Department of Obstetrics & Gynecology, Mutah Medical Faculty, Mutah University, Jordan
Reference: Moamar Al-Jefout (2011). Laparoscopy for Diagnosis and Treatment of Endometriosis, Advanced Gynecologic Endoscopy, Dr. Atef Darwish (Ed.), ISBN: 978-953-307-348-4, InTech, DOI: 10.5772/16733. Available from: http://www.intechopen.com/books/advanced-gynecologic-endoscopy/laparoscopy-for-diagnosis-and-treatment-of-endometriosis
Endometriosis is defined as the presence of endometrial like stroma and glands outside the uterine cavity (Giudice and Kao, 2004). Laparoscopy has been recognized as the gold standard for endometriosis diagnosis and has been used for the surgical treatment of endometriosis. Diagnosis of endometriosis is currently made following laparoscopic inspection of the pelvis, preferably with histological biopsy confirmation (Mettler et al., 2003), although the correlation of biopsy with visual inspection depends on the experience of the endoscopist, inter-observer variability, the technique of excision and the care and experience of the pathologist (Poncelet and Ducarme, 2007). In one recent study, only 67% of lesions identified at laparoscopy as possible endometriosis proved to have the histological features of endometriosis (Stratton et al., 2003). Moreover, visual inspection of the pelvis also has its own limitations, particularly for the diagnosis of atypical and non-peritoneal endometriosis.
Endometriotic lesions can vary in colour, mostly non-black, red, white or like burned powder. In clinical observation the age of a lesion can be estimated from the colour of these lesions. It appears that clear papules are limited to a younger age group (17-31 years), than the red (16-43 years) and black (20-52 years) lesions (Redwine, 1987).
Many studies have clearly shown that there is a substantial delay in endometriosis diagnosis which inevitably has negative effect on quality of life of endometriosis patients (Matsuzaki et al., 2006, Hadfield et al., 1996, Zrubek et al., 1999, Ballard et al., 2006, Stratton, 2006). Ballard et al. demonstrate that the definitive diagnosis of endometriosis is frequently delayed for many years (2006). In a series of patients from southeastern England the mean delay from onset of symptoms to definitive diagnosis was 102 months (9.5 years). Delays usually occurred at every stage in the diagnostic process. An average patient waited for 18 months before been seen by a family doctor. The general practitioner subsequently waited 3 years before referring the patient for a specialized opinion by a gynaecologist, and it takes a further 9 months before the diagnosis is made. This delay is even longer in cases with deep infiltrating endometriosis and advanced endometriosis stage IV (Matsuzaki et al., 2006).
The review by Wykes, C. B showed that there are very few good quality studies in the literature regarding the role of laparoscopy in the diagnosis of endometriosis (Wykes et al., 2004). A negative laparoscopy for endometriosis is helpful and women can be adequately reassured without the need for further testing, while a positive laparoscopy is less informative without histological confirmation. A false positive laparoscopy can hugely affect the woman’s quality of life, perception of her own health, fertility and even sexual life.
The aim of surgical management is to remove visible areas of endometriosis and restore anatomy by division of adhesions. Yet, treatment frequently must be individualized. However, distinguishing patients who need no treatment from patients who need intermediate or extensive treatment can be difficult. There are three recognized types of endometriosis:peritoneal endometriosis, ovarian endometriomas and deep adenomyotic nodules of the rectovaginal septum (Nisolle and Donnez, 1997).
Few principles have to be considered regarding the surgical management of endometriosis:
Severe disease must be treated differently from mild to moderate disease.
Patients with pain symptoms associated with endometriosis must be approached differently from patients seeking fertility.
Clinicians and patients should be aware that the expected benefit is depending on operator skills (Vercellini et al., 2009).
Jansen and Russell have shown that peritoneum which looks completely normal does not contain histological features of endometriosis, therefore excision of all abnormally looking peritoneum, deep nodules and ovarian lesions should remove the disease (1986). Yet a downside of this approach is the risk for future adhesion formation.