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Excision of endometriosis with laparosonic coagulating shears
May 1999, Vol. 6, No. 2
The journaJ of the American Association of Gynecologic Laparoscopists
Excision of Endometriosis with Laparosonic Coagulating Shears Martin L. Robbins, M.D.
Abstract Excision of endometriotic lesions allows the diagnosis to be confirmed and may provide long-term relief of symptoms. Laparoscopic excision is generally accepted for treatment of all stages of disease and can be accomplished safely with laser, electrosurgery, or ultrasonic energy. Ultrasonic energy uses the 5-mm hook blade for excision and 5-mm harmonic scalpel ball electrode for coagulation. Disease was excised by laparosonic coagulating shears (LCS) in 14 women. All patients had an uneventful postoperative course, with 13 (93%) remaining pain free 7 to 18 months postoperatively. The LCS is easy to use and allows endometriosis to be excised with an adequate margin of safety. (J Am AssocGyneco! Laparosc6(2):199-203, 1999)
Pelvic endometriosis may be managed with ultrasonic energy using the 5-mm hook blade for excision and the 5-ram harmonic scalpel ball electrode for coagulation, 1 laser, 2'3 and electrical energy. 4 The laparosonic coagulating shears (LCS; Ethicon Endosurgery, Cincinnati, OH) incorporates ultrasonically activated technology in a clamp coagulator and allows excellent cutting with concomitant hemostasis? It facilitates dissection and excision of peritoneal lesions.
(9 women), dyspareunia (7), chronic pelvic pain (5), and infertility (1). Five patients also had hysteroscopy for menorrhagia. Each lesion was completely excised by incorporating a margin of normal peritoneum all the way around the perimeter of the lesion. Using traction and countertraction, dissection was carried down to normal retroperitoneal tissue. No operative complications occurred. All specimens excised were sent for histologic examination. The women had uneventful postoperative courses. Thirteen patients were discharged the same day. The remaining one was admitted for postoperative bowel care (intravenous fluids, antibiotics) after resection of an endometriotic lesion in pefirectal tissues that required laparoscopic repair of the anterior rectal wall. Discoid
Materials and Methods
Operative laparoscopy was performed with complete excision of peritoneal lesions using the LCS in 14 women. Indications for surgery were dysmenorrhea From the Ambulatory Surgery Center, Menomonee Falls, Wisconsin.
Address reprint requests to Martin L. Robbins, M.D., State Street Obstetrics and Gynecology, 148 State Street, Portland, ME 04101; fax 207 879 3979. Presented in part at the 54th annual scientific congress of the American Society of Reproductive Medicine, San Francisco, California, October 3-9, 1998; and the 27th annual meeting of the American Association of Gynecologic Laparoscopists, Atlanta, Georgia, November 10-15, 1998. Accepted for publication February 8, 1999.
199
Excision of Endometroisiswith LaparosonicCoagulating Shears Robbins
resection of a small area of anterior rectal wall was necessary to excise the endometriotic lesion completely. The patient was discharged pain free 4 days postoperatively.
