Endometriosis Surgery and Adhesion Prevention Nicholas Leyland, BASc , MD,MHCM, FRCSC Chief of OB/GYN St Joseph’s Health Centre, Medical Director of Women’s, Children’s and Family Health Program. Associate Professor OB/GYN, University of Toronto. Left Ureterolysis

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Interceed: Years of proven efficacy in a wide variety of procedures: Adhesiolysis Myomectomy Ovarian Surgery Tubal Surgery Surgical Treatment for Endometriosis Excellent safety profile Over 10 years of clinical experience

Years of proven efficacy in a wide variety of procedures:

Adhesiolysis Myomectomy Ovarian Surgery Tubal Surgery Surgical Treatment for Endometriosis

Excellent safety profile Over 10 years of clinical experience

Surgical Approach: Objectives Is Surgery Even Necessary: Indications What to do: Burn or Cut? Special Situations: Endometriomas Deep Infiltrating Endometriosis Adjunctive Surgical Techniques and Prevention of Adhesions

Is Surgery Even Necessary: Indications

What to do: Burn or Cut?

Special Situations:

Endometriomas

Deep Infiltrating Endometriosis

Adjunctive Surgical Techniques and Prevention of Adhesions

Is Surgery Even Necessary? Risks – 0.2-3% overall complication rate Requires additional expertise and training Reimbursement limitations/OR resources limited Excellent medical options exist for pain GnRH Agonists, Aromatase Inhibitors, Mirena IUS

Risks – 0.2-3% overall complication rate

Requires additional expertise and training

Reimbursement limitations/OR resources limited

Excellent medical options exist for pain

GnRH Agonists, Aromatase Inhibitors,

Mirena IUS

Indication for Surgical Management of Endometriosis Diagnosis Acute, chronic pain Significant impact on quality of life Failure of medical therapy Infertility investigation and treatment Endometrioma Secondary organ involvement (bowel, bladder, ureter, nerve)

Diagnosis

Acute, chronic pain

Significant impact on quality of life

Failure of medical therapy

Infertility investigation and treatment

Endometrioma

Secondary organ involvement (bowel, bladder, ureter, nerve)

Surgery Pros and Cons Diagnosis and Treatment Prolonged therapeutic effect Fecundity Improvement (EndoCAN) Risk of injury to organs Greater adhesions Limited resources Limited expertise Negative Laparoscopy Advantages Disadvantages

Diagnosis and Treatment

Prolonged therapeutic effect

Fecundity Improvement

(EndoCAN)

Risk of injury to organs

Greater adhesions

Limited resources

Limited expertise

Negative Laparoscopy

Advantages

Disadvantages

Macroscopic appearance of endometriosis black, red, vesicular POD obliteration Marked distorted anatomy Endometriotic cysts Adhesions Bowel endometriosis

Additional Limitations of Surgery Missed lesions: false negative laparoscopy Required Expertise – Most grads not comfortable with advanced and many basic endoscopic techniques Ob/Gyn Endoscopy Survey, Raymond,Ternamian,Leyland JMIG 2004

Missed lesions: false negative laparoscopy

Required Expertise –

Most grads not comfortable with advanced

and many basic endoscopic techniques

Ob/Gyn Endoscopy Survey, Raymond,Ternamian,Leyland JMIG 2004

SURGICAL OPTIONS: EXCISION OR ABLATION? For Endometriosis

Surgical Options: Excision vs. Ablation Excision Multiple energy modalities (Laser, Scissors, Harmonic) Ablation Laser, electrosurgery

Excision

Multiple energy modalities (Laser, Scissors, Harmonic)

Ablation

Laser, electrosurgery

Surgical Options: “to cut or not to cut” Histologic diagnosis Greater depth of treatment Requires greater skill Injury to adjacent organs Faster Less skill required Unable to determine full extent Thermal damage risk Excision Ablation

Histologic diagnosis

Greater depth of treatment

Requires greater skill

Injury to adjacent organs

Faster

Less skill required

Unable to determine full extent

Thermal damage risk

Excision

Ablation

DOES SURGERY HELP? Endometriosis Related Pain

Does Surgery Help Pain? Sutton et al Fertil Steril 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. Fertil Steril 2004 (n=39) Lap excision improved pain at 6 months compared with diagnostic laparoscopy (80% vs. 32 %)

Sutton et al Fertil Steril 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. Fertil Steril 2004 (n=39)

Lap excision improved pain at 6 months compared with diagnostic laparoscopy (80% vs. 32 %)

Does Surgery Help Pain? Cochrane Library: “ Laparoscopic surgery reduces pelvic pain caused by endometriosis” Laparoscopic surgery for pelvic pain associated with endometriosis (Cochrane Review 2008) Jacobson TZ, Barlow DH, Garry R, Koninckx P

Cochrane Library:

“ Laparoscopic surgery reduces pelvic pain caused by endometriosis”

Ablation versus Excision Limited evidence* Wright et al JMIG 2005 (n=24) Mild disease, 6 month follow up ALL lesions treated Equally effective BUT did not include Deeply infiltrating disease Both likely effective to some degree for MILD disease but more involved disease requires wide excision for pain relief *Consensus statement for the management of chronic pelvic pain and endometriosis: proceedings of an expert-panel consensus process Chronic Pelvic Pain/Endometriosis Working Group, GAMBONE et al.

Limited evidence*

Wright et al JMIG 2005 (n=24)

Mild disease, 6 month follow up

ALL lesions treated

Equally effective BUT did not include

Deeply infiltrating disease

Both likely effective to some degree for MILD disease but more involved disease requires wide excision for pain relief

*Consensus statement for the management of chronic pelvic pain and endometriosis: proceedings of an expert-panel consensus process

Chronic Pelvic Pain/Endometriosis Working Group, GAMBONE et al.

