Download - Excision of Endometriosis - Fallopian Tube Serosa

©2012, the Lumenis Group of Companies. All rights reserved. Lumenis, its logo, UltraPulse and SurgiTouch are trademarks or registered trademarks of the Lumenis Group of Companies. Specifications are subject to change without notice. PB-1143470 Rev. A

Technique Guide | September 2012 | of 6

CASE INTRODUCTION

Anatomy & Definition:

• Endometriosisisdefinedasthepresenceof‘endometrialglandsandendometrialstromaoutsideoftheuterus’.Thisdiseaseisseeninmultipleareas,butmostcommonlyinthefemalepelvis(Fig.1–6).Whenthese‘rests’ofectopicendometriumsitontheserosaofthefallopiantube,surgicalexcisionmustbeaccomplishedwithoutinjurytothebloodsupplytothetube.

Patient History & Symptoms:

• Patientisa28yearoldwomanwhocomplainsofpelvicpainwithaleftsidedpredominance.Painisworseatthetimeofovulation.Patienthasapasthistoryofendometriosis,andhashadonelaparos-copywithfulgurationofseveralendometriosislesions.

Relevant Physical Findings & Diagnostics:

• Routinephysicalexaminationincludingacompletepelvicexamrevealsonlynon-specifictendernessintheleftadnexa.Ultrasoundexaminationiscompletelywithinnormallimits.

Diagnosis:

• Presumptivediagnosisincludes:

º Endometriosis

º Pelvicadhesions

PREOPERATIVE

Treatment Management & Objective:

• Drugtherapiesarecapableof‘suppressing’endometriosis,butnotofdestroyingit.Therefore,theyareoflittleuseexcepttopalliatethesymptomsofthedisease.

• Totalexcisionofallabnormalappearingperitoneumwithminimaltraumatonativetissuesisthemosteffectiveformofsurgicaltreat-ment(‘LAPEX’).Effectiveexcisionofendometriosisrequireslearningtorecognizeallappearancesofthedisease.Someofthemostcom-monappearancesaredemonstratedbelow(Fig.3–6:allphotosofspecimenpathologicallyproventocontainendometriosis):

Excision of Endometriosis – Fallopian Tube SerosaUsingtheBestEnergySourceforPreciseandDelicateDissectionofFragileTissuesLaserused:UltraPulseCO2Laser

Robert B. Albee Jr., MD, FACOG, ACGE-Founder,CenterForEndometriosisCare,Atlanta,Georgia,www.centerforendo.com

Wendy K. Winer, R.N., B.S.N., CNOR-EndoscopicSurgerySpecialist,CenterForEndometriosisCare

Ken R. Sinervo, M.D., M.S., F.R.C.S.C.-MedicalDirector,CenterforEndometriosisCare

Figure1 Figure2

Figure3-Whitefibroticnodule Figure4-Redimplant

Figure5-Powderburnlesion Figure6-Clearpapules

TheUltraPulsecarbondioxidefreebeamlasercreatesaremarkablylimitedadjacentzoneofinjuryandisuniqueinitsability toexcise tissueexactlyas intendedandwithacontrollabledepthofpenetration.Underlyingvascularitycanoftenbepreservedwithoutanylossinfunctionality.Becauseoftheseadvantagesoverotherenergysourcesusedintheexcisionofendometriosis,theobjectiveofcompletediseaseremovalwithminimalresidualtissuetraumaismoreconsistentlymet.



• Next,thediseasemustbeexcisedinamannerthatisminimallydestructivetotheadjacentnormaltissues.Allenergysourcesleavebehindazoneofinjuryinthenormaltissuethatsurroundstheimplantofendometriosis.Thesurgicalobjectiveistominimizethedamageleftbehind,yetcompletelyremoveallofthedisease. Scissors,bipolarscissors,harmonicscalpels,plasmajets,monopolorinstruments,andlasersallleaveazoneofinjurybehindwhenusedtoexcisetissues.TheUltraPulsecarbondioxidelaserusedtoexciseina‘cuttingmode’istheidealinstrumentforreducingthiszoneofinjuryduetoitshighpulseenergycapabilitieswhichleadtoaverysmallzoneofthermalimpact.

• Parenthetically,somesurgeonsmayattempttodestroy/removeimplantsofendometriosisusingablativetechniques.Energysourcesusedfortissueablationincludeelectricalenergy,harmonicscal-pel,andlaser(usingtheNd:Yag-,KTP-andtheCO2laser).Ablativetechniquesrequirethesurgeontoguessatthedepthofpenetrationoftheenergyintothetissue.Theresultofstoppingtheenergytoo

soonisthatdiseaseisleftbehind.Theresultofleavingtheenergyonfortoolongistoriskinjurytoadjacenttissuesandextendtheareaofthermaldamage.

