Nodules, Cul-de-sac disease, endometriomas, & pain
Extensive endometriosis means bulky deep fibrotic endometriosis deposits that can often be palpated preoperatively as tender pelvic nodules. These nodules consist of endometriosis glands and stroma surrounded by fibromuscular tissue that has accumulated over many years in response to cyclic monthly activation of the endometriosis. They represent a longstanding chronic inflammatory response.
In the female without previous hysterectomy, the anterior peritoneal reflection on the rectum (rectouterine pouch or pouch of Douglas) folds at an average distance of 4 cm from the anal verge. The rectovaginal fascial septum separates the rectum from the vagina.
In 1921, Sampson defined cul-de-sac obliteration as “extensive adhesions in the cul-de-sac obliterating its lower portion and uniting the cervix or the lower portion of the uterus to the rectum; with adenoma of the endometrial type invading the cervical and the uterine tissues and probably also (but to a lesser degree) the anterior wall of the rectum.” (7) Cul-de-sac obliteration secondary to endometriosis implies the presence of retrocervical deep fibrotic endometriosis beneath the peritoneum. This endometriosis is located on or in the anterior rectum, posterior vagina, posterior cervix (the cervical vaginal angle between the upper vagina and the cervix), the rectovaginal septum, or the uterosacral ligaments; often one area predominates.
Partial cul-de-sac obliteration (PCDSO) means that deep fibrotic endometriosis is severe enough to alter the course of the rectum, fusing it to a portion of posterior vagina. With complete cul-de-sac obliteration (CCDSO), fibrotic endometriosis and/or adhesions involve the entire cul-de-sac between the cervicovaginal junction (and sometimes above) and the rectum.
At laparoscopy, careful inspection of the cul-de-sac is necessary to evaluate the extent of upward tenting of the rectum. To determine if cul-de-sac obliteration is partial or complete, a sponge on a ring forceps is inserted into the posterior vaginal fornix (and a rectal probe in the rectum). The normal cul-de-sac will show a portion of vaginal wall between the cervix and rectum as a distinct and separate bulge. The utero-sacral ligaments will be of normal calibre and lateral. Partial cul-de-sac obliteration occurs when rectal tenting is visible but a protrusion from the sponge in the posterior vaginal fornix is noted between the rectum and the inverted “U” of the uterosacral ligaments. Complete cul-de-sac obliteration is diagnosed when the outline of the sponge in the posterior fornix cannot be visualised initially through the laparoscope: the rectum or fibrotic endometriosis nodules completely obscure the identification of the deep cul-de-sac.
Partial and complete cul-de-sac obliteration are the same disease, requiring the same surgical dissection. Both indicate that deep fibrotic endometriosis is present on the anterior rectum and the posterior vagina, areas from which it can be completely excised. Yet the American Society of Reproductive Medicine Classification makes partial obliteration Stage 1 and complete cul-de-sac obliteration Stage 4; go figure it!
Preoperatively, transvaginal sonography is done to evaluate the ovaries in cases involving a pelvic mass, retrocervical nodules, or fibroids, and a CA 125 assay is obtained if persistent enlargement is documented. Ultrasound findings of a round shaped adnexal mass with thick wall and homogeneous, low-level echo pattern is highly suggestive of endometrioma. Another pattern has irregular margins with septations and an anechoic appearance. Intravenous pyelograms (IVP) are rarely necessary preoperatively, as ureteral dilation is readily evident at laparoscopic examination. An IVP is ordered postoperatively if abdominal pain persists after surgery on or near the ureter. Presently, there is no indication for CT scan or MRI prior to laparoscopic ovarian surgery.
In all cases careful inspection of the abdomen and pelvis is done. The ovaries are evaluated for visual evidence of malignancy. Washings are taken if indicated. Endometriomas are drained by mobilizing them from the pelvic sidewall.
Enlarged ovaries containing cysts are either free in the peritoneal cavity or attached to the pelvic sidewall, uterosacral ligament, or cul-de-sac. If attached to these structures, the cyst is frequently an endometrioma. An aquadissector is used to mobilize the ovaries by lifting them from the pelvic sidewall. Often this maneuver will result in drainage of chocolate-like hemosiderin filled fluid from the undersurface of the ovary. After this occurs, the ovary is completely mobilized from the pelvic sidewall to its hilum using aquadissection and careful blunt dissection to reduce pelvic sidewall peritoneal damage. If no endometrioma is readily identified, and the patient has “unexplained infertility” or pre- or postmenstrual spotting, a knife electrode connected to monopolar cutting current (70 W) is used to incise and drain areas on the ovary with superficial endometriosis and cysts suspicious for endometrioma. The clinical distinction between an endometrioma (pathology to be excised) and a corpus luteum cyst (normal, vascular tissue best left alone) may be difficult, and conservative discretion is advised to avoid the trauma and risk of removing normal tissue. An endometrioma has a thick white fibrotic capsule while a corpus luteum cyst capsule is yellow.
