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Laparoscopic treatment of a deep endometriotic nodule in the ischiatic tuberosity
In this challenging surgery performed by Professor Arnaud Wattiez, we present the case of a 39-year-old woman suffering from deep infiltrating endometriosis and infertility with no previous surgeries. The patient presented with chronic pelvic pain, dyschezia, and dyspareunia. Preoperative workup included MRI and rectosigmoidoscopy. MRI revealed a nodule at the level of the right uterosacral ligament. Rectosigmoidoscopy revealed a bulging of the anterior rectal wall located at 6cm from the anal verge where biopsy revealed fibrosis. The patient’s physical examination demonstrated the presence of a retrouterine nodule at the site of the right uterosacral ligament measuring 3cm.
A Wattiez, R Fernandes, M Puga, J Alves, C Redondo Guisasola
Surgical intervention
6 years ago
2047 views
35 likes
0 comments
03:00
Laparoscopic treatment of a deep endometriotic nodule in the ischiatic tuberosity
In this challenging surgery performed by Professor Arnaud Wattiez, we present the case of a 39-year-old woman suffering from deep infiltrating endometriosis and infertility with no previous surgeries. The patient presented with chronic pelvic pain, dyschezia, and dyspareunia. Preoperative workup included MRI and rectosigmoidoscopy. MRI revealed a nodule at the level of the right uterosacral ligament. Rectosigmoidoscopy revealed a bulging of the anterior rectal wall located at 6cm from the anal verge where biopsy revealed fibrosis. The patient’s physical examination demonstrated the presence of a retrouterine nodule at the site of the right uterosacral ligament measuring 3cm.
Contemporary aspects on etiopathogenesis: strategies on diagnosis
This lecture addresses the etiopathogenesis of endometriosis, as defined by the presence of endometrial glands and stroma out of the uterine cavity. Endometriosis is present in 6-10% of women worldwide, 50-70% of women with pelvic pain and 30-50% of women with infertility. The main risk factors are early menarche, nulliparity and family history. Diagnosis frequently takes a long time from the onset of the first symptoms and constitutes a major healthcare problem in the United States. The most popular theory is retrograde menstruation, but other explanations are coelomic metaplasia, genetic predisposition, immune system dysfunction and environmental factors, which by means of inflammation, prostaglandin production and nerve regeneration could lead to pain and infertility. Endometriosis lesions have a known dependence with ovarian estrogens, but local conversion of androstenedione to estradiol inside the implants has been demonstrated, leading to proliferation of nerve fibers even after oophorectomy. Medical treatment aims to decrease inflammation, estrogen synthesis and local conversion of androgens to estrogens for a limited period of time. Surgical treatment aims to remove lesions and disrupt nerve production in the tissue, but there is a high percentage of symptom recurrence. Regarding infertility, endometriosis can cause adhesions affecting the ovary and the tube, but can also affect spermatozoa motility, migration of the embryo and prevent implantation, accounting for poor pregnancy outcomes in women with endometriosis.
To better visualize the expert's powerpoint presentation, please click here.
Ceana Nezhat
Lecture
7 years ago
2270 views
57 likes
0 comments
21:58
Contemporary aspects on etiopathogenesis: strategies on diagnosis
This lecture addresses the etiopathogenesis of endometriosis, as defined by the presence of endometrial glands and stroma out of the uterine cavity. Endometriosis is present in 6-10% of women worldwide, 50-70% of women with pelvic pain and 30-50% of women with infertility. The main risk factors are early menarche, nulliparity and family history. Diagnosis frequently takes a long time from the onset of the first symptoms and constitutes a major healthcare problem in the United States. The most popular theory is retrograde menstruation, but other explanations are coelomic metaplasia, genetic predisposition, immune system dysfunction and environmental factors, which by means of inflammation, prostaglandin production and nerve regeneration could lead to pain and infertility. Endometriosis lesions have a known dependence with ovarian estrogens, but local conversion of androstenedione to estradiol inside the implants has been demonstrated, leading to proliferation of nerve fibers even after oophorectomy. Medical treatment aims to decrease inflammation, estrogen synthesis and local conversion of androgens to estrogens for a limited period of time. Surgical treatment aims to remove lesions and disrupt nerve production in the tissue, but there is a high percentage of symptom recurrence. Regarding infertility, endometriosis can cause adhesions affecting the ovary and the tube, but can also affect spermatozoa motility, migration of the embryo and prevent implantation, accounting for poor pregnancy outcomes in women with endometriosis.
