Description: Endometriosis is defined as the presence of endometrial glands and stroma in ectopic locations. There are numerous theories about the etiology of endometriosis, including (a) the peritoneal cavity is seeded with cells which are transported via the fallopian tubes during menses; (b) totipotent cells in the peritoneal cavity are transformed by hormonal exposure into endometrial cells; (c) endometrial cells are transported intravascularly or via lymphatics to ectopic sites, where they respond to hormonal stimuli (this theory has been used to explain the presence of endometriosis in the brain and pleura); (d) failure of natural killer cells to eliminate ectopic endometrial cells, which is suggested by decreased cytotoxic response of the immune system; and (e) it is an inherited disorder. Intervention usually is indicated for intractable pain, infertility, or impaired function of the gastrointestinal (GI) or genitourinary (GU) tracts or thoracic cavity. GU endometriosis may range from superficial involvement of peritoneum overlying the ureters and bladder to deep infiltrating endometriosis penetrating through to bladder mucosa. Scarring and fibrosis can cause ureteral obstruction and hydronephrosis with renal insufficiency. Patients with GI endometriosis may have thickening of the rectovaginal septum, suggesting obliteration of the posterior cul-de-sac or rectosigmoid involvement. Adhesions may make rectovaginal examination difficult or painful. Pelvic structures may be immobile (known as “frozen pelvis”), suggesting adhesions are fixing bowel or bladder to the uterus. In severe cases of GI endometriosis, sigmoidoscopy should be performed to r/o malignancy and to determine whether endometriosis has penetrated through to the bowel mucosa.

Laparoscopy (Fig. 8.4-1) is the most appropriate surgical technique for the diagnosis and treatment of endometriosis. Data from animal and clinical studies suggest laparoscopic surgery is more effective for adhesiolysis, causes fewer de novo adhesions than laparotomy, and reduces impairment of tuboovarian function. Special consideration must be given to the patient’s past history of abdominal or pelvic surgery, pelvic inflammatory disease (PID), and endometriosis. These factors will affect the choice of surgical approach. Conservative surgery is indicated for women who desire pregnancy and whose disease is responsible for their symptoms of pain or infertility. Surgery improves fertility and offers at least temporary pain relief. Bilateral oophorectomy might be necessary to eliminate the estrogen that sustains and stimulates the ectopic endometrium. Hysterectomy with bilateral salpingo-oophorectomy (BSO) may be indicated for patients with severe symptoms who have not responded to medical or conservative surgical treatment and who do not desire fertility (please see Laparoscopic Hysterectomy, p. 869).

Pelvic Endometriosis: A Foley catheter should be placed prior to the beginning of the procedures to allow continuous drainage of the bladder, thereby reducing the likelihood of trocar injury to the bladder. In a patient with no history of pelvic surgery, the direct trocar insertion method may be used with an intraumbilical incision because this is the anatomical area closest to the fascia and peritoneum and involves the least risk of injury to retroperitoneal structures. Once the incision is made, towel clips on either side of the umbilicus are placed, the abdominal wall is lifted up, and the trocar is placed through the skin incision. Using an intraumbilical incision and inserting the trocar at 90° facilitates access to the abdominal cavity and decreases the risk of injury to the major pelvic vessels. This technique of direct trocar insertion may not be suitable for patients who have had prior laparotomy or laparoscopy because of risk of adhesions. Another method of entry uses the Veress needle. An intraumbilical incision is made, the abdominal wall is lifted, and the Veress needle is inserted through the skin incision while connected to a high flow CO₂ insufflation. This method allows for the abdomen to be insufflated prior to trocar placement. The patient is then placed in steep Trendelenburg position. Two lateral 5-mm ports are placed about 2 cm cephalad and 2 cm medial to the anterior superior iliac spine under direct visualization, taking care to avoid the inferior epigastric vessels. A third 5-mm port is placed 2-3 cm above the pubic symphysis, again under direct visualization. The suction irrigator, a blunt laparoscopic grasper, and the bipolar cautery are placed into trocars. Filmy adhesions of the bowel or omentum to the anterior abdominal wall or uterus are lysed using CO₂ laser, bipolar cautery, monopolar scissors, or hydrodissection. Treatment of peritoneal endometriosis ranges from laser ablation of superficial peritoneal implants to excision and dissection of deeply embedded, fibrotic areas. Scarring from endometriosis that has penetrated the peritoneum to involve deeper structures destroys normal surgical planes and distorts anatomical relationships, and patients are at risk for accidental ureteral or vascular injury at the time of surgery. Identifications of ureters and blood vessels are critical prior to treatment of the pelvic sidewall disease. Although different modalities have been used, hydrodissection and high-power superpulse or ultrapulse CO₂ lasers are the best option for endometriosis treatment. Because the CO₂ laser does not penetrate water, this fluid backstop allows the surgeons to work on selected tissue with a greater safety margin.

