Surgical treatment of endometriosis via laser laparoscopy*

Transcription

1 FERTILITY AND STERILITY Copyright < 1986 The American Fertility Society Printed in U.S.A. Surgical treatment of endometriosis via laser laparoscopy* Camran Nezhat, M.D.t+ Scott R. Crowgey, M.D. Charles P. Garrison, M.D. Northside Hospital, Georgia Institute of Technology and West Paces Ferry Hospital, Atlanta, Georgia The carbon dioxide laser has been used laparoscopically for the removal of endometriotic implants, excision of endometrioma capsules, and lysis of adnexal adhesions in 102 patients. These patients were followed for a period ranging from 12 to 18 months, during which time there were 62 pregnancies, including 9 spontaneous abortions and 1 elective termination. The rates of conception after surgery were as follows: 75% for patients with mild endometriosis, 62% for patients with moderate endometriosis, 42.1% for patients with severe endometriosis, and 50% for patients with extensive endometriosis. Of 102 patients presenting with infertility attributed to endometriosis, 60.7% conceived within 24 months after laser laparoscopy. In this patient group, no immediate or subsequent laparotomy was required before conception was achieved, nor was hormonal therapy enacted during the study period after surgery. Fertil Steril 45:778, 1986 Recent advances in endoscopic surgery techniques and the increased sophistication of surgical instruments has offered new operative methods and techniques to the gynecologic surgeon. Laser techniques have evolved rapidly over the past few years in a number of specialties. The techniques we evaluated have increased the success rate of pregnancies and permitted surgery that produced minimal trauma for patients. Received August 1, 1985; revised and accepted February 12, *Presented at the Forty-first Annual Meeting of The American Fertility Society, September 28 to October 2, 1985, Chicago, Illinois. tdirector, Gynecology Laser Workshop and In Vitro Fertilization Program, Northside Hospital. :j:reprint requests: Camran Nezhat, M.D., Northside Hospital, 5555 Peachtree Dunwoody Road, N.E., Suite 276, Atlanta, Georgia Research Engineer, Georgia Institute of Technology. 778 Nezhat et al. Laser laparoscopy for endometriosis THE LASER MATERIALS AND METHODS The CO2 laser is a gas molecular laser that emits light in the infrared range of 10,600 mm. One advantage of the laser is the focal point of the beam, 0.2 to 0.8 mm in diameter, which allows precise controlled tissue distribution. In addition, because of the CO2 laser's collimated beam, there is no lateral damage on impact. This beam can be defocused with the micromanipulator of the coupler or by increasing the distance of the scope or the second puncture probe from the tissue. (Currently, 28- and l8-cm lenses can be used through the operative channel of a laparoscope or a second puncture probe). The CO2 laser beam is totally absorbed by water in soft tissues up to a depth of 0.1 mm from the point of impact, leaving underlying tissue unharmed and allowing a rapid dispersion of heat. Fertility and Sterility

2 Therefore, there is low risk of thermal damage to underlying or surrounding tissue. In addition to precision, the laser permits a bloodless incision by coagulating small (0.5 mm) blood vessels. For the procedures discussed herein, the CO 2 laser (Sharplan 733, Advanced Surgical Technologies, Allendale, NJ) was used. The CO2 laser was used either through the operating channel of the laparoscope or through a specially adapted second puncture trocar.1 A micromanipulator coupler was used, and attached to the laparoscope or to the probe. A 28- or 18-cm zinc arsenide lens was used in the coupler to focus the laser beam. The laser laparoscopes used for these procedures were the Eder Laser Laparoscope and Micromanipulator (Edward Weck Co., Research Triangle Park, NC), the Wolf Laser Laparoscope and Micromanipulator (Richard Wolf Medical Instruments Corp., Rosemont, IL), and the (Karl Storz Endoscopy America, Inc., Culver City, CA). The only contributing factor to infertility in this patient group was endometriosis. Other causes of infertility (hormonal, male factor, etc.) had been eliminated as the probable cause of the patients' infertility. The possible need for laparotomy or more extensive additional