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Evidence-based data for endometriosis management are limited. Experiments are excluded without adequate animal models. Data are limited to symptomatic women and occasional observations. Hormonal medical therapy cannot be blinded if recognised by the patient. Randomised controlled trials are not realistic for surgery, since endometriosis is a variable disease with low numbers. Each diagnosis and treatment is an experiment with an outcome, and experience is the means by which Bayesian updating, according to the past, takes place. If the experiences of many are similar, this holds more value than an opinion. The combined experience of a group of endometriosis surgeons was used to discuss problems in managing endometriosis. Considering endometriosis as several genetically/epigenetically different diseases is important for medical therapy. Imaging cannot exclude endometriosis, and diagnostic accuracy is limited for superficial lesions, deep lesions, and cystic corpora lutea. Surgery should not be avoided for emotional reasons. Shifting infertility treatment to IVF without considering fertility surgery is questionable. The concept of complete excision should be reconsidered. Surgeons should introduce quality control, and teaching should move to explain why this occurs. The perception of information has a personal bias. These are the major problems involved in managing endometriosis, as identified by the combined experience of the authors, who are endometriosis surgeons.

Objective Ovarian pregnancy is a rare but well-known pathology. However, pathophysiology, diagnosis and treatment are not clearly established. Data sources. All case reports published in Pubmed from Nov 2011 till Nov 2022. Study eligibility criteria. A systematic review and 2 case reports of ovarian pregnancy Study appraisal and synthesis methods. Not applicable Results Ovarian pregnancies occur in 8% of women without or blocked oviducts and in 23% on the other side than the corpus luteum and the symptoms of ovarian pregnancies are not specific. Therefore ovarian pregnancy has to be suspected in all women with abdominal bleeding. As for extrauterine pregnancies, the presence of an intrauterine pregnancy does not rule out an ovarian pregnancy. Surgical excision is the preferred treatment. Important is that in women with both an intra-uterine and an ovarian pregnancy, care should be taken not to damage the corpus luteum. Conclusions Ovarian pregnancies can occur in women with blocked tubes, on the other side of the corpus luteum, in the presence of an intrauterine pregnancy, and even when pregnancy tests or tranvaginal ultrasonography are negative. The diagnosis being difficult to exclude, a laparoscopy is indicated in all women with intra-abdominal bleeding, keeping in mind that an intra-uterine pregnancy cannot be exluded and that a corpus luteum need to be respected.

Background CO2 pneumoperitoneum (PP) during laparoscopic surgery, can cause hypoxia and desiccation in the peritoneal mesothelial cell, resulting in a time-dependent retraction and bulging of these cells, an acute inflammatory reaction and enhanced adhesion formation. Since hypoxia is prevented by adding 4% of oxygen (O2) to the CO2 PP, the aim of this study was to evaluate the effect of adding 4% O2 to the CO2 PP on mesothelial cell morphology. Methods In a standardized laparoscopic mouse model (n=8 mice per group), a control group with a 30- or 60-min PP with humidified CO2 + 4% of O2 (groups I and II) was compared to a hypoxic group with 30- or 60-min humidified pure CO2 (groups III and IV) and a desiccation group with 60-min of dry CO2 PP (group V). The effect upon the peritoneum morphology was evaluated by scanning electron microscopy (SEM) of abdominal wall peritoneal biopsies. Biopsies, taken immediately (n=4) and 24 hrs (n=4) after surgery, were compared to a group without PP (group VI, n=4). SEM pictures were blindly scored for cell retraction, deletion of microvilli, fibrin deposition, holes in the epithelial layer and visibility of cell borders using a semi-quantitative scoring system. Results PP Hypoxia (CO2 PP) has a deleterious effect upon mesothelial morphology, immediately (holes: p= 0.04) and 24 hrs later (cell retraction: p=0.005; total score: p=0.03) . Desiccation has also a deleterious effect immediately (microvilli p=0.0090; fibrin deposition p=0.05) and 24 hrs after surgery (cell retraction: p=0.0036; holes: p=0.0004; microvilli: p Conclusions These data confirm that CO2 PP and dry gas have a deleterious effect on mesothelial cell morphology. Humidification of the insufflation gas reduces this deleterious effect. The hypothesis of a protective effect of adding O2 failed to reach significance.

