Laparoscopic Excision of Deep Fibrotic Endometriosis of the Cul-de-sac and Rectum

Diagnosis and treatment of endometriosis is the most frequent reason for gynecologic operative laparoscopy in the United States (Peterson et al,1990). Therefore, the laparoscopist must be thoroughly familiar with the current standards of diagnosis and management of this complex disease. The most common presentations of endometriosis include pelvic pain, infertility, and adnexal mass. The ovaries, the posterior leaf of the broad ligament, and the cul-de-sac of Douglas behind the uterus are the most common locations of endometriosis, and the left side is more frequently affected than the right, as the recto sigmoid and its mesocolon both often involved with endometriosis enter the pelvis from the left side (Redwine,1987;Vercellini et al,1998). Extensive endometriosis refers to bulky deep fibrotic endometriosis deposits that can often be palpated preoperatively as tender pelvic nodules. These nodules consist of endometriotic glands and stroma surrounded by fibromuscular tissue that have accumulated over many years in response to cyclic monthly activation of the endometriosis. They represent a long-standing chronic inflammatory response. Histopathologic examination to document endometriotic glands and stroma is necessary to substantiate a diagnosis of the endometriosis in any suspect lesion. Extensive endometriosis usually involves the posterior cul-de-sac of Douglas, the area surrounded posteriorly by the anterior rectum, anteriorly by the posterior vagina and cervix, and laterally by the uterosacral ligaments. The lesions can often obliterate the normal anatomy of the cul-de-sac, with the rectum sticking to the posterior vagina, cervix, and uterine fundus. One or both pelvic sidewalls overlying the ureters and the rectosigmoid are often affected. Less commonly involved areas include the anterior cul-de-sac (the area above the bladder and the anterior uterus), the appendix, and the small bowel. Extensive bulky endometriosis may also be present in the uterine muscle itself, where it is called adenomyosis. The revised American Fertility Society classification (rAFS, 1985) for endometriosis does not address extensive deep cul-de-sac endometriosis because it does not allow points for intestinal disease. Extensive cul-de-sac disease that does not cause complete obliteration is often classified as Stage 1 or 2. This is the same stage often assigned to women with no endometriosis after the surgeon sees the remains of retrograde menstruation, resembling coffee grounds or tobacco stains. TeLinde and Scott (1952) defined the objectives of surgical treatment of endometriosis in 1952: "one should excise or fulgurate all evident endometriosis." The surgical objectives of laparoscopic treatment are similar (ie, to remove all evident endometriosis by excising large superficial and deep lesions and vaporizing smaller deposits). Laparoscopic surgery can often decrease the considerable and obvious traumas of open laparotomy for conditions that can be managed in a more conservative manner. However, laparoscopic excision of endometriosis can be a frustrating, time-consuming experience. Laparoscopic surgery for endometriosis requires a thorough knowledge of scissors, electrosurgery, carbon dioxide (CO2) laser, and suturing techniques for dissection and hemostasis. The operative advantages of a laparoscopic approach to the cul-de-sac include: