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A Surgery on DIER; Cullen vs Sampson
Cullen was teaching and provided mentorship. In this period at 1980s to advance my skills. His vision included that gynecologists
Johns Hopkins, Sampson published 17 articles and book reviews on who would manage women with endometriosis should develop
various medical disorders, including gynecological subjects as well their laparoscopic skills to an advanced level and also be competent
as surgeries on the pelvic ureter. In 1908, Sampson reviewed Cullen’s in the broader context of abdominal surgery in order to manage
book on Adenomyomata of the Uterus for Annals of Surgery, a colorectal and urogenital aspects, as these areas were often
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book that undoubtedly captured his imagination and influenced involved. Some of Bruhat’s protégés have reached very high
his future research path. Thereafter, Sampson moved into private levels of expertise and undertake segmental bowel resections
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practice in Albany, New York, and was attached to Albany Medical using linear and circular stapling devices. However, I, along with
College where he became Professor of Gynecology through to his most gynecologists who have advanced laparoscopy skills, shy
retirement in 1945. away from resections, preferring to follow the advice of those like
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At Albany, Sampson developed our current understanding of Jacques Donnez that “at the level of the bowel, a ring of fibrosis
the condition of endometriosis, including its pathogenesis. In 1913, may be left behind” without any future concern. The decision of
he described vascular features related to uterine myoma and the which approach to follow must undoubtedly depend upon case
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unique venous drainage underlying abnormal uterine bleeding. In numbers managed, as using the stapling device requires a practiced
1918, he demonstrated a metastatic mechanism that can form the skill. Given that my group has recognized only 30 such cases over
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basis of a theory for endometriosis in unusual locations. His better- a 30 years period involving laparoscopic excisional surgery for
known theory of an implantation mechanism following retrograde around 4,000 cases of endometriosis and adenomyosis, the idea of
menstruation was a later idea published in 1927. 9 developing competency with bowel-resection devices was simply
Sampson also discussed the clinical management of too foreboding. 9
adenomyosis involving the rectovaginal septum, with viewpoints
contrary to those of Cullen. In 1921, he described operations on 23 conclusIon
cases of deep infiltrating rectovaginal endometriosis, concluding
“I have never resorted to the extremely radical operations This commentary is presented in response to the recent RCT
(referring to bowel resections). I have purposely kept close to the study reported from France which applied advanced statistics to
uterus, undoubtedly sometimes leaving adenoma in the rectal evaluate the surgical management of DIER – either by colorectal
wall”. All these cases had hysterectomy with bilateral salpingo- resection/re-anastomosis or by a more conservative surgical
oophorectomy (strongly advising not to leave any ovarian tissue procedure involving nodular resection. The clinical outcomes were
in order to ensure that the endometriosis tissue would regress). similar, undoubdtedly because the surgeons were each utilizing
Sampson stated that “on the whole, the results have been quite the procedure with which they were comfortable. Of course, I am
satisfactory because the growth is usually only mildly invasive”. 9 very pleased that my conservative surgery was not found to be
statistically inferior from those who undertook bowel resections,

pAthogenesIs of AdenomyosIs And dIe but I remain in admiration of their ability to avoid complications.

As a laparoscopic surgeon with 47 years of experience, I am
As mentioned earlier, in 1918, Sampson demonstrated a metastatic also perplexed at the perceived need to subject every medical
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mechanism that, I believe, forms the basis of a theory for process and surgical procedure to an RCT while completely ignoring
endometriosis in unusual locations, including the cul-de-sac as an the historical evolution of the subject. With respect to the sister
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extension from areas of adenomyosis in the posterior uterine wall. conditions of endometriosis and adenomyosis, I have always turned
It also explains the mechanism for the formation of adenomyosis to John Sampson for the best advice; his descriptive articles from a
within the uterus when the protective “anemic zone” of venules is century ago have been, for me, fully clarifying.
disrupted. In cases where the uterus is distorted by either being
deeply retroverted and retroflexed, particularly if it also included Acknowledgments
myomata, this predilects to the formation of adenomyosis in the
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posterior wall. Sampson described these underlying uterine I thank those colleagues who assisted me to establish advanced
features in two-thirds of his cases of DIER. His better-known laparoscopic skills for treating the infertility-related conditions
theory of implantation following retrograde menstruation was of endometriosis, adenomyosis and leiomyomata. Their patience
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a later idea published in 1927 and which, while explaining the and support have also enabled them to develop the necessary
majority of peritoneal endometriosis, does not really explain DIER advanced skills for the preparation of young women undergoing
or endometriosis located in unusual, even extrapelvic sites. The fertility-related management. This was achieved by surrounding
latter are, to my mind, well explained by the metastatic process, the patient with three gynecologists at different stages of career
and such needs to be understood when undertaking surgical development (operator, assistant, and bottom-end manipulator) for
corrections. This means the surgical procedure should include advanced surgeries. This meant income opportunities were diluted
ventrosuspension of the uterus and remove all leiomyomata along but their names are reflected in our collaborative publications over
with resection of adenomyoma in addition to en bloc excision of these 40 years.
the rectovaginal nodules.
references
1. Roman H, Tuech JJ, Huet E, et al. Excision vs colorectal resection
nodulAr excIsIon vs bowel resectIon for in deep endometriosis infiltrating the rectum: 5 year follow-up of

DIER patients enrolled in a randomised controlled trial. Hum Reprod
2019;34(12):2362–2371. DOI: 10.1093/humrep/dez217.
Having adopted laparoscopy in 1973, I attended the facility in 2. Cullen TS. Adenomyoma of the Uterus. Philadelphia: W. B. Saunders;
Clermont-Ferrand, France, headed by Maurice Bruhat in the early 1908. p. 294.

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