Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_190_библиотеки_им_акад_М_И_Перельмана
.pdf
Serosa
https://t.me/med1917
Pelvic floor
Ghosted lesion
on serosal surface
Mucosa
Figure 10.3.20. In patients with circumferential lesions, the rectum is
transected distal to the lesion and the proximal limb is prolapsed into
the distal bulb.
An incision is made through the bowel serosa and muscularis,
and the lumen is entered. The lesion is excised entirely from
the anterior rectal wall. After complete excision of the lesion,
the pelvic cavity is irrigated and suctioned. Debris is extracted
through the operative channel of the laparoscope by using a long
grasping forceps, or from the anus by using polyp forceps, and
submitted for pathology.Thebowelis repairedtransverselyin one
layer. Two traction sutures are applied to each side of the defect,
transforming it to a transverse opening (Figure 10.3.23).The stay
sutures are brought out through the right and left lower quadrant trocar sleeves. The sleeves are removed and then replaced
in the peritoneal cavity next to the stay sutures, and the sutures
are secured outside the abdomen. The bowel is repaired by placing several interrupted through-and-through sutures in 0.4- to
0.6-cm increments until it is completely anastomosed (Figure
10.3.24). Polyglactin or polydioxanone sutures with a straight
needle (Ethicon) and extracorporeal knot tying are used. At the
end of the procedure, sigmoidoscopy is done to ensure that the
closure is watertight and that there is no bowel stricture. Results
from our center’s experience with its use during laparoscopic
treatment of adhesions, endometriosis, and associated disease of
the bowel also are provided. Intraoperative sigmoidoscopy is a
safe and efficacious procedure that can aid in the evaluation and
treatment of pelvic pathology and facilitate identification and
management of bowel injuries. It should be considered a valu-
Laparoscopic Treatment of Endometriosis — 287
able adjunctwhen such casesare encountered by gynecologic and
pelvic surgeons.[156,157] As an alternative, at times it is possible
to excise thenodule and staple it; thedefect closes simultaneously
by articulated vascular staplers.
CUL-DE-SAC RESTORATION
Cul-de-sac obliteration, which is common among patients
with severe endometriosis and pain, suggests rectovaginal
involvement with deep endometriosis and dense adhesions and
significant distortion of the regional anatomyinvolving the bowel,
vaginal apex, posterior cervix, ureter, and major blood vessels
(Figure 10.3.25). Transrectal ultrasonography is sensitive and
specific for diagnosing the presence of rectovaginal endometriosis.[158] In one study, infiltration of the rectal and vaginal walls
was identified correctly inall thepatients inwhom itwas present,
but rectal infiltration in three women was not confirmed by the
surgeon and the pathologic specimen. Rectal endoscopic ultrasonography was shown by other researchers to provide a reliable
indication of the presence of deep bowel infiltration in patients
with retroperitoneal endometriotic lesions.[159] The preoperativeuseofendoscopicultrasonographyas a diagnostic instrument
may facilitate preparing a patient for laparoscopic surgery.
Cul-de-sac restoration should not be attempted by an inexperienced laparoscopist or a gynecologist unfamiliar with bowel
and urinary tract operations. Most of these situations involve the
rectum and the rectovaginal space and do notrequire bowel resection. To aid in identifying anatomic landmarks and tissue planes,
an assistant stands between the patient’s legs and does a rectovaginal examination with one hand while holding the uterus up
with a rigid uterine elevator. An uninvolved area of peritoneum
is identified and injected with 5 to 8 mL of diluted vasopressin
(10 U in 100 mL of lactated Ringer’s solution) with an 18-gauge
laparoscopic needle. Using the CO
laser, scissors, electrosurgi-
2
cal knife, needle, or harmonic scalpel, the peritoneal adhesions
are cut. With the high-power CO
laser and hydrodissection, the
2
rectum attached to the uterosacral ligaments and the back of the
cervix is separated. If rectal involvement is more extensive, a sigmoidoscope can be used to guide the surgeon and rule out bowel
perforation. After complete separation of the rectum, lesions on
the rectum or rectovaginalseptumareremovedorvaporized(Figure 10.3.26). The cul-de-sac is filled with irrigation fluid and is
observed through the laparoscope while air is introduced into the
rectum through the sigmoidoscope. Air bubbles observed in
the cul-de-sac fluid indicate perforation. As the assistant guides
the gynecologistby doing arectovaginal examination, therectum
is freed from the back of the cervix. Generalized oozing or bleeding is controlled with an injection of 3 to 5 mL of vasopressin
solution (one ampule in 100 mL of lactated Ringer’s solution),
laser, or bipolar electrocoagulator. Bleeding from the stalk vessels
caused by dissection or vaporization of the fibrotic uterosacral
ligaments and pararectal area is controlled with a bipolar electrocoagulator, clips, or sutures.
