9.1 Introduction
Endometriosis affects women worldwide. One study demonstrated the prevalence and incidence rates of endometriosis respectively to be 8.1 and 3.5 per 1000 women [1]. Although much has been studied and discovered about this disease in the last few decades, its etiology and clinical manifestations remain an enigma for many professionals involved in the treatment and care of women with endometriosis [2]. The symptoms are variable and may not be related to the extension of the disease. These symptoms include dysmenorrhea, deep dyspareunia, chronic pelvic pain, intestinal and/or urinary cyclical symptoms, and infertility [3].
There are three distinct types of endometriosis: superficial endometriosis, ovarian endometriomas, and deeply infiltrating endometriosis (DIE). This differentiation is important in the therapeutic management of the disease. In 1996, the American Society for Reproductive Medicine (ASRM) revised an established surgical classification categorizing the disease in four different stages defined by a point system according to the surgical findings [4]. The pathophysiology of endometriosis, its effects on local surrounding organs and tissues, and the mechanisms by which it causes pain and possibly infertility has been studied extensively [5].
Surgical management of endometriosis is directed toward alleviating the symptoms of the disease, preserving organ function, and, in cases of compromised fertility, reestablishing the reproductive potential of the affected patient. Surgical diagnosis and eradication of endometriosis, combined with medical suppression, can provide the most favorable long-term results. Conservative and medical management of endometriosis exists, yet the discussion of those approaches is outside the scope of this chapter.
9.2 Preoperative Evaluation and Diagnosis
Although the diagnosis of endometriosis can be suspected from clinical examination as well as the patient’s history and narrative description, it is widely accepted that the gold standard for diagnosis is either direct visualization of endometriotic lesions and implants or pathologically confirmed biopsy of the lesion. Currently, video-laparoscopic diagnosis and treatment of endometriosis is preferential to laparotomy. Both have shown similar results as far as treatment and outcomes are concerned. A detailed vaginal and rectovaginal digital examination supplanted with transvaginal ultrasonography (TVUS) and at times transrectal ultrasonography (TRUS) are noninvasive methods used to help with the diagnosis of endometriosis and to strategize multidisciplinary treatment plans if needed [6].
Treatment depends on the age of the patient, the location of the disease, the severity of symptoms, and the desire for future fertility. Surgical intervention is usually indicated for pain, infertility, or impaired function of the involved organ, such as the bladder, ureter, or bowel.
9.3 Surgical Treatment of Pelvic Endometriosis
Video-laparoscopic surgery for the diagnosis and potential treatment of endometriosis begins with a careful examination of abdominal and pelvic anatomy. Broadly speaking, endometriosis can be divided into four categories:
1. Superficial peritoneal endometriosis.
2. Ovarian endometrioma.
3. Deep infiltrating endometriosis (>5 mm implants).
4. Extragenital endometriosis (e.g., diaphragmatic, pulmonary, etc.).
Visual inspection of the uterus, fallopian tubes, ovaries, bladder reflection, and cul-de-sac with utero-sacral ligaments are routinely performed. Para-ovarain fossae are examined bilaterally with the retraction of the adnexum away from the underlying peritoneum. Even though typical powder-burn and cherry-red spot lesions are easily identified (Figure 9.1), the surgeon should look for atypical presentation of endometriosis, such as white and clear lesions vesicular lesions (Figure 9.2), and peritoneal retractions.
Figure 9.1 Atypical endometriosis lesion.
Figure 9.2 Typical blue endometriosis lesion.
Examination of the intestines, omentum, curvature of the stomach, the gallbladder, and both lobes of the liver is carried out. Visualization of the spleen, if possible, is done as well. Inspection of both hemidiaphragms is performed for signs of diaphragmatic endometriosis (Figure 9.3). Mossy endometriosis secondary to ascites has also been described (Figure 9.4) [7]. The surgical management of the extragenital endometriosis including endometriosis of the thoracic cavity and diaphragm is outside of the scope of this discussion.
Figure 9.3 Endometriosis of the diaphragm behind the liver.
