New wireless ultrasound for Deep Infiltrating Endometriosis (DIE)

This is the case of a patient with Deep Infiltrating Endometriosis (DIE) managed with a new ultrasound wireless device. The use, potential, advantages and drawbacks of the new device are discussed. Its practical application for the DIE nodule resection, adhesiolysis and myomectomy are shown.

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New wireless ultrasound for Deep Infiltrating Endometriosis (DIE)

Authors

A Wattiez, M Puga, C Redondo, Al Ussia, C Penati

Abstract

This is the case of a patient with Deep Infiltrating Endometriosis (DIE) managed with a new ultrasound wireless device. The use, potential, advantages and drawbacks of the new device are discussed. Its practical application for the DIE nodule resection, adhesiolysis and myomectomy are shown.

Classification

live recorded, winners

Keywords

New wireless ultrasound, Deep Infiltrating Endometriosis, DIE

Media type

Surgical video

Duration

19'38''

Publication

2013-02

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E-publication

WeBSurg.com, Feb 2013;13(02).
URL: http://www.websurg.com/doi-vd01en3914.htm

New wireless ultrasound for Deep Infiltrating Endometriosis (DIE)

1. Introduction 00'06''

We present the case of a 27-year-old patient complaining with severe dysmenorrhea, dyschezia and infertility. The preoperative work-up found a 2.5cm endometriotic nodule in the torus uterinus with adhesion of the rectosigmoid junction.

2. Lateral attachment of sigmoid colon 00'29''

The lateral attachment of the sigmoid colon is divided by means of a new ultrasound wireless device. The characteristics of the device are presented (performance for grasping, dissection, coagulation and division).

3. Dissection of retroperitoneal spaces 01'47''

The dissection is performed by stretching the tissue using the two instruments. This technique permits to access normal tissue using normal anatomical planes. Heavy adhesions are divided with the ultrasound device. The fat belongs to the bowel. Consequently, it is pulled medially and the sigmoid colon is dissected from the peritoneum and the left adnexa.

4. Anatomical landmarks 03'14''

The division of the attachment of the sigmoid colon allows for access to the left ureter, the pararectal fossa and to the IP ligament with the left adnexa. The left ureter position is demonstrated: always running medial to the IP ligament.

5. Left pararectal fossa dissection 04'08''

After the ureter has been identified, surgery is pursued by opening the left pararectal fossa. The ureter is pushed laterally and the space is developed progressively between the ureter and the lateral rectal wall. Notice again how the dissection is performed only by traction and counter-traction of the tissue and not by cutting in order to respect anatomical planes. Endometriotic (chocolate-like) liquid from the rupture of endometrioma is aspirated immediately in order to reduce visual impairment. The pararectal fossa is dissected caudally until the bottom of the pelvis.

6. Left adnexa adhesiolysis 05'20''

Heavy adhesions between the sigmoid colon and the left adnexa are divided. The sigmoid colon is completely freed, but the rectum is still adherent to the uterus.

7. Anterior aspect of pararectal fossa 06'36''

The anterior aspect of the pararectal fossa is developed using the same technique while the assistant pulls the rectosigmoid junction cranially. Attention should be paid to the presence of splanchnic nerves that can be found at this level. These nerves should be preserved in order to reduce the risk of dysfunctional disorders. The left pelvic dissection and anatomical landmarks are shown.

8. Right pararectal fossa dissection 08'39''

The right side of the procedure starts with the identification of the anatomical structures. The bowel is retracted to the left; the promontory, the ureter, and the iliac artery bifurcation are displayed. The retroperitoneum is opened and the pararectal fossa is developed. As soon as the retroperitoneal space has been opened, carbon dioxide enters the areolar tissue and there come the so-called “bubbles” which are an important guideline for the dissection plane.

9. Rectovaginal space 09'43''

The adhesion between the anterior wall of the rectum and the torus uterinus are now divided. The dissection is pursued caudally by both sides of the rectum until the normal rectovaginal space is reached. The ultrasound device proves to be very effective and safe during the procedure. However, probably the most important factor in the success of the surgery lies in meticulous tissue dissection.

10. Final result of rectovaginal dissection 11'27''

The nodule is completely dissected and the rectovaginal space is exposed. There are some remaining parts of the nodule in the bowel wall that will be re-evaluated later on during the surgery.

11. Left ureteral dissection 12'17''

The ureter is dissected from the ovarian fossa until its entry into the ureteral channel. Attention must be paid not to strip the adventitia during ureterolysis, as the vascularization of the ureter runs by this layer. The coagulation power of the ultrasound device is probably not as effective as that of bipolar cautery. However, this issue must be analyzed cautiously, taking into account several reports about the deleterious effect of excessive coagulation in the scarring of some tissues (such as muscle and vagina).

12. Tubal patency test 14'15''

Bilateral tubal patency is controlled with a methylene blue test. However, the external aspect of the tubes remains distorted by the presence of adhesions mainly in the left side. The left tube adhesiolysis is improved. During this procedure, some remaining endometriotic implants are found.

13. Re-inspection of the remaining lesions 16'07''

After a thorough inspection of the rectal wall with the help of the rectal probe, only a small area of retraction has been freed. Some remaining parts of the nodule are still attached to the torus uterinus and to the retrocervical area, but they are easily resected.

14. Myomectomy 18'16''

A subserous fibroma is resected. The serosa is opened with ultrasound and the myoma is enucleated simply with the assistance of a corkscrew. The uterine surface is closed with one figure-of-eight stitch of monocryl 2/0. An intracorporeal knotting technique is used.