Deep endometriosis: definition, diagnosis, and treatment.

Deep endometriosis, defined as adenomyosis externa, mostly presents as a single nodule, larger than 1 cm in diameter, in the vesicouterine fold or close to the lower 20 cm of the bowel. When diagnosed, most nodules are no longer progressive. In >95% of cases, deep endometriosis is associated with very severe pain (in >95%) and is probably a cofactor in infertility. Its prevalence is estimated to be 1% -2%. Deep endometriosis is suspected clinically and can be confirmed by ultrasonography or magnetic resonance imaging. Contrast enema is useful to evaluate the degree of sigmoid occlusion. Surgery requires expertise to identify smaller nodules in the bowel wall, and difficulty increases with the size of the nodules. Excision is feasible in over 90% of cases often requiring suture of the bowel muscularis or full-thickness defects. Segmental bowel resections are rarely needed except for sigmoid nodules. Deep endometriosis often involves the ureter causing hydronephrosis in some 5% of cases. The latter is associated with 18% ureteral lesions. Deep endometriosis surgery is associated with late complications such as late bowel and ureteral perforations, and recto-vaginal and uretero-vaginal fistulas. Although rare, these complications require expertise in follow-up and laparoscopic management. Pain relief after surgery is excellent and some 50% of women will conceive spontaneously, despite often severe adhesions after surgery. Recurrence of deep endometriosis is rare. In conclusion, defined as adenomyosis externa, deep endometriosis is a rarely a progressive and recurrent disease. The treatment of choice is surgical excision, while bowel resection should be avoided, except for the sigmoid

N2O strongly prevents adhesion formation and postoperative pain in open surgery through a drug-like effect

Background: Microsurgical tenets and peritoneal conditioning during laparoscopic surgery (LS) decrease postoperative adhesions and pain. For a trial in human, the strong beneficial effects of N2O needed to be confirmed in open surgery (OS). Results: In a mouse model for OS, the effect of the gas environment upon adhesions was evaluated. Experiment I evaluated desiccation and the duration of exposure to CO2, N2O or CO2 + 4%O2. Experiment II evaluated the dose-response curve of adding N2O to CO2. Experiment III compared humidified CO2 + 10% N2O during LS and OS. In OS, 30- and 60-min exposure to non-humidified CO2 caused mortality of 33 and 100%, respectively. Mortality was prevented by humidification, by dry N2O or dry CO2 + 4%O2. Adhesions increased with the duration of exposure to CO2 (p < 0.0001) and decreased slightly by humidification or by the addition of 4% O2. N2O strongly decreased adhesions at concentrations of 5% or greater. With humidified CO2 + 10% N2O, adhesion formation was similar in OS and LS. Conclusions: The drug-like and strong beneficial effect of low concentrations of N2O is confirmed in OS.Medicine, Faculty ofNon UBCObstetrics and Gynaecology, Department ofReviewedFacult

The digital operating room and the surgeon

The “word digital operating room” aims to integrate the images, information, and work flow available in the hospital and in the operating theater. In addition, it can distribute and record information while adding intelligence. The understanding of a digital operating room thus is highly variable. Whereas digital operating rooms are rapidly being incorporated in the hospitals, the clinical validation of improved quality of surgery is limited. The proven and expected usefulness of image distribution in one OR (routing and switching)or outside the OR (broadcasting), of integrating information, of image and video registration, and of intelligence, is reviewed with the perspective of quality and safety of surgery. It is expected that the digital OR will contribute to the learning and teaching and to the quality of surgery. Especially, the introduction of intelligence will be a major step forward. It remains important however that we, endoscopic surgeons,remain closely involved in shaping and orienting this future

Pathogenesis of endometriosis: the genetic/epigenetic theory

OBJECTIVE: To study the pathophysiology of endometriosis. DESIGN: Overview of observations on endometriosis. SETTING: Not applicable. PATIENT(S): None. INTERVENTIONS(S): None. MAIN OUTCOME MEASURE(S): The hypothesis is compatible with all observations. RESULT(S): Endometriosis, endometrium-like tissue outside the uterus, has a variable macroscopic appearance and a poorly understood natural history. It is a hereditary and heterogeneous disease with many biochemical changes in the lesions, which are clonal in origin. It is associated with pain, infertility, adenomyosis, and changes in the junctional zone, placentation, immunology, plasma, peritoneal fluid, and chronic inflammation of the peritoneal cavity. The Sampson hypothesis of implanted endometrial cells following retrograde menstruation, angiogenic spread, lymphogenic spread, or the metaplasia theory cannot explain all observations if metaplasia is defined as cells with reversible changes and an abnormal behavior/morphology due to the abnormal environment. We propose a polygenetic/polyepigenetic mechanism. The set of genetic and epigenetic incidents transmitted at birth could explain the hereditary aspects, the predisposition, and the endometriosis-associated changes in the endometrium, immunology, and placentation. To develop typical, cystic ovarian or deep endometriosis lesions, a variable series of additional transmissible genetic and epigenetic incidents are required to occur in a cell which may vary from endometrial to stem cells. Subtle lesions are viewed as endometrium in a different environment until additional incidents occur. Typical cystic ovarian or deep endometriosis lesions are heterogeneous and represent three different diseases. CONCLUSION(S): The genetic epigenetic theory is compatible with all observations on endometriosis. Implications for treatment and prevention are discussed.status: publishe

