{"paper_id":"844c78ca-7b83-4e14-a6d1-d0bce11c2956","body_text":"Page 1 of  4\nCase Based Discussion of Surgical Approach to Deep \nInfiltrating Endometriosis\nHasib Ahmed*\nMedway NHS Foundation Trust, UK\nIntroduction\nEndometriosis presents a diagnostic challenge as clinical \nsymptoms do not correlate well with the extent of disease [1]. \nCramer, et al. [2] found that menstrual cycle length shorter than 27 \ndays, menses longer than 7 days and severe cramping dysmenorrhea \nwere predictive of endometriosis with relative risks of 2.1 (95%CI \n1.5-2.9), 2.4 (95%CI 1.4-4.0) and 6.7(95%CI 4.4-10.2) respectively. \nThe study compared 268 women with infertility and laparoscopically \nconfirmed endometriosis with 3794 women admitted for delivery \n(controls) using a retrospective questionnaire. The study was \nlimited by recall bias and the criteria for laparoscopic diagnosis \nwere not clearly defined. No significant correlation was found with \nchronic pelvic pain. The issue has been studied prospectively [3,4] \nin 134 women scheduled for laparoscopy for chronic pelvic pain \n(CPP). Dyschezia, dyspareunia, and non-menstrual pain were all \nidentified as predictors of deep infiltrating endometriosis (DIE) \nwith odds ratios of 3.9 (95%CI 1.7-8.9), 4.6 (95%CI 1.5-14.2) and \n2.5 (95%CI 1.1-5.6) respectively. Mrs. SF presented with all of these \nsymptoms to a greater or lesser extent. One criticism of Chapron’s \nstudy is that the diagnosis was made on laparoscopic appearance \nwithout histological confirmation. Visualization alone has been \nshown to have a positive predictive value (PPV) for endometriosis \nof 45% and up to 36% of lesions were down staged on histology [5].\nCase Report\nMrs. SF, a 36-year-old nulliparous lady, gave a 20-month history \nof dysmenorrhea, dyspareunia and dyschezia. Examination revealed \na tender nodule high in the pelvis. A diagnosis of rectovaginal \nendometriosis had been made at diagnostic laparoscopy 18 \nmonths previously. She elected to undergo surgery to excise the \nendometriosis. The risks of injury to the ureters, other organs and \nvessels were discussed including the small risk of an undiagnosed \nbowel injury requiring temporary colostomy. Mrs. SF gave her  \n \ninformed consent. She received pre-operative bowel preparation  \n(Citrimag ® Sanochemia UK) and on table distal colonic washout \n(chlorhexidine 0.05%). A colorectal surgeon was available. A closed \nlaparoscopy was performed under GA with the patient in modified \nLloyd-Davis position. A Spackmann uterine manipulator was used. \nTwo 5mm accessory lateral ports were inserted under direct vision. \nInspection confirmed endometriosis involving both uterosacral \nligaments (USLs). The Pouch of Douglas (PoD) was obliterated with \nthe course of both ureters pulled medially toward an endometriotic \nnodule. Insertion of a rectal probe with anteversion of the uterus \nallowed indirect palpation of the nodule in the midline and to \nthe left. Both ovaries and tubes were normal. The course of both \nureters was pulled medially toward the endometriotic nodule. \nBoth ovaries and tubes were normal. A normal area of peritoneum \non the left ovarian fossa above the ureter was opened with 90w \nmonopolar diathermy on scissors and medial counter-traction. \nThe peritoneum was cleared from the underlying ureter using cold \nscissors and blunt dissection. This process was continued until \nthe ureter was released laterally. The affected peritoneum was \nreflected anteromedially with monopolar and blunt dissection to \nopen the proximal left USL allowing access to the left pararectal \nspace. Peritoneum in the right ovarian fossa was similarly reflected \nmedially releasing the ureter laterally. The rectovaginal nodule \nwas dissected in continuity. The rectovaginal space was entered \nbilaterally with a mixture of sharp and blunt dissection. A 90w \nmonopolar cutting diathermy spark on scissors was used to enter \nthe rectovaginal septum in the midline. Using a combination of \ncounter traction on the nodule and monopolar dissection of the \nnodule off the rectum disease was removed with USLs in continuity. \nThe vagina was inadvertently entered and sutured laparoscopically. \nHemostasis was confirmed. The raw surface was coated with \nSprayshield™ (Covidien UK). Rectal gas check was negative. Closure \nwas routine.