Ovarian endometriosis: Type 1 endometrioma < 2 cm are resected using laser or bipolar coagulation. Larger Type I endometriomas may require excision using laparoscopic graspers and scissors., for Type II endometriomas, the procedure begins with lysis of periovarian adhesions using CO₂ laser or monopolar scissors. The ovarian cortex is evaluated, the endometrioma is identified, the cyst wall is perforated, and an irrigation device is inserted to assess the cyst contents and wall. Suspicious areas are biopsied and sent to pathology. A plane is developed between the cyst wall and ovary by grasping the wall and separating it from ovarian stroma. Difficult areas where endometriosis has embedded through the cyst wall, disrupting planes, require hydrodissection with vasopressin solution and bipolar cautery to control bleeding in the ovarian bed. In some cases, it is necessary to remove a portion of the ovary attached to the cyst wall until a plane can be found. Redundant ovarian tissue is approximated with low power laser or electrosurgery to avoid adhesions. Suturing should be avoided if possible but, if needed, can be used to close the defect.

Bladder endometriosis: If the lesions are superficial, hydrodissection and vaporization are adequate for treatment. Using hydrodissection, the areolar tissue between the serosa and muscularis beneath the implants is dissected. The lesion is circumscribed with the CO₂ laser and fluid is injected into the resulting defect. The lesion is grasped and dissected with the laser. Traction allows the small blood vessels supplying the surrounding tissue to be coagulated as the lesion is resected. Frequent irrigation is necessary to remove char, ascertain the depth of vaporization, and ensure that the lesion does not involve the muscularis or mucosa. Endometriosis extending to the muscularis but without mucosal involvement can be treated laparoscopically, and any residual or deeper lesions may be treated successfully with hormonal therapy. When endometriosis involves full bladder wall thickness, the lesion is excised and the bladder is reconstructed in one later. Cystoscopy is performed simultaneously, and bilateral ureteral stents may be inserted for ureteral identification. The lesion is excised by first holding the bladder dome near midline with laparoscopic graspers. An incision is made 5 mm beyond the lesion with the CO₂ laser. The specimen is completely excised and removed from the abdominal cavity. CO₂ is used to distend the bladder, allowing observation of its interior. After again identifying the ureters and examining the bladder mucosa, the bladder is closed with laparoscopic suturing. Cystoscopy is performed to identify any leaks; the duration of laparoscopic segmental cystotomy is about 35 min.

Patients are discharged the same day and instructed to take antibiotics while an indwelling catheter is present. The catheter is removed 7-14 days later, and a cystogram or iv contrast computed tomography scan is performed.

Appendectomy: Appendix (a common site for endometriosis) is identified, mobilized, and examined laparoscopically. If adhesions are present they are lysed using either the CO₂ laser or laparoscopic scissors. The meso-appendix is then coagulated using laparoscopic bipolar cautery and scissors or a vessel-sealing device. At this time a laparoscopic GI stapler is introduced through a 10- to 12-mm port and placed across the meso-appendix and appendix. It is extremely important to closely examine the placement of the stapler and its proximity to the rectum. After adequate placement is observed, the entire appendix and meso-appendix are stapled and cut in a single motion. The specimen is removed, and the staple line is inspected for hemostasis. Copious amounts of irrigation fluid are used to minimize bacterial contamination.

Thoracic endometriosis: Laparoscopically identified endometrial lesions on the diaphragm can be visualized and treated with hydrodissection and CO₂ laser fulguration, but this requires an experienced gynecologist and thoracic surgeon. If large lesions are visualized then video-assisted thoracoscopic surgery (VATS) is the preferred method of treatment. Lesions found during VATS are treated either by bipolar diathermy, CO₂ laser, or sharp dissection.

Robotic assistance: Robotic-assisted laparoscopic surgery is relatively new to the field of gynecologic surgery. The available evidence demonstrates the feasibility and safety of robotic-assisted laparoscopic surgery in benign gynecologic disease, but further studies are needed to define the role of robotics in this field. With the advent of robotic-assisted surgery, the previously described procedures can be performed with three-dimensional visualization, improved magnification, and greater operative flexibility. The only major difference is location and sometimes size of the trocars used for the robotic arms as well as possible increased operative time. Patient positioning is not different from standard laparoscopy.

See Anesthetic Considerations following Laparoscopic Hysterectomy, p. 869.

