Endometriosis Surgery the Ascot Experience

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Endometriosis Surgery the Ascot Experience
Endometriosis Surgery the Ascot Experience
Dr Mark Insull

• Dr Mark Insull

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Endometriosis Ascot

• AGES meeting Melbourne 1995. Guest speaker David
  Redwine.
• Bend, Oregon experience February 1996.
• Introduction of laparoscopy with excision of
  endometriosis March 1996.
• 2002 Endometriosis Centre at Ascot.
• Development of database 2002.
• 2006 Endometriosis Ascot formed with Hilary
  Liddell, Mark Insull and Graeme Washer (general
  surgeon).

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Endometriosis Ascot

• Tertiary referral unit.
• Multi-disciplinary team.
• Established a surgical database. Over 1000
  patients being followed up post-surgery. Five
  year follow up in progress.
• Referrals from general practitioners and
  gynaecologists.
• Comprehensive questionnaire and pain score
  assessment completed at first visit.

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Endometriosis Ascot

• Modified AFS score plus operative details
  recorded.
• Follow-up visit two to four weeks later. Any
  complications recorded.
• Questionnaire sent out six months later then
  yearly for five years.
• Weekly meeting with endometriosis co-ordinator.

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Pain score evaluation

• Visual analogue scale 0 10
• SymptomsDysmenorrheaPain with Bowel
  MotionsPain with MicturitionDeep
  DyspareuniaMidcycle PainPain throughout
  MonthIntermenstrual BleedingMenorrhagia

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Pre-operative assessment
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Surgical management of endometriosis

• Specialised surgical nursing team.
• Four port operative laparoscopy. (Ports higher
  rather than lower). Two lateral five mm ports and
  two midline 10mm ports.
• Rumi manipulator.
• Hassan canula entry vertical incision
• LUQ incision if midline scar
• Excision of all endometriosis using monopolar
  electrical current 90 watts cutting, 50 watts
  coagulation pure current.

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Surgical management of endometriosis

• Operative photographs.
• Surgery takes 1 to 2 hours rectal probe
• If RIF pain, have a good look at appendix
• If IMB, hysteroscopy to exclude polyp
• If Menorrhagia, Mirena IUCD
• One to two nights in hospital and approximately
  one week off work.

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Database analysis

• 1134 surgeries on surgical database.
• Age groups21 and under - 18022 35 -
  57936 and over - 375
• Modified AFS scoresStage 0 84 (7) Stage I
  234 (21)Stage II 458 (40) Stage III 158
  (14)Stage IV 200 (18)
• Histological confirmation 88
• Negative histology 5

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Database analysis

• 16 patients were adolescents (lt 21 yrs)
• 15 patients had infertility investigated and
  treated.
• 16 patients with endometriomas
• 18 patients had Grade IV endometriosis
• 14 patients had hysterectomies as treatment for
  menorrhagia in conjunction with excision of
  endometriosis.

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Adolescent Endometriosis

• 16 of total patients were adolescents
• Main symptoms dysmenorrhea and menorrhagia.
• Of those adolescents that identified themselves
  as sexually active, 65 had dyspareunia.
• Conservative management in the first instance.
• Anti-inflammatories, o/c, mirena.
• If successful, suggest review in early to mid
  20s.
• If breakthrough pain, consider laparoscopy and
  excision of endometriosis.

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Adolescent Endometriosis

• 180 young women under 21 years of age have had
  surgery (66 of the adolescents reviewed at the
  centre)
• 82 had histologically proven endometriosis
• Of those with positive histology, the majority
  (over 80) had minimal to mild disease (Stage I
  and II).
• A small number had Stage III disease, and only 1
  patient had severe (Stage IV) disease

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Fertility

• 15 of database patients had fertility issues.
• Referrals from general practitioners and
  Fertility Associates.
• Exclude other causes of infertility and where
  appropriate liaise closely with tertiary
  fertility unit.
• Routine excision of endometriosis found combined
  with tubal perfusion and where appropriate
  hysteroscopy.
• Pregnancy rates improve after surgery for all
  grades of endometriosis.

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Endometriomas

• CA125 and follow-up scan if appropriate.
• Pre-operative FSH/LH/Oestradiol.
• Pre-operative counselling regarding ovarian
  function.
• Can be a marker for severe Grade IV endometriosis
  with obliterated cul-de-sac and rectal
  involvement.

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Endometriomas

• If cul-de-sac nodule evident clinically, or if
  extreme pain scores, consider bowel prep with
  general surgeon on standby.
• Surgery operative laparoscopy with mobilisation
  of the ovaries, ovarian cystectomy in the
  majority of cases (size not an issue),
  reconstitution and relocation of the ovary.
• Combine with excision of endometriosis where
  appropriate.
• Post-operative FSH and Oestradiol as necessary
  one to two months post-op.

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Severe endometriosis

• Nearly 20 of database patients had grade IV
  disease, reflecting our role as a tertiary
  referral unit.
• Approx 5 to 7 of women with endometriosis have
  Grade IV disease.
• If severe disease, two stage laparoscopy with
  picoprep, general surgeon on standby (Graeme
  Washer) and adequate time to perform surgery (2
  to 4 hours).
• Patient counselling regarding risks and
  complications including the small risk of delayed
  bowel leak and temporary colostomy.

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Surgical management of severe endometriosis

• Four port operative laparoscopy
• Divide gross adhesions to gain access to pelvis
• Bilateral ureterolysis
• Mobilise ovaries, ovarian cystectomy where
  indicated
• Excise uterovesical and pelvic side wall
  endometriosis
• Mobilise rectum from the back of the uterus and
  cervix until cul-de-sac reached
• Excise endometriosis from rectal wall
• Longitudinal reinforcing sutures (maxon) into
  rectal wall where appropriate
• Bowel resection uncommon (approx 5 of severe
  disease)

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Histology
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Severe endometriosis

• Post-operative management - drip, drain,
  catheter removed when passing flatus- 3 day
  hospital stay- 2 weeks off work
• 2 serious complications requiring a return to
  theatre- 1 delayed bowel leak and temporary
  colostomy- 1 ureteric fistula

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Hysterectomy

• 14 of patients who had surgery for endometriosis
  underwent planned hysterectomy (with conservation
  of ovaries)
• - Total laparoscopic hysterectomies 132
• - LAVH 29- Abdominal hysterectomies
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• Main indications menorrhagia (failed medical
  treatment)
• Significant number will have adenomyosis on
  pre-operative scan or confirmed by histology

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Hysterectomy

• Surgery takes two to three hours
• Three nights in hospital
• Three weeks off work on average
• Low complication rate and excellent
  post-operative pain score reduction

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Conclusion

• Plan to follow-up patients on database for five
  years and publish findings
• Continue to work closely with Fertility
  Associates
• Would welcome any gynaecologists interested in
  observing our surgery
• Currently investigating the place of robotic
  assistance in gynaecological surgery

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