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Endometriosis and adenomyosis are chronic gynecological conditions that affect millions of women worldwide, causing debilitating pain, heavy menstrual bleeding, and fertility challenges. Traditional surgical approaches often involved invasive procedures with prolonged recovery times. However, advancements in minimally invasive techniques, particularly laparoscopic surgery, have revolutionized treatment, offering effective solutions with reduced recovery times and improved quality of life.
Understanding Endometriosis and Adenomyosis
Endometriosis occurs when tissue similar to the uterine lining grows outside the uterus, often affecting the ovaries, fallopian tubes, and pelvic cavity. This misplaced tissue responds to hormonal changes, leading to inflammation, scarring, and adhesions that cause pain and infertility.
Adenomyosis, sometimes referred to as "endometriosis interna," involves the growth of endometrial tissue into the uterine muscle wall. This condition can result in an enlarged uterus, severe menstrual pain, and heavy bleeding, significantly impacting daily life.
Both conditions require precise diagnosis and tailored treatment plans. Laparoscopic surgery has emerged as a gold standard for managing these conditions, offering both diagnostic and therapeutic benefits.
The Role of Laparoscopic Surgery
Laparoscopy is a minimally invasive surgical technique that uses small incisions, a high-definition camera, and specialized instruments to visualize and treat internal organs. Unlike traditional open surgery, laparoscopy minimizes tissue damage, reduces scarring, and promotes faster recovery. For endometriosis and adenomyosis, laparoscopic solutions provide targeted interventions with high precision.
Laparoscopic Treatment for Endometriosis
Laparoscopy is often the preferred method for both diagnosing and treating endometriosis. During the procedure:
Diagnosis: A laparoscope is inserted through a small incision near the navel, allowing the surgeon to visualize endometrial implants, adhesions, and cysts (endometriomas). This confirms the presence and extent of the disease, often missed by imaging alone.
Excision: Using specialized tools, surgeons meticulously remove endometrial lesions, cysts, and adhesions while preserving healthy tissue. Excision is more effective than ablation (burning tissue) as it reduces the likelihood of recurrence.
Fertility Preservation: For women seeking to conceive, laparoscopy can improve fertility by removing obstructions and restoring pelvic anatomy.
Benefits include reduced postoperative pain, shorter hospital stays (often same-day discharge), and a lower risk of complications compared to open surgery.
Endometriosis and adenomyosis are chronic gynecological conditions that affect millions of women worldwide, causing debilitating pain, heavy menstrual bleeding, and fertility challenges. Traditional surgical approaches often involved invasive procedures with prolonged recovery times. However, advancements in minimally invasive techniques, particularly laparoscopic surgery, have revolutionized treatment, offering effective solutions with reduced recovery times and improved quality of life.
Understanding Endometriosis and Adenomyosis
Endometriosis occurs when tissue similar to the uterine lining grows outside the uterus, often affecting the ovaries, fallopian tubes, and pelvic cavity. This misplaced tissue responds to hormonal changes, leading to inflammation, scarring, and adhesions that cause pain and infertility.
Adenomyosis, sometimes referred to as "endometriosis interna," involves the growth of endometrial tissue into the uterine muscle wall. This condition can result in an enlarged uterus, severe menstrual pain, and heavy bleeding, significantly impacting daily life.
Both conditions require precise diagnosis and tailored treatment plans. Laparoscopic surgery has emerged as a gold standard for managing these conditions, offering both diagnostic and therapeutic benefits.
The Role of Laparoscopic Surgery
Laparoscopy is a minimally invasive surgical technique that uses small incisions, a high-definition camera, and specialized instruments to visualize and treat internal organs. Unlike traditional open surgery, laparoscopy minimizes tissue damage, reduces scarring, and promotes faster recovery. For endometriosis and adenomyosis, laparoscopic solutions provide targeted interventions with high precision.
Laparoscopic Treatment for Endometriosis
Laparoscopy is often the preferred method for both diagnosing and treating endometriosis. During the procedure:
Diagnosis: A laparoscope is inserted through a small incision near the navel, allowing the surgeon to visualize endometrial implants, adhesions, and cysts (endometriomas). This confirms the presence and extent of the disease, often missed by imaging alone.
