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3. Laparoscopic Entr

Techniques: Consensus 3

3. Wu MH, Lin CC, Yan

YC, et al. Cardiovascular collapse durin

naecolo

ic lapa-

roscop

comp

icate

monar

ema: report o

a case. J Formos Me

Assoc

1994;93:629–632.

4. Peterson HB, Hu

a JF, P

ips JM. American Association o

Gynaeco

ogic Laparos-

copists’ 1988 mem

ers

ip survey on operative

aparoscopy. J Repro

5:5

7–5

5. Levy BS, Hulka JF, Peterson HB, et al. Operative laparoscopy: American Association

f Gynaecologic Laparoscopists, 1993 membership survey. J Am Assoc Gynaecol

arosc. 1994;1:301–305.

6. Vilos GA. Laparoscopic bowel in

uries: fort

liti

ated

naecolo

ical cases in

anada. J Obstet G

naecol Can

2002;24:224–230

7. Chandler JG, Corson SL, Wa

LW. Three spectra of laparoscopic entr

access in

ries. J Am Co

Sur

2001

;

192

:47

–4

90.

8. Lam A, Rosen DMB. Laparoscopic

owe

vascu

ar comp

ications: s

erres nee

e an

cannu

e rep

ace

? J Am Assoc G

naeco

Laparosc

199

301

–

9. Ternamian AM. Laparoscopy wit

out trocars.

urg En

osc.

;11

5–

818

0. Ternamian AM, Deitel M. Endoscopic threaded imaging port (Endo TIP) for lapa-

roscopy: experience with different body weights. Obes Surg

1999

;

9:44–47.

1. Garr

R. Towards evidence-based laparoscopic entr

techniques: clinical problems

as.

naecol Endosc.

999;8:403–406

https://t.me/med1917

. Complications of Laparoscopic Surger

r En

metri

eremy T. Wrigh

omp

ications o

aparoscopic surgery are in

act

ewer t

an t

ose reporte

aparotomy [1],

ut t

eir potentia

severity an

ure to

iagnose

em quic

y an

treat t

em e

ective

y means t

at t

e patient can

e severe

ill

ore a

iagnosis is ma

e, wit

catastrop

ic resu

ts. Ina

vertent

owe

njury at

aparotomy is regar

as a recognize

azar

, particu

uring

adh

esio

ysis. Suc

enterostomies are usua

y imme

iate

y recognize

epaire

wit

minima

postoperative seque

ae.

Adh

esio

ysis at

aparoscopy,

owever, is usua

y carrie

out using

nergy sources suc

iat

ermy,

aser energy, or u

trasoun

. T

ese tec

iques may cause isc

emic

amage t

at is not apparent at t

e time o

proce

ure

may present to anot

er p

ysician some

ays

ater. Conservative manage

ent wi

urt

iagnosis, so t

at t

e patient

ecomes grave

y i

urgery t

en wi

usua

y require

eca

iversion, an

ere wi

e mu

tisystem

ure, a varia

e stay on an intensive care unit, an

possi

y even

eat

nevita

y, suc

cases wi

e su

ject to critica

inci

ent appraisa

s, poten

interna

investigations

or assessment o

e practice, Genera

ica

ounci

comp

aints, an

civi

itigation

or persona

injury an

neg

igence

]

