FIRST TIME THIS PRESENTATION IN SAIMS MEDICAL COLLEGE ON 21 SEPT 2010

1. Endometriosis and laparoscopy when and how much DR. KAWITA BAPAT

2. Special thanks Dr.VinodBhandari sir Manjudidi Shilpa and Mohit Dr. Ratna madam and Priya

3. Why I chose this topic Mesmerising Disillusioning Confusing Debilitating Interesting Progressive Recurring Worsening Challenging DABANG

4. ENDOMETRIOSIS ECTOPIC ENDOMETRIAL TISSUE TRUE INCIDENCE UNKNOWN DOES NOT DISCRIMINATE RACE HISTOLOGY ENDOMETRIAL GLAND

5. Presentation Pelvic pain Mass Infertility Menstrual irregularities Uncommon and rare problems Diaphragmatic pain cat menial pnumothorex Bowel obstruction

6. when ? LAPAROSCOPIC Management of Endometriosis Diagnosis Acute, chronic pain Significant impact on quality of life Failure of medical therapy Infertility investigation and treatment Endometriomas Secondary organ involvement (bowel, bladder, ureter, nerve)

7. Macroscopic appearance of endometriosis Endometriotic cysts Adhesions black, red, vesicular Bowel endometriosis marked distorted anatomy Pod obliteration

9. Endoscopy classification Wet Endometriosis Superficial Flimsy adhesions Less severe Can be treated by laparoscopic surgery Dry Endometriosis Extremely painful Deep infiltrating Pouch of douglas Recto vaginal septum Uterosacral ligaments Dense fibrosis Difficult to treat

10. When and how much Take a step in the right direction:Innovative, Compassionate & Extraordinary care . a new beginning

11. When and why Laparoscopic Surgical Approach: Objectives Is Surgery Even Necessary: Indications What to do: Burn or Cut? Special Situations: Endometriomas Deep Infiltrating Endometriosis Adjunctive Surgical Techniques

12. Is laparoscopy Even Necessary? Risks – 0.2-3% overall complication rate Requires additional expertise and training Excellent medical options exist for pain GnRH Agonists, Aromatase Inhibitors Mirena IUS

13. Laparoscopic procedures practiced - Electrosurgical ablation of superficial endometriotic deposits - Laser ablation. - Excision of endometrioma. - Excision of deep fibrotic deposits and adhesiolysis. - Hysterectomy & bilateral salpingo-oophorectomy.

14. Surgical Options: “to cut or not to cut” Excision Histological diagnosis Greater depth of treatment Requires greater skill Injury to adjacent organs Thermal damage risk Ablation Faster Less skill required Unable to determine full extent Thermal damage risk

15. ovarian Endometriomas

17. Confirm the diagnosis histological

18. Reduces risk of recurrence over fulguration

19. Reduce the risk of infection at IVF

20. Improves access to follicles and possibly improve ovarian response

22. Endometriomas Excision Tissue specimen Decrease recurrence Post op adhesions Risk of decreasing number of follicles Fulguration Simpler technique ? Preserve greater ovarian tissue Risk of Recurrence

23. Deeply infiltrating endometriosis May be responsible for “failed surgical treatment” Identification is difficult Deep Dyspaurenia Rectovaginal exam Rectal Ultrasound MRI

24. Hysterectomy Along with removal of endometriotic implants Bilateral oophorectomy Subtotal hysterectomy or supra-cervical should not be done

25. Approach to Managing Endometriosis Available expertise Accurate diagnosis Surgical skills Anatomy knowledge Dissection skills Knowledge of energy Suturing skills Specialized team Multi-disciplinary approach Nurse educator Family physician Bowel surgeon Urologist Pain Specialists

26. Laparoscopy pros and cons Advantage Diagnosis and Treatment Prolonged therapeutic effect Fecundity Improvement Disadvantage Risk of injury to organs Greater adhesions Limited resources Limited expertise Negative Laparoscopy

27. ADJUNCTIVE SURGICAL TECHNIQUES Surgical Options 1.-Adhesion Prevention 2.- PresacralNeurectomy 3.- Appendectomy Up to 20% diseased in endometriosis/pain patients Appendectomy: “Hockey Stick” Sign Adhesions: for Advanced Endometriosis Surgery Ureterolysis Suturing Bowel lesions Cystoscopy Rigid Sigmoidscopy

28. Does laparoscopy Help Pain? Sutton et al FertilSteril 1994 (n=63) Laser ablation + LUNA improves pain at 6 months versus expectant management (63 vs. 23%) At 73 months, 55% of follow up (n=38) pain free (JSLS 2001) Abbot J et al. FertilSteril 2004 (n=39) Lap excision improved pain at 6 months compared with diagnostic laparoscopy (80% vs. 32 %)

29. Endometriomas Excision versus Fulguration Recurrence of pain (19 mos vs. 9.5 mos) Berretta et al FertilSteril 1998 Recurrence of symptoms at 2 years(15.8% vs. 56.7%) Re-operation rate (5.8% vs. 22.9%) Alborzi et al. FertilSteril 2004 Overall: EXCISION OF CYST preferable for PAIN

30. adhesions

31. Additional Limitations of laparoscopy Missed lesions: false negative laparoscopy Required Expertise Most not comfortable with advanced and many basic endoscopic techniques Ob/Gyn Endoscopy Survey, Raymond,Ternamian,Leyland JMIG 2004

32. TAKE HOME MESSAGES Ideal practice: diagnose and remove endometriosis surgically at same time treated early and aggressively by surgical destruction or excision excision and ablation provides pain relief Pain can be reduced by removing the entire lesions in severe and deeply infiltrating disease Role for adjunctive procedures is evidence based Adhesion barriers have a role

33. Take Home Messages Consider Adjunctive Surgical Procedures: PresacralNeurectomy Appendectomy Adhesiolysis and Adhesion Prevention

34. hope Management stepwise Follow up regular Correct counselling See and treat approach One stop solutions