Laparoscopic management of endometriosis

1. Dr. Prashant Pujara (D.G.O., D.N.B.)
Assistant Gynecologist at Vardaan Women Hospital

2. Introduction
 Presence & growth of functioning endometrial gland
and stroma outside the uterus
 Prevalence...:
 5% reproductive age group
 15-90% chronic pelvic pain
 20-65% infertility, 25-40% of
infertility patients
have endometriosis
Te Linde 11th edition 2015

3. Presentation
 Pain
 Dysmenorrhea (co-menstrual/progressive)
 Dyspareunia (deep)
 Dyschesia
 Infertility
 Fecundity: 15-20% (normal)→ 2-10% (endometriosis)
 Fecundity α severity of disease
Can symptomatology help in the diagnosis of endometriosis?
Findings from a national case-control study—Part 1. BJOG
2008; 115:1382–1391.

4. Diagnosis
 Clinical (signs & symptoms)
 USG (TAS, TVS, TRS) & MRI (in advanced cases)
 Bio-markers (CA-125, PP14)
 Laparoscopy + histological verification of endometrial
gland and/or stroma is the gold standard
 -ve laparoscopy: highly accurate to exclude endo.
 +ve laparoscopy: without histology limited value
 +ve histology confirms diagnosis & excludes malignancy,
 -ve histology doesn’t exclude disease

5. Medical Management
 Indications:
 Pain only
 Clinically suspected endometriosis
No benefit for infertility

6. Medical Management (cont.)
→drugs available
newer drugs→

7. Surgical Management
 Indications:
 Pain (failed medical mx)
 Infertility
 Endometrioma (damages ovary)
 Pelvic adhesion
 Moderate/severe disease distorting anatomy
 HSG or hysteroscopy alone can’t replace
laparoscopy in the evaluation of Infertility before
going for IUI or IVF respectively

8. Why Laparoscopy...?
 Advantages...
 Magnification
 Better visualisation of subtle lesions
 Less tissue trauma & desiccation
 Smaller incisions
 Speeder post-op recovery
 Less post-operative adhesions & complications
 When...
 In the follicular phase (less recurrence)
Cas Lek Cesk. Cochrane Database of Systemic reviews 2006; 145 (3) : 195-200

9. How surgical mx help...?
 ↓ses inflammation in pelvis
 ↓ses toxicity to embryos & gamets
 Enhanced uterine receptivity
 Restores anatomy (tubo-ovarian relationship)
 Restores spontaneous ovulation (in endometrioma)
 Associated pathologies can be treated (e.g., myoma,
hydrosalphinx, adhesions)

10. Pain (failed medical mx)
 ‘See & treat’, if identified at laparoscopy
 Consider ablation or excision of peritoneal
endometriosis to reduce pain
 Adhesiolysis & excision of DIE improves pain
 No role of conservative sx in pain associated with
recurrent endometriosis
Proctor, et al., 2005
(Healey, et al., 2010, Wright, et al., 2005)

11.  Don’t perform laparoscopic uterosacral nerve ablation
(LUNA) as an additional procedure to conservative sx
 LPSN is effective as an additional procedure to
conservative surgery

12. Endometrioma
 Seen in 17-44% of patients with endometriosis
 Anovulation may occur in 15-25% of cases of
endometriosis

13.  Prefer cystectomy instead of drainage & coagulation
(better pain relief, lower post-op recurrence)
 Cystectomy is associated with lower recurrence
compared with CO2 laser vaporization
Ovarian cystectomy versus laser vaporization in the treatment of ovarian endometriomas: a
randomized clinical trial with a five-year follow-up. Fertil Steril 2011; 96: 251-254
Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst
Rev 2008:CD004992.

14.  Cystectomies which should not be done...!!!
 Video: What not to do...?
 Just because we can do something, doesn’t mean we
should

15.  Endometrioma or functional cyst...?
 Associated peritoneal implants
 Adhesions to the posterior leaf of the broad ligament
 The hilum is streched medially
 The utero-ovarian ligament may be normal
 A brown area is often seen on the ovarian surface
 The ovariolysis induces the rupture
of the cyst
 The cyst fluid “chocolate”

16.  Classification of endometrioma...
 Type 1 (fibrotic)
 More difficult to remove
 Piecemeal these cysts walls carefully
 Type 2 (invasion of functional cysts)
 IIA: functional cyst, small endometrial implant, cyst wall
easily separated
 IIB: functional cyst, endometriosis deeply involving cyst wall,
cyst wall easily separated except at base of implant
 IIC: extensive periovarian adhesions, extensive
involvement of cyst wall with implant, implants
penetrate deeply, excision is difficult
(close to type 1)

17.  Endometrioma is an ovarian mass
 For best results... “Complete excision is required, not
partial treatment by coagulation”
 Along with cystectomy...
 Peritoneal cytology,
 Inspection of the abdomen, pelvis
 Inspection of the contralateral ovary
 Endocystic examination
 Careful peritoneal lavage
 Optimal debulking.....??!!!

