Resection of Superficial Endometriosis: 3 Laparoscopic Techniques

Table of Contents

• Procedure Summary
• Authors
• Youtube Video
• What is “Resection of Superficial Endometriosis: 3 Laparoscopic Techniques?
• What are the Risks of Resection of Superficial Endometriosis: 3 Laparoscopic Techniques?
• Video Transcript

Video Description

Endometriosis is estimated to affect 10% of women of reproductive age, and about 1 million people in Canada. Superficial endometriosis is often diagnosed at time of laparoscopy, and comprehensive and safe resection of superficial endometriosis relies on application of precise and proficient surgical technique.

Presented By

Affiliations

Department of Obstetrics and Gynecology

Credit Valley Hospital

St. Michael’s Hospital

University of Toronto

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What is Resection of Superficial Endometriosis: 3 Laparoscopic Techniques?

Resection of Superficial Endometriosis: 3 Laparoscopic Techniques refers to minimally invasive methods used to treat superficial endometriosis, a condition where endometrial tissue grows outside the uterus, causing pain and other symptoms. The three primary laparoscopic techniques aim to remove these lesions with minimal impact on surrounding tissues and structures. Here’s a breakdown of the main techniques:

• Ablation (or Cauterization): Involves using heat to burn off endometriosis lesions. This method is generally less invasive and used for small, superficial lesions, but it may not fully address deeper tissue involvement.

• Excision: Involves cutting out endometriotic tissue, providing thorough removal of lesions. Excision is often used for cases where endometriosis has spread or if there’s a need for tissue sampling. This technique can reduce the chance of recurrence more effectively than ablation.

• Laser Vaporization: Uses a laser to precisely vaporize superficial lesions while minimizing damage to surrounding tissues. This technique allows surgeons to remove lesions with high accuracy, often preserving fertility.

These laparoscopic techniques are chosen based on the extent of endometriosis, location of lesions, and patient goals, such as symptom relief or fertility preservation.

What are the Risks of Resection of Superficial Endometriosis: 3 Laparoscopic Techniques? 

Video Transcript: Resection of Superficial Endometriosis: 3 Laparoscopic Techniques

Resection of superficial endometriosis, three laparoscopic techniques.

Endometriosis is estimated to affect 10% of women of reproductive age and an unknown number of trans and non-binary people, totalling more than 1 million people in Canada. The extent of disease may be highly variable, ranging from minimal superficial deposits to deep lesions affecting multiple pelvic organs.

Pelvic endometriosis manifests in three subtypes, superficial peritoneal, ovarian, and deeply infiltrating. Superficial peritoneal endometriosis, defined as endometrial-like tissue extending up to five millimetres under the peritoneal surface, is the most common, comprising approximately 80% of all cases.

Surgical excision of endometriosis can confirm the pathologic diagnosis and reduce pain symptoms. Superficial endometriosis is often diagnosed at time of laparoscopy and comprehensive and safe resection relies on the application of precise and proficient surgical technique.

In this video we will review three laparoscopic techniques for the resection of superficial endometriosis, one, hydrodissection with a suction irrigator, two, excision with monopolar electrosurgery, and, three, laparoscopic laser excision. We will demonstrate the steps involved and discuss the advantages and disadvantages of each of these three techniques.

Our first technique demonstrates hydrodissection with a suction irrigator. After the lesions to be removed are identified, the first step is to make a small incision in the peritoneum. Next, the tip of the suction irrigator is bluntly inserted and irrigation is injected into the plane. This hydrodissects the peritoneum and endometriosis off the connective tissue below to aid in excision.

Activation of the irrigation can be repeated multiple times to achieve adequate dissection of the desired area. After this, the tissue is easily resected using a monopolar L-hook or instrument of choice.

Once completed, we see that the superficial peritoneum is resected and the underlying tissue is left intact. This technique is ideal for dissection of larger surface areas with minimal scarring. Suction irrigators are inexpensive and widely available on most laparoscopic instrument sets.

The next technique demonstrates resection using monopolar electrosurgery. Here, laparoscopic scissors are used. The first step is to gently grasp and elevate adjacent areas of tissue and make an incision in the peritoneum. Next, the underlying connective tissue is dissected off the peritoneum so only a thin layer is resected.

This can be done with blunt traction, pushing away from the cut edge of the peritoneum, by activation of the monopolar scissors in a cutting motion, or by using intermittent bursts of electrosurgery on the coagulation setting. Excellent traction and countertraction are necessary. A combination of these techniques is repeated until the entire lesion is undermined.

 Following this, the remaining edge of the peritoneum is cut, removing the endometriotic lesion. This technique is ideal for small focal areas of endometriosis. It can also be of benefit for resecting thicker, more fibrotic, or scarred tissue, as it has the benefit of combining both blunt and sharp dissection. This technique does, however, result in more thermal spread to surrounding tissue, so it is essential to understand the relative position of important anatomical structures.

The last technique demonstrates tissue resection using a laparoscopic laser. First, the area to be resected is identified. Then the CO2 laser is used in a circumferential fashion to outline the lesion. A generous border of at least one centimetre is left around the area of endometriosis.

 The edge of the cut peritoneum is then grasped and elevated. Blunt or laser dissection is used to remove the underlying connective tissue so only a thin layer of peritoneum is resected. The suction irrigator is then used as a backstop and the peritoneum is cut following the previous outline and removed.

This technique has the advantage of allowing the operator to dissect both large and small areas of peritoneum. It allows for very superficial resection of tissue as the laser has a depth of penetration of 0.1 to 0.5 millimetres, leaving the underlying tissue intact. This facilitates resection of lesions near the ureter or vasculature.

This technique requires the availability of a laparoscopic laser and surgical training and proficiency with this instrument. Laser laparoscopy represents the more costly of the instruments used in the three techniques demonstrated.

In this video we reviewed three surgical techniques for laparoscopic resection of superficial endometriosis, hydrodissection, monopolar electrosurgery, and laser laparoscopy.

In conclusion, these three techniques offer valuable options for resecting superficial endometriosis. The choice of technique may depend on the location and characteristics of the lesion and underlying tissue, surface area of desired tissue resection, availability and cost of instruments, as well as the surgeon’s training, experience, and preference.