Luca Minelli

Laparoscopic Colorectal Resection for Bowel Endometriosis: Feasibility, Complications, and Clinical Outcome

OBJECTIVE To evaluate the short- and long-term outcomes of laparoscopic colorectal resection for endometriosis. DESIGN AND PATIENTS This study included 357 consecutive patients who underwent colorectal resection. We evaluated intraoperative and postoperative complications, symptom outcomes, and long-term follow-up. MAIN OUTCOME MEASURE Three hundred forty-three patients (96.1%) underwent laparoscopic colorectal resection, and radical endometriosis ablation was in 334 patients (93.6%). RESULTS Fourteen (3.9%) required laparoconversion. Median operating time was 300 (range, 85-720) minutes, with a median estimated blood loss of 250 (range, 50-550) mL. Radical endometriosis ablation was achieved in 334 patients (93.6%). Median ileus was 4 (range, 1-8) days, with a median postoperative hospitalization of 8 (range, 3-36) days. Early and late complications were observed in 44 patients (12.3%) and, in 35 of these (79.5%), surgical management was necessary. Median follow-up after colorectal resection was 19.6 (range, 6-48) months. The median preoperative and postoperative dyspareunia scores were 8 (range, 4-10) and 3 (range, 0-10), respectively (P < .04), and the median preoperative and postoperative gastrointestinal tract symptom scores were 7 (range, 2-10) and 2 (range, 0-10), respectively (P < .05). During follow-up, 24 of 286 recurrences (8.4%) were registered. Patients who previously underwent surgery for endometriosis showed a higher risk of recurrence compared with patients undergoing primary surgery (13.2% vs 3.4%; P < .048). CONCLUSIONS Laparoscopic colorectal resection for severe endometriosis is feasible and markedly improved endometriosis-related symptoms. Despite the risk of major postoperative complications, the procedure shows good results in terms of recurrence rate and could be adopted as the primary approach for patients with symptomatic colorectal infiltrating endometriosis.

Laparoscopic colorectal resection for deep infiltrating endometriosis: analysis of 436 cases.

BackgroundComplete removal of all visible lesions is considered the adequate treatment of pelvic endometriosis in order to reduce recurrence. Laparoscopic colorectal resection of bowel endometriosis is still challenging. A large series is reported.MethodsA longitudinal evaluation of surgical and clinical complications of 436 cases of severe endometriosis with colorectal resection was carried out. All procedures were performed laparoscopically in a single center and short-term complications were surveyed.ResultsThe overall complication rate was 8.3% with need for laparoconversion in 3.2%. Sixty patients required blood transfusion (13.7%), and rectovaginal fistulae were the most frequent postoperative complication (3.2%).ConclusionLaparoscopic colorectal resection for endometriosis is a relatively safe procedure in a context of close collaboration between gynecologists and surgeons, although it requires adequate training.

Laparoscopic treatment of bowel endometriosis in infertile women

BACKGROUND The purpose of the study was to determine the influence of bowel endometriosis on fertility, and to study whether its removal improves fecundity in women with endometriosis-associated infertility. METHODS Three groups of infertile patients were included in the study. Group A (60 women) consisted of patients who underwent surgery for endometriosis with colorectal segmental resection. In group B, 40 patients with evidence of bowel endometriosis underwent endometriosis removal without bowel resection. Group C consisted of 55 women who underwent surgery for moderate or severe endometriosis with at least one endometrioma and deep infiltrating endometriosis but without bowel involvement. The women were clinically evaluated before laparoscopy and then at 1 month, at 6 months and at each year up to 4 years after surgery. Main outcome measures were surgical complications as well as post-operative pregnancy rate, time to conception and monthly fecundity rate. RESULTS The monthly fecundity rates (MFR) in groups A, B and C were 2.3, 0.84 and 3.95%, respectively. The difference in the MFR between groups was significant (P < 0.05). CONCLUSIONS The presence of bowel infiltration by endometriosis seems to negatively influence the reproductive outcome in women with endometriosis-associated infertility. The complete removal of endometriosis with bowel segmental resection seems to offer better results in terms of post-operative fertility.

Discoid or segmental rectosigmoid resection for deep infiltrating endometriosis: a case-control study

OBJECTIVE To evaluate the efficacy of discoid resection for the treatment of deep infiltrating endometriosis and whether it could be considered to be a valid alternative to the rectosigmoid segmental resection. DESIGN Case-control study. SETTING Departments of Obstetrics and Gynecology, Ospedale Sacro Cuore of Negrar, Verona, and Catholic University of the Sacred Heart, Rome, Italy. PATIENT(S) Women with deep infiltrating and intestinal endometriosis divided into study group (48 patients) and control group (88 patients). INTERVENTION(S) All patients underwent laparoscopic endometriosis excision plus discoid rectosigmoid resection (study group) or segmental resection (control group). MAIN OUTCOME MEASURE(S) Short- and long-term outcomes. RESULT(S) In the study group, median operating time was 200 minutes, with a median estimated blood loss of 203 mL. Median ileus was 3 days with a median postoperative hospitalization of 7 days. Early complications were observed in six patients (12.5%), and in two of them (4.16%) a surgical management was necessary. Median follow-up period was 33 months, and five recurrences (10.4%) were registered. In the control group, no significant differences were noticed except for longer operative time, more temporary ileostomy, postoperative fever, and long-term bladder dysfunctions. CONCLUSION(S) Laparoscopic mechanical discoid resection is feasible, markedly improved endometriosis related symptoms, and could be considered as a worthy alternative to classic segmental resection in selected patients.

