Advanced laparoscopic surgery for the removal of rectovaginal septum endometriotic or adenomyotic nodules.
; NISOLLE, Michelle
in Bailliere's Clinical Obstetrics & Gynaecology (1995), 9(4), 769-74
In the pelvis, three different forms of endometriosis (Donnez et al, 1992) must be considered: (1) peritoneal, (2) ovarian, (3) rectovaginal septum. By evaluation of the mitotic activity and the stromal ... [more ▼]
In the pelvis, three different forms of endometriosis (Donnez et al, 1992) must be considered: (1) peritoneal, (2) ovarian, (3) rectovaginal septum. By evaluation of the mitotic activity and the stromal vascularization, we have recently suggested (Nisolle et al, 1993) that peritoneal red lesions were the most aggressive form of the disease and progress to the so-called typical or black lesion, which must be considered as an enclosed implant surrounded by fibrosis. This type of infiltration must be clearly differentiated from the rectovaginal endometriotic nodule. Koninckx (1993) recently described three types of deep-infiltrating endometriosis: deep-infiltrating endometriosis of type I is a rather large lesion in the peritoneal cavity, infiltrating conically with the deeper parts becoming progressively smaller. It has been suggested that this type of endometriosis is caused by infiltration. In type II lesions, the main feature is that bowel is retracted over the lesion which thus becomes deeply situated in the rectovaginal septum although not actually infiltrating it. Type III lesions are the deepest and most severe. They are spherically shaped, situated deep in the rectovaginal septum, often only visible as a small typical lesion at laparoscopy or often not visible at all. This lesion is often more palpable than visible and is acutely tender if the patient is examined at the time of menstruation, and gives rise to severe dyspareunia. In our experience there are two different types of 'deep-infiltrating endometriosis': 1. True deep-infiltrating endometriosis caused by the invasion of a very active peritoneal lesion deep in the retroperitoneal space. In cases of lateral peritoneal invasion, uterosacral ligaments can be involved as well as the anterior wall of the rectosigmoid bowel junction resulting in a retraction, adhesions and secondary obliteration of the cul-de-sac. 2. Pseudo deep-infiltrating endometriosis or adenomyosis of the rectovaginal septum. This lesion originates from the rectovaginal septum tissue and consists essentially of smooth muscle with active glandular epithelium and scanty stroma. In our study, the rectovaginal nodule was histologically similar to an adenomyoma (Zaloudek and Norris, 1987). It was a circumscribed, nodular aggregate of smooth muscle, endometrial glands and endometrial stroma. As in the 'adenomyoma', secretory changes were frequently absent in 'endometriotic' rectovaginal nodules. The invasion of the muscle by a very active glandular epithelium, without stroma, proved that the stroma is not necessary for invasion in this particular type of pathology called adenomyosis. In some instances, it can be seen that the vaginal pluristratified epithelium was replaced by a glandular epithelium. The fact that ciliated cells were present and the co-expression of both vimentin and cytokeratin (Donnez and Nisolle, personal communication) proved the Mullerian origin of the nodule, where certain histological characteristics are completely different to those observed in peritoneal lesions (Nisolle et al, 1990). In our series, deep fibrotic tissue assumed to contain endometriosis was excised or vaporized from the anterior rectum with the aid of multiple rectovaginal examinations. Cul-de-sac dissection was followed by excision of deep fibrotic endometriosis, without cul-de-sac reconstruction. In three cases, the bowel lumen was entered. A comprehensive laparoscopic procedure, while not eradicating all the endometriosis, may result in considerable pain relief or a desired pregnancy. [less ▲]Detailed reference viewed: 5 (0 ULg)
Treatment of dysfunctional bleeding and fibroids by advanced endoscopic techniques with the Nd:YAG laser: from the present to the future.
; ; et al
in Bailliere's Clinical Obstetrics & Gynaecology (1995), 9(2), 329-45
Both the electrical current of the resectoscope and the energy of the Nd:YAG laser have been effective tools in the destruction of endometrial tissue to a sufficient depth to avoid regeneration. GnRH ... [more ▼]
Both the electrical current of the resectoscope and the energy of the Nd:YAG laser have been effective tools in the destruction of endometrial tissue to a sufficient depth to avoid regeneration. GnRH-agonist therapy effects a decrease in the total uterine cavity area which facilitates surgical treatment and reduces the risk of fluid overload syndrome. The recurrence rate of meno/metrorrhagia is higher when the uterine cavity is more than 10 cm2. The use of GnRH-agonists represents an adjunct for preoperative reduction of submucosal myomas so that subsequent hysteroscopic myomectomy is possible. A two-step hysteroscopic therapy combined with GnRH-agonist therapy is performed when the largest portion of the submucosal myoma is located in the uterine wall. In cases of numerous submucosal and intramural myomas, a laparoscopic supracervical hysterectomy is performed because of the high risk of recurrence after the hysteroscopic procedure. [less ▲]
Endoscopic management of ectopic pregnancy.