The ureters are usually lateral to the uterosacral ligaments. If
the dissection is extended lateral to the uterosacral ligaments, the
ipsilateral ureter should be identified by opening the overlying
peritoneum and tracing it to the area of the lesion. The ureter,
uterine arteries, and uterine veins are exposed. Bipolar forceps
or hemoclips must be available and fully functional to control
unexpected bleeding.
288 — Bulent Berker, Thomas H. S. Hsu, Keith L. Lee, Ceana Nezhat, Farr Nezhat, and Camran Nezhat
https://t.me/med1917
Stapler in
rectal stump
A
Trocar puncturing
staple line of
rectal stump
Laparoscopic
reattachment
of anvil to shaft
C
B
Completion of
double stapled
end-to-end
anastomosis
Figure 10.3.21. (A) The ILS stapler is placed into the rectum. (B) The anvil trocar within the proximal bowel
is inserted into the stapling device using the laparoscope. (C) The device is fired, creating an end-to-end
anastomosis.
For patients who have posterior cul-de-sac nodularity and
infiltration of endometriosis toward the vagina, dissection and
resection of the nodularity continue as an assistant palpates the
nodule to ensure its removal.[160–162] Endometriosis rarely
penetrates the mucosa of the colon but commonly involves the
serosa, subserosa, and muscularis. When significant portions of
both muscularis layers have been excised or vaporized and the
mucosa is reached, the bowel wall is reinforced by interrupted
4-0 PDS. The procedure requires maximal coordination between
the assistant and the surgeon.
When the rectovaginal space is dissected and hemostasis is
accomplished, the pelvis is filled with lactated Ringer’s solution
to observe the cul-de-sac and the area of dissection under water.
This magnifies and clarifies the dissected tissue to help identify residual disease, verify the intact anatomy of the ureters and
bowel, and coagulate small bleeders. The raw surfaces of the rectum or cul-de-sacare not reperitonealized becauseseveralstudies
have demonstrated that reperitonealization is not necessary and
promotes adhesion formation.[95,96,138,139]
This procedure was accomplished in 185 women age 25 to
41 years.Eighty patients had completeposterior cul-de-sacobliteration. All were managed successfully by laparoscopy and dis-
charged within 24 hours, except for nine patients with bowel
perforation and one with a partial bowel resection, who were discharged after 2 to 4 days. The procedures lasted from 55 to 245
minutes. Among 185 patients, 174 were available for follow-up
after 1 to 5 years. Moderate to complete pain relief was observed
in 162 of 174 patients (93%). Thirteen (8%) required two procedures, and four required three procedures. Twelve (7%) had
persistent or worse pain postoperatively.[163]
In an unpublished study by one of the authors (B.B.), a
series of 356 women who underwent laparoscopic treatment
of bowel endometriosis with different techniques, two patients
required intraoperative laparotomy early in the authors’ experience. The first patient underwent laparotomy for repair of
enterotomy after treatment of infiltrative rectal endometriosis.
The other patient required laparotomy for anastomosis after an
unsuccessful attempt to place a purse-string suture around the
patulous rectal ampulla. Significant postoperative complications
occurred in 1.7% of these patients. Two women developed leaks
and pelvic infections. One required a temporary laparoscopic
colostomy with subsequent takedown and repair, and one was
managed with prolonged drainage. One woman had a bowel
stricture requiring resection and anastomosis by laparotomy.
Laparoscopic Treatment of Endometriosis — 289
https://t.me/med1917
A
Figure 10.3.22. The rectalstump,containingtheendometrial lesion, is prolapsed through the anal canal.(A)The
RL60 linear stapler is applied. (B) Using a sharper electrosurgical knife (Ethicon), the rectal stump is transected
proximal to the lesion.
Rectum
One developed a pelvic abscess and subsequently underwent
laparoscopic right salpingo-oophorectomy. One patient had an
immediaterectalprolapsethatwas reducedwithoutsurgicalmanagement. Her original bowel symptoms persisted, and she finally
had a colectomy.
