Opioid Use After Laparoscopic Surgery for Endometriosis and Pelvic Pain.

STUDY OBJECTIVE: The primary objective was to quantify postoperative opioid use after laparoscopic surgery for endometriosis or pelvic pain. The secondary objective was to identify patient characteristics associated with greater postoperative opioid requirements. DESIGN: Prospective, survey-based study in which subjects completed 1 preoperative and 7 postoperative surveys within 28 days of surgery regarding medication usage and pain control. SETTING: Tertiary care, academic center. PATIENTS: A total of 100 women with endometriosis or pelvic pain. INTERVENTIONS: Laparoscopic same-day discharge surgery by fellowship-trained minimally invasive gynecologists. MEASUREMENTS AND MAIN RESULTS: A total of 100 patients were recruited and 8 excluded, for a final sample size of 92 patients. All patients completed the preoperative survey. Postoperative response rates ranged from 70.7% to 80%. The mean number of pills (5 mg oxycodone tablets) taken by day 28 was 6.8. The average number of pills prescribed was 10.2, with a minimum of 4 (n = 1) and maximum of 20 (n = 3). Previous laparoscopy for pelvic pain was associated with a significant increase in postoperative narcotic use (8.2 vs 5.6; p = .044). Hysterectomy was the only surgical procedure associated with a significant increase in postoperative narcotic use (9.7 vs 5.4; p = .013). There were no difference in number of pills taken by presence of deep endometriosis or pathology-confirmed endometriosis (all p >.36). There was a trend of greater opioid use in patients with diagnoses of self-reported chronic pelvic pain, anxiety, and depression (7.9 vs 5.7, p = .051; 7.7 vs 5.2, p = .155; 8.1 vs 5.6, p = .118). CONCLUSION: Most patients undergoing laparoscopic surgery for endometriosis and pelvic pain had a lower postoperative opioid requirement than prescribed, suggesting surgeons can prescribe fewer postoperative narcotics in this population. Patients with a previous surgery for pelvic pain, self-reported chronic pelvic pain syndrome, anxiety, and depression may represent a subset of patients with increased postoperative opioid requirements.

Abdominal wall endometriosis: an update in diagnosis, perioperative considerations and management.

PURPOSE OF REVIEW: Abdominal wall endometriosis (AWE) is rare with limited evidence guiding diagnosis and treatment. The purpose of this review is to provide an update of the diagnosis, perioperative considerations, and treatment of AWE. RECENT FINDINGS: Recent studies further characterize presenting symptoms and locations of AWE. Prior abdominal surgery remains the greatest risk factor for the development of AWE. Newer evidence suggests that increasing BMI may also be a risk factor. Ultrasound is first-line imaging for diagnosis. Magnetic resonance image is preferred for surgical planning for deep or extensive lesions. Laparotomy with wide local excision is considered standard treatment for AWE with great success. Novel techniques in minimally invasive surgery have been described as effective for the treatment of AWE. A multidisciplinary surgical approach is often warranted for successful excision and reapproximation of skin and/or fascial defects. Noninvasive therapies including ultrasonic ablation or cryotherapy are also emerging as promising treatment strategies in select patients. SUMMARY: Recent studies provide further evidence to guide diagnosis through physical exam and imaging as well as pretreatment planning. Treatment options for AWE are rapidly expanding with novel approaches in minimally invasive and noninvasive therapies now available.

Pain and Quality of Life after Laparoscopic Excision of Endometriosis.