perative

aparoscopy a

ways carries t

e potentia

or severe comp

ica-

ions. T

is c

apter examines strategies

or avoi

ing an

ucing t

ese as

as possi

ndometriosis Surger

ometriosis surgery is associate

wit

a particu

ris

or com

plications. Superﬁ

cial peritoneal disease such as powder burn, sago grain,

ﬂ

ame hemorrhages, and white scars are frequently found in the ovarian fossae,

n t

e uterosacra

igaments, an

in t

e pouc

Doug

as. T

ey over

ie t

reat vesse

s o

e pe

vis, t

e ureter, an

possi

y t

e rectum at t

e peritonea

reﬂ

ection in the pouch of Douglas. Ovarian involvement may also include the

ascu

ar ovarian

igament an

e vascu

ar p

exus over

ying t

e ureter. Treat

ent o

ese areas

y a

ation, t

ermocoagu

ation, or

aser vaporization runs

e ris

erma

amage to un

ying structures, w

may not

e imme-

iate

y apparent

https://t.me/med1917

4. Complications of Laparoscopic Surger

for Endometriosis 3

ore a

vance

isease an

previous sur

to mar

anatomica

istortion. A

esive

owe

isease

requent

invo

vin

e si

moi

on an

so sma

owe

esions, o

iteration o

e pe

vic cu

e sac

uterosacra

rectovagina

ometriosis, an

invasion o

e muscu

aris o

e rectum,

particularly at the peritoneal reﬂ ection, add hazard to this already difﬁ

. Mana

ement o

ﬁ

rotic no

ar rectova

ina

ometriosis can

arge

owe

amage, sma

owe

amage (as sma

owe

esions to t

area are not uncommon), ureteric damage, and signiﬁ

cant hemorrhage.

ure 4.1 s

ows severe in

ﬁ

tratin

ar en

ometriosis o

t u

tra-

oun

igament. Me

y t

ere is tet

ering o

e rectum to t

igament, t

muscu

aris

eing invo

. Latera

y t

e ureter can

e seen

rawn me

cau

y t

isease. Latera

to t

is is t

e uterine vascu

ature, t

e area

itse

eing

emorr

agic an

ﬂ

ame

. Excision requires care

issection

preservation o

e ureters,

vesse

s, an

recta

ometriosis o

is nature gives rise to severe symptoms, particu

yspareunia, an

ysc

ezia. Dysc

ezia, or pain

ecation, is a

very important symptom to e

icit. It is

requent

y associate

wit

pain sitting

own, particu

uring t

e menses. Inquiry s

esta

er t

ymptom is present t

roug

out t

e menstrua

cyc

e or on

uring menses [2].

Pain

uring menses is

y to

e associate

wit

partia

recta

invo

vement,

i.e., t

e recta

mucosa is spare

, an

y t

e peritonea

sur

ace an

muscu

aris

are invo

, w

ereas continuous recta

pain an

ysc

ezia suggest

ness invo

vement, w

as o

vious signi

ﬁ

cance in p

anning treatment an

counse

ing

or t

e patient

igure 4.1

Left ultrasound ligament showing a filtrating and nodular endometriosis

https://t.me/med1917

6 J.T. Wri

ent Counsel

equate preoperative patient counse

can prevent muc

nee

ess

omp

aint

iti

ation. Most women wit

isease are

esperate

p; t

ave severe s

mptoms and have usuall

had multiple dia

nostic procedures,

trials of hormone manipulation, and possible superﬁ

cial destructive therapy

o t

isease usin

ative or vaporizin

tec

niques. Bot

ormona

manipu

lation and ablative or vaporization therapy cause ﬁ

brosis and scarring without

fully removing what is often deeply inﬁ

ltrating disease.

he patient’s histor

has to be taken methodicall

, and each episode of

reatment carefull

documented. Questionnaires with structured questions are

seful in documentin

severit

of s

mptoms and previous interventions and

heir outcome. Computer pro

rams linked to databases are a ver

useful data-

ollection tool, either in real time or subse

uent to consultations [3]. The

atient histor

should be supplemented b

careful ph

sical examination, with

articular reference to notin

areas of tenderness and nodularit

in the utero-

sacral ligament and posterior pelvic pouch. All the ﬁ

ndings require careful

ocumentation, preferabl

usin

a structured approach. Followin

this, the

patient should be given a realistic appraisal of the likely beneﬁ

ts an

com

ica-

ions o

sur

, inc

e ris

s o

ureteric or

owe

ama

e, an

e pos

sibility of hemorrhage signiﬁ

cant enough to require blood transfusion. The

eed for laparotom

to deal with an

of these complications must be stressed

t should be emphasized that the purpose of sur

is to remove the areas

of inﬁ

ltrating endometriosis and that this will be carried out using the best

vai

e means,

e it

aparoscop

aparotom

atients should have osmotic and mechanical bowel

aration

rior

o sur

, supplemented when necessar

on-table rectal lava

e prior to the

deﬁ

nitive procedure being carried out.