Excision: Using specialized tools, surgeons meticulously remove endometrial lesions, cysts, and adhesions while preserving healthy tissue. Excision is more effective than ablation (burning tissue) as it reduces the likelihood of recurrence.
Fertility Preservation: For women seeking to conceive, laparoscopy can improve fertility by removing obstructions and restoring pelvic anatomy.
Benefits include reduced postoperative pain, shorter hospital stays (often same-day discharge), and a lower risk of complications compared to open surgery.
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LearningTranscript
00:00And we will now invite Dr. Girjah Waag, laparoscopic approach to endometriosis and adenomyosis, cutting-edge techniques and decent advantage.
00:13Good afternoon, everybody. And at the outset, I would like to thank the organizers, especially Dr. Mishra and Dr. Milla for calling me here and giving me this wonderful opportunity of sharing whatever little I know about the challenges that we face with endometriosis and adenomyosis treatment.
00:43I bring you greetings from, why is this not moving? Yeah.
00:48From Pune, Bharati Vidya Peetal University Medical College, I head the department.
00:53And we are a center of excellence for metal fetal medicine.
00:59We also have laparoscopy, infertility, fetal medicine and gyna cancer fellowships.
01:06And based on all this, with my experience of last 32 years, I bring this presentation to you.
01:11So we all know endometriosis and adenomyosis are chronic gynecological conditions that significantly impact the quality of life of women, especially due to pain, dysmenorrhea, dyspareunia and infertility.
01:25And despite there being a lot of research, the definitive cure for these conditions remains elusive and treatment often focuses on managing symptoms.
01:33Now, there have been three very, very important evolutions which change the entire landscape to approach these conditions.
01:42One is the advent of minimal access surgery, better diagnosis and treatment, MRI, especially for invasive disease,
01:50because now we are able to categorically look at which tissue planes are involved,
01:54and robotic surgery, because it has definitely contributed to precision and flexibility.
02:01So whenever we look at minimal invasive surgery, it is considered the gold standard for surgical approach.
02:08And there are a huge lot of novel surgical techniques which are continuously developing.
02:13And these are the ones which I am going to discuss here today.
02:17Now, these innovations are with aims to reduce the disease recurrence, improve fertility rates, provide better long-term symptom relief.
02:25And in addition, robotic acid-assisted laparoscopy has revolutionized the treatment of complex cases such as DIEs, offering improved precision and efficacy.
02:34And therefore, in the next 14 minutes, we'll explore the latest advancements in surgical approaches, the clinical efficacy, and future directions,
02:43emphasizing the need for individualized multidisciplinary care to optimize patient outcomes.
02:48Now, when we look at the recent advancements in laparoscopic surgery for endometriosis,
02:53one of the most important pivotal thing is correct diagnosis.
02:57And this is a wonderful paper which has come from the Godd et al. group.
03:02And herein, we find that whenever we are doing diagnostic laparoscopy, maybe we are missing quite a few cases.
03:10And for that, they have proposed that we can fill in fluid.
03:14So this is called a transvaginal hydrolaparoscopy, wherein you put in fluid inside the peritoneum.
03:21Either if you have done a diagnostic histoscopy precedingly, you can consider using that.
03:26But if the woman's tubes are blocked or the tubal epithelium is affected,
03:30then you may consider putting it through the pouch of Douglas.
03:34What you are seeing here is even a similar technique can be used for sonographic evaluation.
03:39I don't know why I am not able to get my point at the yard.
03:42So even sonographic evaluation can be done by sonography guided.
03:47One can put in a histoscopy by putting in a fluid inside the peritoneum.
03:50Or you can put in a fluid inside the peritoneum with a needle.
03:54And then you do a diagnostic laparoscopy.
03:57It will definitely have a better diagnostic result than you would do in the, you know, just directly.
04:06So they evaluated 2,288 patients from a Belgian fertility clinic.
