Is excision of endometriosis necessary to treat pain?
Anyone asking this question has little experience with extensive disease. Extensive endometriosis usually results in severe pain that can be relieved by excision of the endometriosis. Most women with extensive cul-de-sac endometriosis have some degree of nodularity and/or tenderness of their uterosacral ligaments, anterior rectum, and posterior vagina-cervix during rectovaginal exam. The object of the surgery is to remove the painful, tender nodule. Postoperative examination after excision of the previously known lesion should confirm the absence of nodularity and tenderness, documenting that excision of the area of maximum tenderness and nodularity caused by endometriosis is the best treatment for pelvic pain caused by this condition. Unfortunately, many gynecologists fail to do an adequate rectovaginal examination to discover the lesion in the first place.
How can you remove the tender nodule without excision? I don’t know! When areas thought to be endometriosis by laparoscopic examination are subjected to treatment with laser or electrosurgery for ablation, only the "tip of the iceberg" is usually treated. The deeper components of the lesion go untreated as the surgeon under treats because of fear of late complications to the rectum and or ureter. This type of treatment can't possibly work. It usually stimulates the endometriosis lesion with resultant increase in the inflammation both inside the lesion and surrounding it. The end point of laparoscopic (and laparotomy) surgical procedures to excise endometriosis should be a normal rectovaginal exam with a mobile distensible vagina, a free rectum, and the absence of nodularity as palpated with a rectovaginal exam while probing the area visualized with the laparoscope.
Endometriosis is a discreet lesion: Endometrial glands and stroma surrounded by fibromuscular tissue, making the white and fibrotic. Symptomatic black-brown lesions are always surrounded by white fibromuscular scar.
Most endometriosis treated in the United States is not endometriosis; rather, it is old blood from retrograde menstruation or discharge from a corpus luteum (“coffee grounds or tobacco stained” tissue). The pathologist sees hemosiderin laddened macrophages. Without excisional biopsy, we have no accurate idea of the number of people with “real” endometriosis that have been treated in the past. Thus, present data regarding treatment are meaningless as they usually report on the “destructive” treatment of degenerating blood cells instead of endometriosis glands.
I ask you, if a suspected area of endometriosis is ablated without specimen taking, how can we ever know if that patient really had endometriosis to start with? We know that many things can cause pelvic pain including retrograde menstruation, physiological cysts, uterine contractions, and that some certainly are psychosomatic. Women that are told that the old blood from retrograde menstruation is endometriosis may forever feel that they are victims of this condition, no matter what future treatment is applied. This just does not represent good medicine.
I will describe the examination to diagnose endometriosis & the techniques to excise it:
The most common presentations produced by endometriosis are pelvic pain, infertility, and adnexal mass. The ovaries, the posterior leaf of the broad ligament, and the cul-de-sac of Douglas behind the uterus are the most frequent locations, and the left side is more frequently affected than the right.
Extensive endometriosis usually involves the posterior cul-de-sac of Douglas, the area surrounded posteriorly by the anterior rectum, anteriorly by the posterior vagina and cervix, and laterally by the uterosacral ligaments. These lesions can often obliterate the normal anatomy of the cul-de-sac with the rectum stuck to the posterior vagina, cervix, and uterine fundus. One or both pelvic sidewalls overlying the ureters and the rectosigmoid are often affected. In addition, less commonly involved areas include the anterior cul-de-sac (the area above the bladder and the anterior uterus), the appendix and the small bowel. Extensive bulky endometriosis may also be present in the uterine muscle itself where it is called ‘adenomyosis’.
Extensive endometriosis means bulky deep fibrotic endometriosis deposits that can often be palpated preoperatively as tender pelvic nodules. These nodules consist of endometriosis glands and stroma surrounded by fibromuscular tissue that has accumulated over many years in response to cyclic monthly activation of the endometriosis. They represent a longstanding chronic inflammatory response.