If an endometrioma is discovered by either of these two methods, the cyst cavity is rinsed with lactated Ringer’s solution and then excised using 5 mm biopsy forceps, grasping forceps, and sometimes scissors (Semm, Mettler 1980)(Reich, McGlynn 1986). Experience has proven that drainage is not enough. Ovarian endometriomas up to 15 cm are excised. The cyst wall is most firmly attached to the ovarian cortex in the area of cyst rupture during mobilization, i.e., the portion that was adhered to the pelvic sidewall or uterosacral ligament, and not to the portion near the ovarian hilum. To help create an initial plane between normal ovarian cortex and endometrioma cyst wall, cutting current (70 W) through a knife electrode tip is applied at the cyst wall-cortex junction to develop a dissection plane in this firmly attached area. This step is particularly useful near the utero-ovarian ligament as rough avulsion can lead to excessive bleeding. The laparoscope is brought close to the area of dissection, magnifying it to identify the cyst wall clearly. This incision is extended through the visible 360o opening if possible. The cutting current will destroy endometriosis at the ovarian cortex-endometrioma junction while making a divot of separation between the two structures. Thereafter, biopsy or grasping forceps are placed to stabilize the ovarian cortex and endometrioma cyst wall while traction is exerted on the endometrioma cyst wall to peel it from inside the ovary. If the cyst wall is felt to be incompletely excised, the cyst cavity can be desiccated or fulgurated to destroy any remaining endometrioma. Otherwise, the endometrioma may recur. Excision can be done with minimal bleeding from the cyst wall bed and the ovarian wall edges usually reapproximate quite well, though occasionally extracorporeal suturing is required, especially after removal of large endometriomas. Hemostasis is checked by underwater examination inside the ovary, and individual bleeders are identified using irrigation through an irrigating channel and coagulated with microbipolar forceps. When removal results in a large, asymmetrical defect, the ovary is suture repaired, usually with one purse-string absorbable suture, applied close to the utero-ovarian ligament in one direction and the infundibulopelvic ligament in the other. Although suturing is not thought to be necessary for reapproximation by many surgeons, anyone who has operated on many of these women realizes that the open ovary is very receptive to small and large bowel; I suspect that those who preach that all ovaries should not be suture repaired are not comfortable with suturing techniques.
In most cases of ovarian endometrioma, endometriosis of the pelvic sidewall and/or uterosacral ligament is present. These lesions should be excised after enucleation of the endometrioma to prevent recurrence. Pelvic sidewall endometriosis peritoneal excision usually requires ureterolysis to free the underlying ureter from the lesion.
Oophorectomy can also be considered for pain or mass arising from ovarian endometrioma in women not desiring future fertility. This is especially indicated for left pelvic pain if the left ovary is enmeshed in rectosigmoid adhesions because they tend to recur.
Before removal, the ovary is released from all pelvic sidewall and bowel adhesions. It is imperative that the surgeon visualize the course of the ureter. The peritoneum above the ureter is opened with sharp scissors. Smooth grasping forceps are then opened parallel and perpendicular to the retroperitoneal structures until the ureter is identified. Scissors can be used to further dissect the ureter throughout its course along the pelvic sidewall.
The uterus is anteverted and displaced to the contralateral side. The fallopian tube is grasped and pulled medially to stretch out the infundibulopelvic ligament containing the ovarian vessels. The anterior and posterior leaves of the broad ligament are opened with scissors lateral and medial to the infundibulopelvic ligament and a free ligature (2-0 Vicryl) passed through the window thus created and tied extracorporeally using the Clarke-Reich knotpusher. This is repeated twice until two proximal ties and one distal one are placed, and the ligament then divided. While applying traction to the cut distal pedicle, the broad ligament is divided to the round ligament just lateral to the uteroovarian artery anastomosis using cutting current through a spoon electrode. Two free ligatures are placed around the uteroovarian ligament, which is then divided.
Alternatively, Kleppinger bipolar forceps are used to compress and desiccate the infundibulopelvic ligament, the broad ligament, the fallopian tube isthmus, and the utero-ovarian ligament with bipolar cutting current (25-35 W). In most cases, 3 contiguous areas are desiccated. Laparoscopic scissors are used to divide the pedicle. (Reich H, 1987)
The free ovary is removed through the umbilicus or cul-de-sac. Large endometriomas are usually sufficiently cystic and pliable that, once separated from the pelvic sidewall, they can be removed through the umbilical incision.
When the ovary is retroperitoneal, embedded in the pelvic sidewall, a lateral approach is advocated. The peritoneum lateral to the ovary and the infundibulopelvic ligament where it crosses the iliac vessels is incised with dissecting scissors and the broad ligament opened by bluntly separating the extraperitoneal areolar tissues. The peritoneal incision is extended to the round ligament, lateral to the infundibulopelvic ligament. The infundibulopelvic ligament is pulled medially with grasping forceps to expose the ureter at the pelvic brim where it crosses the common or external iliac artery. It may be necessary to reflect the ureter off the medial leaf of the broad ligament for a short distance to aid in its identification, although this is not always required. The infundibulopelvic ligament is ligated, divided, and its distal cut end put on traction with traumatic grasping forceps for the rest of the oophorectomy. The medial leaf of the broad ligament with its contained ovary is freed from the pelvic sidewall vessels and areolar tissue. The ureter is peeled off the retroperitoneal ovary for most of its pelvic course until the uteroovarian ligament can be isolated and divided.
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