Posterior Deep Infiltrating Endometriotic Nodules: Operative Considerations according to Lesion Size, Location, and Geometry, during One’s Learning Curve
We conducted this prospective cohort study to standardize our laparoscopic technique of excision of posterior deep infiltrating endometriosis (DIE) nodules, according to their size, location, and geometry, including 36 patients who were grouped, according to principal pelvic expansion of the nodule, into groups with central (group 1) and lateral (group 2) lesions, and according to nodule size, into ≤2？cm (group A) and >2？cm (group B) lesions, respectively. In cases of group 1 the following operative steps were more frequently performed compared to those of group 2: suspension of the rectosigmoid, colpectomy, and placement of bowel wall reinforcement sutures. The opposite was true regarding suspension of the adnexa, systematic ureteric dissection, and removal of the diseased pelvic peritoneum. When grouping patients according to nodule size, almost all of the examined parameters were more frequently applied to patients of group B: adnexal suspension, suspension of the rectosigmoid, systematic ureteric dissection, division of uterine vein, colpectomy, and placement of bowel wall reinforcement sutures. Nodule size was the single most important determinant of duration of surgery. In conclusion, during the building-up of one’s learning curve of laparoscopic excision of posterior DIE nodules, technique standardization is very important to avoid complications. 1. Introduction Deep infiltrating endometriosis (DIE) is a particular form of endometriosis that extends >5？mm under the peritoneal surface [1]. These lesions develop in the form of retroperitoneal nodules that consist histologically of endometrial epithelium and stroma, surrounded by muscular hyperplasia and fibrosis [2]. DIE nodules are rich in nerve fibers [3] and are commonly associated with severe cyclic or acyclic pelvic pain such as dysmenorrhea, deep dyspareunia, and nonmenstrual pain and organ-specific symptoms related to bladder or intestinal dysfunction (dyschezia, constipation, diarrhea, rectal bleeding, frequency of micturition, and hematuria) [4–6]. Radical surgical exeresis of DIE lesions is the mainstay of treatment for this form of endometriosis. Medical therapies may temporarily alleviate painful symptoms, but recurrence rates after their discontinuation are high [7, 8]. Furthermore, performing inadequate primary surgery not only results in disease progression with persistence or aggravation of painful symptoms but also renders any future procedure difficult and potentially dangerous [9, 10]. DIE nodules represent a real operative challenge due to common involvement of vital
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