Minor complications included skin ecchymosis, temporary
urinary retention, temporary diarrhea or constipation, and
dyschezia. Donnez and coworkers [160] described a series of 500
women who underwent a laparoscopic procedure with excision
of deep fibrotic endometriotic nodules of the rectovaginal septum for pelvic pain or infertility. Excision of the endometriotic
nodules resulted in considerable pain relief. Histologically, the
rectovaginal nodule was similar to an adenomyoma, as it was a
circumscribed nodular aggregateof smooth muscle andendometrial glands and stroma. The variations in estrogen receptor and
progesterone receptor content suggested aregulatory mechanism
different from that of eutopic endometrium. On the basis of
these observations, the authors suggested that nodules of the rectovaginal septum should be considered an entity distinct from
peritoneal and ovarian endometriosis and originating from the
mullerian rests present in the rectovaginal septum.[164]
Hepatic Endometriosis
Hepatic endometriosis is rare and was first described in
1986.[165] So far, 15 cases of hepatic endometriosis have
been reported in the literature. This rare condition raises several diagnostic and therapeutic challenges. When symptomatic,
endometriosis of the liver is difficult to diagnose. It is often
confused with other pathologies of the liver. Recently, we
described two patients with hepatic endometriosis managed
Endometrioma
on serosal
B
surface
laparoscopically.[166] The diagnosis of extrapelvic endometriosis is difficult, and it is often made many years after the onset
of symptoms. On the other hand, hepatic endometriosis is so
uncommon that such a diagnosis before surgical exploration
demands a high degree of suspicion. Women should be evaluated
for upper abdominal pain associated with the onset of the menstrual cycle. However, this is notthe most commonmanifestation
of the hepatic endometriosis encountered in the cases reported
in the literature. Excluding one, all patients described in the literature had epigastric or right upper quadrant pain; including
one of our patients, only two patients complained of characteristic cyclic pain related with menses. These findings demonstrate
that medical history regarding pain may not be that helpful in
diagnosing hepatic endometriosis. One of the significant advantages of laparoscopy is the ability to explore the upper abdominal region, which may be a difficult task when performing a
laparotomy for the treatment of pelvic endometriosis. This benefit of laparoscopy always should be exploited. Regardless of the
indication for surgery, complete visual inspection of the entire
abdominal cavity, including the upper abdominal region, should
be performed routinely. The laparoscopic approach may be recommended as an optionforthe treatment of hepaticendometriosis in proper settings.
Diaphragmatic Endometriosis
The diaphragm rarely is a reportedsiteofendometriosis.[169]
Women should be asked about pleuritic, shoulder, or upper
abdominal pain occurring with menses because they do not
make the connection betweenthese distant anatomic landmarks.
The laparoscope is excellent for diagnosing and possibly treating
290 — Bulent Berker, Thomas H. S. Hsu, Keith L. Lee, Ceana Nezhat, Farr Nezhat, and Camran Nezhat
https://t.me/med1917
Sites of endometriosis
and fibrotic tissue
Suction irrigator
Segment containing
endometriosis
is being excised
Defect in sigmoid
after lesion
is removed
A
Stay sutures pulling
incision edges together
C
Figure 10.3.23. (A) Schematic representation of a bowel segment shows endometrial implants. The lesion involves the intestinal mucosa and is
excised. (B) The pelvic cavity has been irrigated and suctioned. The longitudinal defect is seen. (C) The bowel is repaired transversely in one layer.
Two traction sutures are applied to each side, transforming it into a transverse opening. The right and left stay sutures, held with grasping forceps,
are secured outside the abdominal cavity and are used to pull the incisional edges together. (D) The bowel is repaired by using several interrupted
through-and-through 0 polyglactin or polydioxanone sutures on a straight needle. Extracorporeal knot tying is used.
D
endometriosis on the diaphragm, which is difficult to reach by
laparotomy.[168]
Before diaphragmatic endometriosis is treated by laparotomy or laparoscopy,other optionsare discussed with thepatient
because an operation at this location may injure the diaphragm,
phrenic nerve, lungs, or heart.
For women interested in preserving their reproductive
organs, medical treatment should be administered. If the patient
scope at the umbilical port and placingthree additional trocarsin
the upper quadrant (right or left, according to implant location),
similar to the arrangement forlaparoscopic cholecystectomy. Two
grasping forceps are usedtopush the liver from the operativefield
and allowbetter exposure ofthe diaphragm. Lesions are removed
with hydrodissection and vaporization or excision. If a diaphrag-
matic defect is formed, it is repaired with 4-0 PDS or staples.
does not want to preserve her reproductive organs, bilateral
oophorectomy may relieve her symptoms, and further intervention may not be necessary. However, if she does want to preserve
her fertility potentialandsymptomsarenot responsivetomedical
therapy, surgical intervention may be attempted after all possible
complications have been discussed.