Operative Technique Three 10-ram ports were placed through the umbilicus and in both lower quadrants lateral to the inferior epigastric vessels. The upper abdomen and pelvis were inspected systematically at the start of every case. Photographs were taken before resection for chart documentation. Pelvic anatomy, pathology to be treated and its relationship to bowel, urinary tract, and vessels were identified. The LCS can function as a tissue grasper and blunt dissector. It has an inactive backstop and an active blade with rotational shear, blunt, and flat surfaces. Tissue effects are moderated by power level (50-100 ~), grip strength, tissue tension, and blade geometry. Power level 5 (100 ja) produces the most rapid cutting with minimal but adequate coagulation effect, whereas level 1 (50 ~a) produces maximum coagulation with slow cutting. When using the foot pedal, the surgeon sets the generator at "variable" power level, which is often level 3, whereas "full" power is always level 5. The tighter the grip the quicker the cutting; the looser the grip the more tissue coagulation. Tissues are incised more rapidly if placed on tension. All blade surfaces produce both cutting and coagulation to varying degrees; the shear blade produces the most rapid cutting with the least coagulation effect, the blunt blade gives more hemostasis with slightly slower cutting, and the flat blade gives the most hemostasis with very slow cutting. For example, when coagulating and dividing ovarian vessels, the flat blade is used with a loose grip at level 3. Tissue is held safely away from bowel and pelvic sidewall, but purposely not on tension. When adequate coagulation of and division tissue are achieved, the instrument is rotated, bringing the shear blade into contact with tissue while tightening the grip and lifting up on tension at full power (level 5). To avoid bleeding it is important to allow sufficient time for ultrasonic energy to take effect by letring tissue fall away from the blade without pulling the instrument through the pedicle. When working on pelvic sidewall lesions, the shear blade at level 5 is used with a tight grip while placing tissue to be incised on tension. As long as one is careful to lift peritoneum
up and away from underlying tissues, there is no effect on underlying structures. When working on the pelvic sidewall the LCS is placed through an ipsilateral cannula site. A grasping forceps from the contralateral side is used to sweep underneath and lift up the ovary. Then the ovary is held back with the shaft of the LCS, and the grasping forceps is used to elevate normal peritoneum adjacent to the lesion to be excised. The retroperitoneal space is safely entered with the LCS by making a small peritoneal incision. The LCS is used to spread the peritoneal opening as the grasping forceps takes hold of the peritoneal edge (Figure 1).
FIGURE 1. (A) Peritoneum is elevated adjacent to an endometriotic lesion in preparation for entering the retroperitoneal space.
(B) The LCS is used to spread the opening into the retroperitoneal space, while the grasping forceps takes hold of the peritoneal edge.
200
May 1999, Vol. 6, No. 2
TheJournal of the American Association of Gynecologic Laparoscopists
FIGURE 2. (A) Endometriotic implants and fibrosis covering the left pelvic sidewall over the left ureter.
FIGURE 3. (A) Large left ovarian endometrioma and severe endometriosis involving the ovaries, entire cul-de-sac, and all pelvic peritoneal surfaces.
(B) Left pelvic sidewall endometriosis resected. The left ureter is seen and had normal peristalsis.
(B) Normal pelvis after removal of the ovarian endometrioma and complete excision of all areas of endometriosis.
Traction and countertraction are applied repeatedly during dissection. All visible areas of disease are resected (Figures 2 and 3). Hemostasis is checked at low (6 mm Hg) intraabdominal pressure and under irrigation fluid at the end of the procedure.
According to the American Society for Reproductive Medicine classification, of the 14 patients, 1 had minimal, 6 mild, 4 moderate, and 3 severe disease. Pathologic specimens were reported as follows: 1. Right and left bladder flap, right and left pelvic sidewall, right and left uterosacral ligaments, cul-de-sac, and right pelvic brim all positive for endometriosis; 6-cm right ovarian endometrioma 2. Right and left pelvic sidewalls, left uterosacral ligament, and cul-de-sac positive for endometriosis; right ovarian corpus luteum cyst; left bladder flap; coagulated connective tissue
