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The ovarian cyst is being separated
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from the ovarian stroma
Laparoscopic Treatment of Endometriosis — 277
Removing type IIC
C
A portion of the ovarian cortex and ovarian cyst
with severe endometriosis has been removed
Figure 10.3.8. (Continued )(C) Surface implants penetrate the cyst wall deeply, making excision difficult. The degree of invasion of the cyst wall
forms the basis for differentiating these subgroups.
The difference in the recurrence rate andbetween the cumulative
clinical pregnancy rates in the three groups was not statistically
significant after 36 months of follow-up. The investigators concluded that laparoscopic ovarian fenestration and coagulation of
endometriomas led to faster conception than did ovarian cystectomy by laparotomy. Furthermore, laparoscopic ovarian fenestration and coagulation of endometriomas were associated with
cumulative clinical pregnancy rates and recurrence rates over 36
months that were similar to those associated with ovarian cystectomy.
Genitourinary Endometriosis
Endometriosis may spread to the urinary system in 1% to
2% of women with symptomatic endometriosis. Endometriosis
of the urinary tract tends to be superficial but may be invasive
and cause complete ureteral obstruction.[111] Decreasedbladder
capacity and stability unresponsive to conventional therapy may
result. Goldstein and Brodman [112] reported one case of bladder endometriosis that they monitoredcystometrically for 4 years.
They found that decreased bladder capacity and bladder instability that were not responsive to conventional parasympatholytic
therapy were corrected after surgical destruction of superficial
bladder endometriosis. When bladder symptomsrecurred2 years
later, a course of danazol again reversed bladder instability. Clinicians should consider endometriosis in cases of refractory and
Figure 10.3.9. The resected ovary and adjacent side wall of the pelvis
are wrapped with Interceed (Gynecare).
unexplained urinary complaints. If urinary tract endometriosis is suspected, an intravenous pyelogram (IVP), ultrasound
278 — Bulent Berker, Thomas H. S. Hsu, Keith L. Lee, Ceana Nezhat, Farr Nezhat, and Camran Nezhat
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of the kidneys, and a routine blood and urine work-up are
indicated. In selected cases of recurrent hematuria, cystoscopy
is suggested.
Superficial implants over the ureter are treated with a variation of hydrodissection. Approximately 20 to 30 mL of lactated
Ringer’s solution is injected subperitoneally on the lateral pelvic
wall; this elevates the peritoneum and backs it with a bed of
fluid. The CO
laser may be used to create a 0.5-cm opening on
2
this elevation. The opening in the peritoneum is made anteriorly
and laterally, close to the corresponding round ligament. The
hydrodissection probe is inserted into the opening, and approximately 100 mL of lactated Ringer’s solution is injected under
300 mm Hg pressure into the retroperitoneal space along the
course ofthe ureter.The fluid surrounds the ureter, moves it posteriorly, and allows superficial laser dissection or vaporization of
the area.
After a water bed is created, a superpulse or ultrapulse CO
laser or any other cutting device (20 to 80 W) may be used to
vaporize or excise the lesion with a circumference of 1 to 2 cm.
When the lesions are large or excision is preferred, a circular line
with a 1- to 2-cm margin is made around the lesion. The peritoneum is held with an atraumatic grasping forceps and peeled
away with the help of a cutting instrument and the suction–
irrigator probe. If the endometrial implant is embedded and has
formed scarring down to the subperitoneal connective tissue,
hydrodissection allows water to tunnel beneath the lesion, often
separating scar tissue. Then the lesion can be treated safely. After
vaporization or excision of these lesions, the area is irrigated and
washed to remove all charcoal and verify that the nonpenetrating
endometriosis (to the lumen of ureter bladder) has been treated
properly. In more than 500 consecutive procedures (275 bladder
and 250 ureter), there were no major complications involving
vesical or ureteral injury.[15] Two patients were unable to void
immediately postoperatively. An indwelling catheter was placed
and removed the day after surgery, and then those women were
able to void. Four patients with bladder endometriosis experienced minimal hematuria that resolved several hours postoperatively. After hydrodissection of the broadligaments and thepelvic
side wall, about 5%ofthepatients developed swelling of the external genitalia, most likely from the penetration of water through
the inguinal canal to the labia majora. This swelling resolved in
most patients within 1 to 2 hours without sequelae.
