10

Endoscopic surgery

J. D O N N E Z M. NISOLLE F. CASANAS

Advanced operative laparoscopy techniques for laser adhesiolysis and vaporization of endometriotic implants have been developed and laser surgeons are thus able to remove endometriosis from the reproductive structure with great precision. There are at least three advantages of laser laparoscopy over conventional operative laparoscopy: precise destruction of diseased tissue, minimal bleeding and minimal damage to the adjacent normal tissue. Tissue reaction and postoperative adhesion formation have been shown to be no greater than with conventional methods.

PERITONEAL ENDOMETRIOSIS

Diagnosis

Endometriosis most commonly affects the pelvic peritoneum close to the ovaries, including the uterosacral ligaments, the ovarian fossa peritoneum and the peritoneum of the cul-de-sac.

The diagnosis of peritoneal endometriosis at the time of laparoscopy is often made by observation of typical puckered, black or bluish lesions~ These lesions are clearly visible, but endometriosis can be easily overlooked when typical black or bluish pigments are not seen. During the 1980s, numerous studies (Jansen and Russell, 1986; Redwine, 1987; Stripling et al, 1988; Donnez and Nisolle, 1988; Martin et al, 1989; NisoUe et al, 1990) described not only the typical endometriotic lesions but also the numerous subtle appearances of peritoneal endometriosis. These lesions, frequently unpigmented, were diagnosed as endometriosis on biopsy by Jansen and Russell (1986). The increased diagnosis of endometriosis at laparoscopy is due to the surgeon's growing ability to detect such subtle lesions with experience (the diagnosis of endometriosis at laparoscopy increased from 42% in 1982 to 72% in 1988). The greatest change is in the detection of 'subtle' lesions, which increased from 15% in 1986 to 65% in 1988 (Martin et al, 1989).

Bailli~re's Clinical Obstetrics and G ynaecology-- 839 Vol. 7, No. 4, December 1993 Copyright © 1993, by Bailli~re Tindall ISBN 0-7020-1753-1 All rights of reproduction in any form reserved

840 J. DONNEZ ET AL

Endometriosis lesions occur in a wide range of colours (only a small proport ion are black) and may be easily missed unless meticulous inspection is carried out to identify small or non-haemorrhagic lesions.

Different appearances of peritoneal endometriosis

The typical peritoneal endometriotic lesion results from tissue bleeding and retention of blood pigment, producing brown discoloration of tissue. Puckered, black lesions are a combination of glands, stroma, scar and intraluminal debris. These pigmented lesions are often surrounded by areas of non-pigmented lesions (Table 1).

Sometimes the subtle endometriotic lesions are the only lesions seen at laparoscopy. These subtle forms are more common and may be more active than the puckered, black lesions.

Table 1. Laparoscopic appearance of peritoneal endometriosis.

Typical aspect Puckered, black lesion

Subtle lesions White opacification (Jansen and Russell, 1986) Red, flame-like lesion (Jansen and Russell, 1986) Glandular excrescences (Jansen and Russell, 1986) Subovarian adhesions (Jansen and Russell, 1986) Yellow-brown peritoneal patches (Jansen and Russell, 1986) Circular peritoneal defect (Chatman, 1981) Petechial peritoneum (Donnez and Nisolle, 1988) Hypervascularization areas (Donnez and Nisolle, 1988)

Histologic study of peritoneal endometriosis

Histologic study confirms the presence of both epithelium and stroma of the endometrial type in puckered, black lesions in more than 95% of cases; in subtle appearances of peritoneal endometriosis, these tissues occur in more than 90% of red lesions and in more than 50% of white lesions. Morphologic characteristics of peritoneal endometriosis (Table 2) were studied in 109 biopsies with histologically proved endometriosis. An endometriotic lesion was considered 'active' when typical glandular epithelium appeared to be either proliferative or completely unresponsive to hormones with typical stroma. Such a lesion was found in 76% of cases. Areas of oviduct-like epithelium with ciliated cells were demonstrated in 55% of peritoneal endometriotic foci.

Table 2. Histologic appearance of peritoneal endometriosis: results from 109 biopsies.

Typical glandular epithelium and stroma Active endometriosis Oviduct-like epithelium Epithelial height (Ixm) Mitotic index (per 10 3 )

109 (100%) 83 (76%) 46 (55%) 14.8+3.2 0.6

ENDOSCOPIC SURGERY 841

The epithelial height and the mitotic index were calculated in typical glandular epithelium. The epithelial height was measured with a micrometer and the mitotic index was calculated by counting mitotic figures for 2000 epithelial cells. The values were respectively 14.8+ 3.2 txm and 0.6 per thousand.

