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References

LAPAROSCOPIC SURGERY FOR ADVANCED ENDOMETRIOSIS
Harry Reich, M.D.

NOTE: This article was written for gynecologic surgeons. Terminology used throughout this page may be unfamiliar to the layperson, but the surgical principles discussed should be reasonably understandable.

This review article discusses the laparoscopic surgical techniques used for the treatment of extensive endometriosis. Thick peritoneal implants and ovarian endometrioma treatment is followed by an in depth description of cul-de-sac disease, bowel endometriosis, and bowel resection. Hysterectomy is included because of its application in the treatment of pain from adenomyosis. It is hoped that dedication to these techniques which emphasize excision of the disease will result in cure of this debilitating condition

Diagnosis and treatment of endometriosis is the most frequent reason for gynecologic operative laparoscopy in the United States (Peterson et al, 1990). It is therefore important for the laparoscopist to be thoroughly familiar with the current standards of diagnosis and management of this complex disease.

The theory that best fits my clinical experience is that stray müllerian cells don't quite make it to the inside of the uterus and remain in the pelvic tissue after the embryonic stage and are later triggered by estrogen stimulation to differentiate into functioning endometrial glands and stroma. These functioning endometrial glands stimulate a monthly recurring inflammatory response which results in the laying down of white fibromuscular tissue around them. When these lesions are completely excised, endometriosis does not recur. I do not believe that "endometriosis" without surrounding white scar represents a pathological entity.

The most common presentations where endometriosis is found are pelvic pain, infertility, and adnexal mass. The ovaries, the posterior leaf of the broad ligament, and the cul-de-sac are the most frequent locations, and the left side is more frequently affected than the right.

TeLinde and Scott defined the objectives of surgical treatment of endometriosis in 1952: "one should excise or fulgurate all evident endometriosis." The surgical objectives of laparoscopic treatment are similar, i.e., to remove all evident endometriosis by excising large superficial and deep lesions and vaporizing smaller deposits.

The operative advantages of a laparoscopic approach to cul-de-sac obliteration include: easy intraoperative access to the rectum and vagina, a magnification source which is easier to manipulate then an operating microscope, and the ability to perform an underwater examination at the end of the procedure during which all blood clot is evacuated and complete hemostasis obtained. The general advantages of laparoscopy include: same day diagnosis and treatment, short hospitalization, rapid recuperation, superior cosmetics, excellent patient acceptance, cost effectiveness, and results at least equal to laparotomy.

Excision of endometriosis can be a frustrating, time-consuming experience when attempted laparoscopically. Laparoscopy is a method of access and not a method of treatment. While the surgeon's hands are much further from the area being treated than during laparotomy, his eye (or eyes with video) is right on top of it, much like when using the operating microscope for pelvic reconstructive surgery. The advanced laparoscopic surgeon uses a variety of treatment modalities and requires equipment for mechanical cutting, electrosurgery, CO2 laser, aquadissection, suturing, and stapling.

Laparoscopic techniques for hemostasis
Bleeding problems are common and difficult to resolve. Laparoscopic endometriosis surgery requires a thorough knowledge of electrosurgical, laser, and suture techniques for dissection and hemostasis.

Current is used to cut and coagulate (desiccate); coagulation current is rarely used. The tip of a spoon electrode is used to cut. The round body of the electrode is used to tamponade arteriolar bleeding vessels after which cutting current is applied to coagulate them. Diffuse venous bleeding can sometimes be controlled with fulguration, the noncontact application of high-voltage coagulation current to the tissue through a 1 to 2 mm spark or arc. Cutting with coagulation is done with cutting current through the broad round spoon using power above 100 W. Finger control of monopolar electrosurgery is advised using a long electrode attached to a hand pencil. Persistent arterial bleeding from small or large vessels requires bipolar desiccation.

Bipolar electrodes can only desiccate, and a cutting waveform is selected when using these forceps. Bipolar forceps use high-frequency low-voltage cutting current (20-50 W) to coagulate vessels as large as the ovarian and uterine arteries. (Reich H, 1987) The Kleppinger bipolar forceps (Richard Wolf) are excellent for large vessel hemostasis. Specially insulated microbipolar forceps containing a channel for irrigation and a fixed distance between the electrodes (#8383.091, R. Wolf Instruments, Vernon Hill, IL) are used for precise hemostasis. The bleeding sites are irrigated with irrigant pushed through the cleaning channel of the microbipolar forceps by the Marlow Pump Vac Plus (88-2050) for vessel identification before coagulation and to prevent formation of an eschar that can stick to the electrode. Irrigation is used during underwater examination to identify bleeding vessels before coagulation by removing surrounding blood products.

The carbon dioxide laser at 20-30 W is shot through the operating channel of an operating laparoscope perpendicular to the surgeon's field of vision to separate fibrotic endometriosis from normal tissue. An effect similar to a blended current can be obtained with conventional CO2 laser through the operating channel of an operating laparoscope when used above 50 W as the large spot size with diameter from 2 to 4 mm obtained controls most arteriolar and venous bleeding. (Reich, H et al. 1991 a)

Suturing with large curved needles using 5-mm lower quadrant incisions requires a special technique to put them into the peritoneal cavity. (Reich H et al. 1992) Lower abdominal incisions placed lateral to the rectus muscle ensure an obvious tract on removing the trocar sleeve that is very easy to re-enter. To suture with a CT-1 needle, the trocar sleeve is taken out of the abdomen and loaded by introducing a needle driver through the trapless sleeve (Apple) to grasp the distal end of the suture, pulling the suture through the trocar sleeve, reinserting the instrument into the sleeve, and grasping the suture 2 cm from the needle. The needle driver is inserted back into the peritoneal cavity through the original tract, as visualized on the monitor; the needle follows through the soft tissue and the trocar sleeve is pushed downward over the driver to reinsert it at its original position in the peritoneal cavity.

At this stage, the needle driver, usually an oblique curved one (Cook OB/GYN, Spencer, IN) applies the needle to the tissue to be approximated. Afterward, the needle is placed in the anterior abdominal wall parietal peritoneum for removal after the suture is tied. The suture is cut adjacent to the needle, and the cut end of the suture is pulled out of the peritoneal cavity; the knot then is tied with the Clarke-Reich knotpusher (Marlow Surgical, Willoughby, OH) without loss of pneumoperitoneum because of the tight seal of the trocar sleeve. The surgeon holding both strands makes a simple half-hitch. The knot-pusher is put on one strand of the suture just above the knot, the suture is held firm across the index finger, and the throw is pushed down to the tissue defect. The second throw is made in the same direction (i.e., a slip knot) while exerting tension from above to further secure the tissue. The knot is squared with the third and fourth throws by pushing half-hitches made in opposing fashion down to the knot to secure it firmly. To retrieve the needle, the trocar sleeve is pulled out and the needle holder inside it drags the needle through the soft tissue. The trocar sleeve is replaced easily with or without another suture. Care is taken to avoid compressing polymeric braided or monofilament suture between the jaws of traumatic needle drivers or graspers as they are at risk of surface damage and later disruption. Disposable stapling and suturing instruments rarely are used because of their expense. Conventional sutures and bipolar desiccation work better.