The surgical management of 28 womenwho haddeeply infiltrating urinary tract endometriosis has been described.[113] All
procedures were accomplished laparoscopically: seven involved
the bladder, and 21 the ureter. Patients who had vesical
endometriosis underwent partial cystectomy and primary repair.
Partial ureteral obstruction was found in 17 women; 10 underwent ureterolysis and excision of endometriosis, and seven had
partial wall resection. Four patients with ureteral involvement
had complete obstruction. Three underwent partial resection
and ureteroureterostomy, and one had ureteroneocystostomy.
Severe infiltrative endometriosis of the bladder and the ureter
may present without specific symptoms and may cause silent
compromise of renal function.
Laparoscopic closure of intentional or unintentional bladder lacerations during operative laparoscopy was done in 19
women with one layer using interrupted absorbable polyglycolic
suture or polydioxanone suture (PDS) followed by 7 to 14 days
of transurethral drainage.[114] Complications were limited to
one vesicovaginal fistula that required reoperation. After 6 to 48
months offollow-up,allthese patientshadagood outcome. Anew
laparoscopic technique for the treatment of infiltrative ureteral
endometriosis, a laparoscopic vesicopsoas hitch, was described.
In a 36-year-old woman with infiltrative endometriosis of the
ureter after partial ureteral resection, it was noted that a tensionfree anastomosis to the bladder was not possible. Thus, a laparoscopic vesicopsoas hitch was done.[115]
As a result, depending on the extent of ureteral involvement,
ureterolysis with or without ureteral resection can be performed
safely and effectively with the laparoscopic approach. The ultimate goal is to avoid ureteral obstruction and loss of renal function. Successisdependentoncarefulpreoperativeevaluation,surgical planning, and careful postoperative follow-up. Radiologic
imaging, laparoscopy, and ureteroscopy are useful techniques for
disease staging that the laparoscopic surgeon should be familiar
with. Complete resection remains the mainstay of therapyincases
2
refractory to conservative medical management. Urinary symptoms generally resolve, and recurrence generally does not occur
provided that the lesion is completely resected. In experienced
hands, laparoscopy is not only feasible but also has become the
standard of care in many centers.
Ureteral Involvement
Ureteral involvement by endometriosis is rare and occurs
in 0.1% to 0.4% of cases. It most commonly affects the distal ureter, less commonly the mid-ureter, and rarely the proximal ureter.[116–118] Lesions are typically extrinsic, with a
smaller fraction of cases involving the lumen of the ureter (i.e.,
intrinsic). The extrinsic-to-intrinsic ratio has been reported
at 3:1 to 4:1, and the left ureter appears to be more frequently involved.[116,117,119] In cases of ureteral involvement,
the patient typically has concomitant pelvic endometriosis that
causes external compression, inflammation, and fibrosis of the
involved ureter. The patient may present with symptoms of renal
colic, hematuria, or silent urinary obstruction with loss of renal
function. The latter presentation is worrisome, and early recognition is of key importance in preventing irreversible damage
to the kidneys.[118,120–122] Thus, ureteral endometriosis must
be on the differential diagnosis in a premenopausal woman
with unilateral or bilateral ureteral obstruction of uncertain
etiology.
DIAGNOSIS
Silent obstruction with loss of renal function occurs in 5% to
30% of women with endometriosis; thus, early disease recognition is critical.[123,124] Diagnosis is most easily made by
laparoscopy with tissue biopsy, and in cases of primary intrinsic
ureteral endometriosis, retrograde pyelogram and ureteroscopy
are useful.[117,124] Radiologic imaging of the ureter, including
IVP, retrograde pyelograms, and computed tomographic IVP,
is useful in defining the extent of ureteral involvement and for
preoperative planning.
SURGICAL TECHNIQUE
Preoperative assessment ofthe locationand extent of ureteral
involvement is key to successful surgical management. Intraoperatively, ureterolysis is performed, and the goal is to treat
all pelvic endometriosis with excision or ablation. The surgical techniques of laparoscopic ureterolysis for endometriosis are
similar to that first described for the treatment of retroperitoneal
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fibrosis when the technique was first described.[125,126] During ureterolysis, care is takento preserve the periureteral vascular
supply if the ureter is not directly affected by endometriosis, fibrosis, or inflammation. The blood supply to the distal ureter typically comes laterally from the iliac artery, whereas the mid- and
proximal ureters’ blood supply comes medially from the aorta.
