Danie Botha FEMBRYO Fertility and Gynaecology Clinic Port Elizabeth UCT Postgraduate Refresher Course 2015 ESHRE GUIDELINES 2014 Laparoscopy and prevention of adverse outcome Overview Risk factors in performing surgery for endometriosis ID: 538471
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AVOIDING COMPLICATIONS IN ENDOMETRIOSIS SURGERY
Danie BothaFEMBRYO Fertility and Gynaecology ClinicPort ElizabethUCT Postgraduate Refresher Course 2015Slide2
ESHRE GUIDELINES 2014Slide3
Laparoscopy and prevention of adverse outcomeSlide4
OverviewSlide5
Risk factors in performing surgery for endometriosisSlide6
General complications of Laparoscopic surgerySlide7
Surgeon specific risk factorsSlide8
Surgical expertise and Anatomy
A thorough knowledge of pelvic anatomy is of paramount importance. A surgeon who is familiar with all structures met at operation is best able to appreciate the distortions produced by disease and to take advantage of the natural planes of cleavage.Slide9Slide10Slide11Slide12
Ovarian endometriomas
Cochrane review: Excision of cyst wall associated with reduced recurrence of endometrioma
.
Hart RJ et al. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst. Rev 2, CD004992 2008
Stripping technique: Take care to minimize damage and inadvertent removal of normal ovarian tissue.
Biacchiardi et al. Laparoscopic stripping of endometriomas negatively affects ovarian follicular reserve even if performed by experienced surgeons. Reprod. Biomed. Online 23 (6),740-746 (2011
)
Drainage
should be performed through single incision. Identify cleavage plain, gentle stripping to prevent bleeding.
Prevent excessive bipolar cautery.
Combined technique of stripping and ablation recommended. Partial cystectomy followed by ablation in area of hilum.
Donnez J, et al. Laparoscopic management of endometriomas using a combined technique of excisional and ablative surgery. Fertil Steril. 94 (1), 28-32 (2010)Slide13
Large
endometriomas
: (>5cm diameter): Three step procedure advised:
Small puncture site on
antimesenteric
border of the ovary. Irrigation and drainage and biopsy for histology.
This is then followed by 3/12 of GnRH analogue treatment, thereafter ablation by laparoscopy.
Tsolakidis
D, et al. The impact on ovarian reserve after laparoscopic ovarian cystectomy
vesrus
three-stage management in patients with
endometriomas
: a prospective randomized study.
Fertil
Steril
.94(1), 71-77 (2010)
Recurrence rate of 8% in follow up of up to 11 years and smaller decrease in AMH levels.
Shah DK, et al. Effects of surgery for
endometrioma
on ovarian function. J. Minim. Invasive Gynecol. 21(2),203-209 (2014)
Haemostasis either by bipolar cautery or sutures: No difference in AMH levels or IVF outcome.
Takashima A et al. Effects of bipolar electrocoagulation versus suture after laparoscopic excision of ovarian
endometrioma
on the ovarian reserve and outcome of in vitro fertilization. J. Obstet.
Gynaecol
. Res. 39(7),1246-1252 (2013)Slide14
Antibiotic prophylaxis for prevention of
endometrioma abscess
The most likely pathogens to cause an abscess are anaerobic bacteria and aerobic Gram-negative bacilli
.
First generation cephalosporin (
Cephazoline
) adequate for prophylaxisSlide15
Urinary tract endometriosis
Berlanda N et al, Ureteral and vesical endometriosis. Two different clinical entities sharing the same pathogenesis Obstet. Gynecol.
Surv
. 64 (12). 830-842 (2009)Slide16
Vascular supply of UreterSlide17
Bladder endometriosis
Superficial
peritoneal implants
: On bladder, careful dissection with skinning technique, closure of defect with 3.0 monofilament.
Infiltrative lesions of mucosa in bladder dome
: partial cystectomy. Close bladder in two or three layers with methylene blue control.
Posterior wall of bladder or trigone
, insertion of double J
stents 6-8
weeks postoperatively and urinary catheter for 7-10 days.
Adhesions between the anterior uterine wall and the
vesico
-uterine fold
should be divided before performing partial
cystectomy
Control by cystoscopySlide18
Ureteral injury would seem most likely in patients undergoing complicated
gynecological
procedures with distorted pelvic anatomy. However, studies reveal that most ureteral injuries occur during simple routine pelvic surgeries, such as an uncomplicated hysterectomy. This seeming paradox may be due to a
false sense of security that surgeons who perform routine pelvic surgeries develop and become neglectful of fundamental techniques and surgical principles
for avoiding ureteral injurySlide19
Ureteral endometriosis
Intrinsic: 15% of cases with fibrosis of the
muscularis
and mucosa.
Extrinsic: 85% of cases, infiltration of the overlying peritoneum, leading to compression and
hydronephrosis
.
More common on left ureter.
Main aim is to relieve obstruction, preserve renal function and prevent recurrence.
Double J stent for 6 weeks.
Identify ureter above level of disease. Preserve adventitial layer to prevent devascularisation. If critical stenosis: perform end –to-end anastomosis. Tension free anastomosis importantSlide20
Bowel endometriosisSlide21Slide22Slide23Slide24Slide25
Avoiding complicationsSlide26
ADDITIONAL MEASURES: OVARIAN SUSPENSIONSlide27
OVARIAN SUSPENSIONSlide28
ADDITIONAL MEASURES: ADHESION PREVENTIONSlide29
SUMMARYSlide30
Thank you
With ageing comes expertise, and with expertise, fear to do what has seemed so simple in the past.
With fear, comes prayer. Start there.