Endometriosis
6 min read

Restoring Anatomy in Deep Infiltrating Endometriosis

Restoring Anatomy in Deep Infiltrating Endometriosis
Last updated:

Table of Contents

Video Description

Through a single surgical case, this video discusses technical tips in restoring anatomy in the setting of deep infiltrating endometriosis.

Presented By

male doctor avatar
Dr. Ari Sanders
male doctor avatar
Dr. Jonathon Solnik
 

Affiliations

University of Toronto, Mount Sinai Hospital & Women’s College Hospital

Watch on YouTube

Click here to watch this video on YouTube.

What is Restoring Anatomy in Deep Infiltrating Endometriosis?

Restoring Anatomy in Deep Infiltrating Endometriosis (DIE) involves surgical removal of deeply infiltrating endometriotic lesions. DIE, a severe form of endometriosis, causes chronic pain and infertility. The procedure, typically laparoscopic, excises lesions from affected organs like the bowel and bladder to restore function and alleviate symptoms. Patients often experience severe pelvic pain, painful periods, and fertility issues. Diagnosis usually includes imaging techniques like ultrasound or MRI, confirmed during diagnostic laparoscopy. Postoperative care may involve hormonal therapies to prevent recurrence and manage symptoms.

What are the Risks of Restoring Anatomy in Deep Infiltrating Endometriosis?

The risks of restoring anatomy in Deep Infiltrating Endometriosis (DIE) encompass a range of surgical and postoperative complications. Here are some key risks associated with this procedure:

  • Surgical Complications: Surgery for DIE, often laparoscopic, can lead to complications such as bleeding, infection, and damage to surrounding organs, including the bowel, bladder, and ureters.
  • Adhesion Formation: There is a risk of new adhesions forming post-surgery, which can cause pain and require further surgical intervention.
  • Infertility: While surgery aims to improve fertility, there is a possibility that it might not fully restore reproductive function, and in some cases, it might even worsen fertility issues.
  • Recurrence of Endometriosis: Despite successful surgery, endometriotic lesions can recur, necessitating additional treatments or surgeries in the future.
  • Chronic Pain: Some patients may continue to experience chronic pelvic pain even after surgical intervention due to nerve damage or incomplete removal of lesions.
  • Emotional and Psychological Impact: The ongoing pain, infertility, and need for repeated treatments can significantly impact emotional and psychological well-being, leading to anxiety, depression, and reduced quality of life.
  • Bowel and Bladder Dysfunction: Surgical removal of lesions from the bowel and bladder can result in temporary or permanent changes in bowel and bladder function, such as incontinence or constipation.

It is essential for patients undergoing surgery for DIE to have a thorough discussion with their healthcare provider about these risks and to have a comprehensive postoperative care plan to manage potential complications and improve overall outcomes.

Video Transcript: Restoring Anatomy in Deep Infiltrating Endometriosis

We present a 38-year-old with long-standing endometriosis, complicated by other chronic pain syndromes, who has failed medical therapies and has undergone six prior laparoscopies, including left salpingo-oophorectomy. Pre-operative imaging showed a retroverted uterus with adenomyosis and a right ovary adherent to the uterus and colon. We proceeded with laparoscopic hysterectomy, excision of deep infiltrating endometriosis and right salpingo-oophorectomy for definitive management.

With the understanding that hysterectomy does not always result in the desired outcome. After obtaining safe entry, we found significant adhesive disease between the posterior uterus, right ovary and rectosigmoid colon. We began by dividing physiologic adhesions to mobilise the colon and access the pelvic sidewall. We started lateral and cephalad, where anatomy had not been altered, and then moved cauda and into the pelvis.

The round ligament was transected and the broad ligament opened to further develop the perirectal space. Using a suction irrigator, a blunt dissection parallel to the larger vessels was performed to delineate the anterior division of the internal iliac artery. The left uterine artery and obliterated umbilical artery were identified. The ureter was coursing along the mesorectum due to the previous retroperitoneal dissections.

It was skeletonised with blunt dissection superficial to the ureter sheath to avoid devascularisation. The dissection was performed medially to preserve the pelvic blood supply arising laterally from the internal iliac vessels. A similar course of action was taken on the right-hand side, although the dissection in the right perirectal space was more straightforward initially as it had been mostly spared during her prior surgeries.

The perirectal space was then opened to help delineate the border of the rectum on the right-hand side, aid in mobilisation and aid in identification of the ureter laterally. Meticulous dissection was then undertaken to carefully dissect the rectosigmoid colon off of the right ovary and posterior aspect of the uterus. This dissection was performed using a combination of blunt and sharp dissection, along with monopolar electrosurgery.

We worked lateral to medial, starting on the patient’s right, being careful in identifying the correct tissue plane between the ovary and colon to avoid inadvertent injury, but also to minimise risk of ovarian remnant syndrome. The rectum was then mobilised on the patient’s left and dissected away from the left parametrium, where due to her disease and prior surgeries, the left ureter was running into a tunnel of dense fibrotic tissue.

A vessel loop is used here to help identify the ureter and aid in its mobilisation. At this point, the rectum had been freed laterally, with both perirectal spaces identified. Dissection was now undertaken medially to free the rectum from the posterior aspect of the uterus. The vast majority of her endometriosis and fibrosis was retrocervical in nature, accounting for the dense adhesive disease in this area. Eventually, the small right endometrioma seen on pre-op imaging was incised.

This was drained further to aid in dissection. General surgery performed an intraoperative consult and assisted with further dissection in this area. Our goal was to leave as much fibrotic tissue with the specimen as possible without causing inadvertent bowel injury. A rectal probe was then placed to deflect the rectum posteriorly. Dissection was then carried out towards the rectovaginal septum. And eventually, an avascular plane, posterior to the vagina, was developed.

We then needed to free both ureters from the fibrotic tunnels they were running through within the perimetria. We found the monopolar scissors provided enhanced tactile sensation of fibrotic versus healthy tissue. Again, a combination of blunt and sharp dissection was used to complete the ureterolysis on the left, working primarily on the medial aspect of the ureter. Right ureterolysis was then performed in a similar fashion.

On this side, we used a laparoscopic mixture grasper to mobilise the ureter within the fibrotic tunnel through which it was running. We then freed the ureter from this tunnel with sharp dissection and monopolar electrosurgery using the laparoscopic scissors. Eventually, the ureter was displaced laterally, allowing us to proceed with a colpotomy. A colpotomy was then performed using monopolar scissors overtop of a RUMI uterine manipulator and a Koh Cup.

This was started anteriorly, continued laterally and then completed posteriorly. You can see us using the scissors and suction to help locate the Koh Cup, as well as ensure we left as much fibrosis with the specimen as possible. Palpation after colpotomy can also help to identify remaining vaginal fibrotic tissue which can then be further excised. The vaginal vault was closed with a barbed suture, haemostasis was achieved and absence of bowel injury was confirmed with the bubble test.

The patient had voiding dysfunction initially that resolved spontaneously two months after surgery. This can be seen following such aggressive posterior dissection. Pathology returned is adenomyosis, dense fibrosis and adhesive disease and a focus of endometriosis on the right fallopian tube. She is now over two years out from surgery and still reporting significant improvement in pain. She is off all narcotic medications, although she does have symptoms related to her surgical menopause and is currently being followed by the menopause clinic.