There is also a fine network of vessels that travel along the length
of the ureter. Thus, ureterolysis must preserve the periureteral
tissue and adventitia of the ureter. In cases in which extrinsic
ureteral involvement is minimal, ureterolysis alone may be all
that is needed.[127] The principles of success include atraumatic
handling of the ureterand when feasible, interposition of normal
tissue, such as omentum.
In cases in which the ureter is strictured and directly affected,
the goal is to resect all of the diseased ureter and then reconstitute urinary continuity. Surgical principles of ureteral surgery
are the same in laparoscopy. The ureter should be spatulated,
and fine interrupted absorbable sutures such as 5-0 or 4-0 are
used. In the majority of cases, only the distal third of the ureter
is involved, and when the length of the involved ureter is short
(≤2 cm), resection followed by an end-to-end ureteroureterostomy may be performed.[128] However, when involvement of
the distal ureter is more extensive, ureteral reimplantation to the
dome of the bladder in a refluxing, tension-free manner may be
needed. To identify the most appropriate location for the reimplant, the bladder may be filled with saline, and the cystoscope
may be used to “light” a location on the dome of the bladder that
can be reached easily by the spatulated ureter. A simple 5-0 holding stitch is placed laparoscopically onto the bladder detrusor at
the cystoscope light. A transmural cystotomy can then be created
precisely around this stitch for the reimplant.
If additional ureter length is needed, a vesicopsoas hitch with
or without a vesical flap may be performed.[116] The detrusor fiber of the bladder is tacked down to the psoas with either
absorbable or nonabsorbable suture to minimize tension on the
reimplanted ureter. The laparoscopic surgeon should be aware
of the location of the genital–femoral nerve as it crosses the surface of the psoas. The stitch is usually placed parallel to the nerve
either lateral or medial to it to avoid nerve entrapment. Should
additional length be required, the contralateral superior vesical
pedicles can be divided to give upward mobility to the bladder. Rarely, a vesical flap or an ileal ureter may also be used for
replacement of the entire ureter.[116,129] However, the laparoscopic approach for complete ureteral substitution is technically
demanding and beyond the scope of our discussion.Nevertheless,
it is important to note that in selecting a vesical flap, a bladder of
sufficient capacity is required.
Except for simple cases ofureterolysis in whichureter manipulation is minimal, a double-J ureteral stent is placed and left
indwelling for 3 to 6 weeks. In clinic follow-up, the stent is
removed and an IVP is typically obtained in 3 to 4 weeks to
assess ureter anatomy and to rule out strictures. A renal bladder
ultrasound may also be useful in assessment of hydronephrosis.
Laparoscopic Treatment of Endometriosis — 279
Figure 10.3.10. At laparoscopy, a 3- to 4-cm nodule was found over
the left ureter about 4 cm above the bladder, distorting the course of
the ureter.
colleagues [130] ona36-year-old woman with long-termureteral
obstruction caused by endometriosis. The condition had been
diagnosed previously at laparoscopy. The patient refused conventional laparotomy and had a nephrostomy tube for 4 years.
At laparoscopy, a 3- to 4-cm fibrotic nodule over the left ureter
was seen approximately 4 cm above the bladder, distorting the
course of the ureter (Figure 10.3.10). This corresponded to the
level of obstruction seen on radioimaging techniques. Under
direct laparoscopic observation, an attempt to place a retrograde
catheter was unsuccessful, and so the nodule was excised. The
left retroperitoneal space was entered at the pelvic brim. After
all associated endometriosis, fibrosis, or adhesions were treated,
the ureter was dissected (Figure 10.3.11). The nodule involved
the entire thickness of the ureter; a partial resection was done
(Figure 10.3.12).