To evaluate the prevalence of endometriosis and peritoneal pockets and to analyze whether these pockets are associated with pain.Analysis of prospectively registered data of all women undergoing laparoscopy for infertility or pelvic pain between 1988 and 2011 at KU Leuven University Hospital.Of 4497 women, 191 had 238 pockets, with a prevalence of 4.7% in women with infertility only, 4.9% in women with infertility and pelvic pain, and 3.5% in women with pelvic pain only (P = 0.045 for all infertility vs. pelvic pain only). Prevalence did not vary by age. Pockets were associated with endometriosis (P 0.0001), which was found in 77% of women with pockets. Among women with infertility only, the prevalence of endometriosis was higher in women with pockets (P = 0.0001) than in women without. The prevalence of endometriosis was similar in women with infertility and pelvic pain or pelvic pain only. Pelvic pain as an indication for surgery was associated simultaneously (through logistic regression) with endometriosis (P 0.0001) and pockets (P = 0.040). Pelvic pain severity was associated simultaneously with pockets (P = 0.0026) and the severity of subtle (P = 0.001), typical (P = 0.030), cystic ovarian (P = 0.051), and deep endometriosis (P 0.0001). Pelvic pain severity was not associated with endometriosis in the pockets or the diameter or location of pockets.The prevalence of pockets was low, at between 3.5% and 5%. Women with infertility only and pockets had more endometriosis than women without. Severe pelvic pain and pelvic pain as an indication for surgery were associated with the presence of pockets as well as the presence and severity of endometriosis.

For 100 years, pelvic endometriosis has been considered to originate from the implantation of endometrial cells following retrograde menstruation or metaplasia. Since some observations, such as the clonal aspect, the biochemical variability of lesions and endometriosis in women without endometrium, the genetic-epigenetic (G-E) theory describes that endometriosis only begins after a series of cumulative G-E cellular changes. This explains that the endometriotic may originate from any pluripotent cell apart from the endometrium, that ‘endometrium-like cells’ can harbour important G-E differences, and that the risk is higher in predisposed women with more inherited incidents. A consequence is a high risk after puberty which decreases progressively thereafter. Considering a 10-year delay between initiation and performing a laparoscopy, this was observed in the United Arab Emirates, Belgium, France and USA. The subsequent growth varies with the G-E changes and the environment but is self-limiting probably because of the immunologic reaction and fibrosis. That each lesion has a different set of G-E incidents explains the variability of pain and the response to hormonal treatment. New lesions may develop, but recurrences after surgical excision are rare. The fibrosis around endometriosis belongs to the body and does not need to be removed. This suggests conservative excision or minimal bowel without safety margins and superficial treatment of ovarian endometriosis. This G-E concept also suggests prevention by decreasing oxidative stress from retrograde menstruation or the peritoneal microbiome. This suggests the prevention of vaginal infections and changes in the gastrointestinal microbiota through food intake and exercise. In conclusion, a higher risk of initiating endometriosis during adolescence was observed in UAE, France, Belgium and USA. This new understanding and the limited growth opens perspectives for earlier diagnosis and better treatment.

To investigate why security of identical knot sequences is variable and how to avoid occasionally insecure knots.A factorial design was used to assess factors affecting the security of half knot (H) and half-hitch (S) knot combinations. The effect of tying forces and the risk factors to transform H knots into S knots were investigated. The risk factors evaluated were as follows: starting with an H1 or H2 instead of an H3 knot, inexperience, short sutures, and monomanual knot tying. Security of transformed knots, S2S1 and S2S2 knots, and their recuperation with 2 additional half hitches, SSb or SbSb, were evaluated.Training center for laparoscopic suturing.Not applicable.Security of knots was evaluated in vitro.The forces that caused knot combinations to open before breaking of the suture were used to calculate the risk of opening with low forces. Tying more strongly increased the security of half knots (H2H1sH1s) (p.02) and half hitches (p.001). The forces needed to transform an H3 into an S3 are higher than those for an H2 (p.001), and the risk increases when the surgeon is inexperienced (p.001), when sutures are short (p.001), and when monomanual knot tying (p.001) is used. Inadvertently made S2S1 and S2S2 knots are dangerous, with the exception of the symmetric S2S2, which is stable. Unstable knots such as S2S1a and S2S2a knot combinations improve with 2 additional blocking half hitches (SbSb), but S2S2aSbSb remains occasionally insecure.To reduce the risk of accidentally transforming a first H into an S knot, it is recommended to start with an H3, tie with force, avoid short sutures, and use bimanual suturing. This permits the recommendation to use preferentially H3H2 knots or 5 half hitches (SSSbSbSb). When in doubt, half knot combinations should be secured with at least 2 blocking half hitches.

Cystic ovarian endometriosis is a cause pain and of infertility. For infertility, surgical treatment has been suggested for cysts larger than 3 or 4cm in diameter only. Surgical treatment is moreover postponed as long as possible or until pain becomes too severe in order to avoid ovarian damage and a decreased ovarian reserve and to avoid recurrences and repeat surgery and adhesion formation. Our recent understanding of the pathophysiology of endometriosis, of its initiation and its growth, probably permits a more effective prevention of recurrences. In addition, adhesion free surgery has become a reality. We therefore suggest performing surgery for cystic ovarian endometriosis early in life when cysts are small followed by an active prevention of recurrences. When cysts are small superficial destruction instead of excision seems logical. Also, THL and under-water coagulation should be considered In conclusion, without discussing the management of larger symptomatic cystic endometriosis, we suggest that early surgical treatment of small cyst is the way to go.