TeLinde and Scott defined the objectives of surgical treatment of endometriosis in 1952: “one should excise or fulgurate all evident endometriosis.” The surgical objectives of laparoscopic treatment are similar, i.e., to remove all evident endometriosis by excising large superficial and deep lesions and vaporising smaller deposits.(2) Hystopathological examination to document endometriosis glands and stroma is necessary to substantiate a diagnosis of the endometriosis in any suspect lesion.
Clinical Symptoms and Dignosis
The most common symptom for extensive endometriosis diagnosis is pelvic pain, and the most common sign is pelvic tenderness. This pain is usually more severe on one side and often radiates to the back and legs. The pain may be present throughout the menstrual cycle but especially during the menses (severe dysmenorrhea). Dyspareunia is common. Pain during bowel movements (dyschezia) may also be present. Pelvic pain can be severe enough that the patient is refractory to conventional medical therapy.
Deep full thickness vaginal endometriosis may present with irregular vaginal bleeding. Deep rectal endometriosis is rarely accompanied by rectal bleeding. Most rectal bleeding associated with endometriosis is from hemorrhoids caused by straining during bowel movements, which may result in some cases from a fibrotic endometriosis-related rectosigmoid stricture.
In contrast to mild endometriosis, laparoscopy may not be necessary to diagnose extensive endometriosis of the deep cul-de-sac. It is usually strongly suspected by clinical examination. Laparoscopy is then used to treat it. Yet, histopathological examination of the excised tissue is necessary to confirm the diagnosis of endometriosis: no typical endometriosis glands with surrounding stroma usually means no endometriosis. Ablation of suspected lesions with no pathological specimen always leaves doubt as to whether the lesion treated was endometriosis, fibrosis (old scar tissue), or ‘old blood’ (hemosiderin-ladened macrophages).
The rectum and vagina are readily accessible, and their examination should be the mainstay of clinical diagnosis. If the patient accepts a recto-vaginal examination, this may reveal nodularity or tenderness in the uterosacral ligaments. Cul-de-sac nodularity is pathognomonic of endometriosis. This nodularity is caused by the fibromuscular tissue surrounding endometriosis glands and stroma inside the uterosacral ligaments near their insertion into the cervix and in the angle made by anterior rectum and posterior vagina or by posterior vagina and cervix. Rectovaginal exam is diagnostic when deep cul-de-sac or recto-vaginal septum nodularity are palpated and specific tenderness in these nodules elicited. Unfortunately, most gynaecologists routinely “defer” rectal examination.
Despite the discomfort involved, a rectovaginal examination should be done routinely in patients with pelvic pain and/or a past history of endometriosis. Prior explanation does much to allay the patient’s fears, especially the fear of losing fecal control. The cervix is put on upward tension using the index finger in the vagina and the middle finger in the rectum palpates the uterosacral ligaments including their insertion and the junction of vagina with cervix and rectum. If nodules are discovered, their tenderness and mobility from the surrounding tissues is assessed as is the degree to which the rectum is tented to the lesion. The withdrawn finger is inspected for blood.
During the rectovaginal examination, a good clinician can often pinpoint the tender endometriosis nodules to be excised during surgery. These patients should not be subjected to a diagnostic laparoscopy, but should be referred to a surgeon with experience in excising cul-de-sac and rectal endometriosis.
Clinicians must be aware that a line of evidence exists suggesting that there is no relationship between extent of disease and severity of pain, and no correlation between the location of pain compared with the location of endometriosis implants. (3) This is not the case with extensive endometriosis!
Special Equipment for Excision of Endometriosis
A 3-chip camera system is mandatory. Most one-chip cameras cannot visualize the endometriosis deposits as the surrounding fibrosis causes too much glare on the videomonitor when the laparoscope is placed close to the peritoneum.
A combination of scissors, CO2 laser (Ultrapulse at 200millijoules,Coherent, CA), electrosurgery with various instruments (electrodes), and aquadissection is used for dissection. Strong, usually reusable, straight blunt tipped scissors have the advantage of supplying both tactile sensation and a crunch-like feeling when cutting adjacent to or across fibrotic endometriosis itself or at its junction with softer normal tissue. A Valtchev uterine mobilizer (Conkin Surgical Instruments, Toronto, Ontario, Canada) is used to antevert the uterus and delineate the posterior vagina. For complete cul-de-sac obliteration dissection, a sponge on a ring forceps is inserted into the posterior vaginal fornix and a #81 French rectal probe is placed in the rectum to define them.