\n*Corresponding author: Hasib Ahmed, Divisional Director, Women’s & Children’s, \nMedway NHS Foundation Trust, UK.\nReceived Date: January 05, 2019\nPublished Date: January 11, 2019\nISSN: 2641-6247                                                                                                                           DOI: 10.33552/WJGWH.2019.01.000523\nWorld Journal of \nGynecology & Women’s Health\nCase Report Copyright © All rights are reserved by Hasib Ahmed\nThis work is licensed under Creative Commons Attribution 4.0 License  WJGWH.MS.ID.000523.\n\n\nWorld Journal of Gynecology & Women’s Health                                                                                                             Volume 1-Issue 5\nCitation: Hasib Ahmed. Case Based Discussion of Surgical Approach to Deep Infiltrating Endometriosis. W J Gynecol Women’s Health. 1(5): \n2018. WJGWH.MS.ID.000523. DOI: 10.33552/WJGWH.2019.01.000523.\nPage 2 of  4\nMrs. EM, a 32-year-old nulligravida, presented with 1-week \nhistory of worsening lower abdominal pain. Appendicectomy was \nher only past medical history. She reported a regular menstrual \ncycle and described cramping period pains. She and her husband \nwere trying for a pregnancy. Urinary ß Hcg was negative. There \nwas lower abdominal tenderness with rebound tenderness in the \nleft iliac fossa. Pelvic examination revealed an exquisitely tender \ncystic mass to the left of the midline with reduced mobility. The \nworking diagnosis was of an ovarian cyst accident and the patient \nwas prepared for emergency laparoscopy under general anesthetic. \nInformed consent was obtained for laparoscopy proceeding to \novarian cystectomy/oophorectomy if indicated. The patient was \nplaced in modified Lloyd Davis position, cleaned, draped and \ncatheterized. Open laparoscopy with a disposable Hasson trocar \nwas performed. A 15-mmHg pneumoperitoneum was established \nand two 5 mm lateral ports and one 10-12mm suprapubic port \nwere placed under direct vision. There was a 7cm diameter left \nsided ovarian endometrioma applied to the left pelvic sidewall \nand firmly attached to the left uterosacral ligament. The right \novary contained a corpus luteum. The endometrioma was bluntly \nmobilized. Grasping the left ovarian suspensory ligament caused \nbleeding which was controlled with bipolar diathermy at 40w. \nThe antimesenteric surface of the endometrioma was opened \nand the capsule enucleated with a combination of sharp and \nblunt dissection. The endometrioma was drained of old blood. \nThe cyst capsule was removed in a disposable bag (Endocatch™ \nTyco Hampshire). Closure was routine. An endometriotic cyst was \nconfirmed histologically. Mrs. EM’s pain recurred 9 months after \nsurgery. She is currently on an assisted conception program.\nDiscussion\nOn examination a tender nodule was palpable high on the \nleft uterosacral ligament. In a retrospective cohort study logistic \nregression analysis of signs and symptoms in patients with \nendometriosis showed tenderness in the Pouch of Douglas (PoD) \nwas associated with a 75% chance of DIE. (Wright JT personal \ncommunication). The clinical features of Mrs. SF were suspicious \nof DIE and this was confirmed at a previous laparoscopy. One could \nargue that surgical treatment of endometriosis could have been \nperformed at her first laparoscopy rather than the 2-stage treatment \nshe received. Excisional surgery at first laparoscopy showed \nimprovement in 80% of the treatment group at 12 months versus 32 \nin the placebo group in an RCT of 39 women [6]. However, surgery \nfor DIE