Postoperative adhesions represent a frequent complication of abdominal surgery. Adhesions can result from infection, ischemia, and foreign body reaction, but commonly develop after any surgical procedure. The morbidity caused by adhesions affects quality of life and, therefore, it is paramount to continue to raise awareness and scientific recognition of the burden of adhesions in healthcare and clinical research. This 2021 Global Expert Consensus Group worked together to produce consented statements to guide future clinical research trials and advise regulatory authorities. It is critical to harmonize the expectations of research, to both develop and bring to market improved anti-adhesion therapies, with the ultimate, shared goal of improved patient outcomes.

Ovarian pregnancy is a rare but well-known pathology. However, pathophysiology, diagnosis and treatment are not established. Therefore, all case reports on ovarian pregnancy published in PubMed from November 2011 till November 2022 were reviewed and two case reports were added. In these 84 case reports, 8% of ovarian pregnancies occurred in women without or with blocked oviducts and 23% were localised on the other side than the corpus luteum. Since symptoms are not specific, ovarian pregnancy has to be suspected in all women with abdominal bleeding. Surgical excision is the preferred treatment. However, since an associated intra-uterine pregnancy cannot be excluded, care should be taken not to interrupt this intra-uterine pregnancy with the uterine cannula or by damaging the corpus luteum. In conclusion, in women with abdominal bleeding, an ovarian pregnancy cannot be excluded, even in women with a negative pregnancy test or an empty uterus on transvaginal ultrasonography. Therefore, a laparoscopy is indicated but the surgeon should realise that an associated intra-uterine pregnancy also cannot be excluded and that therefore care should be taken not to interrupt this intra-uterine pregnancy by the uterine cannula or by damaging the corpus luteum.

Background and Objective: to study the natural history of endometriosis. Materials and methods: the analysis of all women (n=2086) undergoing laparoscopy for pelvic pain and endometriosis between 1988 and 2011 at University Hospital Gasthuisberg. Main outcome measures: the severity of subtle, typical, cystic and deep endometriosis in adult women, with or without a pregnancy, as estimated by their pelvic area and their volume. Results: the number of women undergoing a laparoscopy increased up to 28 years of age and decreased thereafter. Between 24 and 44 years, the severity and relative frequencies of subtle, typical, cystic and deep lesions did not vary significantly. The number of women younger than 20 years was too small to ascertain the impression of less severe lesions. The severity of endometriosis lesions was not less in women with 1 or more previous pregnancies or with previous surgery. There was no bias over time since the type and severity of endometriosis lesions remained constant between 1988 and 2011. Conclusions: severity of endometriosis does not increase between 24 and 44 years of age, suggesting that growth is limited by intrinsic or extrinsic factors. Severity was not lower in women with a previous pregnancy. What is new: considering the time needed for lesions to become symptomatic together with the diagnostic delay, the decreasing number of laparoscopies after age 28 is compatible with a progressively declining risk of initiating endometriosis lesions after menarche, the remaining women being progessively less susceptible.

OBJECTIVE: To study the pathophysiology of endometriosis. DESIGN: Overview of observations on endometriosis. SETTING: Not applicable. PATIENT(S): None. INTERVENTIONS(S): None. MAIN OUTCOME MEASURE(S): The hypothesis is compatible with all observations. RESULT(S): Endometriosis, endometrium-like tissue outside the uterus, has a variable macroscopic appearance and a poorly understood natural history. It is a hereditary and heterogeneous disease with many biochemical changes in the lesions, which are clonal in origin. It is associated with pain, infertility, adenomyosis, and changes in the junctional zone, placentation, immunology, plasma, peritoneal fluid, and chronic inflammation of the peritoneal cavity. The Sampson hypothesis of implanted endometrial cells following retrograde menstruation, angiogenic spread, lymphogenic spread, or the metaplasia theory cannot explain all observations if metaplasia is defined as cells with reversible changes and an abnormal behavior/morphology due to the abnormal environment. We propose a polygenetic/polyepigenetic mechanism. The set of genetic and epigenetic incidents transmitted at birth could explain the hereditary aspects, the predisposition, and the endometriosis-associated changes in the endometrium, immunology, and placentation. To develop typical, cystic ovarian or deep endometriosis lesions, a variable series of additional transmissible genetic and epigenetic incidents are required to occur in a cell which may vary from endometrial to stem cells. Subtle lesions are viewed as endometrium in a different environment until additional incidents occur. Typical cystic ovarian or deep endometriosis lesions are heterogeneous and represent three different diseases. CONCLUSION(S): The genetic epigenetic theory is compatible with all observations on endometriosis. Implications for treatment and prevention are discussed. ispartof: FERTILITY AND STERILITY vol:111 issue:2 pages:327-340 ispartof: location:United States status: published