Relationship between typical and subtle endometriotic lesions

Brown and black coloration appears to be related to the amount of intra- luminal haemosiderin and debris. The dark, pigmented lesions that compose the usual visual criteria for diagnosis of endometriosis are the late consequence of this cyclic growth and regression of the lesions, when tissue bleeding and discoloration by blood pigment have already taken place.

During the 1980s, several authors hinted at the variety of subtle appear- ances possible with endometriosis. Some of them (Jansen and Russell, 1986) suggested the possibility of a biologic continuum between non-pigmented and pigmented endometriotic lesions. In some cases, they proved their hypothesis by second-look laparoscopy: the non-pigmented lesions untreated during the first laparoscopy progressed to the typical pigmented endometriotic areas within the course of 6-24 months. It is an argument in favour of the serosal metaplasia theory over the implantation theory of Sampson (1927) in the aetiology of peritoneal endometriosis.

Endometriosis of macroscopically normal peritoneum

Identification of endometriosis in biopsy specimens from areas of apparently normal peritoneum in patients with known endometriosis was reported by Murphy et al (1986). By scanning electron microscopy, 25% of specimens that appeared normal on gross inspection were found to contain evidence of endometriosis.

By light microscopy, an incidence of 13% was reported in the study of Nisolle et al (1990). Biopsies were taken from a visually normal peritoneum, contiguous with pigmented lesions or with areas of subtle appearances of peritoneal endometriosis. Vasquez et al (1984) documented microscopic implants of endometriosis on the peritoneal surface by scanning electron microscopy in patients with unexplained infertility in whom no endometri- osis was observed at the time of laparoscopy.

Histologic study of biopsies from visually normal peritoneum in infertile women without any typical or subtle endometriotic lesions revealed the presence of endometriosis in 6% of cases (Nisolle et al, 1990). Unsuspected peritoneal endometriosis can thus be found in visually normal peritoneum of infertile women with or without associated endometriosis. Our data confirm that the operating surgeon did not make the diagnosis in at least 6% of patients, despite the significant increase in the diagnosis and documentation of endometriosis. This suggests that the absence of endometriosis in infertile women must be confirmed by biopsy from uterosacral ligament peritoneum.

8 4 2 j . DONNEZ ET AL

Laparoscopic therapy of peritoneal endometriosis

Superficial implants are treated by coagulation using bipolar coagulation, the carbon dioxide laser, the KTP or the argon laser. As the CO2 laser causes minimal thermal damage, it appears to be the best instrument.

In general, power densities between 2500 and 5000W/cm 2 are used. Debulking of endometriotic implants is best carried out using a continuous firing mode (Donnez, 1987; Donnez et al, 1989c; Nezhat et al, 1989), unless the lesion is overlying a vital structure, such as the ureter, urinary bladder, colon or larger blood vessels, in which case single (or repeat) pulse mode of 0.05~). 1 second in duration provides safer vaporization of the lesions. This duration allows a 100-200 p~m depth of vaporization, thus substantially limiting the depth of penetration.

Vaporization of an endometriotic implant provokes the bubbling of old blood, followed by a curdy, white material representing vaporized retro- peritoneal fat, and the appearance of 'bubbling water' confirms the complete vaporization of the lesion. The absorption of the CO2 laser by water prevents a deeper penetration of the laser beam for a few seconds after the complete destruction of the implant. Occasional irrigation with 0.9% saline or Ringer-lactate solution is helpful throughout the procedure to wash off debris and provide a backstop for the laser beam.

OVARIAN ENDOMETRIOSIS

Three different types of ovarian endometriosis (Donnez et al, 1993) can be classified as follows:

1. Superficial haemorrhagiclesions. 2. Haemorrhagic cysts (endometriomas). 3. Deep infiltrating ovarian endometriosis (infrequent).

Superficial lesions

Superficial ovarian lesions are small, vesicular lesions covering the ovarian cortex, or small implants, usually found on the lateral surface of the ovary. Adhesions between the ovary and the broad ligament are often observed.

From a histopathological point of view, the endometrial cyst may be lined by free endometrial tissue similar histologically and functionally to eutopic endometrium. Active ectopic endometrial tissue can cover the inner surface of a small cavity in the ovary. In some instances, atypical epithelium and ciliated cells are found (Nisolle et al, 1988).

Endometriomas

The term 'chocolate cyst' was applied by Sampson (1927) to describe the endometrial cyst of the ovary. In large endometriomas, the cyst is often lined by a flattened endometrial epithelium. The cyclical changes of these enclosed lesions are less significant than those in free-growing lesions, and

E N D O S C O P I C SURGERY 843

late secretory changes and menstrual bleeding are absent..The mobilization of the cysts from their fixed position provokes the rupture and subsequent spillage of contents.