Equipment
High flow CO2 insufflation to 15 L/min or more is necessary to compensate for the rapid loss of CO2 during suctioning. The ability to maintain a relatively constant intra-abdominal pressure between 10 and 15 mm Hg during laparoscopic surgery is essential.

Operating room tables capable of a 30 Trendelenburg's position are extremely valuable for laparoscopic cul-de-sac work. Unfortunately these tables are rare, and this author has much difficulty operating when only a limited degree of body tilt can be attained. For the past 20 years a steep Trendelenburg's position (20 -40), with shoulder braces and the arms at the patient's sides, has been used without adverse effects.

Extracorporeal tying is facilitated by using a trocar sleeve without a trap to avoid difficulty in slipping knots down to the tissue. A short trocar sleeve that doesn't protrude far into the peritoneal cavity, has a screw grid for retention, and has no trap, is ideal. (Reich H, McGlynn F. 1990) Both a reusable (Richard Wolf, Vernon Hills, IL) and a disposable version (Apple Medical, Bolton, MA) are available. The former is better for rapid instrument exchanges, but the Apple has a tight seal, preventing loss of pneumoperitoneum when pushing the knot down.

Laparoscopy was never thought to be a sterile procedure before the incorporation of video because the surgeon operated with his or her head in the surgical field, attached to the laparoscopic optic. It is not possible to sterilize skin. Since 1983, this author maintains a policy of not sterilizing or draping the camera or laser arm. Infection has been rare.

Preoperative Preparation
Surgical skill remains paramount. Ambidexterity separates the laparoscopic surgeon from those trained traditionally, as the surgeon must often hold the camera with the dominant hand.

Laparoscopy is performed prior to ovulation if possible. Many methods are available to avoid operating on or injuring an ovary containing a corpus luteum. I prefer using low dose oral contraceptives, e.g. Loestrin 1.5/30 (Norethindrone Acetate 1.5 mg and Ethinyl Estradiol 30mcg.) or Lo/Ovral (Norgestrel 0.3 mg. And Ethinyl Estradiol 0.03 mg). Alternatively, Norethindrone acetate, 10 mg daily, or gonadotropin-releasing hormone (GnRH) agonists [leuprolide acetate for depot suspension (Lupron Depot), 3.75 mg IM], may be used starting after ovulation in the cycle preceding surgery or before or during the menses before surgery to avoid operating on ovaries containing a corpus luteum. Some administer depoleuprolide acetate one month prior to the procedure, dependent only upon when the patient wants the surgery and not on where she is in her menstrual cycle. Autologous blood donation is considered, but rarely is necessary.

Pre- or postoperative ovarian suppression is not used for therapy as little endometriosis gland or stromal reduction occurs.(Metzger et al. 1988) In our clinical experience, depoleuprolide and danazol therapy rarely result in long term pain relief when ovarian endometrioma and/or deep fibrotic endometriosis exist and may make surgical procedures more difficult and less effective. After suppression is discontinued, endometriotic foci become reactivated to their original state. I prefer using low dose oral contraceptives in rare selected cases as they are equivalent to GnRH agonists and much less expensive.

The patient is optimized medically for coexistent problems. Patients are encouraged to hydrate and eat lightly for 24 hours prior to admission on the day of surgery. When extensive cul-de-sac involvement with endometriosis is suspected preoperatively, either because of clinical presentation or from another doctor's operative record, a mechanical bowel preparation, (polyethylene glycol-based isosmotic solution: GoLYTELY [Braintree Labs, Braintree, MA] or Colyte [Reed Carnick, Jersey City, NJ]), 1 gallon, is administered orally the afternoon before surgery, to induce a brisk self-limiting diarrhea that rapidly cleanses the bowel without disruption of electrolyte balance. In less severe cases, magnesium citrate and a Fleet's enema are administered routinely the evening before surgery to evacuate the lower bowel. Neomycin base, 1 gm, and erythromycin base, 1 gm, oral antibiotics are given in high risk cases in 3 doses; the last dose is given 8 hr. or less prior to the surgery. Intravenous antibiotics, usually cefoxitin 2 gm or cefotetan 2 gm, are administered before surgery in all cases. Lower abdominal, pubic, and perineal hair is not shaved. A Foley catheter is inserted during surgery when bladder filling is noted and is removed, along with the IV, when the patient is awake and aware of it, usually in the recovery room.

Positioning of the Patient
All laparoscopic procedures for extensive disease are done using general endotracheal anesthesia with orogastric tube suction to minimize bowel distention. Prior to induction of anesthesia, bilateral ulnar pads (Zimfoam: laminectomy arm cradle set: Zimmer, Warsaw, Indiana) are applied and both arms tucked at the side, the right on a padded arm board. Straight shoulder braces at right angles to the table are placed over the acromio-clavicular joint, and the legs are placed in lithotomy position with the hips extended (thigh parallel to abdomen) using Allen stirrups (Edgewater Medical Systems, Mayfield Heights, OH) or knee braces, that are adjusted to the individual patient by the nursing staff before she is anesthetized.

The patient is flat (0o) until after the umbilical trocar sleeve is in place; then the patient is placed in a steep Trendelenburg's position (20o -30o). Anesthesia examination is done before prepping the patient. A Foley catheter is inserted during surgery when the bladder becomes distended.

Incisions
Three laparoscopic puncture sites including the umbilicus are used: 10 mm umbilical, 5 mm right, and 5 mm left lower quadrant. I stand on the left side of the patient and use my dominant right hand to hold, manipulate, and focus the camera. My laparoscopic puncture sites have not evolved over the past 20 years as I do not feel that more and larger trocar sleeve incisions, used by many surgeons today, represent progress. The left lower quadrant puncture is the major portal for operative manipulation. The right trocar sleeve is used for retraction with atraumatic grasping forceps. Large masses are removed through the upper posterior vagina.

