{"paper_id":"6163317f-0ea7-4cb3-ac85-d1d0de0e0aa0","body_text":"Submit Manuscript | http://medcraveonline.com\nBackground\nEndometriosis is defined as functional endometrial tissue located \noutside of the uterine cavity (ectopic), often involving other structures \nwithin the rest of the genital tract or pelvic peritoneum. 1 The \ncondition primarily affects up to 10% of reproductive age women. 1 \nSeveral theories have been proposed to explain the pathophysiology \nof endometriosis; most common ones being retrograde menstrual \nendometrial implantation or peritoneal lining metaplasia. The \nsymptoms typically experienced by patients with endometriosis \nstem from endometriotic tissue involving specific structures. Typical \nsymptoms of endometriosis include dysmenorrhea, non-cyclic \ndyspareunia, irregular or heavy menstrual bleeding, dyschezia, and \ninfertility. \nEndometriotic involvement of the gastrointestinal (GI) tract may \ncause a spectrum of symptoms, ranging from simple to complex. 2 \nHowever, a third of patients may be asymptomatic; and diagnosed \nincidentally.3 Endometriosis is a clinical diagnosis of exclusion, \nand diagnosis of endometriosis is established through laparoscopic \nprocedures retrieving tissue biopsy. 3 A definitive diagnosis of \nendometriosis can only be made by histological evaluation of lesions \nremoved during surgery.4 Neither Serum markers nor imaging studies \nare diagnostic – rather only support the diagnosis of endometriosis. 4 \nThe histologic appearance consists of endometrial glands and \nstroma with varying amounts of inflammation and fibrosis – unique \nto endometriosis. 4 Histological evaluation is crucial because visual \nappearance of the lesions during laparoscopy is variable - studies have \nreported a marked discrepancy between the visual appearance and the \nhistology.4 Robotic-assisted (RA) - laparoscopic surgery, has shown \npromising results with regards to pain relief, laparotomy conversions \nor complication when treating stage IV endometriosis.5 \nThe most common sites for endometriotic involvement are the \novaries (54.9%), posterior broad ligament (35.2%), anterior cul-de-\nsac (34.6%), posterior cul-de-sac (34.0%) and uterosacral ligament. 3 \nOccasionally, endometriotic tissue may be detected within the GI \ntract, or very rarely, the respiratory tract. 3 Although endometriotic \ninvolvement of the appendix is rare (0.8%), it can present with \nvariety of symptoms, or be asymptomatic. 2,6 Even rarer are severe \nsymptoms of underlying appendiceal endometriosis presenting as \nacute appendicitis or acute abdomen. 7–9 Laparoscopic appendectomy \nis the gold standard treatment for endometrial appendiceal because it \nallows for thorough surgical exploration of the abdomen, especially in \npatients with recurrent or unexplained pelvic pain.2,6,10 \nSingle Incision Laparoscopic Surgery (SILS) is a new technique, \ngaining popularity for its versatile use in various surgical procedures. \nObstet Gynecol Int J. 2018;9(4):276‒279. 276\n© 2018 Rezai et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which \npermits unrestricted use, distribution, and build upon your work non-commercially.\nDa vinci SILS-appendectomy for appendiceal \nendometriosis secondary to stage IV endometriosis: \na case report and review of literature\nVolume 9 Issue 4 - 2018\nShadi Rezai,1,5 Neil D Patel BS,2 Alexander \nC Hughes,2 Ninad M Patil,3 Elise Bardawil,5 \nCassandra E Henderson,4 Xiaoming Guan5\n1Department of Obstetrics and Gynecology, Southern California \nKaiser Permanente, USA\n2St. George’s University, School of Medicine, St. George’s, \nGrenada\n3Department of Pathology & Immunology, Baylor College of \nMedicine, USA\n4Maternal and Fetal Medicine, Department of Obstetrics and \nGynecology, Lincoln Medical and Mental Health Center, USA\n5Division of Minimally Invasive Gynecologic Surgery, \nDepartment of Obstetrics and Gynecology, Baylor College of \nMedicine, USA\nCorrespondence: Xiaoming Guan MD PhD, Section Chief and \nFellowship Director, Division of Minimally Invasive Gynecologic \nSurgery, Department of Obstetrics and Gynecology, Baylor \nCollege of Medicine, 6651 Main Street, 10th Floor, Houston, \nT exas, 77030, USA, T el (832) 826-7464, Fax (832) 825-9349, \nEmail xiaoming@bcm.edu\nReceived: June 01, 2017 | Published: August 01, 2018\nAbstract\nBackground : Endometriosis is defined as functional endometrial tissue located \noutside of the uterine cavity. Typical symptoms include dysmenorrhea, non-cyclic \ndyspareunia, irregular or heavy menstrual bleeding, dyschezia, and