Deep endometriosis surgery

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Silvia Thornton
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Univ Sacro Cuore, Italy, Honorary Consultant UK, Hon Prof Moscow Univ ** Consultant

1 JDD Lyon 24-25/11/2016 Deep endometriosis surgery Philippe R. Koninckx *,*** Anastasia Ussia **,*** *Prof em KU leuven Belgium, Univ Oxford UK, Univ Sacro Cuore, Italy, Honorary Consultant UK, Hon Prof Moscow Univ ** Consultant Univ Sacro Cuore, Gemelli, Roma ***Gruppo Italo Belga, Leuven Rome, Belgium Italy. *Disclosure : shareholder EndoSAT

2 Deep endometriosis : definition The past > 5 mm PK 94 Too much typical lesions included The future Adenomyotic nodule Generally unique Generally > 1 cm End stage Infiltrating Metastatic :

3 Deep endo : natural history A non progressive disease A non recurrent disease Following an incident cells start to develop clonally into cystic or deep lesions. But at diagnosis lesions are rarely progressive Recurrences of 1% of 5% are rather incomplete surgery

5 Our Rules What is deep endometriosis? What is the indication for surgery? How do we plan surgery? Which preop exams Informed consent Surgery 1. judge if do 2. prepare 3 excise To treat women with endometriosis

6 Deep endometriosis Rule I The indication for surgery is clinical Symptoms...Perineal pain Clinical exam Infertility can be an indication for diagnostic laparoscopy Imaging alone is not an indication for deep endometriosis surgery Long medical treatment without a diagnosis is a mistake

Deep endometriosis Rule II Once the decision for surgery is taken Exclude hydronefrosis -> stent Exclude major bowel obstruction : only occlusion of >50% over >3 cm = elective bowel

7 Deep endometriosis Rule II Once the decision for surgery is taken Exclude hydronefrosis -> stent Exclude major bowel obstruction : only occlusion of >50% over >3 cm = elective bowel resection When bigger than 3 cm start to worry US of MRI can(not)make the decision of bowel resection They can be useful for patient counseling For estimating duration of surgery and planning

is limited for low lesions MRI, CAT, US : little added value US, IVP, CAT,

8 Preoperative exams For a (pelvic) surgeon who can deal with Contrast-enema To exclude sigmoid stenosis >50% bladder bowel and ureters Added usefullness is limited for low lesions MRI, CAT, US : little added value US, IVP, CAT, MRI To diagnose hydronefrosis -> preop ureter stenting since 18% ureter lesions

Can we predict severity ultrasound, MRI, transrectal ultrasound, coloscopy NO : To decide to do/refer NO : To decide to do a bowel resection (except extreme

9 Can we predict severity ultrasound, MRI, transrectal ultrasound, coloscopy NO : To decide to do/refer NO : To decide to do a bowel resection (except extreme cases) Prediction of frozen pelvis Prediction of depth of bowel wall invasion US = estimation // specif-sensit < 80% MRI, Transrectal US / circomference coloscopy

10 Our practice Bowel resection Rectum <1 % All > 4 cm Sigmoid 10% All > 1 cm Conservative excision Nodule diameter 2-3 >3 1 layer suture % % 2 layer suture 5-20 % %

11 Deep endometriosis Statement III Once the decision for surgery is taken Choose and know your instruments High flow insufflator + trocar with 7 mm side opening (to open vagina) Uterine manipulator Soft coagulation bipolar and scissors CO2 laser, Ultracision, hook

12 Deep endometriosis Statement IIIa Multidisciplinarity : an advantage or the blind leading the blind?

13 Completeness of surgery Theoretically impossible to remove all endometriotic cells Metastatic in lymph nodes Fibrosis around deep endometriosis Cut the head and the rest dies

14 Expertise required pain ++ perineal Radiation All exams Negative Clinical, MRI, contrast enema hysterectomy

15 Instruments Deep endo : : manipulator uterine manipulator

16 Deep endometriosis rule IV during surgery Judge difficulty : if you can do : do Match you limits (4-5h) with completeness Frozen pelvis : Previous surgery Previous IVF Size : difficulty and time increase exponentially especially when bigger than 3 cm Sigmoid (evt 2 steps) Ischial spine prepare the operating field Start to excise

17 Deep endo surgery : a fixed strategy Exposure Lift ovary + identify/dissect ureter No risk

18 A fixed Surgical Strategy : en bloc resection First Lateral Excise endometriosis around ureter risk : ureter lesion when hydronefrosis risk : when surrounding deep endo, especially low! nerves Extend to uretero-sacral and para rectal space risk : innervation hypogastric nerve Second Posterior part : ischeal spine risks ischeal spine bleeding & parasympaticus

19 A fixed Surgical Strategy : en bloc resection The nodule Leave attached to the uterus = elevation Dissect between bowel and nodule up to rectovaginal space Excise nodule from vagina Other : balance risk and completeness - ovary vagina bowel

20 Sigmoid endometriosis : fix first

21 Sigmoid endometriosiss Sigmoid endometriosis : first fix Step 2 incise

22 History of deep endo surgery Those that tried to be conservative became less aggressive over time without increasing recurrences with similar results Based upon understanding of the disease

23 c 5 cm

24 Considerations for bowel resection Technically often not necessary Microscopic endo is no longer an argument Small resections Level of lesion Technically easier & faster Shared responsibility with surgeons

25 Conclusion Sigmoid : liberal use of bowel resection Rectum- low rectum leaves bowel attached to vagina Less aggressive : complete is not possible Knowledge of innervation Try and see With experience <20% up to 1-2 %

26 deep endometriosis surgery today Bowel preparation Knowledge of anatomy Arteries of the rectosigmoid are terminal arteries with thus an increased risk of ischemic necrosis after coagulation Do not open the bowel concept? Sutures <-> circular stapler <-> linear stapler leak free Hand sewn = automatic stapler Leaks = Difficult diagnosis since up to 20% of resection anastomosis have some leak at Cat Scan Protective colostomy or ileostomy Is always more prudent but inherent complications unclear when necessary. Videoregistration obligatoire

27 Late bowel Perforation : symptoms Acute pain disappearing spontaneously No other clinical symptoms for 24 hours CRP : increases after 6-12 hours

28 Late bowel Perforation : less than 24h Surgery 3 pm 6 am acute pain 10 am : info Immediate lap

30 Deep Endometriosis surgery Most lesions are non progressive and not recurrent, surrounded by fibrosis as a remnant of the inflammatory reaction -> remove the lesion not the fibrosis Sigmoid : small resection Rectum : bowel resection is almost always avoidable Lavage and conditioning but no more saline Late bowel perforation Know the symptoms = experienced team Early repeat laparoscopy Probably very rare provided right technique +lavage + conditioning

Deep Endometriosis Surgery pro conservative surgery?

ISGE OPAIJA 26-29/5/2016 Deep Endometriosis Surgery pro conservative surgery? Introduction Feasability of conservative surgery No need to be that radical Conclusions Gruppo Italo Belga HH Leuven VDR Rome