Can extensive endometriosis be adequately treated at laparotomy?
Treatment options for pain or infertility secondary to cul-de-sac obliteration include ovarian suppression therapy with danazol or gonadotropin releasing hormone agonist, or surgery. For present infertility or the preservation of fertility, reconstructive surgery can be considered either via laparotomy microsurgery or laparoscopy, depending on the skill and experience of the surgeon. For pain, when future fertility is not desired, hysterectomy with bilateral salpingo-oophorectomy is performed commonly. The problem with the hysterectomy approach is that it is usually performed with an intrafascial technique, leaving fibrotic endometriosis on the vagina and rectum, assuming that it will resolve after castration; future surgical procedures may be necessary for pain from vaginal cuff or rectal endometriosis.
At laparotomy, retrocervical deep fibrotic endometriosis should usually be managed with bowel resection, assuming that the major portion of the lesion infiltrates the anterior rectum. In those cases the deep fibrotic lesion is mobilized, starting on the posterior uterus and progressing downward to the rectum where it appears to be attached.
Is laparotomy for extensive endometriosis a lost art? (In NYC it is.)
Did it ever have any long-term benefit?
Did it ever have any long-term benefit?
I did a 20 month review (1998-1999) of 424 patients at Columbia Presbyterian Medical Center, NYC, with pelvic pain and a discharge diagnosis of endometriosis. Laparotomy was done in 108 of these cases. Of the laparotomies, 76 were abdominal hysterectomy, including 20 supracervical hysterectomies with bilateral salpingo-oophorectomy. Supracervical hysterectomy was typically done for women with extensive cul-de-sac endometriosis that could not be adequately resected at laparotomy despite the presence of a colon and rectal surgeon in 8 of the cases. In fact, no endometriosis of the deep cul-de-sac was excised by laparotomy there. During this same time span, laparoscopy was done to excise endometriosis in all of my cases with one conversion to laparotomy.
When I trained at the Boston Hospital for Women from 1972 to 1975, the most renowned endometriosis surgeon was Dr. Robert Kistner. He did a high volume of endometriosis laparotomy cases that consisted of uterine suspension, salpingoovariolysis with excison of endometriomas followed by ovarian repair, and presacral neurectomy. The deep cul-de-sac including anterior rectum and posterior vagina was largely neglected. Other surgeons followed doing similar work to Dr. Kistner , including Celso Ramon Garcia, Ronald Batt, and Robert Franklin, all of who progressed to laparotomy excison of anterior rectal lesions. The latter two do much of their work by laparoscopy today. Dr. John Rock and Paolo Vercellini appear to be the present day advocates by their publications for a predominately laparotomy approach to treating extensive endometriosis. Other noteworthy papers discussing the laparotomy approach to extensive endometriosis include those by Grey and Coronado.
Until the end of the 1970’s, minimal and mild endometriosis was destroyed endoscopically by unipolar or bipolar coagulation. Treatment of more severe endometriotic disease was by laparotomy: mostly radical by hysterectomy, often leaving some rectovaginal endometriosis, and, in younger women, by adnexectomies, rarely cystectomies, and anterior recections of the rectum. The literature of the period focuses on infertility and on mild endometriosis and is biased by the fact that deep endometriosis-unless very severe and large-was not recognized and thus untreated.
In the late seventies and the early eighties microsurgery was promoted, emphasizing careful destruction of superficial endometriosis by bipolar coagulation or resection and removal of ovarian endometriosis followed by reconstruction of the ovary. The underdiagnosing of deep endometriosis continued.
From 1986-1987 onwards, the concept of non-pigmented endometriosis was introduced. Unfortunately, the resultant increased recognition of endometriosis in women previously classified as “normal” to women classified as having minimal endometriosis was counterbalanced by the normal women with hemosiderin ladened macrophages from retrograde menstruation classified as minimal to mild endometriosis. This is important in the interpretation of medical and surgical result data from this time period since groups of ‘normal’ women contained variable numbers of unrecognised and untreated women with minimal endometriosis and many women who were treated for endometriosis were, in fact, disease free. The bias of non-recognition of the majority of deep endometriotic disease persisted.
The increasing use of endoscopic surgery for the treatment of ovarian endometriosis was paralleled by a diversification of techniques with possibly different results. The removal of the cyst wall by stripping followed by suturing or gluing of the ovary is technically similar to microsurgery. Vaporization of the cyst wall is poorly defined ranging from focal treatment to superficial vaporization to deeper vaporization.
In the nineties, deep endometriosis has been increasingly recognized during laparoscopic surgery, or by clinical examination. Resection of deep endometriosis comprises techniques ranging from complete resection to debulking and resection-reanastomosis of the rectum, a difference that is rarely stated clearly in the literature. With the recent trend to recognize and to treat deep endometriosis this “enthusiasm” is already producing and may continue to produce a progressive shift of the severity of the reported series of deep endometriosis, which will (but hopefully will not) include increasing numbers of women with less severe deep endometriosis, which was previously diagnosed as mild to moderate disease. (The recognized experts must monitor them and themselves.)
Laparoscopic treatment of deep cul-de-sac disease by excision was first presented and severely criticized at the Endometriosis World Congress in 1988 when I debated Robert Franklin. Over the next 3 years the “laparotomy clan” (mainly con artists supporting self interest) censored this work. Finally in 1991, it was published in the Journal of Reproductive Medicine and many similar publications by other authors followed.
I do not think that endometriosis can be as adequately resected using laparotomy as by laparoscopy. At laparotomy, the ovary and vesicouterine peritoneal fold are readily accessible, but the surgeon is far from the deep posterior cul-de-sac. Work on the anterior rectum, posterior vagina, and ureters may be much more difficult than with a laparoscope right on top of the lesion being excised. However, if laparotomy surgery is done, the patient should be positioned in a lithotomy position so that the surgeon has ready access to the vagina and rectum during the operation.
The operative advantages of a laparoscopic approach to the cul-de-sac include:
- Easy intraoperative access to the rectum and vagina.
- A magnification source which is easier to manipulate then an operating microscope so that the surgeon can get a very close view of lesions involving the deep pelvis and rectum.
- The ability to perform an underwater examination at the end of the procedure during which all blood clot is evacuated and complete hemostasis obtained.
- The general advantages of laparoscopy which include same day diagnosis and treatment, short hospitalisation, rapid recuperation, superior cosmetics, excellent patient acceptance, cost effectiveness, and results at least equal to laparotomy.
The laparotomy guys/gals think laparoscopy is synonymous with the “run & gun” offence, i.e., no hard work to get a basket. Actually the laparoscopic approach is hard work best described by Ron Batt’s laparotomy approach: a series of mini-operations including specimens from each uterosacral ligament insertion, the posterior vagina, the posterior cervix, the anterior rectum, and tissue surrounding one or both the ureters. I think that the laparotomizers are ritualistically performing some kind of pagan ceremony. But I will admit that the man who invented laparotomy was a genius!
Batt, R. In The Atlas of Female Infertility Surgery (second edition). Editor: R. Hunt. Publisher: Year Book Medical Publishers, Inc., 1992.
Coronado C, Franklin R, Lotze E, et al: Surgical treatment of symptomatic colorectal endometriosis. Fertil Steril 63:411, 1990
Crosignani PG, Vercellini P: Conservative surgery for severe endometriosis: should laparotomy be abandoned definitively? Human Reprod 1995; 10:2412-8
Gray LA. Endometriosis of the bowel; role of bowel resection, superficial excision and oophorectomy treatment. Annals of Surgery 1973;177:580-7.
Koninckx PR, Martin DC. Deep endometriosis: a consequence of infiltration or retraction or possibly adenomyosis externa? Fertil.Steril. 1992;58:924-928.
Redwine DB. Laparoscopic en bloc resection for treatment of the obliterated cul-de-sac in endometriosis. J.Reprod.Med. 1992;37:695-698.
