Vol. 58, No.3, September 1992
FERTILITY AND STERILITY
Printed on acid-free paper in U.S.A.
Copyright © 1992 The American Fertility Society
Second-look laparoscopy after laparoscopic cystectomy of large ovarian endometriomas
Michel Canis, M.D. Gerard Mage, M.D. Arnaud Wattiez, M.D.
Charles Chapron, M.D. Jean Luc Pouly, M.D. Salim Bassil, M.D.
Department of Obstetrics, Gynecology and Reproductive Medicine, Polyciinique de I'Hotel Dieu, Centre Hospitalier Regional et Universitaire de Clermont Ferrand, Clermont-Ferrand, France
Because medical therapy is not an effective treatment, ovarian endometriomas should be managed surgically. The best laparoscopic technique for the management of ovarian endometriomas (1, 2) has yet to be defined. Laparoscopic stripping of ovarian endometrioma has been described as the treatment of choice in two recent reviews (1, 2). Although difficulties may be encountered and the ovaries are generally left open, both the effectiveness of this procedure and postoperative adhesion formation have been rarely studied. We addressed these issues using data obtained at second-look laparoscopy, performed within 3 to 6 months of the laparoscopic treatment. MATERIALS AND METHODS
A continuous series of 42 patients who underwent a second-look laparoscopy within 3 to 6 months of a laparoscopic cystectomy for an ovarian endometrioma of >3 cm in diameter were included in this study. The mean age at laparoscopic treatment was 32.9 ± 6 years. At both laparoscopies, the patients were staged according to the revised American Fertility Society (AFS) classification scheme (3). Fifteen patients (35.7%) had stage III endometriosis and a unilateral endometrioma> 3 cm. Twenty-seven patients (64.3%) had stage IV endometriosis, including 11 patients with bilateral endometriomas of >3 cm. Thus, in all 53 ovarian endometriomas> 3 cm were Received March 2, 1992; revised and accepted May 22, 1992. Reprint requests: Maurice Antoine Bruhat, M.D., Department of Obstetrics, Gynecology and Reproductive Medecine, Polyclinique de I'Hotel Dieu, 13 Building Charles de Gaulle 63033 Clermont-Ferrand, France. Vol. 58, No.3, September 1992
included. The mean diameter, established from a preoperative ultrasonographic examination, was 5.6 ± 1.9 cm (range 3.5 to 11 cm). Because 10 patients with stage IV endometriosis had contralateral endometrioma < 3 cm, 21 adnexae without deep ovarian endometriosis were included to study adhesion formation on the contralateral adnexa. Forty-one patients had an uneventful postoperative recovery. One patient had a retrouterine hematocoele, treated laparoscopically in the 3rd postoperative week. Four months later, this patient underwent a third laparoscopy that was considered as her second-look laparoscopy. As for any ovarian cyst, the entire peritoneal cavity was thoroughly scrutinized and a peritoneal fluid cytology was performed (4). Thereafter, the endometrioma was freed from all adhesions. Frequently, the cyst opened spontaneously during ovariolysis, and the chocolate fluid spilled out. The pelvic cavity and the cyst were then copiously irrigated with warm saline. The endometrioma was opened with scissors on the most dependent part. An immediate laparotomy would have been performed if any sign of malignancy had been found during peritoneal, ovarian, or endocystic examination (4). Under permanent visual control, the cyst wall and the ovarian cortex were separated using two atraumatic grasping forceps pulling slowly in opposite directions. Hemostasis was achieved with bipolar coagulation. The ovarian capsule was left open with no endoscopic sutures used. The procedures included the treatment of all existent pelvic endometriosis. The macroscopic diagnosis of ovarian endometrioma was always confirmed by pathological examination. Postoperatively, all the patients underwent ovarian Canis et al.
