- Email: [email protected]
Multidisciplinary Resection of Deeply Infiltrative Endometriosis
Accepted Manuscript Title: Multidisciplinary Approach to Resection of Deeply Infiltrative Endometriosis Using the Robotic Platform Author: Gaby N. Moawad, Paul Tyan, Elias D. Abi Khalil, David Samuel, Vincent Obias PII: DOI: Reference:
S1553-4650(17)31219-0 https://doi.org/doi:10.1016/j.jmig.2017.09.025 JMIG 3294
To appear in:
The Journal of Minimally Invasive Gynecology
Received date: Revised date: Accepted date:
22-8-2017 15-9-2017 26-9-2017
Please cite this article as: Gaby N. Moawad, Paul Tyan, Elias D. Abi Khalil, David Samuel, Vincent Obias, Multidisciplinary Approach to Resection of Deeply Infiltrative Endometriosis Using the Robotic Platform, The Journal of Minimally Invasive Gynecology (2017), https://doi.org/doi:10.1016/j.jmig.2017.09.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
Multidisciplinary Approach to Resection of Deeply Infiltrative Endometriosis Using
2
the Robotic Platform
3
Gaby N Moawad 1, Paul Tyan 1, Elias D Abi Khalil 1, David Samuel 2, Vincent Obias 3
4 5
1 George Washington University, Division of Minimally Invasive Gynecologic Surgery,
6
2 George Washington University, School of Medicine and Health Sciences, 3 George
7
Washington University, Department of Surgery
8 9 10
Corresponding author contact information: Gaby Moawad. 900 23rd St NW, Washington, DC 20037. Email: [email protected]
11 12
Key words: Endometriosis; Deeply infiltrative endometriosis; Robotic surgery;
13
Multidisciplinary robotic surgery; Bladder endometriosis; Rectal endometriosis
14 15
Disclosures: Dr. Moawad is a speaker for Intuitive Surgical and Applied Medical. All
16
other authors have nothing to disclose.
17 18
Objective:
19
To describe a multidisciplinary approach for resection of deeply infiltrative endometriosis
20
using the robotic platform.
21
Design:
1
Page 1 of 6
22
A technical video showing a step-by-step approach for resection of deeply infiltrative
23
endometriosis. (Canadian Task Force classification level III). IRB approval was not
24
required for this study.
25
Setting:
26
There is considerable involvement of bowel and bladder by deeply infiltrative
27
endometriosis. 1-3 The need for operative procedures involving multiple organs while
28
performing a complete resection is common.
29
The benefits of minimally invasive surgery for gynecological pathology have been
30
documented in numerous studies. Patients had fewer medical and surgical complications
31
postoperatively, better cosmesis and quality of life. 4-6 We believe that deeply infiltrative
32
endometriosis does not preclude patients from having a minimally invasive resection
33
procedure. In this video, we describe how the robotic platform was utilized for a
34
seamless transition between surgical specialties including gynecology, colorectal, and
35
urology to ensure complete resection of endometriosis lesions involving multiple organs.
36
Patient:
37
A 47-year-old with a four-year history of severe pelvic pain, dysuria, dyspareunia,
38
dyschezia, and dysmenorrhea failing multiple medical therapies presented to our clinic to
39
discuss surgical options. After thorough counseling, the decision was made to proceed
40
with definitive surgical management. Postoperatively the patient was admitted for two
41
days of postoperative inpatient care. After meeting all immediate postoperative
42
milestones, she was discharged with an indwelling Foley catheter to follow-up in the
43
clinic with all three surgical specialties. At the 1-week interval, she was seen by the
44
Urology team, where her indwelling catheter was removed after a cystoscopy was
2
Page 2 of 6
45
performed documenting adequate healing. Two weeks postoperatively the patient was
46
seen by the Gynecology and Colorectal teams and was noted to be healing adequately
47
from the procedure. Her six-week visit was also unremarkable. She kept following with
48
the gynecology team for her yearly well-woman exams and has been symptom-free for
49
two years after surgery. She is kept on daily Norethindrone to minimize recurrence.