STUDY OBJECTIVE: To evaluate the long-term impact of laparoscopic excision of endometriosis on quality of life through pain reduction as measured by the Endometriosis Health Profile-30 (EHP-30) in uterine-sparing (preservation of the uterus and at least 1 ovary) and nonuterine-sparing (removal of the uterus) surgery. DESIGN: Cohort study. SETTING: Academic medical center. PATIENTS: Sixty-one women who had undergone laparoscopic excision of endometriosis for pelvic pain were enrolled in a tissue-procurement study. INTERVENTIONS: Patients who had previously completed an EHP-30 preoperatively and at 4 weeks postoperatively were mailed a copy of the EHP-30 2.6 to 6.8 years after their index surgery. MEASUREMENTS AND MAIN RESULTS: The primary outcome was quality of life as measured by changes in the EHP-30 scores before their index surgery and those measured weeks and years later. The secondary outcome was a comparison of the EHP-30 scores between patients who underwent excision of endometriosis alone and those who underwent excision of endometriosis with hysterectomy +/- oophorectomy. From 2011 to 2015, 61 women underwent laparoscopic excision of endometriosis for pelvic pain. Forty-six of the 61 patients completed the EHP-30 for a response rate of 75%. The patients demonstrated significant improvement in all 5 scales of the EHP-30 (pain, control and powerlessness, emotional well-being, social support, and self-image) at 4 weeks postoperatively (p <.001), which persisted for up to 6.8 years in follow-up (p <.001) when compared with their baseline scores. The improvement in EHP-30 scores did not differ by American Society for Reproductive Medicine staging or index surgery. Definitive surgery (total laparoscopic hysterectomy/bilateral salpingo-oophorectomy) was not associated with improved outcomes when compared with uterine-sparing surgery. CONCLUSION: Laparoscopic excision of endometriosis offers improvement in all quality-of-life domains as measured by the EHP-30, including a reduction in pain, an effect that may persist for up to 6.8 years. These findings suggest that laparoscopic excision of endometriosis with uterine preservation can be considered as an option for discussion during counseling for treatment of endometriosis.

Risk-reducing Bilateral Salpingo-oophorectomy: Assessing the Incidence of Occult Ovarian Cancer and Surgeon Adherence to Recommended Practices.

STUDY OBJECTIVE: This study aimed to determine the incidence of ovarian cancer diagnosed at the time of risk-reducing bilateral salpingo-oophorectomy in a large cohort of patients with a BRCA mutation. In addition, we aimed to determine the adherence to the recommended practices for performing a risk-reducing bilateral salpingo-oophorectomy as described by the American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncology. We sought to determine if adherence differed by the type of training (i.e., gynecologic oncologists vs benign gynecologists). DESIGN: Descriptive, retrospective analysis. SETTING: Academic medical center. PATIENTS: Two hundred sixty-nine patients with a known BRCA mutation. INTERVENTIONS: Prophylactic risk-reducing bilateral salpingo-oophorectomy performed either by a gynecologic oncologist or a benign gynecologist between July 2007 and September 2018. MEASUREMENTS AND MAIN RESULTS: Among 269 patients who underwent risk-reducing bilateral salpingo-oophorectomies, 220 procedures were performed by gynecologic oncologists, and 49 were performed by benign gynecologists. Washings were not performed in 5% of the procedures performed by gynecologic oncologists and 37% of the procedures performed by benign gynecologists (p <.001). Complete serial sectioning of the adnexa was not performed in 12% of the procedures performed by oncologists, and 13% of the procedures performed by benign gynecologists (p = .714). There were 8 cases (2.9%) of tubal or ovarian cancer diagnosed within this cohort. Of these cases, only 3 (1.1%) were diagnosed at the time of surgery and met the criteria for conversion to a staging procedure. CONCLUSION: Because the incidence of ovarian cancer diagnosis at the time of risk-reducing bilateral salpingo-oophorectomy is low and is often not diagnosed at the time of surgery owing to the presence of only microscopic disease, it may not be necessary for gynecologic oncologists to exclusively perform these procedures. However, this study also revealed that when this procedure is performed by benign gynecologic surgeons, some of the recommended practices are not routinely followed. If general gynecologic surgeons are to routinely perform risk-reducing bilateral salpingo-oophorectomies, it is important to promote better adherence to these practices.

Comparison of Laparoscopic Hysterectomy in Patients with Endometriosis with and without an Obliterated Cul-de-sac.

