Endometriosis and the Surgeon

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Endometriosis and the Surgeon

• Dr Robert Hawthorn
• Dept Gynaecology
• Southern General Hospital
• Glasgow

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Endometriosis

• Definition
• Presence of functional endometrium in sites other
  than endometrial cavity
• uterosacral ligaments
• ovaries
• Peritoneum (pouch of Douglas)
• Uterus(adenomyosis)
• Rectovaginal septum
• Others (bowel,bladder,lungs, scar etc)

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Endometriosis

• Aetiology retrograde menstruation(Sampson) Mulle
  rian duct remnant metaplasia
• blood / lymphatic spread
• implantation
• Immunology
• Genetic factors
• esp severe endometriosis
• Age, Socio economic status, Race

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Endometriosis the surgeon

• Pathophysiology
• neo angiogenesis
• recurrent growth cycles
• inflammatory change, fibrosis
• capsular fibrosis, adhesions

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Endometriosis the surgeon

• History
• Dysmen, heavy periods, dyspareunia, infertliity
  (pain vs fertility)
• IBS type symptoms
• Cyclical rectal bleeding
• Pain on defaecation
• Cyclical pain in other sites
• Urinary symptoms very uncommon

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Endometriosis the surgeon

• Diagnosis
• Clinical examination
• Fixed pelvic mass
• Vaginal nodule palpable/visible
• Fixed retroverted uterus
• tender uterosacral ligaments
• Rectal examination

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Endometriosis

• Findings with severe disease
• Nodular tender uterosacral ligts gt60
• Fixed retroverted uterus 40-70
• Adnexal mass 60
• Cyclical haematuria lt2
• Rectal bleeding lt1

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Endometriosis the surgeon

• Diagnosis
• Laparoscopy
• Ultrasound
• endometriomata/cysts/urinary tract
• ?endoanal ultrasound
• MRI
• Sigmoidoscopy
• Contrast studies
• Histology from specimen

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Endometriosis

• Management
• Dietary change
• Medical
• Non hormonal
• analgesia
• avoidance of constipation
• homeopathy / herbal

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Endometriosis

• Management (contd)
• Medical
• Hormonal
• Induce 3-6 months amenorrhoea
• Combined pill
• Cerazette
• Mirena
• Depot provera (Implanon)
• - GnRH analogues

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Endometriosis

• Management
• Side effects vs symptoms
• Pain and fertility
• Fertility
• Pain management
• Other symptoms (GI, urinary, menstrual)
• Medical vs surgical

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Endometriosis the surgeon

• Surgery
• Pre operative counselling
• Fertility issues/Anti Mullerian Hormone
• Laparoscopy/laparotomy
• Scope of surgery eg oophorectomy, hysterectomy
• Risks of surgery
• Stoma counselling/ sites
• HDU care / ward transfer

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Endometriosis the surgeon

• Surgical
• Bowel involvement/ rectum recto vaginal septum
• Adhesions
• Usually both
• Urinary tract

• Gynaecological
• Superficial disease
• Infiltrating nodules
• Ovarian (bilat)
• Fertility sparing(AMH)

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Endometriosis the surgeon

• Bowel involvement
• Shaving
• Disc/wedge resection
• Segmental resection
• Colostomy??

• Other deposits
• Ablation superficial
• Helium beam/ laser
• Excision
• Ovary strip capsule vs ablation

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Endometriosis the surgeon

• Laparotomy- dense adhesions, total occlusion POD,
  hysterectomy, bowel resection
• Shaving - moblie nodules in prerectal fascia
• Resection fixed and and involving muscle (disc
  / anterior rectal)

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Endometriosis the surgeon

• Shaving vs resection
• Recurrence
• 5 -74 vs 04
• Complicaton
• 1.224 vs 4-17

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Endometriosis the surgeon

• Outcome
• Pain (dysmen, dyspareunia, CPP)
• 90 to 100 relief (Chapron 2001)
• QOL sig improved (Garry 2000)
• Re operation 36
• Recurrent endometriosis 15
• Nerve ablation
• Better in severe disease
• ? resection hysterectomy

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Endometriosis the Surgeon

• Outcome Fertility I
• Min and mild endometriosis
• Previously thought that medical and surgical Rx
  of no benefit
• Canadian group(New Eng J Med 1997) sig increased
  pregnancy rate in treated group vs observed (30
  vs 20)

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Endometriosis the surgeon

• Outcome Fertility II
• Treatment of moderate and severe disease
  equivalent to microsurgery (50-80)
• Treatment of large endometriomata pregnancy rates
  to 30 (Sutton 1993)
• Rectovaginal rectosigmoid disease
• Pregnancy in 50 (rAFS gt116)
• IVF

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Endometriosis the surgeon
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Endometriosis the surgeon

• Summary
• Disease not easily assessed without surgical
  intervention , multiple procedures
• Severe disease managed surgically
• esp fertility issues and bowel involvement
• Laparoscopy / laparoscopic surgery
• Adhesions and bowel involvement increase risks
  and time of surgery
• Colorectal, urological and pain management input
  
• Conservative approach with radical excision
• Availabilty of IVF

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Endometriosis the surgeon

• Conclusions
• Few RCTs esp of surgical mamagement
• Poorly understood debilitating disease
• Variable presentation
• Surgical and medical management issues
• Best dealt with by team approach
• ? Endometriosis treatment centres

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Endometriosis and the Surgeon

• Dr Robert Hawthorn
• Dept Gynaecology
• Southern General Hospital
• Glasgow

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Endometriosis the surgeon

• Pre op
• Bowel prep
• Local protocol for injury / repair
• Previous laparoscopy findings

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Endometriosis the surgeon
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Endometriosis the surgeon
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Endometriosis the surgeon