Endometriosis Foundation of America
Endometriosis 2013 / Endometriosis on the Pelvic Side Wall, Ureter & Bladder
CY Liu, MD
Well, we have learned to recognize and identify endometriosis and we have learned how to excise the endometriosis by using microsurgical technique. In a way endometriosis is an inflammatory disease. It always causes adhesions and distortion of anatomy. So on the pelvic side wall - of course, the important thing is the ureter because maybe you are doing obgyn surgery, pelvic sidewall surgery or close to the uterosacral ligament. The most important thing to remember is the ureter.
We start with this patient who obviously has quite a bit of endometriosis involving the pelvic sidewall. We need to identify the ureter, and usually you try to identify the ureter above the pathology around the pelvic brim. Just concentrate on looking at the ureter and dissecting to the cul-de-sac. By the time, as I say, the ureter all the way down to the peak pelvis always has already been separated, away from you.
As I said the endometriosis always causes distortion and adhesion. In this case the uterosacral ligament, the ureter, the uterine artery all are pulled together and as you can see with this technique you can separate the ureter from the uterosacral ligament, from the ovary, from the uterine artery. And the name you will come across is the ovarian cyst. So doing surgery under the ovarian cyst close to the ureter is a tricky thing because the ureter can go above the cyst, go through the cyst or go below the cyst or behind the cyst. Again, the key is concentrating on looking at the ureter and just keep on dissecting the ureter. By the time you - the ureter beyond the pathology the ovarian cyst is gone.
Another case - with ten minutes I tried to put as much material out there. Actually the picture is quicker than my speech. In this case the ureter is encapsulated by the adhesions. You see the structure here? This is a ureter right here and the uterine artery actually is coming over here. So the ureter, okay you see that you have the artery now, right here, the uterine artery and ureter actually grew together. This is a young patient; she still wanted to preserve her fertility. She really did not want to sacrifice the uterine artery at this point. On top of that we had to make sure the endometriosis has not already invaded through the muscularis of the ureter, and...the hydroureter. In this case you can see the uterine artery has been separated from the ureter. Here is the ureter and you can see the adhesive planes here but the capsule, the ureter is still intact. In that case, just take your time and continue to cut and lyze those adhesions. Then the ureter can be restored back to normal after adhesion.
Now this patient was operated...surgery was a hysterectomy, after that we could...on of the left ureter did not have time to come out. So I thought I would probably catch the ureter with a cup closure but did not realize there was a burn right here a hole on the ureter with a thermal injury and I saw that urine continued to leak out and interfered with inspection. I tried to close it first, stop the leakage so I could see better and also as a marker of the lesion where the leakage is. Then we dissected the ureter from the pelvic brim all the way down and come down to the lesion, the area here. We cut...to urine detail right away. Now with these kinds of cases do not just close it because this ureter still has more injury.
Thermal injury creates a lot of bad tissue and that tissue will never heal. You must do a defragment, cut all the bad tissue off before you can repair it. Keep on cutting until you see bleeding that is key, it means you cut all the burned, bad tissue out. You see that every cut all the dead tissue out, a small hole becomes a large lesion like that. But those are healthy tissues. The ureter and the bladder are very, very forgiving. If you repaired it properly they heal very well. After that you just make sure you have not another caliber of the - this is actually here is the bladder, the bladder is right there already and you just use in the...6 or 5-0 PDFs, then close it up and then have the urologist put a double J in and put in the drain, which really is not necessary because with the microsurgical technique they really do not need urine.
This is another case, you see there as a big tubular structure here, like a blood vessel. But then you pay attention to it you see the peristalsis are moving this way from cervix to the cul-de-sac. The only organ that would do that tubular structure is the ureter. So is the hydroureter and this patient, interestingly, in the pelvis is quite clean except on this part of traction. Continue to dissect out the ureter to make sure this ureter, the endometriosis, has not embedded into the muscularis. If it has invaded the muscularis you must dissect it. You will not be able to just excise the endometriosis and restore that anatomy, normal anatomy... With this case we decided to do a segmental resection. See the hydroureter? In order to do the reanastomosis you must have a tension free reanastomosis, so in this case we have to excise and try to cut as little of the healthy tissue as possible.
