Surgical Management of Pelvic Endometriosis
Endometriosis can produce cysts within the ovary as well as reactive adhesions. Endometriosis produces inflammation, sometimes exceedingly severe, in the vicinity of implants (Fig. 25–1). It is curious that the inflammatory response does not necessarily coincide with the severity of endometriosis. The appearance of pelvic endometriosis may likewise assume a variety of patterns, ranging from brownish spots to colorless microcysts (Fig. 25–2A–E).
Endometriosis surgery is performed after attempts at medical therapy have failed to resolve symptoms and eliminate visible lesions. The surgery discussed in this chapter is conservative (i.e., preserves the reproductive organs). The radical treatment strategy is removal of the reproductive organs via hysterectomy, as illustrated in Chapter 11 in Section B. A rather confusing term used indiscriminately is “definitive treatment at surgery.” This phrase typically is used in reference to hysterectomy, but in fact could mean conservative management. Therefore this term would be better eliminated from usage. Surgical removal of the endometriosis with preservation of the uterus and adnexa is accomplished by sharp excision or laser surgery. The best laser for this purpose is the superpulsed carbon dioxide (CO2) laser. Another acceptable laser is the KTP-532 fiberoptic laser. The least preferred device is the neodymium yttrium-aluminum-garnet (Nd:YAG) laser because it produces the greatest degree of thermal artifact (coagulation necrosis). Unless otherwise specified, the laser referenced herein will be a superpulsed CO2 laser delivered laparoscopically or directly via handpiece. In strategic areas of endometriosis involvement, injection of sterile water or saline beneath implants creates a heat sink as well as a plane for dissection and serves to protect normal underlying tissue from damage (Fig. 25–3A, B).
Vaporization of implants is performed at a setting of 5 to 10 W at 100 to 300 pulses/sec and 0.1 to 0.5 msec width with a beam diameter of 1 to 2 mm (Fig. 25–4A–G). When peritoneal or tubal surfaces are to be “brushed” (i.e., very superficially vaporized), power (power density) is reduced sufficiently to permit a single cell layer or a few cell layers to be selectively eliminated (Fig. 25–5A–E). Deeper vaporization or excision may be required. The depth is determined by magnified observation of the wound. As long as siderophagic blood is emitted from the site, endometriosis is present (Fig. 25–6A–G). The most severe cases of endometriosis (stage 4) will require combinations of treatment strategies, including vaporization, excision, adhesiolysis, cystectomy, and possible partial organ excision followed by pelvic reconstruction (Fig. 25–7A–F).
Endometriosis may extend deeply into underlying tissue. In the cul-de-sac, penetration may reach the rectovaginal septum. In these instances, the tissue should be sharply resected by using a combination of laser and scissors (Fig. 25–8A, B).
FIGURE 25–1 Foci of endometriosis deep in the ovarian fossa. Note the extensive inflammatory reaction in the peritoneum surrounding the overt endometrial implants.
