LAPAROSCOPIC TOTAL PERITONEAL EXCISION
A SAFE SURGICAL PROCEDURE
FOR THE MANAGEMENT OF ENDOMETRIOSIS•10th Congress of the European Society for Gynaecological Endoscopy - Lisbon, Portugal November 22nd - 24th 2001. Abstract FCV01-03, Page 33.FCV01 03, Page 33.
•VIII World Congress on Endometriosis. San Diego, California. February 24th - 27th, 2002.
•1st European Endoscope Surgery, Glasgow 16-18 June 2003. Review in Gynaecological Practice - June 2003 Volume 3 issue 1; p14p14.
•Global Congress of Gynaecological Endoscopy, San Francisco, California - November 10-13, 2004. The Journal of American Association of Gynaecoligical laparoscopists. August 2004, Vol. 11, No. 3 Supplement; pS39
•14th annual congress of the International Society for Gynaecologic Endoscopy London April 3 6 2005•14th annual congress of the International Society for Gynaecologic Endoscopy, London, April 3-6 2005
•XVIII FIGO World Congress of Gynaecology and Obstetrics, Kuala Lumpur, Malysia - 5-11 November 2006.
MR A K TREHAN, FRCOG, FRCS (Edin)
CONSULTANT MINIMAL ACCESS GYNAECOLOGIST WITH SPECIAL INTEREST IN ENDOMETRIOSIS
DEWSBURY & DISTRICT HOSPITALWEST YORKSHIRE, ENGLAND, UK
“EXCISION OF ENDOMETRIOSIS”
MODERN & ACCEPTEDSURGICAL
MANAGEMENT OF ENDOMETRIOSIS
CONVENTIONAL PRACTICE
EXCISE ENDOMETRIOTIC LESIONEXCISE ENDOMETRIOTIC LESION AND
LEAVE SO CALLED NORMAL LOOKINGLEAVE SO CALLED NORMAL LOOKING PERITONEUM
CONVENTIONAL PRACTICECONVENTIONAL PRACTICE
PARTIAL EXCISION OF PELVIC PERITONEUM
Copyright Trehan
Endometriosis mainly a generalisedEndometriosis mainly a generalised disease of pelvic peritoneum and if one looks carefully so called normal lookinglooks carefully so called normal looking
peritoneum have an abnormal vasculaturevasculature
Endometriotic vascular changes-Neovascularisation Peritoneum
Alth h th i b i d t i i i th lid f l i ti f thAlthough there is no obvious endometriosis in these slides; careful inspection of the so
called normal looking peritoneum has abnormal vascular changes due to endometriosis
Copyright Trehan Copyright Trehan
Copyright Trehan Copyright Trehan
Failure of conventional practicep
• Incomplete excision/removal
• Disease recurrence new disease at new site(recurrence rate reported 14-36%)
I SUGGEST COMPLETE REMOVAL OF PERITONEUM
COVERING:COVERING:
B th i f• Both ovarian fossa• Uterosacral ligament
P h f D l• Pouch of Douglas
THUS
EXCISE BOTH ABNORMAL AND SO CALLEDNORMAL LOOKING PERITONEUMNORMAL LOOKING PERITONEUM
TOTAL PERITONEAL EXCISION
TOTAL PERITONEAL EXCISION
EXCISION OF PELVIC PERITONEUM BOTH OVARIAN FOSSA, UTERO SACRAL LIGAMENT & POUCH OF DOUGLAS Copyright Trehan
TOTAL PERITONEAL EXCISION
EXCISION OF PELVIC PERITONEUM BOTH OVARIAN FOSSA, UTERO SACRAL LIGAMENT & POUCH OF DOUGLAS
Copyright Trehan
SACRAL LIGAMENT & POUCH OF DOUGLAS
REASON FOR TOTAL EXCISIONREASON FOR TOTAL EXCISION
To Reduce Chances Of Recurrence
So called normal looking peritoneum between frank clinical lesions has –
• Sub-clinical endometriosis
• Continued susceptibility to metaplasticContinued susceptibility to metaplastic changes/retro-grade menstruation
REASON FOR TOTAL EXCISIONREASON FOR TOTAL EXCISION(CONTINUED)
Better symptomatic reliefy p
• May result in complete destruction of retro-May result in complete destruction of retro-peritoneal nerves
OvaryUterovaginal Plexus
Bladder
UterusRectum
Bladder
REASON FOR TOTAL EXCISION(CONTINUED)
Reduced complications
• Starting dissection from so called normal looking g gperitoneum helps in better delineation of anatomy
OBJECTIVE
DETERMINE SAFETYOF
LAPAROSCOPIC TOTAL PERITONEUMEXCISIONEXCISION
DESIGN:
Retrospecti e- Retrospective
- 100 consecutive cases to October 2004
- Total Peritoneal Excision in patient with uterus
