The Benefits of the THL Procedure in Diagnosing Endometriosis

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Dr. Ivo Brosens: “This is the last speaker and I’m pleased now to introduce Tom Lyons who’s Clinic Professor at Emory University in Atlanta and is Director of the Center for Women’s Care and Reproductive Medicine. I’m so pleased to have Tom participate in our work because I have a high regard for what he has been doing in introducing and evaluating new techniques such as supracervical hysterectomy, and he has been assisting us in running our courses on laparoscopy – Tom.”

Dr. Thomas Lyons: “Thank you, Ivo, and I appreciate the invitation to be here. I think that at the very least, all of us here should be very appreciative and congratulate with vigor Dr. Gordts and Dr. Brosens and the people at Leuven. I think this work is absolutely fantastic, and they deserve a round of applause. To follow them, unfortunately, is me so I really want to give you our experience and I want to actually tell you my experiences which is probably going to be similar to yours in that you see this very impressive work and you see these pictures and videos which I felt were terribly impressive and immediately begin to think of the ways that you can possibly use them to help your practice and to help in women’s healthcare. 

In my opinion, and not being a reproductive endocrinologist although I do a lot of work with endometriosis, etc., I began to look at slightly different directions than Dr. Gordts and the people at Leuven. But again, my experience is still the same, in that we are visualizing a space in the female pelvis that is really the area where most of the pelvic pathology resides. Certainly statistically that is true, and we are visualizing this with such good accuracy that we’re actually seeing things now that we’ve not been able to see before, and actually, we’re now having to sort of re-categorize and re-catalogue some of our prior thoughts. Some of the things we’ve seen, some of these very fine adhesions, we now have biopsied and have found are positive for endometriosis. We would not have thought that before and you can’t even see them in laparoscopy so I think it’s pretty exciting. What I want to do is show you a video that gives you our experience the way we’ve approached this. It is a bare minimum compared to the lovely video that you just saw with Dr. Gordts but I do want to go ahead and start this video, and I’ll talk as we go through this about the things that we can see on the video. 

Our experiences really started as of the middle of summer, I went over and visited with Dr. Gordts and his colleagues in April and then after working through IRV approval and some other things, we began doing cases around the first of July. We started our experience - you see us putting the equipment together here - using it in patients who are going to have laparoscopy done. Most of these were patients who were having procedures performed be that hysterectomy or other procedures done laparoscopically. They were being done under general anesthetic originally, we have done some patients under local at this time and find that it’s a very do-able procedure under local but again, our procedures were originally done in patients who we were anticipating other laparoscopic procedures to follow. You see this presented quite clearly, this is the obturator and dilator and the Veress needle set up. You see our patients are more elegantly draped because we’re about to do operative laparoscopy on them, but again, it’s a very simple, easy procedure. We do place the patients in a pretty steep Trendelenburg as much Trendelenburg as we’re comfortable with, and again, I think that helps a little bit. The angle of the Veress needle is further downward into the pelvis then you would anticipate. This is what the needle looks like coming through under laparoscopy. We did only a few patients where we actually had the laparoscope in place when we placed the needle in the cul-de-sac but we did do that a few times just to become more comfortable. It’s a single procedure and I find that I actually slide the dilator in over the Veress needle with one hand, and I don’t find it very difficult to do. Once we assure ourselves that we are in the abdominal cavity and the peritoneal cavity, we remove the speculum, and actually, we can even remove the tenaculum if necessary. 

These have been done both on patients with uteruses and without. I found that usually I’m further end down then I anticipate when I go in so I usually have to back out. Again, what’s on this video is just a series of pathology that we were able to visualize. Unfortunately, since I’m closer than you are, I can barely see this but here you see some filmy adhesions on this area here. This is the small bowel that has been bound down into the pelvis and adhesions are quite clearly seen. It’s not hard to visualize at all, I think that, again, the colors are quite nice. Actually, it’s not quite as clear on this large screen as it is in the video in surgery itself. Again, the pelvic side wall and you can see both the white sclerotic changes that are consistent with endometriosis and also you’ll see a little bit of carbonization in certain cases - this is either carbonization or it may very well be endometriosis. In this particular case, it was endometriosis. Sometimes you’ll see the same type of pattern in patients who have had prior laser therapy or ablative therapy with carbonization left. But, again, these dense adhesions are quite common and excellent visualization of the pelvic sidewall. Systemic evaluation was seen. With the fimbriated ends, everyone in the room always sort of takes a deep breath and sighs when you see this because it really is gorgeous stuff. The amazing thing is these very, very fine adhesions that you see on the ovary, here’s the left fimbria. 