procedures like colostomy or hysterectomy were discussed preoperatively with the patient. Before embarking on the treating of a large endometrioma, careful laparoscopic assessment was done to reduce the chance of draining a pelvic malignancy. The cysts that had the appearance of endometriomas were first aspirated for cytology. Peritoneal washing would have been performed if suspicion of malignancy existed. The procedures were performed under general endotracheal anesthesia with patients placed in the lithotomy position. The bladder was drained, and a cervical cannula was placed for manipulation of the uterus and for intraoperative injection of diluted indigo carmine. Each patient received 1 gm Mefoxin (Merck Sharp & Dohme, West Point, PA) intravenously at the start of the procedure, as a prophylactic single dose. After pneumoperitoneum induction, the operating laparoscope was inserted intraumbilically. A 5-mm second-puncture trocar was then inserted in the midline approximately 2 to 4 cm above the symphysis pubis. An atraumatic alligator grasping forceps (Eder Instruments Company, Chicago, IL) was then introduced through the second puncture site for traction or manipulation as needed during surgery. When necessary, a third incision was made either in the midline, one-third of the way between the laparoscope and suprapubic trocars, or along the suprapubic line, 2 to 3 inches from the second trocar. This third incision allowed the insertion of the special CO2 laser probe, a suction-irrigator, or othh auxiliary instruments as needed during surgery. A focused beam of 6000 to 12,000 W (0.5 mm spot size, at a 15- to 30-W setting) was employed to vaporize endometriosis implants from the ovary, pelvic sidewall, cul-de-sac, tubes, uterosacral ligaments, bladder flap, and peritoneum or capsule of endometriomas. The continuous or pulse mode of the CO2 laser was used. Pulse mode was used for delicate dissection, particularly around the ureters, bowels, and vessels. Pulse mode was approximately 1.7 per second with a shutter opening of 0.05 to 0.1 seconds. Endometriomas up to 7 cm in diameter and any peritubal or periovarian adhesions were also treated through laser lysis. When the cavity was opened, the internal wall was examined for excrescent tumor. In the event one had been found, a frozen section would have been performed. Large endometriomas were aspirated and irrigated several times with a doublebore needle (Rocket of London, London, UK), routinely used for ovum retrieval in in vitro fertilization programs. The endometriomas were then bivalved and the capsule dissected and removed when possible. Any residual capsule was then vaporized. This reduced the possibility that the ablation of the capsule would be incomplete. Endometriomas' capsules can be up to 4 to 5 mm thick, which makes vaporizing the whole capsule difficult and time-consuming. If oozing occurred from the lysis area, a Jackson-Pratt drain (Goleta, CA) was inserted in the abdominal cavity and removed the next day. The patients were routinely discharged 2 to 4 hours after surgery. RESULTS Of the 102 patients, only 2 required draining. Operating time was between 20 minutes and 3% hours, according to the stage of the disease. In a few instances patients stayed longer, up to 20 hours after surgery (one-night stay). The duration of infertility in the patients ranged from 12 to 192 months. Fourteen (13.1%) patients had experienced endometriosis-related infertility for 12 to 23 months before surgery. For Nezhat et al. Laser laparoscopy for endometriosis 779

3 Table 1. Total of 102 Patients with Endometriosis No. of No. of Stage patients pregnancies I. Mild II. Moderate III. Severe 19 8 IV. Extensive 8 4 Total % Spontaneous abortion % (47%) of the patients, the duration of infertility was 24 to 36 months, with 40 patients (39.2%) reporting infertility for over 36 months. The parity of the 102 patients presenting was as follows: nulliparous, 78 patients (76%); parous, 24 patients (23%). Pregnancy rates were tabulated for a follow-up period of 18 months. During this period, there were 62 pregnancies (Tables 1 to 3), including 52 term pregnancies, 9 spontaneous abortions, and 1 elective termination of pregnancy. During the follow-up period, 18 ofthe 24 patients (75%) with stage IIAFS2 endometriosis conceived. Four