The intraumbilical incision overlies the area where skin, deep fascia, and parietal peritoneum of the anterior abdominal wall meet in the thinnest part of the abdominal wall, permitting less applied insertion force and little opportunity for the parietal peritoneum to tent away from the Veress needle and primary trocar. This vertical midline incision initially is made with a #15 blade (never a #11) on the inferior wall of the umbilical fossa extending to and just beyond its bottom. In thin patients, frequently this incision traverses the deep fascia, but intraperitoneal injury is avoided by using the thumb to pull the umbilicus onto the surgeon's forefinger, a maneuver which controls the incision's depth. After CO2 insufflation through a Veress needle to an intra-abdominal pressure of 25-mm Hg, the trocar is seated vertically just inside the skin in the fascial dimple stuck to peritoneum. It is not necessary to lift the anterior abdominal wall during trocar insertion after establishment of a 4-6 L pneumoperitoneum at 25 mm Hg, because the parietal peritoneum and skin move as one. The palmed Apple trocar is positioned in the incision with moderate pressure against the peritoneum at a 90o angle and is upturned to approximately 45o in one continuous thrusting motion by wrist rotation. The result is a parietal peritoneal puncture directly beneath the umbilicus. The high pressure setting used during initial trocar insertion then is lowered to 10 to 15 mm Hg intra-abdominal pressure to diminish the development of vena caval compression and subcutaneous emphysema during long laparoscopic procedures. A 10-mm laparoscope is inserted and the procedure is viewed on a videomonitor.

After reducing the intra-abdominal pressure to 15-mm Hg, the lower quadrant trocar sleeves are placed above the pubic hairline and lateral to the rectus abdominus muscle located by direct laparoscopic inspection of the anterior abdominal wall. When the anterior abdominal wall parietal peritoneum is thickened from previous surgery or obesity, the position of the muscle is judged by palpating and depressing the anterior abdominal wall with the back of the scalpel; the wall appears thicker where rectus muscle is enclosed. The incision made with a #11 blade should be lateral to this area near the anterior superior iliac spine. The lateral trocar sleeves always must be placed above or lateral to the uterine fundus.

Peritoneal Implants
Superficial fibrotic or hemorrhagic peritoneal endometriosis is treated by excising the endometriosis implant and its adjacent peritoneum. Brown hemosiderin deposits on the peritoneal surface are not endometriosis and can be peeled away with irrigation. Scissors, a CO2 laser beam at 20-30 W Surgipulse or ultrapulse, or unipolar cutting current are used. Scissors with microbipolar electrosurgical backup is the technique of choice as peritoneum rarely bleeds Unipolar cutting current is used rarely today, except when the vesicouterine peritoneal fold is stuck to the anterior uterus. An elliptical incision is made in normal peritoneum surrounding the fibrotic portion of the lesion, its edge lifted upward, and the lesion undermined using scissors or the hydraulic effect of pressurized irrigant from a suction-irrigation-dissection device (aquadissector) to push the fibrotic endometriosis from underlying pelvic sidewall, rectum, or bladder. This makes undercutting of the lesion with scissors, electrosurgery, or laser easy and safe. Scissors, electrosurgery, or laser are used to divide fibrotic adherences. Microbipolar forceps coagulate small bleeders. After peritoneal excision, the ureter, anterior rectal wall, and upper posterior vagina are inspected and superficial endometriosis in these areas excised or vaporized. The uterus, tube, and ovary do not have loose peritoneum, and implants on these surfaces should be ablated directly or excised.

Small pinpoint lesions can be vaporized using the CO2 laser or unipolar cutting-current electrosurgery with resultant drainage of hemosiderin-filled fluid in cases where deposits have progressed to just beneath the peritoneum. The base of the lesion is then vaporized until normal tissue is seen.

Endometriomas
Preoperatively, transvaginal sonography is done to evaluate the ovaries in cases involving a pelvic mass, retrocervical nodules, or fibroids, and a CA 125 assay is obtained if persistent enlargement is documented. Ultrasound findings of a round shaped adnexal mass with thick wall and homogeneous, low level echo pattern is highly suggestive of endometrioma. Another pattern has irregular margins with septations and an anechoic appearance. Intravenous pyelograms (IVP) are rarely necessary preoperatively, as ureteral dilation is readily evident at laparoscopic examination. An IVP is ordered postoperatively if abdominal pain persists after surgery on or near the ureter. Presently, there is no indication for CT scan or MRI prior to laparoscopic ovarian surgery.

In all cases careful inspection of the abdomen and pelvis is done. The ovaries are evaluated for visual evidence of malignancy. Washings are taken if indicated. Endometriomas are drained by mobilizing them from the pelvic sidewall.

Enlarged ovaries containing cysts are either free in the peritoneal cavity or attached to the pelvic sidewall, uterosacral ligament, or cul-de-sac. If attached to these structures, the cyst is frequently an endometrioma. An aquadissector is used to mobilize the ovaries by lifting them from the pelvic sidewall. Often this maneuver will result in drainage of chocolate-like hemosiderin filled fluid from the undersurface of the ovary. After this occurs, the ovary is completely mobilized from the pelvic sidewall to its hilum using aquadissection and careful blunt dissection to reduce pelvic sidewall peritoneal damage. If no endometrioma is readily identified, and the patient has "unexplained infertility" or pre- or postmenstrual spotting, a knife electrode connected to monopolar cutting current (70 W) is used to incise and drain areas on the ovary with superficial endometriosis and cysts suspicious for endometrioma. The clinical distinction between an endometrioma (pathology to be excised) and a corpus luteum cyst (normal, vascular tissue best left alone) may be difficult, and conservative discretion is advised to avoid the trauma and risk of removing normal tissue. An endometrioma has a thick white fibrotic capsule while a corpus luteum cyst capsule is yellow.

If an endometrioma is discovered by either of these two methods, the cyst cavity is rinsed with lactated Ringer's solution and then excised using 5 mm biopsy forceps, grasping forceps, and sometimes scissors (Semm, Mettler 1980)(Reich, McGlynn 1986). Experience has proven that drainage is not enough. Ovarian endometriomas up to 15 cm are excised. The cyst wall is most firmly attached to the ovarian cortex in the area of cyst rupture during mobilization, i.e., the portion that was adhered to the pelvic sidewall or uterosacral ligament, and not to the portion near the ovarian hilum. To help create an initial plane between normal ovarian cortex and endometrioma cyst wall, cutting current (70 W) through a knife electrode tip is applied at the cyst wall-cortex junction to develop a dissection plane in this firmly attached area. This step is particularly useful near the utero-ovarian ligament as rough avulsion can lead to excessive bleeding. The laparoscope is brought close to the area of dissection, magnifying it to identify the cyst wall clearly. This incision is extended through the visible 360o opening if possible. The cutting current will destroy endometriosis at the ovarian cortex-endometrioma junction while making a divot of separation between the two structures. Thereafter, biopsy or grasping forceps are placed to stabilize the ovarian cortex and endometrioma cyst wall while traction is exerted on the endometrioma cyst wall to peel it from inside the ovary. If the cyst wall is felt to be incompletely excised, the cyst cavity can be desiccated or fulgurated to destroy any remaining endometrioma. Otherwise, the endometrioma may recur. Excision can be done with minimal bleeding from the cyst wall bed and the ovarian wall edges usually reapproximate quite well, though occasionally extracorporeal suturing is required, especially after removal of large endometriomas. Hemostasis is checked by underwater examination inside the ovary, and individual bleeders are identified using irrigation through an irrigating channel and coagulated with microbipolar forceps. When removal results in a large, asymmetrical defect, the ovary is suture repaired, usually with one purse-string absorbable suture, applied close to the utero-ovarian ligament in one direction and the infundibulopelvic ligament in the other. Although suturing is not thought to be necessary for reapproximation by many surgeons, anyone who has operated on many of these women realizes that the open ovary is very receptive to small and large bowel; I suspect that those who preach that all ovaries should not be suture repaired are not comfortable with suturing techniques.

