Endometriosis: Pathogenesis and Treatment 2014 Ed.

24. Systematic Laparoscopic Surgery for Complete Obliteration of the Cul-de-sac

Yoshiaki Ota Masaaki Andou1Keiko Ebisawa1Kazuko Fujiwara1Tomonori Hada1Hiroyuki Kanao1 and Ikuko Ota2

(1)

Department of Obstetrics and Gynecology, Kurashiki Medical Center, Kurashiki, Japan

(2)

Department of Obstetrics and Gynecology, Kurashiki Heisei Hospital, Kurashiki, Japan

Yoshiaki Ota

Email: yoshimon@cj8.so-net.ne.jp

Abstract

Endometriosis has been reported as a major cause of pelvic pain. Most notably, deep infiltrating endometriosis is a very active disease that occurs in 20 % of women with endometriosis. We have been actively dissecting deep infiltrating diseased areas within the sacral ligaments around the uterus in order to improve dysmenorrhea and chronic pelvic pain caused by deep infiltrating endometriosis. Laparoscopic surgery is an ideal option to treat deep infiltrating endometriosis involving complete cul-de-sac obliteration due to its minimal invasiveness and ability to achieve an appropriate depth of surgical field. It is important to prevent pain recurrence by providing systematic surgery and removing the deep infiltrating endometriosis safely and widely. To reduce recurrence, it is ideal to provide postoperative education to maintain the effect of surgery.

Keywords

Complete cul-de-sac obliterationDeep infiltrating endometriosis (DIE)Laparoscopic surgery

24.1 Introduction

Endometriosis occurs in 6–10 % of women of reproductive age [1]. There are three histological classifications: peritoneal endometriosis, endometrioma, and deep infiltrating endometriosis [2]. Treatment is largely divided into either surgical or pharmacological intervention.

In pharmacological intervention, recently, it has become a trend to use either low-dose estrogen–progestin (LEP) or dienogest but neither option is practical for women who are preparing to conceive.

On the other hand, the surgical option is expected to provide early pain relief.

Endometriosis has been reported as a major cause of pelvic pain. Most notably, deep infiltrating endometriosis is a very active disease that occurs in 20 % of women with endometriosis and is strongly associated with pelvic pain [34].

Furthermore, deep infiltrating endometriosis is not only a cause of infertility, but also may lead to functional impairments of retroperitoneal organs by causing compartment pressure and constriction.

We have been actively dissecting deep infiltrating diseased areas within the sacral ligaments around the uterus in order to improve dysmenorrhea and chronic pelvic pain caused by deep infiltrating endometriosis.

It is important to prevent possible residual diseases and ureteral and rectal injury when considering cases specifically involving complete cul-de-sac obliteration.

Laparoscopic surgery is an ideal option to treat deep infiltrating endometriosis involving complete cul-de-sac obliteration due to its minimal invasiveness and ability to achieve an appropriate depth of surgical field.

In this article, focusing on deep infiltrating endometriosis with complete cul-de-sac obliteration, we report our surgical methods and results.

24.2 Subjects

Between January 2008 and July 2012, we performed 622 laparoscopic surgical resections of endometriosis in patients of childbearing age. Among them, those with and without deep infiltrating endometriosis (DIE) numbered 369 and 253, respectively. Therefore, 60 % of cases had DIE (Fig. 24.1). We divided our cohort into four groups, as follows: 372 (age: 33.91 ± 5.75) cases without postoperative pharmacological treatment, 123 (age: 31.60 ± 5.70) cases with postoperative low-dose estrogen–progestins (LEP), 35 (age: 30.94 ± 5.97) cases with postoperative treatment with 1 mg of dienogest, and 92 (age: 33.32 ± 6.23) cases of postoperative treatment with 2 mg of dienogest (Table 24.1).

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Fig. 24.1

Sixty percent of cases had deep infiltrating endometriosis

Table 24.1

Between January 2008 and July 2012, we performed 622 laparoscopic surgical resections of endometriosis in patients of childbearing age

 

No postoperative pharmacotherapy (n = 372)

COC treatment (n = 123)

Dienogest treatment 1 mg/day (n = 35)

Dienogest treatment 2 mg/day (n = 92)

P-value

Age (years)

33.91 ± 5.75

31.60 ± 5.70

30.94 ± 5.97

33.32 ± 6.23

0.01

Presence of deep infiltrating endometriosis

185

48

8

12

0.01

+

187

75

27

80

Beecham classification

Stage I

16

1

1

1

0.08

Stage II

209

65

14

26

Stage III

60

21

7

17

Stage IV

87

36

13

48

Laterality of endometriotic cysts

31

5

2

10

0.075

+

Monolateral

196

76

17

40

Bilateral

145

42

15

43

24.3 Surgical Methods: Excision of Cul-de-sac Obliteration and DIE Method

Firstly, in the case of complete cul-de-sac obliteration, deep infiltrating endometriosis is distributed around the uterosacral ligament.

