Publication:
Surgical Technology International XVI - Gynecology
Article title:
Abdominal Dermolipectomy in Laparotomy with Stoma Surgery: Case Report

Contents:

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Author(s)

Linda A. Lewis, M.D.
Postdoctoral Fellow

 

Camran Nezhat, M.D., F.A.C.O.G., F.A.C.S.
Clinical Professor of OB/GYN and Surgery


Center for Special Minimally Invasive Surgery
Stanford University Medical Center, Palo Alto, California, USA


Abstract
The most common site of extragenital endometriosis is the intestinal tract, which accounts for approximately 80% of all extragenital endometriosis. The symptoms of intestinal endometriosis are crampy pain, flatulence, painful tenesmus, hyper-peristalsis, progressive constipation, diarrhea alternating with constipation, and occasionally rectal bleeding. As endometriosis in this location often undergoes fibrotic changes, it can be resistant to hormonal therapy, which makes surgical therapy the only option for many women. Until recently, laparoscopic treatment of bowel endometriosis was thought to be impossible. Development of several safe and effective techniques for laparoscopic treatment of intestinal endometriosis has made such treatment possible. In this chapter, the authors describe five proven techniques for treatment of intestinal endometriosis: shaving, disk excision, anterior rectal wall excision, segmental resection, and appendectomy.

INTRODUCTION

 

Endometriosis is defined as the presence of endometrial-like tissue outside of the uterus. The ectopic endometrial tissue induces a chronic inflammatory reaction in the location of the endometriosis implant. Invasion of the endometriosis foci into surrounding tissue and the associated inflammation destroys tissue planes and is thought to be partially responsible for the symptoms associated with endometriosis.1 Endometriosis is a progressive disease that affects 10% to 15% of reproductive age women, and is second to leiomyomas in frequency of gynecologic disorders.2 Patients with endometriosis are often first seen with symptoms of pelvic pain, dysmenorrhea, and infertility, although some women with endometriosis are asymptomatic.
The surgical treatment of endo-metriosis should be individualized. The patient’s age, fertility plans, and quality-of-life issues must be taken into consideration when planning surgical treat- ment. Historically, treatment of endometriosis consisted of hysterectomy and bilateral salpingooophorectomy. After the 1960s, conservative management was introduced and became an option for some women.3 Conservative management consists of treatment of all endometriosis lesions while maintaining the reproductive organs. Although this management dose preserve fertility, recurrence and the need for subsequent treatment is a risk. Approximately 25% of patients who undergo conservative surgical management will require subsequent surgical treatment.4
The next revolution in treatment of endometriosis came with the introduction of video laparoscopy in 1986,5 and the recognition that adhesion formation is significantly less with laparoscopy compared to laparotomy.6,7 Before this realization, treatment of endometriosis, conservative or definitive, was done by way of laparotomy. Since laparoscopy minimizes adhesion formation and maximizes visualization of endometriotic lesions, patients treated thoroughly by laparoscopy have been shown to have better outcomes (pain, fertility, recovery time, and complication rates) than those treated by laparotomy.5,8-10
Before the introduction of laparoscopic treatment of endometriosis, bowel endometriosis lesions were treated minimally, given the potential complications and uncertainty of benefit. In the1990s, the first laparoscopic bowel resection for endometriosis was performed and subsequent studies have confirmed to be safe and effective to treat intestinal endometriosis laparo-scopically.10-13
In this chapter, the incidence, symptoms, and diagnosis of intestinal endo-metriosis are reviewed. Then, the four proven techniques for treatment of infiltrative bowel endometriosis are reviewed. Finally, outcome of treatment for infiltrative bowel endometriosis with respect to infertility and pain are discussed.