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Jon Ivar Einarsson MD PhD MPHDirector of Minimally Invasive Gynecologic SurgeryBrigham and Women’s HospitalAssociate Professor of Obstetrics and GynecologyHarvard Medical School
I have no financial relationship witha commercial entity producinghealth‐care related products and/orservices
Maintain exposure at all times Do not proceed without having exposure Do not proceed without orientation/anatomic landmarks
Always know where your ureters are Enter the retroperitoneal space early in distorted anatomy
“You got to know when to hold ‘em, know when to fold‘em,
know when to walk away and know when to run”
Surgery is like chess – you should think at least 2 games ahead Communicate
What will you need next? Cystoscope Interceed Sutures
If you don’t have what you need, it is your fault
Extremely important Easiest to find ureters at
pelvic brim –make a small incision at pelvic brim, medial to the IP ligament and carry the incision along the pelvic sidewall aiming at the uterosacral ligament – this will make identification of the ureter easy
Avoid dissecting parallel to the ureter prior to finding it –if you are in the wrong plane it will take you a while to find the ureter
STRATEGY Follow similar principles throughout Break down into steps
Step 1 – Left ureteral dissection and bowel mobilization Dissection starts at left pelvic brim Mobilize sigmoid colon Enter retroperitoneum Find left ureter Follow ureter down to uterine vessels Drain ovarian endometrioma/free ovary and suspend to round ligament
Consider using plain gut to leave the ovaries suspended
Step 2 – Right ureteral dissection Open retroperitoneum at right pelvic brim and perform right sided ureterolysis
Important!! – the ureterolysis needs to be completed all the way down to uterines – the ureters can be distorted medially at any point…more often towards the lower end of their course
The ureters are pulled medially here and can be very close to bowel and uterosacral ligaments
Mobilize and/or drain right ovary and suspend to round ligament
Step 3 – Hysterectomy or not If hysterectomy is planned mobilize bladder and skeletonize uterines – coagulate IF bowel is away
If possible remove the uterus and then tackle bowel, but often need to partially mobilize bowel first
If no hysterectomy, consider suspending the uterus to anterior abdominal wall with sutures and remove the uterine manipulator
This frees up the vagina for manual exploration which can guide the dissection
Step 4 – Remove endometriosis off bowel/bladder/ureter Dissect rectosigmoid off uterus/cervix/vagina Prefer to stay on uterine/vaginal side Make sure the bowel is fully mobilized from ureters Can use dilute vasopressin to reduce oozing Don’t use energy next to the bowel/ureters
Incidence of bowel endometriosis 5.3‐12% Rectum and Sigmoid are most commonly affected with 90% cases in this area
Common symptoms include pelvic pain, dyschezia (especially during menses), deep dyspareunia and less frequently rectal bleeding
Diagnosis can be made by clinical exam, MRI, transvaginal ultrasound, transrectal ultrasound, virtual CT colonoscopy or Barium Enema
What causes these symptoms? Anterior or lateral fixation of the rectum to adjacent structures Rectal stenosis (more likely at rectosigmoid junction) Cyclic inflammation of the rectal wall, causes▪ Diarrhea▪ Dyschezia▪ Feeling of incomplete bowel emptying during menstruation
Concurrent IBS, Crohn’s and Ulcerative Colitis are fairly common
Some GI symptoms therefore may not be from endometriosis
Removing an endometriosis nodule may not improve GI symptoms
Constipation usually does not improve There is usually significant improvement in dyspareunia, pelvic pain and dyschezia after surgery
Sensitivity Specificity Pros Cons
MRI 86% 100% Detects extrapelvic endo Expensive
Transvaginal ultrasound 92.9% 90% Gynecologist friendly User dependent
Transrectal ultrasound 97% 89.3% High sensitivity Radiologist
Other options include virtual CT colonoscopy and Barium Enema
Preoperative evaluation can be helpful for planning surgical times, teams and equipment
Ultimately though, the surgeon must make a decision intraoperatively on how to proceed
The plan can change!
