Management of pelvic endometriosis by means of intraabdominal carbon dioxide laser*

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1 FERTILITY AND STERIUTY Copyright 1984 The American Fertility Society Vol. 41, No.!. January 1984 Printed in U.SA. Management of pelvic endometriosis by means of intraabdominal carbon dioxide laser* Augusto P. Chong, M.D.t Michael S. Baggish, M.D. Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Mount Sinai Hospital, Hartford, Connecticut, and the University of Connecticut, School of Medicine, Farmington, Connecticut A significant number of patients with severe pelvic endometriosis are at risk of developing pelvic adhesions and/or loss of ovarian function. Although numerous surgical techniques have been advocated, none has any clear advantage over the others. This article presents a new surgical method for conservative management of pelvic endometriosis. The CO 2 laser, directed via the microscope or the freehand piece of the articulated arm, was utilized to vaporize focal endometrial implants, to excise endometrial cysts, and to lyse pelvic adhesions in 54 patients. Fourteen of 23 patients (60.8%) attempting pregnancy have conceived at the time of this report. The observed advantages of laser surgery for endometriosis are a bloodless field, precision destruction (vaporization), precision cutting, and the ability to treat poorly accessible areas. Fertil Steril41:14, 1984 Endometriosis is a condition characterized by the ectopic growth of endometrial glands and stroma, most frequently on pelvic peritoneal surfaces. (This disorder has been previously suggested to afflict predominantly women of upper socioeconomic strata who marry and attempt childbearing later in their reproductive life cycles.) The principal symptoms associated with pelvic endometriosis is pain, most often intensifying just prior to and during menses, and infertility. The latter may not bear any relationship to the degree and number of endometriotic implants. Although Received April 19, 1983; revised and accepted September 16,1983. *Presented at the Thirty-Ninth Annual Meeting of The American Fertility Society, April 16 to 20, 1983, San Francisco, California. treprint requests: Augusto P. Chong, M.D., Director, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Mount Sinai Hospital, 500 Blue Hills Avenue, Hartford, Connecticut several theories of origin have been postulated over the years and numerous clinical models have been reported to demonstrate the plausibility of one theory over all others, the etiology of this disease remains nebulous. An animal model l has substantiated the retrograde menstruation thesis ofsampson 2 ; however, this mechanism alone fails to explain the growth of benign endometrium at sites distant from the pelvic peritoneum. Two major therapeutic approaches for the amelioration of endometriosis have evolved over recent years; medical and surgical treatment. Medical management currently consists of pseudopregnancy produced by continuous oral contraceptive administration and pseudomenopause secondary to danazol treatment. The surgical approach may be radical-i.e., total abdominal hysterectomy (preservation of the ovaries may be associated with the risk of persistence of disease and symptoms-or conservative. Conservative surgery preserves the pelvic reproductive viscera 14 Chong and Baggish CO 2 laser treatment of endometriosis Fertility and Sterility

$----------_.- _. Table 1. Indications for Intraabdominal Use of CO 2 Laser in Pelvic Endometriosis \ Type No. % Primary infertility 35 65.$

