Endometriosis Foundation of America
Medical Conference – 2012
Applied Pelvic Anatomy for the Management of Endometriosis and Adnexal Disease
Grace Janik, MD
Thank you, and thank you Dr. Seckin for inviting me to this inspired meeting, and especially that my partner, Charles Koh is the honored surgeon this year. We have been partners for over 20 years and he is a very creative guy who has really been the inspiration for a lot of our endometriosis work over the years. It has been exciting to be part of the really early stages of laparoscopic treatment of endometriosis in the early 1980s.
The learning objectives are to really apply the knowledge of anatomy which is the key to safely perform extensive peritoneal resection of endometriosis, management of adnexal pathology and presacral neurectomy. We will also touch upon some of the outcomes of this extensive peritoneal resection. The key for the anatomy really comes from the deep infiltrating disease. You often hear patients that were treated, what we could, and we had to leave the rest because it was over something important. Well, almost always it is over something important when it is deep; whether it is the rectum, ureter, bladder and disease often will have some involvement of the uterosacral ligament with extension over to the cardinal ligament, ureters, bladder. Often times these areas are confluent, so completely engulfing each other. The concept of radical excision endometriosis is excision down to normal tissue, clear margins, almost like a cancer treatment. It includes bowel, bladder, ureter wherever it takes you. What it does not include is hysterectomy and oophorectomy.
Urinary tract endometriosis is one of our keys and one percent of endometriosis will have some involvement of the urinary tract. Eight-four percent usually affects the bladder and 15 percent the ureter. The symptoms of bladder endometriosis can very much mimic interstitial cystitis with some urgency and frequency being the key, even some suprapubic pain. The concept of how to resect is really wide excision and when we know it is going to extend deep to the mucosa often times to place catheters so these may not be necessary but we do need to identify the opening of the ureter. To closure with a two layer closure and this does not necessarily need to be water tight.
Here is a partial thickness resection. We are outlining the disease and often times you do not know for sure how deep the disease is going to take you, and there are circumstances deeply infiltrating but it does not go through the bladder mucosa. The lower example here does. In this case we actually knew ahead of time this patient did have endometriosis in her bladder because she had a previous cystoscopy. Stents were placed, the area was marked by cystoscopy and this entire area was able to be resected and then sewn together. Understanding the different layers and being prepared to suture when necessary is key. The two core concepts are understanding of anatomy and the ability to repair and the ability to suture. Looking at the literature of the successful cystectomy seems to be very good. The bladder is forgiving so an easier place to start.
The ureter is more complex. In the ureter the endometriosis can be above the ureter, it can be extending around intrinsic disease or it can be deep extending into the mucosa. Literature is a bit contaminated with understanding how much extrinsic versus intrinsic there really is. The actual pathology of the mucosa involvement may be over estimated. Even how many cases of ureteral endometriosis is quite variable with this world literature report of 125 primarily left sided, but it may really be much more than that. The biggest problem is we do not have a good symptom early phase so 50 percent are asymptomatic that have ureter involvement. We need to be prepared at the time of surgery in order to treat these patients. One of the clues that we can have is the uterosacral ligaments, when they are enlarged greater than 3 cm, we have an 11 percent chance of having ureteral involvement. This is anatomy marker of what we may have. IVP even does not pick up, even in severe cases only 43 percent will have involvement. The biggest problem is 25 to 46 percent of patients will have loss of renal function because we are not picking up when there is ureteral involvement. We cannot go by symptoms. The diagnosis is really the presence and extensive disease at the time of endometriosis surgery.
Now here is where anatomy is especially key. In order to understand how to approach the ureter we have to think about where we have best access and this is at the pelvic brim where it crosses over the iliac vessels and it is pushed most anteriorly. This is your most consistent place to find endometriosis. On the left side you may have to take down the left colon in order to have access to this area. The blood vessels below this area that feed the ureter will be coming in laterally so we can dissect down all the way down to the uterine artery. We have our feeder vessels coming in laterally we have peristalsis of the ureter. This peristalsis will create a tunnel of areolar tissues. We can take advantage of this tunnel in order to open up the peritoneum over the ureter.