50
Interventions:
51
A pelvic preoperative pelvic MRI showed bladder endometriosis and extensive
52
rectovaginal endometriosis. We describe the multidisciplinary approach used for surgery
53
and the procedures done by each specialty.
54
Urology:
55
A cystoscopy was performed preoperatively to assess for full thickness erosions and the
56
location of those lesions in that event. The urology team also reviewed the MRI images
57
with the radiology team, and the endometriosis lesions were suspected to be close to the
58
bladder trigone, keeping in mind that this finding could be overestimated given that the
59
bladder was deflated at the time the imaging was obtained. Accordingly, At the time of
60
surgery, the decision was made to proceed with cystoscopy and ureteral stents placement
61
as a prophylactic measure. An intentional cystotomy and resection of the bladder section
62
involved with endometriosis were performed followed by watertight closure. The trigone
63
area of the bladder was not involved, and ureteral reimplantation was not needed in this
64
case.
65
Gynecology:
66
The Gynecology team operated second and performed and extensive dissection of the
67
retroperitoneal space with the development of the para-rectal and para-vesical spaces.
3
Page 3 of 6
68
They also ligated the uterine artery at its origin, followed by dissection of the utero-
69
vesical space effectively reflecting the bladder off of the lower uterine segment. At this
70
point, they proceeded with a total hysterectomy, and the specimen was removed from the
71
pelvis through the vaginal cuff.
72
Colorectal:
73
Preoperatively the colorectal surgeon ordered a colonoscopy to determine if full thickness
74
erosions are present and reviewed the MRI images with the radiology team. Based on the
75
MRI and colonoscopy, all patients are counseled and consented for the possibility of a
76
Low Anterior Resection (LAR) and loop ileostomy to protect the anastomosis.
77
Based on the understanding that colorectal and gynecologic surgery have a different
78
approach when dissecting the pararectal space at our institution, a discussion between the
79
two teams is initiated at the multidisciplinary session for surgery planning. In the case we
80
present, the colorectal surgeon opted for the removal of the uterus before his dissection
81
was initiated given that he dissects this space presacrally and not retroperitoneally like
82
the GYN counterpart. He would also benefit from the extra space for dissection with the
83
uterus out of the pelvis.
84
The colorectal part of the case was initiated by mobilization of the rectum and dissecting
85
the obliterated recto-vaginal space. The presacral space was then opened followed by
86
mobilization of the rectosigmoid from its attachment. The case was concluded with full
87
transection and re-anastomosis of the rectum section involved with endometriosis. The
88
specimen was also removed from the pelvis through the vaginal cuff.
89 90
Main outcome measures:
4
Page 4 of 6
91
Complete resection of deeply infiltrative endometriosis spanning beyond the scope of one
92
surgical specialty.
93
Results:
94
No immediate intraoperative, perioperative, or long-term complications from surgery.
95
Complete resolution of endometriosis symptoms.
96
Conclusion:
97
We encourage collaborative care for planning and performing comprehensive and safe
98
resection of deeply infiltrative endometriosis.
99 100 101 102 103 104
References: 1. Revised American society for reproductive medicine classification of endometriosis: 1996. Fertil Steril 1997;67:817–21. 2. Bailey HR, Ott MT, Hartendorp P. Aggressive surgical management for advanced colorectal endometriosis. Dis Colon Rectum 1994;37:747–53.
105
3. Knabben L, Imboden S, Fellmann B, Nirgianakis K, Kuhn A, Mueller MD.
106
Urinary tract endometriosis in patients with deep infiltrating endometriosis:
107
prevalence, symptoms, management, and proposal for a new clinical
108
classification. Fertil Steril. 2015;103:147–152. doi: 10.1016/j.
109
fertnstert.2014.09.028.
110
4. Khavanin N, Mlodinow A, Milad MP, Bilimoria KY, Kim JY. Comparison of
111
perioperative outcomes in outpatient and inpatient laparoscopic hysterectomy. J
112
Minim Invasive Gynecol. 2013;20(5):604-10.
5
Page 5 of 6
113
5. Garry R, Fountain J, Brown J, et al. EVALUATE hysterectomy trial: a
114
multicentre randomised trial comparing abdominal, vaginal and laparoscopic
115
methods of hysterectomy. Health Technol Assess. 2004;8(26):1-154.