Endometriosis and pelvic pain are associated. However, only half of the subtle and typical, and not all cystic and deep lesions are painful. The mechanism of the pain is explained by cyclical trauma and repair, an inflammatory reaction, activation of nociceptors up to 2.7 cm distance, painful adhesions and neural infiltration. The relationship between the severity of lesions and pain is variable. Diagnosis of the many causes requires laparoscopy and expertise. Imaging cannot exclude endometriosis. Surgical removal is the treatment of choice. Medical therapy without a diagnosis risks missing pathology and chronification of pain if not 100% effective. Indications and techniques of surgery are described as expert opinion since randomised controlled trials were not performed for ethical reasons, since not suited for multimorbidity while a control group is poorly accepted. Subtle endometriosis needs destruction since some cause pain or progress to more severe disease. Typical lesions need excision or vaporisation since depth can be misjudged by inspection. Painful cystic ovarian endometriosis needs adhesiolysis and either destruction of the lining or excision of the cyst wall, taking care to avoid ovarian damage. Cysts larger than 6 cm need a two-step technique or an ovariectomy. Excision of deep endometriosis is difficult and complication prone surgery involving bladder, ureter, and bowel surgery varying from excision and suturing, disc excision with a circular stapler and resection anastomosis. Completeness of excision, prevention of postoperative adhesions and recurrences of endometriosis, and the indication to explore large somatic nerves will be discussed.

As the diagnosis requires a laparoscopy, we only have data in women with pain and/or infertility. Endometriosis has been considered to be a single disease defined as 'endometrium like glands and stroma outside the uterus'. However, subtle, typical, cystic ovarian and deep endometriosis lesions should be considered to be different pathologies which occur in all combinations and with different severities. All large datasets, especially those based on hospital discharge records, consider endometriosis to be a single disease without taking into account severity. In particular, the variable prevalence and recognition of subtle lesions is problematic. Reliable surgical data are small series not permitting multivariate analysis. Endometriosis is a hereditary disease. The oxidative stress of heavy menstrual bleeding with retrograde menstruation and an altered pelvic microbiome are probably associated with increasingly severe endometriosis. Whether the prevalence is increasing, or whether endometriosis is associated with fat intake or an increased risk of cardiovascular disease is unclear. ispartof: BEST PRACTICE & RESEARCH CLINICAL OBSTETRICS & GYNAECOLOGY vol:71 pages:14-26 ispartof: location:Netherlands status: published

The management of deep endometriosis of the bowel remains debated. A discussion of the management needs to define deep endometriosis, to understand the accuracy and pitfalls of the diagnosis, and to consider postoperative complications, for the rest of the life bladder, bowel and sexual problems together with the results concerning pain, infertility and quality of life.

The histological definition of endometriosis does not take into account surgical observations as vascularization and depth of infiltration.

