adenomyosis
Before surgery, the informed consent comprises
The presumptive diagnosis and the planned surgery. i.e. CO2 laser vaporization/excision with electrosurgery for subtle and deep endometriosis : superficial coagulation or excision of cystic ovarian endometriosis ; discoide excision or bowel resection for deep endometriose.
What will happen when a bleeding occurs, when the bowel has to be opened, when the ureter has to be dissected.
The personal experience and the personal results of the surgeon, i.e. how many surgeries for endometriosis did he perform and what were his results ( % pregnancies, % recurrences, how frequently were other surgeries performed than initially planned such as the conversion rate from laparoscopy to laparotomy
Confirmation that videoregistration of the complete intervention will be done and/or that you will get a copy.
The patient should realise the limits of the surgeon , indeed nobody can operate everything- : when the nodule is bigger than 3 cm or when fixed at the spine and certainly for a sigmoid endometriosis it is reckless to start surgery without sufficient .
The biggest problem is that surgery for endometriosis can be unexpectedly difficult including bowel surgery and suturing of the ureter and the bladder and occasionally a nerve dissection
BEFORE SURGERY : what should have been done before surgery starts
No suspicion of deep endometriosis – or severe adhesions
Endometriosis surgery can be planned as day endometriosis surgery without additional exams
Deep Endometriosis or severe adhesions suspected
(or other exams) to check for hydronefrosis. To know that there is a double ureter is wise to prevent accidents.
IVP (or other exams) to check for hydronefrosis. To know that there is a double ureter is wise to prevent accidents.
Contrast enema to ascertain less than 50% sigmoid occlusion over less tan 2-3 cm
Ultrasound may have suspected a bladder nodule
Full bowel preparation planned
Full informed consent detailing the risks of muscularis lesion, opening of the bowel and bowel resection
A 2 step procedure should be planned for a cystic ovarian endometiosis larger than 5 cm and infertility
A sigmoid resection should be planned if more than 50% occlusion over more than 2-3 cm
Other exams as MRI, transrectal MRI and CAT scan will not change any of these decision and are therefore of limited use
Is a CO2 laser an advantage ?
A CO2 laser is an advantage for superficial and deep endometriosis
The hemostatic properties will prevent capillary bleeding resulting in a cleaner operating field
Tissue damage of 100 micron only : what you see is what you do. Whenever coagulation is needed depth of destruction is at least a few mm leading to an increased risk of adheions.
A CO2 laser makes endometriosis surgery faster, something important for deep endometriosis surgery where surgery of 5 hours can be reduced to 4.
For mild endometriosis the CO2 laser permits to have 2 secondary ports only, within bikini limits
Without a CO2 laser
For superficial lesions : excision will cause bleeding necessitating coagulation and thus tissue damage.
For Deep lesions : adding an extra of 1-2 hours to endometriosis surgery of 4 hours can become difficult.
Superficial coagulation only is a mistake since depth cannot be judged.
Surgery of Subtle Endometriosis
Subtle endometriosis should not be considered a pathology since there is no (proven) association with pain or infertility.
Since laser vaporisation takes a few seconds only without risks, I prefer to treat.
Aggressive coagulation over large areas should be avoided because of the risk of adhesion
Tke main problem is taht subtle endometriosis, which should not considered a pathology is overemphasised and overtreated by the non surgeons.
Surgery of Typical Endometriosis takes 15-30 min only
Beginnende CO2 laser excisie
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.
After surgery 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
Typical endometriosis should be vaporisation or excised. For this the CO2 laser has specific advantages, especially when used with hydroprotection No coagulation since depth cannot be judged
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Surgery of Cystic Ovarian endometriosis needs a lot of expertise not to damage the ovary
Groot endometrioma
How should surgery be done ?
If less than 5 cm in Diameter
Very small lesions can be vaporised. 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 to do this since 1996
If more than 5 cm in Diameter : either a 2 step surgery to preserve the ovary or an adnexectomy since excision can 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
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Complications of ovarian surgery
Damaging the ovary with a decreased ovarian reserve should be avoided
Only videoregistration 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 after surgery a decreased ovarian reserve, whereas reports from excellent surgical groups do not show any decrease Only videoregistration can demonstrate that a plane was missed, or that excessive coagulation, especially of the hilus damaged the blood supply Surgery for cystic ovarian endometriosis therefore is delicate, with superficial coagulation of bleeding vessels only. This carries the risk of some 3-4 % haematomas
Deep endometriosis is considered difficult surgery
We were the first to describe deep endometriosis back in 1989
Surgically 4 Localisations and types should be distinguished
Rectovaginal
Sigmoid
Bladder
rare presentation : ovarian remnant
As indicated on the left slide I performed over 1500 deep endometriosis resections in Leuven, some 300 in Oxford and some 130 in Rome
What is the problem of Surgery
It can be technically very demanding surgery with occasionally surgery of the bowel the ureter and the bladder. Especialy larger lesions can be technically difficult.Therefore this surgery needs a thorough preoperative diagnosis : occasionally a deep endometriosis can be an unsuspected finding. In this rare case it is important not to operate since 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 important .