2 _.- _. Table 1. Indications for Intraabdominal Use of CO 2 Laser in Pelvic Endometriosis \ Type No. % Primary infertility Secondary infertility Other reasons: pelvic pain, dys menorrhea, dyspareunia, pelvic mass Total Table 3. Severity of Endometriosis and Postoperative Danazol Therapy in 54 Patients Treated by CO 2 Laser" Stage No. % Postoperative danazol I IT III IV Total a AFS classification. 9 while removing all visible foci of endometriosis. This doctrine of conservation is usually combined with one or more of the following procedures: adhesiolysis, uterine suspension, and presacral neurectomy. Improvement of pelvic pain and visible amelioration of endometriosis can be expected in 40% of patients treated with danazol, according to Friedlander. 3 Dmowski and Cohen 4 and Greenblatt and Tzingounis 5 report a 50% response rate. Regression of disease, following conservative surgery employing a combination of sharp dissection and needle cautery, varies from 30% (Spangler et a1. 6 ) to 94% (McCoy and Bradford 7 ). Buttram 8 has correlated successful surgical treatment with the severity of disease, i.e., 84% success with the mild stages but 75% and 56%, respectively, with moderate or 'severe endometriosis. In order to better correlate and compare treatment programs, The American Fertility Society9 has proposed a standardized staging system based on a grade-point analysis. Although numerous surgical techniques have been advocated, none has any clear advantage over the others, and no truly innovative tissuesparing method has evolved to date. This article presents a new surgical method for conservative management of pelvic endometriosis. The CO2 laser, directed via the microscope or the freehand piece of the articuated arm, was utilized to vaporize focal endometrial implants, to excise endometrial cysts, and to lyse pelvic adhesions. Table 2. Ages of Women Treated for Endometriosis by Means of CO 2 Laser (54 Patients) Age range yr No % MATERIALS AND METHODS A total of 54 women with endometriosis were treated by CO2 laser at Mount Sinai Hospital between November 1979 and September Of these 54 women treated for pelvic endometriosis with the CO 2 laser, infertility was an indication in 45 patients (83%) (Table 1). The ages ranged between 20 and 40 years, with 80% of the patients falling into the 26-to-35 bracket (Table 2). Patients were staged according to the AFS classification; 94% of the group fell into stage II or stage III categories (Table 3). Three CO 2 laser machines were used for this study: (1) a Xanar Articulator (Xanar Surgical Systems, Colorado Springs, CO); (2) a Biolas Model 405 (Advanced Biomedical Instruments, Woburn, MA); and (3) a Sharplan 733 (Advanced Surgical Technologies, Inc., Schaumburg, IL). The Xanar Articulator was used in 40 cases. Three laser machines were used in order to have an ongoing capability of meeting the scheduled laser surgery, having a backup system available in two operating rooms in case of a breakdown. Although they record different power (in watts), the focal spot diameter of the laser differs, so the actual power density is similar in these machines according to the formula Power density/cm2 = watts power x 100 V SD inmm Each of the lasers is equipped with ~n articulated arm to which an autoclavable handpiece can be attached. A coincident helium-neon laser provides a visible red target onto which the CO 2 laser beam can be directed. Each laser can be attached to a double-headed operating microscope by means of a micromanipulator. Two microscopes were used for this project, a Zeiss OpMi 7P/H and a Zeiss OpMi 6S-P (Carl Zeiss, Inc., Wellesley, MA), both with 300-mm lenses. The Vol. 41, No.1, January 1984 Chong and Baggish CO 2 laser treatment of endometriosis 15

Figure 1 Manipulating and backstop accessories. 'Figure 3 Lysis of adhesions. latter system proved to be more useful.for purposes of illumination.

3 Figure 1 Manipulating and backstop accessories. 'Figure 3 Lysis of adhesions. latter system proved to be more useful.for purposes of illumination. The fiber optic illumination system was remounted from its original stationary position. This mobile light system was created by constructing -an adjustable accordion appliance, which allows the fiber light to be moved around any laser micromanipulator. Manipulating the backstop accessories are required when the laser.is used intraabdominally (Fig. 1). Initially, glass or quartz rods were utilized, but the.laser light beam.fatigued the glass and led to unpredictable fracture. Currently, light-absorbing titanium rods are being evaluated. These measure 9 inches in length and range from 2 to 3 mm 'in diameter. Titanium spatulas with light-dispersing surfaces have served as backstops when adhesions or tubular structures were to be lased. The backstop obviously absorbs stray laser energy as the target tissue is severed (Codman and Shurtloff, Inc., Randolph, MA). The laser's articulated arm was draped with 6-inch sterile double-thickness stockinet. A small opening was cut into the stockinet to allow the sterile handpiece to be attached to the arm. The microscope to which the laser micromanipulator and articulating arm were attached was covered with a standard plastic drape, which was left open at the bottom to allow the laser light to be fired unimpeded. For vaporization of implants (Fig. 2), power settings ranged from 2 to 5 watts, and spot size ranged from 0.2 to 2 mm in diameter. Time exposure ranged from 0.1 to 0.2 seconds in an intermittent fashion. The number of repetitions depended on the depth and thickness of the endometrial implants. Figure 2 Laser photovaporization of endometriotic implants. Figure 4 Laser wedge resection. 16 Chong and Baggish C02 laser treatment of endometriosis Fertility and Sterility

Table 4. Specifications for CO 2 Laser Treatment of Endometriosis Power Procedure Power Spot Time density/em' watts mm sec Implant vapor- 2-5 0.4-2.0 0.1-0.