Objective The objective of this video is to demonstrate different clinical presentations of peritoneal defects (peritoneal retraction pockets) and their anatomic relationships with the pelvic innervation, justifying the occurrence of some neurologic symptoms in association with these diseases. Design Surgical demonstration of complete excision of different types of peritoneal retraction pockets and a comparison with a laparoscopic retroperitoneal cadaveric dissection of the pelvic innervation. Setting Private hospital in Curitiba, Parana, Brazil. Interventions A pelvic peritoneal pocket is a retraction defect in the surface of the peritoneum of variable size and shapes [1] . The origin of defects in the pelvic peritoneum is still unknown [2] . It has been postulated that it is the result of peritoneal irritation or invasion by endometriosis, with resultant scarring and retraction of the peritoneum [ 3 , 4 ]. It has also been suggested that a retraction pocket may be a cause of endometriosis, where the disease presumably settles in a previously altered peritoneal surface [5] . These defects are shown in many studies to be associated with pelvic pain, dyspareunia, and secondary dysmenorrhea 1 , 2 , 3 , 4 . Some studies have shown that the excision of these peritoneal defect improves pain symptoms and quality of life [5] . It is important to recognize peritoneal pockets as a potential manifestation of endometriosis because in some cases, the only evidence of endometriosis may be the presence of these peritoneal defects [6] . In this video, we demonstrate different types of peritoneal pockets and their close relationship with pelvic anatomic structures. Case 1 is a 29-year-old woman, gravida 0, with severe dysmenorrhea and catamenial bowel symptoms (bowel distension and diarrhea/constipation) that were unresponsive to medical treatment. Imaging studies were reported as normal, and a laparoscopy showed a posterior cul-de-sac peritoneal pocket infiltrating the pararectal fossa, with extension to the lateral border of the rectum. Case 2 is a cadaveric dissection of a posterior cul-de-sac peritoneal pocket infiltrating the pararectal fossa, with extension to the pelvic sidewall. After dissection of the obturator fossa, we can observe that the pocket is close to the sacrospinous ligament, pudendal nerve, and some sacral roots. Case 3 is a 31-year-old woman, gravida 1, para 1, with severe dysmenorrhea that was unresponsive to medical treatment and catamenial bowel symptoms (catamenial bowel distention and diarrhea). Imaging studies were reported as normal and a laparoscopy showed left uterosacral peritoneal pocket infiltrating the pararectal fossa in close proximity to the rectal wall. Case 4 is a cadaveric dissection of the ovarian fossa and the obturator fossa showing the proximity between these structures. Case 5 is a 35-year-old woman, gravida 0, with severe dysmenorrhea that was unresponsive to medical treatment, referring difficulty, and pain when walking only during menstruation. A neurologic physical examination revealed weakness in thigh adduction, and the magnetic resonance imaging showed no signs of endometriosis. During laparoscopy, we found a peritoneal pocket infiltrating the ovarian fossa, with involvement in the area between the umbilical ligament and the uterine artery. This type of pocket can easily reach the obturator nerve. Because the obturator nerve and its branches supply the muscle and skin of the medial thigh [ 7 , 8 ], patients may present with thigh adduction weakness or difficulty ambulating [ 9 , 10 ]. Case 6 is a cadaveric dissection of the sacrospinous ligament and the pudendal nerve from a medial approach, between the umbilical artery and the iliac vessels. Case 7 is a 34-year-old woman, gravida 1, para 1, with severe dysmenorrhea and catamenial bowel symptoms as well as deep dyspareunia. The transvaginal ultrasound showed focal adenomyosis and a 2-cm nodule, 9-cm apart from the anal verge, affecting 30% of the bowel circumference. In the laparoscopy, we found a posterior cul-de-sac retraction pocket associated with a large deep endometriosis nodule affecting the vagina and the rectum. In all cases, endometriosis was confirmed by histopathology, and in a 6-month follow-up, all patients showed improvement of bowel, pain, and neurologic symptoms. Conclusion Peritoneal pockets can have different clinical presentations. Depending on the topography and deepness of infiltration, they can be the cause of some neurologic symptoms associated with endometriosis pain. With this video, we try to encourage surgeons to totally excise these lesions and raise awareness about the adjacent key anatomic structures that can be affected.

ispartof: BJOG-AN INTERNATIONAL JOURNAL OF OBSTETRICS AND GYNAECOLOGY vol:126 issue:11 pages:1402-1403 ispartof: location:England status: published

BackgroundTo review women with symptomatic and clinically progressive endometriosis after menopause in the absence of estrogen intake or excessive systemic endogenous production.DesignSeven case reports and a systematic review of the literature from 1995 till February 2018.ResultsOnly 7 case reports from the authors and 29 cases from the literature described women with either cystic ovarian or deep endometriosis. Severity, symptoms, and localization are highly variable. No case report describes symptomatic superficial typical lesions. In 22 of 36 women (61%), symptoms started more than 10 years after menopause.ConclusionsSymptomatic and clinically progressive endometriosis after menopause in the absence of increased systemic estrogen concentrations or exogenous estrogen intake starts more than 10 years after menopause in the majority of women. This observation suggests that a genetic and/or epigenetic incident caused estrogen-independent progression, increased sensitivity to estrogens or increased local production of estrogens. This observation is important for understanding the pathophysiology of endometriosis, for the management of postmenopausal endometriosis, and for individualization of medical therapy of endometriosis since estrogen-independent endometriosis growth probably also occurs before menopause.

"Microsurgery" is a set of principles developed to improve fertility surgery outcomes. These principles were developed progressively based on common sense and available evidence, under control of clinical feedback obtained with the use of second-look laparoscopy. Fertility outcome was the end point; significant improvement in fertility rates validated the concept clinically. Postoperative adhesion formation being a major cause of failure in fertility surgery, the concept of microsurgery predominantly addresses prevention of postoperative adhesions. In this concept, magnification with a microscope or laparoscope plays a minor role as technical facilitator. Not surprisingly, the principles to prevent adhesion formation are strikingly similar to our actual understanding: gentle tissue handling, avoiding desiccation, irrigation at room temperature, shielding abdominal contents from ambient air, meticulous hemostasis and lavage, avoiding foreign body contamination and infection, administration of dexamethasone postoperatively, and even the concept of keeping denuded areas separated by temporary adnexal or ovarian suspension. The actual concepts of peritoneal conditioning during surgery and use of dexamethasone and a barrier at the end of surgery thus confirm without exception the tenets of microsurgery. Although recent research helped to clarify the pathophysiology of adhesion formation, refined its prevention and the relative importance of each factor, the clinical end point of improvement of fertility rates remains demonstrated for only the microsurgical tenets as a whole. In conclusion, the principles of microsurgery remain fully valid as the cornerstones of reproductive microsurgery, whether performed by means of open access or laparoscopy.