In most cases of ovarian endometrioma, endometriosis of the pelvic sidewall and/or uterosacral ligament is present. These lesions should be excised after enucleation of the endometrioma to prevent recurrence. Pelvic sidewall endometriosis peritoneal excision usually requires ureterolysis to free the underlying ureter from the lesion.

Oophorectomy can also be considered for pain or mass arising from ovarian endometrioma in women not desiring future fertility. This is especially indicated for left pelvic pain if the left ovary is enmeshed in rectosigmoid adhesions because they tend to recur.

Before removal, the ovary is released from all pelvic sidewall and bowel adhesions. It is imperative that the surgeon visualize the course of the ureter. The peritoneum above the ureter is opened with sharp scissors. Smooth grasping forceps are then opened parallel and perpendicular to the retroperitoneal structures until the ureter is identified. Scissors can be used to further dissect the ureter throughout its course along the pelvic sidewall.

The uterus is anteverted and displaced to the contralateral side. The fallopian tube is grasped and pulled medially to stretch out the infundibulopelvic ligament containing the ovarian vessels. The anterior and posterior leaves of the broad ligament are opened with scissors lateral and medial to the infundibulopelvic ligament and a free ligature (2-0 Vicryl) passed through the window thus created and tied extracorporeally using the Clarke-Reich knotpusher. This is repeated twice until two proximal ties and one distal one are placed, and the ligament then divided. While applying traction to the cut distal pedicle, the broad ligament is divided to the round ligament just lateral to the uteroovarian artery anastomosis using cutting current through a spoon electrode. Two free ligatures are placed around the uteroovarian ligament which is then divided.

Alternatively, Kleppinger bipolar forceps are used to compress and desiccate the infundibulopelvic ligament, the broad ligament, the fallopian tube isthmus, and the utero-ovarian ligament with bipolar cutting current (25-35 W). In most cases, 3 contiguous areas are desiccated. Laparoscopic scissors are used to divide the pedicle. (Reich H, 1987)

The free ovary is removed through the umbilicus or cul-de-sac. Large endometriomas are usually sufficiently cystic and pliable that, once separated from the pelvic sidewall, they can be removed through the umbilical incision.

When the ovary is retroperitoneal, embedded in the pelvic sidewall, a lateral approach is advocated. The peritoneum lateral to the ovary and the infundibulopelvic ligament where it crosses the iliac vessels is incised with dissecting scissors and the broad ligament opened by bluntly separating the extraperitoneal areolar tissues. The peritoneal incision is extended to the round ligament, lateral to the infundibulopelvic ligament. The infundibulopelvic ligament is pulled medially with grasping forceps to expose the ureter at the pelvic brim where it crosses the common or external iliac artery. It may be necessary to reflect the ureter off the medial leaf of the broad ligament for a short distance to aid in its identification, although this is not always required. The infundibulopelvic ligament is ligated, divided, and its distal cut end put on traction with traumatic grasping forceps for the rest of the oophorectomy. The medial leaf of the broad ligament with its contained ovary is freed from the pelvic sidewall vessels and areolar tissue. The ureter is peeled off the retroperitoneal ovary for most of its pelvic course until the uteroovarian ligament can be isolated and divided.

Extensive Endometriosis
In contrast to mild endometriosis, laparoscopy is often not necessary to diagnose endometriosis of the deep cul-de-sac. It is usually diagnosed by clinical examination. Laparoscopy is then used to treat it. These patients should not be subjected to diagnostic laparoscopy, but should be referred to surgeons capable of treating rectal endometriosis.

Treatment options for pain or infertility secondary to extensive endometriosis include ovarian suppressive therapy with oral contraceptives, danazol, or gonadotropin releasing hormone agonists, or surgery. For infertility or pain in women desiring preservation of fertility, reconstructive surgery can be considered either by laparoscopy or, less effectively, by laparotomy microsurgery, depending on the skill and experience of the surgeon. At laparotomy, the deep fibrotic retrocervical lesion is mobilized, starting on the posterior uterus and progressing downward to the rectum where it appears to be attached; in these cases, the endometriosis may be managed by bowel resection, assuming that the major portion of the lesion infiltrates the anterior rectum.(Gray, LA 1973) For pain, when future fertility is not desired, hysterectomy with bilateral salpingo-oophorectomy is commonly performed. A problem with this approach is that the hysterectomy is often done with an intrafascial technique, leaving fibrotic endometriosis on the vagina and rectum, assuming that it will resolve following castration; future surgical procedures may be necessary for pain from vaginal cuff or rectal endometriosis.

The major indication for laparoscopic treatment of extensive endometriosis is pelvic pain and/or infertility from deep fibrotic endometriosis causing partial or complete cul-de-sac obliteration.(Reich et al. 1991 b) Less frequently encountered symptoms include hypermenorrhea and asymptomatic pelvic mass. The diagnosis is confirmed either at a primary laparoscopic procedure or is known from another surgeon's operative report. Unfortunately, this diagnosis is sometimes missed at diagnostic laparoscopy, if the surgeon looks for blue-brown lesions instead of white fibrotic ones. Symptomatic endometriosis glands are always associated with and surrounded by some degree of fibrosis caused by repetitive long-standing inflammation. The index of suspicion for cul-de-sac or bowel endometriosis should be high when the patient reports deep dyspareunia, pain radiating into the back or leg, pain with bowel movements, tenesmus or rectal bleeding with menses.

The goal of laparoscopic treatment of extensive endometriosis is to excise all visible and palpable endometriosis and to restore normal anatomic relationships. Benefits to the patient include significant symptom relief and resolution of infertility in many cases, circumvention of major abdominal surgery with its related morbidity, and avoidance of the hypoestrogen effects of ovarian suppression therapy, which prohibits fertility during its administration and never eradicates deep infiltrating endometriosis. The laparoscopic approach can be lengthy, and the persistent nature of the disease may dictate more than one application. Therefore, significant determining factors in achieving the desired outcome may be a combination of surgical skill and tenacity and patient persistence.