Follow-up and Histopathologic Reports The patients were followed for 7 to 18 months. Relief of pelvic pain was determined at office visits 2 weeks after surgery and then every 6 months, and by telephone interviews. All patients initially achieved pain relief. The patient with severe rectal disease again experienced worsening central dysmenorrhea 6 months postoperatively. 201
Excision of Endometroisiswith LaparosonicCoagulating Shears Robbins
completely off tissue. Finally, the blade motion is longitudinal so that the direction of energy is parallel to the applied force, thus allowing the surgeon to dissect one tissue layer at a time without an effect on underlying structures. The low pressure at the blade tip causes tissue fluids to vaporize at low temperatures. This causes the cavitation effect that facilitates dissection of tissue planes; and it only creates a water vapor that quickly settles out of the field of view. Since the LCS does not become hot and cools off rapidly, in the nonactivated state it can also serve as a grasping forceps and blunt dissector. The harmonic scalpel was developed so that surgeons could make surgical incisions without blood loss. 6 It consists of a generator, reusable hand piece, blade system, and foot pedal. The blade vibrates 55,500 times/second in a longitudinal direction over an excursion of 50 to 100 ~t. Hemostasis is achieved through coaptive coagulation. Tissue proteins are denatured, thus producing a protein coagulum that seals coapted vessel walls. Laser, electrical, and ultrasonic energy all obtain hemostasis by coaptive coagulation. Laser and electrical energy denature tissue proteins through production of heat, whereas ultrasonic energy does this mechanically. Ultrasonic energy operates in the temperature range of 50 to 100 ~ C, when protein coagulation occurs. Laser and electrosurgical energies create a temperature range of 100 to 400 ~ C when tissue desiccation (100-150 ~ C) and charring (> 150 ~ C) occur. The rapid movement of the blade through tissue and the physical disruption of tissues caused by ultrasonic energy achieve ultrasonic cutting. Since the LCS can be used for cutting, coagulating, dissecting, and grasping, the surgeon is rarely off the tissue. This saves valuable time that is otherwise spent on instrument changes. Hormone treatment has been administered for years with good results for temporary alleviation of pain secondary to endometriosis. Hormone receptor levels vary, and are very low in endometriotic tissue relative to intrauterine endometrium.4 Ectopic endometrium can survive after menopause, after castration, 4 and with very low estrogen levels, and endometriosis can persist despite gonadotropin-releasing hormone therapy. Therefore, other than giving hormone therapy as a temporizing measure, treatment of pelvic endometriosis is surgical. Another advantage of complete
3. Left uterosacral ligament, endometriosis; left ovarian corpus luteum cyst; left pelvic sidewall and cul-de-sac coagulated fibrous fatty tissue 4. Left bladder flap and cul-de-sac fibrous fatty tissue 5. Right and left bladder flaps, right lower abdominal wall, right flank, right pelvic sidewall, and left uterosacral ligament all positive for endometriosis; left pelvic sidewall and fight uterosacral ligament fibrosis 6. Right and left bladder flaps, right and left pelvic sidewalls, left uterosacral ligament, and cul-desac all positive for endometriosis; 5-cm left ovarian endometrioma 7. Right uterosacral ligament endometriosis; 3.7-cm left ovarian endometrioma; right sidewall fibrosis 8. Right and left uterosacral ligaments endometriosis 9. Right and left uterosacral ligaments and pelvic sidewalls chronic inflammation and fibrosis 10. Right pelvic sidewall and cul-de-sac endometriosis; left sidewall, uterosacral ligament fibrous fatty tissue 11. Right and left pelvic sidewalls and cul-de-sac endometriosis; uterosacral ligaments, right paracolic gutter, and peritoneal pocket fibrous fatty tissue; 2.5-cm submucosal uterine fibroid 12. Right and left pelvic sidewalls and cul-de-sac endometriosis 13. Right and left bladder flaps endometriosis; right pelvic sidewall fibrous fatty tissue 14. Right pelvic sidewall, left ovarian tissue endometriosis; retroperitoneal pocket from right side of cul-de-sac colonic wall with endometriosis; left pelvic sidewall, uterosacral, cul-de-sac fibrous fatty tissue Discussion
With the LCS the surgeon can operate safely in close proximity to vital structures. It works at a relatively low temperature range, thus minimizing tissue charring and desiccation. By reducing thermal injury the LCS allows rapid healing, produces little smoke, which gives better visualization, and minimizes postoperative adhesions. The instrument has no electrical current passing through the patient, so there is no chance of electrical spark to nearby tissues. Ultrasonic energy affects only tissues it directly contacts, so it can be safely maintained until the instrument is