As pointed out by Hughesdon (1957) the internal surface of a chocolate cyst is really the external surface of the ovary; the ovarian cortex is identi- fiable by the presence of primordial follicles.

The appearance on ovarioscopy has recently been described by Brosens and Puttemans (1989) dark, fibrotic areas with haemosiderin pigmentation alternate with highly vascularized areas with focal bleeding. The vessels in these areas are often congested, and tend to be larger at the hilus of the ovary.

Three months after drainage of the endometrioma and gonadotrophin releasing hormone (GnRH) agonist therapy (which provokes amenor- rhoea), chocolate-coloured fluid is still present (Donnez et al, 1993). This fact proves that endometrial shedding is not responsible for chocolate- coloured fluid formation. In the authors' opinion, the origin of this fluid could be cyst wall exudation, congested cyst wall blood vessels or inflam- mation around persistent intracystic endometrial foci which are resistant to medical therapy.

Laparoscopic therapy

Drainage

A randomized, parallel group study was conducted in 60 women with laparoscopically confirmed ovarian endometriosis. Ovarian cyst diameter was measured with a probe introduced through a second-puncture incision. All visible peritoneal lesions were vaporized during first-look laparoscopy (Donnez et al, 1993). Suction of chocolate fluid and irrigation of the cystic cavity were performed during the diagnostic laparoscopy. Patients in group I (n = 30) did not receive any therapy. The other patients, in group II (n = 30), received subcutaneous injections of biodegradable goserelin (Zoladex) implant at weeks 0, 4, 8 and 12. Twelve weeks after the start of therapy, laparoscopy was performed and the size of the ovarian cyst was measured.

Response to treatment was evaluated by measuring the modification of ovarian cyst diameter. A significant decrease in cyst diameter was observed following treatment in patients in group II when compared with group I. Average cyst diameter decreased from 3.6 (SD 1.7) cm to 1.8 (SD 1.2) cm in these patients. In group I, the average cyst diameter observed 3 months after suction was unchanged: 3.9 (SD 1.5) cm (Donnez et al, 1993).

Vaporization

Ovarian endometriomas less than 3 cm in diameter. Ovarian endometriosis is treated during first-look laparoscopy if a penetration of no more than 3 cm into the ovary is observed and if the cyst diameter is no larger than 3 cm.

Endometriotic implants of the ovary smaller than 1 cm in diameter were vaporized until follicles containing fluid were encountered or no further

(a)

eb) Figure 1. (a) Cystoscopy and selection of biopsy; (b) vaporization of the epithelial lining of the endometriotic cyst.

ENDOSCOPIC SURGERY 845

pigmented tissue was seen. Larger endometriomas (1-3 cm in diameter) were destroyed as follows. A 3-4 mm portion of the top of the cyst was excised, the chocolate-coloured material was aspirated, and the cyst was washed out with irrigation fluid. After washing, the interior wall of the cyst was examined carefully to exclude any suspected intracystic lesion (ovarian cystoscopy). With a power setting of 40 Watts and continuous mode applica- tion, the interior wall of the cyst was then vaporized to destroy the mucosal lining of the cyst (Figure 1). The vaporization continued until no further pigment could be seen. After copious irrigation, the ovaries were left open.

Ovarian endometriomas more than 3 cm in diameter. In a series of 2912 patients with endometriosis, ovarian endometriomas larger than 3 cm in diameter were found in 481 patients. During diagnostic laparoscopy, the endometrial cyst was washed out with irrigation fluid (saline solution) and a biopsy was taken. Then GnRH agonist therapy using goserelin acetate was given for 12 weeks to reduce the cyst size, followed by second-look lapar- oscopy. If the diameter of the residual endometrial cyst was less than 3 cm after GnRH agonist therapy (n = 233), the interior wall of the cyst was vaporized as described above (Donnez et al, 1989a-c).

If the diameter of the residual cyst still exceeded 3 cm after GnRH agonist therapy, another technique was proposed. In this series, the range of the residual ovarian cyst sizes was 3-8 cm. A portion of the ovarian cyst was first removed by making a circular cut over the protruding ovarian cyst portion, using the CO2 laser. Partial cystectomy was then carried out. Ovarian cystoscopy was performed for evaluation of the interior cyst wall and a biopsy was taken. The residual endometrial cyst wall was then vaporized. To close the ovary, fibrin sealant or staples were used (see the section on closure).

The association of GnRH analogues and laparoscopic surgery was first suggested in the authors' department in 1984 (Donnez et al, 1989a-c). To date, 2150 patients with endometriosis have undergone laparoscopic surgery. Of this number, 917 patients had endometrial ovarian cysts and received GnRH agonist therapy for 3 months prior to laparoscopic surgery. The pregnancy rate was 51% in the group of women with moderate endo- metriosis and 44% in women with severe endometriosis, according to the American Fertility Society (1979) classification. In this series, no patient required laparotomy for bleeding and no bladder or bowel injury was reported.

