1. AVOIDING COMPLICATIONS IN ENDOMETRIOSIS SURGERY
Danie Botha
FEMBRYO Fertility and Gynaecology Clinic
Port Elizabeth
UCT Postgraduate Refresher Course 2015

2. ESHRE GUIDELINES 2014
QUALITY OF LIFE
INFERTILITY

3. Laparoscopy and prevention of adverse outcome
gold standard
standardization of specific surgical techniques
etiology remains unclear.
ablation and surgical techniques.

4. Overview General complications associated with laparoscopy
Risk factors in performing surgery for Endometriosis
Patient specific
Surgeon specific
Disease specific
Specific complications and prevention
Endometrioma
Urinary tract
Bowel complications
Additional measures
Summary

5. Risk factors in performing surgery for endometriosis
1.Patient specific risk factors
Patients who have had prior surgery for intraabdominal or pelvic disease (e.g., diverticulitis, pelvic inflammatory disease) have a higher risk of complications related to adhesions.
Extensive bowel distention, very large abdominal or pelvic mass, and diaphragmatic hernia.
Increased BMI
2.Surgeon specific factors
The frequency of complications may be related to surgeon experience and the number of the specific procedure performed for some, but not all, types of surgical procedures
3.Disease specific factors
Linear increase in complications with advanced grade of disease and specific organ involvement

6. General complications of Laparoscopic surgery
Anaesthetic risk factors
Positioning and pressure points, nerve injuries
Abdominal entry and port site injuries/hernias
Insufflation pressure and cardio-pulmonary dysfunction
Thermal injuries

7. Surgeon specific risk factors
Surgical expertise
Anatomy
Pre operative assessment
Multidisciplinary approach

8. Surgical expertise and Anatomy
A thorough knowledge of pelvic anatomy is of paramount importance.  A surgeon who is familiar with all structures met at operation is best able to appreciate the distortions produced by disease and to take advantage of the natural planes of cleavage.

11. Intra-operative complications Post-operative complications
Group A
1 case of intraoperative bleeding >600ml
2 cases of bowel injury
1 conversion to laparotomy
Group B
1 case of ureteric injury
Post-operative complications
6 Cases of fever
2 cases of paralytic ileus
1 case of bladder dysfunction
3 Cases of fever
1 case of paralytic ileus

12. Ovarian endometriomas
Cochrane review: Excision of cyst wall associated with reduced recurrence of endometrioma . Hart RJ et al. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst. Rev 2, CD
Stripping technique: Take care to minimize damage and inadvertent removal of normal ovarian tissue. Biacchiardi et al. Laparoscopic stripping of endometriomas negatively affects ovarian follicular reserve even if performed by experienced surgeons. Reprod. Biomed. Online 23 (6), (2011)
Drainage should be performed through single incision. Identify cleavage plain, gentle stripping to prevent bleeding.
Prevent excessive bipolar cautery.
Combined technique of stripping and ablation recommended. Partial cystectomy followed by ablation in area of hilum. Donnez J, et al. Laparoscopic management of endometriomas using a combined technique of excisional and ablative surgery. Fertil Steril. 94 (1), (2010)

13. Large endometriomas: (>5cm diameter): Three step procedure advised:
Small puncture site on antimesenteric border of the ovary. Irrigation and drainage and biopsy for histology.
This is then followed by 3/12 of GnRH analogue treatment, thereafter ablation by laparoscopy. Tsolakidis D, et al. The impact on ovarian reserve after laparoscopic ovarian cystectomy vesrus three-stage management in patients with endometriomas: a prospective randomized study. Fertil Steril .94(1), (2010)
Recurrence rate of 8% in follow up of up to 11 years and smaller decrease in AMH levels. Shah DK, et al. Effects of surgery for endometrioma on ovarian function. J. Minim. Invasive Gynecol. 21(2), (2014)
Haemostasis either by bipolar cautery or sutures: No difference in AMH levels or IVF outcome. Takashima A et al. Effects of bipolar electrocoagulation versus suture after laparoscopic excision of ovarian endometrioma on the ovarian reserve and outcome of in vitro fertilization. J. Obstet. Gynaecol. Res. 39(7), (2013)

14. Antibiotic prophylaxis for prevention of endometrioma abscess
The most likely pathogens to cause an abscess are anaerobic bacteria and aerobic Gram-negative bacilli.
First generation cephalosporin (Cephazoline) adequate for prophylaxis

15. Affecting 1% of patients undergoing surgery.
Urinary tract endometriosis Berlanda N et al, Ureteral and vesical endometriosis. Two different clinical entities sharing the same pathogenesis Obstet. Gynecol. Surv. 64 (12) (2009)
Affecting 1% of patients undergoing surgery.
85% bladder involvement
10% ureter
4% kidney
2% urethra.
Usually associated with more commonly lesions of pelvis such as nodules of uterosacral ligaments and rectovaginal septum

16. Vascular supply of Ureter

17. Bladder endometriosis
Superficial peritoneal implants: On bladder, careful dissection with skinning technique, closure of defect with 3.0 monofilament.
Infiltrative lesions of mucosa in bladder dome: partial cystectomy. Close bladder in two or three layers with methylene blue control.
Posterior wall of bladder or trigone, insertion of double J stents 6-8 weeks postoperatively and urinary catheter for 7-10 days.
Adhesions between the anterior uterine wall and the vesico-uterine fold should be divided before performing partial cystectomy
Control by cystoscopy

18. Ureteral injury would seem most likely in patients undergoing complicated gynecological procedures with distorted pelvic anatomy.  However, studies reveal that most ureteral injuries occur during simple routine pelvic surgeries, such as an uncomplicated hysterectomy.  This seeming paradox may be due to a false sense of security that surgeons who perform routine pelvic surgeries develop and become neglectful of fundamental techniques and surgical principles for avoiding ureteral injury

19. Ureteral endometriosis
Intrinsic: 15% of cases with fibrosis of the muscularis and mucosa.
Extrinsic: 85% of cases, infiltration of the overlying peritoneum, leading to compression and hydronephrosis.
More common on left ureter.
Main aim is to relieve obstruction, preserve renal function and prevent recurrence.
Double J stent for 6 weeks.
Identify ureter above level of disease. Preserve adventitial layer to prevent devascularisation. If critical stenosis: perform end –to-end anastomosis. Tension free anastomosis important

20. Bowel endometriosis

25. Avoiding complications

26. ADDITIONAL MEASURES: OVARIAN SUSPENSION

27. OVARIAN SUSPENSION

28. ADDITIONAL MEASURES: ADHESION PREVENTION

29. SUMMARY
Avoiding complications in laparoscopic surgery for endometriosis :
Patient counselling and pre operative investigation
Referral centres with Multi disciplinary approach
Instrumentation and surgical team
Sound knowledge of pelvic anatomy
Organ sparing surgery and microsurgical technique
Documentation of procedure
Short term and long term follow up

30. Thank you
With ageing comes expertise, and with expertise, fear to do what has seemed so simple in the past.
With fear, comes prayer. Start there.