202
May 1999, Vo[. 6, No. 2
TheJournd of the American Association of Gynecologic Laparoscopists
excision of all visible disease is that postoperative hormone therapy is generally not necessary. Therefore, favorable results can be attributed to surgery. Traditionally, surgical treatment of endometriosis was by open laparotomy, which required a long recovery and increased the propensity for developing adhesions. Results of operative laparoscopy are as good as or better than those of open surgery with regard to operating time, estimated blood loss, recovery time, endometrioma recurrence rate, and pregnancy rate. v With exposure, illumination, magnification, and ability to work in close proximity to tissue at laparoscopy, experienced laparoscopic surgeons are able to treat mild to extensive endometriosis more thoroughly and safely than possible with open laparotomy) The visualization that laparoscopy affords is particularly important, given how subtle the appearance of endometriotic lesions can be. 9With systematic, detailed laparoscopic inspection, the surgeon can inspect the pelvis for all lesions. The naked eye at open laparotomy cannot inspect the pelvis this closely. Endometriosis can be treated surgically by ablation, coagulation, excision, or a combination of these. The deepest disease is commonly the most symptomatic. In one study, lesions penetrated more than 2 mm in 61% and more than 5 mm in 25% of patients? ~ Monopolar electrosurgery is safe, but the depth of coagulation is variable and may cause significant tissue injury. Bipolar electrosurgical coagulation reliably coagulates lesions held between the forceps, but may penetrate only 1 to 2 mm through lesions that are flat and cannot be grasped. Thermal coagulators are relatively safe but coagulate to no more than 2 mm. The CO2 laser, argon beam coagulator, potassiumtitanyl-phosphate laser, and neodynium:yttriumaluminum-garnet laser coagulate to a depth of 0.04 to 0.5 mm, 2 mm, 2 mm, and 0.3 to 4.4 mm, respectively. 11-13 The depth that endometriosis penetrates can vary within a single lesion. When vaporizing or coagulating lesions it is important to treat deeper portions of the disease completely to avoid skip areas, which result in residual endometriosis and persistent pain. Given the variable depth from coagulation techniques and the risk for creating skip areas with vaporization, laparoscopic excision provides the most complete surgical treatment for pelvic endometriosis. Excision
203
of disease with the LCS appears to be safe and efficacious. References
1. Miller CE, Ferland RJ, McCarus SD: Clinical efficacy of the ultrasonically activated scalpel for cytoreduction of endometriosis lesions. J Am Assoc Gynecol Laparosc 2(4, suppl):S32, 1995 2. Nezhat C, Silfen S, Nezhat F, et al: Surgery for endometriosis. Curr Opin Obstet Gynecol 3(3):385-393,1991 3. Martin DC. Carbon dioxide laser laparoscopy for endometriosis. Obstet Gynecol Clin North Am 18(3):575-583, 1991 4. Redwine DB: Endometriosis persisting after castration: Clinical characteristics and results of surgical management. Obstet Gynecol 83:405-413, 1994 5. Amaral JF: The experimental development of an ultrasonically activated scalpel for laparoscopic use. Surg Laparosc Endosc 4(2):92-99, 1994 6. Amaral JF: Laparoscopic application of an ultrasonically activated scalpel. Gastrointest Endosc Clin North Am 3:381-392, 1993 7. Bateman BG, Kolp LA, Mills S: Endoscopic versus laparotomy management of endometriomas. Fertil Steril 62:690-695, 1994 8. Nezhat C, Nezhat F, Nezhat C: Operative laparoscopy (minimally invasive surgery): State of the art. J Gynecol Surg 8:111-141, 1992 9. Martin DC. Endometriosis subtle lesions. Female Patient 19:48-54, 1994 10. Martin DC, Hubert GD, Vander Zwaeg R, et al: Laparoscopic appearances of peritoneal endometriosis. Fertil Steril 51:63-67, 1989 11. Martin DC, Hubert GD, Levy BS: Depth of infiltration of endometriosis. J Gynecol Surg 5:55-59, 1989 12. Taylor MV, Martin DC, Poston W, et al: Effect of power density and carbonization on residual tissue coagulation using the continuous wave carbon dioxide laser. Colposc Gynecol Laser Surg 2:169-175, 1986 13. Joffe SN, Brackett KA, Sankar MY, et al: Resection of the liver with the Nd:YAG laser. Surg Gynecol Obstet 163:437-442, 1986
The journaJ of the American Association of Gynecologic Laparoscopists
Excision of Endometriosis with Laparosonic Coagulating Shears Martin L. Robbins, M.D.