4 Table 4. Specifications for CO 2 Laser Treatment of Endometriosis Power Procedure Power Spot Time density/em' watts mm sec Implant vapor , in ization termittent Lysis of ad , continu hesions ous Ovarian ex Continuous ,500 cision For lysis of adhesions (Fig. 3), power settings ranged from 5 to 15 watts, with other settings remaining constant. For ovarian excision procedures (Fig. 4), the power was set at 20 to 30 watts with continuous exposure (Table 4). When extensive raw surfaces resulted from adhesion dissection, free peritoneal grafts obtained from the parietal peritoneum of the anterior abdominal wall were used to cover the denuded areas. Coated Vicryl (6-0 or7-0) was used to approximateresected ovaries and to attach free-peritoneal grafts. Ringer's lactate solution, to which 5000 units of heparin were added to each liter, was used as an irrigant. One hundred to 200 ml of 32% Dextran (Hyskon; Pharmacia Laboratories, Piscataway, NJ) was instilled into the pelvis following surgery and prior to closing the abdomen. The severity and incidence of endometriosis in the patients treated with the CO 2 laser are shown in Table 3. Most patients received danazol, 400 mg twice daily, for 6 to 9 monthsafter'the operative procedure. Staging of pelvic endometriosis was done following the classifications proposed by The American Fertility Society.9 derwent more than one procedure, e.g., lysis of adhesions and vaporization. One or 2 ml of a 1:30 diluted solution of vasopressin was injected into the operative site to obtain vascular spasm, especially when ovarian resection was carried out. The purpose of the latter was to constrict vessels to a diameter of 1 mm or less so that the transecting laser beam would seal the vascular channel. The most important single technical aid to laserexcisional surgery is careful, constant traction and countertraction at the line of incision. Not only does this allow for more rapid resection, but it protects surrounding tissue from heat damage. The action of laser light on endometrial implants was precise and predictable. The laser spot could be focused to < 0.5 mm or > 2 mm, depending on the size of the lesion to be destroyed. For very precise vaporization, we preferred to use power densities of 1000 watts/cm 2 or less at intermittent time exposures of 0.1 to 0.2 second. The initial impact caused brownish fluid to exit the lesion and vaporize into a mist. When no further fluid was observed and the vaporization had created a shallow crater 1 mm deep, laser exposure was discontinued. Biopsies of these sites revealed no visible cellular structures; however, neighboring mesothelium within a few microns appeared normal. No sutures were placed in the craters, and no bleeding was observed. In the eight cases where second-look laparoscopy was performed (at least 12 weeks postoperatively) healing appeared to be excellent, with an absence of scar formation. Foci of endometriosis on the posterior aspect of the ovary and deep in the cul-de-sac were vaporized indi- RESULTS The handpiece was the most convenient method for directing laser light for vaporization of endometriotic implants and for resection of endometriomas.procedures were performed with visual enhancement by the microscope or with magnifying glasses (2.5 times). Adhesions were lysed utilizing the handpiece; however, fine or dense peritubal or peri ovarian adhesions were best separated by a fine laser beam controlled via the micromanipulator. The number and types of procedures performed with the laser were lysis of adhesions, 22; vaporization of endometrial implants, 40; ovarian cystectomy, 24; presacral neurectomy, 4; and partial oophorectomy, 4. Most patients un- Figure 5 Vaporization of endometriosis using the reflecting power of the laser. Vol. 41, No.1, January 1984 Chong and Baggish CO 2 laser treatment of endometriosis 17

Figure ~ Laser photovaporization of endometriotic cystic wall. rectly by reflecting the laser beam from a stainless steel mirror (Fig. 5). Bleeding was virtually absent in every case.

Additionally, the fine laser spot delivered by intermittent bursts provided easy, precise cutting and complete hemostasis.

