Endometriosis and laparoscopy when and how

3,424 views

Published on

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

Published in: Education
0 Comments
7 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
3,424
On SlideShare
0
From Embeds
0
Number of Embeds
23
Actions
Shares
0
Downloads
158
Comments
0
Likes
7
Embeds 0
No embeds

No notes for slide
  • TODAYi have to speak Endometriosis (from endo, "inside", and metra, "womb") is a debilitating gynecological medical condition in females in which endometrial-like cells appear and flourish in areas outside the uterine cavity, most commonly on the ovaries. The uterine ...vast topic
  • Priya gave me a call and asked me on which topic i will like to speak i told her ek debate rakh do mivhagaint lap hyspriya are nahi madam aisa mat karoaao choose kar lo topic so i decided
  • Explanation to patients is why when where whwt how all diiffcult
  • Endometriosis debilitating gyn condition patient can present with any of the following conditions depending on the site of endometriosis
  • Definitive diagnosis is by laparoscopy - visualisation, biopsy and histology. The revised American Fertility Society (rAFS) staging system is in common usage with a grading system of minimal / mild / moderate / severe disease but has limitations with regard to management of pain symptoms
  • Significant benefit in select cases but duration unknown ( Zullo , Am J ObstetGynecol, 2003) Despite even the best surgical techniques, post-surgical adhesions form in the majority of patients undergoing gynecologic pelvic surgery Adhesions following some gynecologic surgery are a major cause of post-operative pelvic pain, infertility, bowel obstruction and the need for repeat surgery . Adhesion barriers are a method of enhancing good surgical technique in reducing post-surgical adhesions
  • Endometriosis and laparoscopy when and how

