ENDOMETRIOSIS AND LAPAROSCOPY

WHEN AND HOW MUCH

DR. KAWITA BAPAT

SPECIAL THANKS

Dr.Vinod Bhandari sir

Manju didi

Shilpa and Mohit

Dr. Ratna madam and Priya

Table 40-1. American Society for Reproductive Medicine revised classification of endometriosis.

Peritoneum Endometriosis < 1 cm 1-3 cm > 3 cm

  Superficial 1 2 4

  Deep 2 4 6

Ovary R Superficial 1 2 4

  Deep 4 16 20

  L Superficial 1 2 4

  Deep 4 16 20

  Posterior Cul-de-sac ObliterationPartial

4  Complete

40

  Adhesions < 1/3Enclosure

1/3-2/3Enclosure

> 2/3Enclosure

Ovary R Filmy 1 2 4

  Dense 4 8 16

  L Filmy 1 2 4

  Dense 4 8 16

Tube R Filmy 1 2 4

  Dense 41 81 16

  L Filmy 1 2 4

  Dense 41 81 16

1If the fimbriated end of the fallopian tube is completely enclosed, change the point assignment to 16. Staging: Stage I (minimal): 1-5; stage II (mild): 6-15; stage III (moderate): 16-40; stage IV (severe): > 40. (Reproduced with permission from Revised ASRM classification. Fertil Steri 1997; 67:819.)American Society for Reproductive Medicine revised classification of endometriosis.

WHY I CHOSE THIS TOPIC

Mesmerising Disillusioning Confusing Debilitating Interesting Progressive Recurring Worsening Challenging

DABANG

ENDOMETRIOSIS

ECTOPIC ENDOMETRIAL TISSUE

TRUE INCIDENCE UNKNOWN

DOES NOT DISCRIMINATE RACE

HISTOLOGY ENDOMETRIAL GLAND

PRESENTATION Pelvic pain

Mass

Infertility

Menstrual irregularities

Uncommon and rare problems

Diaphragmatic pain

cat menial pnumothorex

Bowel obstruction

WHEN ? LAPAROSCOPIC MANAGEMENT OF ENDOMETRIOSIS

Diagnosis Acute, chronic pain Significant impact on quality

of life Failure of medical therapy Infertility investigation and

treatment Endometriomas Secondary organ

involvement (bowel, bladder, ureter, nerve)

MACROSCOPIC APPEARANCE OF ENDOMETRIOSIS

black, red, vesicular Endometriotic cysts Adhesions

Pod obliteration Bowel endometriosis

marked distorted anatomy

ENDOSCOPY CLASSIFICATION

Wet Endometriosis

Superficial Flimsy adhesions Less severe Can be treated by

laparoscopic surgery

Dry Endometriosis

Extremely painful Deep infiltrating

Pouch of douglas Recto vaginal septum

Uterosacral ligaments

Dense fibrosis Difficult to treat

WHEN AND HOW MUCH Take a step in the

right direction:

Innovative, Compassionate & Extraordinary care .

a new beginning

WHEN AND WHY Laparoscopic Surgical Approach: Objectives

Is Surgery Even Necessary: Indications What to do: Burn or Cut? Special Situations:

Endometriomas Deep Infiltrating Endometriosis

Adjunctive Surgical Techniques

IS LAPAROSCOPY EVEN NECESSARY?

Risks – 0.2-3% overall complication rate

Requires additional expertise and training

Excellent medical options exist for pain

GnRH Agonists, Aromatase Inhibitors

Mirena IUS

LAPAROSCOPIC PROCEDURES PRACTICED

- Electrosurgical ablation of superficial endometriotic deposits

- Laser ablation. - Excision of endometrioma. - Excision of deep fibrotic deposits and

adhesiolysis. - Hysterectomy & bilateral salpingo-

oophorectomy.