Figure 9.4 Mossy endometriosis secondary to ascites (video).
Video Link: www.fertstert.org/article/S0015-0282(16)62663–8/abstract [7].
As demonstrated by Sutton in 1994 and confirmed by Abbott 10 years later [4,8], both laparoscopic excision of endometriosis and laparoscopic ablation have produced significant reduction in pelvic pain. The greatest reduction in pain scores after treatment was observed in stages II and III (ASRM classification), while stage I showed moderate improvement in pain scores [4]. Nevertheless, in a randomized, placebo-controlled trial, laparoscopic excision of endometriosis resulted in significantly more symptomatic relief than laparoscopy alone (80% vs. 32%) [7].
9.4 Management of Superficial Peritoneal Endometriosis
Once the endometriosis lesions are identified, the important nearby anatomic structures are visualized and identified. Very often, the visible endometriosis lesion represents “the tip of the iceberg,” with underlying retroperitoneal disease being larger than the visible lesion. The laparoscopic hydro dissection technique is utilized successfully and with good results [9]. In instances where superficial endometriosis implants are positioned away from underlying structures (e.g., ureter or the bowel), simple excision of the peritoneal implant is carried out:
1. Peritoneum with identified lesion is tented up utilizing grasping forceps (Figure 9.5).
Figure 9.5 Step 1: Grab peritoneum away from sidewall and ureter.
2. Small 4–5 mm incisional window is made next to the peritoneal implant with either laser, laparoscopic scissors, or electrosurgical instrument (Figure 9.6).
Figure 9.6 Step 2: Make incision and allow pneumo dissection.
3. Hydro dissection is utilized to create a “cushion” and help with interface separation. The fluid entering the retroperitoneal space moves the lesion slightly away and medial from vital underlying structures and provides a “heat sink” for thermal spread during further use of electrosurgery. The tip of the laparoscopic suction-irrigator is then inserted into the incision and the high-pressure irrigation with either normal saline or lactated Ringer’s solution is performed (Figure 9.7).
Figure 9.7 Step 3: Extend peritoneum incision parallel to retroperitoneal structure.
4. Peritoneal implant is removed utilizing traction-counter traction technique and either sharp dissection or preferred energy device (CO2 laser vs. monopolar current vs. ultrasonic energy) (Figure 9.8).
Figure 9.8 Step 4: Separate lesion from ureter.
5. Meticulous homeostasis is achieved with superficial bipolar fulguration, if anatomy allows, utilizing bipolar forceps (Figure 9.9).
Figure 9.9 Step 5: Excise the endometriotic lesion.
6. The removed specimen is sent to pathology for final examination.
7. Use of adhesion-prevention agents is controversial but could be applied laparoscopically if warranted.
Vaporization and ablation of superficial peritoneal implants is also performed with the help of various energy devices, although in our practice vaporization and excision remains the most favorable option depending on the location and depth of penetration of the lesions.
9.5 Management of Ovarian Endometriomas
The European Society of Human Reproduction and Embryology recommends surgical and histology evaluation of cysts > 3 cm in diameter and with characteristics of ovarian endometriomas (Figure 9.10).
Figure 9.10 Bilateral ovarian endometriomas (left: type I endometrioma, right: type II endometrioma).
Ovarian endometriomas should be distinguished from superficial endometriosis of the ovary (Figures 9.11 and 9.12).
Figure 9.11 Superficial endometriosis involving the surface of the ovary.
Figure 9.12 Ovarian endometrioma.
Surgical excision of endometriomas via a stripping technique has been demonstrated to be superior to cyst drainage and ablation, while the effect of endometriosis treatment on overall fertility remains unknown. Excisional surgery has shown to improve spontaneous pregnancy rates 9–12 months after surgery compared to ablative surgery [10].
The typical surgical procedure can be described as follows:
If the ovary with the endometrioma is adherent to the pelvic sidewall, peritoneal dissection with ureterolysis is performed to free the ovary from its attachments.