Here is our line of dissection and with that, even when we have compressing endometriosis, by following these anatomic clues and staying on the medial surface we often times can liberate the endometriosis off the ureter. In many cases the ureter will recover and in some cases it will not. If the disease is too fibrotic we have resect that ureter and reanastomose. Here is the concept of how to do ureterolysis so mobilizing the left colon and then find the ureter at the pelvic brim. You do not necessarily need to open up the peritoneum over the ureter at the pelvic brim, you can identify and open up the peritoneum over the ureter when you start having disease or you start to lose the ureter. We tend to use laser we prefer KTP laser, you can use scissors also. Some people do cautery but there is not a lot of bleeding in this area so it may be preferable to use scissors to control thermal spread. Here we have the ureter isolated. This is small instrumentation that we use to cut upon in order to mobilize. When you get down close to the uterine artery what is going to happen is the ureter is going to start to go deep a little bit. You will start to see some distends of areolar tissue as your kind of marker that the next thing that is going to come is the uterine artery. Once the ureter is identified then the next phase is to identify uterosacral ligaments and open up rectovaginal space. This is a consistent start of all cases.
Here is a case starting with ureterolysis, so first normalizing anatomy and here is where, we work with residents, we have a resident based teaching practice. Opening up with ureterolysis, the resident is assisting on the left. You want to take advantage of this ureteral space, this contractive space of areolar tissue. You can see that things are not going well. You have to be on the medial surface in order to take advantage of the space. Also, this instrument is a bit big, this grasper. You can see we have had an injury here to the ureter by not really thinking about the actual anatomic relationships and pushing the ureter forward instead of protecting the ureter. When these things happen, you just carry on and with the ability to suture it is easy to place a suture and stent after placing indigo carmine in order to identify the opening. Here is the opening in the ureter and we can go ahead and anastomose. Stent placement would be ideal, though for these very small injuries would not be required. You can use a very small suture. Even some of our thoughts of when we need to re-implant versus re-anastomose need to be reconsidered with the magnification and access that we have to the pelvis that we may really not need to be doing re-implantation.
This is a patient referred with obstruction. You can see this area of endometriosis and we are doing ureterolysis. This is an old case. In this case it is very fibrotic. We have this constrictive band right around the ureter and you can see the hydronephrosis that is present. By using very small instrumentation we can liberate and you can see the ureter recovering right before our eyes and no other treatment is necessary.
This is another old case. This is a patient with multiple previous surgeries. In this case the ureter looks terrible. After the endometriosis had been removed there is no recovery so we need to resect and re-anastomose this area. You can see how thick the ureter is. Understanding the thickness we can really avoid the mucosa, take advantage of the muscularis and do multiple small sutures to re-anastomose the ureter, which is really much thicker than the fallopian tube and easier to anastomose. Here is the end result. The patient goes home the same day with stent placement.
How to think about bowel in the rectovaginal space? Pain is one of the key features with bowel endometriosis, dyspareunia is second, rectal pain and then some diarrhea and constipation symptoms. Very low on the list is rectal bleeding. This is a view of different cul-de-sacs. I want to do a quiz with you on this. So, here is normal…oh, this one has a label on it so I cannot quiz you – shoot! There is one without a label someone put the wrong on in. I will still quiz you. This one obviously is endometrioma, so obliterated cud-de-sac, which is part of the classification problems is not necessarily the key to what is abnormal. This one is pretty easy once you mobilize endometriomas. Okay, between number one and number two you are going to vote which you think is most difficult. Who thinks number one is the most difficult? Nobody. Who thinks number two is the most difficult? Okay, most of you. Actually, it is number one. And why its anatomic clues, it is really all about anatomy. So here you can see the disease and it looks bad but here you have uterosacral ligaments that you can identify, you have got ovarian _____ space. You have got the ovaries separated, so even though you can see the disease your anatomical relationships are correct. But here, if you really study it, what you have got is you have got the ovarian suspensor ligament pulled into the uterosacral and you have the rectum pulled to the back of the uterus. Your tubes are medially displaced. Here is your cul-de-sac, this line right here, so you are going to have to drop this down and chances are this area on the bowel is going to be probably very deep. This one, even though it does not look as dramatic because you cannot see the disease it is buried under here and probably more difficult. Here is how things look on cross-section. Here is normal hysterectomy and here is hysterectomy with endometriosis. Look at all this disease. This is a cul-de-sac extending to the uterosacrals. You can understand why hysterectomy is not the correct answer for treatment of endometriosis. If this patient had a hysterectomy and you sewed this cuff back up they are going to have bowel symptoms, dyspareunia, all of the symptoms are going to maintain. Maybe not as much menorrhagia with your period because you do not have a period but the majority of the symptoms untreated. Hysterectomy is not the correct answer.