pregnancies resulted in spontaneous abortions (22%) (Table 1). Of the 51 patients with stage IIIAFS endometriosis, 32 (62.7%) became pregnant. Four of the 32 pregnancies resulted in spontaneous abortions (12.5%) (Table 1). Of the 19 patients with severe endometriosis, stage III/AFS, 8 (42.1 %) conceived. One patient miscarried at 6 weeks' gestation. One patient terminated the pregnancy, because the principals involved separated (Table 1). In the patient group characterized as stage IV/AFS, 4 (50%) (4 of 8) became pregnant (Table 1). None of the patients experienced any postoperative infection, bleeding, or thermal injury because of the CO2 laser. There were no ectopic pregnancies. Table 3 lists the age ranges of these patients. Of 78 nulliparous patients, 47, or 60.2%, became pregnant; and of 24 parous patients, 15, or 62.5%, achieved pregnancy. Of the 62 women who conceived after laser laparoscopy, 12 (24.1%) were 20to 25 years of age, 20 (32%) were 25 to 30 years of age, 27 (43%) were 30 to 35 years of age, and 3 (4.8%) were 35 to 41 years of age (Table 4). DISCUSSION As noted earlier, management and treatment of infertility because of endometriosis may be effected either surgically or medically.3-lo 780 Nezhat et al. Laser laparoscopy for endometriosis Danazol has been considered one of the best methods for medical treatment of endometriosis when no significant peritubal or periovarian adhesions are present. Danazol therapy is advantageous in that it avoids major surgery while providing excellent pregnancy rates in mild (stage II AFS) to moderate (stage III AFS) endometriosis.4. 6 Treatment with danazol,4-6 however, is expensive and prolonged, lasting for up to 9 months. In addition, undesirable side effects, including menstrual irregularities, weight gain, nervousness, depression, acne, etc., have been reported. Recently, a case of bilateral sensorineural hearing loss has been associated with this therapyy In comparison with hormonal therapy, laser laparoscopic treatment of endometriosis can be relatively simple and inexpensive, especially if it is effected at the same time as diagnostic laparoscopy. In terms of efficacy of treatment, this study shows favorable results, compared with published pregnancy rates for different stages of endometriosis treated by drugs or conservative surgery. Of particular interest is the conception rate for patients with endometriosis classified as severe (stage IIIIAFS) and extensive (stage IV/AFS). Mild, moderate, and severe endometriosis has been treated before via laparoscope with nonlaser techniques.l2-l6 Frangeheiml6 treated large endometriomas laparoscopically by aspirating the contents. Sixty percent of the punctured cysts did not refill, but 40% did refill and required subsequent surgical removal. Table 2. Pregnancy Rate in 8 to 12 and 18 Months in 102 Patients with Endometriosis No. of months No. of pregnancies % Total 62 Fertility and Sterility

4 Table 3. Distribution of Pregnancy in 102 Patients with Endometriosis No. of Age No. of patients pregnancies % Total The CO2 laser laparoscope was first used by Bruhat et al.17 in France and Tadir et al. 18 in Israel. Daniell and Pittaway1 provided the impetus for the use of this equipment in the United States. Subsequent studies by Kelly and Roberts,7 Feste,19 and Martin8 suggest the value of these techniques. Keye and Dixon20 have introduced.the use of the argon laser for photocoagulation of endometriosis, and Lomano21 has suggested the use of the neodymium Y AG for this purpose. Neither the argon nor the Y AG has been used for extensive laparoscopic dissection. The current work of Joffe et al.22 in the development of an artificial sapphire tip for the Y AG laser in extensive intraabdominal surgery at laparotomy has the potential for laparoscopic fiber-directed dissection. When the CO2 laser is used through the laparoscope, the surgeon's line of vision and the beam are almost coincident. They are almost coincident because the line of vision and the line of the CO2 laser beam emerge from two different channels. This is an important point for one to consider to prevent any inadvertent tissue damage. The high intensity of the scope's light source causes some diminution of the ReNe aiming beam. Any additional lights for photographic purposes further obscure the