A surgical trauma results within minutes in exudation, platelets, and fibrin deposition. Within hours, the denuded area is covered by tissue repair cells/macrophages, starting a cascade of events. Epithelial repair starts on day 1 and is terminated by day 3. If repair is delayed by decreased fibrinolysis, local inflammation, or factors in peritoneal fluid, fibroblast growth starting on day 3 and angiogenesis starting on day 5 results in adhesion formation. For adhesion formation, quantitatively more important are factors released into the peritoneal fluid after retraction of the fragile mesothelial cells and acute inflammation of the entire peritoneal cavity. This is caused by mechanical trauma, hypoxia (e.g., CO 2 pneumoperitoneum), reactive oxygen species (ROS; e.g., open surgery), desiccation, or presence of blood, and this is more severe at higher temperatures. The inflammation at trauma sites is delayed by necrotic tissue, resorbable sutures, vascularization damage, and oxidative stress. Prevention of adhesion formation therefore consists of the prevention of acute inflammation in the peritoneal cavity by means of gentle tissue handling, the addition of more than 5% N 2 O to the CO 2 pneumoperitoneum, cooling the abdomen to 30°C, prevention of desiccation, a short duration of surgery, and, at the end of surgery, meticulous hemostasis, thorough lavage, application of a barrier to injury sites, and administration of dexamethasone. With this combined therapy, nearly adhesion-free surgery can be performed today. Conditioning alone results in some 85% adhesion prevention, barriers alone in 40%–50%.

Endometriosis is known as a cause of pelvic pain and infertility. The epidemiology of endometriosis is important since the prevalence and severity of endometriosis might be linked to pollution and to our modern lifestyle, comprising food intake, chemical disruptors, postponement of the first pregnancy, and stress, as indicated by “a career women’s disease.” Epidemiological data based upon hospital discharge records should be viewed with caution. Indeed, that subtle lesions are considered pathology causes a major increase in prevalence, while the laparoscopic recognition and histological confirmation of subtle and typical lesions vary with the expertise and interest of the surgeon. The epidemiological data published by surgical groups on severe forms, as cystic and deep endometriosis, have a referral bias and lack the numbers required for meaningful statistics. Fundamental to understanding epidemiology of endometriosis is that it is unclear that all presentations of endometriosis constitute one disease. We therefore performed a systematic review of the incidences and severity of subtle, typical, cystic, and deep endometriosis lesions separately. The only data found were that severe endometriosis carries a greater hereditary risk and that the prevalence of subtle endometriosis decreases with age whereas the prevalences of typical, cystic, and deep endometriosis increase with age. Surgeons that witnessed over the last 20 years in over 1000 interventions each the evolution of deep endometriosis, however, had a strong impression that severity and prevalence of deep endometriosis are increasing. In conclusion, there are no solid epidemiologic data of each type of endometriosis separately. With all restrictions imposed by the referral bias and by a clinical impression, the consistency of the observation of deep endometriosis surgeons should be a reason for concern. The investigation of the epidemiology of deep endometriosis is suggested since it is relevant because it is clinically severe pathologic and feasible since it can be done from hospital-based records. Indeed, most women will ultimately have surgery with solid information on severity and an unbiased diagnosis if defined as “adenomyosis externa.”

STUDY OBJECTIVE: To investigate the security of various knot combinations in laparoscopic surgery. DESIGN: Prospective nonrandomized trial (Canadian Task Force classification II). SETTING: Storz Training Centre, Sao Paulo, Brazil. INTERVENTION: Different knot combinations (n = 2000) were performed in a laparoscopic trainer. Dry or wet 2.0 polyglycolic acid or dry 2-0 poliglecaprone 25 was used. The tails were cut at 10 mm, and the loops were tested in a dynamometer. The primary endpoints were the forces at which the knot combination opened or at which the suture broke. Resulting tail lengths were measured. MEASUREMENTS AND MAIN RESULTS: Surprisingly, the combination of a 2-throw half knot (H2) and a symmetric 1-throw half knot (H1s) (a surgical flat knot) opened at

Background Microsurgical tenets and peritoneal conditioning during laparoscopic surgery (LS) decrease postoperative adhesions and pain. For a trial in human, the strong beneficial effects of N2O needed to be confirmed in open surgery (OS). Results In a mouse model for OS, the effect of the gas environment upon adhesions was evaluated. Experiment I evaluated desiccation and the duration of exposure to CO2, N2O or CO2 + 4%O2. Experiment II evaluated the dose-response curve of adding N2O to CO2. Experiment III compared humidified CO2 + 10% N2O during LS and OS. In OS, 30- and 60-min exposure to non-humidified CO2 caused mortality of 33 and 100%, respectively. Mortality was prevented by humidification, by dry N2O or dry CO2 + 4%O2. Adhesions increased with the duration of exposure to CO2 (p 2. N2O strongly decreased adhesions at concentrations of 5% or greater. With humidified CO2 + 10% N2O, adhesion formation was similar in OS and LS. Conclusions The drug-like and strong beneficial effect of low concentrations of N2O is confirmed in OS.