STUDY OBJECTIVE: To determine if intraoperative outcomes for patients undergoing laparoscopic hysterectomy with endometriosis and an obliterated cul-de-sac are different than patients with endometriosis and no obliteration of the cul-de-sac. DESIGN: A retrospective cohort study. SETTING: An academic tertiary care hospital. PATIENTS: Patients undergoing total laparoscopic hysterectomy with endometriosis between 2012 and 2016. INTERVENTIONS: Total laparoscopic hysterectomy, laparoscopic modified radical hysterectomy, and other procedures as indicated. MEASUREMENTS AND MAIN RESULTS: A total of 333 patients undergoing hysterectomy were found to have endometriosis at the time of surgery. Ninety-six (29%) patients were found to have stage IV endometriosis as defined by the American Society for Reproductive Medicine staging criteria. Of those, 55 (57%) had an obliterated cul-de-sac, and 41 (43%) did not. The remaining 237 (71%) patients had stage I, II, or III endometriosis. Fifty-one (93%) patients with an obliterated cul-de-sac required laparoscopic modified radical hysterectomy compared with 12 (29%) patients with stage IV endometriosis without obliteration and 60 (25%) patients with stages I through III endometriosis (p < .0001). The median total surgical time in minutes differed among the 3 groups as follows: obliterated cul-de-sac = 159 minutes, stage IV endometriosis without obliteration = 108 minutes, and stages I through III endometriosis = 116 minutes (p <.0001). Additional procedures at the time of hysterectomy were more frequently performed for patients with an obliterated cul-de-sac and included salpingectomy (p = .02), ureterolysis (p <.0001), enterolysis (p <.0001), cystoscopy (p = .0006), ureteral stenting (p <.0001), proctoscopy (p <.0001), oversewing of the bowel (p <.0001), and anterior resection and anastomosis (p = .006). CONCLUSION: Patients with stage IV endometriosis and an obliterated cul-de-sac required laparoscopic modified radical hysterectomy and various other intraoperative procedures more than patients with stage IV endometriosis without obliteration and stages I through III. Patients with obliterated cul-de-sacs who are identified intraoperatively should be referred to minimally invasive gynecologic specialists because of the difficult nature of these procedures and extra training required to perform them safely with limited morbidity.

Tigers in the Sidewall: Surgical Approaches to Excision of Lateral Deep Infiltrating Endometriosis.

OBJECTIVE: To describe the surgical approaches and excisional techniques used in an extreme case of deep infiltrating endometriosis (DIE) affecting the lateral pelvic side wall. DESIGN: A technical video showing the excision of advanced lateral DIE. SETTING: An academic tertiary care hospital. INTERVENTIONS: A 32-year-old woman, gravida 2, para 1, presented for definitive surgical management of endometriosis-associated pelvic pain. Intraoperative findings revealed severe retroperitoneal fibrosis tethering the external iliac vein, internal iliac artery, obturator nerve, medial umbilical ligament, and ureter. The patient underwent laparoscopic management of the DIE involving the lateral pelvic side wall. We demonstrate the surgical methods and tools required to overcome a unique endometriotic nodule that would not allow for traditional lysis of adhesions from the pelvic side wall. Instead, we used a nontraditional surgical approach by tunneling under the external iliac vascular to tackle the dissection from a lateral to medial direction to free the obturator nerve and internal iliac artery from the ureter and endometriotic nodule. CONCLUSION: Extreme cases of DIE involving the pelvic side wall require surgical finesse when normal planes of dissection are obliterated. Knowledge of retroperitoneal anatomy is critical to overcome unexpected lateral pelvic side wall endometriosis because the disease is rarely confined to the surface. Innovative surgical thinking complemented by an array of surgical tools will ultimately allow the surgeon to master these difficult endometriotic resections.

Intravenous acetaminophen vs saline in perioperative analgesia with laparoscopic hysterectomy.