To better visualize the expert's powerpoint presentation, please click here.
Various approaches to uterine artery ligation at laparoscopy
Isolating the uterine artery can be performed safely and efficiently with a proper knowledge of the anatomy, as pelvic vascular anatomy is relatively constant with a very predictive retroperitoneal course. In this video, authors review the anatomy relevant to the uterine artery and demonstrate various approaches to ligating it laparoscopically. It is essential as it provides hemostasis and reduces the incidence of potential injury to bladder and ureter, particularly in cases where anatomical relationships have been distorted by intra-abdominal adhesions as in cases of previous surgery, severe endometriosis or large fibroids or when access to the cervix is limited due to wide uteri or to a fibrogenic cul-de-sac or when access to the vesicouterine space is obliterated due to previous surgeries. The various approaches to ligating the uterine artery in relation to the broad ligament are lateral, posterior, anterior, and medial. These approaches can be used based on the patient’s pathology and requirements.
H Grover, R Syed, A Padmawar
Surgical intervention
5 months ago
9469 views
84 likes
24 comments
07:04
Various approaches to uterine artery ligation at laparoscopy
Isolating the uterine artery can be performed safely and efficiently with a proper knowledge of the anatomy, as pelvic vascular anatomy is relatively constant with a very predictive retroperitoneal course. In this video, authors review the anatomy relevant to the uterine artery and demonstrate various approaches to ligating it laparoscopically. It is essential as it provides hemostasis and reduces the incidence of potential injury to bladder and ureter, particularly in cases where anatomical relationships have been distorted by intra-abdominal adhesions as in cases of previous surgery, severe endometriosis or large fibroids or when access to the cervix is limited due to wide uteri or to a fibrogenic cul-de-sac or when access to the vesicouterine space is obliterated due to previous surgeries. The various approaches to ligating the uterine artery in relation to the broad ligament are lateral, posterior, anterior, and medial. These approaches can be used based on the patient’s pathology and requirements.
Surgical complications - it is possible to prevent them
Complications after laparoscopic surgery for endometriosis may occur even with a skilled surgeon and ideal circumstances. Success is linked to many factors, and not only to the surgeon’s experience. It is necessary to inform the patient in order to avoid medico-legal problems. An appropriate diagnosis must be performed, including clinical examination and all other necessary investigations. Proper instruments, anatomical knowledge, and exposure help to prevent severe complications. Make sure that you visualize the ureters at the beginning of the surgery as they always tend to go medially. In addition, ureterosacral resection should be avoided in order to prevent bladder dysfunction. Always prefer discoid excision of the bowel rather than bowel resection and make sure the suture does not exceed 3cm on the bowel, and avoid any vertical suturing when possible. If there is a history of surgery or a lesion near the ostia or a ureteral stenosis, ureteral stents should be placed. At the end of the procedure, it is recommended to carry out a blue dye or an air test, a cystoscopy or to place drains. A postoperative consultation is essential.