• Asweshowintheattachedphotographs(Fig.9-12),thereisaminimalamountofadjacenttissueinjurywhenthefreebeamoftheUltraPulseCO2Laserisusedtoexcisetheimplant,andthedepthoftreatmentisobservedastheexcisionprocessiscarriedout.There isnoguessingastotheamountofenergyneededtocompletelyeradicatethedisease.

• Finally,thepotentialforpost-operativeadhesionformationmustbeminimized.Ifweassumethatsurgeryisperformedwithexcellenttechnique,andtheonlyadhesionproducingvariablebeingevaluatedistheenergysourcebeingusedforexcision,thenitisreasonabletoassumethatthefactorofmostimportanceistheinjuryleftbehindinthenormaltissuesthatsurroundthediseaseremoved.BecausethezoneofinjuryisleastwiththeUltraPulseCO2laser,itistheinstrumentofchoiceinouropinion.

# ProductDescription Manufacturer & Number

1 CO2Laser Lumenis:UltraPulse

2OperativeLaparoscope

Storz:LaparoscopeAA26036,5mmoperatingchannel

3LaserLaparoscopeCoupler

Lumenis:NezhatLaparoscopeCoupler 0617-621-01Lumenis:NezhatLaparoscopeAdapter 0617-612-04

4 Port 12 mmApplied:KiiBallonBluntTipSystem,COR47, 12x100mm

5 Port5mmApplied:KiiFirstEntry,CFF03,5x75 or 100 mm

6LaparoscopeLightsource

Storz:Xenon300Mod.20133120andXenonlightcable

7HighFlowCO2 Insufflator(x2)

Storz:HighflowElectronicEndoflatorMod.26430520

8CO2InsufflationWarming and Humidifying

LexiconMedical:Mod.Insuflowwithwarming-,humidifying-,andfilterelements(usewithLexicontubingandsyringe)

9 SuctionSystemStryker:Neptune2Ultra,WasteManagementSystemwithtubingfromX-Streamlaparoscopicirrigationtubingset

10 SmokeEvacuatorStryker:Neptune2Ultra,WasteManagementSystemwithstandardtubingtoattachtothetrumpetvalveofa5mmtrocar

11 Suction Irrigator

NezhatDorseySuctionIrrigatorwithX-Streamlaparoscopicirrigationtubingsetwithsmokevactrumpetvalve,withsuction/irrigationtubing#5552000andreusable28cmsuction/irrigatortipwithholes(fortheCO2laser)

12 IrrigationSystem21000ccbagsofRingersLactate,BARDDavol:X-StreamIrrigationSystem

# ProductDescription Manufacturer & Number

13Generator (Electrosurgery)

ValleyLab:ForceTriadEnergyPlatform

14 Bi-PolarAdlerInstruments:Microbipolar83-9990,tousewiththe28cmsuction/irrigationtip

15 VesselSealingLigaSurelaparoscopicvesselsealinginstrument,#LS1537

16 InstrumentOrganizerMicrotekMedical:DualLaparoscopyInstrumentPouch9”x35”,Ref3545

17 SurgicalTableSterisAmsco3080RLsurgicaltable,provides60degreeTrendelenburg

18 SurgeonStool KangaStools:HealthCareLogistics,#8420

19 LaparoscopeCamera Storz:HDlaparoscopiccamera

20 Video/PhotoSystem

Storz:AIDAHDConnectvideorecording,Mod.202056Sony:DigitalColorPrinter,Mod. UP-DR80MD

21 Monitors(x2)Storz:OR1HDWideview #SC-WU23-A1515

22ConvectiveWarmingSystem

Smith:Mod.EquatorLevel1

23 FilterWhite

BardDavolInc.:Laparoscopicinsufflationtubingwithfilter#5820222withluerlockconnectiontoinsufflator,10ftlengthtubingwith0.1micronfilter

24 RectalManipulator AppleMedical:Mod.900-595,goldhandle

25 UterineManipulator AppleMedical:PelosiUterineManipulator

26 Forceps,Grasper

IntegraJaritInstruments:WinerGraspingForceps,Mod.600-123andAdler3mm“mini”grasper&3mmblackinstrumentadaptor(tousewiththe28cmsuction/irrigatortip)

Table 1.MajorEquipmentandInstrumentation(notereferencenumbersinFig.7onthefollowingpage):


Technique Guide|September2012|Page3of6

Figure7Operativeset-upwithmajor equipment(seeTable1)



PATIENT PREPARATION

• Anesthesia:Ageneralanesthesiaisadministeredbytheanesthesiadepartment.Thepatientisintubatedandmuscleparalysisisusedtocontrolrespirations.

