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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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SURGICAL MANAGEMENT
Surgical treatment of thoracic endometriosis is required if symptoms persist despite hormonal suppression of ectopic
endometrium.
Thoracocentesis and chest tube placement are initial therapeutic interventions in the emergency room until further action is
taken.
Secondary prevention of recurrent pneumothorax due to thoracic endometriosis is treated using blebectomy, pleurodesis, and
diaphragmatic repair.
Video-assisted thoracoscopic surgery (VATS) and combined laparoscopy in a single session was first described by Nezhat
et al.
14
in 2009, and his findings confirmed the necessity of exam of abdominal side of the diaphragm for complete
treatment of TES.
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Positioning for Video-Assisted Thoracoscopic Surgery
Patient is positioned for a posterior-lateral thoracotomy for complete visualization of diaphragm.
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Positioning for Laparoscopy
The patient should be placed in the dorsal lithotomy position.
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Procedures and Techniques (Video 6.5.1 )
For all surgical cases, a double-lumen endotracheal tube is used for single-lung ventilation during the VATS procedure. A
bronchial blocker is used to isolate the lung when the double-lumen endotracheal tube cannot be inserted. If the VATS
procedure is performed first, the patient is placed in either the left or right decubitus position, depending on the laterality of
the suspected thoracic endometriosis. A trocar is inserted through a midaxillary incision. The camera is then placed into the
thoracic cavity, and the cavity is explored. Additional ports are placed posteriorly and anteriorly as needed for visualization
and creation of the desired operative angle.
If there is evidence of endometriosis, it is treated via ablation, excision, or resection. Smaller lesions are ablated or excised
with a carbon dioxide (CO
2
) laser or plasma jet energy.
15
Deep diaphragm lesions are treated with a diaphragm resection, either via an endoscopic stapling device or by excision and
manual suturing.
2,16
For extensive diaphragmatic perforation that necessitate resection, use of various mesh or bovine pericardial patches has
been reported.
17
A silastic flexible drain is then placed in the pleural space to release the pneumothorax and is attached to a water seal. The
incisions are closed in layers, and the chest tube is secured to the skin using silk suture. If the opposite chest cavity is to be
examined as well, the patient is repositioned, with repeat skin preparation, draping, and the procedure is repeated on the
opposite side.
Once the VATS is completed, attention is turned to the abdomen for traditional laparoscopy. The patient is undraped and
repositioned on a beanbag in the dorsal lithotomy position with the arms adducted. Care is taken to ensure that there are no
pressure points, especially at the shoulders. The abdomen is entered using a closed-entry technique with a Veress needle
and concurrent CO
2
gas insufflation.
18
In patients with prior abdominal surgery with a high likelihood of intraabdominal
adhesions, a 20-gauge spinal needle attached to a syringe half filled with normal saline solution is inserted next to the Veress
needle for “mapping.”
19
The plunger is drawn back, and if CO
2
gas from the pneumoperitoneum easily appears in the
syringe, intraperitoneal insufflation is likely, with minimal surrounding adhesions. This is repeated in a full range of directions
anticipated for trocar entry. After establishment of pneumoperitoneum, a 10-mm camera port is placed at the umbilicus.
Thereafter, additional ports are placed in the right and left lower quadrants and suprapubically under laparoscopic
visualization.
Initially, the pelvis and diaphragm are explored with the patient in the steep Trendelenburg position to assess the extent of
intra-abdominal disease and identify abnormalities or distortions. The patient is then placed in the steep reverse
Trendelenburg position to evaluate the upper abdominal walls, liver, and diaphragm for the presence of endometriosis. The
liver is pushed caudally with a grasper or liver retractor to view the adjacent diaphragm. A surgical plan is constructed to
optimally restore normal anatomy and excise all areas of endometriosis. The abdominopelvic and visceral diaphragmatic
endometriosis is treated via hydrodissection followed by excision or ablation with monopolar or bipolar current.
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PEARLS AND PITFALLS
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OUTCOMES
Recurrence of endometriosis-related pneumothorax despite surgical and hormonal treatment has been seen in 8% to 40% of
patients and is higher than nonendometriosis-related pneumothorax (5%).
