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Deep Endometriosis of the Bowel: A Surgical Approach
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97 Plenary 6: Endometriosis (2:00 PM − 3:00 PM) 2:20 PM Outcomes in Women Undergoing Conservative Compared to Definitive Surgery for Chronic Pelvic Pain: A Prospective Cohort Lee C,* Yong PJ, Bedaiwy M, Williams C, Allaire C. Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada *Corresponding author. Study Objective: To compare chronic pelvic pain and quality-of-life outcomes in women undergoing conservative or definitive surgery for pelvic pain. Design: A prospective cohort analytic study (Canadian Task Force Classification II-2). Setting: A tertiary referral center for endometriosis in Vancouver, Canada. Patients or Participants: A total of 676 patients underwent surgical interventions for pelvic pain between December 2013 and July 2016. 517 patients underwent conservative surgery whereas 159 patients underwent definitive surgery. Interventions: Patients underwent either conservative or definitive surgery for chronic pelvic pain. Conservative surgery was defined as excision and/or cautery of endometriosis. Definitive surgery involved a hysterectomy and/or bilateral salpingo-oophorectomy. Measurements and Main Results: Chronic pelvic pain (differentiated from dysmenorrhea or dyspareunia) was determined at baseline, 1-year, and 2-years on a patient-reported numeric rating scale (0-10). Similarly, the Endometriosis Health Profile (EHP)-30 questionnaire functional pain scale (0-100%, lower score indicating better quality-of-life) was determined at baseline, 1 year, and 2 years. The average age of women undergoing surgery was 34 § 8 for conservative surgery and 39 § 6 for definitive surgery. There was no statistically significant difference in self-reported chronic pelvic pain between the two groups at baseline (7 § 2 vs. 7 § 2, p = 0.35), at 1-year (6 § 2 vs. 6 § 2, p = 0.56), or at 2-years (6 § 2 vs. 6 § 3, p = 0.51). For quality-of-life, there was no difference in baseline EHP-30 scores (54% vs. 57%, p = 0.31). However, a statistically significant difference in EHP-30 scores was identified for definitive vs. conservative surgery at 1-year (34% vs. 20%, p <0.001) and at 2-years (33% vs. 20%, p = 0.001). Conclusion: There was no difference in self-reported chronic pelvic pain after follow-up from conservative vs. definitive surgery. However, definitive surgery (hysterectomy +/- BSO) was associated with improved quality-oflife. This improvement may be a result of the elimination of dysmenorrhea. Plenary 6: Endometriosis (2:00 PM − 3:00 PM) 2:30 PM Deep Endometriosis of the Bowel: A Surgical Approach Zhu CR,1,* Suen MW,2 Tadros S,3 Singh SS4. 1Obstetrics and Gynecology, The Ottawa Hospital, Ottawa, ON, Canada; 2Obstetrics and Gynecology, Royal Columbian Hospital, Vancouver, BC, Canada; 3General Surgery, The Ottawa Hospital, Ottawa, ON, Canada; 4Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, ON, Canada *Corresponding author. Video Objective: The objectives of this video are to define bowel endometriosis and to explore various surgical parameters for the different types of surgical excision. Then, a specific surgical approach will be demonstrated. Setting: Our case is of a 34 year old nulliparous woman who presented for surgical management of deep endometriosis, as she was unable to tolerate medical management. She also presented with rectal bleeding and fecal urgency. This case was performed at a tertiary care setting hospital in Canada. Interventions: Surgical management of bowel endometriosis is indicated for symptom and pain relief, intolerance to medical management and to prevent complete obstruction. Importantly, operative planning and
S13 management should involve a multidisciplinary team involving gynecologists, general or colorectal surgeons and radiologists. When planning a surgical approach to deep endometriosis of the bowel, patient characteristics such as age and BMI, as well as their specific symptoms and level of pain, quality of life and fertility goals must be considered. As well, the actual lesion must be investigated with respect to size, number, location, depth of infiltration, and amount of intestinal wall circumference involved. Then, various surgical techniques can be performed depending on these specific characteristics, such as nodule shaving, nodular resection and segmental resection and re-anastomosis. For our surgical case, segmental resection and re-anastomosis was indicated after intra-operative colonoscopy showed significant luminal obstruction. The video demonstrates a blood vessel preservation and nerve sparing approach, highlighting blood supply, sympathetic and para-sympathetic innervation. Conclusion: The patient was discharged post-operative day 2 and reported complete resolution of symptoms at her clinical follow-up. This surgical video demonstrates and advocates a multidisciplinary approach to bowel endometriosis to improve patient quality of life. Plenary 6: Endometriosis (2:00 PM − 3:00 PM) 2:40 PM How we do it: Identification and Dissection of the Sacrospinous Ligament and Lumbosacral Spinal Root on a Patient with Endometriosis of the Pelvic Floor Souza CA,1,* Crispi CP,2 S e AB,2 Crispi C, Jr.2 Hajar F,3 Xavier MAB4. 