Abstract Excision of endometriotic lesions allows the diagnosis to be confirmed and may provide long-term relief of symptoms. Laparoscopic excision is generally accepted for treatment of all stages of disease and can be accomplished safely with laser, electrosurgery, or ultrasonic energy. Ultrasonic energy uses the 5-mm hook blade for excision and 5-mm harmonic scalpel ball electrode for coagulation. Disease was excised by laparosonic coagulating shears (LCS) in 14 women. All patients had an uneventful postoperative course, with 13 (93%) remaining pain free 7 to 18 months postoperatively. The LCS is easy to use and allows endometriosis to be excised with an adequate margin of safety. (J Am AssocGyneco! Laparosc6(2):199-203, 1999)
Pelvic endometriosis may be managed with ultrasonic energy using the 5-mm hook blade for excision and the 5-ram harmonic scalpel ball electrode for coagulation, 1 laser, 2'3 and electrical energy. 4 The laparosonic coagulating shears (LCS; Ethicon Endosurgery, Cincinnati, OH) incorporates ultrasonically activated technology in a clamp coagulator and allows excellent cutting with concomitant hemostasis? It facilitates dissection and excision of peritoneal lesions.
(9 women), dyspareunia (7), chronic pelvic pain (5), and infertility (1). Five patients also had hysteroscopy for menorrhagia. Each lesion was completely excised by incorporating a margin of normal peritoneum all the way around the perimeter of the lesion. Using traction and countertraction, dissection was carried down to normal retroperitoneal tissue. No operative complications occurred. All specimens excised were sent for histologic examination. The women had uneventful postoperative courses. Thirteen patients were discharged the same day. The remaining one was admitted for postoperative bowel care (intravenous fluids, antibiotics) after resection of an endometriotic lesion in pefirectal tissues that required laparoscopic repair of the anterior rectal wall. Discoid
Materials and Methods
Operative laparoscopy was performed with complete excision of peritoneal lesions using the LCS in 14 women. Indications for surgery were dysmenorrhea From the Ambulatory Surgery Center, Menomonee Falls, Wisconsin.
Address reprint requests to Martin L. Robbins, M.D., State Street Obstetrics and Gynecology, 148 State Street, Portland, ME 04101; fax 207 879 3979. Presented in part at the 54th annual scientific congress of the American Society of Reproductive Medicine, San Francisco, California, October 3-9, 1998; and the 27th annual meeting of the American Association of Gynecologic Laparoscopists, Atlanta, Georgia, November 10-15, 1998. Accepted for publication February 8, 1999.
199
Excision of Endometroisiswith LaparosonicCoagulating Shears Robbins
resection of a small area of anterior rectal wall was necessary to excise the endometriotic lesion completely. The patient was discharged pain free 4 days postoperatively.
