AVOIDING COMPLICATIONS IN ENDOMETRIOSIS SURGERY Danie Botha FEMBRYO Fertility and Gynaecology Clinic Port Elizabeth UCT Postgraduate Refresher Course 2015

ESHRE GUIDELINES 2014 QUALITY OF LIFE INFERTILITY

Laparoscopy and prevention of adverse outcome gold standard standardization of specific surgical techniques etiology remains unclear. ablation and surgical techniques.

Overview General complications associated with laparoscopy Risk factors in performing surgery for Endometriosis Patient specific Surgeon specific Disease specific Specific complications and prevention Endometrioma Urinary tract Bowel complications Additional measures Summary

Risk factors in performing surgery for endometriosis 1.Patient specific risk factors Patients who have had prior surgery for intraabdominal or pelvic disease (e.g., diverticulitis, pelvic inflammatory disease) have a higher risk of complications related to adhesions. Extensive bowel distention, very large abdominal or pelvic mass, and diaphragmatic hernia. Increased BMI 2.Surgeon specific factors The frequency of complications may be related to surgeon experience and the number of the specific procedure performed for some, but not all, types of surgical procedures 3.Disease specific factors Linear increase in complications with advanced grade of disease and specific organ involvement

General complications of Laparoscopic surgery Anaesthetic risk factors Positioning and pressure points, nerve injuries Abdominal entry and port site injuries/hernias Insufflation pressure and cardio-pulmonary dysfunction Thermal injuries

Surgeon specific risk factors Surgical expertise Anatomy Pre operative assessment Multidisciplinary approach

Surgical expertise and Anatomy A thorough knowledge of pelvic anatomy is of paramount importance.  A surgeon who is familiar with all structures met at operation is best able to appreciate the distortions produced by disease and to take advantage of the natural planes of cleavage.

Intra-operative complications Post-operative complications Group A 1 case of intraoperative bleeding >600ml 2 cases of bowel injury 1 conversion to laparotomy Group B 1 case of ureteric injury Post-operative complications 6 Cases of fever 2 cases of paralytic ileus 1 case of bladder dysfunction 3 Cases of fever 1 case of paralytic ileus

Ovarian endometriomas Cochrane review: Excision of cyst wall associated with reduced recurrence of endometrioma . Hart RJ et al. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst. Rev 2, CD004992 2008 Stripping technique: Take care to minimize damage and inadvertent removal of normal ovarian tissue. Biacchiardi et al. Laparoscopic stripping of endometriomas negatively affects ovarian follicular reserve even if performed by experienced surgeons. Reprod. Biomed. Online 23 (6),740-746 (2011) Drainage should be performed through single incision. Identify cleavage plain, gentle stripping to prevent bleeding. Prevent excessive bipolar cautery. Combined technique of stripping and ablation recommended. Partial cystectomy followed by ablation in area of hilum. Donnez J, et al. Laparoscopic management of endometriomas using a combined technique of excisional and ablative surgery. Fertil Steril. 94 (1), 28-32 (2010)

Large endometriomas: (>5cm diameter): Three step procedure advised: Small puncture site on antimesenteric border of the ovary. Irrigation and drainage and biopsy for histology. This is then followed by 3/12 of GnRH analogue treatment, thereafter ablation by laparoscopy. Tsolakidis D, et al. The impact on ovarian reserve after laparoscopic ovarian cystectomy vesrus three-stage management in patients with endometriomas: a prospective randomized study. Fertil Steril .94(1), 71-77 (2010) Recurrence rate of 8% in follow up of up to 11 years and smaller decrease in AMH levels. Shah DK, et al. Effects of surgery for endometrioma on ovarian function. J. Minim. Invasive Gynecol. 21(2),203-209 (2014) Haemostasis either by bipolar cautery or sutures: No difference in AMH levels or IVF outcome. Takashima A et al. Effects of bipolar electrocoagulation versus suture after laparoscopic excision of ovarian endometrioma on the ovarian reserve and outcome of in vitro fertilization. J. Obstet. Gynaecol. Res. 39(7),1246-1252 (2013)

Antibiotic prophylaxis for prevention of endometrioma abscess The most likely pathogens to cause an abscess are anaerobic bacteria and aerobic Gram-negative bacilli. First generation cephalosporin (Cephazoline) adequate for prophylaxis

Affecting 1% of patients undergoing surgery. Urinary tract endometriosis Berlanda N et al, Ureteral and vesical endometriosis. Two different clinical entities sharing the same pathogenesis Obstet. Gynecol. Surv. 64 (12). 830-842 (2009) Affecting 1% of patients undergoing surgery. 85% bladder involvement 10% ureter 4% kidney 2% urethra. Usually associated with more commonly lesions of pelvis such as nodules of uterosacral ligaments and rectovaginal septum

Vascular supply of Ureter

Bladder endometriosis Superficial peritoneal implants: On bladder, careful dissection with skinning technique, closure of defect with 3.0 monofilament. Infiltrative lesions of mucosa in bladder dome: partial cystectomy. Close bladder in two or three layers with methylene blue control. Posterior wall of bladder or trigone, insertion of double J stents 6-8 weeks postoperatively and urinary catheter for 7-10 days. Adhesions between the anterior uterine wall and the vesico-uterine fold should be divided before performing partial cystectomy Control by cystoscopy

Ureteral injury would seem most likely in patients undergoing complicated gynecological procedures with distorted pelvic anatomy.  However, studies reveal that most ureteral injuries occur during simple routine pelvic surgeries, such as an uncomplicated hysterectomy.  This seeming paradox may be due to a false sense of security that surgeons who perform routine pelvic surgeries develop and become neglectful of fundamental techniques and surgical principles for avoiding ureteral injury

Ureteral endometriosis Intrinsic: 15% of cases with fibrosis of the muscularis and mucosa. Extrinsic: 85% of cases, infiltration of the overlying peritoneum, leading to compression and hydronephrosis. More common on left ureter. Main aim is to relieve obstruction, preserve renal function and prevent recurrence. Double J stent for 6 weeks. Identify ureter above level of disease. Preserve adventitial layer to prevent devascularisation. If critical stenosis: perform end –to-end anastomosis. Tension free anastomosis important

Bowel endometriosis

Avoiding complications

ADDITIONAL MEASURES: OVARIAN SUSPENSION

OVARIAN SUSPENSION

ADDITIONAL MEASURES: ADHESION PREVENTION

SUMMARY Avoiding complications in laparoscopic surgery for endometriosis : Patient counselling and pre operative investigation Referral centres with Multi disciplinary approach Instrumentation and surgical team Sound knowledge of pelvic anatomy Organ sparing surgery and microsurgical technique Documentation of procedure Short term and long term follow up

Thank you With ageing comes expertise, and with expertise, fear to do what has seemed so simple in the past. With fear, comes prayer. Start there.