The steps on how to approach, how to begin this, is you mobilize the ovaries and put all adhesions back and then you have perirectal fats access to the cu-de-sac, separate disease however it naturally separates. We are not fixated on leave it on the bowel, leave it on the vagina, so we will go either way depending on how the disease takes us. You need to have good manipulation and we use a ring in the rectum for identification. Here is entering into the cul-de-sac. This is an extension of that first video that had the ureter and this is another important anatomy landmark. The perirectal fats just medial to the uterosacral is fairly thick in this area. So this is the optimal place to enter into the rectovaginal space. You do your ureterolysis, you carry down, you dissect the uterosacral ligaments and then open into the rectovaginal space. When we first started doing this we would think we fell into the rectum and it was kind of scary at first. Then you got a sense of what that space is like. You can open up rectovaginal space all the way down to the perineum. This lateral portion of fat, this is really your friend, this is you access to the cul-de-sac. Once you have these lateral access points you can drop the rectum down and open up that rectovaginal space. You can extend it medially. Here is how we have access and you can see the endometriosis with the ring in the rectum just snapping and rubbing across. We know we have deep fibrotic disease here.
This is the third in that series and here we have got the uterosacral ligaments, opening them up, and here we have the rectovaginal space open and now we can do our proper assessment of what we have on the vagina and what we have on the rectum. You can see that it is thickened fibrotics. We have deep endometriosis that is extending into the vagina. We do not know for sure how deep it is but knowing the layers and what to expect we know that we can start shaving this down and it is important to have a balloon inside of the vagina if you think you may enter. Dissecting, often times we will use scissors when there is some element of palpation that we want so we have some tactile feedback. You can see the endometriosis here, so you can sense a fibrosis and you see the endometriosis as the dissection continues. That is a huge amount of fibrosis that at first was visually not apparent. With palpation it is still not adequate so you need to get all the disease out. You need to have clean margins and in doing that we are down to our deepest layer and we are opening into the mucosa. With the balloon that is present you can see the balloon here we do not lose gas and we can sew this area and carry on with the rest of the dissection.
The bowel has multiple layers, so understanding these layers helps us to know where we are and how to treat. We have got peritoneum, the longitudinal fibers, the circular and then the mucosa. When we see these different layers of fiber we know how deep we are and what we need to suture. You can have bowel endometriosis that is more mounded and will look more dramatic but it is actually the deeper disease that is more problematic. Here is this mound look that is probably easier to shave off. It is when you have this crater and sometimes the crater edges will even come next to each other and touch, to the point that you do not see much. It is like an iceberg. Here is a side view of this type of crater illusion, you can see it here. Here is mucosa and here is this big cratering of bowel endometriosis that is coming down and really causing a narrowing of the bowel that is present. Our options depend on the depth and the size, partial thickness or skinning, full thickness where we will go all way through to the mucosa and we do this for under three cm. If it is deep and wide we will do resection and colectomy. Here is partial thickness and you can see this is really quite a bit of endometriosis but you stay close to the endometriosis and we can see here our longitudinal fibers. In this we have at later times done reinforcing suturing but in the early days we did not suture these depths that went to the longitudinal fibers. It is based on some data by Philip Koninckx that showed decreased and delayed injuries. We did not have any delayed injuries before but we thought we would take advantage of someone else’s injuries and do reinforcing suturing. That is the same with laser.
Here, this is full thickness. This always starts the same, mobilize the adhesions, do ureterolysis then open up the rectovaginal space. You identify the ureter on this side and it is really for identification of the ureter, you do not necessarily need to do full distance ureterolysis you just need to achieve your goal. Then, opening up the rectovaginal space starting laterally and then here we can see the drop and you can see that coming in, that cratering type of effect. Starting with scissors to debulk and trying to do partial thickness oftentimes we will start with partial thickness but it is not adequate, just like with the vagina, you can still see the disease is present. We know that it is deep enough that you come through. We have a rectal probe, oftentimes when we come through we will put a stitch on the side so you do not get disoriented to what is horizontal as you are operating, scissors coming through to the other side. Then the closure is the same with all the closures, two layer closures although it is essential that this one is water tight.