BACKGROUND: Opioids are effective for the treatment of postoperative pain but can cause nausea and are associated with dependency with long-term use. Nonopioid medications such as acetaminophen offer the promise of decreasing these nondesirable effects while still providing patient comfort. OBJECTIVE: The purpose of this study was to compare intravenous acetaminophen with placebo and to evaluate postoperative pain control and opioid usage after laparoscopic hysterectomy. STUDY DESIGN: We conducted a prospective double-blind randomized study with 183 patients who were assigned randomly (1:1) to receive acetaminophen or placebo (Canadian Task Force Design Classification I). Patients received either 1000 mg of acetaminophen (n=91) or a placebo of saline solution (n=92) at the time of induction of anesthesia and a repeat dose 6 hours later. Both groups self-reported pain and nausea levels preoperatively and at 2, 4, 6, 12, and 24 hours after extubation with the use of a visual analog scale with a score of 0 for no pain to 10 for highest level of pain. Patients self-reported pain, nausea, and postoperative oral opiates that were taken after discharge. All opiates were converted to milligram equivalents of oral morphine for standardization. RESULTS: There were no significant differences in generalized abdominal pain at any time point postoperatively that included 2 hours (placebo 3.6±2.5 vs acetaminophen 4.4±2.5; P=.07) and up to 24 hours (placebo 3.3±2.4 vs acetaminophen 3.6±2.5; P=.28). Similar results were observed for nausea scores. There were no differences in opioid consumption at any time point including intraoperatively (placebo 4.4±3.9 vs acetaminophen 3.3±4.0; P=.06), post anesthesia care unit (placebo 10.5±10.3 vs acetaminophen 9.7±10.3; P=.59), and up to 24 hours after surgery (placebo 1.4±2.0 vs acetaminophen 1.6±2.1; P=.61). There were no differences in demographics or surgical data between groups. CONCLUSION: There was no difference between acetaminophen and placebo groups in postoperative pain, satisfaction scores, or opioid requirements. Given the relatively high cost ($23.20 per dose in our study), lack of benefit, and available oral alternatives, our results do not support routine use during hysterectomy.

Use of Uterine Characteristics to Improve Fertility-Sparing Diagnosis of Adenomyosis.

Objective: To describe patient demographics, determine accuracy of clinical diagnosis, and evaluate reliability of laparoscopic uterine characteristics in the diagnosis of adenomyosis. Materials and Methods: Enrollment included 117 patients undergoing laparoscopic hysterectomy for benign indications. Intraoperatively, the attending surgeon predicted uterine weight; evaluated the presence of fibroids; and commented on the uterus' shape, color, and consistency while probing it with a blunt instrument. A prediction was also made about whether final pathology would reveal adenomyosis. Standardized video recordings were obtained at the start of the case. Each video was viewed retrospectively twice by three expert surgeons in a blinded fashion. Uterine characteristics were reported again with a prediction of whether or not there would be a pathologic diagnosis of adenomyosis. These data were used to calculate inter-and intrarater reliability of diagnosis. Results: Women with adenomyosis were more likely to complain of midline pain as opposed to lateral or diffuse pain (p = 0.048) with no difference in the timing of the pain (p = 0.404), compared to patients without adenomyosis. Uterine tenderness on examination was not an accurate predictor of adenomyosis (p = 0.566). Preoperative diagnosis of adenomyosis by clinicians was poor, with an accuracy rate of 51.7%. None of the intraoperative uterine characteristics were significant for predicting adenomyosis on final pathology, nor was any combination of the features (p = 0.546). Retrospective video reviews failed to reveal any uterine characteristics that generated consistent inter- or intrarater reliability (Krippendorff's α < 0.7) in making the diagnosis of adenomyosis. Conclusions: Clinical and video diagnosis of adenomyosis have low accuracy with no uterine characteristics consistently or reliably predicting adenomyosis on final pathology. (J GYNECOL SURG 34:183).

Uterine-sparing Laparoscopic Resection of Accessory Cavitated Uterine Masses.

