BENIGN INVASION OF ENDOMETRIUM IN THE MYOMETRIUM PRODUCING A DIFFUSELY ENLARGED UTERUS WHICH MICROSCOPICALLY EXHIBITS ECTOPIC NONNEOPLASTIC ENDOMETRIAL GLANDS AND STROMA SURROUNDED BY HYPERTROPHIC AND HYPERPLASTIC MYOMETRIUM

1. ADENOMYOSIS&
RECTO VAGINAL
ENDOMETRIOSIS
DR NIKITA TREHAN GYNAECOLOGIST AND LAP
SURGEON SUNRISE HOSPITAL DELHI ,IMH DUBAI

2. DEFINATION
 BENIGN INVASION OF ENDOMETRIUM IN THE
MYOMETRIUM PRODUCING A DIFFUSELY
ENLARGED UTERUS WHICH MICROSCOPICALLY
EXHIBITS ECTOPIC NONNEOPLASTIC ENDOMETRIAL
GLANDS AND STROMA SURROUNDED BY
HYPERTROPHIC AND HYPERPLASTIC MYOMETRIUM

3. SURGICAL/HISTOLOGIC
CLASSIFICATION.grimbiziseta
lfertilster 2013
DIFFUSE ADENOMYOSIS SMOOTH MUSCLE HYPERPLASIA
WITH ECTOPIC ENDOMETRIUM
FOCAL ADENOMYOSIS ADENOMYOMA,CYSTIC ADULT
ADENOMYOMA
POLYPOIDAL
ADENOMYOSIS
TYPICAL OR ATYPICAL
SPECIAL CATEGORIES ADENOMYOSIS OF
ENDOCERVICAL TYPE
RETROPERITONEAL
ADENOMYOSIS OR
RECTOVAGINAL ENDOMETRIOSIS

4. IMAGING
MRI BETTER SPECIFICITY WHEN FIBROIDS COEXIST
JUNCTIONAL ZONE {INNERMOST MYOMETRIAL LAYER}
TVS ; MYOMETRIAL HETEROGENECITY MYOMETRIAL
CYSTS.HIGHSPECIFICITY &PPV MORE THAN 90 PERCENT

5. SYMPTOMS AND AIMS OF
TREATMENT
ABNORMAL UTERINE
BLEEDING
REDUCTION OF BLEEDING
PELVIC PAIN
DYSMENORRHOEA
DYSPARENUNIA CHRONIC
PELVIC PAIN
REDUCTION OF PAIN
POOR REPRODUCTIVE
OUTCOME
ACHEIVEMENT AND
EVOLUTION OF
PREGNANCY

6. NON SURGICAL OPTIONS
 CONTINIOUS
OCP,DEPOPROVERA, LNG
IUD,DANAZOL
IUD,INTRACERVICAL
DANAZOL 2 WEEKLY ,GNRH
AGONISTS,MRGFUS
 BASIC PRINCIPLE OF
HORMONAL TREATMENT IS
ONLY “SUPPRESSION”OF THE
DISEASE AND SURGERY IS
THE MAINSTAY FOR
“TREATMENT”OF THE
DISEASE.

7. Classification of Uterus
sparing techniques
SURGICAL
CATEGORY
TECHNIQUE DESCRIBED
VARIANT
COMPLETE
EXCISION
ADENOMYOMEC
TOMY
CLASSICAL
TECH,MODIFICATI
ONS;Ushaped,Ov
erlapping flaps
,Triple flap
PARTIAL EXCISION PARTIAL
ADENOMYOMEC
TOMY
Classical
tech,TransverseHi
ncision,Asymmetri
c dissection

8. The Osada Technique

9. Adenomyomectomy Video

10. Namrata Video

11. ADVANTAGES&
DISADVANTAGES
 MORE THAN 70PERCENT REDUCTION OF
MENORRHAGIA AND DYSMENORRHOEA.
MORE THAN 50%SPONTANEOUS CONCEPTIONS IN
8 MONTHS.
MISCARRIAGE RATE DECREASED DRASTICALLY.
WE RECOMMEND AN ELECTIVE CAESAREAN AT 37
WEEKS COMPLETE.