1. Adhesions between the affected ovary and the uterus and/or broad ligaments are lysed sharply or with the help of preferred energy sources.
2. Utilizing traction-counter traction techniques, the capsule of the cyst is removed by striping technique: chocolate fluid that sometimes leaks during cystectomy is suctioned and copiously irrigated for complete evacuation (Figure 9.13).
Figure 9.13 Traction-counter traction technique for excision of ovarian endometrium. Note that the entire cyst wall is excised.
3. Electrosurgery is reserved for cases where superficial fulguration is required; suturing of the ovary has potential for adhesion formation and future fertility compromise. However, at times selective intracortical suturing with fine monofilament absorbable sutures such as 4-0 Polydixanone for approximation of ovarian edges is necessary.
4. Use of adhesion-prevention agents is controversial but can be accomplished laparoscopically based on surgeon’s preference. Wrapping of the fallopian tubes in adhesion barriers have been reported to cause adhesions and must be avoided.
9.6 Management of Deeply Infiltrating Endometriosis
Deeply infiltrating endometriosis (DIE) is characterized by endometriotic implants that penetrate more than 5 mm into the affected tissue and is responsible for painful symptoms whose severity is strongly correlated with the depth of the DIE lesions. DIE may involve sites such as the uterosacral ligaments (USL), the rectovaginal septum (RVS), the posterior vaginal wall, the bowel, and the urinary tract. We will discuss the surgical management of colorectal and urinary tract DIE.
9.6.1 Rectovaginal and Pararectal Endometriosis
Resection of pararectal and rectovaginal (RV) lesions start with developing the pararectal space and/or relaxing excision:
1. Rectovaginal digital examination is performed prior to initiation of surgical intervention to gauge the position and the involvement of the disease process.
2. Relaxing excision is made between the ipsilateral ureter and the uterosacral ligament, allowing the mobilization of the uterosacral ligament with the potential lesion medially.
3. Pararectal space, classically defined as a triangle between the hypogastric artery, uterine artery, and the ureter, can be approached either from the opening of the broad ligament above, also known as “the superior approach,” or from the peritoneal dissection with ureterolysis.
4. Once pararectal space is developed and noticed to be free of endometriosis, the rectum is retracted to the contralateral side. Use of rectal probes or end-to-end anastomosis (EEA) sizer can facilitate exposure, since it allows for the manipulation of the rectum and aids in pararectal dissection.
5. Uterine manipulator can aid displacing the uterus anteriorly and to the contralateral side.
6. Traction-counter traction is utilized while tenting the lesion with the laparoscopic grasper. The lesion is excised utilizing a variety of laparoscopic instruments, ideally avoiding middle rectal vessels and intramesenteric nerve bundles.
7. The resection of the RV lesion is carried into the vaginal fornices and the lesion is removed with excision of the associated vaginal wall.
8. Vaginal defect is closed and reapproximated with the variety of available absorbable suture material.
Not uncommonly, the lesion will be in very close proximity to the rectal wall and extend all the way to the muscles of the pelvic floor. Routine intraoperative procto-sigmoidoscpy can be performed and the rectum examined “under water” to demonstrate the integrity of the rectal wall and absence of microscopic perforations, particularly if the electrosurgical instruments were used [11].
9.6.2 Endometriosis of Gastrointestinal Tract
The bowel is involved in approximately 10% of endometriosis cases. The most commonly affected sites are the rectum and sigmoid 76%, the appendix 18%, and the cecum 5%. Other segments less frequently involved include the ileum, jejunum, or other parts of small intestine in 3% of the cases [11,12]. The surgery is necessary when the small intestine is affected due to the risk of obstruction and in symptomatic rectosigmoid disease, because medical therapy is either temporarily effective or ineffective. In less than 1%, it invades intestinal lumen, thus detection with colonoscopy is rare.