is technically challenging with particular risks of injury to \nthe large bowel and ureters. On this basis assessment of the extent \nof disease by laparoscopy is justified to inform discussion with the \npatient. Furthermore, laparoscopies are negative in 35% of women \nwith CPP [7]so one step management may not be appropriate. The \nureters were dissected laterally away from the nodule as described \nin M05B. A cold scissor technique is preferable to avoid thermal \ninjury. However, if excessive bleeding is encountered, measures \nto secure hemostasis, such as bipolar diathermy may cause occult \ninjury with delayed presentation. Ureteric stents and collaboration \nwith urological colleagues are helpful, particularly if endometriosis \nis found to be involve the ureter directly. \nAnother issue is whether specific non-invasive tests can \nimprove clinical diagnostic accuracy to facilitate treatment at index \nlaparoscopy. There is insufficient data to support transvaginal \nultrasound for the diagnosis of DIE [8] but Magnetic Resonance \nImaging (MRI) is emerging as a potential modality for non-invasive \ndiagnosis with a PPV of 92.1% [9]. MRI is an expensive test, which \nrequires special expertise to interpret the images. In selected \npatients with a convincing clinical picture it may be appropriate \nto prepare for major excision at index laparoscopy as long as the \npatient is fully informed. \nHaving established the diagnosis of DIE the next issue is \nplanning the method and extent of treatment. Ovarian suppression \nwith gonadotrophin releasing hormone analogues results in \nsymptomatic relief during the course of treatment but the effects \nare temporary with gradual return of symptoms [10]. Surgical \nexcision is established as an effective treatment for rectovaginal \ndisease [11] and the USLs are one of the commonest locations for \nDIE [12].\nIn cases of DIE involving the USLs en-bloc dissection of the \nUSLs is an effective treatment option [13,14]. In a cohort of 107 \nwomen the left USL was involved almost twice as often as the \nright (64.5% vs. 35.5% P<0.01). This leads us on to a discussion \nas to whether one or both USLs should be removed. In the case \ndescribed a greater volume of disease was present in the left USL \nwhich may support a unilateral approach. However, several authors \nhave reported microscopic endometriotic disease in visibly normal \nperitoneum [15-17]. The approach in M05A was to excise the USLs \nen-block while performing a rectal shave of the nodule off the \nrectum. Ergonomically the patient was positioned in a modified \nLloyd Davis position at hip height of the surgeon. The camera \nstack was positioned adjacent to the patient’s right leg with the \nscreen perpendicular to the gaze of the operator. The monopolar \nelectrosurgical technique using 3mm Wolf™ (Richard Wolf UK Ltd) \nscissors is a variation of that described by Redwine DB [18]. The \ncutting current was set at 90w with the scissors passed through the \noperating channel of 0° 10mm operating laparoscope. The tip of the \nWolf scissor blade was used ‘like a pencil’ to direct the monopolar \nspark to the line of dissection. The tissue just on the nodule side \nwas vaporized with counter traction away from the rectum creating \na plane of cleavage. The high-power cutting current creates a spark \nwith which tissue is vaporized with reduced depth of thermal \nspread compared to contact diathermy. The technique allows \nbloodless dissection of diseased tissue but requires skill in terms of \naccuracy of placement and speed of movement of the scissor blade. \nThere are inherent risks to the rectum and urinary tract with \nsuch surgery. A readily available colorectal surgeon is desirable \nin case of inadvertent injury to the bowel. It is routine practice \nto formally prepare the bowel to minimize the risk of peritoneal \ncontamination in the event of bowel injury. This established \npractice has recently been challenged by Bucher P , et al. [19] from \ntheir RCT involving 153 patients which showed significantly lower \nmorbidity in patients undergoing left sided colonic surgery with \nno formal bowel preparation compared to those who had received \nbowel preparation (11% morbidity vs. 24%, p=0.038). The rectal \n\nCitation: Hasib Ahmed. Case Based Discussion of Surgical Approach to Deep Infiltrating Endometriosis. W J Gynecol Women’s Health. 