5 Figure ~ Laser photovaporization of endometriotic cystic wall. rectly by reflecting the laser beam from a stainless steel mirror (Fig. 5). Bleeding was virtually absent in every case. Fine adhesions were vaporized under microscopic control. This aided the surgeon in identifying and sighting the direction of tissue planes. Additionally, the fine laser spot delivered by intermittent bursts provided easy, precise cutting and complete hemostasis. Whenever possible, a manipulating rod was slipped behind the adhesion for protection of neighboring tissues and for traction on the adhesion. In addition to hemostasis, the use ofthe laser to excise or uncap ovarian endometriomas provides a unique advantage. Whenever the endometrioma occupied a substantial part of the ovary, suchthat its total removal might result in ovarian failure, the cyst was opened by the laser. An eliptical portion of the cyst wall was then excised, and the chocolate fluid contents were drained. The interior of the cyst was next exposed by eversion, and the interior lining was superficially vaporized, with complete destruction of the lining of those cysts. Untreated portions of the cysts were sent to the pathology laboratory (Fig. 6). The cavity was finally closed by approximating the walls with fine sutures. Table 5 shows the status of our patients and the length of follow-up. Over two thirds of our patients have been followed for less than 1 year. Seven women have been at least temporarily lost to follow-up. Fourteen pregnancies have occurred to date (Table 6), and nine women have either finished or discontinued their postoperative danazol therapy and are now attempting pregnancy. Danazol was given postoperatively to patients with advanced stage II endometriosis (> 10 points) and to 78.5% of those with stage III endometriosis. Three patients did not receive danazol because they showed signs of mild hirsutism and were overweight (Table 3). Of the 14 patients who became pregnant, 11 received danazol postoperatively (78.5%). DISCUSSION Technically, the CO 2 laser has some strategic advantages over other operative methods for the conservative treatment of endometriosis. Hemostasis and predictable precision are two major benefits. The ability of the laser beam to reach into recessed or otherwise poorly visible areas, e.g., the interior of endometriotic cysts, represents a technologic advance previously unavailable to the gynecologist. The follow-up period is too short for us to quantitate any significant difference in outcome (especially with regard to pregnancy) between this laser-treated series of patients and women treated by conventional surgical methods. Second-look laparoscopy should be performed in most, if not all, patients to assess the results of conservative surgery; however, many women whose symptoms have been more or less completely ameliorated object to this additional operative procedure. The purpose of this study was to explore the use of the laser as a surgical tool, not as a substitute Table 5. Follow-Up Status of Women Treated by CO 2 Laser for Pelvic Endometriosis No. treated No. on No. attempting No. preg- No. lost to Length of follow-up No. % with danazol danazol pregnancy nant follow-upl dropouts nw ;;; < Total Chong and Baggish CO 2 laser treatment of endometriosis Fertility and Sterility

6 Table 6. Severity of Endometriosis and Incidence of Pregnancy (24 Patients) No. try- No. preg- Stage idg Dant % I IT ill IV 2 Total a aaverage. for medical treatment. Even though 78% of the patients who conceived received danazol postoperatively, conclusions cannot be drawn as to the efficacy of danazol in this study because it was used in a nonrandomized fashion. A collaborative, randomized, multicenter study performed by surgeons expert in laser and nonlaser techniques will ultimately provide the "acid test" of hard data and will determine whether the laser will be the instrument of choice for the treatment of pelvic endometriosis. Acknowledgment. The authors wish to acknowledge the invaluable technical assistance of Ms. Helene Simon in the preparation of the manuscript. REFERENCES 1. dizerega GS, Barber DL, Hodgen GD: Endometriosis: role of ovarian steroids in initiation, maintenance, and suppression. Fertil Steril 33:649, Sampson JA: Intestinal adenomas of the endometrial type. Arch Surg 5:217, Friedlander RL: The treatment of endometriosis with danazol. J Reprod Med 10:197, Dmowski WP, Cohen ME: Treatment of endometriosis with an antigonadotropin, danazol: a laparoscopic and histologic evaluation. Obstet Gynecol 46:147, Greenblatt RB, Tzingounis V: Danazol treatment of endometriosis: long-term follow-up. Fertil Steril 32:518, Spangler DB, Jones GS, Jones HW Jr: Infertility due to endometriosis. Am J Obstet Gynecol 109:850, McCoy JB, Bradford WZ: Surgical treatment of endometriosis with conservation of reproductive potential. Am J Obstet Gynecol 87:394, Buttram VC Jr: Surgical treatment of endometriosis in the infertile female: a modified approach. Fertil Steril 32:635, American Fertility Society: Classification of endometriosis. Fertil Steril 32:633, 1979 Vol. 41, No.1, January 1984 Chong and Baggish CO 2 laser treatment of endometriosis 19

Endometriosis. Assoc.Prof.Pawin Puapornpong, Faculty of Medicine, Srinakharinwirot University.

Endometriosis. Assoc.Prof.Pawin Puapornpong, Faculty of Medicine, Srinakharinwirot University. Endometriosis Assoc.Prof.Pawin Puapornpong, Faculty of Medicine, Srinakharinwirot University. Endometriosis Definition: Ectopic Endometrial Tissue True Incidence Unknown:? 1-5% Does NOT Discriminate by