• PatientPositioning:(seeAORN2012RecommendedGuidelines).Thepatientispositionedonastandardsurgicaltableinthesemi-lithotomyposition.ThetablemattressisvelcroedtothetabletopreventslidingduringtheTrendelenburgpositioning.Thearmsarecarefullywrappedforprotectionandplacedbesidethetrunktoallowthesurgeontoworkatthelevelofthepatientsshoulders.Protectiveboots(AllenMedicalSystemsPALstirrupswithfeatherlift,#10023)areusedtocushionthepatient’sfeet,ankles,andcalves.Pneumaticcompressiondevices(ALPalternatinglegpressureforDVTprophy-laxis,40-60mmHg)areusedonthepatientscalvesandthighs.

• Pelvicexaminationisthenperformed,andthecervixgentlydilatedtoan21Prattdilator.Asingletoothtenaculumisplacedontheante-riorlipofthecervixanda‘Pelosi’uterinemanipulatoristheninsertedintotheuterusandaffixedtoasingletoothtenaculum.

• Arectalmanipulator(AppleMedical,900-575,goldhandle)isthenplacedintherectumforlatermanipulationasneeded.

• PatientDraping:(seeAORN2012RecommendedGuidelinesforpatientdrapingandpreppingofthesurgicalsite).AfteraChloraprep(withtint,Carefusion,Leawood,KS)skinprepiswidelydoneoverthesurgicalsite,a‘laparoscopy’drape(KimberlyClark”LaparoscopyPack”)isthenusedtomaintainasterileoperatingfield.Adisposableinstrumentorganizerisusedonthepatientsleftlegtokeepthemostoftenusedlaparoscopicinstrumentswithinreachofthesurgeon.

• PortPlacement:Usingthe‘Hasson’openlaparoscopytechnique,a11mm,balloontipumbilicalportisplaced(AppliedMedical:’COR47’).Rightandleftlowerquadrant5mmaccessoryportsarealsoplacedaftertransilluminatingtheanteriorabdominalwalltoavoidtheinferiorepigastricvessels(Fig.8).Laparoscopicvisualizationoftheabdominalwallperitoneumisusedduringportplacementtoavoidinjurytounderlyingoradhesedtissues.

Insufflation & Smoke Evacuation:

• Insufflationisaccomplishedwithtwo(20–30liter/min,highflow)carbondioxideinsufflatorsasnotedabove.Bothoftheinsufflatorsaresetto15mmHgpressure.Oneoftheinsufflatorsisattachedtotheoperativecolumnofthelaser.ThisinsufflatorsuppliesacontinuousflowofCO2gastheoperativechannelofthescopeintotheabdomen.It has an important function of preventing smoke from accumulating in the scope and obstructing the laser beam and interfering with the transmission of the laser energy onto the tissue.Thesecondinsufflatorisattachedtooneofthe5mmports.Theuseofthetwoinsufflatorsallowsthepneumoperitoneumtobemaintainedevenwithcontinu-ouscoincidentsuctionforsmokeevacuation(thesmokeevacuationtubingisconnectedtooneofthe5mmportsandthenpassedoffthestérilefieldandconnectedtotheStrykerNeptunesystemthathasaportalspecificallyforsmokeevacuation).Theluerlocksuctionatthe5mmportisregulatedbythesurgeonand/orsurgicalassistant.

OPERATIVE

Surgical Procedure & Technique:

• InthiscaseweshowtheuniqueadvantagesoftheUltraPulseCO2 laserinmeetingtheaboveobjectives(completeexcision,minimalthermalandmechanicaltrauma(precision),andminimaladhesionpotential)whenendometriosisisonafragilearealikethefallopiantube.Thesmallestdisruptionofthefallopiantubemesentery’sbloodsupplycanresultinanon-functionaltube.

• Webeginexcisionduringtheprocedureafterareasofendometrio-sishavebeenidentified.Inthiscasewewillfocusonasingleareaofendometriosisontheleftfallopiantube(techniqueseeFig.13).