t is wise to

ocument t

e a

vice t

at is

iven to patients, an

e aut

upp

ements t

is wit

a persona

etter to t

e patient out

inin

e con

ition,

history, physical ﬁ

ndings, proposed surgery, and likely complications. Such

explanation, although time-consuming, signiﬁ

cantly reduces the risk of patient

aint

Surg

cal Techn

ques

issection should start and sta

in normal tissue surroundin

the endo

etriotic lesion, aimin

to remove the area with a small rim of normal tissue.

s the disease is frequently peritoneal, the surgeon should aim to stay as

superﬁ

cial as possible, dissecting away from great vessels. Energy sources such

s diatherm

or laser vaporization work much better when the tissue is under

ension, and the use of probes, such as a rectal probe or va

inal probe, will

elp considerabl

both in maintainin

tension and keepin

these structures

rom t

e area o

issection, an

us ina

vertent

ama

e. Hemostasis is

sometimes difﬁ

cult to achieve, but immediate identiﬁ

cation and coagulation

sma

-vesse

issection to procee

quic

kly

, a

https://t.me/med1917

4. Complications of Laparoscopic Surger

for Endometriosis 3

patients w

ave

tip

e sur

eries wi

requent

o consi

era

venous an

capi

ary oozing (Figure 4.2)

Copious suction and irrigation will help to keep the operative ﬁ

ear,

ut t

e steep Tren

urg position o

ten a

opte

uring t

is sort o

surgery

means that considerable volumes of ﬂ

uid will collect in the abdominal cavity

owe

ﬂ

oat on t

is, risin

er in t

e a

omen an

scurin

e view. Re

ar suction an

a continuous c

on t

e vo

umes in

use

into

aspirate

rom t

e a

omina

cavity wi

eep t

e situation un

contro

. During t

e proce

ure, recta

integrity s

e routine

y c

and this can be quickly and easily carried out by ﬂ ooding the pelvis with ﬂ

passing air un

er pressure into t

e rectum, w

can

e simp

y ac

ieve

y using a

er syringe.

n many centers, t

is sort o

surgery is

est carrie

out using a team

approac

, as a segmenta

recta

resection or anterior-wa

isc resection ma

e necessary, an

e gyneco

ogist may not

ave t

e s

s or experience to

ect a competent repair. T

e growt

aparoscopic

owe

surgery means

at many units wi

ave surgeons wit

e necessary s

s, an

a goo

wor

partners

ip can si

ﬁ

cant

increase patient sa

. Particu

caution is necessary w

en a gyneco

ogist is as

to un

erta

e a proce

ure or

give an opinion on a patient w

o is a

rea

y anest

etize

, w

regretta

bly

can

e quite commonp

ace. As experience an

aparoscopic proce

ures

grow, particu

y among surgeons in training, requests to atten

e operat

ing t

eater w

en severe en

ometriosis is unexpecte

y con

ﬁ

rme

are increas-

ing

y common. T

e surgeon may

e invite

to un

erta

e a

iagnostic or

erapeutic proce

ure on a patient w

o is poor

y prepare

emotiona

lly

ysica

y. Bowe

injury in t

ese circumstances may

to consi

era

eca

soi

ing, an

emorr

age may occur, a situation w

ere on

y emergenc

resources rat

er t

an previous

y crossmatc

are avai

e. A patient

gure 4.2. Pe

vis wit

perioperative vagina

emorr

age

https://t.me/med1917

8 J.T. Wri

een ina

equate

assesse

counse

not ta

dly

up wit

aparotom

eca

iversion an

trans

usion runnin

n t

ese circumstances

care

assessment an

ocumentation wit

a view to

undertaking deﬁ

nitive surgery at a later date is far preferable to undertaking

n imme

iate proce

ure, re

ess o

ow muc

pressure one is un

er.

nvitations ma

e exten

to un

erta

e t

ese proce

ures on co

eagues’ patients w

om t

e surgeon

as not previous

y assesse

or counse

owever tempting it is to un

erta

e t

ese proce

ures, eit

or t

e privi

ege

ein

o so, or

or pecuniar

vanta

e, un

ess t

e patient

een proper

y examine

counse

, it is an unwise practice.

