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OUTCOMES
PRs in women with endometriomas (Table 6.2.2).
41
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Table 6.2.2 Pregnancy Rates in Women with Endometriomas
41
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COMPLICATIONS
Bleeding
Inadvertent cyst rupture intraoperatively: 6% to 27% with subsequent spread of the endometriosis to other parts of the
pelvis
30,42
Damage to ovarian reserve
Infection
Adhesions
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KEY REFERENCES
1. Redwine D. Ovarian endometriosis: a marker for more extensive pelvic and intestinal disease. Fertil Steril. 1999;72:310–
315.
2. Santulli P, Lamau MC, Marcellin L, et al. Endometriosis-related infertility: ovarian endometrioma per se is not associated
with presentation for infertility. Hum Reprod. 2016;31:1765–1775.
3. Giudice LC, Kao LC. Endometriosis. Lancet. 2004;364(9447):1789–1799.
4. Gazvani R, Templeton A. Peritoneal environment, cytokines and angiogenesis in the pathophysiology of endometriosis.
Reproduction. 2002; 123(2):217–226.
5. Agarwal A, Aponte-Mellado A, Premkumar B. The effects of oxidative stress on female reproduction: a review. Reprod
Biol. 2012;10:49.
6. Gupta S, Agarwal A, Agarwal R, et al. Impact of ovarian endometrioma on assisted reproduction outcomes. Reprod
Biomed. 2006;13:349–360.
7. Dubuisson JB, Chapron C. Classification of endometriosis. The need for modification. Hum Reprod. 1994;9(12):2214–
2216.
8. Hughesdon PE. The structure of endometrial cysts of the ovary. J Obstet Gynaecol Br Emp. 1957;64(4):481–487.
9. Donnez J, Nisolle M, Gillet N, et al. Large ovarian endometriomas. Hum Reprod. 1996;11(3):641–646.
10. Nezhat F, Nezhat C, Allan CJ, et al. Clinical and histologic classification of endometriomas. Implications for a mechanism
of pathogenesis. J Reprod Med. 1992;37(9):771–776.
11. Wykes CB, Clark TJ, Khan KS. Accuracy of laparoscopy in the diagnosis of endometriosis: a systematic quantitative
review. BJOG. 2004; 111(11):1204–1212.
12. Van Holsbeke C, Van Calster B, Guerriero S, et al. Endometriomas: their ultrasound characteristics. Ultrasound Obstet
Gynecol. 2010;35(6):730–740.
13. Froehlich JM, Metens T, Chilla B, et al. MRI of the female pelvis: A possible pitfall in the differentiation of haemorrhagic
vs. fatty lesions using fat saturated sequences with inversion recovery. Eur J Radiol. 2012;81(3):598–602.
14. Nezhat C, Crowgey SR, Garrison CP. Surgical treatment of endometriosis via laser laparoscopy. Fertil Steril.
1986;45(6):778–783.
15. Jacobson TZ, Duffy JM, Barlow D, et al. Laparoscopic surgery for pelvic pain associated with endometriosis. Cochrane
database Syst Rev. 2009;(4):CD001300.
16. Chang F, Chou H, Soong Y, et al. Efficacy of isotopic 13 CO
2
laser laparoscopic evaporation in the treatment of infertile
patients with minimal and mild endometriosis: A life table cumulative pregnancy. J Am Assoc Gynecol Laparosc.
1997;4:219–223.
17. Keyhan S, Hughes C, Price T, et al. An update on surgical versus expectant management of ovarian endometriomas in
infertile women. Biomed Res Int. 2015;2015:1–9.
18. Dunselman GAJ, Vermeulen N, Becker C, et al. ESHRE guideline: management of women with endometriosis. Hum
Reprod Adv Access Publ. 2014;29(3):400–412.
19. Littman E, Giudice L, Lathi R, et al. Role of laparoscopic treatment of endometriosis in patients with failed in vitro
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fertilization cycles. Fertil Steril. 2005;84(6):1574–1578.
20. Opøien HK, Fedorcsak P, Åbyholm T, et al. Complete surgical removal of minimal and mild endometriosis improves
outcome of subsequent IVF/ICSI treatment. Reprod Biomed Online. 2011;23(3):389–395.
21. Buescher E, Schipper E, Nezhat C. Laparoscopic equipment and operating room setup. In: Nezhat C, Nezhat F, Nezhat
CH, eds. Nezhat’s Video-Assisted and Robotic-Assisted Laparoscopy and Hysteroscopy with DVD. 4th ed. New
York, NY: Cambridge University Press; 2013:23.
22. Hamdan M, Dunselman G, Li TC, et al. The impact of endometrioma on IVF/ICSI outcomes: a systematic review and
meta-analysis. Hum Reprod Update. 2015;21(6):809–825.
23. Guo SW. Recurrence of endometriosis and its control. Hum Reprod Update. 2009;15(4):441–461.
24. Vercellini P, Somigliana E, Viganò P, et al. Surgery for endometriosis-associated infertility: a pragmatic approach. Hum
Reprod. 2009;24(2):254–269.
25. Cheewadhanaraks S. Comparison of fecundity after second laparotomy for endometriosis to in vitro fertilization and
embryo transfer. J Med Assoc Thai. 2004;87(4):361–366.
26. Demirol A, Guven S, Baykal C, et al. Effect of endometrioma cystectomy on IVF outcome: a prospective randomized
study. Reprod Biomed Online. 2006;12(5):639–643.