visibility of the ReNe beam. Gradually the systems are becoming more sophisticated, and the instrument companies are providing more efficient auxiliary instruments. We have avoided the significant back strain associated with operating directly through the laparoscope by refining videomonitoring techniques. With this technique, which we have been calling videolasroscopy, we have excised endometriomas of up to 7 cm in size and in stage IV/ AFS endometriosis. With the use of video-monitoring systems, we have decreased the time and back strain of direct laparoscopic visualization. The use of a video camera, video recorder, and a high-resolution video monitor in conjunction with the laser laparoscopic procedures provide two benefits. Fatigue, brought on by long, complicated procedures can be minimized as the surgeon works in a more comfortable, upright posture, working from the monitor rather than by direct eye contact with the scope. Secondly, a video recording of the procedure is available for future reference. Karl Storz's Videocamera (Karl Storz Endoscopy America, Inc.) and the Wolf Video Camera (Richard Wolf Medical Instruments Corp.) were used interchangeably. Both of these cameras provide good resolution and good-quality videotapes. The second puncture laser probe has an 8-mm double ring channel which allows the simultaneous transmission of laser beam and insufflation of fresh CO2, Control of insufflation is facilitated through two valves located at the base of the probe. Insufflation of fresh CO2 through the laser channel (probe) at a rate of 2 liminute causes smoke to be forced out of the laser's path, and moisture does not accumulate on the focusing lens or mirror in the coupler. The drawbacks encountered with using the CO2 laser directly through the laparoscope includeinadequate smoke evacuation and diminution of the visibility of the red helium/neon guide. Advantages of laser laparoscopy over laparotomy are a faster recovery period and a shorter hospital stay. Minimal handling of the tissue and less exposure to air reduce secondary dryness of tissue, and elimination of glove powder during a laparotomy probably diminishes the formation of postoperative adhesions. Furthermore, susceptibility to bacterial contamination.and oozing from the abdominal wall incision maybe increased by laparotomy, in comparison with laparoscopy, and may enhance adhesion formation. The use of the laser in preference to cautery or surgical excision of endometrioma may forestall the formation of postoperative adhesions, to which the ovaries are vulnerable. Finally, use of the laser can preclude the Table 4. Duration of Infertility in 102 Patients with Endometriosis No. of months mos. or more No. of patients % Nezhat et ai. Laser laparoscopy for endometriosis 781

5 formidable complications associated with the use of cautery. 23 Energy from the CO2 laser is focused so precisely that the tissue beyond 100 fj.m is unaffected. This precision allows destruction of endometriosis close to vital structures, such as the ureters, bowel, and blood vessels, when the surgery is performed by an expert laser laparoscopist. This precision is not possible with cautery. It must be emphasized that laser laparoscopy should be performed only by experienced operative laparoscopists. This requires the surgeon to have extensive training and experience with the laser. It should not be attempted by inexperienced laparoscopists who are not comfortable with multiple puncture techniques. More advanced disease should be treated only when the surgeon thinks that the procedure can be done as well or better than if it were done via laparotomy. DeCherney stated, "The obituary of laparotomy for pelvic reconstructive surgery has been written; it is only its publication that remains. A burgeoning of reconstructive surgery with the use of the endoscope will revolutionize gynecologic surgery.,,24 We believe it has done so. CO2 laser laparoscopy could well be the way of the future for treatment of a large number of diseases of the reproductive organs and particularly endometriosis, especially with daily improvement of laser equipment. In the not too distant future, every operating room will be equipped with different types of lasers. The laser laparoscopist will be able to use the CO2 laser close to the ureters, bowel, or