116 117
6. Aarts JW, Nieboer TE, Johnson N, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2015;8:CD003677.
118
6
Page 6 of 6
S1553-4650(17)31219-0 https://doi.org/doi:10.1016/j.jmig.2017.09.025 JMIG 3294
To appear in:
The Journal of Minimally Invasive Gynecology
Received date: Revised date: Accepted date:
22-8-2017 15-9-2017 26-9-2017
Please cite this article as: Gaby N. Moawad, Paul Tyan, Elias D. Abi Khalil, David Samuel, Vincent Obias, Multidisciplinary Approach to Resection of Deeply Infiltrative Endometriosis Using the Robotic Platform, The Journal of Minimally Invasive Gynecology (2017), https://doi.org/doi:10.1016/j.jmig.2017.09.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
Multidisciplinary Approach to Resection of Deeply Infiltrative Endometriosis Using
2
the Robotic Platform
3
Gaby N Moawad 1, Paul Tyan 1, Elias D Abi Khalil 1, David Samuel 2, Vincent Obias 3
4 5
1 George Washington University, Division of Minimally Invasive Gynecologic Surgery,
6
2 George Washington University, School of Medicine and Health Sciences, 3 George
7
Washington University, Department of Surgery
8 9 10
Corresponding author contact information: Gaby Moawad. 900 23rd St NW, Washington, DC 20037. Email: [email protected]
11 12
Key words: Endometriosis; Deeply infiltrative endometriosis; Robotic surgery;
13
Multidisciplinary robotic surgery; Bladder endometriosis; Rectal endometriosis
14 15
Disclosures: Dr. Moawad is a speaker for Intuitive Surgical and Applied Medical. All
16
other authors have nothing to disclose.
17 18
Objective:
19
To describe a multidisciplinary approach for resection of deeply infiltrative endometriosis
20
using the robotic platform.
21
Design:
1
Page 1 of 6
22
A technical video showing a step-by-step approach for resection of deeply infiltrative
23
endometriosis. (Canadian Task Force classification level III). IRB approval was not
24
required for this study.
25
Setting:
26
There is considerable involvement of bowel and bladder by deeply infiltrative
27
endometriosis. 1-3 The need for operative procedures involving multiple organs while
28
performing a complete resection is common.
29
The benefits of minimally invasive surgery for gynecological pathology have been
30
documented in numerous studies. Patients had fewer medical and surgical complications
31
postoperatively, better cosmesis and quality of life. 4-6 We believe that deeply infiltrative
32
endometriosis does not preclude patients from having a minimally invasive resection
33
procedure. In this video, we describe how the robotic platform was utilized for a
34
seamless transition between surgical specialties including gynecology, colorectal, and
35
urology to ensure complete resection of endometriosis lesions involving multiple organs.
36
Patient:
37
A 47-year-old with a four-year history of severe pelvic pain, dysuria, dyspareunia,
38
dyschezia, and dysmenorrhea failing multiple medical therapies presented to our clinic to
39
discuss surgical options. After thorough counseling, the decision was made to proceed
40
with definitive surgical management. Postoperatively the patient was admitted for two
41
days of postoperative inpatient care. After meeting all immediate postoperative
42
milestones, she was discharged with an indwelling Foley catheter to follow-up in the
43
clinic with all three surgical specialties. At the 1-week interval, she was seen by the
44
Urology team, where her indwelling catheter was removed after a cystoscopy was
2
Page 2 of 6
45
performed documenting adequate healing. Two weeks postoperatively the patient was
46
seen by the Gynecology and Colorectal teams and was noted to be healing adequately
47
from the procedure. Her six-week visit was also unremarkable. She kept following with
48
the gynecology team for her yearly well-woman exams and has been symptom-free for
49
two years after surgery. She is kept on daily Norethindrone to minimize recurrence.
50
Interventions:
51
A pelvic preoperative pelvic MRI showed bladder endometriosis and extensive
52
rectovaginal endometriosis. We describe the multidisciplinary approach used for surgery
53
and the procedures done by each specialty.