Deep infiltrating endometriosis is attached to the rectum and urinary tubes.

Therefore, when removing the deep infiltrating endometriosis, it is important to separate the rectum and urinary tube from the diseased area in order to prevent tissue damage and avoid leaving residual diseases.

Therefore, we have been dissecting interstitial spaces between deep infiltrating endometriosis and the urinary tube which center around the uterosacral ligament.

This interstitial space is Okabayashi’s pararectal space, and we have termed the outside of the uterosacral ligament “the lateral pararectal space, LPRS.”

Furthermore, we refer to the interstitial space between the rectum and lateral pararectal space as “the median pararectal space, MPRS” (Fig. 24.2).

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Fig. 24.2

Anatomy of cul-de-sac obliteration. “The lateral pararectal space” is consistent with the outside of the uterosacral ligament. “The medial pararectal space” is consistent with the interstitial space between the rectum and lateral pararectal space

24.3.1 Method to Separate Ureter

In most cases, deep infiltrating endometriosis is distributed around the uterosacral ligament and cervix uteri, and almost all cases involve adhesion of the lower urinary tube to the outer side of the uterosacral ligament.

Especially, adhesion occurs between the uterosacral ligament and either the urinary tube or rectum, and the urinary tube may be unpredictably shifted; therefore, identifying and separating the urinary tube first may facilitate a safe operation.

In cases of cul-de-sac obliteration, we identify the urinary tube where it crosses the common iliac artery and trace it down as far as possible.

We locate and unfold the posterior side of the broad ligament of the uterus, and identify the urinary tube.

Next, we open the LPRS which consists of the internal aspect of the urinary tube and extraluminal space of the uterosacral ligament.

This leads to separation of the urinary tube from the deep infiltrating endometriosis centered around the uterosacral ligament (Fig. 24.3).

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Fig. 24.3

LPRS lateral pararectal space. Developing on the right side of the LPRS. The ureter was separated from the sacral ligament

24.3.2 Method to Obliterate Complete Cul-de-sac Adhesion

In the case of complete cul-de-sac adhesion, the strongest adhesion is at the posterior uterine cervix and anterior aspect of the rectum.

When the direction of the rectum is not clear, it is possible to cause rectal damage while dissecting between the posterior uterine cervix and anterior aspect of the rectum.

Therefore, we have been approaching from the lateral rectal side.

We dissect the lateral rectal fossa from the rectum and then deeply obliterate the space outside the lateral rectal fossa.

This space is the MPRS described earlier. Then, we proceed to dissect the MPRS further anterior toward the posterior part of the vagina.

This leads to complete separation of the deep infiltrating endometriosis centered around the uterosacral ligament and rectum.

Furthermore, it has become possible to laterally identify part of the anterior aspect of the rectum.

In this way, dissecting from the lateral side leads to gradual identification of the rectal outline.

Approaching the right and left lateral sides leads to identification of the remaining strongest point of adhesion between the posterior uterus and anterior rectum.

At this step, since we have clearly outlined the anterior aspect of the rectum, it is safe to proceed with dissecting the center part of the rectum.

Dissection of the remaining center part of the rectum leads to separation of the cul-de-sac obliteration (Fig. 24.4).

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Fig. 24.4

MPRS medial pararectal space. Developing on the right side of the MPRS. The rectum was separated from the side of the sacral ligament

24.3.3 Method of Deep Infiltrating Endometriosis Excision

Firstly, disseminate the LPRS to separate the ureter and deep infiltrating endometriosis centered around the uterosacral ligament. Then, by disseminating the MPRS to separate the rectum, deep infiltrating endometriosis will be isolated, attaching to the posterior aspect of the uterus in the shape of an upside-down U.

This isolated deep infiltrating endometriosis will be removed from the posterior side of the uterus without injuring the deep uterine vein.

Since the urinary tube and rectum have been isolated, it is possible to further separate the diseased area systematically (Fig. 24.5).

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Fig. 24.5

Isolation of DIE in the shape of a horseshoe. The LPRS and MPRS should be developed to isolate DIE from the lateral pararectal space. It is shaped like a horseshoe

24.3.4 Checking Damage After Excision of Cul-de-sac Obliteration

As described earlier, it is important to check for rectal damage after disseminating the MPRS and removing the cul-de-sac obliteration.

Firstly, we perform digital rectal examination by extending the dissected area, and confirm that damage is not present laparoscopically.

Then, we perform a leak test. The leak test is performed by pumping 50–100 mL of air into the rectum using a large soft catheter (Figs. 24.6 and 24.7).

