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Laparoscopic Management ofEndometriosis
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Fig. 2 (continued)
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Fig. 2 (continued)
U. A. Menakaya and V. K. Oriji
7 Classication ofEndometriosis
The classication of endometriosis is another challenge in the management of endometriosis due to
the multiple clinical and anatomical manifestations
of the disease [36]. Efforts to develop a classication system for endometriosis have struggled to
yield a suitable system that enhances endometriosis-related symptom management, prognosis for
response to therapies, prediction of recurrence,
association with other disorders, quality of life and
other key elements of concern (surgeon expertise)
to women with endometriosis [36].
A good classication system should be one
that benets women with endometriosis. It should
be simple to explain and easy to perform and
allow a simple description of the disease. It
should also correlate well with the principal
symptoms of endometriosis and have the capacity to give prognostic information, predict
response to treatment and recurrence of symptoms after treatment. It must be empirically and
scientically based and should have general consensus [51]. A number of pre- and intraoperative
classication systems that address some of the
key concerns of women living with endometriosis are currently in clinical use.
7.1 Preoperative Classication
Preoperative classication of endometriosis is
important because it can improve the comprehension of disease severity and enable appropriate preoperative counseling and the triage of
women to different forms of treatment [43]. It
can also assist with theatre list planning and
reduce the need for multiple laparoscopic surgeries [52, 53].
7.1.1 Ultrasound-Based
Endometriosis Staging System
(UBESS)
An UBESS can be utilized preoperatively to predict the level of complexity of laparoscopic surgery expected for endometriosis [54]. UBESS is
a three-stage preoperative staging system that
predicts the severity of pelvic endometriosis and
is based on the histological phenotypes of endometriosis, the anatomical locations of deep inltrating endometriosis and their sonographic
markers of local invasiveness. The three stages of
UBESS (I–III) correlate well with the three levels
of complexity of laparoscopic surgery for endometriosis as described by the Royal College of
Obstetricians and Gynaecologists (Levels 1–3)
(see Table2).
Laparoscopic Management ofEndometriosis
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An ultrasound-based endometriosis staging system to predict complexity of laparoscopic surgery [54]
Table 2
UBESS
stages
Stage I Positive SST in PC
Stage II Positive SST in PC
Stage III Positive SST in PC
SST site-specic tenderness, PC posterior pelvic compartment, POD pouch of Douglas, DE deep endometriosis
Adapted from Menakaya etal. [54]
7.2 Intraoperative Classication
A number of intraoperative classication system
for endometriosis are in current clinical use. The
most commonly used classication system is the
rAFS classication system [55] (see Table3). In
the rAFS classication system, minimal to mild
disease describes supercial peritoneal endometriosis and possible presence of small deep
lesions and mild lmy adhesions with no endometrioma. Moderate to severe disease describes
the presence of supercial peritoneal endometriosis, deeply invasive endometriosis with moderate to extensive adhesions between the uterus
and bowels and/or endometrioma cysts with
Features assessed on transvaginal
ultrasound Interpretation Complexity level of surgery
Mobile ovaries, no endometrioma
POD: Positive sliding sign
DE nodules: Absent
+ Endometrioma present ± mobile
ovaries
POD: ± positive sliding sign
± Non-bowel DE nodules
Bowel DE nodules
± Endometrioma ± mobile ovaries
POD: Positive or negative sliding
sign
± Non-bowel DE nodules
+ Bowel DE nodules
No hard markers for
endometriosis
Endometrioma
± Non-bowel DE
Normal POD
+ Bowel DE
± Abnormal POD
Table 3
The revised AFS intraoperative staging for
endometriosis
rAFS stages
Stage 1
(minimal)
Stage 2 (mild) 6–15
Stage 3
(moderate)
Stage 4
(severe)
Level 1
Negative laparoscopy or mild
stage disease
Level 2
Moderate-stage disease
Level 3
Higher-stage disease
Points
assigned Description
1–5
16–40
>40
• Few supercial
implants
• More and deeper
implants
• Many deep implants
• Small cysts on one or
both ovaries
• Presence of lmy
adhesions
• Many deep implants
• Large cysts on one or
both ovaries
• Many dense adhesions
moderate to extensive adhesions involving the
ovaries and tubes. The template for recording
ndings at laparoscopy is shown in Fig.3. The
rAFS classication has limited predictive ability
for persistent pelvic pain and pregnancy after
surgery.
Another intraoperative classication system
in current use is the endometriosis fertility index
(EFI) [56]. The EFI provides a simple clinical
tool that incorporates the rAFS to predict pregnancy rates for patients after surgical treatment of
endometriosis [56]. Unlike the rAFS classication system, the EFI is a useful prognostic tool
for developing treatment plans in infertile patients
with endometriosis (see Fig.4) [56].
