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Endometriosis: surgical perspectives
Dr. med Thomas Gyr
Dr. med. Christian Polli
Chairman of Gynecology and Obstetrics
Chief of service of Gynecology and Obstetrics
Endometriosis center, Ospedale Civico di Lugano
SEF/EEL certification since 2014
Endometriosis: surgical perspectives
Endometriosis center, Ospedale Civico di Lugano
SEF/EEL certification since 2014
Dr. med Thomas Gyr
Chairman of Gynecology and Obstetrics
Chief of service of Gynecology and Obstetrics
Role of surgery in Endometriosis
1. Diagnosis
2. Treatement
Titolo presentazione / Data / Pag. 3
1. Diagnosis
2. Treatement
Pain
1. Diagnosis
2. Treatement
Pain
Infertility
Role of surgery in Endometriosis:
Diagnosis
LAPAROSCOPY can confirm the presence
and the localisation of the disease:
I.
II.
III.
IV.
Peritoneal wall
Ovaries (Endometriomas)
Rectovaginal space
Other (Bladder, Abdominal wall, Ombilic….)
Diagnosis
Peritoneal:
Diagnosis
Ovaries (ENDOMETRIOMAS):
Diagnosis
Rectovaginal:
Diagnosis
Bladder:
Diagnosis
Surgical techniques in Endometriosis:
SCORES
Ezian
rASRM
Diagnosis
See and Treat/Discuss
AIMS
- Remove all visible lesions
- Re-establish normal
anatomy
- Preserve the ovarian
function
Laparoscopy should be the standard
approach
See and Refer
- Beyond surgery for diagnostic
purpose and removal for early stage
disease, it is recognized that
complex endometriosis is not for
every gynecologist and can be the
most challenging and difficult type of
pelvic surgery with potential for
significant risks and complications.
Multidisciplinary counseling, expertise
and support in certified centers.
Center of endometriosis ORL:
Organization chart
Direzione Generale EOC
Giorgio Pellanda
Ospedale Regionale di Lugano
Luca Jelmoni*
Qualità
Adriana Degiorgi
Responsabile Centro Endometriosi
Dr. med. Thomas Gyr
Centro ProCrea
- Dr. med. Michael Jemec
ENDOHELP
- Francesca Gaia
Centro Terapia del Dolore
- Dr. med. Sergio Castelanelli
Partners
Dr. med. Valerio Vitale
Dr. med. Filippo Del Grande
Segretariato
Federico Milva
Radiologia
Prof. Luca Mazzucchelli
Reparto
Annalisa Ruzzitu
Patologia
Dr. med Fernando Jermini
Dr. med. Giordano Venzi
Urologia
Prof. Raffaelle Rosso
Dr. med Dimitri Christoforidis
Chirurgia
Ambulatorio
Dr. med Thomas Gyr
Irene Schärli – aiuto medico
Incoming patients
General
practitioners
Population
External
gynaecologists
Associate
residents
Unit’s
Partners
ProCrea
Endohelp
The endometriosis center ORL in
numbers:
Type of procedures
Bowel resection 1 3
1
Abdominal wall resection 1 2
Bladder lesions resection
2 3
Hysterectomy
3 1
4
13
Endomertriomas resection
16
Rectovaginal endometriosis resection
8
13
0
2010
6
9
10
2011
2012
1
7
8
10
20
2013
3
30
40
50
The endometriosis center ORL:
Details
Min.
Average
Max.
Age
22 y
35 y
56 y
Operation time
0h40’
2h27’
5h00’
Hospitalization time (days)
1
4.96
18
Preoperative Pig-tail insertion
Complications
8% (N=8)
15% (N=16)
Complains
1% (N=1)
Referred patient to University centre
6% (N=6)
Complications
Type
Data
Acute depression
1% (N=1)
Urinary infections
5% (N=5)
Bladder disorders
2% (N=2)
Ureteral lesions (stenosis, fistula, etc.)
3% (N=3)
Peripheral nerve lesions
1% (N=1)
Post operative hematoma
2% (N=2)
Allergic skin reaction
1% (N=1)
Intra-operative skin lesion
1% (N=1)
Meta analysis of CHAPRON and al.
Rates of major and minor surgical complication associated with laparoscopy range from 1.4% to 7.5%
Pain treatement
Peritoneal endometriotic lesions
- EXCISION within 2-3 mm of clear
surgical margins (avoid
thermocoagulation)
- ATTENTION must be paid to the
underlying structures as i.e.
ureter/vessels/nerves
Surgical techniques in Endometriosis
Peritoneal endometriotic lesions
Pain treatement
Endometriomas
- Every attempt should be made to
remove endometriosis cyst
completely. Sharp careful dissection
with scissors and punctual hemostasis
is by far considered better than
the stripping technique.
- Always consider complete aspiration
of the «chocolate» content
Pain treatement
Endometriomas
- Ovarian defect will close
spontaneously (if less than
5cm).Sometimes it is necessary
to close the cortex of the ovary
with some 3-0 absorbable sutures
(Hemostasis +++)
Pain treatement
Endometriomas
Pain treatement
Rectovaginal Endometriosis
Surgery to face only in the case of adequate counseling,
planning and availability of trained surgical team.
TECHNIQUE
- Mobilization of the uterus and
Suspension of the ovaries.