infertility. \nPreviously, Robotic Assisted (RA)-laparoscopic surgery was the procedure of choice \nwhen treating stage IV endometriosis. Single Incision Laparoscopic Surgery (SILS) is \na new technique, gaining popularity for its versatile use in various surgical procedures. \nWe present a case report of a patient with stage IV appendiceal endometriosis managed \nwith Da Vinci RA-SILS appendectomy and a literature review. \nCase: The patient was a 34-year-old female Gravida 0, Para 0 with a chief complaint \nof dysmenorrhea, chronic pelvic pain and cramping. She reported a history of \ninfertility for 18 months. The patient was diagnosed with a right pelvic sidewall \nnodule with endometriosis, left round ligament endometriosis, left anterior broad \nligament endometriosis, posterior cul-de-sac endometriosis, with bladder, uterine, and \nappendiceal endometriosis. The patient underwent hysteroscopy, chromotubation, and \nDa Vinci RA-SILS resection of appendiceal endometriosis. \nConclusion : Although rare, endometriotic involvement of appendix can be a \nsymptomatic complication of gastrointestinal involvement and may present as acute \nappendicitis or even nonspecific abdominal pain, requiring appendectomy. With \nmodern advancements, it is now preferred to perform Da Vinci RA-SILS appendectomy \nin the setting of endometriosis for both surgical and cosmetic reasons.\nKeywords: appendiceal endometriosis, appendix, chromotubation, da vinci \nSILS appendectomy, da vinci SILS resection of endometriosis, deep-infiltrating \nendometriosis, dyschezia, dysmenorrhea, endometriosis, endometriosis of appendix, \ninvasive endometriosis, laparoscopy, single-site robotic excision of endometriosis, \nstage IV endometriosis\nObstetrics & Gynecology International Journal \nCase Report\n Open Access\n\n\nDa vinci SILS-appendectomy for appendiceal endometriosis secondary to stage IV endometriosis: a case \nreport and review of literature\n277\nCopyright:\n©2018 Rezai et al.\nCitation: Rezai S, Neil DPBS, Alexander CH, et al. Da vinci SILS-appendectomy for appendiceal endometriosis secondary to stage IV endometriosis: a case \nreport and review of literature. Obstet Gynecol Int J. 2018;9(4):276‒279. DOI: 10.15406/ogij.2018.09.00347\nCurrent applications for the procedure include, but are not limited \nto: tubal ligation, hysterectomy, appendectomy, cholecystectomy, \ngastrectomy, colectomy, and nephrectomy.11 The procedure is gaining \ntraction because of reduced post-operative pain or complications, \nand cosmetic advantages.11 We present a case report of a patient with \nstage IV appendiceal endometriosis managed with Da Vinci RA-SILS \nappendectomy and a literature review. \nPresentation of the case\nThe patient was a 34-year-old female, Gravida 0 Para 0, with a \nchief complaint of dysmenorrhea, chronic pelvic pain and cramping, \nwith Mittelschmerz, since menarche at age 13. Her pain was \nunresponsive to medications and worsening over the past year. She \nreported regular menses every 24-26 days. In addition, the patient also \nreported new-onset dyschezia and dysuria with urinary frequency and \nurgency. The patient denied dyspareunia however reported post-coital \nbleeding. She reported a history of infertility and had been trying to \nconceive for the past 18 months. She did not report any history of \nhospitalization or surgery. \nPhysical exam revealed vital signs within normal limits, and \nBMI of 23.35 kg/m 2. Positive findings included pain on palpation \nof a bladder nodule and a left vaginal fornix nodule. There were no \npalpable adnexal masses; rectal exam was within normal limits. A \nhysterosalpingogram (HSG) one year prior had shown bilateral tubal \npatency and no uterine filling defects. Her most recent transvaginal \nultrasound showed adenomyosis. Pelvic MRI showed a 3.8 cm \ncomplex, septated, low signal intensity, non-enhancing lesion arising \nfrom the left adnexa, possibly representing an endometrioma. There \nare epithelial changes along the bladder and uterosacral ligaments \nwith no evidence of endometriosis (Figure 1). \nFigure 1 Pelvic MRI showed a 3.8 cm complex septated low signal intensity \nnon-enhancing lesion arising from the left adnexa, possible representing and \nendometrioma. There are epithelial changes along the bladder and uterosacral \nligaments with no evidence of endometriosis.