Treatment of intestinal endometriosis depends on the location of the lesion, single- or multifocal lesions(s), size of the lesion, depth of penetration, skill, and experience of the surgeon and availability of proper instrumentation. Techniques used for excision of gastrointestinal DIE lesions include rectal shaving, disc excision, and segmental resection [11–14]. Shaving of lesions involving bowel mesentery, serosa, or less than 2–3 mm superficial muscularis has been performed with CO2 lasers since the early 1990s with good long-term results and less morbidity [15]. Trans-abdominal or trans-rectal discoid excision is performed for single infiltrative lesions with more than 5 mm depth of penetration as long as it does not invade more than one-third of the bowel wall [13,14]. Segmental resection with EEA is performed for lesions larger than 3 cm, multifocal lesions, or in cases of narrowing of the lumen [13,14]. The necessity of each particular technique and the surgical outcomes have been debated for decades, with all approaches showing good results when done at high-volume centers and with proper surgical technique.
9.6.3 Shaving Technique
Shaving of bowel endometriosis can be used for more superficial lesions that are not circumferential and do not constrict the lumen of the bowel. The technique is as follows:
1. The lesion involving the bowel wall is identified, palpated using the tip of suction-irrigator, and elevated by grasping forceps. A proctosigmoidoscopy or rectal probe can be used for exposure and to facilitate identification of the lesion if necessary.
2. The ureters are identified and the pararectal spaces are developed bilaterally.
3. The lesion is placed on traction using grasping forceps and full-thickness “shaving” technique is carried out from proximal to distal end using variety of laparoscopic instruments (video; Nezhat C, Nezhat F, Nezhat CH. Nezhat’s Video-Assisted and Robotic-Assisted Laparoscopy and Hysteroscopy with DVD. 4th edition. New York: Cambridge University Press, 2013).
4. The surgeon should follow the contour of the bowel around the endometriotic nodule. The goal is to free the nodule completely from the bowel wall and to identify the healthy tissue surrounding the nodule (Figure 9.14).
Figure 9.14 Endometriosis nodule being excised from surface of bowel using the rectal shaving technique.
5. After procedure, air is injected into the rectum, which is submerged in the irrigation fluid, and the bowel is compressed above the site of dissection to ensure that there is no leakage. A dilute solution of methylene blue is introduced into the rectum to assess for the thickness integrity of the wall [16].
If the bowel lumen is entered, the defect is repaired by placing several through-and-through single interrupted delayed absorbable sutures (Figure 9.15).
Figure 9.15 Repair of bowel using a single interrupted layer of delayed absorbable suture.
Alternatively, stay sutures are placed in the corners of the opening to the bowel and either trans-abdominal or transanal Endo Stapler is applied for repair.
If complete bowel resection is required, this can be achieved by laparoscopically assisted anterior resection and anastomosis (Figure 9.16).
Figure 9.16 Laparoscopic technique of low anterior resection.
1. The rectum is mobilized entirely with the development of pararectal and presacral spaces.
2. Ureters are identified bilaterally, sometimes with prior stent placement.
3. Hemostasis is achieved using electrosurgical techniques on branches of inferior mesenteric vessels.
4. The rectum is transected proximally to the lesion and the proximal end is prolapsed either transanally, transvaginally, or transabdominally though minilaparotomy (< 4 cm incision).
5. The anvil of a circular stapler is placed into the proximal end and secured with purse-string absorbable suture.
6. The distal end of the rectum and the endometriosis lesion is prolapsed either transanally, transvaginally, or through mini-laparotomy incision and the liner stapler is used to separate and remove the lesion.
7. The rectal stump is brought back into the pelvis, the anvil is attached to the shaft of the circular stapler, and stapler is fired under laparoscopic guidance completing EEA.
The bowel is examined for possible stricture and leaks by proctosigmoidoscopy with examination “under water” technique described previously [16].
9.6.4 Discoid Resection
Discoid resection entails wedge resection of the anterior wall of the rectum. Two techniques have been described in the literature: (1) resection of the endometrial nodule followed by suture repair or (2) resection of the endometrial nodule using either linear stapler trans-abdominally (Figure 9.17) or circular stapler trans-anally [15,17,18].
