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Endometriosis Surgery the Ascot Experience

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Introduction of laparoscopy with excision of endometriosis March 1996. ... Pain with Micturition. Deep Dyspareunia. Midcycle Pain. Pain throughout Month ... – PowerPoint PPT presentation

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Title: Endometriosis Surgery the Ascot Experience


1
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).

4
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.

5
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.

6
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

18
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.

19
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.

20
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

21
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.

22
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.

23
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.

24
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.

25
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
    2
  • 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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