04:12And endometriosis was not diagnosed by ultrasound or clinical exam before the procedure.
04:17And their main outcomes were feasibility, pathological identification and increased pregnancy rates.
04:22And they found that 16% of the men in 365 patients had, so they had endometriosis, more than 70% on the left side,
04:33characterized by neoangiogenesis, and 20% had spontaneous conception post-fulguration,
04:4058% rate after 8 months, 43.8% total in vivo pregnancy rates with spontaneous or IUI conception,
04:48and nearly 30% clinical pregnancy rates after 8 months.
04:52Then coming on to that particular group where fertility is not an issue,
04:56but women want the uterus to be removed because of pain.
05:01And then the challenges are that there are absolutely stuck viscera to the uterus.
05:07Now in this condition, there is a group which has proposed retrograde total laparoscopic hysterectomy.
05:14And this is something which has certain key steps where you process the round ligament,
05:18the anterior lobe of the broad ligament of the uterus and the ovarian ligament,
05:22dissect the urethral roof, finally dissect the vaginal wall.
05:26And this is found to be a simple and a safe dissection of tissue planes as close as possible
05:30to the edge of the adhesions, avoidance of bladder and rectal injuries,
05:34and reduced bleeding, minimizing the possibility of conversion to expletive laparoscopy.
05:38So you can see here, this is a completely obliterated pouch of Douglas,
05:43and this has been well studied on an MRI.
05:46And then you are getting an access to the retroperitoneum,
05:50which is open parallel to the IPL, and the ureter is identified,
05:54and following this ureter till the uterine artery,
05:57we saw how Dr. Shailesh Puntambekar had demonstrated in his video,
06:00and identified the coagulation of the uterine artery at its origin from the internal iliac artery,
06:05which helps in keeping the field devoid of bleeding.
06:09And uterine artery is coagulated but not transacted.
06:12Blunt dissection of the vasicovaginal space is done,
06:15and then you can consider doing the retrograde incision of the vagina,
06:19and retrograde dissection of the paracolpom.
06:22So this total laparoscopic retrograde hysterectomy was studied in 92 cases by Yamamoto and group.
06:29In 2021, they published this,
06:31and this proved to be a feasible and safe approach to severe endometriosis with an obliterated cul-de-sac.
06:37Now another important aspect is how do you suture the posterior vaginal breach horizontally or vertically.
06:44And this was a publication which showed that symptomatic retrovaginal endometriosis
06:48compared two suturing directions, horizontal and vertical,
06:52for closing the posterior vaginal defect in women with endometriosis involving vaginal mucosal infiltration.
06:58And they concluded that horizontal suturing of the posterior vaginal phonics defect
07:02may be associated with a higher frequency of severe postoperative complications
07:07and less effective pain control.
07:10Now endometrioma is another very easy fruit to pluck,
07:14and many times it is approached, sometimes not correctly.
07:18And usually it is very important to not only just drain and aspirate and leave it,
07:24it's very important that the cyst wall is properly excised.
07:28I don't know whether this is going to run.
07:30There, if necessary, one can consider doing a hydro dissection for this.
07:35Fulguration, sclerosing agents or suturing can be used.
07:39Now I'll give you a story of one woman who had reported in an emergency,
07:43a 32-year-old married for two years, had an acute pain.
07:48On the POCUS, that is point-of-care ultrasound,
07:50was diagnosed to have hemorrhagic cysts in both the ovaries
07:53and was quickly taken for an emergency surgery without any workup.
07:57And then they went and drained both the sides, hemorrhagic cysts,
08:03fulgurated them, and this woman came to me after six months of this treatment.
08:07And when I asked her as to what is the reason of how she wanted to get pregnant,
08:13and then when we did her ultrasound, her ovaries had become completely small,
08:16and her AMH was just about 0.01, her FSH was already 68.
08:23That means this woman had gone in an acquired premature ovarian failure.
08:27Now this is something that one must definitely try and avoid.
08:31So one must definitely drain, aspirate, do a proper cyst wall excision.