1(5): \n2018. WJGWH.MS.ID.000523. DOI: 10.33552/WJGWH.2019.01.000523.\nWorld Journal of Gynecology & Women’s Health                                                                                                             Volume 1-Issue 5 \nPage 3 of  4\ngas test with saline in the pelvis and air inserted into the anal canal \nwith a 50ml bladder syringe is used. Absence of bubbles is taken \nas confirmation of rectal integrity. In the event of a small injury \nto the rectum primary repair without resorting to defunctioning \ncolostomy is possible if the bowel has been appropriately prepared. \nThe routine use of prophylactic antibiotics is established practice. \nIn the case described full thickness disease of the vagina led to \nentry into the vagina which was sutured laparoscopically. The \npatient experienced leakage of clear fluid from the vagina in the \nimmediate post-operative period. After exclusion of a ureteric or \nbladder injury the patient was treated conservatively. Histology of \nthe nodule confirmed fibrosis with foci of endometriosis. \nAnother important debate is around the extent of surgery \nto excise rectovaginal endometriosis which varies from rectal \nshaving, as described in M05A, to discoid and segmental resection. \nCollaboration with a colorectal surgical colleague is invaluable and \na multidisciplinary team approach in treatment centers has been \nadvocated for these complex patients [20,21].\nIn a histological review of 16 patients undergoing full thickness \ndisc resection prior to segmental resection, disc resection alone \nwas associated with residual disease in 43.8% (95% CI 19.8-70.1) \n[22]. How important this incomplete excision would be clinically \nis unclear. Anastomotic leak, pelvic abscess and rectovaginal \n(RV) fistulae following segmental resection are recognized \ncomplications. In a retrospective review of 95 patients in a single \ntertiary center undergoing rectal shave (19%), disc resection (21%) \nand laparoscopic assisted low anterior resection (15%); there were \nno anastomotic leaks and a re-operation rate by laparotomy of 8% \n[23]. In a retrospective cohort of 128 patients with histologically \nproven rectovaginal endometriosis and conservative laser surgery \nin a multidisciplinary setting; 32 women required rectal repair \nincluding 3 segmental resections [24]. Three women had RV fistulae \nrequiring laparotomy and defunctioning colostomy including 1 \nrequiring ureteric re-implantation for uretero-vaginal fistula. One \npatient required ureteric stenting. In the 56 women followed locally \n12.5 % reported cure with a further 73.5% reporting significant \nimprovement. The authors conclude that a conservative approach \nto surgery for rectovaginal endometriosis gives similar results \nwhen compared to radical surgery but with fewer complications. \nThe recommendation for treatments in ‘centers of excellence’ is re-\niterated and is the likely way forward. \nMrs. EM was a case of symptomatic endometrioma treated \nby laparoscopic stripping of the capsule. An anonymous survey \nof the surgical approach to this problem to 1240 UK specialist \ngynecologists showed that management is far from uniform \n[25]. Among 651 respondents (52.5%) 487 (74.8%) adopted a \nsurgical approach: 42.3% by laparotomy with ovarian cystectomy \nas the usual (94.7%) procedure. The 249 (56%) who adopted a \nlaparoscopic approach were divided between fenestration (61%) \nand excision (53%). That almost half the respondents in Jones’ \nsurvey resorted to laparotomy may be due to