You will see after you remove, even resected the ureter they are happy. It is just instant relief right away. Then you try to do a reanastomosis and try to save as much healthy tissue as possible. Then you put the ureter back by using...talking about microsurgical technique, like a tubal reanastomosis. Basically you start with a 6:00 o'clock, 12:00 o'clock, I put the 2, 4, 8 and 10 with either 6-0 PDFs, or 5-0 or 6-0 bipolar will be okay interrupted and then put a double stent in. This will heal very well. We had probably about 16 to 17 cases of segmentally utero resection and an increase of 100 percent success rate. We must be doing something right. So, 6:00 o'clock, 12:00 o'clock and this was 6 and 12 that cut suture long so we could twist around and put the suture on the 2, 4, 10 and 8. Urethral reanastomosis is actually easier than endo tubal reanastomosis. Tubal reanastomosis you try to avoid...the sutures... Urethral reanastomosis just go through and through, make sure it is a big bite and when you tie a knot tie the knot with...you do not want to tie the cut and...and then end with a double stent catheter there. It will heal very well. Just repair... As I said we have 16, 17 cases. Every single one is doing well. They can go home the next day. That is the beauty of it.
Let us look at the bladder, here is a cyst. This patient, every time has a period has a hematuria and...you see that endometriosis is right here. This you need to excise it. This patient was actually operated by the urologist before she came to me and actually the urologist has second...stent through here in which they got into the bladder. They do not want to deal with endometriosis. This patient, laparoscopically again you see some adhesions in the cul-de-sac, again some of the endometriosis. You see that...excised. Those nodules actually cling to the bowel lumen. The bladder and endometriosis all grew together here. You must free the bladder away from the cervix first. We keep it completely free from the cervix. It will start to do - here it is free now, see the cervix right here? I just point where you will excise the endometriosis of the bladder. You must enter into the bladder to see the margins. With cutting I use unipolar cutting with 100 watt pure cut and thus reduce the chance of a thermal injury. The bladder has been entered, we excised totally. You are into the bladder now and you can see the ureter catheter. This was a prolapse of catheter that yellow one...very busy. Urologists would not come in they can put a guide wire through that and then put the double J in very quickly. We put the ureter caps in ourselves and in the end you...endometriosis nodule but with associated formation. Then we will close this bladder with two layers, two or three layers. We heat the first layer with zero clomid...just continues through and through.
As I said the bladder and the ureter are very, very forgiving. If you close it well and then of course it must be watertight I...just though and through it, mucosa, muscularis, mucosa, muscularis and continue suture. Secondly I may use the 2-0 micro to reduce the tension. This is zero clomid but this is healing very well. Make sure you test it if it is watertight. That is very important. Leave the catheter in for about seven to ten days. It will work.
Now, this case by the time I finished excision about almost one...to one/tenth of...gone. But there...we had heard within three months. It is amazing how the bladder recovers so well.
That is my ten minute talk about the ureter and bladder in a very fast way and since Harry is not here I will do it for him about the bowel.
Very quickly, as I said ten minutes is not long. This is a cul-de-sac lesion, not big at all but by the time you excise and keep on excising it becomes a big hole. You see, we consider excising you have seen this kind of a picture many times.
But still this is a key here. You think you already excised all the endometriosis lesion and nodules there but this kind of case we do frequently, rectovaginal examination intraoperatively. Even after we excise we think we excised it all but when you put your finger in you feel the nodules, you need to excise more. Then you cut this...feels kind of hard and excise some more and then increase...into the bowel but it does not matter, the lesion has to be excised. You see the bowel has been entered, lumen but here the nodule is still there. Imagine cutting the lesion laparoscopically and ending up with a huge nodule and you can see her stool. This patient did not have very good bowel prep but it does not matter. At least she had her enema. This is the rectal probe there but still there is more lesion. A recent rectovaginal exam in surgery is very important. With extensive endometriosis it is not unusual for us to do rectovaginal exams eutopically ten times or more. So we make sure all the tissue not only looks normal but feels normal. The adhesion can be closed with the bowel typically you can use 2-0 vicryl.
Now the rectum has a big lumen. We can close either this way or transfer, it does not matter. I...because this did not have a big enough lumen and usually I want to leave the rectal probe there and make sure I do not create too big a construction. Typically you can use continuous or interrupted 2-0 vicryl and at the first layer after you closed it you either put the rectal probe - I usually use a large 40...with a 30cc balloon, like 24/40 into the rectum. Then just pull up the lumen to about 40cc then probe through the anus. Laparoscopically use any instrument to compress the upper sigmoid colon and then from below infuse quite a bit of indigo carmine dye solution. Make sure there is no leakage at the first layer then stick on there, just kind of reinforce it and check the tension of the first layer. Again, we have done quite a bit of bowel resections, discoid bowel resections. They are all healing very well. We have not had any problems with leakage or something like that. That is because this, we call it patent's text, is extremely, extremely important.
