Endometriosis

Although extensive efforts have been made in attempts at improving prospects of pregnancy for patients with the disease, results remain marginal. Neither medical therapy nor surgery alone or in combination produces significant improvement in pregnancy rates.

However, for relief of pain both medical and surgical therapies have been employed with success although cure rates are not available. For invasive (Type III) disease and large endometriomas, surgical therapy appears to be the only solution as medical therapy has demonstrated no efficacy in these areas.

Surgical therapy revolves around three basic techniques:

• Vaporization
• Coagulation;
• Excision

Of these techniques, excision is by far the most appropriate. If the surgeon has significant expertise in the recognition of endometriosis, at times vaporization or coagulation can be used but in most cases excision is the wiser choice. Excision offers two basic advantages:

• Pathologic Confirmation
• Adequate removal of the lesion

Because endometriosis may extend several millimeters into the tissue and because epithelial cancers can mimic this disease it is always wise to have a histologic confirmation of the diagnosis.

Laparoscopy has been defined as the gold standard in surgical treatment of endometriosis for several reasons:

• Minimally invasive approach
• Superior visualization - microscopic
• Superior access - posterior pelvis
• Microsurgical accuracy of excision
• Less scarring
• Ability to repeat the surgery without compromising results

The surgical approach to endometriosis should be aggressive. Most patients should be bowel prepped and counseled appropriately preoperatively. A single stage approach is preferable if the clinical picture warrants this type of surgery.

Pain mapping ( i.e. determining the location of the pain) should be performed preoperatively using a systematic regimen.

Intraoperative mapping may be used under conscious sedation in order to better target excisional therapy. Ovarian preservation is possible in a large percentage of patients and, despite using an aggressive surgical approach, hysterectomy is rarely necessary. If significant adenomyosis or uterine corpus disease is present, however, uterine removal is required.

Laparoscopic surgery seems to be the most appropriate method of therapy for individuals with pain, rectovaginal disease, or bowel involvement secondary to endometriosis. Risk is low with this approach although the technical demands are prodigious. Surgical therapy of invasive endometriosis remains one of the most difficult tasks for the gynecologic surgeon.

BIBLIOGRAPHY

1. Mettler L, Geisel H, & Semm K. Treatment of female infertility due to obstruction by operative laparoscopy. 1979, Fertil Steril 32:384-389.
2. Martin DC. C02 laser laparoscopy for endometriosis associated with infertility. 1986, J Reprod Med 31: 1089-1094.
3. Keye WR, Hansen LW, Astin M, & Poulson AM. Argon laser therapy of endometriosis: a Review of 92 consecutive patients. 1988, Fertif Steril, 47:208-212.
4. 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@
5. Martin DC, Hubert GD. Depth of infiltration of endometriosis. Abstracts of the 41st meeting of the American Fertility Society, October 10- 1 3, 1988.
6. Brosens IA. New principles in the treatment of endometriosis. Acta Obstet Gynecol Sc,and Suppi 1994; 159: 18-21.
7. Koninckx PR, Martin D. Treatment of deeply infiltrating endometriosis. Curr Opin Obstet Gynecol 1994; 6(3): 231-241.
8. Coronado C, Franklin RR, Lotze EC, Bailey HR, Valdes CT. Surgical treatment of colorectal endometriosis. Fert Steril 1990; 53(3): 411-416.
9. Gray LA. Endometfiosis of the bowel: role of bowel resection in superficial excision and oophorectomy in treatment. Ann Surg 1973; 177(5): 580-587.
10. Magos A. Endometriosis: radical surgery. Ballieres Clin Obstet Gynecol 1993; 7(4):849-864.
11. Bruhat MA, Manhes K Mages G, & Pouly JL. Treatment of ectopic pregnancy by means of laparoscopy. Fertil Stefil 1980, 33:411-414.
12. Gomel V. Operative laparoscopy: a time for acceptance. Fertil Steril 1989; 52: 1-11.
13. Bateman BG, Kolp LA, Ntits S. Endoscopic versus laparotomy management of endometriomas. Fertil Stefil 1995; 62: 690- 695.
14. Canis M, Mage G, Manhes H, Pouly JL, Wattiez A, Bruhat. Laparoscopic treatment of endometriosis. Acta Obstet Gynecol Scand Suppl 1989; 150: 15-20.

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