- Included - Mild to severe endometriosis (stage I-IV)- Included - Mild to severe endometriosis (stage I-IV)
- Excluded – Hysterectomy with excision or hysterectomy in the past
- All operation undertaken by one surgeon (Mr A K Trehan)
SETTINGS:District General Hospital- District General Hospital
MEDICAL TREATMENT FAILURE PRIOR TO EXCISION
TOTAL NO. OF PTS FAILED MEDICAL TREATMENT NO. OF TIMES MEDICAL TREATMENT TRIED AND FAILED
100 68 = 68% 1 FAILURE 43%
2 FAILURE 15%
3 FAILURE 8%
4 FAILURE 2%
TOTAL 68%
TECHNIQUETOTAL PERITONEAL EXCISION
• 3 Port Entry – 10mm sub-umbilical x 1- 5mm side ports x 2- 5mm side ports x 2
• Oozing from raw surface checked at end of• Oozing from raw surface checked at end of operation at 6mm pressure
• Anti-adhesion solution
• Prophylactic antibioticProphylactic antibiotic
DEGREE/STAGE OF ENDOMETRIOSIS
Mild 37/100 = 37%• Mild 37/100 = 37%(Superficial scarrings)
• Moderate 42/100 = 42%• Moderate 42/100 = 42%(Deep scarring & adhesions)
• Severe 21/100 = 21%Severe 21/100 = 21%(Deep scarring, major adhesions, chocolate cyst & bowel involvement)
1
Copyright TrehanSevere Endometriosis with Kissing Ovaries
1
Copyright Trehan
Severe Endometriosis with Kissing Ovaries following excision
2
Copyright TrehanExtensive Scarring with previous laser surgery
2
Copyright TrehanExtensive scarring with previous laser surgery following excision
Opened Vagina
3
Opened Vagina following excision
RECTUM
Copyright TrehanExcision of Recto-Vaginal Endometriosis
3
Opened Vagina
Copyright TrehanExcision of Recto-Vaginal Endometriosis
UTERUS
3
Vagina stitchedVagina stitched
Copyright TrehanExcision of Recto-Vaginal Endometriosis
Extensive dissection for Endometriosis involving Ureter
Copyright Trehan
Extensive dissection for Endometriosis involving Ureter
Extensive dissection for Endometriosis involving Ureter &
Copyright Trehan
Extensive dissection for Endometriosis involving Ureter & major blood vessels
PATIENT CHARACTERISTIC & ANALYSISPATIENT CHARACTERISTIC & ANALYSIS
MEAN RANGE• Mean age 34yrs 20-50yrsg y y
• Mean weight 66kg 37 107kg• Mean weight 66kg 37-107kg
• Mean Hb deficit 2g/dl 0.1-3.7g/dl
• Mean theatre 189mins 100-375minstioccupancy time
Histological Confirmation of Endometriosis
• Histologically confirmed 84/100 = 84%• Histologically confirmed - 84/100 = 84%
• Histologically not confirmed - 16/100 = 16%
HOSPITAL STAYHOSPITAL STAY RELATES TO THE
NUMBER OF POST-OPERATIVE NIGHTS IN THE HOSPITAL
Total No. of Total No. of Median day stay in % of pt hadPatients Nights Hospital overnight stay
100 110 1(range 1-2) 90%
• 90% of patients could be discharged home inspite of prolonged operation (mean theatre occupancy 189mins – range 100-375mins)
• 10% of the patients who stayed an extra night was mainly for: Social reasons• Social reasons
• Lived far away (Scotland, York and Goole)
COMPLICATIONSCOMPLICATIONS
• Blood Transfusion 0/100 0%• Blood Transfusion 0/100 0%
Pyrexia 0/100 0%• Pyrexia 0/100 0%
W d li ti 0/100 0%• Wound complication 0/100 0%
C i t l t 0/100 0%• Conversion to laparotomy 0/100 0%
MINOR COMPLICATIONSMINOR COMPLICATIONS
• Uterine fundal perforation 1/100– No ill consequences – no special treatment needed
• Serosal abrasion of large bowel 1/100– No ill consequences – Hospital stay one day– Usual diet from day of operation
TOTAL - 2/100 = 2%O / 00 %( No ill consequences, no morbidity, not required any special postoperative care or treatment)
MAJOR COMPLICATIONSMAJOR COMPLICATIONS
INJURY TO INTERNAL ORGANS –
• Bladder 0/100 0%• Ureter 0/100 0%• Bowel 0/100 0%• Major blood vessels 0/100 0%
READMISSION WITHIN 4 WEEKS OF OPERATION
• For surgical complication 0/100 0%
• Other reason 1/100 1%– Anxiety and chest pain – discharged within 12 hours of