\nThe patient underwent hysteroscopy, chromotubation, and Da Vinci \nRA-SILS resection of endometriosis. During surgery, patient was \nnoted to have stage IV endometriosis with appendiceal involvement \n(Figure 2A & 2B). This was managed surgically by general surgery \nusing Da Vinci RA-SILS appendectomy (Figure 2C). In addition, \ncystoscopy, and ureteral stent placement and removal were performed \nby Urology. Intraoperative findings and pathologic specimen \nevaluation confirmed the diagnosis of right pelvic side wall nodule \nwith endometriosis, left round ligament endometriosis, left anterior \nbroad ligament endometriosis, posterior cul-de-sac endometriosis, \nwith bladder, uterine, and appendix endometriosis. \nSILS technique (gynecology/urology)\nInitially, a 15 mm port access incision was made at the umbilicus \nentering the peritoneum and docking the robot. Using the monopolar \nhook and blunt dissection, the left ovary and fallopian tube were freed \nfrom the left pelvic sidewall, and a portion of the posterior cul-de-sac \nperitoneum was removed. Subsequently, endometriosis and nodules \ninvolving right and left pelvic sidewall, left round ligament, anterior \nbroad ligament, and anterior uterus were carefully removed. The \nUrology team carefully dissected off the bladder from the anterior \nuterine endometriosis nodule. Hemostasis was achieved with the \nbipolar. The pelvis and abdomen were inspected, and hemostasis was \nnoted throughout. Chromotubation was performed with immediate \nspill of dye from the right fallopian tube and delayed spill of dye from \nthe left fallopian tube. An Interceed absorbable adhesion barrier was \nplaced over the area of dissection along the left pelvic sidewall and the \nanterior surface of the uterus and bladder.\nFigure 2 Intraoperative Images: 2A: Multiple endometriotic implants on the \nbowel; 2B: Appendix/Bowel; 2C: The appendix stapled off with a tan reload \nstapler and the mesentery with a gray reload stapler.\nRA-SILS appendectomy technique\nRA-SILS access was established via the 15 mm umbilical incision. \nThe appendix was visualized with endometriosis affecting primarily \nthe retroperitoneal tip. The affected area was incised laterally to \nmobilize the cecum, and the appendix was dissected out until the base \nwas identified. At this point the 12 mm port was inserted on the left \nside and the appendix was stapled off with a tan reload stapler and \nthe mesentery with a grey reload stapler. The appendix, including the \nsurrounding peritoneum with endometriosis was excised, placed in \na bag, and removed via the single site port site. Multiple specimens \nwere collected and sent to pathology. Pathologic examination \nconfirmed the presence of endometriosis in the right pelvic side wall \nnodule, left round ligament, left anterior broad ligament, bladder and \nuterine serosa, and outer appendiceal wall (Figure 3). At postoperative \n3-week follow-up, the patient reported normal bowel movements and \nonly mild left pelvic pain.\nFigure 3 Pathology Images: 3A: At low power, endometriosis (encircled) is \nnoted in the outer appendiceal muscularis (H&E); 3B: On higher power, an \nendometrial-type gland (black arrow) surrounded by endometrial-type stroma \n(white arrow) is seen within smooth muscle (H&E).\n\n\nDa vinci SILS-appendectomy for appendiceal endometriosis secondary to stage IV endometriosis: a case \nreport and review of literature\n278\nCopyright:\n©2018 Rezai et al.\nCitation: Rezai S, Neil DPBS, Alexander CH, et al. Da vinci SILS-appendectomy for appendiceal endometriosis secondary to stage IV endometriosis: a case \nreport and review of literature. Obstet Gynecol Int J. 2018;9(4):276‒279. DOI: 10.15406/ogij.2018.09.00347\nDiscussions\nThe signs and symptoms of endometriosis can be nonspecific, \nor it may even be asymptomatic. However, endometriosis remains \na leading cause of chronic pelvic pain in reproductive age women. \nAlthough rare, endometriosis can involve the appendix causing pain \nand distress; or be found incidentally. Similar to acute appendicitis, \nthe laparoscopic surgical approach is considered to be the gold \nstandard. As cosmetic outcomes have become more important in \nsurgery, minimally invasive or SILS procedures are being used more \noften. Taking a traditional approach and adding a modern twist, SILS \nappendectomy is now an acceptable procedure to surgically treat \nsymptomatic and asymptomatic appendix-focused conditions. The \nmain benefits come from ease of access within the abdominal cavity, \nwith gentle tissue handling and manipulation. In addition, SILS \nallows for proper tissue dissection and the use of the Endoloop as an \nalternative to the larger trocar for stapler use.12 \nPrior to SILS, Double-incision laparoscopic appendectomy (DILA) \nwas introduced as a means of further minimizing the invasiveness \nof traditional laparoscopic surgery, by decreasing then number of \nincisions.13 A randomized control trial has demonstrated that DILA \ncan be performed with equivalent operative outcomes with superior \ncosmetic outcomes. 