DIAGNOSIS

Rectovaginal exam is diagnostic when deep cul-de-sac and recto-vaginal septum nodularity can be palpated and specific tenderness in these nodules elicited. Unfortunately, most gynecologists routinely avoid rectal examination. On occasion endometriosis is visualized by speculum examination penetrating the full thickness of the vagina posterior to the cervix. Preoperative tissue biopsy of a vaginal or rectal lesion is rarely diagnostic.

The rectum and vagina are readily accessible, and their clinical examination should be the mainstay of diagnosis. Cul-de-sac nodularity is pathognomonic of endometriosis. This nodularity is caused by endometriosis infiltrating inside the uterosacral ligaments near their insertion and by endometriosis in the angle made by rectum and vagina or by vagina and cervix. A rectovaginal examination should be done routinely in patients with pelvic pain and/or past history of endometriosis despite patient discomfort. Prior explanation does much to limit embarrassment with resultant spasm of the anterior abdominal wall, anal sphincter and buttocks, especially a warning that they may feel that they're losing control of their continence during the examination, though this is unlikely. The patient is asked to strain down as if defecating. The gloved lubricated middle finger is placed at the anus and the index finger at the vagina. Gentle pressure is applied until the sphincter yields and the finger eases into the anus. The cervix is put on upward tension using the index finger in the vagina and the middle finger palpates the uterosacral ligaments including their insertion and the junction of vagina with cervix. If nodules are discovered, their mobility from the surrounding tissues is assessed, especially the degree to which the rectum is tented to the lesion. The withdrawn finger is inspected for blood.

Cul-de-sac Obliteration
In 1921, Sampson defined cul-de-sac obliteration as "extensive adhesions in the cul-de-sac obliterating its lower portion and uniting the cervix or the lower portion of the uterus to the rectum; with adenoma of the endometrial type invading the cervical and the uterine tissues and probably also (but to a lesser degree) the anterior wall of the rectum." Cul-de-sac obliteration secondary to endometriosis implies the presence of retrocervical deep fibrotic endometriosis beneath the peritoneum. This endometriosis is located on or in the anterior rectum, posterior vagina, posterior cervix (the cervical vaginal angle between the upper vagina and the cervix), the rectovaginal septum, or the uterosacral ligaments; often one area predominates.

Partial cul-de-sac obliteration (PCDSO) means that deep fibrotic endometriosis is severe enough to alter the course of the rectum, fusing it to a portion of posterior vagina. With complete cul-de-sac obliteration (CCDSO), fibrotic endometriosis and/or adhesions involve the entire cul-de-sac between the cervicovaginal junction (and sometimes above) and the rectum.

At laparoscopy, careful inspection of the cul-de-sac is necessary to evaluate the extent of upward tenting of the rectum. To determine if cul-de-sac obliteration is partial or complete, a sponge on a ring forceps is inserted into the posterior vaginal fornix (and a rectal probe in the rectum). The Normal cul-de-sac will show a portion of vaginal wall between the cervix and rectum as a distinct and separate bulge. The utero-sacral ligaments will be of normal caliber and lateral. Partial cul-de-sac obliteration occurs when rectal tenting is visible but a protrusion from the sponge in the posterior vaginal fornix is noted between the rectum and the inverted "U" of the uterosacral ligaments. Complete cul-de-sac obliteration is diagnosed when the outline of the posterior fornix cannot be visualized initially through the laparoscope: the rectum or fibrotic endometriosis nodules completely obscure the identification of the deep cul-de-sac.

Surgical Technique
Deep fibrotic nodular endometriosis involving the cul-de-sac requires excision of nodular fibrotic tissue from the uterosacral ligaments, posterior cervix, posterior vagina, and the anterior rectum; less commonly, the sigmoid colon and lateral rectum are involved. (Reich et al. 1991 b)

A combination of scissors, Surgipulse(400 millijoules) or Ultrapulse (200 millijoules) CO2 laser, electrosurgery with knife or spatula electrodes, and aquadissection is used for dissection. Straight blunt tipped scissors have the advantage of supplying both tactile sensation and a crunch-like feeling when cutting across fibrotic endometriosis or cutting at the junction of hard fibrosis with soft normal tissue. If available, a Valtchev uterine mobilizer (Conkin Surgical Instruments, Toronto, Ontario, Canada) is the best available instrument to antevert the uterus and delineate the posterior vagina throughout complicated cases. For complete cul-de-sac obliteration dissection, a sponge on a ring forceps is inserted into the posterior vaginal fornix and a #81 French rectal probe (Reznik Instruments, Skokie, IL) is placed in the rectum to define the rectum and posterior vagina.

The patient is placed in steep Trendelenburg position to allow the small intestines to fall out of the pelvis. Attention is first directed to dissection of the anterior rectum from the posterior vagina throughout its area of attachment until loose areolar tissue in the rectovaginal space is reached. This technique leaves the bulk of the lesion to be excised on the posterior vagina, including some that was originally more closely associated with the rectum. Using the rectal probe as a guide to rectal location, the rectal serosa is opened at its junction with the cul-de-sac lesion with CO2 laser or scissors. Careful sharp and blunt dissection then ensues until the rectum, normal or with contained fibrotic endometriosis, is separated from the posterior uterus, cervix, and upper vagina, and rectum with surrounding loose areolar tissue is identifiable below the lesion. Blunt scissors are the main instrument used for blunt dissection. A suction irrigator without holes in the side of its distal tip is used for "blunt" aquadissection and suction-traction. Laser, electrosurgery, or scissors are used for sharp dissection. Excision of the fibrotic endometriosis from the posterior vagina, uterosacral ligaments, and rectum is attempted only after anterior rectal mobilization is completed.

The ureter lies lateral to most cul-de-sac lesions, especially when they are placed on medial traction. With the uterosacral ligament pulled medially, there is very little risk of ureteral damage. When a ureter is close to the lesion, its course is traced starting at the pelvic brim, and when necessary, the peritoneum overlying the ureter is opened to confirm ureteral position deep in the pelvis. Uterosacral fibrotic endometriosis may envelop the ureter, necessitating its dissection and excision. Microbipolar forceps with irrigation between the tips are used to control arterial and venous bleeding.

Uterosacral ligaments infiltrated with endometriosis are removed early in the operation, sometimes before rectal mobilization. They frequently make up a large portion of a rectal nodule. Normal caliber ligament is identified on the pelvic sidewall, divided and put on traction. The peritoneum is incised on both sides of the ligament, and the thickened portion of the ligament is excised to and including its insertion into the cervix. Normal appearing, soft loose areolar tissue, adipose tissue, uterine vessels, and ureter are found beneath the ligament. Fibrotic tissue at the periphery of the excision is coagulated with an irrigating microelectrode, especially at the junction of cervix with uterine fundus. Rarely the ligament will be involved all the way to the sacrum. in these cases, it may be best to divide the ligament in its middle and keep traction on the sacral side of the ligament, pulling it away from rectum, ureter, and hypogastric vessels.

