Pearl. Avoid using Kleppinger forceps to indiscriminately coagulate the bloody stroma in the crater created after the cystectomy, because doing so can result in excessive destruction of ovarian tissue or inadvertent coagulation of hylar vessels that would interrupt the blood supply to the ovary, compromising its function.16
Suturing. Some surgeons find that fenestration, drainage, and coagulation of the cyst wall is acceptable, but we have concerns not only about incomplete ablation of the endometriosis on the cyst wall, which may be responsible for the higher recurrence rate of disease, but also about the risk of thermal injury to underlying follicles, which may compromise ovarian reserve.16
Hemostasis. Once complete hemostasis has been achieved, the decision to approximate (or not) the edges, preferably with fine absorbable suture, is based on how large the defect is and whether or not the edges of the crater spontaneously come together. For large craters, we usually close the ovary with a 3-0 or 4-0 Vicryl continuous suture, imbricating the edges to expose as little suture material as possible to reduce postoperative formation of adhesions, which is common after ovarian surgery.17
Last, we ensure that hemostasis is present. Often we apply an anti-adhesion solution, such as icodextrin 4% (Adept). This agent has been shown to reduce postoperative adhesion formation, especially after laparoscopic surgery for endometriosis.18
A high level of skill is needed
Ovarian endometriomas signal advanced disease; advanced surgical skills are required to treat them adequately. Simple drainage is of little therapeutic value and should seldom be considered a treatment option. Although drainage plus ablation of the cyst wall ameliorates symptoms, excision of endometriomas should be considered preferable because it provides a more favorable outcome, a lower risk of recurrence of endometriomas and symptoms, and a higher rate of spontaneous pregnancy in previously infertile women.7-9
To recap, we advise the surgeon to:
- Manage ovarian endometriomas with resection of the entire cyst wall, grasping and stripping the thinnest layer of the cyst wall without removing underlying functional ovarian stroma.
- Avoid excessive cauterization of the underlying ovarian stroma by utilizing micro-bipolar forceps and applying energy only around bleeding vessels.
- Close stromal defects, when the crater is large and its edges do not spontaneously come together, by approximating the edges with an imbricating resorbable suture.
CASE continued
As in most cases of advanced endometriosis, S. D. also had diffuse implants of deep and superficial endometriosis on the peritoneum of the pelvic sidewalls and on the anterior and posterior cul de sac.
Should you ablate or resect these lesions? Are there advantages to either approach?
Ablation of endometriosis implants may involve either electrocoagulation of the lesion with bipolar energy or laser vaporization/coagulation, which destroys or devitalizes active endometriosis but does not actually remove the lesion. Ablation destroys the lesion without getting a specimen for histologic diagnosis.
Resection of endometriosis implants involves complete removal of the lesion from its epithelial surface to the depth of its base. Resection can be performed with scissors, laser, or monopolar electrosurgery. Resection removes the lesion in its entirety, yielding a histologic diagnosis and allowing you to determine whether, indeed, the entire specimen has been removed.
The question of what is more effective—ablating or resecting endometriosis implants?—was addressed in a prospective study in which 141 patients with endometriosis-related pain were randomized at laparoscopic surgery to either excision or ablation/coagulation of endometriosis lesions.19 Six months postoperatively, the pain score decreased by, on average, 11.2 points in the excision group and 8.7 points in the coagulation/ablative group.
Because the difference in those average pain scores was not statistically significant, however, investigators concluded that the techniques are comparable, with similar efficacy. That interpretation has been criticized because the study was underpowered and included only patients who had mild endometriosis—leaving open the possibility that deep endometriosis may not be adequately treated by electrocoagulation or ablation.
In contrast to superficial endometriosis, which may respond similarly to ablation or resection, deep endometriosis is difficult to ablate either with electrosurgery or a laser because the energy cannot reach deeper layers and active disease is therefore likely to be left behind. Moreover, when endometriosis overlies vital structures, such as the ureter or bowel, ablation of the lesion may cause thermal damage to the underlying organ, and such damage may not manifest until several days later, when the patient experiences, say, urinary leakage in the peritoneum or symptoms of bowel perforation.
FIGURE 5 illustrates a case in which CO2 laser ablation of endometriosis that had been causing deep dyspareunia did not alleviate symptoms. Because those symptoms persisted, the patient was referred to our center, where a second laparoscopy revealed deep nodules of endometriosis, 1 to 2 cm in diameter, extending from the right and the left uterosacral ligaments deep into the perirectal space, bilaterally.