the cardinal sins of surgery
Lack of skills/experience
Before undergoing surgery Check
- Which endometriosis is suspected? and which surgery will be performed?
- information and informed consent : Check the contract
- preoperative exams
- if probably no deep endometriosis or severe adhesions, surgery can be planned as day surgery without additional exams. Check what will be done if severe endometriosis is found nevertheless.
- if deep Endometriosis or severe adhesions are likely, surgery can be unexpectedly difficult with bowel surgery, suturing of the ureter, bladder surgery or nerve dissection. Therefore it is needed to
- exclude hydronephrosis by IVP or other exams.
- exclude bowel stenosis of less than 50% over less than 2-3 cm by contrast enema
Medical therapy before surgery?
- medical therapy can be given for a short time before surgery to help with the diagnosis
- is rarely useful for surgery
Our surgery principles
Read our principles as recently published
Read how our new understanding changes treatment
- surgery is performed during diagnostic laparoscopy
- 1% unexpected severe deep endometriosis requiring, a bowel resection will be operated during a second surgery.
- important to know which type of intervention you do NOT want e.g. removal of uterus or ovaries.
- we prefer surgery with CO2 laser for superficial endometriosis and hydrosalpinges
- scissors and bipolar electrosurgery when dissection is needed
- Vaporization with a CO2 laser
- Aggressive coagulation or stripping of large areas should not be done.
- A common mistake is exaggerated coagulation with removal of large areas
- for the diaphragm superficial coagulation to prevent perforation
- Results :Some 50% will conceive and pain will be less
Cystic Ovarian endo
- Less than 3 cm: unclear whether treatment is necessary
- 3 to 5 cm in Diameter excision since less recurrences
- A cystic corpus luteum should not be operated.
- Alcoholization is being evaluated
- If > 5 cm To preserve the ovary, a 2 step surgery is needed. After a 10 min day surgery intervention with aspiration and rinsing of the endometrioma, and 3 months of GNRH therapy the cyst can be excised. The alternative is to remove the ovary
- Without the necessary skills, surgery risks to decrease ovarian reserve. Only video-registration can demonstrate mistakes. Surgery for ovarian cysts is erroneously considered ‘easy’.
- Recurrence rate of 5%
- Pain : disappears in over 90%
- Fertility : 70% spontaneous pregnancy rate within 1 year
Types of deep endometriosisDeep endometriosis can be difficult surgery.
- We perform less than 5% bowel resection is (read our reviews) in over 2500 deep endometriosis resections in Leuven, some 300 in Oxford and 250 in Rome.
- The decision of bowel resection is taken during surgery, not before surgery. As published we think that many bowel resections are avoidable.
- If bowel resections are decided because of Ultrasound images way to many bowel resections are performed
of the rectum or recto-sigmoid
- In our experience complete discoid excision is almost always possible. see a recent systematic review discussing this.
- When bigger than 3*3*3 cm experience is necessary.
- Excision should be complete but a rim of fibrosis can be left.
- a muscularis resection with one layer suture in some 50%
- a full thickness resection in some 20% with a double layer suture.
- Care is taken not to damage the nerves and the risk of temporary bladder retention.
- A low bowel resection is very rarely indicatedsince the 30% live long bowel, 30% bladder and 40% sexual problems.
- Deep endometriosis of the sigmoid: A contrast enema is the best diagnostic method to judge the degree of bowel stenosis. I the stenosis is more than 50% over more than 2-3 cm we do an elective sigmoid resection is performed. As published, over the years sigmoid resections were more liberally used since easier and a low complication rate.
Of the bladder
- If the lesion is big, a cystoscopy is needed to check the position of the ureters.
- Excision can be radical without hesitation since the bladder heals well The bladder is my friend
- Deep endometriosis always involves at least ureter dissection.
- A stent is needed only when hydronefrosis
- all ureter lesions can be treated by laparoscopy with excellent outcome as we demonstrated15 years ago
This is a rare pathology and easily missed unless experienced.
As recently described these cause pain and need surgery. A small hole hides a big defect, which is easily missed
Complications and Postop management
- Deep endometriosis surgery requires experience and a team, Read our papers, to understand the principles such as: leaving a layer of fibrosis on the bowel, why re-implantation of the ureter is the past, how to avoid bowel resections ( up to 14% of women with a bowel resection for endometriosis did not have endometriosis,
- As a rule of thumb, surgeons get tired after 5 hours with less attention and precision.
- POSTOPERATIVE MANAGEMENT.
- A 1 layer prophylactic suture requires an hospitalization for 4 days; a double layer suture for 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, requires a bladder catheter for 7 days.
- Video-registration permits the early diagnosis of complications and repeat laparoscopy.
- Management of Complication
- late bowel perforation (see our publication in 1996) : after the introduction of lavage with 8 liters this risk has fallen below 0.5%. Since symptoms are vague Immediate recognition by repeat laparoscopy is needed.
- 1-2% recto-vaginal fistulas. 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.
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