Description: Ectopic pregnancy is defined as a pregnancy occurring outside the uterus. The majority of ectopic pregnancies occur in the fallopian tubes (95-97%); the remainder occurs in the cornua (2-4%), ovary (0.1%), cervix (0.1%), or abdomen (0.03%). Ectopic pregnancy remains a leading cause of maternal morbidity and mortality. Predisposing factors include Hx of tubal ligation or other tubal surgery, pelvic inflammatory disease (PID), IUD use, and Hx of in vitro fertilization (IVF) or other treatments for infertility. Other associations include developmental anomalies of the Müllerian system, intrauterine polyps, or myomas.

Patients present with lower quadrant pain, vaginal bleeding, and an ↑ β-hCG. Treatment options for an asymptomatic ectopic gestation include operative laparoscopy or a trial of medical management with intramuscular methotrexate. In cases where the size of the ectopic pregnancy is too large for conservative medical management (> 3.5 cm), and the patient is hemodynamically stable, operative management is essential. Hypotension or an acute abdomen in the presence of a positive β-hCG value are strongly suggestive of rupture and require expeditious surgical intervention.

Access to the abdomen is obtained in the usual fashion (e.g., through a Veress needle or direct-trocar insertion, as described in previous section). Ruptured tubal pregnancies can be treated endoscopically if the bleeding has ceased or can be controlled. Actively bleeding vessels are identified and cauterized, and forced irrigation is used to dislodge clots and trophoblastic tissue. Depending on their size, the products of conception (POCs) are removed through either a 5- or 10-mm trocar sleeve or placed into an endoscopic bag for removal; for larger POCs a minilaparotomy can be performed. Copious irrigation should follow to ensure hemostasis and identify and remove any remaining trophoblastic tissue. Trophoblast is invasive, and residual tissue may implant into bowel, bladder, peritoneum, or other abdominal structures and cause significant future morbidity.

For an unruptured ectopic pregnancy, the tube is identified and stabilized using laparoscopic forceps. To minimize bleeding, 5-7 mL of a solution of 50 U vasopressin in 100 mL NS is injected into the mesosalpinx just below the
ectopic pregnancy and over the antimesenteric surface of the tubal segment containing the gestation. Intravascular injection of vasopressin solution can precipitate acute arterial HTN, bradycardia, or even death; therefore, care must be taken to avoid intravascular injection. A linear incision is made over the thinnest portion of the tube. The pregnancy usually protrudes through the incision, and forceful irrigation will dislodge the POCs from its implantation site.

In a ruptured tubal or isthmic pregnancy, resection of the tubal segment containing the gestation is preferable to salpingostomy. Segmental tubal resection is performed with bipolar cautery, laser sutures, or stapling devices. Similarly, total salpingectomy can be performed by progressive coagulation and cutting the mesosalpinx, which is separated from the uterus using bipolar coagulation and scissors or laser. The isolated tube segment containing the ectopic pregnancy is removed intact or in sectioned parts through the 10-mm trocar sleeve. At the completion of the procedure, the abdomen is irrigated and inspected, and incisions are closed in the usual fashion.

Hydrosalpinx: A hydrosalpinx is a fluid-filled fallopian tube, which occurs after an inflammatory process (e.g., PID, tuboovarian abscess, or endometriosis) damages the serosa and mucosa of the tube. This results in occlusion at the fimbriated end and accumulation of tubular fluid. This can occur unilaterally or bilaterally. Currently, for women with hydrosalpinges who are to undergo IVF, strong consideration should be made for laparoscopic salpingectomy prior to IVF treatment. This is the most widely used method for treatment of hydrosalpinges in the group of infertile women undergoing IVF. The procedure is performed as described earlier for resection of a tubal segment.

Tuboovarian Abscess: Tuboovarian abscess (TOA) is a severe complication of pelvic inflammatory disease. PID results from an ascending infection from the vagina or cervix, which results in salpingitis. If this is not recognized early and adequately treated with antibiotics, this infection can then spread to the ovaries, resulting in unilateral or bilateral TOAs. Laparoscopic access to the abdomen is performed with an umbilical port and two lateral ports. Using a suction-irrigator and laparoscopic forceps, the entire abdominal cavity is examined for purulent material. Once the abscess is localized, it is drained with the suction-irrigator. Care is taken to lyse adhesions as needed using blunt dissection and hydrodissection. Adhesions encountered in this situation are usually filmy and can be disrupted without need for sharp dissection. Meticulous dissection of the abscess and surrounding adhesions is vital for the success of this procedure. Once the ovary is freed, a small incision is made to allow for copious irrigation. The laparoscopic forceps can be used to separate any adhesions at the fimbriated end of the fallopian tubes. The procedure is completed with copious irrigation of the abdominal cavity. In cases where the TOA is chronic, laparoscopy will show that the walls of the abscess are denser, and surrounding adhesions may cause structures to be matted together. In this case, sharp dissection may be needed, but care should be taken as planes of dissection can be difficult to define.

Usual preop diagnosis: Ectopic pregnancy; adnexal mass