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MRI Correlation to Intra-Operative Findings of Deeply Infiltrative Endometriosis
Abstracts / Journal of Minimally Invasive Gynecology 23 (2016) S1–S252 This consists of three units: Marwah’s uterine manipulator, copper cup insulated from outside with metalon, a spatula. The insulated copper cup and the spatula are connected with wires which fit into the bipolar electrosurgical unit. When colpotomy is carried out the spatula glides over the insulated copper cup with the tissue in between thus forming a bipolar unit which then cauterizes and cut.This being a bipolar unit the lateral thermal spread is minimal. It is safer than using monopolar cautery, easier and better than harmonic to use as it does not slip, neither damages the cervical cup and the smoke generated is also less. 389
Video Session 14 - Endometriosis (2:15 PM - 3:15 PM)
S137
Our institution is a major referral center for endometriosis related pelvic pain. Clinical history and physical exam are telling of the presence of disease but may not be comprehensive in detecting the full extent of the endometriosis. Deeply infiltrative endometriosis is a severely debilitating disease in reproductive age women where endometriotic tissue may extent into the retroperitoneal space or the wall of pelvic organs greater than a depth of at least 5 mm. Using MRI can be extremely useful in cases where deeply infiltrative endometriosis is suspected. This allows for preoperative Mapping of lesions and helps the surgeon plan complete surgical excision and to guide them to the best approach. The goals of this video include a review of our institutions MRI endometriosis protocol, review characteristics on MRI suggestive of deeply infiltrative endometriosis, and to show intra-operative correlation to findings depicted on MRI.
2:15 PM – GROUP A Deeply Infiltrating Endometriosis: As Seen on MRI Lum D,1 Co S,2 Chang S,2 Ghanouni P.2 1Obstetrics and Gynecology, Stanford University, Stanford, California 2 Radiology, Stanford University, Stanford, California Magnetic resonance imaging can be a complementary adjunct in the evaluation of complex cases of endometriosis. Deeply infiltrating endometriosis, defined as endometrial implants that infiltrate adjacent structures at a depth of more than 5mm from the peritoneal surface, can usually be detected on MRI. Examples of deeply infiltrating endometriosis include the obliterated posterior cul-de-sac, urinary tract and bowel endometriosis. Preoperative detection of deeply infiltrating endometriosis with MRI can be helpful in preoperative counseling and surgical planning when an extensive dissection is necessary. Limitations of MRI include the varied sensitivity, access to an MR system, cost, and need for high resolution images. However, in select cases, as shown in this video, MRI can aid the gynecologic surgeon in preoperative counseling and planning. 390
Video Session 14 - Endometriosis (2:15 PM - 3:15 PM) 2:22 PM – GROUP A
Endometriotic Nodule of the Cardinal Ligament Elkattah R, Mohling S, Furr R. Division of Minimally Invasive Gynecology, University of Tennessee Chattanooga College of Medicine, Chattanooga, Tennessee Our patient is a 35 year-old Caucasian woman presenting with transfusiondependent anemia secondary to abnormal and heavy uterine bleeding. On evaluation, she was found to have a 17cm enlarged and fibroid uterus. A robotic-assisted hysterectomy with bilateral salpingectomy was planned. During surgery the patient was found to have deeply infiltrative endometriosis within the left cardinal ligament leading to left-sided hydronephrosis. We describe the associated challenges of this dissection and provide a list of tips that aid in complete excision of such deeply infiltrative endometriotic nodules. 391
Video Session 14 - Endometriosis (2:15 PM - 3:15 PM) 2:29 PM – GROUP A
MRI Correlation to Intra-Operative Findings of Deeply Infiltrative Endometriosis Ito TE,1 Taffel M,2 Moawad GN.1 1Obstetrics and Gynecology, George Washington University, Washington, District of Columbia; 2Radiology, George Washington University, Washington, District of Columbia
393
Video Session 14 - Endometriosis (2:15 PM - 3:15 PM) 2:36 PM – GROUP A
Techniques for Exploration and Ablation of Endometriosis in Upper Abdomen and Thorax Kim S,1 Lutz M,1 Raymond D,2 Falcone T.1 1Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio; 2Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio Extrapelvic endometriosis, while mostly medically managed, when selected well, can be treated surgically. Here we describe the techniques of laparoscopic exploration of the abdomen and thorax for diaphragmatic endometriosis and destruction with ablation. The upper abdomen is explored employing four 5-mm ports in the umbilicus and subcostally. The falciform ligament is dissected down to mobilize the liver. The right hemi-diaphragm is ablated using JPlasma device. The thorax is explored through video-assisted thoracoscopic surgery with three ports in a triangulated fashion. Inferior pulmonary ligament and the pleural hemi-diaphragm are explored and endometriosis lesions are identified and ablated while carefully avoiding the nearby critical anatomical structures. Good selection of cases with detailed discussion with the patients regarding treatment options is essential in the success of surgical approach to diaphragmatic endometriosis management. One should consider employing VATS for thorough evaluation and removal of extensive diaphragmatic endometriosis.
394
Video Session 14 - Endometriosis (2:15 PM - 3:15 PM) 2:47 PM – GROUP B
Excision of a Large Adnexal Endometriotic Nodule Masquerading as Salpingitis Isthmica Nodosa Cook A, Hopton E. Vital Health Institute, Los Gatos, California This video presents a case of deeply invasive paratubal endometriosis proximal to the uterine fundus, masquerading as salpingitis isthmica nodosa (SIN). The differential diagnosis of endometriosis is demonstrated and surgery is performed to fully resect the invasive disease while preserving tubal function. This case demonstrates the importance of complete resection of paraisthmic endometriosis for the resolution of pelvic pain and the feasibility of preserving tubal function, thereby conserving the patient’s fertility.