Surgical management of endometriosis-associated pain

Endometriosis and pelvic pain are associated. However, only half of the subtle and typical, and not all cystic and deep lesions are painful. The mechanism of the pain is explained by cyclical trauma and repair, an inflammatory reaction, activation of nociceptors up to 2.7 cm distance, painful adhesions and neural infiltration. The relationship between the severity of lesions and pain is variable. Diagnosis of the many causes requires laparoscopy and expertise. Imaging cannot exclude endometriosis. Surgical removal is the treatment of choice. Medical therapy without a diagnosis risks missing pathology and chronification of pain if not 100% effective. Indications and techniques of surgery are described as expert opinion since randomised controlled trials were not performed for ethical reasons, since not suited for multimorbidity while a control group is poorly accepted. Subtle endometriosis needs destruction since some cause pain or progress to more severe disease. Typical lesions need excision or vaporisation since depth can be misjudged by inspection. Painful cystic ovarian endometriosis needs adhesiolysis and either destruction of the lining or excision of the cyst wall, taking care to avoid ovarian damage. Cysts larger than 6cm need a 2 step technique or an ovariectomy. Excision of deep endometriosis is difficult and complication prone surgery involving bladder, ureter, and bowel surgery varying from excision and suturing, disc excision with a circular stapler and resection anastomosis. Completeness of excision, prevention of postoperative adhesions and recurrences of endometriosis, and the indication to explore large somatic nerves will be discussed

Clinical and Morphological Features of Focal Adenomyosis

Background: Adenomyosis is a very real problem encountered in modern gynecology due to the increase in the incidence, severity of the disease, and absence of effective methods of conservative treatment. The aim of the study was to investigate the clinical and morphological features of the focal and diffuse forms of adenomyosis. Methods and Results: The study involved 70 women who applied to the Center with the diagnosis of ‘adenomyosis’. Examination included transvaginal sonography (TVS), magnetic resonance spectroscopy (MRS), and morphological study of the adenomyotic foci. With a probability of 99%, one can argue that focal adenomyosis (FA) in its clinical features is different from diffuse adenomyosis (DA) in all its major manifestations. Conclusion: FA has unique morphological characteristics and clinical features. The diagnosis of FA should be based on a complex of clinical and instrumental data in conjunction with morphological process verification. Besides, there are difficulties in the diagnosis of FA, which is a major reason for the incorrect determination of the treatment tactic for patients. However, the application of MRS allows the preoperative identification of the biochemical structure of the focus and determination of its borders, and in the postoperative period, selection of optimal treatment tactics based on the identified morphological features of the removed adenomyotic foci

Which Knots Are Recommended in Laparoscopic Surgery and How to Avoid Insecure Knots

STUDY OBJECTIVE: To investigate why security of identical knot sequences is variable and how to avoid occasionally insecure knots. DESIGN: A factorial design was used to assess factors affecting the security of half knot (H) and half-hitch (S) knot combinations. The effect of tying forces and the risk factors to transform H knots into S knots were investigated. The risk factors evaluated were as follows: starting with an H1 or H2 instead of an H3 knot, inexperience, short sutures, and monomanual knot tying. Security of transformed knots, S2S1 and S2S2 knots, and their recuperation with 2 additional half hitches, SSb or SbSb, were evaluated. SETTING: Training center for laparoscopic suturing. PATIENTS: Not applicable. INTERVENTIONS: Security of knots was evaluated in vitro. MEASUREMENTS AND MAIN RESULTS: The forces that caused knot combinations to open before breaking of the suture were used to calculate the risk of opening with low forces. Tying more strongly increased the security of half knots (H2H1sH1s) (p <.02) and half hitches (p <.001). The forces needed to transform an H3 into an S3 are higher than those for an H2 (p <.001), and the risk increases when the surgeon is inexperienced (p <.001), when sutures are short (p <.001), and when monomanual knot tying (p <.001) is used. Inadvertently made S2S1 and S2S2 knots are dangerous, with the exception of the symmetric S2S2, which is stable. Unstable knots such as S2S1a and S2S2a knot combinations improve with 2 additional blocking half hitches (SbSb), but S2S2aSbSb remains occasionally insecure. CONCLUSION: To reduce the risk of accidentally transforming a first H into an S knot, it is recommended to start with an H3, tie with force, avoid short sutures, and use bimanual suturing. This permits the recommendation to use preferentially H3H2 knots or 5 half hitches (SSSbSbSb). When in doubt, half knot combinations should be secured with at least 2 blocking half hitches.status: publishe