08:37If you are not able to do the cyst wall excision, you can do hydro dissection,
08:41separate the cyst wall, and whenever you are fulgurating the inside of the cavity,
08:45be very careful because you may destroy her reserves of the follicles,
08:50the ovarian follicles which are in the ovary,
08:52and in that case one may consider using sclerosing agents.
08:56So therefore there have been certain innovations here as well,
09:00where people are using hybrid APC water jet surgery system,
09:04so that that will help in removing and clearing the inside of the cyst,
09:09and not causing adhesions.
09:10There can be use of plasma energy instead of the traditional energy source,
09:15and you can see that this is the place where the ovary has been filled with a sclerosing agent,
09:21which will blanch and then gradually get absorbed,
09:24and it will take care of the tissues inside.
09:26And we have to understand that the presence of the endometriotic cyst itself in the ovary
09:31does cause damage to it,
09:33and there are various ways in which it can be considered to be treated properly.
09:38Now ovaryopexy is another wonderful thing that can be done,
09:44because many times ovary comes in the field of surgery,
09:47because it's freely there,
09:49and that can get injured.
09:51So in such a case one can consider suspending the ovary to the lateral pelvic wall,
09:55and then consider doing the rest of the surgery,
09:59and keeping it there so that there will be no adhesion formation.
10:02But people have gone ahead and done a further evolution in that,
10:06where they have applied the hyaluronic acid gel,
10:09rather than doing an ovary and suspicion,
10:12and this was a randomized clinical trial,
10:14which compared both these things,
10:16and it was found that the endogel may effectively reduce the risk of adhesions
10:20three months post-surgery.
10:21Even after one has done endometriosis surgery,
10:25it is important that there is some sort of an adhesion barrier which can be put in,
10:29and you can see here that this is an adhesion where a gel is formed,
10:33and that is injected around the place where we have done all the surgical evacuation,
10:39fulguration, and cleaning,
10:40so that adhesions won't be formed.
10:43Likewise, there are certain powder for hemostasis,
10:45with subsequent gel transformation for adhesion prevention in ovary and cyst surgeries,
10:49which can be considered,
10:51and this kind of a powder of tissue is known to not only cause hemostasis,
10:56but also acts as an adhesion barrier.
10:59When things have improved and moved on,
11:02and where robotic-assisted transvaginal,
11:04as well as natural orifice,
11:06or robotic-assisted surgeries,
11:08have done a lot of evolution in treating endometriosis,
11:11especially deep infiltrating one,
11:14and one can consider doing a robotic single port surgery,
11:17using the Darwin CU surgical system,
11:20so that there will be no repeated sort of port accesses on the mother's tummy,
11:25and you can see here that this is a single port through which the various arms have been inserted,
11:30so that one can avoid any kind of deportation onto the skin and adherence.
11:36One can also consider the fluorescence-guided surgery,
11:39which is used to improve the detection of endometriotic lesions during surgery,
11:42using fluorescent dyes such as indocyanin green,
11:45and these images using white light and near-infrared indocyanin green modes help us in identifying which is the tissue which requires to be fulgurated and taken care of,
11:55and that would help in better approach.
11:58Now coming to the later part of my talk and that is adenomyosis.
12:02Now adenomyosis is not only the swelling of the uterus,
12:06but this particular thing is responsible for various problems,
12:10and this is a condition which is prevalent nearly about 50 to 60% of women would be presenting,
12:17and they usually present with AUBA,
12:19that is abnormal uterine bleeding because of A,
12:22we use the palm coin classification for doing this.
12:25So it's an enlarged uterus with an increased surface,
12:28there are a lot of overexpression in the adenomyotic tissue and result of ectopic endometrium,
12:34and there can be certain co-existing conditions which may confound your diagnosis,
12:39such as the uterine fibroids and the endometriosis is usually seen to be very commonly associated with adenomyosis and vice versa.
12:47So clinically we are looking at the medical history,
12:50the pelvic examination will reveal certain typical findings where there will be a diffusely enlarged mobile painful uterus,
12:57and then the differentiation will depend on the help of imaging,
13:01and this would be usually ultrasonography is supposed to be the gold standard of diagnosis,
13:06and MRI can add to this information.
