LAPAROSCOPIC TOTAL PERITONEAL EXCISION

A SAFE SURGICAL PROCEDURE

FOR THE MANAGEMENT OF ENDOMETRIOSIS•10th Congress of the European Society for Gynaecological Endoscopy - Lisbon, Portugal November 22nd - 24th 2001. Abstract FCV01-03, Page 33.FCV01 03, Page 33.

•VIII World Congress on Endometriosis. San Diego, California. February 24th - 27th, 2002.

•1st European Endoscope Surgery, Glasgow 16-18 June 2003. Review in Gynaecological Practice - June 2003 Volume 3 issue 1; p14p14.

•Global Congress of Gynaecological Endoscopy, San Francisco, California - November 10-13, 2004. The Journal of American Association of Gynaecoligical laparoscopists. August 2004, Vol. 11, No. 3 Supplement; pS39

•14th annual congress of the International Society for Gynaecologic Endoscopy London April 3 6 2005•14th annual congress of the International Society for Gynaecologic Endoscopy, London, April 3-6 2005

•XVIII FIGO World Congress of Gynaecology and Obstetrics, Kuala Lumpur, Malysia - 5-11 November 2006.

MR A K TREHAN, FRCOG, FRCS (Edin)

CONSULTANT MINIMAL ACCESS GYNAECOLOGIST WITH SPECIAL INTEREST IN ENDOMETRIOSIS

DEWSBURY & DISTRICT HOSPITALWEST YORKSHIRE, ENGLAND, UK

“EXCISION OF ENDOMETRIOSIS”

MODERN & ACCEPTEDSURGICAL

MANAGEMENT OF ENDOMETRIOSIS

CONVENTIONAL PRACTICE

EXCISE ENDOMETRIOTIC LESIONEXCISE ENDOMETRIOTIC LESION AND

LEAVE SO CALLED NORMAL LOOKINGLEAVE SO CALLED NORMAL LOOKING PERITONEUM

CONVENTIONAL PRACTICECONVENTIONAL PRACTICE

PARTIAL EXCISION OF PELVIC PERITONEUM

Copyright Trehan

Endometriosis mainly a generalisedEndometriosis mainly a generalised disease of pelvic peritoneum and if one looks carefully so called normal lookinglooks carefully so called normal looking

peritoneum have an abnormal vasculaturevasculature

Endometriotic vascular changes-Neovascularisation Peritoneum

Alth h th i b i d t i i i th lid f l i ti f thAlthough there is no obvious endometriosis in these slides; careful inspection of the so

called normal looking peritoneum has abnormal vascular changes due to endometriosis

Copyright Trehan Copyright Trehan

Copyright Trehan Copyright Trehan

Failure of conventional practicep

• Incomplete excision/removal

• Disease recurrence new disease at new site(recurrence rate reported 14-36%)

I SUGGEST COMPLETE REMOVAL OF PERITONEUM

COVERING:COVERING:

B th i f• Both ovarian fossa• Uterosacral ligament

P h f D l• Pouch of Douglas

THUS

EXCISE BOTH ABNORMAL AND SO CALLEDNORMAL LOOKING PERITONEUMNORMAL LOOKING PERITONEUM

TOTAL PERITONEAL EXCISION

TOTAL PERITONEAL EXCISION

EXCISION OF PELVIC PERITONEUM BOTH OVARIAN FOSSA, UTERO SACRAL LIGAMENT & POUCH OF DOUGLAS Copyright Trehan

TOTAL PERITONEAL EXCISION

EXCISION OF PELVIC PERITONEUM BOTH OVARIAN FOSSA, UTERO SACRAL LIGAMENT & POUCH OF DOUGLAS

Copyright Trehan

SACRAL LIGAMENT & POUCH OF DOUGLAS

REASON FOR TOTAL EXCISIONREASON FOR TOTAL EXCISION

To Reduce Chances Of Recurrence

So called normal looking peritoneum between frank clinical lesions has –

• Sub-clinical endometriosis

• Continued susceptibility to metaplasticContinued susceptibility to metaplastic changes/retro-grade menstruation

REASON FOR TOTAL EXCISIONREASON FOR TOTAL EXCISION(CONTINUED)

Better symptomatic reliefy p

• May result in complete destruction of retro-May result in complete destruction of retro-peritoneal nerves

OvaryUterovaginal Plexus

Bladder

UterusRectum

Bladder

REASON FOR TOTAL EXCISION(CONTINUED)

Reduced complications

• Starting dissection from so called normal looking g gperitoneum helps in better delineation of anatomy

OBJECTIVE

DETERMINE SAFETYOF

LAPAROSCOPIC TOTAL PERITONEUMEXCISIONEXCISION

DESIGN:

Retrospecti e- Retrospective

- 100 consecutive cases to October 2004

- Total Peritoneal Excision in patient with uterus

- Included - Mild to severe endometriosis (stage I-IV)- Included - Mild to severe endometriosis (stage I-IV)

- Excluded – Hysterectomy with excision or hysterectomy in the past

- All operation undertaken by one surgeon (Mr A K Trehan)

SETTINGS:District General Hospital- District General Hospital

MEDICAL TREATMENT FAILURE PRIOR TO EXCISION

TOTAL NO. OF PTS FAILED MEDICAL TREATMENT NO. OF TIMES MEDICAL TREATMENT TRIED AND FAILED

100 68 = 68% 1 FAILURE 43%

2 FAILURE 15%

3 FAILURE 8%

4 FAILURE 2%

TOTAL 68%

TECHNIQUETOTAL PERITONEAL EXCISION

• 3 Port Entry – 10mm sub-umbilical x 1- 5mm side ports x 2- 5mm side ports x 2

• Oozing from raw surface checked at end of• Oozing from raw surface checked at end of operation at 6mm pressure

• Anti-adhesion solution

• Prophylactic antibioticProphylactic antibiotic

DEGREE/STAGE OF ENDOMETRIOSIS

Mild 37/100 = 37%• Mild 37/100 = 37%(Superficial scarrings)

• Moderate 42/100 = 42%• Moderate 42/100 = 42%(Deep scarring & adhesions)

• Severe 21/100 = 21%Severe 21/100 = 21%(Deep scarring, major adhesions, chocolate cyst & bowel involvement)

1

Copyright TrehanSevere Endometriosis with Kissing Ovaries

1

Copyright Trehan

Severe Endometriosis with Kissing Ovaries following excision

2

Copyright TrehanExtensive Scarring with previous laser surgery

2

Copyright TrehanExtensive scarring with previous laser surgery following excision

Opened Vagina

3

Opened Vagina following excision

RECTUM

Copyright TrehanExcision of Recto-Vaginal Endometriosis

3

Opened Vagina

Copyright TrehanExcision of Recto-Vaginal Endometriosis

UTERUS

3

Vagina stitchedVagina stitched

Copyright TrehanExcision of Recto-Vaginal Endometriosis

Extensive dissection for Endometriosis involving Ureter

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Extensive dissection for Endometriosis involving Ureter

Extensive dissection for Endometriosis involving Ureter &

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Extensive dissection for Endometriosis involving Ureter & major blood vessels

PATIENT CHARACTERISTIC & ANALYSISPATIENT CHARACTERISTIC & ANALYSIS

MEAN RANGE• Mean age 34yrs 20-50yrsg y y

• Mean weight 66kg 37 107kg• Mean weight 66kg 37-107kg

• Mean Hb deficit 2g/dl 0.1-3.7g/dl

• Mean theatre 189mins 100-375minstioccupancy time

Histological Confirmation of Endometriosis

• Histologically confirmed 84/100 = 84%• Histologically confirmed - 84/100 = 84%

• Histologically not confirmed - 16/100 = 16%

HOSPITAL STAYHOSPITAL STAY RELATES TO THE

NUMBER OF POST-OPERATIVE NIGHTS IN THE HOSPITAL

Total No. of Total No. of Median day stay in % of pt hadPatients Nights Hospital overnight stay

100 110 1(range 1-2) 90%

• 90% of patients could be discharged home inspite of prolonged operation (mean theatre occupancy 189mins – range 100-375mins)

• 10% of the patients who stayed an extra night was mainly for: Social reasons• Social reasons

• Lived far away (Scotland, York and Goole)

COMPLICATIONSCOMPLICATIONS

• Blood Transfusion 0/100 0%• Blood Transfusion 0/100 0%

Pyrexia 0/100 0%• Pyrexia 0/100 0%

W d li ti 0/100 0%• Wound complication 0/100 0%

C i t l t 0/100 0%• Conversion to laparotomy 0/100 0%

MINOR COMPLICATIONSMINOR COMPLICATIONS

• Uterine fundal perforation 1/100– No ill consequences – no special treatment needed

• Serosal abrasion of large bowel 1/100– No ill consequences – Hospital stay one day– Usual diet from day of operation

TOTAL - 2/100 = 2%O / 00 %( No ill consequences, no morbidity, not required any special postoperative care or treatment)

MAJOR COMPLICATIONSMAJOR COMPLICATIONS

INJURY TO INTERNAL ORGANS –

• Bladder 0/100 0%• Ureter 0/100 0%• Bowel 0/100 0%• Major blood vessels 0/100 0%

READMISSION WITHIN 4 WEEKS OF OPERATION

• For surgical complication 0/100 0%

• Other reason 1/100 1%– Anxiety and chest pain – discharged within 12 hours of

readmissionreadmission

RE OPERATIONRE-OPERATION

RE-OPERATION WITHIN SIX MONTHS OF INITIAL OPERATION:

0/100 = 0%

RISK OF PELVIC ADHESIONSRISK OF PELVIC ADHESIONS FOLLOWING

TOTAL PERITONEAL EXCISIONTOTAL PERITONEAL EXCISION

• 10 patients had second look for diagnostic/p gtherapeutic procedure

• No pelvic adhesion detected(A single strand of adhesion or very few flimsy adhesions not included)

EXCISION OF PELVIC ENDOMETRIOSIS DOES NOT CAUSE PELVIC ADHESION

BEFORE EXCISION AFTER EXCISION

Copyright TrehanCopyright Trehan

SECOND LOOK LAPAROSCOPY

Copyright TrehanCopyright Trehan

Copyright Trehan PATIENT NO. 1

EXCISION OF PELVIC ENDOMETRIOSIS DOES NOT CAUSE PELVIC ADHESION

AFTERBEFORE AFTER

OVARY

OVARY

SECOND LOOK LAPAROSCOPY

Copyright Trehan Copyright Trehan

OVARY

PATIENT NO. 1Copyright Trehan

EXCISION OF PELVIC ENDOMETRIOSIS DOES NOT CAUSE PELVIC ADHESION

BEFORE AFTER

UTERUS

UTERUSUTERUS

Copyright TrehanCopyright Trehan

SECOND LOOK LAPAROSCOPY

py g

UTERUS

PATIENT NO. 1Copyright Trehan

EXCISION OF PELVIC ENDOMETRIOSIS DOES NOT CAUSE PELVIC ADHESION

AFTER EXCISION – Patient 2

AEXCISION OF PELVIC PERITONEUM BOTH OVARIAN FOSSA, UTEROEXCISION OF PELVIC PERITONEUM BOTH OVARIAN FOSSA, UTERO

SACRAL LIGAMENT & POUCH OF DOUGLASCopyright Trehan

EXCISION OF PELVIC ENDOMETRIOSIS DOES NOT CAUSE PELVIC ADHESION

AFTER EXCISION - Patient 2

AEXCISION OF PELVIC PERITONEUM BOTH OVARIAN FOSSA, UTEROEXCISION OF PELVIC PERITONEUM BOTH OVARIAN FOSSA, UTERO SACRAL LIGAMENT & POUCH OF DOUGLAS

Copyright Trehan

EXCISION OF PELVIC ENDOMETRIOSIS DOES NOT CAUSE PELVIC ADHESION

SECOND LOOK LAPAROSCOPY Patient 2SECOND LOOK LAPAROSCOPY – Patient 2

Copyright Trehan

EXCISION OF PELVIC ENDOMETRIOSIS DOES NOT CAUSE PELVIC ADHESION

SECOND LOOK LAPAROSCOPY – Patient 2

Copyright Trehan

EXCISION OF PELVIC ENDOMETRIOSIS DOES NOT CAUSE PELVIC ADHESION

SECOND LOOK LAPAROSCOPY – Patient 2

Copyright Trehan

EXCISION OF PELVIC ENDOMETRIOSIS DOES NOT CAUSE PELVIC ADHESION

AFTER EXCISION SECOND LOOK LAPAROSCOPY

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Patient 3

SUMMARYSUMMARY

• 90% of patients left hospital after overnight stay inspite of prolonged procedure (mean theatre occupancy 189mins – range 100-375mins)

• 2% patients suffered very minor intra-operative complication which did not cause any post operative ill consequences or morbidity nor did patient require any special post operative care or treatmentrequire any special post operative care or treatment

• No patient suffered any major complication

• No patient was readmitted for surgical complication

N dh i d t t d t d l k N it t th i d• No adhesions detected at second look. New peritoneum at the excised area gave normal appearance.

CONCLUSIONCONCLUSION

• Total peritoneal excision using bipolar coagulator and i i f i l d i i dscissors is a safe surgical procedure in an experienced

hand.

• Overnight Hospital Stay following prolonged procedure• Overnight Hospital Stay following prolonged procedure to excise endometriosis is a safe practice

ACKNOWLEDGEMENTACKNOWLEDGEMENTThanks to the junior doctors, audit and secretarial staff for

undertaking the collection and analysis of this data:undertaking the collection and analysis of this data:

• Dr P Chaudhuri – MRCOG - Staff Grade• Dr P Chaudhuri – MRCOG - Staff Grade• Dr S Sunder – MBBS. MD - SHO

Mrs C Rooke A dit S i• Mrs C Rooke – Audit Supervisor• Miss Z Kitcher - Secretary

Thanks to all of the staff of gynaecological divisionwithout whom our short stay major gynaecologicaly j gy g

programme would not be possible.

THANK YOU

For more information, please visit o o e o at o , p ease s thttp://endometriosis-

consultant co uk/consultant.co.uk/