Operative Technique Three 10-ram ports were placed through the umbilicus and in both lower quadrants lateral to the inferior epigastric vessels. The upper abdomen and pelvis were inspected systematically at the start of every case. Photographs were taken before resection for chart documentation. Pelvic anatomy, pathology to be treated and its relationship to bowel, urinary tract, and vessels were identified. The LCS can function as a tissue grasper and blunt dissector. It has an inactive backstop and an active blade with rotational shear, blunt, and flat surfaces. Tissue effects are moderated by power level (50-100 ~), grip strength, tissue tension, and blade geometry. Power level 5 (100 ja) produces the most rapid cutting with minimal but adequate coagulation effect, whereas level 1 (50 ~a) produces maximum coagulation with slow cutting. When using the foot pedal, the surgeon sets the generator at "variable" power level, which is often level 3, whereas "full" power is always level 5. The tighter the grip the quicker the cutting; the looser the grip the more tissue coagulation. Tissues are incised more rapidly if placed on tension. All blade surfaces produce both cutting and coagulation to varying degrees; the shear blade produces the most rapid cutting with the least coagulation effect, the blunt blade gives more hemostasis with slightly slower cutting, and the flat blade gives the most hemostasis with very slow cutting. For example, when coagulating and dividing ovarian vessels, the flat blade is used with a loose grip at level 3. Tissue is held safely away from bowel and pelvic sidewall, but purposely not on tension. When adequate coagulation of and division tissue are achieved, the instrument is rotated, bringing the shear blade into contact with tissue while tightening the grip and lifting up on tension at full power (level 5). To avoid bleeding it is important to allow sufficient time for ultrasonic energy to take effect by letring tissue fall away from the blade without pulling the instrument through the pedicle. When working on pelvic sidewall lesions, the shear blade at level 5 is used with a tight grip while placing tissue to be incised on tension. As long as one is careful to lift peritoneum
up and away from underlying tissues, there is no effect on underlying structures. When working on the pelvic sidewall the LCS is placed through an ipsilateral cannula site. A grasping forceps from the contralateral side is used to sweep underneath and lift up the ovary. Then the ovary is held back with the shaft of the LCS, and the grasping forceps is used to elevate normal peritoneum adjacent to the lesion to be excised. The retroperitoneal space is safely entered with the LCS by making a small peritoneal incision. The LCS is used to spread the peritoneal opening as the grasping forceps takes hold of the peritoneal edge (Figure 1).
FIGURE 1. (A) Peritoneum is elevated adjacent to an endometriotic lesion in preparation for entering the retroperitoneal space.
(B) The LCS is used to spread the opening into the retroperitoneal space, while the grasping forceps takes hold of the peritoneal edge.
200
May 1999, Vol. 6, No. 2
TheJournal of the American Association of Gynecologic Laparoscopists
FIGURE 2. (A) Endometriotic implants and fibrosis covering the left pelvic sidewall over the left ureter.
FIGURE 3. (A) Large left ovarian endometrioma and severe endometriosis involving the ovaries, entire cul-de-sac, and all pelvic peritoneal surfaces.
(B) Left pelvic sidewall endometriosis resected. The left ureter is seen and had normal peristalsis.
(B) Normal pelvis after removal of the ovarian endometrioma and complete excision of all areas of endometriosis.
Traction and countertraction are applied repeatedly during dissection. All visible areas of disease are resected (Figures 2 and 3). Hemostasis is checked at low (6 mm Hg) intraabdominal pressure and under irrigation fluid at the end of the procedure.
According to the American Society for Reproductive Medicine classification, of the 14 patients, 1 had minimal, 6 mild, 4 moderate, and 3 severe disease. Pathologic specimens were reported as follows: 1. Right and left bladder flap, right and left pelvic sidewall, right and left uterosacral ligaments, cul-de-sac, and right pelvic brim all positive for endometriosis; 6-cm right ovarian endometrioma 2. Right and left pelvic sidewalls, left uterosacral ligament, and cul-de-sac positive for endometriosis; right ovarian corpus luteum cyst; left bladder flap; coagulated connective tissue
