Excision technique- Bucharest Endometriosis Centre
Preoperative patient preparation is required, consisting of a light diet a few days before surgery and a bowel prep the day before surgery.
Endometriosis surgery is one of the most complex laparoscopic procedures, requiring meticulous exposure and dissection of the abdominal and pelvic organs. Therefore, it is necessary to use at least four trocars: a trocar placed at the level of the navel through which a laparoscope is inserted and, three trocars operators placed at both iliac (right, left) and the suprapubic level. During operations for deep endometriosis, the patient is placed on the operating table in ‘lithotomy position’ (gynaecology position). This facilitates access to the vagina and rectum, something that is necessary for this type of intervention.
Creation of pneumoperitoneum (introduction of CO2 to inflate the abdominal cavity) and the placement of trocars vary depending on the location of the disease and experience and habits of each surgeon. At Bucharest Centre, pneumoperitoneum is done through a mini-incision of 1-2 mm located at the left subcostal level (Palmer point), which has a very low risk of intraoperative complications.
When endometriosis affects both the pelvic organs and the diaphragmatic peritoneum or liver surface, both trocars and patient position should be changed. After performing the pelvic surgical time, the surgeon’s position changes, s/he has to ‘work’ on the upper abdominal floor: peritoneal excisions, diaphragmatic excisions, liver resections (rare).
After a thorough inspection of the abdominal and pelvic cavities and trocars placements, recovering the pelvic anatomy, profoundly modified by endometriosis, the surgical intervention begins.
After the dissection of both ovaries on the pelvic peritoneum and, possibly, the drainage of the endometriomas, we carry out suspension of the ovaries to release the Pouch of Douglas. Later, we make the dissection of the rectum-uterine, recto-vaginal nodules, with the penetration into the normal recto-vaginal space that is below the level of the endometriosis lesion.
The uterine suspension is often necessary to facilitate the dissection of the rectum-vaginal space. We use this technique because in deep endometriosis surgery, at Bucharest Centre, we do not use the uterine manipulator; this facilitates access to the vaginal vault and highlights the degree of infiltration of the vaginal walls. Another important time is the dissection of the pararectal spaces and the highlighting of the hypogastric nerves, avoiding their damage.
When lesions are more profound, with infiltration of the parametric (lateral uterus) and paravaginal tissue, the dissection should be performed up to the level of the pelvic floor, the level of the obturator muscles. This type of endometriosis can compress or infiltrate nerve structures such as the obturator nerve or sciatic nerve.
Excision of pelvic endometriosis lesions can be performed with different surgical instruments such as scissors, monopolar hook, ultrasound dissector, LigaSure calliper, Laser dissector, depending on the dissected tissues and the experience of each surgeon. As an Endometriosis Centre with a multidisciplinary team, we practice extensive pelvic excision/resections (nodules, intestinal/bladder resections, diaphragmatic resections) with sutures of muscular defects, hepatic resections (when there is hepatic impairment), at the same time, to avoid multiple surgeries.