blood vessels, and will have the ability to open large endometriomas. If entire removal of the capsule of the endometrioma is prohibitive, or if the CO2 laser produces excessive smoke, the option of ablation or coagulation of the capsule by argon, YAG, or other lasers will exist. The surgical laser is not a panacea. This adjunctive surgical device in the hands of an experienced laparoscopist can broaden his abilities and improve subsequent fertility rates. In our opinion, conservative surgical management of mild to extensive endometriosis should involve the laparoscope. New technology is here to help us. ADDENDUM At the time of the final review of the manuscript in January 1986, we had one ectopic pregnancy in patients with stage 3/AFS endometriosis and two more pregnancies in patients with stage 782 Nezhat et al. Laser Zaparoscopy for endometriosis IV/AFS endometriosis: one miscarried at 4 weeks' gestation; the other patient is 19 weeks pregnant now. REFERENCES 1. Daniell JF, Pittaway DE: Use of the CO 2 laser in laparoscopic surgery: initial experience with the second puncture technique. Infertility 5:15, The American Fertility Society: Classification of endometriosis. Fertil Steril 32:633, Guzick DS, Rock JA: A comparison of danazol and con servative surgery for the treatment of infertility due to mild or moderate endometriosis. Fertil Steril 40:580, Buttram VC Jr, Reiter RC, Ward S: Treatment of endometriosis with danazol: report of a 6-year prospective study. Fertil Steril 43:353, Puleo JG, Hammond CB: Conservative treatment of endometriosis externa: the effects of danazol therapy. Fertil Steril 40:164, Greenblatt RB, Tzingounis V: Danazol treatment of endometriosis: long-term follow-up. Fertil Steril 32:518, Kelly RW, Roberts DK: CO 2 laser laparoscopy: potential alternative to danazol in the treatment of stage I and II endometriosis. J Reprod Med 28:638, Martin DC: CO 2 laser laparoscopy for the treatment of endometriosis associated with infertility. J Reprod Med 30:409, Buttram VC Jr: Surgical treatment of endometriosis in the infertile female: a modified approach. Fertil Steril 32:635, Chong A, Baggish M: Management of pelvic endometriosis by means of intra abdominal carbon dioxide laser. Fertil Steril 41:14, Enyear TJ Jr, Price WA: Bilateral sensorineural hearing loss from danazol therapy. J Reprod Med 29:5, Eward RD: Cauterization of stage I and II endometriosis and resulting pregnancy rate. In Endoscopy and Gynecology, Edited by JM Phillips. Downey, California, American Association of Gynecologic Laparoscopists, 1978, p Sulewski JM, Crucia FD, Brenitskey C: The treatment of endometriosis at laparoscopy for infertility. Am J Obstet Gynecol 128:128, Hasson HM: Electrocoagulation of pelvic endometriosis lesions with laparoscopic control. Am J Obstet Gynecol 132:115, Daniell JF, Christianson C: Combined laparoscopic surgery and danazol therapy for pelvic endometriosis. Fertil Steril 35:521, Frangeheim H: Endoscopy and gynecology. In The Range and Limits of Operating Laparoscopy in the Diagnosis of Sterility, Edited by JM Phillips. Downey, California, American Association of Gynecologic Laparoscopists, 1978, p Bruhat M, Mage C, Manhes M: Use of the CO 2 laser via laparoscopy. In Laser Surgery III, Proceedings of the Third International Society for Laser Surgery, Edited by I Kaplan. Tel Aviv, International Society for Laser Surgery, 1979, p 275 Fertility and Sterility

6 18. Tadir Y, Ovadia J, Zuckerman Z: Laparoscopic application of CO 2 laser. In Proceedings of the Fourth Congress of the International Society for Laser Surgery, Edited by K Atsumi, N Nimsakul. Tokyo, Japanese Society for Laser Medicine, 1981, p Feste JR: Laser laparoscopy: a new modality. Lasers Surg Med 3:170, Keye WR, Dixon J: Photocoagulation of endometriosis with the argon laser through the laparoscope. Obstet Gynecol 62:383, Lomano JM: Laparoscopic ablation of endometriosis with the YAG laser. Lasers Surg Med 3:179, Joffe SN, Daikuzono N, Osborn J, Batra P, Studer R, Sankar MT, Fisher JC: Unpublished data 23. Wheeless CR: Gastrointestinal injuries associated with laparoscopy. In 1977 American Association of Gynecologic Laparoscopists, 1977, p DeCherney A: The leader of the band is tired... Fertil Steril 44:299, 1985 Nezhat et ai. Laser laparoscopy for endometriosis 783