; NISOLLE, Michelle
in Bailliere's Clinical Obstetrics & Gynaecology (1994), 8(4), 707-2
The rationale for the conservative management of ectopic pregnancy is the preservation of reproductive potential. Removal of trophoblast through a linear incision (salpingotomy) can be easily performed by ... [more ▼]
The rationale for the conservative management of ectopic pregnancy is the preservation of reproductive potential. Removal of trophoblast through a linear incision (salpingotomy) can be easily performed by endoscopy. The injection of vasopressin into the broad ligament is required in less than 10% of cases and its routine use is not recommended because of the risk of severe side-effects. The techniques in cases of isthmic or cornual tubal pregnancy are also described. Other alternatives such as expectant management, methotrexate, RU 486 and prostaglandins have also recently been proposed. Although methotrexate therapy has been demonstrated to be effective in cases of unruptured tubal pregnancy, further studies are needed to determine whether or not this medical therapy is a safer option than laparoscopic surgery and to compare the subsequent intrauterine and recurrent ectopic pregnancy rates. Endoscopic salpingotomy is an efficacious procedure. Indeed, residual trophoblast is found in only 5% of cases after this surgical procedure. In these cases of persistent trophoblast, methotrexate is proposed as the medical approach of choice. Evaluation of the postoperative fertility after linear salpingotomy demonstrates an intrauterine pregnancy rate of 63% and a recurrent ectopic pregnancy rate of 8%. In conclusion, endoscopic management of tubal pregnancy is a safe and efficacious therapy. The contraindications are relative and depend essentially on the surgeon's experience. [less ▲]Detailed reference viewed: 4 (0 ULg)
CO2 laser laparoscopic surgery. Adhesiolysis, salpingostomy, laser uterine nerve ablation and tubal pregnancy
; NISOLLE, Michelle
in Bailliere's Clinical Obstetrics & Gynaecology (1989), 3(3), 525-43
Used endoscopically, the CO2 laser offers some advantages over other operative techniques for endometriosis and adhesions but, in spite of the continuing development of new instrumentation there are still ... [more ▼]
Used endoscopically, the CO2 laser offers some advantages over other operative techniques for endometriosis and adhesions but, in spite of the continuing development of new instrumentation there are still problems with the system. The technique needs specialized equipment requiring ongoing biomedical maintenance and specialized technical care in the operating room. Some problems such as the intraperitoneal accumulation of smoke, gas leakage, and difficulty with maintenance of proper beam alignment still occur. In spite of these problems the advantages are numerous: the system allows precise bloodless destruction of diseased tissue and eliminates the risks of cautery. In the hands of an experienced laparoscopist, it appears safe and effective in vaporization of endometriotic lesions, utero-sacral neurectomy, adhesiolysis and salpingostomy. The judicious use of these techniques, combined with carefully planned further investigations by well-trained and experienced laparoscopists and continuing improvements in the delivery systems, will soon reveal the true efficacy of the CO2 laser laparoscope. If studies continue to show pregnancy rates and pain relief to be equivalent to those patients treated by laparotomy, CO2 laser laparoscopy will become the preferred procedure for the management of pelvic endometriosis and its associated adhesions, distal tubal occlusion, pelvic pain and tubal pregnancy. With the exception of using the argon laser to treat endometriosis, the selective absorption characteristic of lasers has not been greatly utilized. While the CO2 laser is heavily absorbed by water and hence vaporizes most cells in a rather indiscriminate fashion, this is not true for other wavelengths, such as argon, Nd-YAG, KTP, krypton, xenon, copper and gold vapour lasers. The energy form of each of these lasers has different properties of penetration, absorption, reflection and heat dissipation. Many of these lasers have not yet been evaluated in human subjects. An exciting, although not new, area of possible laser application involves the use of photosensitizers and fluorescing agents (Dougherty et al, 1978). Some recent experimental studies (Schellhas and Schneider, 1986; Schneider et al, 1988) may lead to new therapeutic possibilities. The surgical laser is not, however, a panacea. Only controlled trials carried out carefully over the next few years will clearly define its potential. In the meantime it is incumbent upon all of us to investigate the clinical, gynaecological and surgical applications in a careful, methodical and scientific manner. [less ▲]Detailed reference viewed: 10 (0 ULg)