Laparoscopic treatment of superficial peritoneal endometriosis

When I first learned the technique of diagnostic laparoscopy as a resident (USA)/registrar (UK) during my surgical training, the diagnosis of endometriosis was most commonly made after observing the classical black powder-burn lesion associated with a deposit of hemosiderin on the peritoneal surface. Subsequently, although we have not made any great advances in understanding the pathogenesis of this obscure disease, we have progressed considerably in the diagnosis and surgical treatment of this condition. We now accept that there are three different types of endometriosis,1 which may coexist or may present separately: namely, deep infiltrating endometriosis (DIE) or, more correctly, adenomyosis; ovarian endometriomas; and superficial peritoneal implants. Although the ovarian endometrioma can be detected by an ultrasound examination, deep infiltrating disease is often better felt as tender nodules by clinical examination, preferably performed during the perimenstruum, and often this disease is not strikingly obvious on laparoscopic examination, certainly to those who are unfamiliar with the diagnosis and treatment of DIE. This chapter will deal almost exclusively with peritoneal disease, but it must be realized that, if adequate pain relief and optimal conditions for conception are to be realized, coexisting endometriosis and endometriomas must also be eradicated at the same time.