Follow-up and Histopathologic Reports The patients were followed for 7 to 18 months. Relief of pelvic pain was determined at office visits 2 weeks after surgery and then every 6 months, and by telephone interviews. All patients initially achieved pain relief. The patient with severe rectal disease again experienced worsening central dysmenorrhea 6 months postoperatively. 201
Excision of Endometroisiswith LaparosonicCoagulating Shears Robbins
completely off tissue. Finally, the blade motion is longitudinal so that the direction of energy is parallel to the applied force, thus allowing the surgeon to dissect one tissue layer at a time without an effect on underlying structures. The low pressure at the blade tip causes tissue fluids to vaporize at low temperatures. This causes the cavitation effect that facilitates dissection of tissue planes; and it only creates a water vapor that quickly settles out of the field of view. Since the LCS does not become hot and cools off rapidly, in the nonactivated state it can also serve as a grasping forceps and blunt dissector. The harmonic scalpel was developed so that surgeons could make surgical incisions without blood loss. 6 It consists of a generator, reusable hand piece, blade system, and foot pedal. The blade vibrates 55,500 times/second in a longitudinal direction over an excursion of 50 to 100 ~t. Hemostasis is achieved through coaptive coagulation. Tissue proteins are denatured, thus producing a protein coagulum that seals coapted vessel walls. Laser, electrical, and ultrasonic energy all obtain hemostasis by coaptive coagulation. Laser and electrical energy denature tissue proteins through production of heat, whereas ultrasonic energy does this mechanically. Ultrasonic energy operates in the temperature range of 50 to 100 ~ C, when protein coagulation occurs. Laser and electrosurgical energies create a temperature range of 100 to 400 ~ C when tissue desiccation (100-150 ~ C) and charring (> 150 ~ C) occur. The rapid movement of the blade through tissue and the physical disruption of tissues caused by ultrasonic energy achieve ultrasonic cutting. Since the LCS can be used for cutting, coagulating, dissecting, and grasping, the surgeon is rarely off the tissue. This saves valuable time that is otherwise spent on instrument changes. Hormone treatment has been administered for years with good results for temporary alleviation of pain secondary to endometriosis. Hormone receptor levels vary, and are very low in endometriotic tissue relative to intrauterine endometrium.4 Ectopic endometrium can survive after menopause, after castration, 4 and with very low estrogen levels, and endometriosis can persist despite gonadotropin-releasing hormone therapy. Therefore, other than giving hormone therapy as a temporizing measure, treatment of pelvic endometriosis is surgical. Another advantage of complete
3. Left uterosacral ligament, endometriosis; left ovarian corpus luteum cyst; left pelvic sidewall and cul-de-sac coagulated fibrous fatty tissue 4. Left bladder flap and cul-de-sac fibrous fatty tissue 5. Right and left bladder flaps, right lower abdominal wall, right flank, right pelvic sidewall, and left uterosacral ligament all positive for endometriosis; left pelvic sidewall and fight uterosacral ligament fibrosis 6. Right and left bladder flaps, right and left pelvic sidewalls, left uterosacral ligament, and cul-desac all positive for endometriosis; 5-cm left ovarian endometrioma 7. Right uterosacral ligament endometriosis; 3.7-cm left ovarian endometrioma; right sidewall fibrosis 8. Right and left uterosacral ligaments endometriosis 9. Right and left uterosacral ligaments and pelvic sidewalls chronic inflammation and fibrosis 10. Right pelvic sidewall and cul-de-sac endometriosis; left sidewall, uterosacral ligament fibrous fatty tissue 11. Right and left pelvic sidewalls and cul-de-sac endometriosis; uterosacral ligaments, right paracolic gutter, and peritoneal pocket fibrous fatty tissue; 2.5-cm submucosal uterine fibroid 12. Right and left pelvic sidewalls and cul-de-sac endometriosis 13. Right and left bladder flaps endometriosis; right pelvic sidewall fibrous fatty tissue 14. Right pelvic sidewall, left ovarian tissue endometriosis; retroperitoneal pocket from right side of cul-de-sac colonic wall with endometriosis; left pelvic sidewall, uterosacral, cul-de-sac fibrous fatty tissue Discussion