Laparoscopic shaving Partial or down to mucosa
Laparoscopic rectosigmoid discoid resection Segmental resection
Lesion size Repair Pros Cons
Shaving <1 cm Suturing Simple Not radical
Discoid <3 cm Circular stapler Simple Not radical
Segmental >3 cm Stapler Radical (?) Complications
Least invasive Effective A recent prospective series of 500 patients with mean follow up of 3.1 years showed high rates of symptom resolution, low recurrence rates (8%), high pregnancy rates (84%) and low complication rates
Mean lesion size 3.4 cm (range 2‐6 cm) Can be performed by the gynecologist Not as radical as resection
Donnez et al. Human Reproduction 2010;25(8):1949‐58
Especially useful for discrete lesions on anterior surface of rectosigmoid Full thickness Circular stapler greatly facilitates this procedure Many will need collaboration with a colorectal surgeon Maybe higher risk of anastomotic complications compared with shaving
For larger lesions or significant narrowing (>60‐80%) of the bowel lumen
Most often requires a team of colorectal and gyn surgeons Higher complications rates, but perhaps lower recurrence rates?
Segmental resection Shaving
Ureteral injury 0.9‐4% 0.8%
Anastomotic leak 3.5% 0%
Conversion to laparotomy 3‐11% 0%
Severe anastomotic stenosis 3% n/a
Rectovaginal fistula 3‐9% 0%
Sepsis and/or pelvic abscess 2‐4% 0%
Median operating time (min) 312 (60‐720) 78 (50‐218)
Rectal perforation 0.4 1.4%
Temporary urinary retention 3‐19.9% 0.8%
Primary temporary ileostomy 14% 0%
Repeat surgery was performed in 12 (2.4%) women after the shaving technique 7 nodule resections 3 segmental bowel resection 2 discoid resection
Recurrence of pelvic pain Overall 7.8% Women who got pregnant after surgery 3.6% Women who did not get pregnant after surgery 15.7%
Reported between 6‐20% Follow up variable A retrospective cohort study at one center compared women who had segmental resection vs women who underwent only “endometriosis removal”
Average follow up was 4 years The most common reason for not performing a bowel resection in patients with rectovaginal endometriosis was lack of adequate surgical consent
Stepniewska et al. Fertil Steril 2010;93:2444‐6.
Resection Shaving p
Complete pain relief for dyspareunia 81% 46% 0.002
Complete pain relief for dyschezia 81% 46% 0.010
Relief of nonmenstrual pain 87% 33% <0.001
Relief of dysmenorrhea 76% 41% <0.001
Recurrence of symptoms 10% 35% 0.002
Need for reoperation 13% 38% 0.005
Anastomotic fistula 3.2% Not reported
Ureteral injury 1.6% Not reported
Bladder injury 1.6% Not reported
Anastomotic stenosis 1.6% Not reported
Urinary retention > 1 month 5% Not reported
Blood transfusion 12.8% Not reported
In 10% of cases the margins are not clear when performing a segmental resection
Bowel endometriosis can be multifocal and may be missed even with a segmental resection
There is some data to suggest that small amounts of residual bowel endometriosis remain quiescent in most cases and do need further treatment
RCT between bowel resection and shaving Enrollment complete (60 total) Pts with symptomatic rectal endometriosis and at least on nodule >20 mm, less than 15 cm from the anus and less than 50% rectal circumference
Primary outcome; major constipation, increased stool frequency, anal incontinence, dysuria and bladder atony
Results will be available 2016
Excision of endometriosis can be challenging Conversion to a laparotomy does not equal defeat
Doing nothing may be the best thing to do in some cases – then refer to a specialist
Master retroperitoneal anatomy – videos, cadaver courses, observe surgeries, participate in advanced cases
Based on available evidence segmental resection should be reserved for cases of severe stricture, mucosal involvement (1‐3%), a large lesion (>3‐6 cm) or multifocal disease