Extensive endometriosis

Extensive endometriosis

Despite massive invasion of the ovary, uterus and sigmoid, the surgeon may elect to be conservative in order to preserve the childbearing function in the young, and ovarian function in the older patient.

Extensive endometriosis

synthes surgical techniques: Extensive endometriosis

The rectosigmoid, for example, may be separated from the area of attachment between the uterosacral ligaments in the manner previously described (page 58). Multiple implants on the pelvic peritoneum and uterosacral ligaments may be excised en masse by careful dissection of the peritoneum from the underlying structures.

Though the ovary may appear to be hopelessly compromised by endometrial cysts, a plane of cleavage can invariably be established between the cyst and normal ovarian tissue. Endometriosis, although it has invasive properties in other areas, is less likely to demonstrate this in the ovary. It is thus possible to preserve an ovary that might otherwise have been sacrificed. Many patients previously infertile have become pregnant following this procedure.

When the sigmoid is fixed to the back of the uterus, two methods are available to establish a proper cleavage plane: (1) if the uterus is drawn sharply toward the symphysis, the serosal surface may crack in the proper plane; (b) if not, a light stroke of the knife above the point of sigmoid attachment will create it.

Figure 1. Before undertaking any dissection of the endometriosis, the tube and ovary must be freed from the back of the broad ligament and the sigmoid from the posterior wall of the uterus. The ovary invariably ruptures. This figure shows a chocolate cyst involving the left ovary, the sigmoid adherent to the posterior wall of the uterus, small implants in the right ovary and a stellate scar on the serosal sigmoid surface.

Figure 2. The rupture of the chocolate cyst in the left ovary is evident. The sigmoid has been separated from the posterior wall of the uterus, exposing the uterosacral ligaments. The surgeon elevates the peritoneum beyond the obvious involvement by endometriosis and gently dissects it from any underlying structures.

Figure 3. The dissection is carried up on the back of the uterus. Firm traction on the flap with Allis forceps and upward traction on the uterus will facilitate this maneuver. The scar of endometriosis on the sigmoid is left undisturbed.

synthes surgical techniques

Extensive endometriosis

Figure 4. Regardless of the extent of endometriosis within the ovarian substance, chocolate cysts can invariably be excised so that some ovarian tissue is left. A definite cleavage plane is usually present. Although there is a chance that the endometriosis may recur, the procedure is warranted when the primary aim is to enhance fertility and preserve ovarian function.

The uterus is held on traction by a figure-of-eight suture placed in the musculature of the uterine fundus. Since the uterus is to be preserved, this is less traumatic than applying a tenaculum, which tends to tear the muscle.

The surgeon then applies a Babcock clamp to the medial edge of the ovarian ligament in order to steady it. Recognizing the fact that normal ovarian tissue tends to thin out over the surface of the cyst wall, the surgeon selects a suitable area and incises the serosal peritoneal cover. The assistant places an Allis clamp to the incised edge and holds it on traction to aid in exposing the plane of cleavage between the cyst and the normal ovarian tissue.

The surgeon grasps the cyst, using gauze to facilitate easier traction, and gently separates the cyst with the handle of the knife as a blunt dissecting instrument. The cyst is then shelled out of the ovary. The resulting defect is closed and the ovary reconstructed with a running lock type catgut suture which begins at the pole and returns to the point of origin.

Figure 5. The chocolate cyst has been excised from the substance of the left ovary and the defect closed with a continuous catgut suture.

Small individual and coalescent cysts have been excised in a wedge – shaped segment from the right ovary. The ovary is then reconstructed with a running suture. The raw area on the pelvic floor and posterior uterine wall is too extensive to permit peritoneal closing either by approximation of the peritoneal edges or by uterine suspension.

Extensive endometriosis

surgical techniques: Extensive endometriosis

 

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