SURGICAL OPTIONS: “TO CUT OR NOT TO CUT”

Excision

Histological diagnosis Greater depth of

treatment Requires greater skill Injury to adjacent

organs Thermal damage risk

Ablation

Faster Less skill required Unable to determine full

extent Thermal damage risk

OVARIAN ENDOMETRIOMAS

OVARIAN ENDOMETRIOMAS

• Laparoscopic ovarian cystectomy

Confirm the diagnosis histological

Reduces risk of recurrence over fulguration

Reduce the risk of infection at IVF

Improves access to follicles and possibly improve ovarian response

May impair ovarian reserve

SURGICAL OPTIONS

EXCISIONMultiple energy

modalities (Laser, Scissors, Harmonic)

ABLATION Laser, electro surgery

ENDOMETRIOMAS

Excision

Tissue specimen Decrease recurrence

Post op adhesions Risk of decreasing

number of follicles

Fulguration

Simpler technique ? Preserve greater

ovarian tissue

Risk of Recurrence

DEEPLY INFILTRATING ENDOMETRIOSIS

May be responsible for “failed surgical treatment”

Identification is difficult Deep Dyspaurenia

Rectovaginal exam

Rectal Ultrasound

MRI

HYSTERECTOMY Along with removal of endometriotic

implants

Bilateral oophorectomy

Subtotal hysterectomy or supra-cervical should not be done

APPROACH TO MANAGING ENDOMETRIOSIS

Available expertise

Accurate diagnosis

Surgical skills Anatomy

knowledge Dissection skills Knowledge of

energy Suturing skills

Specialized team Multi-disciplinary

approach Nurse educator Family physician Bowel surgeon Urologist Pain Specialists

LAPAROSCOPY PROS AND CONS

Advantage

Diagnosis and Treatment

Prolonged therapeutic effect

Fecundity Improvement

Disadvantage

Risk of injury to organs

Greater adhesions Limited resources Limited expertise Negative

Laparoscopy

ADJUNCTIVE SURGICAL TECHNIQUES

Surgical Options 1.-Adhesion Prevention

2.- Presacral Neurectomy 3.- Appendectomy

Up to 20% diseased in endometriosis/pain patients

Appendectomy: “Hockey Stick” Sign Adhesions: for Advanced Endometriosis Surgery

Ureterolysis Suturing Bowel lesions Cystoscopy Rigid Sigmoidscopy

DOES LAPAROSCOPY HELP PAIN?

Sutton et al Fertil Steril 1994 (n=63) Laser ablation + LUNA improves pain at 6

months versus expectant management (63 vs. 23%)

At 73 months, 55% of follow up (n=38) pain free (JSLS 2001)

Abbot J et al. Fertil Steril 2004 (n=39) Lap excision improved pain at 6 months

compared with diagnostic laparoscopy (80% vs. 32 %)

ENDOMETRIOMAS

Excision versus Fulguration Recurrence of pain (19 mos vs. 9.5 mos)

Berretta et al Fertil Steril 1998 Recurrence of symptoms at 2 years(15.8% vs.

56.7%) Re-operation rate (5.8% vs. 22.9%)

Alborzi et al. Fertil Steril 2004

Overall: EXCISION OF CYST preferable for PAIN

ADHESIONS

Additional Limitations of laparoscopy

Missed lesions: false negative laparoscopy Required Expertise Most not comfortable with advanced and many basic endoscopic

techniques

Ob/Gyn Endoscopy Survey, Raymond,Ternamian,Leyland JMIG 2004

TAKE HOME MESSAGES

Ideal practice: diagnose and remove endometriosis surgically at same time

treated early and aggressively by surgical

destruction or excisionexcision and ablation provides pain relief Pain can be reduced by removing the entire

lesions in severe and deeply infiltrating disease

Role for adjunctive procedures is evidence based

Adhesion barriers have a role

TAKE HOME MESSAGES

Consider Adjunctive Surgical Procedures: Presacral Neurectomy Appendectomy Adhesiolysis and Adhesion Prevention

HOPE Management

stepwise Follow up regular Correct

counselling See and treat

approach One stop

solutions