12. WEDGE RESECTION

13. PRINCIPLES OF GROSS
WEDGING
 PRESERVATION OF OVARIAN BLOOD SUPPLY WITHOUT
COMPROMISING ON CORRECTION OF UTERINE
PATHOLOGY IN YOUNG PATIENTS.
 GROWING REASONS FOR HYSTERECTOMY IN YOUNG
INDUVIDUALS LIKE SYMPTOMATIC LEIOMYOMATOUS OR
ADENOMYOMATOUS UTERI IN WOMEN UNDER 45 YRS OF
AGE .ALTERNATE FOR HYSTERECTOMY FOR SYMPTOM
CONTROL
SEVERAL STUDIES HAVE PROVEN THE ROLE OF POST
HYSTERECTOMY OVARIAN FUNCTION NECESSARY FOR
BONE AND GENERAL HEALTH.
RELUCTANCE TO PRESCRIBE HRT (RIGHTLY SO )AFTER WHI
TRIAL AND MILLION WOMEN STUDY,HENCE MORE STRESS
ON ENDOGENOUS OVARIAN HORMONE PRESERVATION.

14. THE OVARIAN BLOOD SUPPLY;In56%cases
ovary gets b.s from uterine+ovarian
arteries.In 40%ovarian artery alone and
in4%uterine artery alone.

15. WORLD STUDIES
 TWO LARGE STUDIES WERE CONDUCTED IN CHINA;1.THE
EFFECT OF HYSTERECTOMY ON OVARIAN BLOOD SUPPLY
AND ENDOCRINE FUNCTION;XIANGYING,LILLI H;COLOR
DOPPLER AND HORMONE STUDIES WERE DONE IN 2
GROUPS OF PATIENTS HYSTERECTOMY AND
MYOMECTOMY;PEAK FLOW SYSTOLIC VELOCITY
,E2,PROGESTERONE FSH ,LH RESULTS.
INFLUENCE OF DIFFERENT OPERATION MODES IN
TREATMENT OF LEIOMYOMA ON REPRODUCTIVE
ENDOCRINE HORMONE LEVELS;COMPARISON OF
SUBTOTAL,TOTAL HYSTERECTOMY,AND
MYOMECTOMY;ZHOGUA,YI,ZAZHI;RESUTS;MYOMECTOMY
DOES NOT INFLUENCE OVARIAN FUNCTION BUT BOTH
TOTAL AND SUBTOTAL HYSTERECTOMY DECREASE
OVARIAN BLOOD FLOW AND ENDOCRINE FUNCTION
6MONTHS AFTER SURGERY.

16. ADVANTAGES AND
DISADVANTAGES
 CERVICAL CANCER IS THE NO 1 CANCER IN
INDIA;NEED FOR CONTINUED PAPS AND CALL
RECALL FOLLOW UP.OVARIAN CANCER FAMILY
HISTORY OR GENE POSITIVE BRCA 1 AND 2.
IN OUR STUDIES ABOUT 0.5 %PATIENTS PRESENTED 2
TO 3 YRS LATER WITH IRREGULAR SPOTTING P/V
AND WERE TREATED WITH DMPA INJECTIONS .NO
FURTHER MANAGEMENT i.e HYSTERECTOMY WAS
NEEDED IN ANY PATIENT.

17. RECTO VAGINAL&BOWEL
ENDOMETRIOSIS
SHAVING/MUCOSAL
SKINNING
MUCOSA OF BOWEL NOT
ENTERED REINFORCING
SUTURES VICRYL
DISCOID RESECTION TRANSANAL CIRCULAR
STAPLER FOR
ANT/ANTEROLAT BOWEL
RESECTION
SEGMENTAL RESECTION FULL THICKNESS WITH NOSE
TECNIQUES
(TRANSANAL/TRANSVAGIN
AL)
PLACEMENT OF OMENTAL
PATCHES
2 STAPLE LINES

18. PRINCIPLES OF RESECTION
 IMPORTANT TO RESECT COMPLETELY THE ENTIRE
DISEASED TISSUE .PRE OPERATIVE COLONOSCOPY
CAN BE VERY HELPFUL IN SHOWING COMPLETE
INFILTRATION BY ENDOMETRIOSIS.AND ALSO FOR
STRICTURES TO BE BYPASSED.
IMPORTANT TO KNOW WHERE THE INFERIOR
HYPOGASTRIC NERVE AND URETER ARE.
IF MORE THAN 50%CIRCUMFRENTIAL
INVOLVEMENT OR LESIONS HIGHER UP >15CMS
FROM ANAL VERGE OR >3CMS LESION SEG
MENTAL RESECTION PREFFERED TO DISCOID .
VERY LOW LESIONS HAVE A HIGHER CHANCE OF
R/V FISTULA SO OMENTAL PATCH.

19. Khajida Video

20. CONSERVATION IMP FOR
BOWEL BLADDER AND
SEXUAL FUNCTION (IMH
EDITED)

21. POST OP SAFETY
LEAK CHECKS.

22. THE BEST WAY TO MAKE
GOD LAUGH IS TO TELL HIM
YOUR PLANS