Aud

aparoscopic sur

enerall

, and for endometriosis in particular, has

developed without any formal assessment of efﬁ

cacy or safety, in either the

hort or lon

term. There is little in the wa

of formal assessment of s

omatolo

, s

mptom relief followin

sur

ical intervention, or the morbidit

ssociated with such intervention. The recordin

of ph

sical si

ns either

urin

clinical assessment or at laparoscop

is poor. The recordin

stems

hat do exist, e.

., the r-AFS score, now the r-ASRM score, a scorin

stem

evised b

the American Fertilit

Societ

, are associated more with evaluatin

he effects of the disease on fertilit

than with pain and discomfort.

he conduct of randomized clinical trials in sur

enerall

, and endo

metriosis surgery speciﬁ

cally, is very difﬁ

cult to undertake because of the large

number of variables involved and the difﬁ

culty of persuading a patient to

nder

o a sham procedure, even if this was ethicall

advisable. Inevitabl

, the

of assessin

the value of this sur

will be in the audit of patient

eries. This requires the careful documentation of s

mptoms, ph

sical si

ns,

surgical ﬁ

ndings, treatment, morbidity, and subsequent change over time of

mptoms and si

ns. A vast amount of data captured durin

interactions with

atients requires such detailed documentation and recordin

that a computer-

zed database with a core data set is the onl

of assessin

this information

roperl

. Such databases now exist commerciall

or can be easil

developed

sin

simple database software

Individual core data sets can then be held centrally so that the efﬁ

cacy and

he morbidit

of various procedures ma

be assessed, with the

reater accu

and predictabilit

of lar

e numbers. It is onl

with this sort of data that

er assessment wou

ossi

Aud

t Result

he author’s personal data series of sur

for severe rectova

inal endo

etriosis associated with either

artial or com

lete obliteration of the cul de

ac over a 2-

ear period is shown cumulativel

in Table 4.1 and Fi

ure 4.3. The

https://t.me/med1917

4. Complications of Laparoscopic Surger

for Endometriosis 3

le 4

Author’s Data for Severe Rectova

inal Endometriosis with Cul de Sac

liter

Januar

000

– 2

000

– 2

000

– 2

000

– 2

000

– 2

000

– 2

000–

April Au

ust December April Au

ust December Apri

000

1 2

24 42 4

ases

% comp

ete 67 63 67 67 64 69 7

iteration

emorr

age 0 4 5 4 3 6

500 m

seromuscular 0 0 5 4 3 3

rectal repair

full-thickness 0 4 12 10 8 10 1

rectal re

air

% ureter

c 0 4 2 2 2 1

amage

o. o

Case

ercenta

14.00

12.00

10.00

8.00

6.00

.00

0.00

0-04

00 01

00-80

00 01

00-12

00 01

00-04

01 01

00-08

imelin

00-12

01 01

00-04

02 01

00-09

Total Cases % Full-Thickess Rectal Repair

Figure 4.3

Cumulative number of patients with severe rectovaginal endometriosis associ

with

liter

f the c

e s

https://t.me/med1917

0 J.T. Wri

er o

patients requirin

eit

er a seromuscu

ar or

-t

ness recta

repair rapidly becomes constant, as does the incidence of signiﬁ

emorr

e (Fi

ure 4.4). Increase

experience re

uces t

e ris

ureteric

ama

espite t

ese cases in w

e posterior cu

e sac is comp

ete

bliterated and thus the anatomical distortion

reater, increased experience