• Aswebegin,thesuctionirrigatorelevatesthelefttubeandalasercircumferenceisdrawn(Fig.9).Forthistypeofdelicatetissuedissec-tion,thelaserpower,asnotedabove,islowered.Whenfiredusingthefootswitch,theUltrapulsemodepulsestointerruptthebeammanytimesasecond.Thisfunctionreducessmokeandallowsthesurgeontoreducetheimpactoftheenergyonthetissue.Thephotoshowsanalmostcompletelyoutlinedgroupoflesions.

• Notetheimpressivelylimiteddepthoftissuepenetration(Fig.10).Verylittleofthesubserosaltissueisbeingimpactedbytheenergy.Justtheserosahasbeenincised.Thistypeofcontrolisuncommonfromanyotherenergysource.

A

B

B

11mm port

5mm port

5mm port

Figure8

Figure9 Figure10



• Next,thelaserisusedtounderminethelesion(Fig.11).Careistakentoremovetherootsofthediseasecompletelybutnottoharmtheunderlyingvessels.Again,noticetheprecisionofthelaserasthetissueisexcisedwithoutanyunderlyingbleeding(seearrowA,notethattheundersurfaceofthelesioncanbeseenshowingthedepthofexcisionisadequate).Thisareaoverliesaplexusofveinsthatmustbepreservedinordertomaintaintubalfunction(arrowB).

Thecompletedexcisionsiteisseenwithnounderlyingvascular compromise,andnicesharpedgeswithoutevidenceofdirectorthermalinjury(Fig.12).

Laser Devices & Technique:

• Lasersystem:LumenisUltraPulseCO2laser

• Laseraccessories: - Lumenis:Nezhatlaserlaparoscopecoupler,#0617-621-01 - Lumenis:Nezhatlaserlaparoscopeadapter,#0617-612-04- Storz:Operativelaparoscope,5mmoperatingchannel,#AA26036

• Technique:(seeFig.13)LaserparametersfortheUltraPulseCO2 laserarementionedthroughoutthisspecificcase.NotallCO2lasersareequalanddifferentapplicationsmayneeddifferentparametersettings.Duetoitshighenergypulsingcapabilities,theUltraPulsedeliversthesmallestamountofthermalimpactamongallCO2lasers.

Laser Parameters:

• ForLumenisUltraPulseCO2laser:8-15WattsUltraPulse,125millijoulespulseenergy

• IngeneralfortheUltraPulseCO2laser:- Thehigherthepowersetting,thehigherthetreatmentspeed

- Thehigherthepulseenergysetting,thesmallerthethermalimpact

- Formoretissueimpactcontrol,usethefootswitchwitha shutteredlaserexposureorselectTimedandRepeatExposuremodesontheuserinterface.

Using8-15WattsUltraPulsewith125millijoulespulseenergy,thelaserisusedtodrawacircumferencearoundtheidentifiedlesion.Asmall1-2mmmarginofnormaltissueisincludedinsidethecircumferenceaslongasthereisnosafetyissueinsodoing.Thedepthofthecircumferentiallaserincisionis1-2mm.Theinsideedgeofthecircumscribedareaisthengraspedandelevated.Thisexposesthejunctionofthelesionandthenormalunderlyingtissue.

Thelaserbeamisthenfiredatthebaseofthelesion.Thedepthofthedissectionunderthelesioniseasilyadvancedasthedeeper,

denser,andmorefibroticareasareencountered.Importantstructuresinthevicinitymustbeidentifiedanddissectedawayfromtheexcisionsiteforsafety.Thedissectioniscontinueduntiltheentireareahasbeenunderminedandcanberemoved.Theremainingtissueisthencarefullyexaminedtoconfirmthatnoevidenceofendometriosisremains.

Ifbleedingvesselsareencounteredthatthelaserbeamhasnotadequatelycontrolled,theymaythenbemicro-coagulatedaslongasthecoagulationdoesnotendangerthebloodsupplytoanyadjacenttissues.

Figure13

LASEREXCISIONTECHNIqUE

Figure11 Figure12

AB



Hemostasis:

• Ifbleedingvesselsareencounteredthatthelaserbeamhasnotadequatelycontrolled,theymaythenbemicro-coagulatedaslongasthecoagulationdoesnotendangerthebloodsupplytoanyadjacenttissues.

Other Technique Tips:

• AdhesionsandAdhesionBarriers:Duetotheabsenceofanyunderlyingvascularinjury,andtheminimalizationofanyresidualde-vitalizedtissue,theuseofadhesionbarriersisnotgenerallyrequired.

• AlternativeEnergySources:Ablativetechniquesperformedwithaharmonicscalpel,unipolarorbipolarelectricity,andtheNd:Yaglaser,simplyofferlessprecision.