13 Successful operations using DILA urged the \npush for SILS, as stated previously, primarily for cosmetic reasons. 11 \nIn direct comparison to traditional laparoscopic appendectomy, SILS \nappendectomy can be conducted with comparable operative times, \nlengths of stay, and procedural complications, and with superior \ncosmetic outcomes – the main downside noted being the cost. 14,15 As \nreported in this case, the use of SILS can be easily manipulated using \nconventional laparoscopic instruments. A previous study outlined \nSILS appendectomy utilizing three trocars (two 10mm and one 5mm), \nusing conventional and optical laparoscopic tweezers (10 mm, 30˚); \nwhile using titanium LT 400 clips to ligate the base and pedicle of the \nappendix.11 \nAs described earlier, the SILS procedure can be applied to \nappendectomy in female patients suffering from endometriosis. A \nprevious study performed to evaluate deeply located endometriosis \nshowed significant involvement of the appendix. Out of the patients \nevaluated, nearly 50% have deep involvement by endometriosis, \nwhile 32% showed appendiceal involvement. 16 Although these \npatients were asymptomatic, the level of infiltration was indicative \nfor surgical intervention. 16 It has been suggested that prophylactic \nconcurrent appendectomy be performed as part of complete \nendometriosis excision.16 Unusually, other intra-abdominal pathology \ncan be mimicked by pain from appendiceal endometriosis.17 Isolated, \ndeeply located appendiceal involvement may be missed by diagnostic \nlaparoscopy; and can present with no external diagnostic features, \ntherefore routine appendectomy has also been advocated in women \nwith recurrent abdominal pain.17–20 \nConclusion\nIn the majority of patients, endometriosis presents very classically \n– dysmenorrhea, non-cyclic dyspareunia, irregular or heavy menstrual \nbleeding, dyschezia, and infertility. Rare presentations can be due to \nendometriotic involvement of the gastrointestinal tract, presenting \nan array of symptoms, but may also be asymptomatic. Although \nrare, endometriotic involvement of appendix can be a symptomatic \ncomplication of gastrointestinal involvement and may present as \nacute appendicitis or even nonspecific abdominal pain, requiring \nappendectomy. Traditionally, both endometriosis and appendicitis \nhave been evaluated and treated laparoscopically. It has been \nproposed, that indicated endometrial appendix removal be performed \nby appropriately trained gynecologists.21 With modern advancements, \nit is now preferable to perform Da Vinci RA-SILS appendectomy in \nthe setting of endometriosis for both surgical and cosmetic reasons.\nAcknowledgments\nDr. Xiaoming Guan is a speaker for Applied Medical, Rancho \nSanta Margarita, and California. \nConflicts of interest\nAuthors did not report any potential conflicts of interests.\nReferences\n1. 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Da vinci SILS-appendectomy for appendiceal endometriosis secondary to stage IV endometriosis: a case \nreport and review of literature. Obstet Gynecol Int J. 2018;9(4):276‒279. DOI: 10.15406/ogij.2018.09.00347\n16. Moulder JK, Siedhoff MT, Melvin KL, et al. Risk of appendiceal \nendometriosis among women with deep-infiltrating endometriosis. Int J \nGynaecol Obstet. 2017;139(2):149–154. \n17. Shen AY , Stanes A. Isolated Appendiceal Endometriosis. J Obstet Gynaecol \nCan. 2016;38(10):979–981. \n18. Fatehchehr S, Macik P, Sinervo K. Small Bowel Segmental Resection and \nReanastomosis with Appendectomy for Invasive Endometriosis. J Minim \nInvasive Gynecol. 2015;22(6S):S138–S139. \n19. Ribeiro DM, Ribeiro GP, Santos TP, et al. Incidental Appendectomy in \nthe Surgical Treatment of Deep Endometriosis Infiltrating the Bowel: \nAnatomo-pathological Findings in a Series of 109 Patients. J Minim \nInvasive Gynecol. 2015;22(6S):S30–S31. \n20. Shavell VI, Mahdi HM, Awonuga AO, et al. Appendectomy in the \ngynecological setting: intraoperative findings and corresponding \nhistopathology. Gynecol Obstet Invest. 2011;71(3):189–92. \n21. Jocko JA, Shenassa H, Singh SS. The role of appendectomy in gynecologic \nsurgery: a Canadian retrospective case series. J Obstet Gynaecol Can . \n2013;35(1):44–8.","source_license":"CC0","license_restricted":false}