Undercystoscopic guidance, a 7Fureteral catheter was passed
through the ureterovesical junction, at which level the ureter
was excised. Indigo carmine was injected into the patient’s intravenous line to ensure patency of the proximal ureter. The distal
ureter was transected over the stent, and the obstructed portion was removed. The ureteral stent was introduced into the
Ureteral Obstruction
The incidence of ureteral obstruction byendometriosisislow,
and conventional therapy previously consistedoflaparotomyand
resection of the obstructed segment of the ureter. Laparoscopic
ureteroureterostomy was accomplished in 1990 by Nezhat and
Dissected ureter
Figure 10.3.11. After all associated endometriosis, fibrosis, and adhesions were treated, the ureter was dissected with the CO
2
laser.
280 — Bulent Berker, Thomas H. S. Hsu, Keith L. Lee, Ceana Nezhat, Farr Nezhat, and Camran Nezhat
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Obliterated ureter
being excised
Obliterated ureteral opening
Ureterovesical
Ureter
junction
Figure 10.3.12. During dissection, it was discovered that the nodule
involvedthe entirethickness ofthe ureter; a partial resection was done.
proximal ureter and advanced into the renal pelvis (Figure
10.3.13). Finally, the edges of the ureter were reapproximated
with sutures. To accomplish anastomosis, four interrupted 4-0
PDS were placed at 6, 12, 9, and 3 o’clock to approximate the
proximal and distal ureteral ostia (Figure 10.3.14). The patient
went home the next day. The postoperative course was uncomplicated. An IVP confirmed ureteral patency and renal function
(Figure 10.3.15). Estimated blood loss was less than 100 mL, and
the procedure lasted 117 minutes. The pathology report confirmed severe endometriosis and fibrosis of the resected ureter.
Since that time, 12 more patients with severe ureteral
endometriosis in whom endometriosis and fibrosis caused partial or complete ureteral obstruction have been treated. All these
patients had a known history of endometriosis and underwent
different surgical and medical treatments. In four women, the
ureteral endometriosis was removed completely without entering the ureteral lumen. In three women, the obstructed ureter
required a complete segmental resection. One right and one left
ureteroureterostomy and one anastomosis of the left ureter to
the bladder (ureteroneocystostomy) were achieved, using four
through-and-through interrupted 4-0 PDS to approximate the
edges over the ureteral catheter. In five women, the ureter
was involved partially. The severe retroperitoneal and ureteral
endometriosis was excised or vaporized cautiously with the CO
laser until ureterotomy occurred. In three women, the ureterotomy was very small and was detected by intravenous injection of indigo carmine. A ureteral stent was left in place, and
no suture was required. In two patients, the ureterotomy was
repaired using 4-0 PDSto overlap the laceration after stent placement. Histologic examination of the resected specimen revealed
fibrosis, endometriosis, or both in all the women. A rare case of
endometriosis with focal severely atypical hyperplasia was found
in the specimenofa 46-year-old woman. She hadundergonetotal
abdominal hysterectomy and BSO followed by HRT at another
institution. All the patients had an uneventful intra- and postoperative course and reported symptomatic relief of their symptoms.Imaging techniquesrevealedpatentureterswithafunctioning kidney in all these patients except one, a 24-year-old woman
Catheter being
advanced through
new ureteral opening
A
New
ureteral
opening
Patent
ureter
B
Figure 10.3.13. The ureteral stent was introduced into the proximal
ureter and advanced into the renal pelvis.
who had been diagnosed several months earlier with pelvic
endometriosis that was treated partially at initial laparoscopy,
followed by GnRH analogue therapy postoperatively. During a
2
Catheter
advanced to
left renal pelvis
Figure 10.3.14. To do an anastomosis, four interrupted 4-0 polydioxanone sutures were placed at 6, 12, 9, and 3 o’clock to approximate the
proximal and distal ureteral edges.
Sutures
in ureter
Figure 10.3.15. An IVPconfirmedbilateralpatencyand renalfunction.
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second laparoscopy, she was found to have severe endometriosis involving left uterosacral ligament, left pelvic sidewall, and
ureter causing complete ureteral obstruction. Segmental resection andureteroureterostomy were accomplished. Intraoperative
intravenous injection of indigo carmine did not reveal any leakage from the ureter and raised the question of a nonfunctioning
kidney. Postoperative follow-up and imaging revealed a 10% to
20% functioning kidney. However, the ureter was noted to be
patent. The authors suggested that in such cases, a ureteral stent
is left in the ureter. This stent remains in place for approximately
2 monthspostoperatively. The patient’s follow-up should include
IVP, ultrasound, or excretion scans.