STUDY OBJECTIVE: To demonstrate surgical techniques utilized during uterine-sparing laparoscopic resections of accessory cavitated uterine masses (ACUMs). ACUMs represent a rare uterine entity observed in premenopausal women suffering from dysmenorrhea and recurrent pelvic pain. The diagnosis is made when an isolated extra-cavitated uterine mass is resected from an otherwise normal appearing uterus with unremarkable endometrial lumen and adnexal structures. Pathologic confirmation requires an accessory cavity lined with endometrial epithelium (and corresponding glands and stroma) filled with chocolate-brown fluid. Adenomyosis must be absent. Although the origin of ACUMs is currently unknown, the most common presentation is a 2-4 cm lateral uterine wall mass at the level of the insertion of the round ligament. Hence it has been hypothesized that gubernaculum dysfunction may be responsible for duplication or persistence of paramesonephric tissue leading to ACUM formation as a new Müllerian anomaly. DESIGN: A stepwise surgical tutorial describing 2 laparoscopic ACUM resections using a narrated video (Canadian Task Force classification III). SETTING: An academic tertiary care hospital. PATIENTS: In this video, we present 2 patients who underwent uterine-sparing laparoscopic resections of their ACUM in order to preserve fertility (Case 1) or avoid the complications and surgical recovery time of a total laparoscopic hysterectomy (Case 2). Case 1 is a 19-year-old, gravida 0, para 0 woman with dysmenorrhea and recurrent pelvic pain who presented for multiple emergency room and outpatient evaluations. Transvaginal ultrasonography was unremarkable except for a 28×30×26mm left lateral uterine mass with peripheral vascular flow that was initially felt to be a leiomyoma or rudimentary uterine horn. MRI imaging, however, demonstrated this mass to be more consistent with an ACUM. This was based on the lack of communication between the lesion and the main uterine cavity exhibited by high T2 signal (compatible with endometrial tissue) surrounding low T2/high T1 signal in the dependent aspects (representing blood products). After counseling regarding treatment options including medical management with hormonal contraception, the patient elected for definitive fertility preserving laparoscopic resection. In contrast, case 2 is a 39-year-old, gravida 3, para 3 woman with a 2 month history or left lower quadrant pain following her last vaginal delivery. Transvaginal ultrasonography showed a 23×18×19mm cystic structure within the left uterine wall, which was confirmed to represent an ACUM on MRI. Although she had no desire for fertility preservation, the patient elected for surgical resection of the mass as opposed to a hysterectomy in order to minimize complications and recovery time. INTERVENTIONS: Laparoscopic resection of ACUMs in patients desiring uterine preservation. MEASUREMENTS AND MAIN RESULTS: Laparoscopic resection of the ACUMs was performed utilizing 2 different techniques. In both cases, dilute vasopressin was injected with a modified butterfly or spinal needle along the uterine-ACUM serosal interphase to aid with hemostasis. In patients desiring to preserve fertility (case 1) monopolar energy is utilized to make an incision along the ACUM serosa to help facilitate dissection. ACUM enucleation is then commenced in a circumferential manner along the ACUM and uterine myometrial interphase utilizing bipolar energy. In contrast to leiomyomas where dissection advances along the pseudocapsule, ACUM have poorly delineated borders with disorganized muscular fibers making dissection particularly difficult. A variety of instruments can be utilized to help in the sequential circumferential dissection in addition to a bipolar device including a single-tooth tenaculum, myoma hook, suction device or fine-needle grasper. Ultimately, the ACUM is transected off its uterine-myometrial attachment and hemostasis is obtain before closing the uterine defect in at least 2 layers using a 2-0 barbed V-Loc (Medtronic, Minneapolis, MN). If fertility preservation is no longer desired, the dissection can greatly be expedited by performing a salpingectomy and skeletonizing the ACUM from the leaves of the broad ligament (case 2). A monopolar L-hook can then be used to transect the ACUM from the remaining uterine body. While difficult, these cases can be completed laparoscopically in approximately 2 hours with minimal blood loss. CONCLUSIONS: ACUMs are hypothesized to represent a previously under recognized Müllerian anomaly linked to gubernaculum dysfunction that occurs in premenopausal women with dysmenorrhea and chronic pelvic pain. Uterine and fertility sparing laparoscopic resection is possible but challenging due to poorly defined planes.

Diagnosis and Management of Abdominal Wall Endometriosis: A Systematic Review and Clinical Recommendations.