Operating room tables capable of a 30º Trendelenburgs’ position are necessary for laparoscopic cul-de-sac work. A steep Trendelenburgs’ position (20 -40º) and shoulder braces with the arms at the patient’s sides are used without adverse effects.
Laparoscopic suturing is useful when operating on deep lesions of the vagina and rectum, but most operations don’t require it. Extracorporeal tying is facilitated by using a trocar sleeve without a trap to avoid difficulty in slipping knots down to the tissue. A short trocar sleeve that doesn’t protrude far into the peritoneal cavity, has a screw grid for retention, and has no trap, is ideal. (4)
Surgical skill remains paramount. Ambidexterity separates the laparoscopic surgeon from those trained traditionally, as the surgeon must often hold the camera with the dominant hand. Use of thermal energy sources (laser and electrosurgery) should be limited to reduce thermal necrosis that may cause adhesion formation during healing. Additional training in bowel, bladder, and ureteral surgery is invaluable.
Deep fibrotic nodular endometriosis involving the cul-de-sac requires excision of white fibronodular tissue from the uterosacral ligaments, posterior cervix, posterior vagina, and the anterior rectum. Less commonly, the sigmoid colon, its mesocolon, and lateral rectum are involved. (6)
Attention is first directed to dissection of the anterior rectum from the posterior vagina throughout its area of attachment until loose areolar tissue in the rectovaginal space is reached. This technique leaves the bulk of the lesion to be excised on the posterior vagina, including some that was more closely associated with the rectum. Using the rectal probe as a guide to rectal location, the rectal serosa is opened at its junction with the cul-de-sac lesion with scissors or the CO2 laser. Careful sharp and blunt dissection ensues until the rectum, normal or with contained fibrotic endometriosis, is separated from the posterior uterus, cervix, and upper vagina. After anterior rectal mobilisation is complete, excision of the fibrotic endometriosis from the posterior vagina (the location of which is continually confirmed by a sponge in the posterior fornix), posterior cervix including its uterosacral ligament insertions, and rectum is done. This is often accomplished ‘en bloc’ as one large specimen, including the insertions of both uterosacral specimens laterally, the anterior rectal component inferiorly, and the posterior cervix-vagina superiorly. The blunt scissors is the main instrument used for this excisional dissection with the tissue to be removed kept on traction using a toothed biopsy forceps.
The ureter lies lateral to most cul-de-sac lesions. When the uterosacral ligament is pulled medially, there is very little risk of ureteral damage. When a ureter is close to the lesion, its course is traced starting at the pelvic brim, and when necessary, the peritoneum overlying the ureter is opened to confirm ureteral position deep in the pelvis. Uterosacral fibrotic endometriosis may envelop the ureter, necessitating deep ureteral dissection and excision of the surrounding endometriosis. Microbipolar forceps with irrigation between the tips are used to control arterial and venous bleeding around the ureter.
Uterosacral ligaments infiltrated with endometriosis are removed early in the operation, sometimes before rectal mobilisation. They frequently make up a large portion of a rectal nodule. The uterosacral ligament is divided lateral to the rectum where normal calibre ligament meets distended fibrotic ligament and put on traction. The peritoneum is incised on both sides of the ligament, and the thickened portion of the ligament is excised to and including its insertion into the cervix. Soft loose areolar tissue, adipose tissue, uterine vessels, and ureter are found beneath the ligament. Fibrotic tissue left at the periphery of the excision is coagulated with an irrigating microelectrode, especially at the junction of cervix with uterine fundus. Rarely the ligament will be involved all the way to the sacrum. In these cases, it may be best to divide the middle of the ligament and, with traction on the sacral side of the ligament, pull it away from rectum, ureter, and hypogastric vessels.