Communications-in-brief
617
suppression with danazol or gonadotropin-releasing hormones analogues for 3 months. Using the revised AFS scoring system (3), we calculated the adnexal adhesion score, adding the points applied to adnexal adhesions. The effectiveness of laparoscopic cystectomy and postoperative adhesions were studied comparing the endometriosis ovarian scores and the adnexal adhesion scores at initial and second laparoscopy. Statistical analysis was performed using Wilcoxon's signed rank test and Spearman's rank correlation. The data are presented as means ± SEM.
adhesion score at initial and second laparoscopy were 3 ± 2.6 and 3.4 ± 4.4, respectively (P > 0.9). Among 34 adnexae with an ovarian adhesion score ~ 8 and an endometrioma> 3 cm (Table 1), a partial or a complete recurrence occurred in 28 cases (82.4%). A positive correlation was identified between the initial and the final adnexal adhesion score (r = 0.41, P < 0.05). Among 21 contralateral adnexae without deep ovarian endometriosis, 17 had an initial adnexal adhesion score::;; 4. In both groups, the mean adnexal adhesion was slightly but not significantly higher at second-look laparoscopy (Table 1). Three of 17 adnexae (17.6%) with an initial adnexal adhesion score ::;; 4 had an adnexal adhesion score of 8 at secondlook laparoscopy. One of these failures was explained by a postoperative hematocoele.
RESULTS
At second-look laparoscopy, the mean score of deep ovarian endometriosis was 1.7 ± 4.8 (P < 0.001). However, at second-look laparoscopy, four persistent deep ovarian endometriomas (7.6%) were diagnosed (2 < 3 cm [3.8%]; 2 > 3 cm [3.8%]). Because of a pathognomonic chocolate fluid, one cyst was tabulated as a persistent endometrioma, despite a negative pathological examination. In the remaining failures, difficulties resulting from hemorrhage, friability of the cyst wall, and size (1 endometrioma was 10 cm in diameter) had been encountered at laparoscopic treatment. The adnexal adhesion score at second-look laparoscopy was slightly but not significantly decreased (Table 1). Among 19 adnexae with an initial ovarian adhesion score ::;; 4 and an ovarian endometrioma > 3 cm, four adnexae (21 %) had an adnexal adhesion score ~ 16 at second-look laparoscopy after treatment of endometriomas of 3.5, 7, 8, and 9 cm in diameter. Excluding these four cases, the adnexal
Table 1
DISCUSSION
Because 92.4% of the adnexae treated for large endometriomas had no deep ovarian endometriosis at second-look laparoscopy, laparoscopic ovarian cystectomy appears to be effective in removing endometriomas of >3 cm. These results, obtained at early second-look laparoscopies, will have to be confirmed in long-term follow-up studies. As expected, persistent endometriomas were found after the dissection of very large cysts and/or friable cyst walls. Although rarely reported, these difficulties that may induce significant bleeding are well known from experienced laparoscopists. Similarly, Fayez and Vogel (5) recently reported a 22% incidence of deep ovarian endometriosis at second-look laparoscopy after stripping of the cystic lining. In our opinion, when
Comparison of Adnexal Adhesion Scores at Initial and Second-Look Laparoscopies Adnexal adhesion score Group
Treatment
All cases (n = 53) Stage III (n = 15) Stage IV (n = 38) Diameter < 6 em (n = 32) Diameter:2: 6 em (n = 21) Unilateral (n = 31) Bilateral (n = 22) Treated adnexae Ovarian adhesion score ~ 4 (n Ovarian adhesion score :2: 8 (n Contralateral adnexae All cases (n = 21) Adnexal adhesion score ~ 4 (n
* Values are means ± 618
Canis et al.
12.7 6.1 15.2 14.9 9.2 12.6 12.7
± ± ± ± ± ± ±
10.8* 5.9 11.3 11.3 9.3 11.4 10.2
Second-look 10.4 5.8 12.1 11.3 8.9 9.4 11.8
± ± ± ± ± ± ±
Probability
10 5.6 10.8 10.9 8.6 9.7 10.5
>0.1 >0.7 >0.1 >0.07 >0.8 >0.1 >0.4
=
19) 34)
3 ± 2.4 18.1 ± 9.9
6.5 ± 7.4 12.5 ± 10.7
>0.1 0.6 >0.08
=
SEM.