JM Wenger
Lecture
7 years ago
9300 views
445 likes
0 comments
24:53
Surgical complications - it is possible to prevent them
Complications after laparoscopic surgery for endometriosis may occur even with a skilled surgeon and ideal circumstances. Success is linked to many factors, and not only to the surgeon’s experience. It is necessary to inform the patient in order to avoid medico-legal problems. An appropriate diagnosis must be performed, including clinical examination and all other necessary investigations. Proper instruments, anatomical knowledge, and exposure help to prevent severe complications. Make sure that you visualize the ureters at the beginning of the surgery as they always tend to go medially. In addition, ureterosacral resection should be avoided in order to prevent bladder dysfunction. Always prefer discoid excision of the bowel rather than bowel resection and make sure the suture does not exceed 3cm on the bowel, and avoid any vertical suturing when possible. If there is a history of surgery or a lesion near the ostia or a ureteral stenosis, ureteral stents should be placed. At the end of the procedure, it is recommended to carry out a blue dye or an air test, a cystoscopy or to place drains. A postoperative consultation is essential.
Laparoscopic uterovaginal anastomoses for cervical agenesis
Cervical agenesis occurs in one in 80,000 to 100,000 births. According to the American Fertility Society, cervical agenesis should be classified as a type 1b Müllerian anomaly. According to the ESHRE/ESGE classification, it is classified in class C4 category.
This is the case of a 16 year-old female patient with primary amenorrhea and episodes of cyclical lower abdominal pain for one year. After complete examination and investigations, diagnosis of isolated cervical agenesis with hematometra and left ovarian chocolate cyst was established. Laparoscopic uterovaginal anastomoses were performed using an innovative technique and an appropriate management of endometriosis. A hysteroscopy was later performed and showed anastomotic patency. As a result, the patient has been experiencing spontaneous regular menstruation for nine months.
Suy Naval, R Naval, Sud Naval, A Padmawar
Surgical intervention
2 years ago
2023 views
178 likes
1 comment
07:49
Laparoscopic uterovaginal anastomoses for cervical agenesis
Cervical agenesis occurs in one in 80,000 to 100,000 births. According to the American Fertility Society, cervical agenesis should be classified as a type 1b Müllerian anomaly. According to the ESHRE/ESGE classification, it is classified in class C4 category.
This is the case of a 16 year-old female patient with primary amenorrhea and episodes of cyclical lower abdominal pain for one year. After complete examination and investigations, diagnosis of isolated cervical agenesis with hematometra and left ovarian chocolate cyst was established. Laparoscopic uterovaginal anastomoses were performed using an innovative technique and an appropriate management of endometriosis. A hysteroscopy was later performed and showed anastomotic patency. As a result, the patient has been experiencing spontaneous regular menstruation for nine months.
Laparoscopic resection of deep endometriotic nodule for pelvic pain, left hydronephrosis and renal function impairment
Renal function impairment is a rare condition when associated with endometriosis. This video shows the laparoscopic resection of a deep endometriotic nodule for pelvic pain, left hydronephrosis and renal function impairment. The left kidney has an almost silent pattern on scintigraphy. The therapeutic strategy consists of freeing the obstacle caused by the endometriotic nodule, placement of a double J (JJ) catheter and monitoring for renal function in the postoperative follow-up. Further laparoscopic nephrectomy is to be discussed if the renal function is not improved.
A Wattiez, J Nassif, I Miranda-Mendoza, J Marescaux
Surgical intervention
10 years ago
2237 views
42 likes
0 comments
07:56
Laparoscopic resection of deep endometriotic nodule for pelvic pain, left hydronephrosis and renal function impairment
Renal function impairment is a rare condition when associated with endometriosis. This video shows the laparoscopic resection of a deep endometriotic nodule for pelvic pain, left hydronephrosis and renal function impairment. The left kidney has an almost silent pattern on scintigraphy. The therapeutic strategy consists of freeing the obstacle caused by the endometriotic nodule, placement of a double J (JJ) catheter and monitoring for renal function in the postoperative follow-up. Further laparoscopic nephrectomy is to be discussed if the renal function is not improved.