Deep endometriosis : rectovaginal and rectosigmoid
Klinische diagnose diepe endo
Most important is to have made or suspected the diagnosis before surgery. Clinically a rectovaginal endometriosis is palpable in 30 to 50% only ; smaller ones can only be detected during menstruation
The Difficulty of surgery should be anticipated In our experience complete discoid excision is almost always possible : . difficulty ioncreases exponentially with size. When bigger than 3 cm and when fixed to the spine a lot of experience is necessary.
In our experience a discoid resection is almost always possible : we only performed 3/2000 low bowel resection. “Shaving” is often used to indicate incomplete resection, ie by leaving some endometriosis on the bowel if necessary. Although not evidence based proven, all better surgeons today believe that incomplete surgery should not be performed
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 endometiosis 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. Alow 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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| diepe endometriose | idem na resectie | kleiner letsel op de uterosacrale band | idem na resectie |
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| RX met rectosigmoid letsel | Parasympaticus: beschadiging veroorzaakt blaasatonie |
muscularis letsel waarvoor een profylactische sutuur nodig is | Complicaties van darmresectie |
Deep endometriosis of the sigmoid
RX : sigmoid lesion
30% occlusion
Big Lesion
5o% occlusion
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 tahn 50% over less than 2-3 cm is we always begin with a discoid resection. Only in 5 % a sigmoid resectie will be necessary. It is important always to start with a discoid resection since otherwise a lot of unnecessary bowel rexections will be performed because of artefacts.
I the stenosis is more than 50% over lmore than 2-3 cm we do an elective sigmoid resection since we consider this technically too difficult for a discoid resection
Sigmoid endometriosis always is invasive. in 90% invasion of the muscularis , in more than 50% transmural
We can be more liberal to do a sigmoid resection tahn 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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| macroscopisch lijkt het een klein letsel | Artefact : een darm spasme waarvoor GEEN resectie nodig is |
een goede manipulator is nuttig | Artefact : dit bleek een adhesie en dus GEEN resectie nodig |
Deep endometriosis : Bladder
Cystoscopie
Diagnosis should be suspected clinically but sometimes an experienced ultrasonographer 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 and heals well
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Deep endometriosis : Ureter involvement and ureter surgery
Deep endometriosis surgery can involve the ureter and cause hydronefrosis. Although rather frequent for larger lesions this can even occur in smaller deep endometriosis
iTherefore the surgeon should know beforehand whether ureter surgery will be probable, and he should have the skills to do so.
If hydronefrosis : a preoperative stent is mandatory since an 18% risk for ureter lesion
If no hydronefrosis : a sytematic stent is overtreatment and should not be used to avoid pain and fibrosis Most importantly all ureter lesions can be treated by laparoscopy with excellent outcome as we demonstrated in 2 recent reviews Een review van de literatuur review in 2007 en onze persoonlijke reeks in 2009
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Deep endometriosis : ovarian remnant Syndrome
Fortunately rare
the ureter is always at the middle of the ovary
always very difficult surgery
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Deep endometriosis : Complications and Postoperative management
Sutuur ureterletsel
POSTOPERATIVE MANAGEMENT. Complete excision of deep endometriosis involves bowel and urinary surgery. The probability depends on the size of the endometriosis and the localisation. The probability can be predicted from the contrast enema and IVP and should be explained before surgery. These clearly are not complications
50 and 90% muscularis invasion of rectum and the sigmoid respectively, with a 1 layer profylactic suture and nil by mouth and an hospitalisation of 4 days.
30 and 50% full thickness resection of rectum and the sigmoid respectively, with a double layer suture and nil by mouth and an hopitalisation of 7 days.
In women with a hydronefrosis 18% ureter wall resection necessitating a suture and a double J stent for 6 weeks. In the absence of an hydronefrosis the risk of ureter lesion is less than 0.5% and a routine stent is not required. A bladder deep endometriosis requires in some 30% a full thickness bladder wall resection, necessitating a suture and a bladder catheter for 7 days. In some women an additional ureter stent is required for 6 weeks.
COMPLICATIONS DURING SURGERY
Incomplete surgery is the worst complication since subsequent surgery becomes much more difficult
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 recognisable 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.
Laatijdige perforatie
Risk management and videoregistration Since videoregistration 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 recognised 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% rectovaginal fistulae 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 laparoscopically.
Results of endometriosis surgery
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, superfical vaporisation 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
pijn 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 iis (partial) destruction of the ovary. This occurs rather frequently if the surgeon is not sufficiently experienced. Therefore quality control should be introduced
Deep endometriosis
PainEndometriosis surgery will cure pain in over 85%. In the remaining 15% the difficult question whether surgery was incomplete cannot be answered without videoregistration
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