This is a vaginal endo. Here is the lower lip of the cervix and here are the vaginal lesions. Every time, that is my experience, every time I see the vaginal lesion endometriosis it is 100 percent that we have to do a bowel resection. That is my experience. I do not know any of your experiences. It seems to me when endometriosis is involved the posterior fornix into the vagina it is bad news. I start with the vaginal approach first. I mark the lesion vaginal so I put you off, tell me, laparoscopically but I inject some tracing before I mark the lesion. This is a vaginal mark just to tell me when I am doing a resection. After that I go into laparoscopically as expected. Everything grew together, the bowel, the ovaries, the cul-de-sac is completely obliterated, endometriomas kissing each other. But anyway, that is not what we are talking about, that is Ted Lee's topic.
Anyway, after you excise the endometrioma and everything else you get into the clean up of the cul-de-sac, get into the vagina - the vagina is entered already. Continue to excise all the endometriosis and pretty soon you are going to get into the bowel. We already expect that and are prepared for it. I am just going to speed up. Here you are the cul-de-sac is really clean now. And here, look at here, there is a rectal probe this is a pretty big lesion. This point, this is quite low segmental resection could be a bit harder but my principle is if I resect the bowel less than 40/50 percent I usually just close it and re-suture. If it is going to be about 50 percent I do a segmental resection with a general surgeon.
When we do bowel surgery, as I say, we have a team; colorectal surgeon, myself, you know we work as a team. But I do the surgery and they kind of help me on that because the general surgeon they are not interested in endometriosis. They are scared of endometriosis. They do not want to touch it. They know the bowel, they know the ureter, they know the...they do not know anything about endometriosis. You have to be the captain of the team. That is very important. Do not let them say, "Ah, I have to open the patient now". That does not make sense at all. But anyway, patent's test, bowel patent's test with each day of closure and it is very important.
For example, here is the first layer, let us see now, the first layer is you see a little blue here? There is some leakage there. This needs to be closed. Blue dye in the... direct use betadine solution I think. The indigo carmine dye is less irritating but betadine copy has more anesthetic property. In general you engage in lavage, we never have any trouble with peritonitis or anything else. So, if you see the blue dye you know you need to reinforce that area. It has to be watertight. I do not use air I just use water and with pressure. Again, those patients doing very well never have any problem with the bowel stricture or something like that.
The last case is segmental bowel resection. This patient, a young woman of 28, every time before her period she would have partial intestinal obstruction signs; cramps, pain just not the typical endometriosis pelvic pain. It was like a bowel obstruction. Then she also had bloody stools. She had a colonoscopy and all the X-rays done and sure enough, there was endometriosis involved, the upper part of the sigmoid colon. This is surgery. I had a gastroenterologist do another colonoscopy for me to identify the lesions. The lesions here, you see them? The gastroenterologist took in the scope. Make sure you delineate the lesion. You can see a tiny bit but actually this lesion is a lot, lot deeper, a lot bigger than what you can visualize from outside. Then, from the point we excised the entire lesion. (I am going to speed up.) When you are doing that this is the...so this is much better with good circulation. So by the time you excise it, the whole thing, it looks like a lot more, this is a pretty big lesion.
Here is a normal mucosa I can see that. This is quite a bit, see how big the lesion is? But the...sigmoid colon has a big lumen. See from here to here? This is about 50 percent. So, I think it is...and you can probably close in...by suture. But, my colorectal surgeon said, "Well, maybe this patient we should do a segmental resection". But, you see with this, if you close transversely she will be okay. Just like old fashion. But, when your colleague says, "I think this probably should be done by segmental resection" I have to go along with him. That is the way we work together. I tried to re-apartment the tissue very quickly so this is a thing...I said, "Well, the lumen is okay and.... mesentery so the suturation is good, we should not have any problem.
But, with your team you have to respect them because they are medically equal or you will have a problem in the team. I let him do it and he did a segmental resection. The only thing that the general surgeon or colorectal surgeon does in bowel surgery is segmental resection. Others we do on our own. Of course this is a...as you can see.
Learn how to suture. If you know how to suture it will take you to the next step in advanced laparoscopic surgery for those who manage the bowel, the bladder and the ureter. As you can see from these few videos if you can do a good suture and tie a good knot you will be very comfortable handling all these things. I am just going to pinch off this video very quickly. I think the 20 minutes is about up. This patient did very well.
Thank you very much.