BACKGROUND AND OBJECTIVES: Laparoscopic surgical excision of bladder nodules has been demonstrated to be effective in relieving associated painful symptoms; the data are lacking concerning the impact of anterior compartment endometriosis on infertility. We conducted this study to evaluate whether or not the surgical excision of deep endometriosis affecting the anterior compartment plays a role in restoring fertility. METHODS: This multicentre, retrospective study included a group of 55 patients presenting with otherwise-unexplained infertility who had undergone laparoscopic excision of anterior compartment endometriosis with histological confirmation. Patient medical records and operative reports were reviewed. Telephone interviews were conducted for long-term followup of fertility outcomes. RESULTS: The pregnancy rate following surgical excision of endometriotic lesions was 44% (n = 11) among those with anterior compartment involvement alone and 50% (n = 15) in case of posterior lesions association without any significant difference. The symptoms related to bladder endometriosis resolved in the 84.2% of the cases with a recurrence rate of 1.8% at the 2-year followup not requiring further surgery. CONCLUSION: Laparoscopic excision of anterior compartment endometriosis is effective in restoring fertility in patients with otherwise-unexplained infertility and in treating endometriosis-related symptoms. ispartof: JSLS-JOURNAL OF THE SOCIETY OF LAPAROENDOSCOPIC SURGEONS vol:22 issue:4 ispartof: location:United States status: published

The health care and the emotional cost of postoperative adhesions that frequently cause chronic pain, infertility, bowel obstruction, and repeat surgery are well known. Our understanding of the pathophysiology of adhesion formation and of its prevention has evolved from good surgical practice based on microsurgical principles, barriers to keep denuded areas separated to the prevention of mesothelial cell damage and of acute inflammation in the entire peritoneal cavity. Oxidative stress, in the surgical lesions and in the peritoneal cavity has an important role in adhesion formation by slowing down repair. This has resulted in virtually adhesion-free surgery, in addition with less CO2 resorption, less postoperative pain, and a faster recovery. The clinical efficacy had been demonstrated by higher pregnancy rates (PRs) using microsurgical tenets.

Evidence based medical and surgical therapies of endometriosis remain debated. A discussion of their limitations and pitfalls might help the clinician.

Background Microsurgical tenets and peritoneal conditioning during laparoscopic surgery (LS) decrease postoperative adhesions and pain. For a trial in human, the strong beneficial effects of N2O needed to be confirmed in open surgery (OS). Results In a mouse model for OS, the effect of the gas environment upon adhesions was evaluated. Experiment I evaluated desiccation and the duration of exposure to CO2, N2O or CO2 + 4%O2. Experiment II evaluated the dose-response curve of adding N2O to CO2. Experiment III compared humidified CO2 + 10% N2O during LS and OS. In OS, 30- and 60-min exposure to non-humidified CO2 caused mortality of 33 and 100%, respectively. Mortality was prevented by humidification, by dry N2O or dry CO2 + 4%O2. Adhesions increased with the duration of exposure to CO2 (p

The pathophysiology of (deep) endometriosis is still unclear. As originally suggested by Cullen, change the definition "deeper than 5 mm" to "adenomyosis externa." With the discovery of the old European literature on uterine bleeding in 5%–10% of the neonates and histologic evidence that the bleeding represents decidual shedding, it is postulated/hypothesized that endometrial stem/progenitor cells, implanted in the pelvic cavity after birth, may be at the origin of adolescent and even the occasionally premenarcheal pelvic endometriosis. Endometriosis in the adolescent is characterized by angiogenic and hemorrhagic peritoneal and ovarian lesions. The development of deep endometriosis at a later age suggests that deep infiltrating endometriosis is a delayed stage of endometriosis. Another hypothesis is that the endometriotic cell has undergone genetic or epigenetic changes and those specific changes determine the development into deep endometriosis. This is compatible with the hereditary aspects, and with the clonality of deep and cystic ovarian endometriosis. It explains the predisposition and an eventual causal effect by dioxin or radiation. Specific genetic/epigenetic changes could explain the various expressions and thus typical, cystic, and deep endometriosis become three different diseases. Subtle lesions are not a disease until epi(genetic) changes occur. A classification should reflect that deep endometriosis is a specific disease. In conclusion the pathophysiology of deep endometriosis remains debated and the mechanisms of disease progression, as well as the role of genetics and epigenetics in the process, still needs to be unraveled.

