technique guide - endometriomas and deep infiltrating endometriosis

Adhesiolysis, followed by Excision and Ablation of

Endometriomas and Deep Infiltrating Endometriosis using

Lumenis FiberLase™ Flexible CO2 Laser Fiber and

AcuPulse™ CO2 Laser

Case by Mariona Rius, M.D. and Francisco Carmona, M.D. | Hospital Clinic, Barcelona, Spain

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PB-2003682_Rev B, November 2015 GYN Technique Guide Series

The main objective of this technique guide is to show how to use the flexible

FiberLase CO2 fiber with the Lumenis AcuPulse CO2 Laser for treatment of

endometriosis. After presenting a clinical case, we describe step by step how the

laser is used in order to perform ablation of an endometrioma, as well as for a

deep infiltrating endometriosis (DIE) nodule.

Preoperative

Past Medical History and Presenting Complaint

Patient is a 44 year old nulliparous woman with past history of endometriosis.

Three years ago, she had a laparoscopy with left endometrioma decapsulation and

fulguration of endometriosis lesions on the right ovary and myomectomy.

Patient reports that for the past two years she has been experiencing pelvic pain

that increases during and after menstruation.

Relevant Physical Findings and Diagnostics

Routine physical examination, including a complete pelvic exam, revealed an

increased uterine size (like 14-16 week pregnancy) and a pelvic mass (8-10 cm)

located in Douglas pouch. The examination was painful.

Ultrasound examination showed a right endometrioma (12cm), a left endometrioma

(4-5 cm) and a deep infiltrating endometriosis (DIE) nodule on right uterosacral

ligament and right ureter.

Diagnosis Large right-side endometrioma (12 cm diameter) and smaller left-side

endometrioma (4 cm diameter)

Deep infiltrating endometriosis nodule over right ureter and right uterosacral

ligament.

CO2 Laser-Assisted Resection and Ablation of Endometriomas and DIE Using FiberLase CO2 Fiber and AcuPulse 40WG CO2 Laser

Francisco Carmona, M.D.

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Operative

Surgical Procedure Adhesiolysis, resection of DIE nodules and ablation of endometriomas.

Anesthesia General anesthesia administered by anesthesia department.

Patient was intubated and muscle paralysis was used to control respirations.

Laparoscopic Instrumentation

Storz HD Endoscope Camera.

Storz (0⁰) laparoscope (Storz, 39301 CS) with 10 mm outer diameter.

Insufflation was accomplished with carbon dioxide insufflator (Storz) set to 14

mmHg pressure. The insufflator was attached to the 12 mm camera port and kept at

high flow rate. A gas warmer was also used (Thermoflator SCB 26432020).

Other major laparoscopic equipment:

▪ Suction and irrigation cannula (Gyrus 60/16/5-1).

▪ Generator for electrosurgery (Valleylab).

▪ Bipolar grasper (Olympus, WA63120 C).

▪ Monopolar scissors and hook (Microline 3904/Olympus A6282).

▪ Forceps, graspers (Storz 33322HM/Olympus 3322F).

Uterine manipulator was placed.

Patient Set Up Patient Position. Patient placed in semilithotomy position on a standard surgical table.

The arms were carefully wrapped for protection and placed beside the trunk to allow

the surgeon to work at the level of the shoulders.

Limb Protection and DVT Prophylaxis. Protective boots were used to cushion the

feet, ankles and calves. For DVT prophylaxis, a pneumatic compression device was

used on the calves with alternating leg pressure (ALP) set to 40-60 mmHg.

Patient prep and drape. After iodine (10% solution) skin preparation was widely

done over the surgical site, a “laparoscopy” drape (Hartmann “Laparoscopy Pack”)

was used to maintain a sterile operating field. A disposable instrument organizer

was used on the patient’s left leg to keep the most used instruments within reach.

Port placement. Pneumoperitoneum was accomplished by direct Veress needle

puncture on Palmer’s point and insufflation of carbon dioxide. Once the

pneumoperitoneum was established, a 12 mm umbilical port was placed for the

endoscope camera (Endopath Xcel, Ethicon endo-surgery). Then four (4) accessory

trocars were placed:

▪ Three (3) 5 mm ports (Endopath Xcel, Ethicon endo-surgery) were placed at left

iliac, right iliac, and suprapubic midline locations.

▪ One (1) 12 mm port (Endopath xcel, Ethicon endo-surgery) was placed at

supraumbilical midline.



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Assistants Two residents assisted by holding the camera and bringing in graspers and

suction/irrigation cannula.

Laser, Accessories and

Purge Air

AcuPulse 40WG CO2 Laser

FiberLase flexible CO2 laser fiber, OD 1.04 mm ,

FiberLase GYN Lap-R Handpiece

Purge air for the fiber was supplied the by low flow internal pump on laser (with

bacterial filter) flowing only when lasing.