Laparoscopic Myomectomy: Technique, Complications, and Ultrasound Scan Evaluations

STUDY OBJECTIVE To evaluate the feasibility, limits, and complications of laparoscopic myomectomy, assess time to full recovery, and evaluate uterine wound healing by ultrasound in the early postoperative period. DESIGN Prospective study (Canadian Task Force classification II-2). SETTING General hospital. PATIENTS Three hundred sixty-eight women undergoing laparoscopic myomectomy. INTERVENTION Laparoscopic myomectomy and laparoscopic and/or hysteroscopic treatment of associated pathologies. MEASUREMENTS AND MAIN RESULTS In these women 768 myomas were removed laparoscopically. Mean operating time was 100.78 +/- 43.83 minutes, mean decreases in hemoglobin and hematocrit were 1.38 +/- 0.93 g/100 ml and 4.8 +/- 2.9 g/100 ml, respectively, and mean length of hospital stay was 2.89 +/- 1.3 days. Intraoperative complications occurred in 12 patients (3.34%) and intraoperative transfusion of autologous blood was required in 10. Main postoperative complications were continuing hemorrhage requiring blood transfusion in three women and second laparoscopy in two. Pyrexia occurred in 12 patients. Average time to full recovery was 10.58 +/- 6.68 days. At 1-month follow-up 12 of 282 women developed further complications: abdominal pain 5, vaginitis 4, metrorrhagia 2, and dysuria 1. Sonographic evaluation of the uterine scar showed a highly echogenic area with ill-defined margins. In 81 women who had sonographic evaluation 30 days postoperatively, the uterine scar was reduced by an average of 44.1% (p <0.001). Of 176 patients screened at day 30, 6 (3.4%) had anechoic areas adjacent to the uterine scar, possibly due to hematoma. A previously unknown myoma, two ovarian cysts, and two pelvic hematoma were also discovered. CONCLUSION . Laparoscopic myomectomy is effective and relatively safe. In skilled hands it has a low risk of complications and appears to be a valid alternative to the open procedure. Sonographic assessment allows detection of alterations in muscular echotexture, but its effectiveness in identifying women at risk of uterine rupture or dehiscence has to be proved.

Laparoscopic management of ureteral endometriosis in case of moderate-severe hydroureteronephrosis

OBJECTIVE To evaluate prospectively the efficacy of laparoscopic ureterolysis versus ureteroureterostomy in women with ureteral endometriosis. DESIGN Prospective study. SETTING Department of Obstetrics and Gynecology, Ospedale Sacro Cuore of Negrar, Verona, Italy, a tertiary care endometriosis referral center. PATIENT(S) Endometriotic patients with moderate-severe ureter dilatation. INTERVENTION(S) All women underwent laparoscopic endometriosis excision and concomitant laparoscopic ureterolysis, ureteroureterostomy, nephrectomy, or laparotomic ureterocystoneostomy. MAIN OUTCOME MEASURE(S) Clinical outcomes were evaluated. RESULT(S) Fifty-six patients with preoperative or intraoperative evidence of moderate-severe ureter dilatation were enrolled. Dysmenorrhea (91%) and dyspareunia (68%) were the symptoms more frequently reported; only two patients had typical obstructive uropathy pain. In 35 cases, laparoscopic ureterolysis, in 17 laparoscopic ureteroureterostomy, in 2 laparotomic ureterocystoneostomy, and in 2 laparoscopic nephrectomy was performed. 11 out of 35 (31.4%) major complications occurred in the ureterolysis group, and 2 out of 17 (11.7%) in the ureteroureterostomy group. Median follow-up time was 21 months. Ureteral endometriosis recurrence was surgically detected in three patients who underwent conservative ureteral surgery. CONCLUSION(S) Preoperative planning should be rigorous, and complete surgical excision of ureteral endometriosis should be ensured by a team of experts familiar with endometriosis, its multiple manifestations, and its management.

