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Endometriosis is a chronic proliferative disorder and needs treatment aggressively to provide relief from its symptoms and arrest progression of the disease.
Treatment options include medical or surgical or a combination of both.
We offer the option depending on the individual patient needs and desires and most importantly the symptoms and the severity of her disease
Our surgical strategy to tackle endometriosis is as follows
MANAGEMENT OF ENDOMETRIOMAS
Preoperatively, transvaginal sonography is done to evaluate the ovaries and a CA 125 assay is obtained if persistent enlargement is documented.
Ultrasound findings of a round shaped adnexal mass with thick wall and homogeneous, low-level echo pattern is highly suggestive of endometrioma. Another pattern has irregular margins with septations and an anechoic appearance.
In all cases careful inspection of the abdomen and pelvis is done.
Endometriomas are drained by mobilizing them from the pelvic sidewall.
An aquadissector is used to mobilize the ovaries by lifting them from the pelvic sidewall. Often this maneuver will result in drainage of chocolate-like hemosiderin filled fluid from the undersurface of the ovary.
After this occurs, the ovary is completely mobilized from the pelvic sidewall to its hilum using aquadissection and careful blunt dissection to reduce pelvic sidewall peritoneal damage.
Experience has proven that drainage is not enough. Ovarian endometriomas up to 15 cm are excised. The cyst wall is most firmly attached to the ovarian cortex in the area of cyst rupture during mobilization, i.e., the portion that was adhered to the pelvic sidewall or uterosacral ligament, and not to the portion near the ovarian hilum.
To help create an initial plane between normal ovarian cortex and endometrioma cyst wall, cutting current through a knife electrode tip is applied at the cyst wall-cortex junction to develop a dissection plane in this firmly attached area.
The laparoscope is brought close to the area of dissection, magnifying it to identify the cyst wall clearly. This incision is extended through the visible 360o opening if possible. The cutting current will destroy endometriosis at the ovarian cortex-endometrioma junction while making a divot of separation between the two structures. Thereafter, biopsy or grasping forceps are placed to stabilize the ovarian cortex and endometrioma cyst wall while traction is exerted on the endometrioma cyst wall to peel it from inside the ovary. If the cyst wall is felt to be incompletely excised, the cyst cavity can be desiccated or fulgurated to destroy any remaining endometrioma. Otherwise, the endometrioma may recur.
Excision can be done with minimal bleeding from the cyst wall bed and the ovarian wall edges usually reapproximate quite well, though extracorporeal suturing is required, especially after removal of large endometriomas.
Hemostasis is checked by examination inside the ovary, and individual bleeders are identified using irrigation through an irrigating channel and coagulated with microbipolar forceps.
When removal results in a large, asymmetrical defect, the ovary is suture repaired,. Although suturing is not thought to be necessary for reapproximation by many surgeons, anyone who has operated on many of these women realizes that the open ovary is very receptive to small and large bowel.
In most cases of ovarian endometrioma, endometriosis of the pelvic sidewall and/or uterosacral ligament is present. These lesions should be excised after enucleation of the endometrioma to prevent recurrence. Pelvic sidewall endometriosis peritoneal excision usually requires ureterolysis to free the underlying ureter from the lesion.
Oophorectomy can also be considered for pain or mass arising from ovarian endometrioma in women not desiring future fertility. This is especially indicated for left pelvic pain if the left ovary is enmeshed in rectosigmoid adhesions because they tend to recur.Before removal, the ovary is released from all pelvic sidewall and bowel adhesions. It is imperative that the surgeon visualize the course of the ureter. The peritoneum above the ureter is opened with sharp scissors. Smooth grasping forceps are then opened parallel and perpendicular to the retroperitoneal structures until the ureter is identified. Scissors can be used to further dissect the ureter throughout its course along the pelvic sidewall.
MANAGEMENT OF RECTOVAGINAL ENDOMETRIOSIS
Most women with extensive cul-de-sac endometriosis have some degree of nodularity and/or tenderness of their uterosacral ligaments, anterior rectum, and posterior vagina-cervix during rectovaginal exam.
The object of the surgery is to remove the painful, tender nodule.
The end point of laparoscopic surgical procedures should be to excise endometriosis so there should be a mobile distensible vagina, a free rectum, and the absence of nodularity as palpated with a rectovaginal exam while probing the area visualized with the laparoscope.
Deep fibrotic nodular endometriosis involving the cul-de-sac requires excision of white fibronodular tissue from the uterosacral ligaments, posterior cervix, posterior vagina, and the anterior rectum.
Attention is first directed to dissection of the anterior rectum from the posterior vagina throughout its area of attachment until loose areolar tissue in the rectovaginal space is reached. This technique leaves the bulk of the lesion to be excised on the posterior vagina, including some that was more closely associated with the rectum. Using the rectal probe as a guide to rectal location, the rectal serosa is opened at its junction with the cul-de-sac lesion with scissors
Careful sharp and blunt dissection ensues until the rectum, normal or with contained fibrotic endometriosis, is separated from the posterior uterus, cervix, and upper vagina.