27. Somigliana E, Benaglia L, Paffoni A, et al. Risks of conservative management in women with ovarian endometriomas
undergoing IVF. Hum Reprod Update. 2014;21(4):486–499.
28. Somigliana E, Vercellini P, Daguati R, et al. Effect of delaying post-operative conception after conservative surgery for
endometriosis. Reprod Biomed Online. 2010;20(3):410–415.
29. Ellis H, Moran BJ, Thompson JN, et al. Adhesion-related hospital readmissions after abdominal and pelvic surgery: a
retrospective cohort study. Lancet. 1999;353(9163):1476–1480.
30. Nezhat C, Saberi NS, Shahmohamady B, et al. Robotic-assisted laparoscopy in gynecological surgery. JSLS.
2006;10(3):317–320.
31. Nezhat C, Stevens A, Balassiano E, et al. Robotic-assisted laparoscopy vs conventional laparoscopy for the treatment of
advanced stage endometriosis. J Minim Invasive Gynecol. 2015;22(1):40–44.
32. Donnez J, Lousse JC, Jadoul P, et al. Laparoscopic management of endometriomas using a combined technique of
excisional (cystectomy) and ablative surgery. Fertil Steril. 2010;94(1):28–32.
33. Hart R, Hickey M, Maouris P, et al. Excisional surgery versus ablative surgery for ovarian endometriomata: a cochrane
review. Hum Reprod. 2005;20(11):3000–3007.
34. Alborzi S, Momtahan M, Parsanezhad ME, et al. A prospective, randomized study comparing laparoscopic ovarian
cystectomy versus fenestration and coagulation in patients with endometriomas. Fertil Steril. 2004;82(6):1633–1637.
35. Beretta P, Franchi M, Ghezzi F, et al. Randomized clinical trial of two laparoscopic treatments of endometriomas:
cystectomy versus drainage and coagulation. Fertil Steril. 1998;70(6):1176–1180.
36. Nezhat C, Nezhat F, Nezhat CH. Nezhat’s Video-Assisted and Robotic-Assisted Laparoscopy and Hysteroscopy with
DVD. 4th ed. New York, NY: Cambridge University Press; 2013.
37. Song T, Lee SH, Kim WY. Additional benefit of hemostatic sealant in preservation of ovarian reserve during laparoscopic
ovarian cystectomy: a multi-center, randomized controlled trial. Hum Reprod. 2014;29(8):1659–1665.
38. Ata B, Turkgeldi E, Seyhan A, et al. Effect ofs hemostatic method on ovarian reserve following laparoscopic
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endometrioma excision; Comparison of suture, hemostatic sealant, and bipolar dessication. A systematic review and meta-
analysis. J Minim Invasive Gynecol. 2015;22(3):363–375.
39. Ata B, Nezhat F, Nezhat C, et al. Four ovarian cancers diagnosed during laparoscopic management of 1011 women with
adnexal masses. Am J Obstet Gynecol. 1992;167:790–796.
40. Nezhat F, Nezhat C, Silfen SL, et al. Laparoscopic ovarian cystectomy during pregnancy. J Laparoendosc Surg.
1991;1(3):161–164.
41. Barri PN, Coroleu B, Tur R, et al. Endometriosis-associated infertility: Surgery and IVF, a comprehensive therapeutic
approach. Reprod Biomed Online. 2010;21(2):179–185.
42. Smorgick N, Barel O, Halperin R, et al. Laparoscopic removal of adnexal cysts: is it possible to decrease inadvertent
intraoperative rupture rate? Am J Obstet Gynecol. 2009;200(3):237.e1–237.e3.
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Chapter 6.3
Laparoscopic Excision of Bowel Endometriosis
Azade h Nezhat, Cam ran Nezhat
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GENERAL PRINCIPLES
Definition
“Bowel Endometriosis” is referred to the subserous fat or adjacent neurovascular branches of bowel wall that are affected
by endometrial-like glands and stroma. Furthermore, endometriotic foci found on the bowel serosa is referred to as
peritoneal endometriosis and not bowel endometriosis.
1
Endometriosis of bowel typically involves the serosa and muscularis propria, rarely involves the submucosa or mucosa.
The rectosigmoid colon is the most common site of bowel endometriosis in 70% to 80% of cases, followed by sigmoid colon,
rectum, ileum, appendix, and cecum.
2
Rectovaginal or bowel involvement is estimated to be present in 3% to 37% of women with endometriosis.
3
Disease limited to the bowel serosa may be asymptomatic.
Nonspecific symptoms may include: pelvic pain, lower back pain, and dyspareunia.
Symptomatology more specific to bowel endometriosis includes dyschezia and/or tenesmus, cyclic hematochezia, and
change in bowel habits.
Rectal bleeding may occur with rare mucosal involvement.
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Differential Diagnosis
Gastrointestinal carcinoma, lesions especially firm and obstructive can be mistaken as bowel endometriosis.
Inflammatory bowel diseases such as Crohn disease, diverticulitis, radiation colitis, ischemic colitis, and stricture.
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Nonoperative Management
GnRH agonist, have been used with success in selected cases.
4
Norethisterone acetate alone or in combination with letrozole also has been reported to improve symptoms of rectovaginal
endometriosis.
5
In patients with severe symptoms, medical therapy may not yield satisfactory long-term solution. Surgical intervention may
be necessary to dissect and resect the involved area.
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