Redwine DB, Koning M, Sharpe DR. Laparoscopically assisted transvaginal segmental resection of the rectosigmoid colon for endometriosis. Fertil.Steril. 1996;65:193-197.
Sharpe DR, Redwine DB. Laparoscopic segmental resection of the sigmoid and rectosigmoid colon for endometriosis. Surg.Laparoscopy.Endosc. 1992;2:120-124.
Tate JJT, Kwok S, Dawson JW, Lau WY, Li AKC. Prospective Comparison of Laparoscopic and Conventional Anterior Resection. Br.J.Surg. 1993;80:1396-1398.
Other References of Interest
Sampson JA. Peritoneal endometriosis due to the menstrual dissemination of endometrial tissue into the peritoneal cavity. Am.J.Obstet.Gynecol. 1927;14:422-469.
Cullen TS. The distribution of adenomyomata containing uterine mucosa. Am.J.Obstet.Gynecol. 1919;80:130-138.
Gruenwald P. Origin of endometriosis from the mesenchyme of the celomic walls. Am.J.Obstet.Gynecol. 1942;44:470-474.
Ridley JH. The histogenesis of endometriosis. A review of facts and fancies. Obstet.Gynecol Survey 1968;1968:23-21.
Jansen RPS, Russel P. Nonpigmented endometriosis: Clinical, laparoscopic, and pathologic definition. Am.J.Obstet.Gynecol. 1986;155:1154-1159.
Stripling MC, Martin DC, Chatman DL, Vander Zwaag R, Poston WM. Subtle appearance of pelvic endometriosis. Fertil.Steril. 1988;49:427-431.
Koninckx PR. Biases in the endometriosis literature. Illustrated by 20 years of endometriosis research in Leuven. Eur.J.Obstet.Gynecol.Reprod.Biol. 12-1998;81:259-271.
Canis M, Mage G, Wattiez A, Chapron C, Pouly JL, Bassil S. Second-look laparoscopy after laparoscopic cystectomy of large ovarian endometriomas [see comments]. Fertil Steril 9-1992;58:617-619.
Bateman BG, Kolp LA, Mills S. Endoscopic versus laparotomy management of endometriomas. Fertil Steril 10-1994;62:690-695.
Ahmed MS, Barbieri RL. Reoperation rates for recurrent ovarian endometriomas after surgical excision. Gynecologic And Obstetric Investigation 1997;43:53-54.
Wheeler JM, et. Recurrent endometriosis : incidence, management, and prognosis. Am.J.Obstet.Gynecol. 1983;146:247-253.
Redwine DB. Conservative laparoscopic excision of endometriosis by sharp dissection: life table analysis of reoperation and persistent or recurrent disease. Fertil Steril 10-1991;56:628-634.
Wheeler JM, Russel Malinak L. Recurrent endometriosis. Contrib.Gynecol.Obstet. 1987;16:13-21.
Damario MA, Rock JA. Pain recurrence: a quality of life issue in endometriosis. Int.J.Gynaecol.Obstet. 1995;50 Suppl 1:S27-42.
Koninckx PR. Is mild endometriosis a condition occurring intermittently in all women? Human Reprod. 1994;9:2202-2205.
Vercellini P, Bocciolone L, Crosignani PG. Is mild endometriosis always a disease? Human Reprod. 1992;7:627-629.
Marcoux S, Maheux R, Berube S, The canadian collaborative group on endometriosis. Laparoscopic Surgery in infertile women with minimal and mild endometriosis. N.Engl.J.Med. 1997;337:217-222.
Martin DC, Demos Berry J. Histology of chocolate cysts. J Gynecol.Surg. 1990;6:43-46.
Bruhat MA, Mage G, Chapron C, Pouly JL, Canis M, Wattiez A. Present day endoscopic surgery in gynecology. Eur.J.Obstet.Gynecol.Reprod.Biol. 1991;41:4-13.
Bruhat MA, Mage G, Pouly JL, Canis M, Wattiez A, Chapron C. Advances in pelviscopic surgery. Ann.N.Y.Acad.Sci. 1991;626:367-371.