Background A Spigelian hernia is a rare hernia through the Spigelian fascia between the rectus muscle and the semilunar line. This hernia is well known in surgery. Symptoms vary from insidious to localised pain, an intermittent mass and/or a bowel obstruction. Results The Spigelian hernia is poorly known in gynaecology. Spigelian hernias may be causally related to secondary trocar insertion. This review is written to increase awareness in gynaecology and is illustrated by a case report in which the diagnosis was missed for 4 years even by laparoscopy. Smaller hernias risk not to be diagnosed and will thus not be treated. Even larger Spigelian hernias might not be recognised and treated appropriately. Conclusions The gynaecologist should consider a Spigelian hernia in women with localised pain in the abdominal wall lateral of the rectus muscle some 5 cm below the umbilicus. Smaller hernias can be closed by laparoscopy without a mesh. Larger hernias require a mesh repair.

Purpose The addition of 4 % O2 and 10 % N2O to the CO2 pneumoperitoneum (PP), together with slight cooling and humidification (conditioning), contributes to reducing adhesions by preventing mesothelial damage. We investigated the effect of peritoneal damage during laparoscopy on tumor implantation. Methods In Experiment 1, different tumor cell concentrations were injected into control mice without PP and into mice with 60-min dry CO2PP (mesothelial damage). In Experiment 2, tumor cells were injected into control mice (group I) and in mice with mesothelial damage (group II). In groups III to VI, mesothelial damage was decreased by adding humidification, humidification + 10 % N2O, humidification + 10 % N2O + 4 % O2, and conditioning, respectively. Results In Experiment 1, the tumors increased with the number of cells injected and with mesothelial damage in the abdominal cavity (p = 0.018) and abdominal wall (p 2PP increased the number of tumors in the abdominal cavity and wall (p = 0.026 and p = 0.003, respectively). The number of tumors was decreased in the abdominal cavity by conditioning (p = 0.030) and in the abdominal wall using humidified CO2 (p = 0.032) or conditioning (p = 0.026). Conclusions Tumor implantation was enhanced by peritoneal damage (60 min of dry CO2PP and desiccation), but this was prevented by conditioning. If confirmed in humans, conditioning would become important for oncologic surgery.

ispartof: FERTILITY AND STERILITY vol:110 issue:3 pages:406-407 ispartof: location:United States status: published

Objective To evaluate the effect of addition of nitrous oxide (N 2 O) to the carbon dioxide (CO 2 ) pneumoperitoneum (PP) and the effect of blood, plasma, or red blood cells (RBCs) on postoperative adhesions in a laparoscopic mouse model. Design Prospective randomized controlled trial. Setting University laboratory research center. Animal(s) BALB/c female mice. Intervention(s) The effect of adding to the 60-minute CO 2 PP 5%, 10%, 25%, 50%, or 100% N 2 O on adhesion formation was evaluated. Subsequently the effect of adding 1 mL blood, or RBCs, or plasma and the effect of adding different concentrations of blood were studied. Finally, the effect of adding 10% N 2 O, 4% O 2 , or both to the CO 2 was evaluated in a control group and after addition of blood. Main Outcome Measure(s) Postoperative adhesions after 7 days. Result(s) N 2 O strongly reduces adhesion formation with a full effect at a concentration of 5% or 10%. Adhesions increase linearly with 0.125 mL to 1 mL blood. In both the control group and after adding blood, 10% N 2 O is the most effective factor in prevention of adhesions. Conclusion(s) N 2 O, from concentrations of 5% upward, strongly prevents adhesion formation. Blood, mainly the plasma, increases adhesion formation. These data extend the concept of the role of acute inflammation and support the importance of good surgical practice with little bleeding and peritoneal cavity conditioning in adhesion prevention.

BACKGROUND: Endometriosis is associated with an inflammatory response. Hence infliximab, an anti-TNF-alpha monoclonal antibody, might relieve pain. METHODS: A randomized placebo-controlled trial was designed with 21 women with severe pain and a rectovaginal nodule of at least 1 cm. After 1 month of observation, three infusions of infliximab (5 mg/kg) or placebo were given. Surgery was performed 3 months later and follow-up continued for 6 months. The primary end-point was pain (dysmenorrhea, deep dyspareunia and non-menstrual pain) rated at each visit by the clinician and on a daily basis by the patient who in addition scored pain by visual analog pain scale and analgesia intake. Secondary end-points included the volume of the endometriotic nodule, pelvic tenderness and the visual appearance of endometriotic lesions at laparoscopy. RESULTS: Pain severity decreased during the treatment by 30% in both the placebo (P < 0.001) and infliximab groups (P < 0.001). However, no effect of infliximab was observed for any of the outcome measures. After surgery, pain scores decreased in both groups to less than 20% of the initial value. CONCLUSIONS: Infliximab appears not to affect pain associated with deep endometriosis. Treatment is associated with an important placebo effect. After surgery, pain decreases to less than 20%. Trials registration number ClinicalTrials.gov: NCT00604864.