Mostimplantsaresuperficialand cause no discomfort. Symptomatic diaphragmatic lesions were found in eight of 4875
patients at our center. Most women prefer BSO, and so it rarely is
necessary to treat these implants surgically. Others benefit from
medical therapy, and the chance of recurrence on the diaphragm
is low.
cardiopulmonary consultant. The pharynx, larynx, and trachea
are examined with a rigid bronchoscope. A flexible scope is
introduced to examine the distal trachea and proximal main
bronchi. Symptomatic diaphragmatic endometriosis implants
were treated in eight women at our center. In three patients, the
lesions were directly over the phrenic nerve or the diaphragmatic
vasculature. The lesions were excised in three, and vaporization
was accomplished in three others. In one patient, the lesion was
treated by combined laser and ultrasound (Cavitational Ultrasonographic Surgical Aspirator [CUSA],Valleylab, Boulder, CO).
In the remainingpatient, only aBSO was done. No intraoperative
B
Edges sutured together
after being pulled together
Endoscopictreatmentbeginsbyintroducinga10-mmlaparo-
After the procedure, the patient should be evaluated by a
Wound closed
https://t.me/med1917
Laparoscopic Treatment of Endometriosis — 291
B
Bowel lumen
Mucosa
muscularis
Serosa
Through-and-through sutures
A
Figure 10.3.24. (A) The wound has been closed. At the end of the operation, sigmoidoscopy is done to ensure
that the closure is watertight and that there is no bowel stricture. The inset shows the through-and-through
suture technique to close the defect. (B) Interceed has been applied to cover the suture line.
or postoperative complications were noted. Six patients were
without pain 6 to 36 months later. In one woman, the pain
returned after 1year, andanother experienced nosignificant pain
relief. Both responded to hormone suppressive therapy.
Experience with 24 women with endometriosis of the
diaphragm was summarized.[169] Operative findings in 17
patients included two to five spots of endometriosis on the
diaphragm measuring 1 cm or less. Some women had numerous lesions scattered across the diaphragm. Lesions were bilateral in eight patients, limited to the right hemidiaphragm in 14
patients, and limited to the left hemidiaphragm in two patients.
In seven patients, six endometriosis lesions were directly in the
line of the left ventricle and three lesions were adjacent to the
phrenic nerve. Endometriosis was infiltrating into the muscular
layer of the diaphragm in seven patients. The symptoms in all
seven symptomatic patients decreased significantly after treatment, with a minimal follow-up period of 12 months. No postoperative complications occurred.
to capture the oocyte. Adhesiolysis along the ovarian surface and
mesosalpinx can beaccomplished,the ovary andtubeare grasped
with atraumatic forceps and pulled apart, and the plane between
them is dissected with alaser, electrode, orscissors.However,fimbrial adhesions should be resected with laparoscopic microscissors only under water or with an ultrapulse CO
laser with high
2
millijoules. Adhesiolysis effected underwater offers aclearer view
of the anatomy than is provided with the pneumoperitoneum
alone. The pelvis is filled with lactated Ringer’s solution to allow
the fimbriae to float freely in the clear fluid away from each other
and from the filmy adhesions. The lighter fimbriae float higher
and separate from the normal tissue. As they float away from
the fimbrial folds, adhesions are grasped with a fine forceps and
atraumatically divided with microscissors without bleeding or
injury to the normal tissues.
RELIEF OF PAIN
Restoration of Tubo-Ovarian Anatomy
Once all lesions are resected or ablated and the adnexa are freed
of adhesions, the anatomic relation between the ovary and ipsilateral tube is evaluated and any distortion caused by adhesions
is corrected. The mesosalpinx often adheres to the ovarian cortex
along the ampullary segment of the tube. These adhesions cover
a significant part of the surface of the ovarian cortex and may
interfere with the ovulatory process at oocyte release. Moreover,
the fimbriae frequently are agglutinated, inhibiting their ability
Besides infertility, the most common complaint of patients with
endometriosis is pain, usually in the pelvis, frequently worse at
menses and occasionally during coital activity. The classic symptom triad ofinfertility, dysmenorrhea, anddyspareunia,although
not diagnostic of endometriosis, strongly suggests the disease.
