The Surgical Approach to the Treatment of Endometriosis

Martin J. Clyman, M.D.
Associate Clinical Professor of Obstetrics and Gynecology. Mt. Sinai School of Medicine, New York

Endometriosis, Aspects and Proceedings of a Symposium
Saint John's Hospital and Health Center, Santa Monica, California
Editor: J.J. Marik

In addition to laparotomy, a number of other procedures by operative laparoscopy and operative culdoscopy are being frequently employed.

After a culdoscopy is done, the posterior fomix and the cul-de-sac can be stretched under local anesthesia, by emplacement of a hemostat and merely stretching the tips. This can result in a two- to three-inch-long opening and a large, bloodless, rather dry area. Special instruments devised over the past fifteen years are then used to grasp the mesosalpinx of the fallopian tube and bring it out into the vaginal vault. Adhesions can be readily lysed under direct vision and by sharp and blunt dissection, hemostasis afforded by cautery coagulation current.

A blue dye, pushed through the uterine cavity at this point, will either emerge through the end of the fallopian tube or, if there is obstruction, will cause the tube to become markedly distended, either partially or completely.

Particularly in cases of infertility problems, and most specifically with endometriosis, the degree of success with this procedure considerably exceeds that of laparotomy, as the latter causes more secondary adhesions after wiping of the serosal surface than does this transvaginal technique. The use of dexamethasone, Decadron® and Phenergan® in infertility cases can help reduce the amount of inflammation and postoperative adhesions. These are placed intraperitoneally, with the patient being given twelve doses, one every four hours intramuscularly in separate syringes.

Biopsy of the fimbriated portion of the tube can be taken by this technique and specimens examined histologically, histochemically or by electron microscopy. Development of ciliated epithelial cells, any scarring, or an increased amount of collagen may be demonstrated.

One patient complained of pain in the right lower quadrant radiating to the buttocks and down the leg: Under local anesthesia, culdoscopy revealed a large chocolate cyst; this was aspirated under direct vision, completely collapsing the sac, after which the cautery ball was inserted and the sac cauterized. Following this procedure, the pain disappeared; several such cases have been followed for from five to seven years without recurrence.

Most endometrial tissue in these large chocolate cysts becomes dormant and does not function after a period of time. After this transvaginal technique of bringing the ovary into the vagina, approximately two out of ten cases have recurrence of the cysts filling after a period of about five years. If pain persists after this procedure, it is due to involvement of other parts of the organ, in which case a laparotomy should be done.

Under laparoscopy, large cysts which appear to be endometrial cysts when aspirated can in fact be merely follicular cysts with hemorrhage. In other cases, what appear to be dermoid cysts can, upon aspiration, yield an oily material. An endometrial cyst, it should be remembered, is not always dark to black in appearance on the surface.

The use of progestational agents prior to surgery, in the author's opinion, can make the dissection rather easier and the lesions somewhat more readily dissectible. However, it is important to recall that considerable shrinkage will result, so that one must be very careful to identify the chocolate and remove the sac completely. With conservative surgery, much of the ovaries can be preserved, and when the patient is continued on progestational or antigonadotropic substances, such as danazol (Danocrine®, Winthrop), postoperatively, the healing proceeds in a much better fashion.

In undertaking tuboplasties, it is important to obtain good endosalpingial mucosa on those infertility patients with endometriosis, as the endosalpingial mucosa will regenerate ciliated epithelial cells. It appears, with the use of the Mulligan Rock Hood, that the regeneration by the foreign body placed there for a period of two to three months is very much superior to that without the presence of the hoods.

In a patient where there is endometriosis of the cul-de-sac with an ovary adherent, a culdoscopy cannot be performed, and laparoscopy is required. One such patient, with a marked endometriosis of the pelvis-involving both ovaries and fallopian tubes in the cal-de-sac-had been placed on danazol. Although this patient still had some dyspareunia, the pain was markedly relieved. A year later, however, reactivation of the tissue occurred, the disease returned, and it was necessary to employ abdominal surgery.

It cannot be over-emphasized that pelvic surgery for endometriosis should be conservative surgery. One should remove the lesions, bearing in mind that even with a very small amount of cortex of the ovary remaining, pregnancy can still occur. It is often easier, of course, to remove the ovaries, but with careful dissection of the endometriotic sac, enough of the cortex of the ovary can be saved so that many hundreds of ova will remain.

Not infrequently, bilateral cornual obstruction due to adenomyosis will be seen, causing a great deal of scarring about the cornual portion of the fallopian tubes. In such cases, a more-than-adequate amount of tissue must be taken out; if the remainder of the fallopian tubes are essentially normal, reimplantation of the fallopian tubes are successful in approximately 40% of the cases, provided that the tubes themselves are not badly damaged. One must be sure to take a core out of the large plug in the adenomysois type of patient, as more scarring occurs in this type than in those without adenomyosis.

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