readmissionreadmission
RE OPERATIONRE-OPERATION
RE-OPERATION WITHIN SIX MONTHS OF INITIAL OPERATION:
0/100 = 0%
RISK OF PELVIC ADHESIONSRISK OF PELVIC ADHESIONS FOLLOWING
TOTAL PERITONEAL EXCISIONTOTAL PERITONEAL EXCISION
• 10 patients had second look for diagnostic/p gtherapeutic procedure
• No pelvic adhesion detected(A single strand of adhesion or very few flimsy adhesions not included)
EXCISION OF PELVIC ENDOMETRIOSIS DOES NOT CAUSE PELVIC ADHESION
BEFORE EXCISION AFTER EXCISION
Copyright TrehanCopyright Trehan
SECOND LOOK LAPAROSCOPY
Copyright TrehanCopyright Trehan
Copyright Trehan PATIENT NO. 1
EXCISION OF PELVIC ENDOMETRIOSIS DOES NOT CAUSE PELVIC ADHESION
AFTERBEFORE AFTER
OVARY
OVARY
SECOND LOOK LAPAROSCOPY
Copyright Trehan Copyright Trehan
OVARY
PATIENT NO. 1Copyright Trehan
EXCISION OF PELVIC ENDOMETRIOSIS DOES NOT CAUSE PELVIC ADHESION
BEFORE AFTER
UTERUS
UTERUSUTERUS
Copyright TrehanCopyright Trehan
SECOND LOOK LAPAROSCOPY
py g
UTERUS
PATIENT NO. 1Copyright Trehan
EXCISION OF PELVIC ENDOMETRIOSIS DOES NOT CAUSE PELVIC ADHESION
AFTER EXCISION – Patient 2
AEXCISION OF PELVIC PERITONEUM BOTH OVARIAN FOSSA, UTEROEXCISION OF PELVIC PERITONEUM BOTH OVARIAN FOSSA, UTERO
SACRAL LIGAMENT & POUCH OF DOUGLASCopyright Trehan
EXCISION OF PELVIC ENDOMETRIOSIS DOES NOT CAUSE PELVIC ADHESION
AFTER EXCISION - Patient 2
AEXCISION OF PELVIC PERITONEUM BOTH OVARIAN FOSSA, UTEROEXCISION OF PELVIC PERITONEUM BOTH OVARIAN FOSSA, UTERO SACRAL LIGAMENT & POUCH OF DOUGLAS
Copyright Trehan
EXCISION OF PELVIC ENDOMETRIOSIS DOES NOT CAUSE PELVIC ADHESION
SECOND LOOK LAPAROSCOPY Patient 2SECOND LOOK LAPAROSCOPY – Patient 2
Copyright Trehan
EXCISION OF PELVIC ENDOMETRIOSIS DOES NOT CAUSE PELVIC ADHESION
SECOND LOOK LAPAROSCOPY – Patient 2
Copyright Trehan
EXCISION OF PELVIC ENDOMETRIOSIS DOES NOT CAUSE PELVIC ADHESION
SECOND LOOK LAPAROSCOPY – Patient 2
Copyright Trehan
EXCISION OF PELVIC ENDOMETRIOSIS DOES NOT CAUSE PELVIC ADHESION
AFTER EXCISION SECOND LOOK LAPAROSCOPY
Copyright Trehan Copyright Trehanpy g
Patient 3
SUMMARYSUMMARY
• 90% of patients left hospital after overnight stay inspite of prolonged procedure (mean theatre occupancy 189mins – range 100-375mins)
• 2% patients suffered very minor intra-operative complication which did not cause any post operative ill consequences or morbidity nor did patient require any special post operative care or treatmentrequire any special post operative care or treatment
• No patient suffered any major complication
• No patient was readmitted for surgical complication
N dh i d t t d t d l k N it t th i d• No adhesions detected at second look. New peritoneum at the excised area gave normal appearance.
CONCLUSIONCONCLUSION
• Total peritoneal excision using bipolar coagulator and i i f i l d i i dscissors is a safe surgical procedure in an experienced
hand.
• Overnight Hospital Stay following prolonged procedure• Overnight Hospital Stay following prolonged procedure to excise endometriosis is a safe practice
ACKNOWLEDGEMENTACKNOWLEDGEMENTThanks to the junior doctors, audit and secretarial staff for
undertaking the collection and analysis of this data:undertaking the collection and analysis of this data:
• Dr P Chaudhuri – MRCOG - Staff Grade• Dr P Chaudhuri – MRCOG - Staff Grade• Dr S Sunder – MBBS. MD - SHO
Mrs C Rooke A dit S i• Mrs C Rooke – Audit Supervisor• Miss Z Kitcher - Secretary
Thanks to all of the staff of gynaecological divisionwithout whom our short stay major gynaecologicaly j gy g
programme would not be possible.
THANK YOU
For more information, please visit o o e o at o , p ease s thttp://endometriosis-
consultant co uk/consultant.co.uk/
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