Endometriosis Surgery and Adhesion Prevention

Nicholas Leyland, BASc,MD,MHCM, FRCSC Chief of OB/GYN St Joseph’s Health Centre,Medical Director of Women’s, Children’s and Family Health Program.Associate Professor OB/GYN, University of Toronto.

Left Ureterolysis

*Trademark©ETHICON, INC. 2007

Interceed:

Years of proven efficacy in a wide variety of

procedures: Adhesiolysis

Myomectomy Ovarian Surgery Tubal Surgery Surgical Treatment for Endometriosis

Excellent safety profile Over 10 years of clinical experience

Surgical Approach: Objectives Is Surgery Even Necessary: Indications

What to do: Burn or Cut?

Special Situations: Endometriomas Deep Infiltrating Endometriosis

Adjunctive Surgical Techniques and Prevention of Adhesions

Is Surgery Even Necessary?

Risks – 0.2-3% overall complication rate

Requires additional expertise and training

Reimbursement limitations/OR resources limited

Excellent medical options exist for pain GnRH Agonists, Aromatase Inhibitors, Mirena IUS

Indication for Surgical Management of Endometriosis

Diagnosis

Acute, chronic pain

Significant impact on quality of life

Failure of medical therapy

Infertility investigation and treatment

Endometrioma

Secondary organ involvement (bowel,

bladder, ureter, nerve)

Surgery Pros and Cons

Diagnosis and Treatment

Prolonged therapeutic effect

Fecundity Improvement

(EndoCAN)

Risk of injury to organs

Greater adhesions Limited resources Limited expertise Negative

Laparoscopy

Advantages Disadvantages

Macroscopic appearance of endometriosis

black, red, vesicular POD obliteration Marked distorted anatomy

Endometriotic cysts

Adhesions Bowel endometriosis

Additional Limitations of Surgery

Missed lesions: false negative laparoscopy

Required Expertise –

Most grads not comfortable with advanced

and many basic endoscopic techniques

Ob/Gyn Endoscopy Survey, Raymond,Ternamian,Leyland JMIG 2004

SURGICAL OPTIONS:EXCISION OR ABLATION?

For Endometriosis

Surgical Options: Excision vs. Ablation Excision

Multiple energy modalities (Laser, Scissors, Harmonic)

Ablation Laser,

electrosurgery

Surgical Options: “to cut or not to cut”

Histologic diagnosis Greater depth of

treatment

Requires greater skill

Injury to adjacent organs

Faster Less skill required

Unable to determine full extent

Thermal damage risk

Excision Ablation

DOES SURGERY HELP?

Endometriosis Related Pain

Does Surgery Help Pain?

Sutton et al Fertil Steril 1994 (n=63) Laser ablation + LUNA improves pain at 6

months versus expectant management (63 vs. 23%)

At 73 months, 55% of follow up (n=38) pain free (JSLS 2001)

Abbot J et al. Fertil Steril 2004 (n=39) Lap excision improved pain at 6 months

compared with diagnostic laparoscopy (80% vs. 32 %)

Does Surgery Help Pain?

Cochrane Library: “Laparoscopic surgery reduces

pelvic pain caused by endometriosis”

Laparoscopic surgery for pelvic pain associated with endometriosis (Cochrane Review 2008)Jacobson TZ, Barlow DH, Garry R, Koninckx P

Ablation versus Excision

Limited evidence* Wright et al JMIG 2005 (n=24)

Mild disease, 6 month follow up ALL lesions treated Equally effective BUT did not include

Deeply infiltrating disease

Both likely effective to some degree for MILD disease but more involved disease requires wide excision for pain relief

*Consensus statement for the management of chronic pelvic pain and endometriosis: proceedings of an expert-panel consensus process

Chronic Pelvic Pain/Endometriosis Working Group, GAMBONE et al.

Additional Surgical Skills for Advanced Endometriosis Surgery Ureterolysis Appendectomy Suturing Bowel lesions Cystoscopy Rigid

Sigmoidscopy

Deeply infiltrating endometriosis

May be responsible for “failed surgical treatment”

Identification is difficult Deep Dyspaurenia Rectovaginal exam Rectal Ultrasound MRI

Deep Versus Superficial Endometriosis: What do you see?