- Furthermore,havingattemptedthistypeofexcisionpreviouslyusingalaparoscopiccuttingscissor,aharmonicscalpel,andamonopolarneedle,weareconvincedthattheUltraPulseCO2laseristheenergysourceofchoicewhenextremelydelicateexcisionisdesired.Theotherinstrumentsdonotprovidethesamepreci-sionandtheyleaveasignificantlygreaternegativeimpactonthenormaltissuewhichsurroundstheexcisionsite.

POSTOPERATIVE

Discharge & Post-Op Instructions:

• Surgeryisperformedas‘outpatient’.Patientshavetheoptionofleavingthehospitalassoonastheydesireandtheyareapprovedfordischargebythenursingstaffofthe‘extendedrecovery’unit.Unlessthereisareasonforcontinuedhospitalization,theymustbedis-chargedwithina23hourinterval.

• Post-operativecareiscoordinatedbetweensurgeons,nurses,andofficestaff.Pamphletsaregiventoeachpatientintheofficeatthetimeofthepre-opvisitthatdescribeexpectednormalsinrecovery,andthestepstotakeincaseofquestionsorproblems.

• Patientsareseenatthe2weekintervalpost-opandthe3monthintervalforroutinepost-opevaluation.

Recovery & Outcome

• Recoveryisexpectedtobeprogressiveovera3weekperiod.Narcoticmedsifrequiredarenotusuallyrequiredformorethan3days.Patientsusuallydrivewithin1week,andresumeallactivitieswithin3weeks.

• Patientsmayfeelpainreliefimmediately,butcompletehealingatthemicroscopiclevelmaytakeupto90days.Painlastinglongerthan90daysisnotlikelytogoaway.

SUMMARY,PEARLS&PITFALLS

• TheUltraPulsecarbondioxidefreebeamlaserisuniqueinitsabilitytoexcisetissueexactlyasintendedandwithacontrollabledepthofpenetration.Underlyingvascularitycanoftenbepreservedwithoutanylossinfunctionality.

• Ithasaremarkablylimitedadjacentzoneofinjuryascanbeseenintheabovecloseupphotographs.Thismeansthereisminimaldamagetothesurroundingtissue.Healingtimeisreducedwhenadjacentcellinjuryisminimized.

• Powerdensityandtreatmentspeedcanbeadjustedeasilybychangingwattage.Thisgivesthesurgeonflexibilitytoadaptto differingdensitiesoftissues.

• Duetothefactthatsalineabsorbslaserenergy,theliberaluseofirrigationonnormaladjacenttissuesoffersanextrameasureof protectionfromamisfiredlaserbeam.

• BecauseofthetheseadvantagesoftheCO2laseroverotherenergysourcesusedintheexcisionofendometriosis,theobjectiveof completediseaseremovalwithminimalresidualtissuetraumaismoreconsistentlymet.Itisnosurprisethatthistreatmentresultsinimprovedfertilityatallstagesofthedisease.

• Theuseofthefreebeamlaserinlaparoscopyrequiresgoingthroughalearningcurveandinitiallyeasycasesandlesions,treatedwithlowerpowersettings,aresuggestedfortheadvancingsurgeon.

LITERATURE

1.Book:TheSurgicalManagementofEndometriosis;ContributingAuthorApril,2004

2.LaparoscopicExcisionofLesionsSuggestiveofEndometriosisorOtherwiseAtypicalinAppearance:RelationshipBetweenVisualFindingsandFinalHistologicDiagnosis;RobertB.Albee,KenSinervo,DeidreT.FisherTheJournalofMinimallyInvasiveGynecology,January2008(Vol.15,Issue1,Pages32-37)

3.Long-termfollow-upofwomensurgicallytreatedforendometriosis;KSinervo,RAlbee;JournaloftheAmericanAssociationofGynecologicLaparoscopists;August2002(Vol.9,Issue3,PageS51)Full-TextPDF(98KB)

4.Endometriosistreatmentoutcomes:Along-termobservationalstudy;RBAlbee,KSinervo;JournaloftheAmericanAssociationofGynecologicLaparoscopists;August2004(Vol.11,Issue3,PageS39)

This Technique Guide is not meant to be a substitute for proper, adequate training and the safe use of the carbon dioxide laser. The laser treatment parameters and technique above are provided as a guide and are based on results published or reported by physicians with experience in this indication. Individual treatment should be based on clinical training, clinical observation of laser-tissue interaction, appropriate clinical endpoints and each physician’s own medical judgement.

Download - Excision of Endometriosis - Fallopian Tube Serosa

Top Related