Then the final form is colectomy. We do very little colectomy in proportion to the other procedures. So we begin the same, but here you can see that this has that deep cratering but in addition it is very long, so it would be a lot of tension and a large area to have to suture. It would be preferred to do colectomy, so make a small incision, bring it out, resect this whole area of bowel using anvil stapler to put back in and staple this area closed. Here is the end result. It is very important for any type of cu-de-sac disease that you do a test of leak at the end. Here is how the incisions look so very small incision. Patients tend to stay in the hospital three to four days typically.
This is our data of deep cul-de-sac endometriosis. It is over a 1,000 patients in this time period (1991 – 2001), so very early days of doing this work and we had 400 that were deep of the 1,000 and only 22 colectomies. The majority were able to be treated with partial and full thickness, which is a little different than some of the literature now where people are more aggressive about doing colectomy. In this group of bowel, 78 percent were pain free or pain controlled followed out three years. The pregnancy rate in this group varies similar to what Dr. D’Hooghe presented, 48 percent in this very severe bowel group. There is a sense that if it is this severe you cannot get pregnant or you should not treat if there is fertility but it is really not true. We looked at the symptoms for the over 1,000 patients over a five year follow up. Eight-two percent would be pain free or pain controlled followed out. Only 18 percent required further surgery. Of the further surgery most happened fairly quickly, within a year. It is if some element of recurrence happens quickly, and then if not, you are okay.
One of our fellows also looked at comparison of the same subgroup with the adolescents. In this group the failure and requiring further surgery was 35 percent in the adolescent group compared to 18 percent in the adult. So this is the same surge and same concept. Both recurrences happened quickly but at a higher level with the adolescents.
Finally, I would like to talk about retroperitoneal ovary. Retroperitoneal ovary can have two groupings; one is ovarian remnants syndrome where the ovary is encapsulated in adhesions that can be part of endometriosis, residual ovarian and then ovarian remnant syndrome where there is persistence of disease. Both of these are associated with endometriosis. Pelvic pain is the key, sometimes there is a mass effect but pain is overwhelmingly the key and people think the ovary is gone – how can this be? Fifty percent of these patients have some history of endometriosis surgery. So, previous cystectomy, previous endometriosis surgery should be a heads up if people are still having pain.
This is a patient that had previous surgeries for endometriosis. For adhesions and endometriosis you start very much the same. First normalization take down of adhesions, in this case using scissors. What we have got here is the common kind of ovarian remnant where essentially the cortex is left behind. The endometrioma is lifted off and you take out the endometrioma but the whole cortex is almost like flattened against the peritoneum and really misinterpreted as being part of the peritoneum and not part of the ovary. You almost treat this as if you have peritoneal endometriosis that is present. Here we have this flattened area of ovary even though she has had an oophorectomy and often times these will be hormonally active. Begin with ureterolysis, a kind of a standard way of approaching endometriosis in general and then remove all the peritoneum that has the ovary attached to it. Here we are coming across and doing this unblock dissection around the area of remnant ovary. This is a KTP laser, it is a fiber laser we have been using for a long time since we started doing endometriosis surgery in the late 1980s and still our preferred tool. We have done other energy sources also but we tend to gravitate back and here is the end result.
Here is the final video of another ovarian remnant. In this case it is at the IP ligament and here is the remnant. They tend to get displaced very high so you have to look for them much higher than you are typically comfortable operating and you have to be very careful the iliac vessel is up in this area. So, take down adhesions and here we have the remnant but it looks very thick so because there is some concern about what really is this vessel it is so thick, we are going to do a more extensive dissection. Then you get all these things that pop up and tell you want to do – wouldn’t that be so nice? This is a nice final one to really understand the anatomy up in this area that we do not always think about. Here is external iliac, the ureter crossing the internal iliac. At this crossing point you can see how the ureters anteriorly displaced. This is very useful. This is the IP. Sound cut out from 26:27 to end at 27:55.
