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Excision of Ovarian Remnant Causing Chronic Pelvic Pain
S94 Conclusion: Diaphragmatic nodules can be easily classified in one of the proposed groups. Considering this classification, different methods of surgical treatments of DE can be chosen, in order to allow a total and safe removal of the lesions, with low complications rate and a significant improvement of patients’ symptoms. Open Communications 27: Endometriosis (4:10 PM − 5:10 PM) 4:45 PM Excision of Ovarian Remnant Causing Chronic Pelvic Pain Jones AS,* Thomas CM, Penketh RJ. Department of Womens’ Health, University Hospital of Wales, Cardiff, Cardiff, United Kingdom *Corresponding author. Video Objective: To demonstrate effective excision of ovarian remnant in chronic pelvic pain following hysterectomy and bilateral salpingoophrectomy for endometriosis. Setting: A 38year-old G0 was diagnosed with endometriosis aged 17, subsequently undergoing 37 laparoscopies for pelvic pain. Total laparoscopic hysterectomy and bilateral salpingoophrectomy was performed aged 32, reported as technically difficult due to deep infiltrating endometriosis and adhesions. She continued to suffer with pelvic pain, with multiple admissions with subacute small bowel obstruction. A trial of progesterone and GNRH was unsuccessful. In 2017 ultrasound showed a cystic structure in the right pelvis, suggesting ovarian remnant confirmed by FSH and oestradiol levels. Interventions: Laparoscopic adhesiolysis and excision of ovarian remnant was scheduled and Clomiphene 50mg prescribed 2 weeks preoperatively to stimulate the ovarian tissue, allowing easier identification and excision. Intraoperative ultrasound demonstrated increased ovarian volume. On entry there were dense adhesions and the pelvis obliterated. Methodical adhesiolysis was achieved with a mixture of blunt dissection and monopolar diathermy. The ovarian remnant was seen on the right side surrounded by thickened peritoneum. The ureter was identified and unexpectedly found pulled medially by adhesions. Ureterolysis was performed down to the ovarian remnant, which was dissected to allow the ureter to fall laterally. The ovarian remnant was safely excised with the cystic elements aspirated to facilitate removal in a retrieval bag via the 5mm right iliac fossa port incision. The ovarian tissue was excised in its entirety and at the end of the procedure the bowel was mobile, lying in its anatomical position. Conclusion: Consider remnant ovarian tissue in endometriosis patients who have had previous difficult hysterectomy and bilateral salpingoophrectomy with continued pain. Clomiphene enlarges remnant ovarian tissue to aid identification and excision. Before excising pathology it is important to identify normal structures when presented with distorted anatomy to ensure a safe approach. Open Communications 27: Endometriosis (4:10 PM − 5:10 PM) 4:52 PM Recurrence of Endometriosis After Laparoscopic Hysterectomy Shirane A,* Andou M, Shirane T, Ichikawa F, Sakate S, Sawada M. Obstetrics and Gynecology, Kurashiki Medical Center, Kurashiki, Japan *Corresponding author. Video Objective: Endometriosis is known to have a remarkably negative effect on the Quality of Life (QOL) of the women. Surgery is considered when medical therapy is unsuccessful or in the setting of infertility. A high recurrence rate is reported in advanced stages of endometriosis. Thus, Complete excision and prevention of recurrence is particularly important. Following hysterectomy, pelvic pain and vaginal bleeding are a rare but
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97 real occurrence. We evaluated the recurrence of pain and bleeding in patients following hysterectomy and infertility sparing procedures. Design: Retrospective cohort. Setting: Kurashiki medical center, private hospital, in Japan. Interventions: We evaluated postoperative recurrence of endometriosis from January, 2004 to December, 2018 in patients who underwent laparoscopic excision of endometriosis, with or without postoperative hormone therapy. Main Results: In our facility, endometriosis recurred in 20 cases (3.85%) out of 519 total laparoscopic hysterectomy (TLH) with ovarian sparing procedures. 17 of the 20 cases were not treated with hormone therapy postoperatively. No recurrence was found in 288 patients who underwent TLH plus bilateral salpingo-oophorectomy. In fertility sparing cases, 7.5%(152/ 2012 cases) had recurrence after surgery. Recurrence rate decreased to 4.9%(85/1750 cases) after January, 2008 compared with 24.7%(67/271) before December, 2007.For fertility sparing endometriosis excision surgery, postoperative recurrence without hormone therapy was found in six (1case in rectum, 5 cases in ovaries) out of fifteen cases. With postoperative hormone treatment using dienogest, a “fourth-generation” progestin, recurrence was found in only one case out of fifteen hormone therapy groups. Median recurrent period was 6 months. Surprisingly, 11 out of 22 fertility sparing cases were diagnosed as endometrioma with 1 month postoperative MRI. Conclusion: Approval of dienogest in 2008 may have contributed to the dramatic improvement in preventing recurrence of endometriosis. Hysterectomy significantly decreases patient symptoms and recurrence rate. Ovarian conservation conferred a higher rate of recurrence of symptoms of endometriosis. Open Communications 27: Endometriosis (4:10 PM − 5:10 PM) 4:59 PM Laparoscopic Management of Rectus Muscle Endometrioisis Fogelson N*. Northwest Endometriosis and Pelvic Surgery, Portland, OR *Corresponding author. Video Objective: To demonstrate technique for laparoscopic management of abdominal wall endometriosis