Communications-in-brief
Fertility and Sterility
the dissection is not satisfactory, densely adherent fragments should be vaporized or fulgurated. Complete excision, which would induce too severe postoperative adhesions (5) and ovarian damages, is required only in patients over the age of 40. Adhesion de novo formation occurred in 21 % of the treated adnexae (4 of 19 cases) and in 17% of the contralateral adnexae (3 of 17 cases). In 4 of these 7 adnexae (3 patients), postoperative adhesions were likely related to the surgical procedure (large endometriomas 3 cases; postoperative complication 1 case). In the remaining 3 adnexae (2 patients), endometriomas of only 4 cm in diameter were associated with large areas of histologically active peritoneal endometriosis. Thus postoperative adhesion formation might be interpreted as a consequence of the natural history of the disease. Similarly, adhesion formation had been reported in patients treated with danazol. In the present study, a partial or complete recurrence of dense adhesions occurred in 28 of the 34 adnexae with an ovarian adhesion score ~ 8 (82.3%). Similarly, the Operative Laparoscopy Study Group concluded that adhesion recurrence is frequent after laparoscopic adhesiolysis (6). Because reduced postoperative adhesion formation is supposed to be an advantage of laparoscopy, our results should be discussed. First, in the revised AFS classification scheme, ovarian adhesion are scored according to the ovarian surface involved, so that the adhesions may be scored more heavily at second-look laparoscopy because of the decreased ovarian diameter. Second, similar results were reported after microsurgical treatment of large ovarian endometriomas. Third, fertility rates after laparoscopic treatment were similar to that reported in microsurgical studies (1). Therefore laparoscopic surgery appears as a valuable alternative to microsurgery. However, its advantages should not be overestimated because adhesion de novo formation has been reported after laparoscopic adhesiolysis (6). In our opinion, one should not get carried away in believing that a procedure is valuable as long as it is performed laparoscopically. After a complete adhesiolysis, ovarian endometrioma should be treated using only one ovarian incision, located on its most dependent part, generally on the anterior ovarian surface. Meticulous hemostasis is required to obtain a permanent visual control allowing a complete treatment of the cyst and minimizing ovarian damage. Ovarian nonclosure has been widely accepted (1, 2). However, approximation of the edges should be obtained using a longitudinal incision performed on the antimesenteric ovarian Vol. 58, No.3, September 1992
border or a vertical incision on the anterior ovarian surface. When the edges will not approximate, several techniques may be used including fibrin glue, 4/0 sutures that are kept inside the ovary (2), or superficial coagulation of the remaining ovarian stroma. The effectiveness of these techniques has to be established in prospective studies. In patients with large endometriomas, a careful preoperative and laparoscopic examination is required to rule out malignancy (4). Patients should be informed of a possible malignancy, and consent for an eventual laparotomy should be taken. Whatever the laparoscopic technique used, a large biopsy of the cystic wall should be routinely performed for pathological examination. SUMMARY
Forty-two patients who underwent a second-look laparoscopy after a unilateral or bilateral intraperitoneal cystectomy for treatment of an ovarian endometrioma of>3 cm were included. At second-look laparoscopy, 92.4% ofthe adnexae treated for a large endometrioma had no deep ovarian endometriosis. Adhesion de novo formation occurred in 21 % of the treated adnexae and in 17% of the contralateral adnexae. Complete or partial recurrence of dense adhesions occurred in 82% of the cases. Laparoscopic cystectomy is effective in treating large endometriomas. However, operative difficulties may be encountered, explaining persistent endometriomas and postoperative adhesions. Key Words: Endometriosis, laparoscopic surgery, endometrioma, second-look laparoscopy, adhesions formation. Acknowledgments. We thank Salil Khandwala, M.D., ClermontFerrand, France, for reviewing this text in English. REFERENCES 1. Cook AS, Rock JA. The role of laparoscopy in the treatment
of endometriosis. Fertil Steril 1991;55:663-80. 2. Martin DC. Laparoscopic treatment of ovarian endometriomas. Clin Obstet Gynecol 1991;34:452-9. 3. The American Fertility Society. Revised American Fertility Society classification of endometriosis: 1985. Fertil Steril 1985;43:351-2. 4. Mage G, Canis M, Manhes H, Pouly JL, Wattiez A, Bruhat MA. Laparoscopic management of adnexal cystic masses. J Gynecol Surg 1990;6:71-9. 5. Fayez JA, Vogel MF. Comparison of different treatment methods of endometriomas by laparoscopy. Obstet Gynecol 1991;78:660-5. 6. Operative Laparoscopy Study Group. Postoperative adhesion development after operative laparoscopy: evaluation at early second-look procedures. Fertil SteriI1991;55:700-4.
Canis et al.