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Fig. 24.6

Air leak test. To check for rectal injury, the air leak test is important. Nelaton’s catheter was inserted into the anus and 50 mL of air was pumped into the rectum using a syringe

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Fig. 24.7

Air leak test. Checking air leak from the rectum using a laparoscope from the inter-abdominal side. Sometimes, pin hole rectal injury occurred in the pararectal area. If rectal injury is overlooked, it will cause serious postoperative complications

24.4 Surgical Outcome

Three hundred and seventy-two subjects who did not receive pharmacological treatment after surgery were divided into two groups: 187 cases with surgical resection of deep infiltrating endometriosis, and 185 cases without deep infiltrating endometriosis. We defined recurrence of chocolate cyst of 2 cm or larger by either ultrasound or MRI, and recurrence of pelvic pain as a VAS score equal to or greater than the score assessed prior to the operation. The cumulative risk of recurrence was calculated using the Kaplan–Meier method, and the log-rank test was performed.

The cumulative risk of recurrence in the group with deep infiltrating endometriosis resection was 6 % at 3 years postoperatively, while that of those who did not require resection was 10 %. No significant difference was observed between these two groups (Fig. 24.8).

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Fig. 24.8

The effect on pain of systematic DIE and endometrioma excision. Comparison of the recurrence rate of pain in the presence/absence of deep infiltrating endometriosis (372 women receiving no medical therapy after surgery). The recurrence rate of pain was 10 % after surgery at 4 years. There was no the significant difference between the No DIE group and Needed DIE excision group for 4 years. Systematic DIE excision mostly controlled pain recurrence for 4 years

Since these results were compared among groups without postoperative pharmacological intervention, they indicate adequate resection of deep infiltrating endometriosis and pain control. Therefore, these results show that our operating method of systematic resection of deep infiltrating endometriosis is effective.

On the other hand, recurrence of chocolate cyst at 4 years postoperatively was 30 % in both groups (Fig. 24.9).

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Fig. 24.9

The effect on endometrioma recurrence of systematic DIE and endometrioma excision. Comparison of recurrence rate of endometrioma by the presence/absence of deep endometriosis (372 women who received no medical therapy after surgery). The recurrence rate of endometrioma was 30 % at 3 years. There was no significant difference between the No DIE group and Needed DIE excision group for 4 years. One reason is that surgery is often incomplete to maintain the ovarian reserve. Endometrioma will recur in 30 % after surgery within 4 years

24.5 Discussion

Treatment for endometriosis is largely divided into two types: surgical intervention and pharmacological treatment.

Recently, it has become a trend to use pharmacological treatment with either low-dose estrogen–progestin (LEP) or dienogest, but neither option is practical for women who are preparing to conceive.

On the other hand, surgery provides rapid pain relief, but, among surgical methods, the biggest setback of fertility – preserving surgery has been the high recurrence rate. It has been reported that the recurrence rate at 2 to 5 years postoperatively of the chocolate cyst was 12 to 30 % [510], while the recurrence rate of pain was 10–49 % [581112].

Also, it has been clearly reported that deep infiltrating endometriosis has an association with strong pelvic pain, and in those with disease around the uterosacral ligament, the odds ratio of chronic pelvic pain was 2.1, while the odds ratio of dyspareunia was 2.0 [2]. Therefore, we have completely removed deep infiltrating endometriosis and optimized surgery to prevent ureteral and rectal injury.

Specifically, in cases with complete cul-de-sac obliteration, we performed LPRS and MPRS to systemically separate the urinary tube and rectum from deep infiltrating endometriosis.

With this method, the 4-year postoperative pain recurrence rate was similar in both groups, that is, almost 15 % for both patients with or without deep infiltrating endometriosis.

These results are from the study of cases without postoperative pharmacological intervention and, therefore, our systematic resection was considered effective for pain control at 4 years postoperatively.

On the other hand, the cumulative risk of recurrence of ovarian chocolate cyst was 30 % at 4 years postoperatively. Recurrence of pain was considered to be the recurrence of deep infiltrating endometriosis, and the recurrence rate of ovarian chocolate cyst was 3 to 5 times higher than that of deep infiltrating endometriosis.

The ovarian reserve needs to be considered in cases of ovarian chocolate cyst surgery; however, it is possible to enucleate large fields in the case of deep infiltrating endometriosis. The recurrence rate may be associated with differences in both operative backgrounds. Therefore, it is important to prevent pain recurrence by providing systematic surgery and removing the deep infiltrating endometriosis safely and widely. On the other hand, in cases of ovarian chocolate cyst, we provide surgery while considering the ovarian reserve. In terms of recurrence, as Vercellini and others reported that recurrence can be reduced to 37 % at 3 years postoperatively by providing combined oral contraceptives (COCs), we think that it is optimal to provide combined oral contraceptives (COCs) postoperatively [13].

24.6 Conclusion

In cases of deep infiltrating endometriosis with complete cul-de-sac obliteration, it is ideal to provide systematic enucleation to avoid rectal and urinary tube damage with the LPRS and MPRS in order to prevent pain recurrence.

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