Smoke Evacuation Smoke evacuator (Buffalo Filter) was connected to one of the 5 mm ports and used only

when lasing.

The carbon dioxide insufflator was kept at high flow.

Laser Parameters The laser parameters for the major surgical steps for which the laser was used are provided

in the table below.

Step Mode and

Power

Exposure

Mode

Time On

Time Off

Distance from

tip to tissue

Adhesiolysis CW

8 Watts

REPEAT On: 0.3 s

Off: 0.1 s

1 mm

Dissection and resection

of DIE nodule over right

ureter and right

uterosacral ligament

SuperPulse

8-12 Watts

REPEAT On: 0.3 s

Off: 0.1 s

1 mm

Ablation of

endometriomas

CW

10-14

Watts

REPEAT On: 0.3 s

Off: 0.1 s

3-5 mm



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Laser Technique After macroscopic inspection of abdominopelvic cavity, the adhesions between right

endometrioma, left endometrioma, posterior wall of the uterus and bowel were

identified. Adhesiolysis was performed by resecting with laser, cold energy (scissors)

and electricity (hook). The decision to use one or the other was based on risk to nearby

structures (bowel, ureter, etc.). The CO2 laser was used when risk was greater. Scissors

and electricity were used when the risk was low.

The right endometrioma (12 cm), which adhered to the posterior wall of the uterus,

was mobilized as described above. First, part of the cyst was resected using graspers

and scissors. Then the CO2 laser was used to ablate the remaining endometrioma.

The left endometrioma was ablated using the CO2 laser. During the ablation, we

start at one margin of the cyst and then we move vertically covering all the surface

of it (we don't use cross-hatch pattern). We know that we have applied enough

energy when the laser deepens 2-3 mm in the tissue.

The right ureter was identified and dissected in order to prevent accidental injury

using blunt dissection.

The DIE nodule on the right ureter and right uterosacral ligament was resected by

grasping the nodule and providing counter traction. Then, SuperPulse CO2 laser

energy was used to dissect and resect, starting from healthy tissue and progressing

to the disease.

Hemostasis Mild bleeding was controlled with the laser beam, with the same laser power and

moving the tip further away from the tissue (2-3 mm).

Moderate bleeding, which couldn’t be controlled with laser beam, was controlled by

bipolar coagulation.

Technique Tips

Effective Ablation of

the Pseudocapsule

Good exposure of the endometrioma pseudocapsule helps to achieve better ablation

of it.

Avoiding Injury to the

Ureter

Identification and careful dissection of the ureter, from healthy to diseased tissue

prior to dissection of deep infiltrating nodules, will prevent ureteral injury.



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Operative Photos

Fig. 1 Visualization of pelvic cavity,

occupied by two endometriomas Fig. 2 Laser ablation of left endometrioma. Laser fiber is

approximately 6-7mm from tissue surface

Fig. 3 Laser ablation of right endometrioma Fig. 4 Final view after procedure. Hemostasis was

carefully reviewed.

Post-Operative

Discharge and

Postoperative Instructions

Patient was discharged from the hospital 24 hours after surgery.

Post-operative care is routinely coordinated between surgeons, nurses and office

staff. Painkillers such as NSAIDS are prescribed in case of pain during the first

postoperative week. Before discharge, while in still in recovery, the nurses give

patients an informative leaflet describing normal recovery period and the steps

to take in case of problems.

Patients are routinely seen in the outpatient clinic 3 to 4 weeks after surgery, in

order to assess the recovery. At that time, further routine follow-up is planned.



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Recovery

and Outcome

Recovery is expected to be progressive over a 2 to 3 week period. NSAIDS are

required for not more than 7 to 10 days. Patients usually resume all activities

within 3 to 4 weeks.

Since the surgery, this patient has been seen twice in the outpatient clinic. The

first visit was one month after surgery and she still had mild post-operative pain.

The second visit was six months after surgery; she reported that she was

asymptomatic.

No record about pregnancy was made since the patient was not planning it.

Discussion

The procedure described above is another technique how to surgically treat endometriosis. It is a reproducible procedure

with a fast learning curve (5 weeks), making it a wide spread technique for all gynecologists who are specialized in

endometriosis. The margin of safety provided by CO2 laser is high, since the laser penetrates just micrometers in the tissue.

This is the reason why we use the laser when the risk of injury on nearby structures is high. Having the opportunity to use

the fiber (and its handpiece) simplifies the procedure since it’s easier to imagine the direction of the laser compared to the

free beam and the fiber produces less smoke. Finally, using the laser for treating endometriosis opens a new field

characterized by safety and easily reproducible techniques.

WARNING

In order to protect the patient and the operating room personnel, operator manuals including the

Clinical, Safety and Regulatory sections, should be carefully read and comprehended before laser operation.

technique guide - endometriomas and deep infiltrating endometriosis

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