Fayez JA, Vogel MF. Comparison of different treatment methods of endometriomas by laparoscopy [see comments]. Obstet.Gynecol. 1991;78:660-665.
Koninckx PR, Meuleman C, Demeyere S, Lesaffre E, Cornillie FJ. Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain [see comments]. Fertil.Steril. 1991;55:759-765.
Koninckx PR, Martin DC. Deep endometriosis: A consequence of infiltration or retraction or possibly adenomyosis externa? Fertil.Steril. 1992;58:924-928.
Redwine DB. Conservative laparoscopic excision of endometriosis by sharp dissection: Life table analysis of reoperation and persistent or recurrent disease. Fertil.Steril. 1991;56:628-634.
Redwine DB. Severe intestinal (GI) endometriosis (E) and pelvic mapping. Fertil.Steril. 1997;S22-S22.
Donnez J, Nisolle M, Gillerot S, Smets M, Bassil S, Casanas-Roux F. Rectovaginal septum adenomyotic nodules: a series of 500 cases. Brit.J.Obstet.Gynaecol. 9-1997;104:1014-1018.
Vercellini P, Trespidi L, De Giorgi O, Cortesi I, Parazzini F, Crosignani PG. Endometriosis and pelvic pain: relation to disease stage and localization. Fertil.Steril. 1996;65:299-304.
Donnez J, Nisolle M, Casanasroux F, Bassil S, Anaf V. Rectovaginal septum, endometriosis or adenomyosis: Laparoscopic management in a series of 231 patients. Human Reprod. 1995;10:630-635.
Candiani GB, Vercellini P, Fedele L, Roviaro G, Rebuffat C, Trespidi L. Conservative surgical treatment of rectovaginal septum endometriosis. J Gynecol.Surg. 1992;8:177-182.
Reich H, McGlynn F, Salvat J. Laparoscopic treatment of cul-de-sac obliteration secondary to retrocervical deep fibrotic endometriosis. J Reprod Med Obstet.Gynecol. 1991;36:516-522.
Neven P, vandeursen H, Baert L, Koninckx PR. Ureteric injury at laparoscopic surgery : The endoscopic management. Case review. Gynaecol.Endoscop 1993;2:45-46.
Koninckx PR, Stukkens K, Meuleman C. Cumulative pregnancy rates following CO2-laser-endoscopic surgery for deeply infiltrating endometriosis. Figo Proceedings 1991.
Koninckx PR, Deprest J, Janssen G, Oosterlynck D, Meuleman C. Cumulative pregnancy rates following CO2-laser endoscopic excision of deeply infiltrating endometriosis. Fertil Steril , Montreal meeting 1993.
Metzgar, D. A., Olive, D. L., & Haney, A. F. Limited hormonal responsiveness of ectopic endometrium: Histologic correlation with intrauterine endometrium. Human Pathology, 19:1417-1424, 1988.
Franklyn M.B.Jr. Laparoscopic surgery of the colon and rectum. In:Principles of advanced laparoscopic surgery, M.E.Arregui, R.J. Fitzgibbons Jr., N. Katkhouda, J. B. McKernan, H. Reich. Springer-Verlag 1995;pp. 300-308.
Ellis H. Anterior resection and other procedures. In: Maingot’s Abdominal Operations, 8th ed. Eds. S.I, Schwartz and H. Ellis. Appleton & Lange, Norwallk, CT. 1990;1049-1075.
Reich H, McGlynn F, Levie M. Establishment of pneumoperitoneum through the left 9th intercostal space. Gynaecological Endoscopy 1995;4:141-143.
Netter, F. Rectum and Anal Canal.Digestive System Part II Lower Digestive Tract. Ciba Collection of Medical Illustration, 1962;pp. 57-59.
Shackelford, R.T.,and Zuidema, G.D.,Anal Dilatation. Surgery of the Alimentary Tract;W.B. Saunders 1982;pp.546-547
Zollinger & Zollinger. Anterior rection stappled. Atlas of Surgical Operations 7th ed.eds. Mc Graw Hill 1993;pp. 57-59.