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U. A. Menakaya and V. K. Oriji
Fig. 3 RAFS template for recording and scoring ndings
at laparoscopy. (Revised American Society for
Reproductive Medicine scoring system for all women
with endometriosis. Reprinted with permission from
Elsevier from Fertil Steril 1997;67:817–821)
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Fig. 4 Endometriosis fertility index surgery form
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U. A. Menakaya and V. K. Oriji
8 Surgical Treatment
The treatment of endometriosis is aimed at achieving three primary objectives. These include a
reduction in pelvic pain symptoms, improvements
in pregnancy rates and delays in recurrence of disease. The prerequisites for successful treatment
outcomes should include a guideline- oriented
approach, a multidisciplinary team care approach
and experience of surgical techniques [57].
The knowledge and skill required for treating
endometriosis at laparoscopy are increasingly
becoming an area of sub-specialization [58]. This
is because the laparoscopic technique, the planning of the surgical intervention, the extent of
information provided to patients and the interdisciplinary coordination make surgical treatment of
endometriosis a challenging intervention.
Surgical treatment should begin with a detailed
historical evaluation of patient symptoms and the
utilization of appropriate and adequate diagnostic
tools. These diagnostic tools are important for
preoperative planning, allocation of theatre time
and appropriate counselling of patients on the
expected outcomes and potential risks associated
with surgical intervention.
At laparoscopy, the abdominal entry techniques
for endometriosis are similar to that utilized for
other gynaecological surgeries. This includes a
standard primary visual port usually via the umbilicus or the palmer’s point and additional two to
three working ports located in the supra public
and/or iliac fossae. During surgery, the complete
resection of all visible foci of disease offers the
best control of symptoms. However, the surgeon
must rst identify all foci of endometriosis through
a systematic evaluation of the pelvis and abdomen
prior to their resection.
8.1 Systematic Evaluation
ofthePelvis at Laparoscopy
fortheDiagnosis
ofEndometriosis
A standardized approach to the evaluation of the
pelvis at laparoscopy for endometriosis has been
recommended. This should incorporate a systematic assessment of the uterus and its adnexa like
the anterior and posterior broad ligament and
ovaries, the peritoneum of ovarian fossae, the
utero-vesical fold, the pouch of Douglas and
pararectal spaces including underneath the uterosacral ligaments. It should also evaluate the rectum and sigmoid for isolated deep endometriosis
nodules, the appendix and caecum as well as the
upper abdomen including the diaphragm and
liver. A pelvic examination under anesthesia is
also recommended to assess for deep endometriosis nodules in the laparoscopic basement, i.e.
rectovaginal septum, vagina or cervix [53].
Such a comprehensive evaluation of the pelvis
would require the patient in Trendelenburg position with at least one secondary port for a suitable
laparoscopic grasper. The laparoscopic grasper
will assist with clearing bowel loops from the
pelvis, uid suctioning and manipulating the ovaries to examine the ovarian fossae (see Fig.5).
8.2 Conservative, Semi-
conservative andRadical
Surgical Treatment
forEndometriosis
Conservative surgery for endometriosis refers to
the resection of visible endometriosis lesions with
preservation of the woman’s reproductive potential. Semi-conservative surgery includes a hysterectomy with the resection of visible endometriosis
lesions but with ovarian conservation. Semiconservative surgery may be indicated for women
with debilitating symptoms who have completed
childbearing but are too young to undergo surgical
menopause. Radical surgical treatment for endometriosis refers to the inclusion of bilateral oophorectomy together with hysterectomy and resection
of visible endometriosis lesions. Patients who
undergo hysterectomy with ovarian conservation
have a sixfold higher rate of recurrence compared
to women who undergo oophorectomy [59].
8.3 Ablation vs. Excision
Excision of lesions is preferred as it includes the
possibility of retrieving samples for histological
diagnosis. Furthermore, ablative techniques are
ab
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239
dc
Fig. 5 Systematic evaluation of the pelvis for endome-
triosis with patient in Trendelenburg position using an
appropriate laparoscopic instrument. (a) Image of the
POD with bowel displaced. (b) Inspection of the right
unlikely to be suitable for managing deep inltrating endometriosis lesions [35]. Ablative techniques could involve the use of CO
laser or
2
energy instruments (unipolar or bipolar) to
destroy visible peritoneal endometriosis lesions.
ovarian fossae. (c) Inspection of the left ovarian fossa. (d)
Inspection of the right upper abdomen. (Images courtesy
of JUNIC Laparoscopy Australia)
ventions. It can be useful for treating minimal,
mild and/or moderate endometriosis and depends
on the skill and expertise of the laparoscopic surgeon. Where the disease at the time of initial laparoscopy is more surgically complex and extensive
than originally anticipated (stage 4 endometriosis), a two-stage treatment process can be consid-
8.4 See andTreat vs. Two-Stage
Approach
ered to ensure complete resection of visible lesions
and normalization of pelvic anatomy.