Excision and stripping

Stripping of the ovaries can be done as described by Semm (1980) or by Bruhat et al (1991). This technique starts with an initial section of adhesions to free the ovary into a more normal anatomic position. After aspiration or drainage of the cyst, the aim is to make the incision and strip the cyst wall from the ovarian cortex so that the edges will fall together at the end of the procedure. Once the cyst has been aspirated or drained, the incision is enlarged and the base examined. One forceps is used to hold the cyst toward

846 J. D O N N E Z ET AL

the anterior wall so that it will not collapse into the deep pelvis. The other two forceps are used to slowly develop a dissection plane, by consecutive traction and countertraction. Once the cyst is stripped, most operators leave the ovary open as long as the edges align reasonably (see below). If the cyst wall is densely adherent in the area of the hilus, the wall (except the adherent area) may be resected and the remnant base vaporized. Vaporization of the adherent area near the hilus is better than coagulation because excessive coagulation can damage the vascularization of the ovary and may result in the loss of that ovary. Stripping techniques have been modified using the CO2 laser so that an initial draining incision is followed by a relaxing incision. The relaxing incision makes it easier to grasp the edge of the cyst wall. In addition, Nezhat et al (1989b) used hydrodissection to increase the oedema in this area and to make stripping easier.

Closure

Current closure techniques include gross suturing, microsurgical closures, pelviscopic closures, glue, titanium clips and no closure. Closure of the ovary has been studied using all these techniques. If the edges align without sutures and there is no bleeding, current practice is not to use sutures. Sutures may be used when the edges will not approximate or when there is bleeding that cannot be controlled by bipolar, thermal or laser coagulation, but are otherwise avoided because of the risk of adhesions due to ischaemia. When sutures are used, they should be small and kept inside the ovary in order to minimize the risk of ischaemic areas occurring directly adjacent to the bowel, fallopian tube, peritoneum and other pelvic structures.

The ovary can be closed using fibrin sealant (Tissucol, Immuno AG, Vienna, Austria). The sealant is injected transabdominally into the intra- ovarian vaporized area and the edges of the ovarian cyst are approximated with atraumatic forceps for 2-3 minutes. After clotting occurs, further mechanical stress should be avoided for 3-5 minutes. At the end of the procedure, copious irrigation of the pelvic cavity prevents deposits of carbon and glue (Donnez and Nisolle, 1991).

Recently, closure of the ovarian edges has been performed using titanium clips (Endohernia, Autosuture USA). The clips permit excellent approxi- mation of the ovarian edges. Often, two or three clips are sufficient to close the ovary.

CONCLUSION

Carbon dioxide laser laparoscopy offers several advantages over cautery of endometriotic implants. With cauterization, the laparoscopist is unable to control the 'star-burst' effect of the unipolar or bipolar cautery and cannot evaluate the depth of cauterization. With the CO2 laser, the laparoscopist is able to control the process of vaporization by visualizing the three- dimensional boundaries of the lesion. Complete destruction and removal of endometriotic implants can be achieved. Numerous studies (Kelly and

ENDOSCOPIC SURGERY 847

Roberts, 1983; Feste, 1985; Davis, 1986; Nezhat et al, 1989; Donnez and Nisolle, 1991) in which women were treated with laser therapy only, resulted in a 53% overall pregnancy rate. The authors' results (Donnez and Nisolle, 1991) confirm these studies and suggest that laser laparoscopy can be as effective as laparotomy in experienced hands.

However, no data exist regarding the value of laser laparoscopy when compared with expectant management, particularly in cases of mild endo- metriosis where a number of reports indicate that a relatively high rate of pregnancy may be expected in patients with mild endometriosis, although their monthly fecundity rate is considerably lower than that of the general population. As suggested by Olive and Haney (1986), the institution of future randomized trials should help to clarify these issues. Combined (hormonal and microsurgical) therapy probably improves the postoperative pregnancy rate because it facilitates surgery and reduces the risk of post- operative adhesions by decreasing the pelvic vascularity. For this reason, preoperative hormonal therapy with G n R H agonists is suggested. Indeed, G n R H agonist therapy is effective in reducing endometrioma size to a greater extent than other drugs. Treatment by sustained release is an effective alternative to existing steroid hormones administered prior to laser laparoscopy. Indeed, subcutaneous G n R H agonist (goserelin) implants induce a significant reduction in the diameter of large ovarian cysts and a decrease in pelvic inflammation (Donnez et al, 1993), so that second-look laser laparoscopy may be carried out for laser vaporization of residual endometriomas without a high risk of subsequent periovarian adhesions.

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