Communications-in-brief
619
FERTILITY AND STERILITY
Printed on acid-free paper in U.S.A.
Copyright © 1992 The American Fertility Society
Second-look laparoscopy after laparoscopic cystectomy of large ovarian endometriomas
Michel Canis, M.D. Gerard Mage, M.D. Arnaud Wattiez, M.D.
Charles Chapron, M.D. Jean Luc Pouly, M.D. Salim Bassil, M.D.
Department of Obstetrics, Gynecology and Reproductive Medicine, Polyciinique de I'Hotel Dieu, Centre Hospitalier Regional et Universitaire de Clermont Ferrand, Clermont-Ferrand, France
Because medical therapy is not an effective treatment, ovarian endometriomas should be managed surgically. The best laparoscopic technique for the management of ovarian endometriomas (1, 2) has yet to be defined. Laparoscopic stripping of ovarian endometrioma has been described as the treatment of choice in two recent reviews (1, 2). Although difficulties may be encountered and the ovaries are generally left open, both the effectiveness of this procedure and postoperative adhesion formation have been rarely studied. We addressed these issues using data obtained at second-look laparoscopy, performed within 3 to 6 months of the laparoscopic treatment. MATERIALS AND METHODS
A continuous series of 42 patients who underwent a second-look laparoscopy within 3 to 6 months of a laparoscopic cystectomy for an ovarian endometrioma of >3 cm in diameter were included in this study. The mean age at laparoscopic treatment was 32.9 ± 6 years. At both laparoscopies, the patients were staged according to the revised American Fertility Society (AFS) classification scheme (3). Fifteen patients (35.7%) had stage III endometriosis and a unilateral endometrioma> 3 cm. Twenty-seven patients (64.3%) had stage IV endometriosis, including 11 patients with bilateral endometriomas of >3 cm. Thus, in all 53 ovarian endometriomas> 3 cm were Received March 2, 1992; revised and accepted May 22, 1992. Reprint requests: Maurice Antoine Bruhat, M.D., Department of Obstetrics, Gynecology and Reproductive Medecine, Polyclinique de I'Hotel Dieu, 13 Building Charles de Gaulle 63033 Clermont-Ferrand, France. Vol. 58, No.3, September 1992
included. The mean diameter, established from a preoperative ultrasonographic examination, was 5.6 ± 1.9 cm (range 3.5 to 11 cm). Because 10 patients with stage IV endometriosis had contralateral endometrioma < 3 cm, 21 adnexae without deep ovarian endometriosis were included to study adhesion formation on the contralateral adnexa. Forty-one patients had an uneventful postoperative recovery. One patient had a retrouterine hematocoele, treated laparoscopically in the 3rd postoperative week. Four months later, this patient underwent a third laparoscopy that was considered as her second-look laparoscopy. As for any ovarian cyst, the entire peritoneal cavity was thoroughly scrutinized and a peritoneal fluid cytology was performed (4). Thereafter, the endometrioma was freed from all adhesions. Frequently, the cyst opened spontaneously during ovariolysis, and the chocolate fluid spilled out. The pelvic cavity and the cyst were then copiously irrigated with warm saline. The endometrioma was opened with scissors on the most dependent part. An immediate laparotomy would have been performed if any sign of malignancy had been found during peritoneal, ovarian, or endocystic examination (4). Under permanent visual control, the cyst wall and the ovarian cortex were separated using two atraumatic grasping forceps pulling slowly in opposite directions. Hemostasis was achieved with bipolar coagulation. The ovarian capsule was left open with no endoscopic sutures used. The procedures included the treatment of all existent pelvic endometriosis. The macroscopic diagnosis of ovarian endometrioma was always confirmed by pathological examination. Postoperatively, all the patients underwent ovarian Canis et al.
