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FIRST TIME THIS PRESENTATION IN SAIMS MEDICAL COLLEGE ON 21 SEPT 2010
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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