With the LCS the surgeon can operate safely in close proximity to vital structures. It works at a relatively low temperature range, thus minimizing tissue charring and desiccation. By reducing thermal injury the LCS allows rapid healing, produces little smoke, which gives better visualization, and minimizes postoperative adhesions. The instrument has no electrical current passing through the patient, so there is no chance of electrical spark to nearby tissues. Ultrasonic energy affects only tissues it directly contacts, so it can be safely maintained until the instrument is
202
May 1999, Vo[. 6, No. 2
TheJournd of the American Association of Gynecologic Laparoscopists
excision of all visible disease is that postoperative hormone therapy is generally not necessary. Therefore, favorable results can be attributed to surgery. Traditionally, surgical treatment of endometriosis was by open laparotomy, which required a long recovery and increased the propensity for developing adhesions. Results of operative laparoscopy are as good as or better than those of open surgery with regard to operating time, estimated blood loss, recovery time, endometrioma recurrence rate, and pregnancy rate. v With exposure, illumination, magnification, and ability to work in close proximity to tissue at laparoscopy, experienced laparoscopic surgeons are able to treat mild to extensive endometriosis more thoroughly and safely than possible with open laparotomy) The visualization that laparoscopy affords is particularly important, given how subtle the appearance of endometriotic lesions can be. 9With systematic, detailed laparoscopic inspection, the surgeon can inspect the pelvis for all lesions. The naked eye at open laparotomy cannot inspect the pelvis this closely. Endometriosis can be treated surgically by ablation, coagulation, excision, or a combination of these. The deepest disease is commonly the most symptomatic. In one study, lesions penetrated more than 2 mm in 61% and more than 5 mm in 25% of patients? ~ Monopolar electrosurgery is safe, but the depth of coagulation is variable and may cause significant tissue injury. Bipolar electrosurgical coagulation reliably coagulates lesions held between the forceps, but may penetrate only 1 to 2 mm through lesions that are flat and cannot be grasped. Thermal coagulators are relatively safe but coagulate to no more than 2 mm. The CO2 laser, argon beam coagulator, potassiumtitanyl-phosphate laser, and neodynium:yttriumaluminum-garnet laser coagulate to a depth of 0.04 to 0.5 mm, 2 mm, 2 mm, and 0.3 to 4.4 mm, respectively. 11-13 The depth that endometriosis penetrates can vary within a single lesion. When vaporizing or coagulating lesions it is important to treat deeper portions of the disease completely to avoid skip areas, which result in residual endometriosis and persistent pain. Given the variable depth from coagulation techniques and the risk for creating skip areas with vaporization, laparoscopic excision provides the most complete surgical treatment for pelvic endometriosis. Excision
203
of disease with the LCS appears to be safe and efficacious. References
1. Miller CE, Ferland RJ, McCarus SD: Clinical efficacy of the ultrasonically activated scalpel for cytoreduction of endometriosis lesions. J Am Assoc Gynecol Laparosc 2(4, suppl):S32, 1995 2. Nezhat C, Silfen S, Nezhat F, et al: Surgery for endometriosis. Curr Opin Obstet Gynecol 3(3):385-393,1991 3. Martin DC. Carbon dioxide laser laparoscopy for endometriosis. Obstet Gynecol Clin North Am 18(3):575-583, 1991 4. Redwine DB: Endometriosis persisting after castration: Clinical characteristics and results of surgical management. Obstet Gynecol 83:405-413, 1994 5. Amaral JF: The experimental development of an ultrasonically activated scalpel for laparoscopic use. Surg Laparosc Endosc 4(2):92-99, 1994 6. Amaral JF: Laparoscopic application of an ultrasonically activated scalpel. Gastrointest Endosc Clin North Am 3:381-392, 1993 7. Bateman BG, Kolp LA, Mills S: Endoscopic versus laparotomy management of endometriomas. Fertil Steril 62:690-695, 1994 8. Nezhat C, Nezhat F, Nezhat C: Operative laparoscopy (minimally invasive surgery): State of the art. J Gynecol Surg 8:111-141, 1992 9. Martin DC. Endometriosis subtle lesions. Female Patient 19:48-54, 1994 10. Martin DC, Hubert GD, Vander Zwaeg R, et al: Laparoscopic appearances of peritoneal endometriosis. Fertil Steril 51:63-67, 1989 11. Martin DC, Hubert GD, Levy BS: Depth of infiltration of endometriosis. J Gynecol Surg 5:55-59, 1989 12. Taylor MV, Martin DC, Poston W, et al: Effect of power density and carbonization on residual tissue coagulation using the continuous wave carbon dioxide laser. Colposc Gynecol Laser Surg 2:169-175, 1986 13. Joffe SN, Brackett KA, Sankar MY, et al: Resection of the liver with the Nd:YAG laser. Surg Gynecol Obstet 163:437-442, 1986