The nding of more extensive and surgically
Where endometriosis is identied at laparoscopy,
it is recommended that these lesions are treated as
this is effective for reducing endometriosisassociated pain, i.e. ‘see and treat’ approach [60].
The see-and-treat approach is cost-effective and
limits patients’ exposure to multiple surgical inter-
complex disease at initial (diagnostic) laparoscopy
presents considerable challenge as regards the preoperative consent and information provided to the
patient as well as the surgical logistics like allocated theatre time [61]. Such scenario may necessitate a second laparoscopy at an appropriate unit
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U. A. Menakaya and V. K. Oriji
with requisite expertise for denitive surgical
treatment after appropriate patient counselling and
adequate theatre time allocation.
A two-stage treatment process may be better
suited for resource-restricted countries where the
ability to predict the complexity of laparoscopic
surgery for endometriosis with transvaginal ultrasound preoperatively is not yet available [53].
9 Outcomes fromSurgical
Treatment
The surgical treatment of endometriosis should
be designed in line with the patients’ individual
needs. The surgeon should discuss with the
patient whether the primary reason for treatment
is acute or chronic endometriosis-related pain or
a desire for fertility [62].
Surgical intervention for endometriosis- related
pelvic pain signicantly decreases postoperative
pain when compared to diagnostic laparoscopy
alone [63–65]. The post-operative pain scores and
quality of life assessments are signicantly
improved in regards to dysmenorrhea, non-menstrual pelvic pain, dyspareunia and dyschezia for a
period of up to 5years post- operatively [65, 66].
Recurrence of endometriosis or exacerbation of
pelvic pain can also occur after successful endometriosis surgery [67]. Up to 36% of women
would require further surgical intervention within
5years of primary surgery [67]. Women who had
more severe disease are more likely to require
repeat procedures [65]. The risk of re-operation
was also increased with the presence of endometriosis on ovary, adhesions in the pouch of Douglas,
bowel, fallopian tubes or ovaries [65, 68].
Repeat procedures were lowest among women
greater than 44years of age, while women who
presented for surgery at an age less than 30 were
signicantly more likely to have a repeat procedure [66]. Furthermore, 38% of women would
continue to experience pelvic pain despite no histologic evidence of endometriosis suggesting that
chronic pelvic pain can be present without recurrence of disease [65, 69].
The outcomes following laparoscopic surgery
to improve fertility outcomes are now better predicted using the endometriosis fertility index
(EFI). The EFI is a simple, robust, and validated
clinical tool that predicts pregnancy rates after
laparoscopic surgery for endometriosis. It provides reassurance to those patients with good
prognoses and avoids wasted time and treatment
for those with poor prognoses [56] (see Fig.4).
10 Complications
fromLaparoscopic Surgery
forEndometriosis
Injuries are fairly common during laparoscopic
surgery for endometriosis especially with treating
deep inltrating endometriosis affecting the bowel
[35, 61]. The injuries could occur at the time of
laparoscopic primary and secondary port entry and
during excision of endometriosis lesions. It can
also occur during the use of laparoscopic energy
instruments resulting in delayed presentation of
diathermy injury to abdominal viscus. The
reported total intraoperative complication rate in
laparoscopic surgery for endometriosis is 2.1%,
and total post-operative complication rate is
reported as 13.9% with 9.5% representing minor
complications and 4.6% major complications [70].
For women undergoing extensive laparoscopic
surgery for endometriosis, the excision of ovarian
endometrioma can result in a signicant impairment of ovarian function, while damage to nerve
structures during resection of the uterosacral ligaments, the parametrium, the rectovaginal septum or
the vaginal cuff to treat deep inltrating endometriosis can lead to serious functional impairments such
as voiding disorders. Therefore a detailed risk-benet analysis and shared decision- making are necessary, and patients must be treated using an
individualized approach that focuses on the primary
reason for treatment.