Additional Surgical Skills for Advanced Endometriosis Surgery Ureterolysis Appendectomy Suturing Bowel lesions Cystoscopy Rigid Sigmoidscopy

Ureterolysis

Appendectomy

Suturing

Bowel lesions

Cystoscopy

Rigid Sigmoidscopy

Deeply infiltrating endometriosis May be responsible for “failed surgical treatment” Identification is difficult Deep Dyspaurenia Rectovaginal exam Rectal Ultrasound MRI

May be responsible for “failed surgical treatment”

Identification is difficult

Deep Dyspaurenia

Rectovaginal exam

Rectal Ultrasound

MRI

Deep Versus Superficial Endometriosis: What do you see?

Ovarian Endometriomas

Ovarian Endometriomas Laparoscopic ovarian cystectomy confirm the diagnosis histologically 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

Laparoscopic ovarian cystectomy

confirm the diagnosis histologically

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

Endometriomas Tissue specimen Decrease recurrence Post op adhesions Risk of decreasing number of follicles (Ragni et al AmJOG 2004) Simpler technique ? Preserve greater ovarian tissue Risk of Recurrence Excision Fulguration

Tissue specimen

Decrease recurrence

Post op adhesions

Risk of decreasing number of follicles

(Ragni et al AmJOG 2004)

Simpler technique

? Preserve greater ovarian tissue

Risk of Recurrence

Excision

Fulguration

Endometriomas Excision versus Fulguration Recurrence of pain (19 mos vs. 9.5 mos) Berretta et al Fertil Steril 1998 Recurrence of symtoms at 2 years(15.8% vs. 56.7%) Re-operation rate (5.8% vs. 22.9%) Alborzi et al. Fertil Steril 2004 Overall: EXCISION OF CYST preferable for PAIN

Excision versus Fulguration

Recurrence of pain (19 mos vs. 9.5 mos)

Berretta et al Fertil Steril 1998

Recurrence of symtoms at 2 years(15.8% vs. 56.7%)

Re-operation rate (5.8% vs. 22.9%)

Alborzi et al. Fertil Steril 2004

Overall: EXCISION OF CYST preferable for PAIN

Ablation versus Excision of Cysts Cochrane Review 2008: Authors' Conclusions: There is good evidence that excisional surgery for endometriomata provides for a more favourable outcome than drainage and ablation with regard to the recurrence of the endometrioma, recurrence of pain symptoms, and in women who were previously subfertile, subsequent spontaneous pregnancy rates Caveat: ART Excisional surgery versus ablative surgery for ovarian endometriomata R J Hart, et al The Cochrane Library 2008

Cochrane Review 2008:

Authors' Conclusions: There is good evidence that excisional surgery for endometriomata provides for a more favourable outcome than drainage and ablation with regard to the recurrence of the endometrioma, recurrence of pain symptoms, and in women who were previously subfertile, subsequent spontaneous pregnancy rates

Caveat: ART

Excisional surgery versus ablative surgery for ovarian endometriomata R J Hart, et al The Cochrane Library 2008

ADJUNCTIVE SURGICAL TECHNIQUES

Additional Surgical Options 1.-Adhesion Prevention 2.- Presacral Neurectomy Significant benefit in select cases but duration unknown ( Zullo , Am J Obstet Gynecol, 2003) 3.- Appendectomy Up to 20% diseased in endometriosis/pain patients

1.-Adhesion Prevention

2.- Presacral Neurectomy Significant benefit in select cases but duration unknown ( Zullo , Am J Obstet Gynecol, 2003)

3.- Appendectomy

Up to 20% diseased in endometriosis/pain patients

Appendectomy: “The Hockey Stick” Sign

Adhesions: 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

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

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Interceed: Years of proven efficacy in a wide variety of procedures: Adhesiolysis Myomectomy Ovarian Surgery Tubal Surgery Surgical Treatment for Endometriosis Excellent safety profile Over 10 years of clinical experience

Years of proven efficacy in a wide variety of procedures:

Adhesiolysis Myomectomy Ovarian Surgery Tubal Surgery Surgical Treatment for Endometriosis

Excellent safety profile Over 10 years of clinical experience

TAKE HOME MESSAGES

Take Home Messages: Ideal practice: diagnose and remove endometriosis surgically at same time Laparoscopic excision and ablation of endometriosis provides pain relief Pain can be reduced by removing the entire lesions in severe and deeply infiltrating disease Role for adjunctive procedures is evidence beased Adhesion barriers have a role

Ideal practice: diagnose and remove endometriosis surgically at same time

Laparoscopic excision and ablation of endometriosis provides pain relief

Pain can be reduced by removing the entire lesions in severe and deeply infiltrating disease

Role for adjunctive procedures is evidence beased

Adhesion barriers have a role

Take Home Messages Consider Adjunctive Surgical Procedures: Presacral Neurectomy Appendectomy Adhesiolysis and Adhesion Prevention

Consider Adjunctive Surgical Procedures:

Presacral Neurectomy

Appendectomy

Adhesiolysis and Adhesion Prevention

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

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

Surgical Approach: Objectives Is Surgery Even Necessary: Indications What to do: Burn or Cut? Special Situations: Endometriomas Deep Infiltrating Endometriosis Adjunctive Surgical Techniques

Is Surgery Even Necessary: Indications

What to do: Burn or Cut?

Special Situations:

Endometriomas

Deep Infiltrating Endometriosis

Adjunctive Surgical Techniques

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