After anterior rectal mobilisation is complete, excision of the fibrotic endometriosis from the posterior vagina (the location of which is continually confirmed by a sponge in the posterior fornix), posterior cervix including its uterosacral ligament insertions, and rectum is done.
This is often accomplished ‘en bloc’ as one large specimen, including the insertions of both uterosacral specimens laterally, the anterior rectal component inferiorly, and the posterior cervix-vagina superiorly. The blunt scissors is the main instrument used for this excisional dissection with the tissue to be removed kept on traction using a toothed biopsy forceps.
The ureter lies lateral to most cul-de-sac lesions. When the uterosacral ligament is pulled medially, there is very little risk of ureteral damage. When a ureter is close to the lesion, its course is traced starting at the pelvic brim, and when necessary, the peritoneum overlying the ureter is opened to confirm ureteral position deep in the pelvis. Uterosacral fibrotic endometriosis may envelop the ureter, necessitating deep ureteral dissection and excision of the surrounding endometriosis. Microbipolar forceps with irrigation between the tips are used to control arterial and venous bleeding around the ureter.
Uterosacral ligaments infiltrated with endometriosis are removed early in the operation, sometimes before rectal mobilisation. They frequently make up a large portion of a rectal nodule.
The uterosacral ligament is divided lateral to the rectum where normal calibre ligament meets distended fibrotic ligament and put on traction. The peritoneum is incised on both sides of the ligament, and the thickened portion of the ligament is excised to and including its insertion into the cervix. Soft loose areolar tissue, adipose tissue, uterine vessels, and ureter are found beneath the ligament. Fibrotic tissue left at the periphery of the excision is coagulated with an irrigating microelectrode, especially at the junction of cervix with uterine fundus. Rarely the ligament will be involved all the way to the sacrum. In these cases, it may be best to divide the middle of the ligament and, with traction on the sacral side of the ligament, pull it away from rectum, ureter, and hypogastric vessels.
The dissection of the fibrotic endometriosis from the thickened vaginal wall proceeds using traction with a biopsy forceps to pull the lesion from one side to the other. Laser, aquadissection, electrosurgery, or scissors are used as needed. Often, with traction and the help of vaginal distension from below using a vaginal sponge pushed forward by a ring forceps, a distinct dissection plane becomes evident above or beneath the rectovaginal fascia, and the lesion can be pulled free from the vaginal wall.
RESECTION OF ENDOMETRIOTIC BOWEL IMPLANTS
Endometriosis of the rectum and/or rectosigmoid may be superficial (serosal or adventitial), in the muscle (muscularis), or full thickness involving both the muscularis and the lamina propria of the mucosa; the mucosal surface is rarely broken. The lesions are anterior or lateral.
Fibrotic endometriosis nodules infiltrating the anterior rectal wall are commonest and may be focal (cicatrixal) or linear (a transverse bar often with associated stricture where the rectum is fused to the posterior vagina).
Under the microscope all of these lesions, and those of the uterosacral ligaments, posterior vagina, and cervix, are made up of fibromuscular tissue surrounding endometriosis glands and characteristic stroma.
Women with suspected or documented extensive endometriosis are counselled preoperatively regarding risk of bowel injury, methods of possible treatment, and the impact of bowel perforation and resection on their hospital stay and postoperative recuperation. Certainly the risk of unplanned rectal perforation is appreciated with any kind of intervention near the bowel, but is particularly threatening with excision of rectal endometriosis due to the fibrotic nature of the disease and related anatomical distortion.
Once separated from the vagina, the rectum and rectosigmoid are examined carefully with a long blunt probe inside. Lesions are assessed to determine if they are superficial, deep, or nodular. Superficial lesions involving the serosa or adventitia are excised by making an elliptical incision around the white fibrotic lesion with a scissors elevating the lesion with a micro-toothed forceps, and undermining it at its junction with soft normal-appearing circular muscularis.
Endometriotic nodules infiltrating the anterior rectal wall are excised, partially or totally, usually with a probe or the surgeon’s finger in the rectum beneath the lesion. Working with scissors at the junction of nodular white fibrosis with yellow and pink soft normal tissue, the lesion is excised.
Deep rectal muscularis defects are closed with suture. The 3-0 suture is applied using curved needles, the knot tied outside the peritoneal cavity, and pushed downward with the knot pusher.
HYSTERECTOMY FOR ENDOMETRIOSIS
Extensive endometriosis (adenomyosis) may be inside the uterus where it may cause symptoms after endometriosis excision.
While excision of endometriosis with uterine preservation is almost always possible, hysterectomy should be considered for women with severe pelvic pain affecting the quality of their life, who do not desire fertility preservation. Concomitant oophorectomy may be performed.
The goal at laparoscopic hysterectomy for extensive endometriosis with cul-de-sac obliteration is the same as in any endometriosis surgery, i.e., to excise all visible and palpable endometriosis implants. The surgeon must first free the ovaries, then the ureters, and finally the rectum from the posterior vagina to the rectovaginal septum. As previously described,deep fibrotic nodular endometriosis involving the cul-de-sac requires excision of the fibrotic tissue from the uterosacral ligaments, posterior cervix, posterior vagina, and the rectum. Hysterectomy with excision of all visible endometriosis usually results in relief of the patient's pain.
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