The dissection of the fibrotic endometriosis from the thickened vaginal wall proceeds using traction with a biopsy forceps to pull the lesion from one side to the other. Laser, aquadissection, electrosurgery, or scissors are used as needed. Often, with traction and the help of vaginal distension from below using a vaginal sponge pushed forward by a ring forceps, a distinct dissection plane becomes evident above or beneath the rectovaginal fascia, and the lesion can be pulled free from the vaginal wall. Sometimes, an endopelvic rectovaginal fascial layer, infiltrated with endometriosis, is identified, and after this layer is excised, soft pliable upper posterior vaginal wall is uncovered. Hypertrophied tissue without endometriosis is often found at the cervicovaginal junction between the insertion of the uterosacral ligaments into the cervix, making it difficult to accurately distinguish fibrotic endometriosis from fibromuscular tissue there. This inverted “U” configuration should be excised or at least biopsied.
Frequent palpation using rectovaginal examinations helps identify occult lesions. On occasion, the lesion infiltrates deep into or completely penetrates the vaginal wall. Dissection is then performed accordingly with removal of all visible palpable fibrotic endometriosis. Electrosurgery using cutting current through a blunt tipped or spoon electrode minimises bleeding from the vascular vagina. Lesions extending full thickness through the vagina are treated with an “en bloc” laparoscopic resection of fibrotic vaginal wall endometriosis from cul-de-sac into the vagina. Pneumoperitoneum is maintained with a sponge or by holding the labia together. The posterior vaginal wall defect is closed laparoscopically using interrupted polyglactin 910 suture on a CT-1 needle (Vicryl: Ethicon, Sommerville, NJ)
Endometriosis of the rectum and/or rectosigmoid may be superficial (serosal or adventitial), in the muscle (muscularis), or full thickness involving both the muscularis and the lamina propria of the mucosa; the mucosal surface is rarely broken. The lesions are anterior or lateral. Posterior wall endometriosis is a rarity but can form a ‘napkin ring’ deformity. Fibrotic endometriosis nodules infiltrating the anterior rectal wall are commonest and may be focal (cicatrixal) or linear (a transverse bar often with associated stricture where the rectum is fused to the posterior vagina). Under the microscope all of these lesions, and those of the uterosacral ligaments, posterior vagina, and cervix, are made up of fibromuscular tissue surrounding endometriosis glands and characteristic stroma.
Women with suspected or documented extensive endometriosis are counselled preoperatively regarding risk of bowel injury, methods of possible treatment, and the impact of bowel perforation and resection on their hospital stay and postoperative recuperation. Certainly the risk of unplanned rectal perforation is appreciated with any kind of intervention near the bowel, but is particularly threatening with excision of rectal endometriosis due to the fibrotic nature of the disease and related anatomical distortion. Traditionally, laparoscopic rectal injury has been treated with laparotomy closure, sometimes with colostomy. This approach, while necessary in rare cases, is more stressful for the patient, both physically and emotionally, as she must then endure the incisional surgery she had elected to avoid. Laparoscopic repair of the bowel with suture or staples is used for most bowel injuries both planned and unplanned.
The knowledge that bowel can be successfully repaired laparoscopically should increase the confidence of the surgeon operating in the deep pelvis. Suturing experience is suggested for laparoscopists who perform extensive endometriosis surgery.
Once separated from the vagina, the rectum and rectosigmoid are examined carefully with a long blunt probe inside. Lesions are assessed to determine if they are superficial, deep, or nodular. Superficial lesions involving the serosa or adventitia are excised by making an elliptical incision around the white fibrotic lesion with a scissors or a CO2 laser at low power, elevating the lesion with a micro-toothed forceps, and undermining it at its junction with soft normal-appearing circular muscularis.
