Surgical Techniques: Abdominal 188.8.131.52 Abdominal Surgery of Endometriosis
Aims and Methods
Characteristics. Endometriosis is one of the most common benign gynecologic diseases. It occurs in sexually mature women and is hormone-dependent (estrogens). The disease is often called a chameleon. This refers to the nonspecific symptoms, the varying degrees of severity, and the many locations of the disease. One of the most frequent symptoms is pain, for example, chronic diffuse pelvic pain, dysmenorrhea, dyspareunia, or pain on defecation. Other symptoms can be bleeding disorders, contact bleeding, bowel evacuation disorders, and infertility. The most frequent locations are the ovaries and the pelvic peritoneum (peritoneum in the pouch of Douglas, ovarian fossae, uterosacral ligaments). Endometriosis is a benign disease but can infiltrate and interfere with other organs. The bowel is affected most often. The rectum is often infiltrated by pronounced endometriosis low in the rectovaginal septum. The severity of endometriosis is classified according to the Revised American Society for Reproductive Medicine Classification of Endometriosis, 1996, or alternatively by the more recent ENZIAN classification, 2003, and the AAGL Classification of Endometriosis, 2013 (p. 66).
Treatment. The exact etiology of endometriosis is unknown. The hypothesis of retrograde menstruation and implantation contrasts with the theory of local metaplasia. For this reason, the reported reccurence rates of endometriosis range from 5%–20% within five years in menstruating women. The treatment of endometriosis depends on the symptoms, the patient′s age, the severity, the location, and the desire to preserve fertility. Opinions are divided on the usefulness of pre- or postoperative hormone treatment. Gestagens as well as gonadotropin-releasing hormone (GnRH) agonists are used for medical therapy in simple and more severe cases. The Cochrane review of these therapies suggests that the success in similar for these two medications. The aim of endometriosis surgery is to prolong the symptom-free period and, where necessary, restore fertility. Operative removal of the endometriotic lesions is regarded as the most effective treatment. In symptomatic endometriosis, all palpated and macroscopically visible endometriotic lesions should first be completely excised. Depending on the superficial and deep extent of the peritoneal endometriosis, this can be achieved by bipolar coagulation, laser, or monopolar scissors. Accompanying adhesions should be divided to restore the normal anatomy as far as possible. The treatment of symptomatic deep endometriosis consists of resection. Because of the usually marked fibrosis of these endometriotic lesions, the widespread involvement of neighboring organs, and the fusion of the original anatomic layers, these procedures are extremely complex and comparable to cancer surgery. When the rectum, sigmoid colon, bladder, or ureter is involved, an interdisciplinary procedure is reasonable, as complete re-section of the endometriosis is the primary aim in these cases. Technical advances in medicine and the increasing level of surgical training mean that minimally invasive operation techniques are becoming ever more important in endometriosis surgery, compared with the open abdominal approach.
Indications and Contraindications
Abdominal endometriosis surgery should be performed only when strictly indicated. It is usual to confirm the presence of severe endometriosis by laparoscopy initially, in addition to thorough gynecologic investigation and diagnostic imaging. Many authors even require histologic confirmation of ectopic endometrium via laparoscopy. The indications for abdominal or combined abdominal and vaginal surgery are severe forms of endometriosis, when endoscopic access is not possible, and when conservative treatment has been unsuccessful, as is usually the case with advanced endometriosis.
Surgery is contraindicated in patients without symptoms, regardless of the extent of the endometriosis, in pregnancy, and in patients with severe bleeding tendencies. Complex procedures have significant risks of complications and these risks need to be explained to the patient so that she can make an informed decision between the benefits and risks and determine whether or not surgery is appropriate.
Operation Risks and Informed Consent
Informed consent must be particularly detailed in view of the benign nature of the disease and because ultimately the procedure is elective. Besides general operation risks (bleeding, infections, delayed wound healing), the possibility of pain persisting must be discussed. The development of adhesions must be explained, as must the risk of injury to the uterus, adnexa, ureters, bowel, and bladder. The need to remove organs if they are injured or severely affected by endometriosis must be discussed in particular detail. The possibility of recurrence and potential need for further surgery should also be discussed.
Medical history, accurate pain history, clinical examination with vaginal and rectovaginal palpation, documentation
Diagnostic imaging (ultrasonography, MRI)
With bowel involvement and/or hydronephrosis: proctocolonoscopy or urologic investigation
Discussion of the extent of the operation, if necessary interdisciplinary, determination of the procedure, discussion of relevant topics (fertility and organ preservation)
Consent to the procedure
Anesthesiologic preoperative investigations according to local practice
Thrombosis prophylaxis: LMWH, ATS
Preoperative laxatives for bowel preparation
Antibiotic prophylaxis: 1st or 2nd generation cephalosporin 30 minutes before surgery, with the addition of metronidazole for bowel procedures if appropriate
Difficult surgery; takes 3–4 hours; surgeon and at least one assistant
Anesthesia and Positioning
Long instruments, stapler