Recently, clinical results of six patients who underwent successful laparoscopic ureteroneocystostomyand vesicopsoas hitch
were published.[131] Five of the six patients had a history of
endometriosis, and their obstructions were diagnosed during
prior surgeries. The other patient was diagnosed with severe
endometriosis of the rectum, bladder, and ureter at the time of
the procedure. All patients had a normal cystogram performed
10 to 14 days postoperatively prior to Foley catheter removal.
Stents were kept in place for 6 to 8 weeks, and an IVP was done 2
weeks after removal. All patients had a normal renal ultrasound,
computer tomography, or IVP at least 1 year postoperatively. As
a conclusion, laparoscopic vesicopsoas hitch can be a safe and
effective alternative to laparotomy with the known benefits of
laparoscopy.
Vesical Endometriosis
Although the bladder wall is one of the sites least frequently
involved with endometriosis, the bladder is the most commonly
affected site in the urinary system, followed by the ureter and
the kidney in a ratio of 40:5:1.[123–133] Patient presentation
is quite variable, and symptoms may consist of suprapubic discomfort, pelvic pain, dysmenorrhea, dysuria, urinary frequency,
urgency, microscopic hematuria, and even cyclical gross hematuria. Endometriomas are typically solitary and most frequently
involvethe dome and posterior wall of the bladder because of the
Laparoscopic Treatment of Endometriosis — 281
relative location of the uterus to the bladder. However, involvement of other locations of the bladder may occur. The lesions
tend to invade the detrusor musculature in an extrinsic fashion
and often remain submucosal.[112]
DIAGNOSIS
Prompt diagnosis requires clinical acumen and vigilance.
Often, patients will give a history of pelvic endometriosis,
cesarean delivery, or other gynecologic surgery.[134] Directvisualization of the endometrioma via cystoscopy and laparoscopy
is important. Cystoscopically, lesions appear as solitary submucosal lesions that are slightly raised, with little surrounding
mucosal edema in the absence of concomitant cystitis or infection. Transurethral biopsy orresection may be inadequate forhistologic diagnosis because of the submucosal nature of the lesion.
Extravesically, the lesions can be identified by laparoscopy, and
direct biopsy remains the gold standard of disease diagnosis and
staging. However, the actual extent of bladder involvement may
be difficult to completely visualize in laparoscopy. Thus, a combined cystoscopic and laparoscopic approach is needed during
definitive surgical resection.
SURGICAL MANAGEMENT
Although medical management can be transiently effective
in some patients, surgical resection of the endometrioma in
toto remains the most definitive therapy. Minimally invasive
approaches using combined cystoscopy and laparoscopy techniques are becoming the standard of care for solitary lesions.
If the lesions are superficial, hydrodissection and vaporization
or excision may be adequate for removal (Figure 10.3.16). Using
hydrodissection,theareolartissuebetweenthe serosa and muscularis beneath the implants is dissected. The lesion is circumcised,
and fluid isinjectedinto the resulting defect.Thelesion is grasped
with forceps and dissected. Frequent irrigation is necessary to
remove char, ascertain the depth of vaporization or excision, and
ensure that the lesion does not involve the muscularis and the
mucosa.
Endometriosis extending to the muscularis but without
mucosal involvement can be treated laparoscopically, and any
residual or deeper lesions may be treated successfully with
postoperative hormone therapy. In selected cases in which the
endometrioma is small and clearly submucosal, a mucosalsparing approach may be used. In this approach, the light of
the cystoscope is simply directed close to the endometrioma to
provide “backlighting” for laparoscopic dissection. If successful,
postoperative irritative voiding symptoms as well as hematuria
may be avoided in the patients.
When endometriosis involves full bladder wall thickness, the
lesion is excised and the bladder is reconstructed.[135] Four
cases of full-thickness bladder endometriosisweretreatedbyexcision and a one-layer reconstruction. The exposure seemed to be
better than that at laparotomy. Simultaneous cystoscopy is performed, and bilateral ureteral catheters are inserted. The bladder
dome is held near the midline with the grasping forceps, and the
endometriotic nodule is excised 5 mm beyond the lesion (Figure
10.3.17).