The indications of transvaginal endoscopy for diagnosis and treatment of infertility
Standard laparoscopy is frequently postponed and omitted in the exploration of the infertile patient. It is a rather invasive and not innocuous procedure. However, direct endoscopic visualization of the pelvis and the uterine cavity is still considered the gold standard and it is preferred over indirect imaging techniques.
The transvaginal single access approach offers the opportunity to explore the uterus and tubo-ovarian organs in an ambulatory “one-stop fertility” clinical setting. Only direct visualization of the pelvis allows for an accurate diagnosis of minimal endometriosis, tubo-ovarian adhesions, sequellae of PID. When indicated, the procedure was completed with a patency test, salpingoscopy and hysteroscopy. In patients without obvious pelvic pathology, transvafinal endoscopy (TVE) can be used as a first-line diagnostic procedure without postponing an early diagnosis and accurate therapy.
Because of the easy access to the fossa ovarica, the preferred implantation site of endometriosis, limited surgical procedures such as adhesiolysis become possible, the same goes for the treatment of ovarian endometrioma, and ovarian drilling. It allows for an accurate and meticulous dissection of peri-ovarian adhesions and hydroflotation is very helpful in the identification of the exact cleavage plane between the different organs. Small scissors, forceps, and a bipolar coagulation probe are used. A meticulous hemostasis is mandatory, as bleeding will disturb visualization in a watery medium. In case of endometriosis, after the endometrioma has been opened, the chocolate fluid is removed and the inner site of the cyst is superfluously rinsed. The bipolar probe is used to fulgurate the inner endometrial layering.
To drill the ovarian capsule, we use a 5 French bipolar needle (Karl Storz, Tuttlingen, Germany). On each ovary, 5 to 10 punctures were created preferentially at the antero-lateral side of the ovary. The 5 French bipolar needle is gently pushed against the ovarian surface and current is activated with an energy output of 70 Watts. The procedure was carried out in the ambulatory patient in a one-day clinical setting.
S Gordts
Lecture
4 years ago
1083 views
32 likes
0 comments
30:53
The indications of transvaginal endoscopy for diagnosis and treatment of infertility
Standard laparoscopy is frequently postponed and omitted in the exploration of the infertile patient. It is a rather invasive and not innocuous procedure. However, direct endoscopic visualization of the pelvis and the uterine cavity is still considered the gold standard and it is preferred over indirect imaging techniques.
The transvaginal single access approach offers the opportunity to explore the uterus and tubo-ovarian organs in an ambulatory “one-stop fertility” clinical setting. Only direct visualization of the pelvis allows for an accurate diagnosis of minimal endometriosis, tubo-ovarian adhesions, sequellae of PID. When indicated, the procedure was completed with a patency test, salpingoscopy and hysteroscopy. In patients without obvious pelvic pathology, transvafinal endoscopy (TVE) can be used as a first-line diagnostic procedure without postponing an early diagnosis and accurate therapy.
Because of the easy access to the fossa ovarica, the preferred implantation site of endometriosis, limited surgical procedures such as adhesiolysis become possible, the same goes for the treatment of ovarian endometrioma, and ovarian drilling. It allows for an accurate and meticulous dissection of peri-ovarian adhesions and hydroflotation is very helpful in the identification of the exact cleavage plane between the different organs. Small scissors, forceps, and a bipolar coagulation probe are used. A meticulous hemostasis is mandatory, as bleeding will disturb visualization in a watery medium. In case of endometriosis, after the endometrioma has been opened, the chocolate fluid is removed and the inner site of the cyst is superfluously rinsed. The bipolar probe is used to fulgurate the inner endometrial layering.
To drill the ovarian capsule, we use a 5 French bipolar needle (Karl Storz, Tuttlingen, Germany). On each ovary, 5 to 10 punctures were created preferentially at the antero-lateral side of the ovary. The 5 French bipolar needle is gently pushed against the ovarian surface and current is activated with an energy output of 70 Watts. The procedure was carried out in the ambulatory patient in a one-day clinical setting.