Communications-in-brief
617
suppression with danazol or gonadotropin-releasing hormones analogues for 3 months. Using the revised AFS scoring system (3), we calculated the adnexal adhesion score, adding the points applied to adnexal adhesions. The effectiveness of laparoscopic cystectomy and postoperative adhesions were studied comparing the endometriosis ovarian scores and the adnexal adhesion scores at initial and second laparoscopy. Statistical analysis was performed using Wilcoxon's signed rank test and Spearman's rank correlation. The data are presented as means ± SEM.
adhesion score at initial and second laparoscopy were 3 ± 2.6 and 3.4 ± 4.4, respectively (P > 0.9). Among 34 adnexae with an ovarian adhesion score ~ 8 and an endometrioma> 3 cm (Table 1), a partial or a complete recurrence occurred in 28 cases (82.4%). A positive correlation was identified between the initial and the final adnexal adhesion score (r = 0.41, P < 0.05). Among 21 contralateral adnexae without deep ovarian endometriosis, 17 had an initial adnexal adhesion score::;; 4. In both groups, the mean adnexal adhesion was slightly but not significantly higher at second-look laparoscopy (Table 1). Three of 17 adnexae (17.6%) with an initial adnexal adhesion score ::;; 4 had an adnexal adhesion score of 8 at secondlook laparoscopy. One of these failures was explained by a postoperative hematocoele.
RESULTS
At second-look laparoscopy, the mean score of deep ovarian endometriosis was 1.7 ± 4.8 (P < 0.001). However, at second-look laparoscopy, four persistent deep ovarian endometriomas (7.6%) were diagnosed (2 < 3 cm [3.8%]; 2 > 3 cm [3.8%]). Because of a pathognomonic chocolate fluid, one cyst was tabulated as a persistent endometrioma, despite a negative pathological examination. In the remaining failures, difficulties resulting from hemorrhage, friability of the cyst wall, and size (1 endometrioma was 10 cm in diameter) had been encountered at laparoscopic treatment. The adnexal adhesion score at second-look laparoscopy was slightly but not significantly decreased (Table 1). Among 19 adnexae with an initial ovarian adhesion score ::;; 4 and an ovarian endometrioma > 3 cm, four adnexae (21 %) had an adnexal adhesion score ~ 16 at second-look laparoscopy after treatment of endometriomas of 3.5, 7, 8, and 9 cm in diameter. Excluding these four cases, the adnexal
Table 1
DISCUSSION
Because 92.4% of the adnexae treated for large endometriomas had no deep ovarian endometriosis at second-look laparoscopy, laparoscopic ovarian cystectomy appears to be effective in removing endometriomas of >3 cm. These results, obtained at early second-look laparoscopies, will have to be confirmed in long-term follow-up studies. As expected, persistent endometriomas were found after the dissection of very large cysts and/or friable cyst walls. Although rarely reported, these difficulties that may induce significant bleeding are well known from experienced laparoscopists. Similarly, Fayez and Vogel (5) recently reported a 22% incidence of deep ovarian endometriosis at second-look laparoscopy after stripping of the cystic lining. In our opinion, when
Comparison of Adnexal Adhesion Scores at Initial and Second-Look Laparoscopies Adnexal adhesion score Group
Treatment
All cases (n = 53) Stage III (n = 15) Stage IV (n = 38) Diameter < 6 em (n = 32) Diameter:2: 6 em (n = 21) Unilateral (n = 31) Bilateral (n = 22) Treated adnexae Ovarian adhesion score ~ 4 (n Ovarian adhesion score :2: 8 (n Contralateral adnexae All cases (n = 21) Adnexal adhesion score ~ 4 (n
* Values are means ± 618
Canis et al.
12.7 6.1 15.2 14.9 9.2 12.6 12.7
± ± ± ± ± ± ±
10.8* 5.9 11.3 11.3 9.3 11.4 10.2
Second-look 10.4 5.8 12.1 11.3 8.9 9.4 11.8
± ± ± ± ± ± ±
Probability
10 5.6 10.8 10.9 8.6 9.7 10.5
>0.1 >0.7 >0.1 >0.07 >0.8 >0.1 >0.4
=
19) 34)
3 ± 2.4 18.1 ± 9.9
6.5 ± 7.4 12.5 ± 10.7
>0.1 0.6 >0.08
=
SEM.