Preoperative Double-Contrast Barium Enema in Patients with Suspected Intestinal Endometriosis

STUDY OBJECTIVES To assess the usefulness of double-contrast barium enema (DCBE) in the diagnosis of endometriotic lesions of the bowel and to define its potential value in preoperative decision making for intestinal surgery. DESIGN Retrospective study (Canadian Task Force classification II-2). SETTING General hospital with a specialized endometriosis unit. PATIENTS One hundred and eight women with symptoms suggestive of intestinal endometriosis who underwent DCBE before laparoscopic surgery. INTERVENTION Laparoscopic complete excision of endometriosis. MEASUREMENTS AND MAIN RESULTS Fifty-five patients were found to have an entirely normal colon on DCBE studies. Twenty-eight of these were found to have adhesions of the bowel at laparoscopy. Radiographic abnormalities suggestive of endometriosis were detected in 53 patients; 20 of these underwent laparoscopic bowel segmental resection, 10 laparoscopic full-thickness disc excision, 4 laparoscopic mucosal skinning, and 4 total laparoscopic hysterectomy with bilateral salpingo-oophorectomies. Fourteen patients refused intestinal surgery. One patient had no endometriosis but severe adhesions. In all cases but one, the radiographic findings on DCBE were confirmed by surgery and with histopathologic examination of the resected specimens (accuracy 99%). In these same cases, the preoperative choice of intestinal surgery remained unchanged during the procedure. CONCLUSION Our data show that, in expert hands, DCBE correlated with a patients clinical history and clinical findings is capable of diagnosing bowel wall involvement due to endometriosis, which could require intestinal surgery. This allows for proper preoperative planning of surgical procedures and a thorough informed consent.

Pregnancy Outcomes and Deliveries after Laparoscopic Myomectomy

STUDY OBJECTIVE To assess pregnancy outcomes and deliveries after laparoscopic myomectomy. DESIGN Retrospective study (Canadian Task Force classification II-2). SETTING General hospital. PATIENTS Three hundred fifty-nine women. INTERVENTIONS Laparoscopic myomectomy and laparoscopic and/or hysteroscopic treatment of associated pathologies. MEASUREMENTS AND MAIN RESULTS Five patients (1.39%) were lost to follow-up. Seventy-two women were pregnant at least once after laparoscopic myomectomy, for a total of 76 pregnancies. Four women conceived twice and four are pregnant as of this writing. One multiple pregnancy occurred. Twelve pregnancies resulted in first-trimester miscarriage, one in an ectopic pregnancy, one in a blighted ovum, and one in a hydatiform mole. One patient underwent elective first-trimester termination of pregnancy. Thirty-one women had vaginal delivery at term and 26 were delivered by cesarean section. No case of uterine rupture or dehiscence occurred. CONCLUSION Our technique of laparoscopic myomectomy appears to allow safe vaginal delivery.

Vaginal cuff dehiscence after hysterectomy: a multicenter retrospective study

OBJECTIVE This study estimates the incidence of vaginal cuff dehiscence resulting from different approaches to hysterectomy. STUDY DESIGN This multicentric study was carried out retrospectively. We retrospectively analyzed 8635 patients; 37% underwent abdominal hysterectomy, 31.2% vaginal hysterectomy, and 31.8% laparoscopic hysterectomy. All the hysterectomies were considered, vaginal evisceration was registered and analyzed for time of onset, trigger event, presenting symptoms, details of prolapsed organs and type of repair surgery. Continuous variables were compared using the one-way analysis of variance between groups as all data followed a Gaussian distribution, as confirmed by the Kolmogorov-Smirnov test. Differences among subgroups were assessed using the Tukey-Kramer multiple comparisons test. Categorical variables were compared with two tailed Chi-square tests with Yates correction or Fishers exact test, as appropriate. Pearsons linear correlation was used to verify linear relationships between the dehiscence interval and patients age at surgery. RESULTS Thirty-four patients (0.39%) experienced vaginal evisceration. The laparoscopic route was associated with a significantly higher incidence of dehiscence (p<0.05). No differences were found between the 6027 patients (69.8%) who had closure of the vaginal cuff and the 2608 (30.2%) who had an unclosed cuff closure technique. CONCLUSION Vaginal evisceration after hysterectomy is a rare gynecological surgical complication. Sexual intercourse before the complete healing of the vaginal cuff is the main trigger event in young patients, while evisceration presents as a spontaneous event in elderly patients. Surgical repair can be performed either vaginally or laparoscopically with similar outcomes.

Laparoscopic conservative surgery for stage IV symptomatic endometriosis: short-term surgical complications

OBJECTIVE To study severe endometriosis as a cause of pelvic pain, which represents one of the most challenging disorders in gynecology. DESIGN Retrospective study. SETTING Teaching hospital. PATIENT(S) A total of 1,363 women with severe endometriosis (revised American Society for Reproductive Medicine [rASRM] stage IV). INTERVENTIONS A detailed survey of all patients with severe endometriosis (rASRM stage IV) who underwent laparoscopy at our center between January 2004 and December 2007 was carried out. MAIN OUTCOME MEASURE(S) Clinical and surgical data were retrieved and assessed according to the extent of surgery performed. Intraoperative, ultra-short, and short-term clinical complications were assessed. RESULTS A total of 1,201 women underwent laparoscopic radical surgery with excision of all visible endometriotic lesions, with a significant improvement of symptoms at 1-month follow-up evaluation. The overall intraoperative complication rate was 2.0%. The morbidity was significantly increased when bowel surgery was performed, with a risk of intraoperative complications that was threefold higher. Of the patients who had bowel surgery, 18 (4.1%) required reintervention within the first week after surgery. CONCLUSION(S) We report on the safety and efficacy of laparoscopic eradication of all visible implants in cases of rASRM stage IV endometriosis when surgery is performed in a referral center.