In intravesical endometriosis cases in which the lesion is
located in the dome, lateral walls,or posterior wall,partial cystectomy with primary repair of cystotomy is the treatment of choice
if adequate postresection capacity can be maintained.[135,136]
282 — Bulent Berker, Thomas H. S. Hsu, Keith L. Lee, Ceana Nezhat, Farr Nezhat, and Camran Nezhat
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Bladder endometriosis
(laparoscopic view)
A
Figure 10.3.16. (A) Endometriosis involves the anterior lower uterine segment and the bladder. The extent of
vesical involvement cannot be ascertained from this view.
Bladder endometriosis
(sagittal section)
B
Figure 10.3.16. (B) The sagittal sections show that the muscularis and mucosal surface of the bladder are
involved.
Severe bladder wall
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endometriosis
Laparoscopic Treatment of Endometriosis — 283
The bladder has
been separated
from the uterus
Figure 10.3.17. Endometriosis involving the bladder is being excised with the CO2laser after the bladder has
been separated from the uterus. The lesion involves the full thickness of the bladder. Bilateral ureteral catheters
were inserted during simultaneous cystoscopy. The endometrial implants were excised 5 mm beyond the lesion.
In rare cases in which the lesions involve areas of the trigone or
near eitherureteral orifice, partial cystectomy with ureteral reimplantation may be necessary. With either approach, cystoscopy
is first used to characterize the full extent of the lesion. Then,
using an electrocautery cutting device through the cystoscope,
the lesion is marked circumferentially. The light intensity of the
laparoscope is turned down to a minimum so that the light of the
cystoscope can be visualized transvesically. The cystoscopically
guided dissection is carried deep into the detrusor musculature
but without bladder perforation. The bladder should be moderately distended during this dissection to avoid inadvertently taking too much normal tissue around the endometrioma. Of note,
overdistention must also be avoided because of the increased risk
of bladder perforation. Once the lesion is marked intravesically,
the surgeon turns to extravesical dissection with laparoscopic
guidance. Cutting “toward the light” of the cystoscope will provide accuracy. Often, the peritoneal covering over the dome of
the bladder must first be incised to gain access to lesions located
near the trigone of deep in the posterior wall of the bladder.
The specimen is removed from the abdominal cavity with
a long grasping forceps through the operative channel of the
laparoscope. Alternatively, once resected, the lesion is placed into
a laparoscopic retrieval device for later removal. CO
gas dis-
2
tends the bladder cavity, allowing excellent observation of its
interior (Figure 10.3.18). After the ureters have been identified
and the bladder mucosa has been examined again, the bladder
is closed with several interrupted or continuous 4-0 throughand-through PDS using extracorporeal or intracorporeal knotting (Figure 10.3.19). The bladder can be closed with resorbable
sutures in one or two layers. In one-layer closures, it is important
to take transmural stitches with more detrusor than mucosa for
inversion of the suture line. Once the cystotomy is closed, the
bladder is tested for leaks with retrograde filling using methylene
blue mixed in saline. Leaks are readily visualized and repaired
with simple interrupted sutures. A closed-suction drain is often
placed in the pelvis and kept for the first 24 to 48 hours but
is not absolutely necessary given the transperitoneal nature of
surgery. The duration of laparoscopic segmental cystectomy is
approximately 35 minutes. Patients are discharged the following
day and instructed to take trimethoprim-sulfamethoxazole for
2 weeks. A urinary catheter is left indwelling for 10 to 14 days
and removed when the postoperative voiding cystourethrogram
or retrograde cystogram demonstrates no leakage at follow-up.
Anticholinergics suchas oxybutynin or tolterodine may be useful
during early recovery to minimize bladder spasms. Blood loss
is minimal. In these reports on excisional treatment for fullthickness bladder endometriosis,the pathology report confirmed
severe endometriosis and fibrosis of the resected bladder wall. No
284 — Bulent Berker, Thomas H. S. Hsu, Keith L. Lee, Ceana Nezhat, Farr Nezhat, and Camran Nezhat
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Pneumoperitoneum
is distending
the bladder cavity
Ureteral
catheter
Part of bladder wall
with severe endometriosis
has been removed
Right ureter
Figure 10.3.18. The lesion is removed with a grasping forceps through a 10-mm trocar sleeve.
intraoperative or postoperative complications were noted.