11 Medical Treatment
ofEndometriosis
Medical treatment of endometriosis is focused on
hormonal suppressive therapy and/or pain therapy for chronic pelvic pain. Other complimentary
therapies useful for endometriosis management
include psychotherapy and pain education, pelvic
Laparoscopic Management ofEndometriosis
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Summary of treatment modalities available for managing endometriosis
Table 4
Modality of
treatment Treatment objectives
Surgical treatment Peritoneal
Pharmacotherapy Hormonal
Complimentary
therapies
Adapted from Beilecke K, Ebert AD: Urogenitale Endometriose. In: Tunn R, Hanzal E, Perucchini D. (Eds.):
Urogynäkologie in Praxis und Klinik. Berlin-New York 2010: 353–73
endometriosis
Ovarian
endometriosis
Deep inltrating
endometriosis
Uterine
adenomyosis
Fertility Surgical removal of implanted endometriosis tissue improves the
suppression therapy
Pain therapy—
involvement of pain
specialist may be
necessary
Psychotherapy and
pain education
Physiotherapy Diagnosis and treatment of functional disturbances of the body
Nutrition Balanced diet with adequate vitamins and minerals, reduction of
Complete removal or ablation of visible endometriosis lesions
Careful cystectomy with complete removal of cyst. The surrounding
healthy tissue must be preserved. Seeding of viable endometriosis cells
through iatrogenic cyst rupture must be avoided. Preferably to suture
the ovary rather than use diathermy to achieve haemostasis
Complete excisional biopsy recommended. This can be achieved via
laparoscopy or laparotomy
Vaginal hysterectomy (VH) is not recommended because of the lack of
opportunity to remove any additional foci of endometriosis that might
be present
Abdominal hysterectomy (AH) and total laparoscopic hysterectomy
(TLH) preferred
Organ-preserving techniques for treating adenomyosis:
– Surgical removal of adenomyoma via laparoscopy or
hysteroscopy
– Endocrine: therapeutic induction of amenorrhea—nonstop oral
contraceptives, progestogens, GnRH analogues
chances for spontaneous conception
Assessment of tubal patency is also recommended
If extensive endometriosis is present with tubal damage, assisted
reproduction should be considered after removal of damaged tubes
The use of the EFI can be useful in post-op patient counselling
Therapeutic induction of amenorrhea: continuous combined oral
contraceptives, progestogens, GnRH analogues
Nonsteroidal anti-inammatory drugs (NSAID), COX inhibitors, mild
opioids, antidepressants, combinations of the above
Positive thinking, relaxation techniques, imagery, understanding pain
origins
alcohol, sugar and caffeine intake, exclusion of fructose or lactose
intolerance.
241
oor physiotherapy and nutrition [71] (see
Table4). Hormonal suppressive therapy is usually over a long period of time, and their side
effects may limit their usefulness.
Recurrence of endometriosis has been reported
in 13–36% of those with medical treatment [26].
12 Multidisciplinary Team Care
Approach
The complete resolution of symptoms of endometriosis is still not possible; however, there is
evidence that the best way to treat symptomatic
patients with endometriosis is with an individualized combination of surgery and hormonal pharmacotherapy, supported by complementary
treatment approaches that include pelvic oor
physiotherapy, pain psychology and pain specialist. It is however acknowledged that the outcomes
of this comprehensive approach to endometriosis
treatment may still fall short of achieving its
objective of addressing the chronication of the
patient’s symptoms. As such, patient management should focus on outcomes that address
improvements in their most troublesome symptom, their quality of life parameters and their satisfaction with treatment.
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U. A. Menakaya and V. K. Oriji
13 Challenges ofManaging
Endometriosis inResourceRestricted Countries
The challenges of managing endometriosis in
resource-restricted countries are gigantic. For
example, options for medical management and
access to complimentary therapy are limited. MRI
services are not available in many centres, and the
expertise required for diagnosing certain phenotypes of endometriosis with transvaginal ultrasonography is lacking in these countries. Physicians
diagnose endometriosis based on historical variables and the exclusion of other differential diagnosis like pelvic inammatory disease.
Laparoscopy is an invaluable tool in the management of endometriosis. Although the development of laparoscopy in resource-restricted
countries is still at an infantile stage, there are
signicant challenges to its widespread use.
These include the high cost of purchase and
maintenance of laparoscopic equipments, the
limited number of endoscopic companies in these
countries and the lack of integrated endoscopic
training in gynaecology residency programmes.
Furthermore, physicians with skills in endoscopic surgery need access to continuing education programmes to improve their recognition of
the disease and develop their expertise in treating
mild, moderate or severe disease.
The treatment of endometriosis is lifelong,
expensive and time-consuming. In resourcerestricted countries, there is signicant lack of
awareness of the disease among physicians and
patients. These countries also have limited healthcare insurance programmes and widespread consumer payer systems such that affordability of
treatment services is virtually impossible for the
women living with endometriosis.
14 Conclusion
Laparoscopy has been a major tool for the surgical management of women with endometriosis
for more than four decades in developed countries. The current evolution of endoscopic surgery in low-resource countries stands to benet
from this experience and must include strategic
efforts that integrate endoscopy training in gynaecology residency programmes. It should also
develop programmes that build the capacity of
surgeons to recognize and treat endometriosis in
ways that improve patient outcomes.
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