- Pararectal space opening/Ureterolysis
- Dissection/Mobilization of the nodule
from the posterior wall of the vagina
Rectal shaving vs. Disk/Segmental bowel resection
Pain treatement
Rectovaginal Endometriosis
PAIN treatement
- Clinicians should not perform laparoscopic
uterosacral nerve ablation (LUNA) as an additional
procedure to conservative surgery to reduce
endometriosis-associated pain (Proctor, et al., 2005).
- Clinicians should be aware that presacral
neurectomy (PSN) is effective as an additional
procedure to conservative surgery to reduce
endometriosis-associated midline pain, but it
requires a high degree of skill and is a potentially
hazardous procedure (Proctor, et al., 2005).
PAIN treatement
- Sometimes clinicians must consider hysterectomy
with removal of the ovaries and all visible
endometriosis lesions, in women who have
completed their family and failed to respond to more
conservative treatments. Women should be informed
that hysterectomy will not necessarily cure the
symptoms or the disease.
INFERTILITY
Based on the guidelines of:
-
Royal College of Obstetricians and Gynecologists
French College of Obstetricians and Gynecologists
European Society of Human Reproduction and Embryology
(ESHRE 2013)
American Society for Reproductive Medecine (ASRM 2012)
The following conclusions on
recommendations can be given
INFERTILITY
A) Factors that determine the need for surgical
interventions include:
1.
2.
3.
4.
AGE (>35 y)
Previous therapies
Nature and severity of symptoms
Location and severity of disease
INFERTILITY
B) Surgical treatment of stage ASRM I/II of endometriosis
in infertile patients prior to assisted reproductive
technologies (ART) leads to improved live birth.
C) For infertile patients with stage ASRM III/IV
endometriosis, conservative laparoscopic surgery is
indicated particular when significant symptoms are
present. The effectiveness of surgical excision of deep
nodular lesions before treatment with ART in women
with endometriosis-associated infertility is not well
established with regard to reproductive outcome.
INFERTILITY
However more recent findings suggest that women with
ASRM stage III/IV have a good chance of spontaneous
pregnancy following laparoscopic resection of the disease.
73% chace to conceive within 12 month
Erin M. and al. - Jan 2015
University of New South Whales – Australia
ENDOMETRIOMAS: TREATEMENT DILEMMA
The most recent evidence suggest to avoid surgical treatement
and proceed to IVF if:
-
Infertile patient is asymptomatic
Older patients
Diminuished ovarian reserve (low AMH)
Bilateral endometriomas
Prior surgical treatement
ENDOMETRIOMAS: TREATEMENT DILEMMA
The most recent evidence suggest to proceed to surgery if:
-
Unilateral cyst more than 4 cm
Invalidant pain symptoms
Intact ovarian reserve (AMH)
Sonografic features for malignancies
(NB incidence less than 1%)
- IVF not planned
CONCLUSIONS
Proceeding directly to FIVET may reduce the time to conceive,
avoid potential surgical complications and limit cost.
Surgery should always be considered
when patients have concomitant pain,
symptoms refractory to medical
management and when malignancy
cannot be ruled out.
INFERTILITY (references)
-
-
-
-
-
Opøien HK, Fedorcsak P, Byholm T and Tanbo T. Complete surgical removal of minimal
and mild endometriosis improves outcome of subsequent IVF/ICSI treatment. Reprod
Biomed Online 2011; 23:389–395.
Benschop L, Farquhar C, van der Poel N and Heineman MJ. Interventions for women with
endometrioma prior to assisted reproductive technology. Cochrane Database Syst Rev
2010:CD008571.
Donnez J, Wyns C and Nisolle M. Does ovarian surgery for endometriomas impair the
ovarian response to gonadotropin? Fertil Steril 2001; 76:662-665.
Hart RJ, Hickey M, Maouris P and Buckett W. Excisional surgery versus ablative surgery
for ovarian endometriomata. Cochrane Database Syst Rev 2008:CD004992. [Edited (no
change to conclusions), published in Issue 5, 2011.]
Bianchi PH, Pereira RM, Zanatta A, Alegretti JR, Motta EL and Serafini PC. Extensive
excision of deep infiltrative endometriosis before in vitro fertilization significantly improves
pregnancy rates. J Minim Invasive Gynecol 2009; 16:174–180.
Papaleo E, Ottolina J, Viganò P, Brigante C, Marsiglio E, De Michele F and Candiani M.
Deep pelvic endometriosis negatively affects ovarian reserve and the number of oocytes
retrieved for in vitro fertilization. Acta Obstet Gynecol Scand 2011; 90:878–884.
INFERTILITY (references)
-
-
-
Marcoux S, Maheux R, Berube S. Laparoscopic surgery in infertile women with minimal or
mild endometriosis. Canadian Collaborative Group on Endometriosis. N Engl J Med
1997;337:217–22.
Parazzini F. Ablation of lesions or no treatment in minimal-mild endometriosis in infertile
women: a randomized trial. Gruppo Italiano per lo Studio dell' Endometriosi. Hum Reprod
1999;14:1332–4.
Chapron C, Vercellini P, Barakat H, Vieira M, Dubuisson JB. Management of ovarian
endometriomas. Hum Reprod Update 2002;8:591–7.
Schenken RS. Modern concepts of endometriosis. Classification and its consequences for
therapy. J Reprod Med 1998;43:269–75.
Donnez J, Nisolle M, Gillet N, Smets M, Bassil S, Casanas-Roux F. Large ovarian
endometriomas. Hum Reprod 1996;11:641–6.
THANK YOU

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