This is an educational video describing and demonstrating a two-step approach to the excision of superficial endometriosis. The authors have no conflicts of interest to disclose. There are three forms of endometriosis and each one requires a different surgical approach. With a focus on surgical principles, this video demonstrates excision of superficial endometriosis. The approach is simply two steps, inspection, identification, followed by isolation and incision.
Surgical Principles and Approach
In the first step, we inspect the entire pelvis, looking for typical and atypical endometriosis. Gunpowder lesions are a classic. Endometriosis can also take the form of peritoneal pockets, adhesions, vesicular, haemorrhagic, papular or scarified lesions. During inspection, at the same time we also identify essential anatomy to avoid injuring, such as ureter, bowel and major vessels.
The second step is isolation and incision. We need to isolate the endometriosis from normal tissue using a variety of surgical techniques and incise around the disease. We isolate the lesion by grasping it and pulling it up away from underlying structures. A small incision is made in the peritoneum. The underlying structures are carefully dissected away and the lesion is removed by incising around the entire lesion.
We will now apply the approach to a surgical case. During the inspection and identification step, it’s essential to take a systematic approach to inspecting the whole pelvis. We start at the right ovarian fossa and proceed in a clockwise fashion. We inspect for areas that appear suspicious of endometriosis and also identify essential anatomy. Close laparoscopy, generally about two centimetres away from the peritoneum, magnifies the view.
By identifying and verbalising the location of suspicious areas and essential anatomy, the surgeon and assistant can develop a gameplan and a strategy for excision, improving communication. At the end of the first step of inspection and identification, all of the pelvic peritoneum should have been seen. From the first step we identified this area as possible endometriosis. A second step of the surgical approach is isolation and incision.
The goal is to isolate the lesion, leave the normal underlying tissue intact and incise around the lesion. The peritoneum is tented up for the initial incision, away from essential anatomy. In this case, lateral to the ureter. A pneumoperitoneum helps the dissection. When the underlying tissue and vessels are dissected away, small precise incisions can be made to incise around the lesion. In general, excision should be approached from the superior lateral margin and dissect inferiorly and immediately. By working in this direction, the dissection planes are clear through the procedure.
Surgical Techniques and Principles
The large majority of tissue dissection relies on three surgical techniques to show the most inherent points, traction, countertraction, push-spread movements and blunt dissection. With a traction applied to the tissue, we can bluntly dissect the underlying tissue away to show the remaining adherent points. We then incise these points. Any instrument can be used, such as scissors or monopolar electrosurgery, but the basic principles are still the same. Traction and countertraction, push-spread movements and blunt dissection.
Avascular Planes and Surgical Layers
Based on avascular planes, there are three surgical layers to the pelvic sidewall. The ureter is always found in the first layer, attached to the peritoneum. After directly visualising the ureter, we can see its path and dissect and incise along the peritoneum with confidence. It’s helpful to reassess occasionally and communicate the extent of the disease left to be excised. This whole band deserves attention, but it’s a mistake to cut deep when there’s only superficial disease.
Principles of Electrosurgery
This damages normal tissue and risks devascularising or even indirectly injuring the ureter. The principle to follow is to stay superficial and close to the peritoneal disease. Principles of elected surgery are important as well. We want a vaporisation tissue effect to minimise the lateral spread of heat. We can achieve this by activating the monopolar electrosurgery millimetres from the tissue in a non-contact fashion.
Good haemostasis is equally important for blood loss, visualisation and minimising scar formation. At times, such as with the uterosacral ligament here, bipolar electrosurgery may be needed for haemostasis. At the end, there should be complete excision of endometriosis with preservation of normal tissue. We’ll demonstrate excision on the other pelvic sidewall following the same principles. The first step is inspection for endometriosis and identification of essential anatomy.
The second step is an isolation and an incision. After grasping the peritoneum and tenting it up away from essential anatomy, the initial incision is made. To improve visualisation, we can follow the principle of dissecting from the known to the unknown. By opening the window wider, we can improve the field of vision. The ureter can then be directly visualised. By traction and countertraction applied to the tissue, gentle blunt dissection will show the adherent points. Push-spread movements, as shown here, are also effective.
When the lesion has been isolated, we can incise the peritoneum. The principle is to stay superficial and close to the peritoneal disease. At the end, it’s important to confirm complete excision of the suspected disease with good haemostasis. Hydrodissection is another technique available in the surgeon’s toolkit. A small peritoneal incision is made and fluid is directed into the retroperitoneum.
Instead of instruments, the pressure of the fluid dissects between tissue planes. This approach can also be applied using a CO2 laser. The lesion is tented up and a small incision is made. The lesion is then isolated from underlying tissue using push-spread movements or blunt dissection and an incision is made around the lesion.
We’ve presented a two-step approach to excision of superficial endometriosis, inspection and identification to visualise suspected endometriosis and essential anatomy, isolation and incision to excise the lesion using a number of surgical techniques and principles. This is a general approach that can be applied to simplify a complex procedure that we hope can educate future gynaecologic surgeons and provide teaching tips for our experts.
We’d like to acknowledge our fellow collaborators and thank you for viewing this educational video.