54
Urology:
55
A cystoscopy was performed preoperatively to assess for full thickness erosions and the
56
location of those lesions in that event. The urology team also reviewed the MRI images
57
with the radiology team, and the endometriosis lesions were suspected to be close to the
58
bladder trigone, keeping in mind that this finding could be overestimated given that the
59
bladder was deflated at the time the imaging was obtained. Accordingly, At the time of
60
surgery, the decision was made to proceed with cystoscopy and ureteral stents placement
61
as a prophylactic measure. An intentional cystotomy and resection of the bladder section
62
involved with endometriosis were performed followed by watertight closure. The trigone
63
area of the bladder was not involved, and ureteral reimplantation was not needed in this
64
case.
65
Gynecology:
66
The Gynecology team operated second and performed and extensive dissection of the
67
retroperitoneal space with the development of the para-rectal and para-vesical spaces.
3
Page 3 of 6
68
They also ligated the uterine artery at its origin, followed by dissection of the utero-
69
vesical space effectively reflecting the bladder off of the lower uterine segment. At this
70
point, they proceeded with a total hysterectomy, and the specimen was removed from the
71
pelvis through the vaginal cuff.
72
Colorectal:
73
Preoperatively the colorectal surgeon ordered a colonoscopy to determine if full thickness
74
erosions are present and reviewed the MRI images with the radiology team. Based on the
75
MRI and colonoscopy, all patients are counseled and consented for the possibility of a
76
Low Anterior Resection (LAR) and loop ileostomy to protect the anastomosis.
77
Based on the understanding that colorectal and gynecologic surgery have a different
78
approach when dissecting the pararectal space at our institution, a discussion between the
79
two teams is initiated at the multidisciplinary session for surgery planning. In the case we
80
present, the colorectal surgeon opted for the removal of the uterus before his dissection
81
was initiated given that he dissects this space presacrally and not retroperitoneally like
82
the GYN counterpart. He would also benefit from the extra space for dissection with the
83
uterus out of the pelvis.
84
The colorectal part of the case was initiated by mobilization of the rectum and dissecting
85
the obliterated recto-vaginal space. The presacral space was then opened followed by
86
mobilization of the rectosigmoid from its attachment. The case was concluded with full
87
transection and re-anastomosis of the rectum section involved with endometriosis. The
88
specimen was also removed from the pelvis through the vaginal cuff.
89 90
Main outcome measures:
4
Page 4 of 6
91
Complete resection of deeply infiltrative endometriosis spanning beyond the scope of one
92
surgical specialty.
93
Results:
94
No immediate intraoperative, perioperative, or long-term complications from surgery.
95
Complete resolution of endometriosis symptoms.
96
Conclusion:
97
We encourage collaborative care for planning and performing comprehensive and safe
98
resection of deeply infiltrative endometriosis.
99 100 101 102 103 104
References: 1. Revised American society for reproductive medicine classification of endometriosis: 1996. Fertil Steril 1997;67:817–21. 2. Bailey HR, Ott MT, Hartendorp P. Aggressive surgical management for advanced colorectal endometriosis. Dis Colon Rectum 1994;37:747–53.
105
3. Knabben L, Imboden S, Fellmann B, Nirgianakis K, Kuhn A, Mueller MD.
106
Urinary tract endometriosis in patients with deep infiltrating endometriosis:
107
prevalence, symptoms, management, and proposal for a new clinical
108
classification. Fertil Steril. 2015;103:147–152. doi: 10.1016/j.
109
fertnstert.2014.09.028.
110
4. Khavanin N, Mlodinow A, Milad MP, Bilimoria KY, Kim JY. Comparison of
111
perioperative outcomes in outpatient and inpatient laparoscopic hysterectomy. J
112
Minim Invasive Gynecol. 2013;20(5):604-10.
5
Page 5 of 6
113
5. Garry R, Fountain J, Brown J, et al. EVALUATE hysterectomy trial: a
114
multicentre randomised trial comparing abdominal, vaginal and laparoscopic
115
methods of hysterectomy. Health Technol Assess. 2004;8(26):1-154.
116 117
6. Aarts JW, Nieboer TE, Johnson N, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2015;8:CD003677.
118
6
Page 6 of 6