The existence of arelationshipbetweenchronic pelvic pain (CPP)
symptoms and endometriosis iswidelyacceptedbygynecologists.
The nature of this relationship remains poorly understood, however. No correlation is found between the stage of endometriosis
according to the rAFS classification and the severity of CPP.
292 — Bulent Berker, Thomas H. S. Hsu, Keith L. Lee, Ceana Nezhat, Farr Nezhat, and Camran Nezhat
https://t.me/med1917
A
Figure 10.3.25. (A) Diffuse endometriosis involves the posterior cul-de-sac and both ovaries associated with
dense periadnexal adhesions.
B
Figure 10.3.25. (Continued )(B) Sagittal view reveals obliteration of the posterior fornix with cul-de-sac nodu-
larity and dense adhesions between the rectum and uterus.
Laparoscopic Treatment of Endometriosis — 293
https://t.me/med1917
Retraction of peritoneum and rectum toward
the uterosacral ligament and back of the cervix
Uterosacral ligament infiltrated
by endometriosis
C
Figure 10.3.25. (Continued )(C) Dissection and resection of these nodularities require an assistant to palpate
them to assure their removal. The inset shows endometrial implants on the posterior vaginal wall.
Endometriotic nodules are seen on the posterior vaginal wall
Focal or localized pain associated with endometriosis usually
responds to removal or destruction of endometriosis and associated adhesions. However, in some women, the pain is disproportionate to the extent of thedisease or does notimprove after resection of endometriosis and adhesions. For intractable or diffuse
pain, interruption ofpelvicnerves by uterosacral resection or presacral neurectomy is advised.[170–172] Definitive surgery consisting of hysterectomy andsalpingo-oophorectomy is very effective for relieving endometriosis-associated pain. This therapeutic
approach would be indicated in women who do not respond satisfactorily to medical and/or conservative surgical treatment and
can accept loss of fertility. Women who have completed childbearing and desire a more definitive approach to their symptoms
may elect to proceed with this treatment as the primary option.
In some cases, symptoms may persist because of adhesions or
other peritoneal lesions that remain in situ.[173]
Sutton and coworkers [176] were able to assess in a prospective, randomized, double-blind controlled clinical study the efficacy of laser laparoscopicoperationsinthe treatment of pain associated with minimal, mild, and moderate endometriosis. At the
time of laparoscopy, they randomized 63 patients with pain (dysmenorrhea, pelvic pain, or dyspareunia) and minimal to moderate endometriosis to laser ablation of endometriotic deposits and
laparoscopic uterine nerve ablation or expectant management.
The study was unique in that both the women and the nurse
who assessed them postoperatively were unaware of the treatment. The study showed that laser laparoscopy results in significant pain relief compared with expectant management 6 months
postoperatively. Among the patients treated by laser laparoscopy,
62.5% reported improvement or resolution of symptoms, compared with 22.6%in the expectant group. Results were poorest for
those with minimal disease, and if only patients with mild and
moderate disease are included, 73.7% of the patients achieved
pain relief. There were no operative or laser complications in this
series. Long-term follow-up of this study revealed that symptom relief continued at 1 year in 90% of those who initially
responded.[175] All symptomatic controls had a second-look
procedure, which showed disease progression in seven (29%),
disease regression in seven (29%), and static disease in 10 (42%).
The benefitsof laser laparoscopyfor painful pelvic endometriosis
continue in the majority of patients at 1 year. In most untreated
patients, painful endometriosis progresses or remains static, but
it may spontaneously improve in others.
Recently, a randomized, blinded,crossover study wasdone to
examine the effect on pain and quality of life for women with all
stages of endometriosis undergoing laparoscopic surgery compared with placebo surgery.[176] Thirty-nine women were randomized to receive initially either a diagnostic procedure or full
294 — Bulent Berker, Thomas H. S. Hsu, Keith L. Lee, Ceana Nezhat, Farr Nezhat, and Camran Nezhat
https://t.me/med1917
A
excisional surgery. After 6 months, repeat laparoscopy was performed, with removal of any pathology present. More women in
the group who were operated on according to protocol reported
symptomatic improvement after excisional surgery than in the
placebo group: 16 of 20 (80%) versus six of 19 (32%). Other
aspects of quality oflifewerealsosignificantlyimproved6months
after excisional surgery but not after placebo. Progression of disease at second surgery was demonstrated for women having only
an initial diagnostic procedure in 45% of cases, with disease
B
Figure 10.3.26. (A) Adherent sigmoid is removed from the posterior aspect of the uterus. The probe serves
as a backstop for the laser, for irrigation, and to put the adhesions on stretch. (B) The dissection continues.