    1. 1. Endometriosis and laparoscopy when and how much <br />DR. KAWITA BAPAT <br />
    2. 2. Special thanks <br />Dr.VinodBhandari sir <br />Manjudidi<br />Shilpa and Mohit<br />Dr. Ratna madam and Priya<br />
    3. 3. Why I chose this topic<br />Mesmerising <br />Disillusioning<br />Confusing <br />Debilitating<br />Interesting <br />Progressive <br />Recurring <br />Worsening <br />Challenging <br /> DABANG <br />
    4. 4. ENDOMETRIOSIS<br />ECTOPIC ENDOMETRIAL TISSUE <br />TRUE INCIDENCE UNKNOWN<br />DOES NOT DISCRIMINATE RACE<br />HISTOLOGY ENDOMETRIAL GLAND<br />
    5. 5. Presentation<br />Pelvic pain<br />Mass<br />Infertility<br />Menstrual irregularities <br />Uncommon and rare problems <br /> Diaphragmatic pain<br /> cat menial pnumothorex <br /> Bowel obstruction<br />
    6. 6. when ? LAPAROSCOPIC Management of Endometriosis <br />Diagnosis <br />Acute, chronic pain <br />Significant impact on quality of life <br />Failure of medical therapy <br />Infertility investigation and treatment <br />Endometriomas <br />Secondary organ involvement (bowel, bladder, ureter, nerve) <br />
    7. 7. Macroscopic appearance of endometriosis<br />Endometriotic cysts <br />Adhesions<br />black, red, vesicular <br />Bowel endometriosis <br />marked distorted anatomy<br />Pod obliteration<br />
    8. 8.
    9. 9. Endoscopy classification <br />Wet Endometriosis<br />Superficial <br />Flimsy adhesions <br />Less severe <br />Can be treated by laparoscopic surgery <br />Dry Endometriosis<br />Extremely painful <br />Deep infiltrating<br /> Pouch of douglas Recto vaginal septum <br />Uterosacral ligaments<br />Dense fibrosis<br />Difficult to treat <br />
    10. 10. When and how much <br />Take a step in the right direction:Innovative, Compassionate & Extraordinary care .<br />a new beginning<br />
    11. 11. When and why <br />Laparoscopic Surgical Approach: <br />Objectives <br />Is Surgery Even Necessary: Indications <br />What to do: Burn or Cut? <br />Special Situations: <br />Endometriomas <br />Deep Infiltrating Endometriosis <br />Adjunctive Surgical Techniques <br />
    12. 12. Is laparoscopy Even Necessary? <br />Risks – 0.2-3% overall complication rate <br />Requires additional expertise and training <br />Excellent medical options exist for pain <br />GnRH Agonists, Aromatase Inhibitors <br />Mirena IUS <br />
    13. 13. Laparoscopic procedures practiced<br />- Electrosurgical ablation of superficial endometriotic deposits<br />- Laser ablation.<br />- Excision of endometrioma.<br />- Excision of deep fibrotic deposits and adhesiolysis.<br />- Hysterectomy & bilateral salpingo-oophorectomy.<br />
    14. 14. Surgical Options: “to cut or not to cut” <br />Excision <br />Histological diagnosis <br />Greater depth of treatment <br />Requires greater skill <br />Injury to adjacent organs<br />Thermal damage risk <br />Ablation <br />Faster <br />Less skill required <br />Unable to determine full extent <br />Thermal damage risk <br />
    15. 15. ovarian Endometriomas<br />
    16. 16. Ovarian Endometriomas <br /><ul><li>Laparoscopic ovarian cystectomy
    17. 17. Confirm the diagnosis histological
    18. 18. Reduces risk of recurrence over fulguration
    19. 19. Reduce the risk of infection at IVF
    20. 20. Improves access to follicles and possibly improve ovarian response
    21. 21. May impair ovarian reserve </li></li></ul><li>SURGICAL OPTIONS<br />ABLATION<br /> Laser,<br /> electro surgery<br />EXCISION<br />Multiple energy modalities <br />(Laser,<br /> Scissors,<br /> Harmonic) <br />
    22. 22. Endometriomas<br />Excision <br />Tissue specimen <br />Decrease recurrence <br />Post op adhesions <br />Risk of decreasing number of follicles <br />Fulguration<br />Simpler technique <br />? Preserve greater ovarian tissue <br />Risk of Recurrence <br />
    23. 23. Deeply infiltrating endometriosis<br />May be responsible for “failed surgical treatment” <br />Identification is difficult <br />Deep Dyspaurenia<br />Rectovaginal exam <br />Rectal Ultrasound <br />MRI <br />
    24. 24. Hysterectomy <br />Along with removal of endometriotic implants <br />Bilateral oophorectomy <br />Subtotal hysterectomy or supra-cervical should not be done<br />
    25. 25. Approach to Managing Endometriosis<br />Available expertise <br />Accurate diagnosis <br />Surgical skills <br />Anatomy knowledge <br />Dissection skills <br />Knowledge of energy <br />Suturing skills <br />Specialized team <br />Multi-disciplinary approach <br />Nurse educator <br />Family physician <br />Bowel surgeon <br />Urologist <br />Pain Specialists <br />
    26. 26. Laparoscopy pros and cons <br />Advantage<br />Diagnosis and Treatment <br />Prolonged therapeutic effect <br />Fecundity Improvement <br />Disadvantage <br />Risk of injury to organs <br />Greater adhesions <br />Limited resources <br />Limited expertise <br />Negative Laparoscopy <br />
    27. 27. ADJUNCTIVE SURGICAL TECHNIQUES <br />Surgical Options <br />1.-Adhesion Prevention <br /> 2.- PresacralNeurectomy<br /> 3.- Appendectomy <br />Up to 20% diseased in endometriosis/pain patients <br />Appendectomy: “Hockey Stick” Sign <br />Adhesions: <br />for Advanced Endometriosis Surgery <br />Ureterolysis<br />Suturing <br />Bowel lesions <br />Cystoscopy<br />Rigid Sigmoidscopy<br />
    28. 28. Does laparoscopy Help Pain? <br />Sutton et al FertilSteril 1994 (n=63) <br />Laser ablation + LUNA improves pain at 6 months versus expectant management (63 vs. 23%) <br />At 73 months, 55% of follow up (n=38) pain free (JSLS 2001) <br />Abbot J et al. FertilSteril 2004 (n=39) <br />Lap excision improved pain at 6 months compared with diagnostic laparoscopy (80% vs. 32 %) <br />
    29. 29. Endometriomas <br />Excision versus Fulguration <br />Recurrence of pain (19 mos vs. 9.5 mos) <br />Berretta et al FertilSteril 1998 <br />Recurrence of symptoms at 2 years(15.8% vs. 56.7%) <br />Re-operation rate (5.8% vs. 22.9%) <br />Alborzi et al. FertilSteril 2004 <br />Overall: EXCISION OF CYST preferable for PAIN <br />
    30. 30. adhesions<br />
    31. 31. Additional Limitations of laparoscopy<br />Missed lesions: false negative laparoscopy <br />Required Expertise<br />Most not comfortable with advanced <br />and many basic endoscopic techniques <br />Ob/Gyn Endoscopy Survey, Raymond,Ternamian,Leyland JMIG 2004 <br />
    32. 32. TAKE HOME MESSAGES <br />Ideal practice: diagnose and remove endometriosis surgically at same time<br />treated early and aggressively by surgical destruction or excision<br />excision and ablation provides pain relief <br />Pain can be reduced by removing the entire lesions in severe and deeply infiltrating disease <br />Role for adjunctive procedures is evidence based <br />Adhesion barriers have a role <br />
    33. 33. Take Home Messages <br />Consider Adjunctive Surgical Procedures: <br />PresacralNeurectomy<br />Appendectomy <br />Adhesiolysis and Adhesion Prevention <br />
    34. 34. hope<br />Management stepwise<br />Follow up regular <br />Correct counselling <br />See and treat approach <br />One stop solutions <br />

    ×