IMPORTANCE: Abdominal wall endometriosis (AWE) is a rare but easily treated cause of pain in women, especially those who have undergone cesarean deliveries. OBJECTIVE: This article reviews the diagnosis and management of AWE, a condition that generally develops after surgery but may arise spontaneously. We present a systematic review of the existing literature on AWE, as well as our clinical recommendations for medical and surgical management. EVIDENCE ACQUISITION: We searched PubMed and other databases using the search criteria "abdominal wall endometriosis," "abdominal wall endometriomas," and "abdominal wall mass." The references of those articles were then reviewed, and additional publications were evaluated. RESULTS: Many case reports and case series have been published describing AWE. The overall quality of evidence is poor due to the lack of prospective studies and heterogeneous descriptions of AWE lesions and treatment options. Based on the available literature, it appears that AWE may arise spontaneously but is generally associated with prior pelvic surgery. Abdominal wall endometriosis can be diagnosed with a careful history and physical examination. Imaging including ultrasound and magnetic resonance imaging can assist with localization of the lesions, and aid in surgical excision and management. Lesions that have been removed in their entirety are unlikely to reoccur. CONCLUSIONS AND RELEVANCE: Although limited, the body of literature describing management of AWE suggests that it can be successfully treated in most patients with careful surgical planning.

Impact of Video Coaching on Gynecologic Resident Laparoscopic Suturing: A Randomized Controlled Trial.

STUDY OBJECTIVE: To determine if the addition of video coaching to an obstetrics and gynecology resident laparoscopic simulation curriculum improves acquisition of suturing skills. DESIGN: Randomized controlled trial (Canadian Task Force classification I). SETTING: Academic teaching hospital with a residency program in obstetrics and gynecology. PATIENTS: Twenty obstetrics and gynecology residents undergoing a 4-week laparoscopic simulation curriculum were video recorded weekly performing a suturing task on a validated vaginal cuff model. INTERVENTIONS: Residents were randomized to standard simulation curriculum or standard curriculum plus weekly video coaching by an expert laparoscopic surgeon. Primary outcome measure was comparison of weekly Global Operative Assessment of Laparoscopic Skills plus Vaginal Cuff Metrics (GOALS+) scores of the suturing task. MEASUREMENTS AND MAIN RESULTS: Baseline GOALS+ scores did not differ across training groups (p = .406), although "senior" (postgraduate years 3 and 4) residents initially had significantly higher GOALS+ scores than "junior" (postgraduate years 1 and 2) residents (p < .001). GOALS+ scores significantly improved from week 1 to week 2 in the intervention group compared with the control group (p < .05). Junior coached residents had significantly higher GOALS+ scores at week 2 (mean, 28.06; standard deviation, 3.10) compared with the junior control residents (mean, 20.75; standard deviation, 6.38; p < .04). Over the 4-week period all residents showed significant improvement (p = .005), with novice residents improving more than experienced residents (p = .001). The junior coached residents exhibited a significant difference between weeks 1 and 2 when compared with the junior residents undergoing the standard curriculum. CONCLUSION: Video coaching during laparoscopic simulation training has the greatest impact early in junior learners' skill acquisition, thus providing another tool for simulation training curricula.

Hemostasis During Ovarian Cystectomy: Systematic Review of the Impact of Suturing Versus Surgical Energy on Ovarian Function.

This systematic review compares the effect of suturing and surgical energy used for hemostasis during ovarian cystectomies on ovarian function. A search of Scopus, Embase, and PubMed databases was conducted through December 1, 2016 for prospective, retrospective, and randomized controlled trials that analyzed ovarian function after ovarian cystectomies where hemostasis was obtained using suturing versus surgical energy. Of the 25 studies identified, 12 with a total of 1133 subjects met the criteria and were included in this review. Analysis of the pooled data strongly supports the use of suturing rather than surgical energy (bipolar or ultrasonic coagulation) for hemostasis, because it provides improved preservation of ovarian function at the time of cystectomy. Four of 8 ovarian reserve markers (anti-Müllerian hormone, antral follicle count, peak systolic velocity, and ovarian volume) demonstrated a positive association using suturing, whereas the remainder of ovarian markers showed a positive trend toward suturing or noninferiority to bipolar energy. In conclusion, suturing for hemostasis after ovarian cystectomy is superior to surgical energy in preserving ovarian function. Further studies are needed to assess whether this difference is clinically relevant in regards to fertility and premature ovarian failure. (USPSTF Level II-1 Evidence).