Video Session 14 - Endometriosis (2:15 PM - 3:15 PM)
S137
Our institution is a major referral center for endometriosis related pelvic pain. Clinical history and physical exam are telling of the presence of disease but may not be comprehensive in detecting the full extent of the endometriosis. Deeply infiltrative endometriosis is a severely debilitating disease in reproductive age women where endometriotic tissue may extent into the retroperitoneal space or the wall of pelvic organs greater than a depth of at least 5 mm. Using MRI can be extremely useful in cases where deeply infiltrative endometriosis is suspected. This allows for preoperative Mapping of lesions and helps the surgeon plan complete surgical excision and to guide them to the best approach. The goals of this video include a review of our institutions MRI endometriosis protocol, review characteristics on MRI suggestive of deeply infiltrative endometriosis, and to show intra-operative correlation to findings depicted on MRI.
2:15 PM – GROUP A Deeply Infiltrating Endometriosis: As Seen on MRI Lum D,1 Co S,2 Chang S,2 Ghanouni P.2 1Obstetrics and Gynecology, Stanford University, Stanford, California 2 Radiology, Stanford University, Stanford, California Magnetic resonance imaging can be a complementary adjunct in the evaluation of complex cases of endometriosis. Deeply infiltrating endometriosis, defined as endometrial implants that infiltrate adjacent structures at a depth of more than 5mm from the peritoneal surface, can usually be detected on MRI. Examples of deeply infiltrating endometriosis include the obliterated posterior cul-de-sac, urinary tract and bowel endometriosis. Preoperative detection of deeply infiltrating endometriosis with MRI can be helpful in preoperative counseling and surgical planning when an extensive dissection is necessary. Limitations of MRI include the varied sensitivity, access to an MR system, cost, and need for high resolution images. However, in select cases, as shown in this video, MRI can aid the gynecologic surgeon in preoperative counseling and planning. 390
Video Session 14 - Endometriosis (2:15 PM - 3:15 PM) 2:22 PM – GROUP A
Endometriotic Nodule of the Cardinal Ligament Elkattah R, Mohling S, Furr R. Division of Minimally Invasive Gynecology, University of Tennessee Chattanooga College of Medicine, Chattanooga, Tennessee Our patient is a 35 year-old Caucasian woman presenting with transfusiondependent anemia secondary to abnormal and heavy uterine bleeding. On evaluation, she was found to have a 17cm enlarged and fibroid uterus. A robotic-assisted hysterectomy with bilateral salpingectomy was planned. During surgery the patient was found to have deeply infiltrative endometriosis within the left cardinal ligament leading to left-sided hydronephrosis. We describe the associated challenges of this dissection and provide a list of tips that aid in complete excision of such deeply infiltrative endometriotic nodules. 391
Video Session 14 - Endometriosis (2:15 PM - 3:15 PM) 2:29 PM – GROUP A
MRI Correlation to Intra-Operative Findings of Deeply Infiltrative Endometriosis Ito TE,1 Taffel M,2 Moawad GN.1 1Obstetrics and Gynecology, George Washington University, Washington, District of Columbia; 2Radiology, George Washington University, Washington, District of Columbia
393
Video Session 14 - Endometriosis (2:15 PM - 3:15 PM) 2:36 PM – GROUP A
Techniques for Exploration and Ablation of Endometriosis in Upper Abdomen and Thorax Kim S,1 Lutz M,1 Raymond D,2 Falcone T.1 1Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio; 2Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio Extrapelvic endometriosis, while mostly medically managed, when selected well, can be treated surgically. Here we describe the techniques of laparoscopic exploration of the abdomen and thorax for diaphragmatic endometriosis and destruction with ablation. The upper abdomen is explored employing four 5-mm ports in the umbilicus and subcostally. The falciform ligament is dissected down to mobilize the liver. The right hemi-diaphragm is ablated using JPlasma device. The thorax is explored through video-assisted thoracoscopic surgery with three ports in a triangulated fashion. Inferior pulmonary ligament and the pleural hemi-diaphragm are explored and endometriosis lesions are identified and ablated while carefully avoiding the nearby critical anatomical structures. Good selection of cases with detailed discussion with the patients regarding treatment options is essential in the success of surgical approach to diaphragmatic endometriosis management. One should consider employing VATS for thorough evaluation and removal of extensive diaphragmatic endometriosis.
394
Video Session 14 - Endometriosis (2:15 PM - 3:15 PM) 2:47 PM – GROUP B
Excision of a Large Adnexal Endometriotic Nodule Masquerading as Salpingitis Isthmica Nodosa Cook A, Hopton E. Vital Health Institute, Los Gatos, California This video presents a case of deeply invasive paratubal endometriosis proximal to the uterine fundus, masquerading as salpingitis isthmica nodosa (SIN). The differential diagnosis of endometriosis is demonstrated and surgery is performed to fully resect the invasive disease while preserving tubal function. This case demonstrates the importance of complete resection of paraisthmic endometriosis for the resolution of pelvic pain and the feasibility of preserving tubal function, thereby conserving the patient’s fertility.