lack of training, lack \nof equipment or both. The same reasons may explain why the 61% \nadopting a laparoscopic approach only treated with fenestration. \nStripping of the capsule is more challenging and associated with \nmore blood loss particularly around the ovarian hilum. There \nare a number of theories put forward to explain the origin of \nendometriomata. Sampson JA [26] first put forward the theory that \nendometriomata were the sequelae of retrograde menstruation \nresulting in implantation of endometrial cells on the peritoneum \nand ovarian cortex. Invagination of the ovarian cortex and occult \nmenstruation from the ectopic endometrium would then give rise \nto blood filled spaces in the ovary. If this represents the etiology, \nthen fenestration and drainage would be the correct treatment \nto preserve ovarian cortex. Alternative explanations include \ninvaginated epithelial inclusions arising in coelomic metaplasia \n[27] and secondary involvement of functional ovarian cysts \n[28]. If the latter explanations represent the process correctly \na cyst capsule should be identifiable which should be amenable \nto stripping. In practice a cyst capsule is usually identifiable and \nlends itself to removal as in M05C. If a capsule is not identifiable, \nor attempted stripping is very difficult and causes excessive \nhaemorrhage, fenestration and bipolar ablation is resorted to in \nmy practice. Normal ovarian stroma containing primordial follicles \nhas been histologically confirmed in 68.9% of excised capsules of \ncysts when the cysts stripped [29]. However, the tissue may not be \nmorphologically normal [30]. For women where future fertility is \nimportant, such as M05C, loss of follicles may be potentially harmful. \nPrior ovarian cystectomy is associated with reduced response \nto stimulated cycles [31,32], and when both ovaries are treated \nsimultaneously; premature ovarian failure postoperatively has been \nreported in 2.4% (95% CI 0.5%-6.8%) [33]. This should be borne in \nmind when counseling patients but should be weighed up against \nthe risk of recurrence of endometriomata which, in one review, \nappears 3 times as likely after coagulation compared to stripping \n(OR 3.01: 95% CI 1.78-5.36; [34]. Vercellini’s review included only \n1 RCT [35] and 2 of the other studies were retrospective. The issue \nhas been the subject of a more recent Cochrane Systematic Review \n[36]. The meta-analysis was restricted to 2 RCTs [37] involving a \ntotal of 164 patients and demonstrates that excision compared \nto fenestration and ablation appears to confer a reduction in the \nrecurrence of: dysmenorrhea (OR 0.15 CI 0.06-0.38); dyspareunia \n(OR 0.14 CI 0.05- 0.44) ; non-menstrual pelvic pain (OR 0.10 CI 0.02-\n0.56): recurrent endometriomata (OR 0.41 95%CI0.18-0.93) and \nis associated with an improved 12 month spontaneous pregnancy \nrate (OR 5.24 CI 1.92-14.27). The studies were not blinded and \ntherefore potentially confounded by assessment and response bias. \nIn addition, the patients in both studies were a mixture of stage III \nand stage IV suggesting extraovarian disease but whether this was \ndealt with concomitantly is not clear in the Beretta study. Extra-\novarian disease was treated in the Alborzi study so differences in \npostoperative pain scores may not necessarily have been due to \ndifferences in the surgical approach to endometriomata. Indeed, \nextraovarian disease was present in Mrs. EM which is a common \nassociation, but this was not radically excised. This could be \nconsidered as incomplete treatment, but the aim of the treatment \nwas to alleviate the patient’s acute symptoms, which was pain and \ntenderness. Future pregnancy was desired, and treatment was \ntailored to her individual needs. In addition, the patient had not \nbeen counselled regarding treatment to other disease in the pelvis. \nOn reflection whenever an endometrioma is suspected preoperative \ndiscussion should include the possibility of treatment of disease \n\nWorld Journal of Gynecology & Women’s Health                                                                                                             Volume 1-Issue 5\nCitation: Hasib Ahmed. Case Based Discussion of Surgical Approach to Deep Infiltrating Endometriosis. W J Gynecol Women’s Health. 