Ten to 13 months postoperatively, the women were doing
well.
Gastrointestinal Involvement
Gastrointestinal endometriosis was described in 1909 by
Sampson [137] during the histologic examination of resected
sigmoid colon that had been diagnosed intraoperatively as a
carcinoma. The gastrointestinal tract is believed to be involved
in 3% to 37% of women with endometriosis.[138–139] However, in a specialized practice, the number of patients with bowel
involvement may be as high as 50% if patients with serosal and
subserosal lesions are included. Endometriotic implants may be
found between the small intestine and the anal canal. The clinical presentation varies from an incidental finding at celiotomy to
bowel obstruction.[140]
Severe endometriosis commonly involves the uterosacral ligaments, rectovaginal septum, and rectosigmoid colon with partial or complete posterior cul-de-sac obliteration. Patients may
present with lower abdominal pain, back pain, dysmenorrhea,
dyspareunia, diarrhea, constipation, tenesmus, and occasionally
rectal bleeding.[138] Symptoms usually occur cyclically at or
about the time of menstruation.
Intestinal endometriosis should be suspected in women of
childbearing age who present with gastrointestinal symptoms
and a history of endometriosis. Proctoscopy and colonoscopy
are suggestive, but the lesions usually are not identified before
laparoscopy. Although microscopic examination of the bowel
mucosa may reveal endometrial glands, colonoscopic biopsy is
usually not diagnostic.[141] In patients with severe symptoms,
medical therapy rarely yields satisfactory long-term results. Surgical intervention is necessary to dissect and resect infiltrating
bowel endometriosis. These patients generally undergo videolaparoscopy after previous surgical or hormonal management fails
to relieve their discomfort. Large bowel resection for obstructing endometriosis of the sigmoid colon was reported in 1909 by
Mackenrodt.[142] Colonic resection has been shown to be safe,
with low morbidity, and to provide satisfactory pain relief and
favorable pregnancy rates.[143]
Intestinal endometriosis involves the rectum and sigmoid
colon in 76% of cases, the appendix in 18%, and the cecum
in 5%. Operative laparoscopy is done to treat endometriotic
implants on the intestinal wall, appendix, and rectovaginal
space.
APPENDICEAL ENDOMETRIOSIS
Reports evaluating gastrointestinal endometriosis suggest
that the appendix is the second most common site of involvement, with only the rectosigmoid colon being more commonly
affected.[144,145] During laparoscopic surgery of patients with
chronic pelvic pain and endometriosis, surgeons should be alert
tothepossiblecontributionofappendicealpathologytothepelvic
Laparoscopic Treatment of Endometriosis — 285
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A
Figure 10.3.19. (A) After the ureteral orifices and the ureteral catheters have been identified, the bladder is
closed with several interrupted through-and-through PDS, using extracorporeal and intracorporeal knot tying.
Cystoscopy is done to identify any leaks. (Continued )
discomfort of patients with endometriosis. Recently, we have
reported the frequency andspectrumof histologically proven diseases of theappendixinpatients undergoing laparoscopic surgery
for chronic pelvic pain in conjunction with endometriosis.[146]
Of the 231 patients with pelvic endometriosis, concomitant
appendiceal pathology was present in 115. Notably, of the 231
patients with pelvic endometriosis, 51 (22.1%) had histologic
evidence of appendiceal endometriosis. Pathology other than
endometriosis was found in 64 (27.7%) of the 231 patients.
In another study of 65 women with symptomatic endometriosis and preoperative right lower quadrant pain, 52 underwent
appendectomy as part of the endoscopic surgery when Gastrografin enema screening or the visual appearance of appendix
was abnormal.[147] Thirty-nine (75%) had histologically confirmed pathology. The current approach for surgical treatment
of endometriosis is to excise or fulgurate all suspected areas. The
appendix also should be carefully evaluated among all patients
undergoing laparoscopy for the evaluation and treatment of
endometriosis. However, more prospective, randomized studies
may be required before “routine” appendectomy can be recommended in women with chronic pelvic pain and endometriosis.