After separation of the rectum from the back of uterus and the upper posterior vagina, deep fibrotic, often nodular, endometriotic lesions are excised from the uterosacral ligaments, the upper posterior vagina, (the location of which is continually confirmed by the sponge in the posterior fornix), and the posterior cervix. The dissection of the fibrotic endometriosis from the thickened vaginal wall proceeds using traction with a biopsy forceps to pull the lesion from one side to the other; laser, aquadissection, electrosurgery, or scissors are used as needed. Usually an endopelvic rectovaginal fascial layer, infiltrated with endometriosis, is identified, and after this layer is excised, soft pliable upper posterior vaginal wall is uncovered. It is frequently difficult to accurately distinguish fibrotic endometriosis from fibromuscular tissue above the vagina at the cervicovaginal junction, as hypertrophied tissue without endometriosis is often found there between the insertion of the uterosacral ligaments into the cervix. The inverted "U" of this configuration should be excised. Frequent palpation using rectovaginal examinations helps identify occult lesions. On occasion, the lesion infiltrates deep into or completely penetrates the vaginal wall. Dissection is then performed accordingly with removal of all visible fibrotic endometriosis. Electrosurgery using cutting current through a blunt tipped or spoon electrode minimizes bleeding from the vascular vagina. Lesions extending totally through the vagina are treated with an "en bloc" laparoscopic resection of fibrotic tissue and vagina from cul-de-sac to posterior vaginal wall; pneumoperitoneum is maintained with a sponge or 30-cc Foley catheter in the vagina or by holding the labia together. The posterior vaginal wall defect is closed laparoscopically using polyglactin 910 (Vicryl) (Ethicon, Somerville, New Jersey).

Bowel Surgery
Endometriosis of the rectum and/or rectosigmoid may be superficial (serosal or adventitial), muscular, or full thickness in the lamina propria of the mucosa; rarely the mucosal surface is broken. The lesions are anterior or lateral; posterior wall endometriosis is a rarity. Fibrotic endometriosis nodules infiltrating the anterior rectal wall may be focal (cicatrixal) or linear (a transverse bar often with associated stricture where the rectum is fused to the posterior vagina). Under the microscope all of these lesions, and those of the uterosacral ligaments, posterior vagina, and cervix, are made up of fibromuscular tissue surrounding endometriosis glands and characteristic stroma.

Women with suspected or documented extensive endometriosis are counseled preoperatively regarding risk of bowel injury, methods of possible treatment, and the impact of bowel perforation and resection on their hospital stay and postoperative recuperation. Traditionally, laparoscopic rectal injury has been treated with laparotomy closure, sometimes with colostomy. This approach, while necessary in some cases, is more stressful for the patient, both physically and emotionally as she must then endure the incisional surgery she had elected to avoid. Laparoscopic suture repair of the bowel is used for selected bowel injuries both planned and unplanned. Certainly the risk of unplanned rectal perforation is appreciated with any kind of intervention near the bowel, but is particularly threatening with excision of rectal endometriosis due to the fibrotic nature of the disease and related anatomical distortion.

The knowledge that bowel can be successfully repaired laparoscopically should increase the confidence of the surgeon operating in the deep pelvis. Acquiring experience in suture repair techniques is suggested for laparoscopists who perform extensive endometriosis surgery.

Once separated from the vagina, the rectum and rectosigmoid are examined carefully with a long rectal probe inside. Lesions are assessed to determine if they are superficial, deep, or nodular. Superficial lesions involving the serosa are excised by first making an elliptical incision around the white fibrotic lesion with a CO2 laser at low power, high energy (10 W), elevating the lesion with a micro-Adson forceps, and undermining it at its junction with soft normal-appearing circular muscularis.

Endometriotic nodules infiltrating the anterior rectal wall are excised, partially or totally, usually with the rectal probe or surgeon's or his assistant's finger in the rectum just beneath the lesion. Working with CO2 laser at the junction of nodular white fibrosis with yellow and pink soft normal tissue, the lesion is excised. Deep rectal muscularis defects are closed with suture. The 3-0 suture is applied using curved needles with an oblique curved needle driver, tied outside the peritoneal cavity, and pushed downward with the Clarke-Reich knot pusher. Enterotomies and full muscularis excisions are closed with suture or the circular stapler. The technique of reperitonealizing the anterior rectum by plicating the uterosacral ligaments and lateral rectal peritoneum across the midline has been abandoned to reduce rectal lumen constriction, especially as the uterosacral ligaments often contain deep endometriosis.

Nodules in the muscularis of the anterior or lateral rectum can usually be excised laparoscopically.(Reich et al. 1991-c) Full-thickness penetration of the rectum may occur during this surgery. Following identification of the rent in the rectum, usually surrounded by fibrotic endometriosis, a closed circular stapler [Proximate ILS Curved Intraluminal Stapler (Ethicon, Stealth)] is inserted into the lumen just past the hole, opened 1-2 cm, and held high to avoid the posterior rectal wall. The proximal anvil is positioned just beyond the hole which is invaginated into the opening and the device closed. Circumferential inspection is made to insure the absence of encroachment of nearby organs and posterior rectum in the staple line and the lack of tension in the anastomosis. The instrument is fired, then removed through the anus. The surgeon inspects the donut of tissue representing the excised hole contained in the circular stapler. Once verified, anastomotic inspection is done laparoscopically underwater after filling the rectum with indigo carmine solution.

Alternately, a double-layer transverse repair is performed using 3-0 silk or Vicryl. Stay sutures are placed at the transverse angles of the defect and brought out through the lower quadrant incisions; the trocar sleeves are then replaced into the peritoneal cavity over the stay sutures. The suture is tied either inside the peritoneal cavity with two laparoscopic needle holders or outside as previously described. Suturing is facilitated by use of short self-retaining trocar sleeves without traps (Wolf or Apple).

Full thickness or muscularis endometriotic nodules of the anterior or lateral rectum can also be resected laparoscopically without opening the rectum, especially if limited to a small circumscribed area. Following delineation of the nodule, the #29 or #33 French circular stapler (Proximate) is used as just described, and the lesion invaginated into its opening. This results in an anterior discoid resection of a wedge of anterior rectum with contained nodule and an anterior staple line.

