Laparoscopic Management of a Liver Endometrioma

Video Description

Demonstration of laparoscopic management of a liver endometrioma – a novel technique. This was a joint surgery performed by MIGS and Thoracic Surgery. The video includes the surgical technique and management of a complication. The video is focused on the surgical footage.

Presented By

Dr. J McCall
Dr. H Alsalem
Dr. S Singh

Dr. E Williams
Dr. G Horwood

Dr. S Gilbert
Dr. K Lortie

Affiliations

University of Ottawa

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What is Laparoscopic management of a liver endometrioma?

Laparoscopic management of a liver endometrioma involves using minimally invasive surgical techniques to remove or treat endometriotic lesions located on the liver. Here’s a breakdown of what this procedure entails:

Laparoscopic Approach: Surgeons use small incisions to insert a laparoscope (a thin tube with a camera) and specialized instruments, allowing them to access the liver without making large cuts. This approach reduces recovery time, minimizes scarring, and lowers the risk of infection compared to open surgery.
Targeted Removal: The surgeon may excise or ablate the endometriotic tissue from the liver. Excision involves carefully cutting out the lesion, while ablation uses energy sources like lasers or heat to destroy the tissue. This targeted approach is crucial as liver endometriomas are rare and require precise handling.
Diagnosis and Symptom Relief: Removing the liver endometrioma can relieve pain, reduce inflammation, and prevent complications such as cyst growth or rupture. Laparoscopy also allows for biopsy and detailed examination of the lesion to confirm diagnosis and rule out malignancy.
Post-Operative Benefits: Due to its minimally invasive nature, laparoscopic management typically leads to faster recovery, shorter hospital stays, and quicker return to daily activities, making it a preferred option for eligible patients with liver endometriosis.

This method is part of an evidence-based approach to treating rare cases of hepatic endometriosis, focusing on patient safety and effective symptom relief.

What are the Risks of Laparoscopic management of a liver endometrioma?

Laparoscopic management of a liver endometrioma, while minimally invasive, carries specific risks:

Injury to Surrounding Organs: The liver is close to major blood vessels and organs, such as the gallbladder and intestines. There’s a risk of accidental injury during the procedure, potentially leading to complications like bile leaks or internal bleeding.
Infection: Any surgery, including laparoscopic, can lead to infections at the incision sites or internally in the abdomen, especially if the liver is inadvertently injured.
Bleeding: The liver is a highly vascular organ, and even minor damage can result in significant bleeding. In some cases, this may require conversion to open surgery to control the hemorrhage.
Conversion to Open Surgery: If complications arise, such as excessive bleeding or unexpected anatomical challenges, the surgeon may need to switch to an open procedure, which involves a larger incision and longer recovery.
Anesthesia Risks: As with all surgeries requiring general anesthesia, there is a small risk of complications, including respiratory issues, allergic reactions, or adverse responses to medications.
Postoperative Adhesions and Pain: Scar tissue (adhesions) may form around the liver or nearby organs post-surgery, potentially causing chronic pain or bowel obstructions in rare cases.
Recurrence of Endometriosis: Although the procedure aims to remove endometriotic tissue fully, there is a risk of recurrence, which may necessitate further treatment or surgery.

These risks underscore the importance of experienced surgical teams and a thorough preoperative assessment to minimize complications and ensure the best possible outcome.

Video Transcript: Laparoscopic management of a liver endometrioma

This is a video demonstration of laparoscopic management of a liver endometrioma. We hope you will enjoy this novel presentation. We do not have any relevant disclosures. The surgical steps for this video are to mobilise the liver, identify the lesions, find the plane between the liver and the diaphragm, and excise the liver endometrioma.

Step one is mobilising the liver. We will do this by taking down the falciform ligament. In the background, you can see hemosiderin deposits on the diaphragm, as well as a large endometriotic nodule. The next step is to introduce a Liver Retractor. This will form into a triangular shape and can mobilise the liver toward the patient’s left side. Now we can see the right hemi-diaphragm on the left of the screen, and the liver on the right.

Here we identify one of the diaphragmatic lesions on the right side. We proceed to find the plane between the liver and the right hemi-diaphragm. As you can see, there are dense adhesions. We are expecting to find an endometrioma here based on MRI. In opening these adhesions, there is suddenly a gush of chocolate-like fluid. We have identified a large liver endometrioma that is contiguous with the right hemi-diaphragm. We will then explore the endometrioma cavity and drain and irrigate the endometrioma.

Next, we proceed to excise the endometrioma from both the liver and the diaphragm. A 30- or 45-degree laparoscope is key to the success of this operation. The energy device used for this procedure is an ultrasonic advanced energy blade. Here, as we have separated the endometrioma from the liver, you can see that a piece of endometrioma remains on the diaphragm. You can start to see the more normal tissue between the liver and the diaphragm, although adhesive disease remains.

We are now looking for a second endometriotic lesion that we identified earlier. We are seeking the plane between the liver and the right hemi-diaphragm. Suddenly profuse bleeding is encountered. In this view, you will recall that the diaphragm is on the left of the screen, and the liver is on the right. We are recalling our anatomy. We believe that we have entered the right hepatic vein, which drains into the inferior vena cava.

We have let Anaesthesia know that we are having significant bleeding. Everyone is communicating well and staying calm. We are fortunate not to be operating alone. We are collaborating with our colleagues in thoracic surgery, who are immensely helpful and managing not only intraoperative, but also post-operative complications.

We are attempting to clamp the vein to stop the bleeding. This is successful. Anaesthesia’s point-of-care haemoglobin shows a haemoglobin of 112. To occlude the vessel, we will now place a figure-of-eight suture. The knot will be tied, extracorporeally. Now we will complete the excision of the endometriomas left on the diaphragm. As shown on our MRI, we expect to find it right about here. Another gush of chocolate-like fluid. We’ll finish resecting the lesion. In the background, you can see the lung and the thoracic cage.

Once removed, we will then be able to proceed with closure. For our closure, we will use an endoscopic suture device to perform interrupted sutures with intracorporeal knots. We start by closing the larger excision. As we have two excisions that run very close to each other, we will close them together to augment the strength of the closure. When the two excisions then diverge, we will separately close the ends of the lesions and then reinforce them.

Finally, we will sew the two repairs together to further strengthen the diaphragm closure. Our patient recovered well. She did experience a reactive pleural effusion that required re-insertion of a chest tube on post-op day one, but this was removed after several days. She was discharged home on post-op day ten and has been recovering well over the last several months. Her catamenial shoulder pain has resolved.

To conclude, the key surgical steps are to mobilise the liver, identify the lesions, find the plane, and excise the liver endometriomas. Thank you for watching our video.