BOWEL RESECTION
In patients who have severe disease of the bowel wall, resection may be necessary. Laparoscopically assisted anterior rectal
wall resection and anastomosis were described in 1991 to treat
symptomatic, infiltrative rectosigmoid endometriosis.[148,149]
Preoperativemechanical and antibioticbowelpreparation is necessary.Three 5-mm suprapubic trocarsareplaced,one each in the
midline, right, and left lower quadrants forthe insertion of grasping forceps, Endoloop suture applicators, a suction–irrigator
probe, and a bipolar electrocoagulator.
The technique includes laparoscopic mobilization of the
lower colon, transanal or transvaginal prolapse, resection, and
anastomosis.[150–153] When the lesion involves only the anterior rectal wall near the anal verge, the rectovaginal septum
is delineated by simultaneous vaginal and rectal examinations
effected by an assistant. The rectum is mobilized along the rectovaginal septum anteriorly to within 2 cm of the anus. Mobilization continues along the left and right pararectal spaces by
electrodesiccating and dividing branches of the hemorrhoidal
artery and partially posteriorly. When the rectum is mobilized
sufficiently, the lesion is prolapsed vaginally or anally and the
286 — Bulent Berker, Thomas H. S. Hsu, Keith L. Lee, Ceana Nezhat, Farr Nezhat, and Camran Nezhat
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Interceed
B
Figure 10.3.19. (Continued )(B) The suture line is covered with Interceed.
nodule is excised. Two stapleapplications may be required to traverse the width of theinvolved mucosa. Therectum is returned to
the pelvis under direct observation, and closure is confirmed by
insufflating the rectum while the cul-de-sac is filled with lactated
Ringer’s solution.
In patients with circumferential lesions, the entire rectum
is mobilized, the lateral rectal pedicles are electrocoagulated, and
the presacral spaceisenteredto the level of thelevator ani muscles
to allow mobilization of the bowel. The branches of the inferior
mesenteric vessels of the bowel segment to be resected are coagulated and cut. Therectumistransected proximalto the lesion, and
the proximal limb is either prolapsed vaginally or into the distal
limb, using Babcock clamps (Figure 10.3.20). A 2-0 purse-string
suture is inserted to the end of the proximal bowel to secure the
opposing anvil of a number 29 or 33 ILS stapler (Ethicon; Figure
10.3.21). The anvil is replaced transanally or transvaginally into
the pelvis along with the proximal bowel.
The rectal stump, containing the endometrial lesion, is prolapsed through the anal canal or vagina and transected proximal to the lesion using an RL60 linear stapler (Ethicon; Figure
10.3.22). The resected segment is sent for pathologic diagnosis.
The rectal stump is replaced through the anal canal or vagina
into the pelvis. The ILS stapler is placed into the rectum, and
the anvil in the proximal limb of the bowel is inserted into the
stapling device by using the laparoscope. The device is fired,creating an end-to-endanastomosis. A proctoscope is usedto examine
the anastomosis for structural integrity and bleeding. The pelvis
is filled with lactated Ringer’s solution and observed with the
laparoscope as the rectum is insufflated with air to check for
leakage. Air leaks can be corrected with 2-0 polyglactin sutures
placed transanally. This technique is identical to resection at
laparotomy.[154]
Another method uses a 60-mm Endostapler (Ethicon) to
resect the bowel intra-abdominally.The Endostapler is fired distal
to the lesion. The proximal limb of the colonis delivered from the
abdomen and exteriorized through a small (2- to 4-cm) incision.
The lesion is amputated, and the anvil of the stapler is inserted
in the lumen after the placement of a purse-string suture. At this
stage, anastomosis is completed with the stapler gun.
Another method to treat severe disease of the anterior wall
of the colon eliminates stapling devices.[155] The extent of the
lesion is evaluated visually and by palpation, using the tip of the
suction–irrigator probe. If the lesion is low enough, an assistant
can identify it by doing a rectal examination. A sigmoidoscope is
used to further delineate the lesion and guide the surgeon. After
the ureters are identified to avoid inadvertent injury, the lower
colon is mobilized in all aspects except posteriorly. Depending
on the location of the lesion, the right or left pararectal area is
entered, and the colon isseparatedfromthe adjacent organs. Fullthickness shaving excision, if necessary, is carried out, beginning
above the area of visible disease. After the normal tissue is identified, the lesion is held at its proximal end with grasping forceps.
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