The head of the circular stapler is passed transanally and advanced proximally. Proper stapler placement is essential. It's head must rest with the anvil portion wedged firmly against the distal stenotic border of the fibrotic endometriosis lesion. Once proper placement has been achieved, the body of the stapler is held firmly in place as the stapler is opened, advancing the anvil portion through the stenotic or endometriosis containing area. When the anvil has cleared the proximal border of the lesion, a "popping" sensation will be felt and the lesion can be visualized within the gap between the anvil and the staple cartridge. A 0 suture can be placed in the musculature anteriorly to fixate the lesion and is left long to push the lesion into the gap of the stapler. Even pressure is placed on both sides of the suture, pushing approximately one half of the bowel containing the lesion into the gap of the stapler. While maintaining this pressure, the stapler is closed, discharged, and subsequently withdrawn. The procedure has been properly performed if a half-moon wedge of bowel can be retrieved from the circular knife of the stapler. (similar to retrieving a doughnut after a circular stapled anastomosis). Patency at the anastomosis can be verified by passing a rectal dilator or probe past the anastomosis. Usually this technique achieves excision of the bulk of the endometriosis lesion anteriorly and produces a patulous outlet. The largest diameter stapler able to pass is used. The major advantages include ease of performance and minimal time for execution. The only complication has been one case of rectal stenosis requiring dilatation.

Strictures are often made up of appendices epiploica fused to fibrotic endometriosis implants on the sigmoid colon. Careful methodical dissection using a high energy pulsed laser to separate these fatty appendages and microbipolar forceps for hemostasis may alleviate the stricture. Pratt dilators ( from #43 to #55) are followed by rectal dilators (#25,#29, & #33). If a #29 or #33 circular stapler can be placed beyond the strictured area, the segment can be resected. Suture on a CTB-1 needle is placed through the sigmoid mesentery below the lesion and tied onto the anvil of the circular stapler, the stapler fired and removed, and the staple line inspected underwater with the large bowel filled with dilute indigo carmine solution.

Concerning the unprepared bowel, quick, staple or suture closure followed by profuse irrigation until the effluent clears is usually satisfactory.

Laparoscopic Low Anterior Resection
This operation is indicated for endometriosis that invades the wall of the rectum and causes pain that is refractory to medical therapy.(Redwine and Sharpe 1991) Anatomically, these lesions are usually located in the distal sigmoid colon and proximal two thirds of the rectum, i.e., lesions that are 7-8cm. proximal to the anal verge.

The proximal and distal extents of the resection are determined. Initially, the sigmoid mesocolon is mobilized. The surgeon must ensure the ability to perform a tension free anastomosis. If sigmoid colon redundancy is not adequate, the splenic flexure is mobilized first. This step is taken in order to avoid inadvertent splenic injury from traction on the splenocolic avascular ligament. The sigmoid colon is retracted medially. The lateral peritoneal reflection is incised, and the incision carried caudally to the level of the anterior peritoneal reflection (cul-de-sac). When the dissection arrives at the level of the iliac vessels, the surgeon locates the left ureter. The ability to visualize the ureter is necessary to prevent injury. The medial aspect of the sigmoid mesentery is incised down to the deep cul-de-sac in the right pararectal gutter. The rectosigmoid is then elevated towards the anterior abdominal wall with the rectal probe to expose the mesorectum and mesocolon. A window is made through the mesocolon to the left side. Careful attention is taken to avoid injury to the iliac vessels or the ureters. The dissection is directed cephalad, the encountered vessels are cauterized, clipped, or ligated, depending on size; vessels greater than 5mm are ligated. This dissection is taken to the level of the descending colon. The mesorectum is then dissected in a similar manner to the level of the levator ani complex if necessary. In the case of endometriosis, a 1 cm margin is adequate.

The decision to perform an intracorporeal or extracorporeal rectosigmoid anastomosis depends on the surgeons' preference, training, and laparoscopic skill level. For the intracorporeal anastomosis, the proximal colon is divided first. Prior to this division, a noncrushing endoclamp or an umbilical tape that is tied only enough to occlude the proximal lumen is applied. The colon is transsected with scissors, electrosurgery, laser or stapler, depending on the surgeon's preference. After division of the distal margin, the specimen is removed through the anus with the aid of a sponge forceps, or through the vagina which is then repaired after specimen retrieval. If staples were used for transection, the distal staple line is removed along with any excess tissue that may interfere with the anastomosis. A circular stapler is introduced through the rectal stump, and its anvil is advanced towards the proximal bowel. (Ravitch et al. 1974) A chromic Endoloop is inserted circumferentially around the extended anvil shaft and distal bowel. An Endoloop is then inserted around the proximal stump to closed it around the anvil. The proximal staple line is resected if present. The anvil is directed through the lumen with the aid of laparoscopic instruments or with the circular stapler if possible. The Endoloop is then secured around the anvil shaft, and excess tissue is resected. If separated, the anvil shaft is laparoscopically guided to its female counterpart. The edges of the colon and rectum are aligned and approximated. Circumferential inspection is made to insure the absence of encroachment of nearby organs in the staple line, and the lack of tension in the anastomosis. The instrument is fired and then removed through the anus. The surgeon must inspect to insure that two complete rings of tissue are contained in the circular stapler. Once verified, the soundness of the anastomosis is confirmed colonoscopically or by rectal enema containing dilute indigo carmine. Also, air may be used to distend the rectum and its anastomotic site, which are inspected laparoscopically underwater with the pelvis filled with 1 to 2 liters of warmed saline solution or sterile water; the surgeon then inspects for air bubbles. When enemas are used one can inspect with or without water.

Laparoscopically assisted transvaginal segmental colon resection for endometriosis has been described.(Redwine) The affected sigmoid colon is mobilized, delivered through a culdotomy, and resected and anastomosed.

Postoperative. Bowel function returns after an average of 24 to 30hrs. Upon passage of flatus or a bowel movement, the patient is started on a diet as tolerated. Usually. the patient starts liquids in the a.m. of the first post operative day and advanced to solids in the p.m. if the a.m. diet was well tolerated. For nausea, Droperidol is used: 1/2 cc IV, repeated one time in 15 m if not effective.

TRANSANAL RESECTION OF ENDOMETRIOSIS
A transrectal approach can be used to resect fibrotic nodular endometriosis in the anterior rectal wall submucosa if located beneath the peritoneal reflection near the level of the midrectum.

The endometrioma is palpated on rectal exam if located submucosally on the anterior wall within 5 cm of the anal verge, just above the levators. The anus is gently dilated manually, a rectal retractor is inserted and placed in the posterior aspect of the rectum, thereby exposing the lesion. The mass can then be grasped with a tenaculum or Allis clamp, and gently retracted distally. A chromic 00 catgut suture is placed 1cm. proximal to the mass, to help with retraction and proper orientation. The mucosa is incised longitudinally, the endometrioma came into view it was resected using a mixture of blunt dissection and electrocautery. The area is inspected for hemostasis. The rectal wall defect is closed transversely with a single continuous layer of 3-0 Vicryl through the mucosa and the muscularis.