1 School of Minimally Invasive Surgery, Instituto Crispi, Rio de Janeiro, Brazil; 2Instituto Crispi, Rio de Janeiro, Brazil; 3Universidade Federal do Paran a, Curitiba, Brazil; 4Instituo Crispi, Rio de Janeiro, Brazil *Corresponding author. Video Objective: Our aim is to raise awareness of pelvic floor endometriosis and describe a technique to dissect the pelvis until the pelvic floor muscles identifying the lumbosacral nerves and the main structures of the pelvis. Setting: A 23-year-old woman with cyclic pelvic pain since menarche had a history of claudication and pain in the right lower limb accompanied by dyschezia. At the vaginal and rectal examination, the patient had a nodule in the region of the right sacrospinous ligament, fixed in the pelvis and painful to palpation. The MRI showed a right posterolateral vaginal wall lesion on the uterosacral ligament and the anterior wall of the rectum, that touched the levator ani muscle infiltrating the sacrospinous ligament. Interventions: The medial dissection of the lesion was performed by developing the pararectal space, resecting the uterosacral ligaments, ureterolysis and identifying the hypogastric nerve. Then, during lateral dissection of the lesion, we identified the iliac vessels and the obturator nerve after pelvic lymphadenectomy. The lumbar trunk, the sacral root S1, the superior gluteal artery and the S2 and S3 roots were identified posteriorly. Thus, we identified the lesion extending from the paracolpus and the rectal wall to the sacrospinous ligament in contact with the levator ani muscle. With both sides dissected, it was possible to approach the lesion preserving noble structures such as the ureter, uterine artery and splanchnic nerves. Conclusion: Although endometriosis on the pelvic floor is a rare condition, deeply infiltrating endometriosis is more often diagnosed in young woman such as our patient. Surgical techniques must be developed to asses those type of lesions and videos like this are a form to discuss different approaches to the pelvic floor. Plenary 6: Endometriosis (2:00 PM − 3:00 PM) 2:50 PM Post-Operative Dienogest Following Conservative Endometriosis Surgery: A Systematic Review and MetaAnalysis
S13 management should involve a multidisciplinary team involving gynecologists, general or colorectal surgeons and radiologists. When planning a surgical approach to deep endometriosis of the bowel, patient characteristics such as age and BMI, as well as their specific symptoms and level of pain, quality of life and fertility goals must be considered. As well, the actual lesion must be investigated with respect to size, number, location, depth of infiltration, and amount of intestinal wall circumference involved. Then, various surgical techniques can be performed depending on these specific characteristics, such as nodule shaving, nodular resection and segmental resection and re-anastomosis. For our surgical case, segmental resection and re-anastomosis was indicated after intra-operative colonoscopy showed significant luminal obstruction. The video demonstrates a blood vessel preservation and nerve sparing approach, highlighting blood supply, sympathetic and para-sympathetic innervation. Conclusion: The patient was discharged post-operative day 2 and reported complete resolution of symptoms at her clinical follow-up. This surgical video demonstrates and advocates a multidisciplinary approach to bowel endometriosis to improve patient quality of life. Plenary 6: Endometriosis (2:00 PM − 3:00 PM) 2:40 PM How we do it: Identification and Dissection of the Sacrospinous Ligament and Lumbosacral Spinal Root on a Patient with Endometriosis of the Pelvic Floor Souza CA,1,* Crispi CP,2 S e AB,2 Crispi C, Jr.2 Hajar F,3 Xavier MAB4. 1 School of Minimally Invasive Surgery, Instituto Crispi, Rio de Janeiro, Brazil; 2Instituto Crispi, Rio de Janeiro, Brazil; 3Universidade Federal do Paran a, Curitiba, Brazil; 4Instituo Crispi, Rio de Janeiro, Brazil *Corresponding author. Video Objective: Our aim is to raise awareness of pelvic floor endometriosis and describe a technique to dissect the pelvis until the pelvic floor muscles identifying the lumbosacral nerves and the main structures of the pelvis. Setting: A 23-year-old woman with cyclic pelvic pain since menarche had a history of claudication and pain in the right lower limb accompanied by dyschezia. At the vaginal and rectal examination, the patient had a nodule in the region of the right sacrospinous ligament, fixed in the pelvis and painful to palpation. The MRI showed a right posterolateral vaginal wall lesion on the uterosacral ligament and the anterior wall of the rectum, that touched the levator ani muscle infiltrating the sacrospinous ligament. Interventions: The medial dissection of the lesion was performed by developing the pararectal space, resecting the uterosacral ligaments, ureterolysis and identifying the hypogastric nerve. Then, during lateral dissection of the lesion, we identified the iliac vessels and the obturator nerve after pelvic lymphadenectomy. The lumbar trunk, the sacral root S1, the superior gluteal artery and the S2 and S3 roots were identified posteriorly. Thus, we identified the lesion extending from the paracolpus and the rectal wall to the sacrospinous ligament in contact with the levator ani muscle. With both sides dissected, it was possible to approach the lesion preserving noble structures such as the ureter, uterine artery and splanchnic nerves. Conclusion: Although endometriosis on the pelvic floor is a rare condition, deeply infiltrating endometriosis is more often diagnosed in young woman such as our patient. Surgical techniques must be developed to asses those type of lesions and videos like this are a form to discuss different approaches to the pelvic floor. Plenary 6: Endometriosis (2:00 PM − 3:00 PM) 2:50 PM Post-Operative Dienogest Following Conservative Endometriosis Surgery: A Systematic Review and MetaAnalysis