Page 41 - WALS Journal

World Journal of Laparoscopic Surgery, May-August 2008;1(2):44-48
Nada Abid Al-Hur Al Ebrahimi
Laparoscopic Excision of Endometrioma

Nada Abid Al-Hur Al Ebrahimi
Diploma in Minimal Access Surgery, Najaf, Iraq

INTRODUCTION give rise to deposits in distant sites such as the umbilicus, the
pleural cavity, and even the brain. 8,9
Endometriosis can have a significant impact on the sufferer, the Risk factors generally relate to exposure to menstruation:
gynecologist and the health care system. For the sufferer, quality early menarche and late menopause increase the risk whereas
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of life may be significantly decreased. For the gynecologist it the use of oral contraceptives reduces. 5
constitutes a considerable workload, accounting for 10–15% of
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new referrals. For the surgeon, the diagnosis and treatment of What is the natural course of endometriosis?
endometriosis accounts for 25–35% of laparoscopies and

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10–15% of hysterectomies each year. Finally for the health Studying the natural course is difficult because of the need for

care system, endometriosis imposes considerable costs; direct repeat laparoscopy. Two studies in which laparoscopy was

costs of surgical therapy are estimated at US$5805 and for repeated after treatment in women given placebo, however,

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medical treatments US$2418. The indirect costs of time away reported that over 6-12 months, endometrial deposits resolved

from employment, the burden of pain and its impact on quality spontaneously in up to a third of women, deterioratedin nearly
of life are also recognized. Surgical treatment of endometriosis half, and were unchanged in the remainder. 12,13
may be effective in relieving dysmenorrhea, dyspareunia, non-
menstrual pelvic pain and dyschesia. 24,27 It is most common in Diagnosis of Endometriosis
the pelvic cavity, including the ovaries, the uterosacral What Features of History and Examination are Important?
ligaments, and pouch of Douglas. Common symptoms include
dysmenorrhea, dyspareunia, non-cyclic pelvic pain, and In women of reproductive age who present with recurrent
subfertility. The clinical presentation is variable, with some dysmenorrhea or pelvic pain you should take a full history of
women experiencing several severe symptoms and others reproduction and carry out a pelvic examination. The cyclical
having no symptoms at all. The prevalence in women without nature of the pain and the relation of the pain to menstruation
points to the diagnosis of endometriosis. Painful micturition,
symptoms is 2-50%, depending on the diagnostic criteria used defecation, and dyspareunia are also associated. In young
and the populations studied. The incidence is 40-60% in women women you should consider other diagnoses such as pelvic
with dysmenorrhea and 20-30% in women with subfertility. 1-3 infection, problems in early pregnancy, ectopic pregnancy,
The severity of symptoms and the probability of diagnosis ovarian cyst torsion, and appendicitis (Table 1). During pelvic
4
increase with age. The most common age of diagnosis is examination, tenderness in the posterior fornix or adnexa,
reported as around 40, although this figure came from a study nodules in the posterior fornix, or adnexal masses may indicate
in a cohort of women attending a family planning clinic. 5 endometriosis. Adolescents presenting with dysmenorrhea do
Symptoms and laparoscopic appearance do not always not require a pelvic examination as disease is uncommon.
correlate. The American Society for Reproductive Medicine Transvaginal ultrasonography can reliably detect
has published a classification of severity of endometriosis at endometriomata (cysts of endometriosis), but failure to reveal
laparoscopy. cystic structures does not exclude the diagnosis of
Several factors are thought to be involved in the endometriosis. 3,14 Magnetic resonance imaging is increasingly
development of endometriosis. Retrograde menstruation used to identify subperitoneal deposits, although retroversion,
remains the dominant theory for the development of pelvic endometriomata, and bowel structures may mask small
endometriosis, though as this is almost universal it is unlikely nodules. 4,15 Although concentrations of the cancer antigen
7-9
to be the sole explanation. The quantity and quality of CA125 are slightly raised in some women with endometriosis,
endometrial cells, failure of immunological mechanisms, the test neither excludes nor diagnoses endometriosis and is
5
angiogenesis, and the production of antibodies against not considered useful in establishing the diagnosis. The
endometrial cells may also have a role. 10,11 Embryonic cells may threshold for surgery is unlikely to be influenced by the CA125

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