• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Endometriosis and laparoscopy when and how
 

Endometriosis and laparoscopy when and how

on

  • 2,310 views

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

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

Statistics

Views

Total Views
2,310
Views on SlideShare
2,299
Embed Views
11

Actions

Likes
0
Downloads
98
Comments
0

2 Embeds 11

http://onedayhysterectomy.blogspot.ru 10
http://www.slideshare.net 1

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • 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 Endometriosis and laparoscopy when and how Presentation Transcript

  • Endometriosis and laparoscopy when and how much
    DR. KAWITA BAPAT
  • Special thanks
    Dr.VinodBhandari sir
    Manjudidi
    Shilpa and Mohit
    Dr. Ratna madam and Priya
  • 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
    Endometriotic cysts
    Adhesions
    black, red, vesicular
    Bowel endometriosis
    marked distorted anatomy
    Pod obliteration
  • 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
    ABLATION
    Laser,
    electro surgery
    EXCISION
    Multiple energy modalities
    (Laser,
    Scissors,
    Harmonic)
  • 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.- PresacralNeurectomy
    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 FertilSteril 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. FertilSteril 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 FertilSteril 1998
    Recurrence of symptoms at 2 years(15.8% vs. 56.7%)
    Re-operation rate (5.8% vs. 22.9%)
    Alborzi et al. FertilSteril 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 excision
    excision 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:
    PresacralNeurectomy
    Appendectomy
    Adhesiolysis and Adhesion Prevention
  • hope
    Management stepwise
    Follow up regular
    Correct counselling
    See and treat approach
    One stop solutions