Of course, salpingoscopy is not the easiest thing to do, it’s easily done by Dr. Gordts but it’s not always easy unless the tube is really facing you perfectly but if you can slide into this it can be quite rewarding. In this case, the ovary itself is smooth and sclerotic just what a normal ovary should look like but because of the hydroflotation you can begin to see some of these very fine adhesive disease. Again, most of the patients who we were doing you see these little fine adhesions on the sidewall. Most of the patients we were doing were actually patients who had had pelvic pain and endometriosis was the prior diagnosis and probably the best for the majority of the patients. We have not only a 30-degree lens but also a 70-degree lens and sometimes the 70-degree lens can be helpful in seeing some areas that are difficult on the sidewall. See these very fine adhesions on the ovary, these are invisible at laparoscopy; I will assure you that when we put the laparoscope in these patients, you can’t see these adhesions. This is, I believe, the 70-degree lens where you can, again, get a better appreciation of some of the sidewall structures. Same thing here but particularly I find that the cul-de-sac is very easily seen with a 70-degree lens as you’re coming out. Trying to slide into the fallopian tube from the side, again, when you look in the abdomen, you will see plenty of fluid, and this is our laparoscope’s end. 

You’ll also see the site at which we entered the abdominal cavity, and usually there’s no bleeding. There’s a typical endometriosis lesion on the left, on the pelvic sidewall. Abnormal vascularity is, I think, better seen because you don’t see the compression of the capillary structures as you would see it with CO2 at laparoscopy. We’ve also had two patients who had obliterated cul-de-sacs and we were successful in performing the procedure. I don’t recommend it but it certainly is a contraindication that you don’t always know. We’ll slip up and probably see the appendix here, and the omentum, omental structures down the center. Here is a dense vascular adhesion in the ovary to the pelvic sidewall. This is an amalgam of different pathologies. This is again the sclerotic and/or different changes that you’ll see with endometriotic lesions. Most of the pathology that I have is endometriosis for obvious reasons since these are mostly patients with pelvic pain. Again, classic endometriotic changes and abnormal vasculature surround all of this. All these patients, of course, had excisional therapy after these procedures were performed and the pathology that we obtained a specimen was consistent with what you’d expect with this visualization. That was the cul-de-sac. Again, it’s not very difficult to obtain a perspective, the first couple of times that you do it, it just takes a little while to get used to the visualization and then once you’re comfortable with it, you really tour around quite easily. 

Tubal from the fimbria, again, you see these fine adhesions on the ovary; this is of course a normal fimbria. We see corpora lutea, some classic endometriotic adhesions superficial on the ovary associated possibly with some abnormal vascularity. And now right back to the cul-de-sac, you’re looking at the uterosacral ligament, little bit of structures, etc. in the cul-de-sac, left ovary, fallopian tube, etc. But I think it’s patently obvious that you can see better underwater as the advertisement says. I think there’s no question that we really are seeing more things in this procedure then we have seen before but I think with that there’s a challenge to us to be able to re-catalogue these abnormalities because we’re really going to have to go through a whole new atlas of changes. We certainly see ureteral activity on the pelvic sidewall, all of these things that you anticipate seeing. This is the ureter, this movement over here, I don’t know if you can see it clearly. There’s the ureteral peristalsis. This is the appendix lying here. And again, we obviously work with really one set of equipment which sort of travels with us. We can do this at several different places; it’s not a difficult procedure to perform. Lateral sidewall endometriosis, you see this plane lesions that have been cauterized before. Here’s the tip of the appendix, you see in the right upper pelvis, more filmy adhesive disease on the ovary. Again, these adhesions when biopsied were, in fact, endometriosis, and some cases endosalpingiosis. 

In our experience, and I’ll just tell you briefly, we’ve done twenty-five cases at this time and we’ve had no significant complications whatsoever, no bleeding. I think we probably did enter the bowel in our first one or two cases but no sequela with that and to this date, I think the procedure has been quite informative to us. My feeling is that one of the areas that this procedure can be helpful to our patients is that it may be a way to do effective screening in high-risk patients for ovarian cancer. That’s one of the areas that we’re going to be looking at over the next several months. Again, I’ve been very happy to be associated with working with this. I really want to thank Dr. Gordts, Dr. Brosens, and the group in Belgium because I think it is going to be something that’s important to our patients. I appreciate you having me here and we’ll be answering some questions later. Thank you.”