all

ows a

reater c

ance o

success

lly

issectin

e recta

muscu

aris awa

the

ucosa

thus

educt

n in

the

eed

full

ess

ectal

ere is an un

erstan

ose w

e a

e num

cases

that

the

kel

hood

ectal

inv

imite

recta

resection is

in t

isease,

or t

e vast majority o

gyne-

ogists an

pro

essiona

s, a recta

repair wi

usua

e regar

s a critica

inci

ent invo

vin

e pro

uction o

inci

ent reports an

an asso

iate

, possi

bly

osti

e au

it, o

ten

ase

on an incomp

ete un

erstan

isease, t

e sur

, an

-term outcome, an

resu

t in a

verse

riticism o

e sur

eon’s wor

. A

verse-inci

ent reports are not usua

lly

mea

ure

ainst a

enominator, an

persona

it series wi

o a

rotectin

onese

ainst suc

criticisms.

As series grow, surgical risks with 90% conﬁ

ence interva

s (CIs) can

enerate

, as is s

own in Box 4.1, an

pre

ictive

actors accurate

y assesse

is wi

improve an

ive an actuaria

ase to patient counse

e pre

ictive

actors

-t

ness recta

invo

vement o

ometriosis

re s

own in Box 4.2.

No. o

Cases

Percenta

.00

3.00

2.00

1.00

.00

0-04

00 01

00-80

00 01

00-12

00 01

00-04

01 01

00-08

Tim

lin

00-12

01 01

00-04

02 01

00-09

Total Cases % Hemorrha

e > 500 mL

ure 4.4

Cumulative number o

patients with severe rectova

inal endometriosis and

ercent with si

icant perioperative hemorrha

https://t.me/med1917

4. Complications of Laparoscopic Surger

for Endometriosis 4

n a

ranc

es o

surgery, innovation

een associate

wit

an initia

increase in mor

ity, an

morta

ity,

ore

ecoming t

e accepte

met

treatment. Goo

examp

es o

is progression are

aparoscopic

ecystectomy an

eart transp

antation. To overcome initia

preju

ice or

indeed to properly assess the efﬁ

cacy and safety of any surgical technique,

meticu

ous au

it com

ine

wit

care

measura

e tec

niques are t

y met

s o

assessment. W

ere possi

e an

ica

, o

course, t

ese

met

s s

e associate

wit

ran

omize

inica

tria

s, w

are now

er way. Surgica

treatment o

ometriosis current

y remains t

e on

ective treatment,

ut on

y a

ew centers are a

e an

ing to carry out

ese proce

ures. A

equate training met

s wou

to an increase in t

num

er o

centers a

e to provi

e t

is surgery

xperience, training, an

it remain t

e cornerstones o

equate

erapy an

are strong

y recommen

eferen

1. Ka

u G, Wrig

t JY. Laparoscopic surgery an

aw.

stetrician & G

naeco

ogist.

2001;3

Box 4.2 Symptoms and S

gns Pred

ve of Severe

Rectovag

nal Endometr

schezia throu

hout mont

inal epithelial involvement

odule

Rectal ﬁ

xity

Box 4.

Hemorr

e 6% (95% CI 2–13

)

Seromuscular re

air 6% (95% CI 2–13

)

Mucosa

repair 9% (95% CI 5–16

)

Rectovaginal ﬁ

stula 1%

(

95% CI 0.2–6 NS*

)

Ureteric ﬁ

stula 1% (95% CI NS)

*NS, not signiﬁ

can

https://t.me/med1917

2 J.T. Wri

. Redwine DB, Wri

ht JT. Laparoscopic treatment of complete obliteration of the cul

e-sac associate

wit

ometriosis:

-term

ow-up o

oc resection.

erti

teri

. 2001;76:358–365

3. Kretz JM, Re

wine DB, O

ive DL. Data

ase management on a persona

computer.

Am Assoc G

neco

Laparosc.

;

5–

289

https://t.me/med1917

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