Communications-in-brief
Fertility and Sterility
the dissection is not satisfactory, densely adherent fragments should be vaporized or fulgurated. Complete excision, which would induce too severe postoperative adhesions (5) and ovarian damages, is required only in patients over the age of 40. Adhesion de novo formation occurred in 21 % of the treated adnexae (4 of 19 cases) and in 17% of the contralateral adnexae (3 of 17 cases). In 4 of these 7 adnexae (3 patients), postoperative adhesions were likely related to the surgical procedure (large endometriomas 3 cases; postoperative complication 1 case). In the remaining 3 adnexae (2 patients), endometriomas of only 4 cm in diameter were associated with large areas of histologically active peritoneal endometriosis. Thus postoperative adhesion formation might be interpreted as a consequence of the natural history of the disease. Similarly, adhesion formation had been reported in patients treated with danazol. In the present study, a partial or complete recurrence of dense adhesions occurred in 28 of the 34 adnexae with an ovarian adhesion score ~ 8 (82.3%). Similarly, the Operative Laparoscopy Study Group concluded that adhesion recurrence is frequent after laparoscopic adhesiolysis (6). Because reduced postoperative adhesion formation is supposed to be an advantage of laparoscopy, our results should be discussed. First, in the revised AFS classification scheme, ovarian adhesion are scored according to the ovarian surface involved, so that the adhesions may be scored more heavily at second-look laparoscopy because of the decreased ovarian diameter. Second, similar results were reported after microsurgical treatment of large ovarian endometriomas. Third, fertility rates after laparoscopic treatment were similar to that reported in microsurgical studies (1). Therefore laparoscopic surgery appears as a valuable alternative to microsurgery. However, its advantages should not be overestimated because adhesion de novo formation has been reported after laparoscopic adhesiolysis (6). In our opinion, one should not get carried away in believing that a procedure is valuable as long as it is performed laparoscopically. After a complete adhesiolysis, ovarian endometrioma should be treated using only one ovarian incision, located on its most dependent part, generally on the anterior ovarian surface. Meticulous hemostasis is required to obtain a permanent visual control allowing a complete treatment of the cyst and minimizing ovarian damage. Ovarian nonclosure has been widely accepted (1, 2). However, approximation of the edges should be obtained using a longitudinal incision performed on the antimesenteric ovarian Vol. 58, No.3, September 1992
border or a vertical incision on the anterior ovarian surface. When the edges will not approximate, several techniques may be used including fibrin glue, 4/0 sutures that are kept inside the ovary (2), or superficial coagulation of the remaining ovarian stroma. The effectiveness of these techniques has to be established in prospective studies. In patients with large endometriomas, a careful preoperative and laparoscopic examination is required to rule out malignancy (4). Patients should be informed of a possible malignancy, and consent for an eventual laparotomy should be taken. Whatever the laparoscopic technique used, a large biopsy of the cystic wall should be routinely performed for pathological examination. SUMMARY
Forty-two patients who underwent a second-look laparoscopy after a unilateral or bilateral intraperitoneal cystectomy for treatment of an ovarian endometrioma of>3 cm were included. At second-look laparoscopy, 92.4% ofthe adnexae treated for a large endometrioma had no deep ovarian endometriosis. Adhesion de novo formation occurred in 21 % of the treated adnexae and in 17% of the contralateral adnexae. Complete or partial recurrence of dense adhesions occurred in 82% of the cases. Laparoscopic cystectomy is effective in treating large endometriomas. However, operative difficulties may be encountered, explaining persistent endometriomas and postoperative adhesions. Key Words: Endometriosis, laparoscopic surgery, endometrioma, second-look laparoscopy, adhesions formation. Acknowledgments. We thank Salil Khandwala, M.D., ClermontFerrand, France, for reviewing this text in English. REFERENCES 1. Cook AS, Rock JA. The role of laparoscopy in the treatment
of endometriosis. Fertil Steril 1991;55:663-80. 2. Martin DC. Laparoscopic treatment of ovarian endometriomas. Clin Obstet Gynecol 1991;34:452-9. 3. The American Fertility Society. Revised American Fertility Society classification of endometriosis: 1985. Fertil Steril 1985;43:351-2. 4. Mage G, Canis M, Manhes H, Pouly JL, Wattiez A, Bruhat MA. Laparoscopic management of adnexal cystic masses. J Gynecol Surg 1990;6:71-9. 5. Fayez JA, Vogel MF. Comparison of different treatment methods of endometriomas by laparoscopy. Obstet Gynecol 1991;78:660-5. 6. Operative Laparoscopy Study Group. Postoperative adhesion development after operative laparoscopy: evaluation at early second-look procedures. Fertil SteriI1991;55:700-4.
Canis et al.
Communications-in-brief
619