Endometriotic nodules infiltrating the anterior rectal wall are excised, partially or totally, usually with a probe or the surgeon’s finger in the rectum beneath the lesion. Working with scissors or the CO2 laser at the junction of nodular white fibrosis with yellow and pink soft normal tissue, the lesion is excised. Deep rectal muscularis defects are closed with suture. The 3-0 suture is applied using curved needles, the knot tied outside the peritoneal cavity, and pushed downward with the Clarke knot pusher. (8) Enterotomies and full muscularis excisions are closed with suture or the circular stapler.
Nodules in the muscularis of the anterior or lateral rectum can usually be excised laparoscopically. (9) Full-thickness penetration of the rectum may occur during this surgery. Following identification of the rent in the rectum, usually surrounded by fibrotic endometriosis, a closed circular stapler [Proximate ILS Curved Intraluminal Stapler (Ethicon, Stealth)] is inserted into the lumen just past the hole, opened 1-2 cm, and held high to avoid the posterior rectal wall. The proximal anvil is positioned just beyond the hole, which is invaginated into the opening, and the device closed. The instrument is fired, then removed through the anus. (9) Alternately, a double-layer transverse repair is done using 3-0 silk or Vicryl. Anastomotic inspection is done laparoscopically underwater after filling the rectum with indigo carmine solution.
Full thickness or muscularis endometriotic nodules of the anterior or lateral rectum can also be resected laparoscopically without opening the rectum, especially if limited to a small-circumscribed area. Following delineation of the nodule, the #29 or #33 French circular stapler (Proximate) is used as just described, and the lesion invaginated into its opening. This results in an anterior discoid resection of a wedge of anterior rectum with contained nodule and an anterior staple line.
Strictures are often made up of appendices epiploica fused to fibrotic endometriosis implants on the sigmoid colon. Careful methodical dissection using a laser to separate these fatty appendages and microbipolar forceps for hemostasis may alleviate the stricture. Concerning the unprepared bowel, quick, staple or suture closure followed by profuse irrigation until the effluent clears are usually satisfactory.
Laparoscopic low anterior resection is indicated for endometriosis encircling the rectum in the deep pelvis, often with some degree of sigmoid obstruction, or for extensive diffuse rectosigmoid endometriosis invading the wall and causing severe symptoms refractory to other therapy. (10) The proximal and distal extents of the resection are determined. The sigmoid mesocolon is mobilised. The left ureter is identified. The mesorectum is dissected to the level of the levator ani complex if necessary. The colon is transsected with scissors, electrosurgery, laser or stapler, depending on the surgeon’s preference. The decision to perform an intracorporeal or extracorporeal rectosigmoid anastomosis depends on the surgeons’ preference, training, and laparoscopic skill level. For the intracorporeal anastomosis, the proximal colon is divided and, after division of the distal margin, the specimen is removed through the anus with a sponge forceps. A circular stapler is introduced through the rectal stump to complete the anastomosis. (11) Two complete rings of tissue should be contained in the circular stapler. Once verified, the soundness of the anastomosis is confirmed by rectal enema containing dilute indigo carmine.
Extensive endometriosis (adenomyosis) may be inside the uterus where it may cause symptoms after endometriosis excision. Adenomyosis is defined as the presence of endometrial glands and stroma interlocked within the myometrium, at least 2.5 mm from the endometrial basalis layer and surrounded by hypertrophied smooth muscle. Magnetic resonance imaging may demonstrate adenomyosis. The low signal intensity junctional zone is increased in thickness. Adenomyomas (nodular bundles of adenomyosis) may present as a low signal intensity mass with indistinct margins.
While excision of endometriosis with uterine preservation is almost always possible, hysterectomy should be considered for women with severe pelvic pain affecting the quality of their life, who do not desire fertility preservation. They require extensive counselling regarding alternatives and may select hysterectomy as their primary procedure if they have persistent or recurrent symptomatology after other surgeries, especially when uterine adenomyosis is suspected. Concomitant oophorectomy is elective.