1(5): \n2018. WJGWH.MS.ID.000523. DOI: 10.33552/WJGWH.2019.01.000523.\nPage 4 of  4\nelsewhere. This is my preferred practice. However, patients are \nnot given mechanical bowel preparation routinely unless there are \nconvincing symptoms or signs of rectovaginal disease (dyschezia, \ncyclical rectal bleeding or the presence of palpable tender disease \nin the USLs or RV septum).\nAcknowledgement\nNone.\nConflict of Interest\nNo conflict of interest.\nReferences\n1. Porpora MG, Koninckx PR, Piazze J, Natili M, Colagrande S, et al. (1999) \nCorrelation between endometriosis and pelvic pain. J Am Assoc Gynecol \nLaparosc 6(4): 429-434.\n2. Cramer DW, Wilson E, Stillman RJ, Berger MJ, Belisle S, et al. (1986) The \nrelation of endometriosis to menstrual characteristics, smoking and \nexercise. J Am Med Assoc 255(14): 1904-1908.\n3. Chapron C, Barakat H, Fritel X, Dubuisson JB, Bréart G, et al. (2004) \nPresurgical diagnosis of posterior deep endometriosis based on a \nstandardised quesstionnaire. Hum Reprod 20(2): 507-513.\n4. Chapro C, Fauconnier A, Dubuisson JB, Vieira M, Bonte H, et al. 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(2005) \nESHRE guideline for the diagnosis and treatment of endometriosis. Hum \nReprod 20(10): 2698-2704.\n21. Redwine DB, Wright JT (2001) Laparoscopic treatment of complete \nobliteration of the cul-de-sac associated with endometriosis: long-term \nfollow-up of en bloc resection. Fertil Steril 76(2): 358-365.\n22. Remorgida V, Ragni N, Ferrero S, Anserini P , Torelli P , et al. (2005) How \ncomplete is full thickness disc resection of bowel endometriotic lesions? \nA prospective surgical and histological study. Hum Reprod 20(8): 2317-\n2320.\n23. Jatan AK, Solomon MJ, Young J, Cooper M, Pathma-Nathan N (2006) \nLaparoscopic management of rectal endometriosis. Dis Colon Rectum \n49(2): 169-174.\n24. Slack A, Child T , Lindsey I, Kennedy S, Cunningham C, et al. (2007) \nUrological and colorectal complications following surgery for \nrectovaginal endometriosis. BJOG 114(10): 1278-1282.\n25. Jones KD, Fan A, Sutton CJ (2002) The ovarian endometrioma: why is it \nso poorly managed? 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Loh FH, Tan AT , Kumar J, Ng SC (1999) Ovarian response after \nlaparoscopic ovarian cystectomy for endometriotic cysts in 132 \nmonitored cycles. Fertil Steril 72(2): 316-321. \n32. Nargund G, Cheng WC, Parsons J (1996) The impact of ovarian cystectomy \non ovarian response to stimulation during in-vitro fertilization cycles. \nHum Reprod 11(1): 81-83. \n33. Busacca M, Riparini J, Somigliana E, Oggioni G, Izzo S, et al. (2006) \nPostsurgical ovarian failure after laparoscopic excision of bilateral \nendometriomas. Am J Obstet Gynecol 195 (2): 421-425.\n34. Vercellini P , Chapron C, De Giorgi O, Consonni D, Frontino G, et al. (2003) \nCoagulation or excision of ovarian endometriomas? Am J Obstet Gynecol \n188(3): 606-610.\n35. Beretta P , Franchi M, Ghezzi F, Busacca M, Zupi E, et al. (1998) Randomized \nclinical trial of two laparoscopic treatments of endometriomas: \ncystectomy versus drainage and coagulation. Fertil Steril 70(6): 1176-\n1180.\n36. Hart R, Hickey M, Maouris P , Buckett W, Garry R (2005) Excisional \nsurgery versus ablative surgery for ovarian endometriomata: a Cochrane \nReview. Hum Reprod 20(11): 3000-3007. \n37. Alborzi S, Momtahan M, Parsanezhad ME, Dehbashi S, Zolghadri J, et \nal. (2004) A prospective, randomized study comparing laparoscopic \novarian cystectomy versus fenestration and coagulation in patients with \nendometriomas. Fertil Steril 82(6): 1633-1637.","source_license":"CC0","license_restricted":false}