6
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COMPLICATIONS
This may include the associated complications of surgery, surgical pleurodesis, and hormonal treatments.
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KEY REFERENCES
1. Nezhat C, Hajhosseini B, Buescher E, et al. Thoracic endometriosis syndrome. Chapter 49. In: Wetter PA, ed. Prevention
and Management of Laparoendoscopic Surgical Complications, 3rd ed. Society of Laparoendoscopic Surgeons.
Miami 2011.
2. Alifano M, Roth T, Broet SC, et al. Catamenial pneumothorax: a prospective study. Chest. 2003;124(3):1004–1008.
3. Nezhat C, King LP, Paka C, et al. Bilateral thoracic endometriosis affecting the lung and diaphragm. JSLS.
2012;16(1):140–142.
4. Sampson JA. Metastatic or embolic endometriosis, due to the menstrual dissemination of endometrial tissue into the
venous circulation. Am J Pathol. 1927;3(2):93–110.43.
5. Joseph J, Sahn SA. Thoracic endometriosis syndrome: new observations from an analysis of 110 cases. Am J Med.
1996;100(2):164–170.
6. Jubanyik KJ, Comite F. Extrapelvic endometriosis. Obstet Gynecol Clin North Am. 1997;24(2):411–440.
7. Rousset-Jablonski C, Alifano M, Plu-Bureau G, et al. Catamenial pneumothorax and endometriosis-related pneumothorax:
Clinical features and risk factors. Hum Reprod. 2011;26:2322–2329.
8. Haga T, Kumasaka T, Kurihara M, et al. Immunohistochemical analysis of thoracic endometriosis. Pathol Int. 2013;
63(9):429–434.
9. Honore’ G. Extrapelvic endometriosis. Clin Obstet Gynecol. 1999;42:699–711.
10. Nezhat CR, Berger GS, Nezhat F, et al. Endometriosis: Advanced Management and Surgical Techniques. New York,
NY: Springer; 1995.
11. Hilaris GE, Payne CK, Osias J, et al. Synchronous rectovaginal, urinary bladder, and pulmonary endometriosis. JSLS.
2005;9(1):78–82.
12. Tsunezuka Y, Sato H, Kodama T, et al. Expression of CA125 in thoracic endometriosis in a patient with catamenial
pneumothorax. Respiration. 1999;66:470–472.
13. Hagneré P, Deswarte S, Leleu O. Thoracic endometriosis: A difficult diagnosis. Rev Mal Respir. 2011;28:908–912.
14. Nezhat C, Nicoll LM, Bhagan L, et al. Endometriosis of the diaphragm: four cases treated with a combination of
laparoscopy and thoracoscopy. J Minim Invasive Gynecol. 2009;16(5):573–580.
15. Nezhat C, Main J, Paka C, et al. Multidisciplinary treatment for thoracic and abdominopelvic endometriosis. JSLS.
2014;18(3):e2014.00312.
16. Alifano M, Cancellieri A, Fornelli A, et al. Endometriosis-related pneumothorax: clinicopathologic observations from a
newly diagnosed case. J Thorac Cardiovas Surg. 2004;127(4):1219–1221.
17. Cieslik L, Haider SS, Fisal L, et al. Minimally invasive thoracoscopic mesh repair of diaphragmatic fenestrations for
catamenial pneumothorax due to likely thoracic endometriosis: a case report. Med J Malaysia. 2013;68(4):366–367.
18. Vilos GA, Vilos AG. Safe laparoscopic entry guided by Veress needle CO
2
insufflation pressure. J Am Assoc Gynecol
Laparosc. 2003;10(3):415–420.
19. Nezhat C, Buescher E, Paka C. et al. Thoracic Endometriosis Syndrome, Chapter 10.2 In: Nezhat C, Nezhat F, Nezhat C,
eds. Nezhat’s Video-Assisted and Robotic-Assisted Laparoscopy and Hysteroscopy. 4th ed. Cambridge, England:
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Cambridge University Press; 2013.
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Section II
Assisted Reproductive Technology
Procedures
7 Transvaginal Oocyte Retrieval
Dar cy E. Broughton, Kenan R. Omurtag
8 Embryo Transfer
Dar cy E. Broughton, Kenan R. Omurtag
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