Ovarian Endometriomas

Ovarian Endometriomas

Laparoscopic ovarian cystectomyconfirm the diagnosis histologicallyreduces risk of recurrence over

fulgurationreduce the risk of infection at IVFImproves access to follicles and

possibly improve ovarian responseMay impair ovarian reserve

Endometriomas

Tissue specimen Decrease

recurrence

Post op adhesions Risk of decreasing

number of follicles (Ragni et al AmJOG 2004)

Simpler technique ? Preserve

greater ovarian tissue

Risk of Recurrence

Excision Fulguration

Endometriomas

Excision versus Fulguration Recurrence of pain (19 mos vs. 9.5 mos)

Berretta et al Fertil Steril 1998

Recurrence of symtoms at 2 years(15.8% vs. 56.7%)

Re-operation rate (5.8% vs. 22.9%) Alborzi et al. Fertil Steril 2004

Overall: EXCISION OF CYST preferable for PAIN

Ablation versus Excision of Cysts

Cochrane Review 2008:

Authors' Conclusions:There is good evidence that excisional surgery for endometriomata provides for a more favourable outcome than drainage and ablation with regard to the recurrence of the endometrioma, recurrence of pain symptoms, and in women who were previously subfertile, subsequent spontaneous pregnancy rates

Caveat: ART

Excisional surgery versus ablative surgery for ovarian endometriomata

R J Hart, et al The Cochrane Library 2008

ADJUNCTIVE SURGICAL TECHNIQUES

Additional Surgical Options

1.-Adhesion Prevention 2.- Presacral

Neurectomy Significant benefit in select cases but duration unknown (Zullo, Am J Obstet Gynecol, 2003)

3.- Appendectomy Up to 20% diseased in

endometriosis/pain patients

Appendectomy: “The Hockey Stick” Sign

Adhesions:

Despite even the best surgical techniques, post-surgical adhesions form in the majority of patients undergoing gynecologic pelvic surgery

Adhesions following some gynecologic surgery are a major cause of post-operative pelvic pain, infertility, bowel obstruction and the need for repeat surgery.

Adhesion barriers are a method of enhancing good surgical technique in reducing post-surgical adhesions

                                                                                

                    

                                                                                              

                                                                 

Post-surgical Adhesions—A common & costly outcome

                                                                                                                    

                         

Despite even the best surgical techniques, post-surgical adhesions form in the majority of patients undergoing gynecologic pelvic surgery

   

Adhesions following some gynecologic surgery are a major cause of post-operative pelvic pain, infertility, bowel obstruction and the need for repeat surgery6

   

It is impossible to predict who will develop adhesions or where they will occur

   

In addition to the emotional cost to the patient, post-surgical adhesions cost the U.S. healthcare system $1.6 billion annually7

   

Adhesion barriers are a proven method of enhancing good surgical technique in reducing post-surgical adhesions

   

 

Interceed:

Years of proven efficacy in a wide variety of

procedures: Adhesiolysis

Myomectomy Ovarian Surgery Tubal Surgery Surgical Treatment for Endometriosis

Excellent safety profile Over 10 years of clinical experience

TAKE HOME MESSAGES

Take Home Messages:

Ideal practice: diagnose and remove endometriosis surgically at same time

Laparoscopic excision and ablation of endometriosis provides pain relief

Pain can be reduced by removing the entire lesions in severe and deeply infiltrating disease

Role for adjunctive procedures is evidence beased

Adhesion barriers have a role

Take Home Messages

Consider Adjunctive Surgical Procedures:

Presacral Neurectomy

Appendectomy

Adhesiolysis and Adhesion Prevention

Approach to Managing Endometriosis:

Available expertise Accurate diagnosis Surgical skills

Anatomy knowledge Dissection skills Knowledge of energy Suturing skills

Specialized team Multi-disciplinary

approach Nurse educator Family physician Bowel surgeon Urologist Pain Specialists

Surgical Approach: Objectives Is Surgery Even Necessary: Indications

What to do: Burn or Cut?

Special Situations: Endometriomas Deep Infiltrating Endometriosis

Adjunctive Surgical Techniques

THANK YOU!