contained within the rectus muscle. Setting: A private practice specialized in the care of women with endometriosis. Interventions: A 41 year old woman complained of severe cyclic pain in the abdominal wall. She had had two previous cesarean deliveries, and noted this mass and the resulting pain after the second surgery. The mass was only palpable to her during her menses, but otherwise was not palpable. Previous imaging via MRI demonstrated a mass within the abdominal wall. An outside surgeon had performed a laparotomy but did not encounter any mass to resect, resulting in no improvement for the patient. Review of the images demonstrated that the mass was entirely retrofascial within the rectus muscle, explaining the previous surgeon’s failure to find a mass. A laparoscopic approach was discussed with the patient and consent was obtained. At laparoscopy, the mass was entirely resected, including portions of rectus muscle and parietal peritoneum, without the need to breach the rectus fascia. Rectus muscle and peritoneum was brought together over the defect. Conclusion: At three months, the patient reports near complete resolution her pain, and a dramatically improved quality of life. Abdominal wall endometriosis is a relatively rare presentation of the disease but presents with some frequency to expert endometriosis practices. In most cases it is the result of iatrogenic seeding of the abdominal wall with native endometrium at the time of cesarean delivery or other surgery. In most cases, subcutaneous tissue and anterior rectus fascia is involved, demanding an open approach to resection. In rare cases such as this, the entire lesion may be under the fascia within the rectus muscle or abdominal obliques, allowing a laparoscopic or robotic approach to full resection.
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97 real occurrence. We evaluated the recurrence of pain and bleeding in patients following hysterectomy and infertility sparing procedures. Design: Retrospective cohort. Setting: Kurashiki medical center, private hospital, in Japan. Interventions: We evaluated postoperative recurrence of endometriosis from January, 2004 to December, 2018 in patients who underwent laparoscopic excision of endometriosis, with or without postoperative hormone therapy. Main Results: In our facility, endometriosis recurred in 20 cases (3.85%) out of 519 total laparoscopic hysterectomy (TLH) with ovarian sparing procedures. 17 of the 20 cases were not treated with hormone therapy postoperatively. No recurrence was found in 288 patients who underwent TLH plus bilateral salpingo-oophorectomy. In fertility sparing cases, 7.5%(152/ 2012 cases) had recurrence after surgery. Recurrence rate decreased to 4.9%(85/1750 cases) after January, 2008 compared with 24.7%(67/271) before December, 2007.For fertility sparing endometriosis excision surgery, postoperative recurrence without hormone therapy was found in six (1case in rectum, 5 cases in ovaries) out of fifteen cases. With postoperative hormone treatment using dienogest, a “fourth-generation” progestin, recurrence was found in only one case out of fifteen hormone therapy groups. Median recurrent period was 6 months. Surprisingly, 11 out of 22 fertility sparing cases were diagnosed as endometrioma with 1 month postoperative MRI. Conclusion: Approval of dienogest in 2008 may have contributed to the dramatic improvement in preventing recurrence of endometriosis. Hysterectomy significantly decreases patient symptoms and recurrence rate. Ovarian conservation conferred a higher rate of recurrence of symptoms of endometriosis. Open Communications 27: Endometriosis (4:10 PM − 5:10 PM) 4:59 PM Laparoscopic Management of Rectus Muscle Endometrioisis Fogelson N*. Northwest Endometriosis and Pelvic Surgery, Portland, OR *Corresponding author. Video Objective: To demonstrate technique for laparoscopic management of abdominal wall endometriosis contained within the rectus muscle. Setting: A private practice specialized in the care of women with endometriosis. Interventions: A 41 year old woman complained of severe cyclic pain in the abdominal wall. She had had two previous cesarean deliveries, and noted this mass and the resulting pain after the second surgery. The mass was only palpable to her during her menses, but otherwise was not palpable. Previous imaging via MRI demonstrated a mass within the abdominal wall. An outside surgeon had performed a laparotomy but did not encounter any mass to resect, resulting in no improvement for the patient. Review of the images demonstrated that the mass was entirely retrofascial within the rectus muscle, explaining the previous surgeon’s failure to find a mass. A laparoscopic approach was discussed with the patient and consent was obtained. At laparoscopy, the mass was entirely resected, including portions of rectus muscle and parietal peritoneum, without the need to breach the rectus fascia. Rectus muscle and peritoneum was brought together over the defect. Conclusion: At three months, the patient reports near complete resolution her pain, and a dramatically improved quality of life. Abdominal wall endometriosis is a relatively rare presentation of the disease but presents with some frequency to expert endometriosis practices. In most cases it is the result of iatrogenic seeding of the abdominal wall with native endometrium at the time of cesarean delivery or other surgery. In most cases, subcutaneous tissue and anterior rectus fascia is involved, demanding an open approach to resection. In rare cases such as this, the entire lesion may be under the fascia within the rectus muscle or abdominal obliques, allowing a laparoscopic or robotic approach to full resection.