18.  Oophorectomy if...
 Evidence of functional ovarian destruction
 Chronic incapacitating pelvic pain & fertility is not
desired

20. Infertility
 rAFS/ASRM stage I & II: To increase pregnancy
rates...
 Operative laparoscopy (excision better than ablation of
lesions) including adhesiolysis should be performed
 CO2 laser vaporization is preferred over monopolar
electrocoagulation
Rep Biom Onl 2011

21.  rAFS/ASRM stage III & IV: To increase pregnancy
rates operative laparoscopy is preferred over expectent
management

22.  Controlled ovarian stimulation with IUI within 6
months of surgery
 Cystectomy in endometrioma >3 cms...
 Improves accessibility of follicles in ART
 No evidence s/o improved pregnancy rates in ART
 Avoid suturing ovarian defect after cystectomy if
possible (never use bipolar)

23.  In endometrioma (>5cms), excision may reduce
ovarian reserve in infertile patients. Donnez’s theory
(3 step protocol) may be used...
 Drainage of endometrioma
 12 weeks GnRH agonists
 Laser vaporisation of interior wall of cyst during second
look lap
Human Reproduction vol.11 no.3 pp.641-646, 1996 Large ovarian endometriomas

24.  Should we, or should we not operate on
endometriomas in patients scheduled for ART...?
Vs.
 The impact of ovarian endometriomas on ART
outcomes is controversial

25.  Against Sx...
 Quality of the oocytes retrieved in IVF cycles is not
improved after Sx
 Patients going for sx might extend the time to pregnancy
 For Sx...
 Helps in getting more oocytes for ART
 Outcomes from ART were not affected by the time
interval between surgery and ART

26.  Be careful about loss of ovarian function in B/L
endometrioma (rule out H/O ovarian sx)
 Frequency of post-surgical ovarian failure after
laparoscopic excision of bilateral endometrioma was
2.4% (95% CI 0.5-6.8%)
 Choose infertile patient with
endometrioma for Sx wisely (age,
surgical technique, U/L vs B/L,
rASRM score)

27.  Pre-op or post-op medical treatment...?

28. Deep endometriosis (DIE)
 Severe form of disease (>5 mm depth) (type I to IV)
 DIE (20%) is classically multifocal
 Anterior
 Vesical (partial vesical resection)
 Ureteric (extrinsic requires freeing the ureter ± adnexectomy
whereas intrinsic requires segmental resection & anastomosis
or neoimplantation)
 Posterior
 Recto-vaginal
 USL (without bowel res)
 Intestinal (nodulectomy)

29.  Consider complete surgical removal of deep
endometriosis (not hysterectomy) to reduce
endometriosis-associated pain and to improve
quality of life
 If presents with infertility → ART without
laparoscopy
 Before surgery
 TRS
 MRI
Bowel resection for deep endometriosis: a systematic review. BJOG 2011; 118:285–291.

30.  Surgical technique ...
 -ve bowel infiltration
 Shaving technique (mucosal skinning)
 +ve bowel infiltration
 Segmental colorectal resection
 Discoid resection
 Stapled resection

31.  Check list at the end of surgery...
 Treatment is complete
 Haemostasis
 Absence of rectal perforation
 Intact ureter (cystoscopy)
 Future....?

32. Hysterectomy...?!!

 In advanced symptomatic endometriosis with failed
medical & conservative sx if family is completed
Bowel resection for deep endometriosis: a systematic review. BJOG 2011; 118:285–291.

33. Adhesion Prevention
 Principles of microsurgery
 Oxidized regenerated cellulose (Interceed) is useful
 Icodextrin has no benefit
 PTFE surgical membrane, hyaluronic
acid products have been proven effective
for adhesion in pelvic surgery, although not specifically
in endometriosis.

34. Superficial peritoneal endometriosis

35. Take home message
 Laparoscopy...
 Provides answer to etiology
 Treats source of pain
 Removes pathology
 Lowers high risk pregnancies by increasing chances of
natural conception
Thank you...!