SMALL BOWEL ENDOMETRIOSIS

Small bowel endometriosis usually involves the terminal ileum. In some cases, it can be treated with CO2 laser vaporization at low power settings. Small bowel injuries can be sutured repaired as previously described.

Small bowel endometriosis with fibrosis or stricture may require mobilization from above, delivery through the umbilicus by extending the incision 1 cm, and resection as the stenosis frequently involves the small bowel mesentery. Alternately, if the lesion is confined to the antimesenteric portion, it can be excised and the bowel closed with interrupted 3-0 silk tied either externally or with intracorporeal instrument ties. Sterile milk or dilute indigo carmine is instilled into the bowel lumen prior to the closing of the last suture to assure the absence of leakage from the defect and to detect occult perforations near the small bowel mesentery. All enterotomies are suture repaired transversely to reduce the risk of stricture. If the endometriosis or stricture involves greater than 50% of the bowel circumference, resection is done. An extracorporeal segmental enterectomy with stapled anastomosis is preferred. The umbilical incision is enlarged to approximately 2.5 cm to permit extrusion and repair of the involved bowel. Using a GIA 60 fired twice, a segmental enterectomy encompassing the lesions is done. The involved mesentery is serially clamped, divided, and ligated with Vicryl 3-0. A functional side-to-side ileoileal anastomosis is constructed with the GIA-60 and a TA 35 used to close the antimesenteric opening. Patency is insured by palpation to assess proper luminal diameter equal to or greater than 2.5 cm; absence of leakage is confirmed by milking succus entericus through the anastomotic site. The bowel is then returned to the abdominal cavity. Pneumoperitoneum is reestablished, and laparoscopic inspection of the anastomosis should reveal no leakage.

UNDERWATER EXAMINATION

At the close of each operation, complete hemostasis is documented by using an underwater examination to detect bleeding from vessels and viscera tamponaded during the procedure by the increased intraperitoneal pressure of the CO2 pneumoperitoneum. The CO2 pneumoperitoneum is displaced with 2-5 L of Ringer's lactate solution, and the peritoneal cavity is vigorously irrigated and suctioned with this solution until the effluent is clear of blood products, usually after 10-20 L. Underwater inspection of the pelvis is performed to detect any further bleeding which is controlled using microbipolar forceps with irrigant pushed through its cleaning channel by the Marlow Pump Vac Plus to coagulate through the electrolyte solution. A final copious lavage with Ringer's lactate solution is undertaken and all clot directly aspirated. At least two L of Ringer's lactate solution are left in the abdomen to separate raw surfaces during early healing, eliminate the pneumoperitoneum, and dilute the peritoneal cavity bacterial count, especially after bowel resection or hysterectomy; this may decrease postoperative infection, further decreasing postoperative hospitalization and recovery time. No other antiadhesive agents are employed.

HYSTERECTOMY
The goal at laparoscopic hysterectomy for endometriosis is the same as in any endometriosis surgery, i.e., to excise all visible and palpable endometriosis implants. The rectovaginal area can be particularly symptomatic and requires careful evaluation and meticulous, systematic excision.

Excision of endometriosis with uterine preservation after pelvic reconstruction is always possible. Hysterectomy should be reserved for women who do not desire fertility preservation. They require extensive counseling regarding alternatives and may select hysterectomy as their primary procedure if they have persistent or recurrent symptomatology after other surgeries, especially when uterine adenomyosis is suspected. Concomitant oophorectomy is elective. If one ovary is diseased, especially if it is on the left, removal is considered as this ovary frequently becomes adherent to the bowel.

Hysterectomy should not be done for stage IV endometriosis with extensive cul-de-sac involvement, unless the surgeon has the skill and time to resect all deep fibrotic endometriosis from the posterior vagina, uterosacral ligaments, and anterior rectum. In these patients, excision of the uterus using an intrafascial technique leaves the deep fibrotic endometriosis behind to cause future problems. Furthermore, it becomes much more difficult to remove deep fibrotic endometriosis when there is no uterus between the anterior rectum and the bladder. After hysterectomy, the endometriosis left in the anterior rectum and vaginal cuff frequently becomes densely adherent to, or invades into, the bladder and one or both ureters. In many patients with stage IV endometriosis and extensive cul-de-sac obliteration, it is preferable to preserve the uterus and prevent future vaginal cuff, bladder, and ureteral problems. (Reich H et al. 1991-b) Obviously, this approach will not be effective when uterine adenomyosis is present. In these cases, after excision of cul-de-sac endometriosis, persistent pain will ultimately require a hysterectomy. Oophorectomy is not usually necessary at hysterectomy for advanced endometriosis, if the endometriosis is carefully removed. Reoperation for recurrent symptoms is necessary in less than 5% of my patients in whom one or both ovaries have been preserved. Bilateral oophorectomy is rarely indicated in women under age 40 undergoing hysterectomy for endometriosis.

In cases of severe endometriosis with cul-de-sac obliteration, the surgeon must first free the ovaries, then the ureters, and finally the rectum from the posterior vagina to the rectovaginal septum. As previously described,deep fibrotic nodular endometriosis involving the cul-de-sac requires excision of the fibrotic tissue from the uterosacral ligaments, posterior cervix, posterior vagina, and the rectum. The most severely affected ovary may be removed, especially if it is on the left. Hysterectomy with excision of all visible endometriosis usually results in relief of the patient's pain.

POSTOPERATIVE CONSIDERATIONS
Postoperatively, the vaginal cuff is checked for granulation tissue between six and 12 weeks, as sutures are usually absorbed by then and healing should be complete. Routine checks at 1-4 weeks are usually not indicated as a pelvic examination could impede healing. Examinations usually within 1 week are indicated for pain, pressure, or pyrexia. Patients usually experience some fatigue and discomfort for approximately 2-4 weeks after the operation, but may perform gentle exercise such as walking and return to routine activities between two and six weeks. Sexual activity may be resumed when the vaginal incision has healed, usually after six weeks.

Deep Fibrotic Endometriosis of Vaginal Cuff Post-Hysterectomy
Excision of these lesions is often more difficult than when a uterus is present. In this author's experience, fibrotic vaginal cuff lesions invariably involve one or both ureters and the base of the bladder. Careful dissection is necessary to free both bladder anteriorly and rectum posteriorly from the vaginal apex. Thereafter, the course of each ureter should be traced but not skeletonized. After this anatomy is identified, full thickness excision of the vaginal cuff including the nodular areas usually results in relief of the patient's pain and/or bleeding.

CONCLUSION
The goal of laparoscopic treatment of extensive endometriosis is to excise all visible and palpable endometriosis and to restore normal anatomic relationships. Benefits to the patient are obvious (but not to many practising physicians)!

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