The goal at laparoscopic hysterectomy for extensive endometriosis with cul-de-sac obliteration is the same as in any endometriosis surgery, i.e., to excise all visible and palpable endometriosis implants. (12) The surgeon must first free the ovaries, then the ureters, and finally the rectum from the posterior vagina to the rectovaginal septum. As previously described, deep fibrotic nodular endometriosis involving the cul-de-sac requires excision of the fibrotic tissue from the uterosacral ligaments, posterior cervix, posterior vagina, and the rectum. Hysterectomy with excision of all visible endometriosis usually results in relief of the patient's pain.
Oophorectomy is not usually necessary at hysterectomy for advanced endometriosis, if the endometriosis is carefully removed. The most severely affected ovary may be removed, especially if on the left as this ovary frequently becomes adherent to the bowel. Reoperation for recurrent symptoms is necessary in less than 5% of my patients in whom one or both ovaries have been preserved. Bilateral oophorectomy is rarely indicated in women under age 40 undergoing hysterectomy for endometriosis.
Hysterectomy should not be done for extensive endometriosis with extensive cul-de-sac involvement, unless the surgeon has the skill and time to resect the deep fibrotic endometriosis from the posterior vagina, uterosacral ligaments, and anterior rectum. In these patients, excision of the uterus using an intrafascial technique leaves the deep fibrotic endometriosis behind to cause future problems. Furthermore, it may be more difficult to remove deep fibrotic endometriosis when there is no uterus between the anterior rectum and the bladder. After hysterectomy, the endometriosis left in the anterior rectum and vaginal cuff frequently becomes densely adherent to, or invades into, the bladder and one or both ureters.
Deep Fibrotic Endometriosis of Vaginal Cuff Post-Hysterectomy
Excision of these lesions is often more difficult than when a uterus is present. In this author’s experience, fibrotic vaginal cuff lesions invariably involve one or both ureters and the base of the bladder. Careful dissection is necessary to free both bladder anteriorly and rectum posteriorly from the vaginal apex. Thereafter, the course of each ureter should be traced but not skeletonized. After this anatomy is identified, full thickness excision of the vaginal cuff and rectal nodular lesions usually results in relief of the patient’s pain and/or bleeding.
Halme J, Hammond MG, Hulka JF, et al. Retrograde menstruation in healthy women and in patients with endometriosis. Obstet.Gynecol. 1984;64:151-154.
Koninckx PR, Meuleman C, Oosterlynck D, Cornillie FJ. Diagnosis of deep endometriosis by clinical examination during menstruation and plasma CA-125 concentration. Fertil.Steril. 1996;65:280-287.
Ravitch MM, Ong TH, Gazzola L. A new, precise, and rapid technique of intestinal resection and anastomosis with staples. SURGERY, Gynecology & Obstetrics, 1974;139:6-10.
Redwine DB and Sharpe DR: Laparoscopic segmental resection of the sigmoid colon for endometriosis. J Laparoendosc Surg 1:217-220,1991.
Reich H, MacGregor T, Vancaillie T: CO2 laser used through the operating channel of laser laparoscopes: In vitro study of power and power density losses. 1991-a:77:40-47.
Reich H, Clarke C, Sekel L: A simple method for ligating with straight and curved needles in operative laparoscopy. Obstetrics and Gynecology, 1992:79:143-147.
Reich H, McGlynn F, Salvat J. Laparoscopic treatment of cul-de-sac obliteration secondary to retrocervical deep fibrotic endometriosis. Journal of Reproductive Medicine 1991-b;36:516-522
Reich H, McGlynn F, and Budin R: Laparoscopic repair of full-thickness bowel injury. J Laparoendosc Surg 1:119-122, 1991
Reich H, Wood C, Whittaker M: Laparoscopic anterior resection of the rectum and hysterectomy in a patient with extensive pelvic endometriosis. Gynecological Endoscopy 1998 7,79-83
Reich H, McGlynn F, and Sekel L: Total laparoscopic hysterectomy. Gynaecol Endosc 2: 59--63, 1993.*
Sampson JA. Perforating hemorrhagic (chocolate) cysts of ovary. Arch Surg 1921; 3:245-323
TeLinde RW, Scott RB. Diagnosis and treatment of endometriosis. General Practice, 5:61-65, 1952.