Surgery for Ovarian and Peritoneal Disease
M. Jean Uy-Kroh
Tommaso Falcone
General Principles
Definition
Endometriosis is a chronic, nonmalignant, condition characterized by pelvic pain and infertility that is hormonally mediated and responsive to hormone suppression and surgical excision. It is defined by the histologic identification of ectopic implants of endometrial glands and stroma. These implants are commonly found on the pelvic peritoneum, abdominal, and pelvic organs. Endometriosis can also be found within remote locations such as the thoracic cavity. The pathogenesis of endometriosis remains unclear.
Differential Diagnosis
Adhesions, pelvic inflammatory disease, mittelschmerz, chronic pelvic pain, malignancy, hemorrhagic ovarian cyst.
Nonoperative Management
Unfortunately, the only way to diagnose endometriosis is with tissue biopsies obtained during surgery. Once surgical pathology confirms ectopic endometriosis tissue, conservative nonoperative management with oral contraceptive pills and nonsteroidal anti-inflammatory drugs is recommended to inhibit ovulation and decrease pain. Other medications such as progestins, gonadotropin-releasing hormone agonists, and aromatase inhibitors may also be utilized to suppress the disease. Nonoperative medical management of this chronic disease is a cornerstone of treatment and should accompany surgical management.
 Figure 12.1. 5.5-cm endometrioma identified by TVUS. |
Imaging and Other Diagnostics
Occasionally a speculum examination can reveal vaginal endometriosis implants that can be biopsied and confirm the diagnosis. More commonly, the pelvic examination yields suggestive but nonspecific findings of endometriosis such as decreased uterine mobility, a palpable adnexal mass, or rectovaginal and uterosacral nodules.
Transvaginal ultrasound is the diagnostic imaging modality of choice for identifying ovarian endometriomas (Fig. 12.1). Rectal endometriosis can also be seen with transvaginal ultrasound, particularly with the addition of rectal contrast, and requires experienced sonographers and a high level of radiographic expertise.
Small endometriomas are identified by abdominal or vaginal ultrasounds obtained at least 6 to 8 weeks apart to differentiate them from hemorrhagic corpus luteal cysts that usually involute during this time period. Larger endometriomas that are 4 to 5 cm or more in diameter are usually diagnosed by their characteristic homogeneous pattern (Fig. 12.2). The hypoechoic cyst may contain diffuse low-level echoes with septations and multiloculations and may not benefit from repeat imaging.
Magnetic resonance imaging (MRI), with enterography, is reserved for equivocal ultrasound findings or for patients with a clinical history consistent with deep infiltrating endometriosis invading the bowel or bladder.
Computed tomography (CT) is not a recommended imaging modality.
For patients who desire fertility, have struggled with infertility, are 35 years of age or older, or have ovarian endometriomas, a serum anti-müllerian hormone level may be useful for fertility counseling.
Figure 12.2. Bilateral 5-cm endometriomas identified by TVUS.
Currently, there are no reliable serum markers for endometriosis. Ca-125 can be elevated in endometriosis and is not recommended unless there is a strong suspicion for malignancy.
Preoperative Planning
An examination under anesthesia is performed to assess uterine position, sacral nodularity, and palpable adnexal masses that may affect incision length or laparoscopic trocar placement.
Angled 30- or 45-degree laparoscopes can increase the range of surgical views, particularly for large adnexal masses.
Cystoscopy is indicated when extensive sidewall adhesiolysis or ureterolysis is performed. Intraoperative intravenous indigo carmine or 10% sodium fluorescein, or presurgical administration of oral pyridium provides urine contrast for easy identification of the urine jets from the ureteral orifices.
Surgical Management
Indications for surgical intervention may include the need to obtain tissue diagnosis, pain refractory to medical management, contraindications to medical therapy, to resect deep infiltrating endometriosis that is causing obstruction to the genitourinary or gastrointestinal tracts, to exclude malignancy in an adnexal mass, to improve pregnancy rates in infertile patients with suspected endometrioma, and to treat chronic pain in the infertile patient who desires pregnancy.
Although endometriosis historically shares many characteristics that are similar to malignancy (tissue biopsy diagnosis, surgically staged condition, and it is colloquially referred to as recurrence of disease instead of persistence of disease) it is crucially important to remember that endometriosis is a benign and chronic condition. Application of malignant surgical principles such as debulking and cytoreduction tend to supersede the overall well-being of the patient. Surgical interventions for endometriosis must be thoughtful and tempered. Extreme surgical management that results in significant patient morbidity or decreased functionality is not encouraged.
When endometriosis affects areas that are vulnerable to tissue damage and destruction, such as ovarian follicles, ablative techniques may be appropriate.
Optimal endometrioma treatment in reproductive age women weighs inadvertent follicle destruction against endometrioma recurrence.
Current endometrioma surgical management is largely influenced by a Cochrane review that demonstrated endometriomas greater than 3 cm have a higher recurrence rate when ablated with bipolar energy versus cyst excision.
Recent investigations suggest that cyst fenestration and plasma vaporization may preserve antral follicles without compromising cyst recurrence or subsequent pregnancy rates.
While we await randomized, prospective investigation that confirms this claim, surgeons must reconsider their techniques to balance adequate treatment of symptomatic disease against unintentional reduction of the very fertility they wish to preserve.
A key to both endometrioma and peritoneal endometriosis excision is identification and separation of endometriosis from healthy tissue.
The goal of the surgery is paramount and should dictate the degree of surgical intervention.
For some patients, excision of a pelvic lesion to exclude malignancy is sufficient. For others, restoration of anatomy and resection of deep infiltrating disease are necessary.
Positioning
Please see low lithotomy positioning described in Chapter 5.
Laparoscopy: The patient’s arms are gently tucked and extremities protected with padding. Her legs comfortably rest in neutral position in adjustable leg stirrups that allow for perineal access and manipulation of the uterus.
Approach
A minimally invasive, laparoscopic approach is the preferred surgical approach for this benign disease. Extensive adhesiolysis, excision, and ablation can be performed safely by an experienced laparoscopic surgeon.
Endometrioma Excision (Video 12.1)Identify anatomic landmarks
First, perform an initial survey to identify landmarks—this is especially helpful in the case of distorted anatomy.
The bilateral medial and lateral umbilical ligaments are helpful to orient the anatomic space, to ensure safe dissection (Tech Fig. 12.1A–C). Perform adhesiolysis and expose the ureter.
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