(Continued )
remaining static in 33% and improving in 22% of cases. Nonresponsiveness to surgery wasreported in 20% ofcases.Asa conclusion, laparoscopic excision of endometriosis was more effective
than placebo at reducing pain and improving quality of life.
Both presacral neurectomy and uterosacral neurectomy
(uterine nerve resection or transection of the uterosacral ligament) havebeenrecommendedfor reliefofchronic pelvicpainassociated withendometriosis, based mostly ondata from observational studies. Presacral neurectomy has been evaluated, however,
Laparoscopic Treatment of Endometriosis — 295
https://t.me/med1917
C
D
Figure 10.3.26. (Continued )(C) Adhesiolysisproceedsuntil the backof the cervix and the uterosacral ligaments
come into view. (D) The rectosigmoid colon is mobilized, and most of the adhesions have been removed.
(Continued )
296 — Bulent Berker, Thomas H. S. Hsu, Keith L. Lee, Ceana Nezhat, Farr Nezhat, and Camran Nezhat
https://t.me/med1917
E
Figure 10.3.26. (Continued )(E) Interceed has been placed over the raw surfaces.
in at least two randomized clinical trials.[177,178] Takentogether,
these two trials suggest that presacral neurectomy has a role
in conservative surgery for endometriosis, but is most effective
for the treatment specifically of midline dysmenorrhea. There
appears to be a small effect, if any, on nonmenstrual pelvic pain
or dyspareunia. Uterosacral neurectomy, also called laparoscopic
uterosacral nerve ablation or laparoscopic uterosacral nerveablation, in a randomized clinical trial has been shown to offer
no additional benefit to laparoscopic surgery for treatment of
endometriosis-associated pelvic pain.[179]
FERTILITY OUTCOMES AFTER ENDOSCOPIC
SURGERY OF ENDOMETRIOSIS
In 1986, we reported our results for the treatment of
endometriosis-associated infertility patients with videolaseroscopy.[180] The CO
laser has been used laparoscopically for
2
the removal of endometriotic implants, excision of endometrioma capsules, and lysis of adnexal adhesions in 102 patients. Of
102 patients presenting with infertility attributed to endometriosis, 60.7% conceived within 24 months after laser laparoscopy.
The rates of conception after surgery were as follows: 75% for
patients with mild endometriosis, 62% for patients with moderate endometriosis, 42.1% for patients with severe endometriosis, and 50% for patients with extensive endometriosis. Controversy remains regarding the benefit of surgical treatment of
endometriosis with respect to improvement in fecundity at the
time of laparoscopy.[58,181] However, because of the progres-
sive nature of the disease in many patients, combined with the
largest prospective, randomized trial demonstrating improved
fecundity with therapy at the time of surgery, it appears prudent
to ablate endometriotic lesions at the time of endoscopic surgery
in patients with minimal and mild endometriosis.[57,182,183]
Because there are no prospective, randomized studies yet, we
are unable to draw any conclusions as to whether endoscopic
treatment of advanced endometriosis will improve reproductive outcome; however, there is no reason to be pessimistic.
Hence, if the multiple aspects of the reproductive cycle are found
to be impaired in women with endometriosis or endometriomas as some investigators claim, it can be normalized by
surgery. Supporting this, a 50% pregnancy rate was obtained
after laparoscopic management in a series of 814 women with
endometriomas.[184] Itcould be that the removalor destruction
of endometriomas provides further benefit than simply restoring
the normal anatomy and ovarian structure.
However, it has been suggested that ovarian surgery in cases
of ovarian endometriomas could be deleterious for the residual
normal ovarian tissue either by removing ovarian stroma with
oocytes together withthe capsule or bythermal damage provoked
by coagulation. In a case controlled study, Aboulghar et al. [185]
reported that the outcome of in vitro fertilization (IVF) in stage
IV endometriosis with previous surgery was significantly lower
compared with an age-matched group of patients with tubal factor infertility. Some investigators reported a marked reduction in
the number of both dominant follicles and retrieved oocytes in
the operated ovary.[186–188] In contrast, othersfailed to observe
this difference.[189,190] The results from these studies are
Соседние файлы в папке Библиотека им академика М.И. Перельмана