13:10So as you can see that there are various kinds of information that one can get on ultrasound,
13:16where you will see that there is a change in the plane between the endometrium and the myometrium,
13:21there can be a focal or a localized adenomyoma or a diffuse adenomyosis,
13:27and this would be better evaluated if you are planning a surgery by doing an MRI which will show,
13:33especially in the posterior adenomyomas, it's always better.
13:37Now in 2015, there was a MUSA criteria which was published,
13:41and this is something that we use categorically to correctly, you know, do what is called as adenomyotic mapping,
13:48which will tell us about various features such as cysts, hyper-echoic islands, fan-shaped shadowing,
13:54translational vascularity, irregular junction zones and interrupted junction zones, etc.
14:00And this would then help us in identifying which are the ones where you have to operate,
14:05and what kind of a surgery would be necessary.
14:07So when we look at imaging in adenomyosis, it is important that MRI and transcriptional ultrasonography are the best approaches,
14:15while hysterosalpingography and computed tomography would really not give us any great results.
14:21So what are the various surgical approaches?
14:24There are uterus-paring resections which can be done for especially women seeking fertility in future,
14:31ineffective or contraindicated first-line therapies and difficult to exercise,
14:35but one has to remember that they are very tough tissues, require sharp dissection,
14:40and adenomyotic uterus described as woody making suturing difficult.
14:44One can consider doing the wedge resection, transverse incision or OSADA type triple flap method,
14:52before, you know, after doing a proper MRI evaluation,
14:56but there are always risks of, you know, there being a uterine rupture early in pregnancy,
15:02because these are more than a myomectomy, and these women would require classical scissor infection,
15:08abnormal placental attachments,
15:10and then there can be post uterine sparing resection management for conception optimization,
15:16delaying pregnancy.
15:17We can consider using hormonal agents like LNG, IUS and pregnancy management,
15:22and one has to be very careful during their pregnancy journey.
15:26Now, outcomes after uterine sparing resection were published in about 12 studies meta-analysis,
15:32and it was found that the recurrence rate is about 12.6%,
15:36re-intervention rate is about 2.6% after a follow-up of about 14 months or so,
15:42and conception rate was found to be 35% of 364 patients,
15:46and therefore, that definitely gives us a promise that we can consider doing this.
15:51There are other treatments which can be also considered,
15:53like ultrasound or MRI-guided focused ultrasonographic surgery,
15:57radiofrequency ablation, laparoscopic radiofrequency ablation,
16:01trans-cervical radiofrequency ablation, thermal ablation,
16:05and recurrence of re-intervention rates.
16:07Usually, these are nearly about 10% to 8.2% in these cases.
16:12So, when we look at their systematic, symptomatic management,
16:16start with an NSAID and give them an LNG, IUS,
16:19and then maybe after, yes, I'm just in the last cycle.
16:23So, symptomatic treatment and giving an adjuvant in the form of a progesterone would help,
16:28and one has to remember that these kind of adenomyomas are also responsible
16:33for causing recurrent pregnancy loss.
16:36This is a picture of the triple flap surgery that I mentioned to you,
16:42and one can consider doing vagary sections.
16:45So, effective management of adenomyosis and endometriosis requires timely
16:49and judicious intervention.
16:51Delays in diagnosis and surgery can worsen patient outcomes,
16:54and surgery alone is not a definitive cure.
16:57A comprehensive multidisciplinary approach is essential for optimal care and true healing.
17:02So, as I can see that there are many surgeons, urologists, laparoscopic surgeons, robotic surgeons here.
17:08I request that, yes, go ahead with whatever treatments you wish to,
17:11but please take your colleague gynecologist for a second opinion
17:16so that there will be a better surgerical approach and better restoration of her health.
17:21Thank you so much.
17:22This being the month of February, I bring you a lot of love from my side.
17:27Thank you so much, ma'am. Thank you.
17:29Thank you. It was an excellent presentation, Bidam, with a practical message.
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