Tips and tricks for diagnostic laparoscopy for endometriosis

All ob-gyns will encounter endometriosis in their practice, but not all of them may have the tools to evaluate for and treat it laparoscopically. However, Olga Fajardo, MD, a second-year MIGS fellow at Vanderbilt University Medical Center in Nashville, Tennessee, provided a few tips and tricks for diagnostic laparoscopy for endometriosis in her presentation at AAGL’s 51st Global Congress on MIGS in Aurora, Colorado.

During her presentation, Fajardo discussed tips and tricks for effective preoperative planning, minimally invasive surgical evaluation and treatment, and postoperative management for endometriosis.

For preoperative planning, Fajardo suggests gathering a thorough history from the patient, including any and all symptoms of dysmenorrhea, pelvic pain, dyspareunia, and GU/GI symptoms such as constipation. Endometriosis can have physical signs on exam, Fajardo continued. During the history and physical exam, ob-gyns should evaluate the pelvic floor myalgia, which is a common disorder associated with endometriosis, which Fajardo added can be treated with pelvic floor physical therapy.

“If you encounter pathology outside of your comfort zone, refer to a MIGS colleague,” Fajardo said. “If there is concern for bowel or bladder involvement, refer the patient to urology or colorectal,” she added.

As far as diagnostic laparoscopy, Fajardo said, the main instruments you will need are Maryland graspers and monopolar scissors. She recommended entering through the abdomen with a 5 to 10 mm scope. She also advised to start with an accessory port to evaluate the pelvis and add more ports if needed. “Remember, do not be afraid to add a fifth port if it makes the procedure more efficient and effective,” she added. Next, Fajardo said to perform a full anatomic survey of the abdomen and pelvis.

Restore normal anatomy, which can be done sharply or bluntly where necessary, according to Fajardo. If there are lesions in close proximity to the ureta or bowel, Fajardo suggested a few tips for excision, including hydrodistension with normal saline to bring the lesion away from underlying structures.

One of Fajardo’s final tips was to drain the endometrioma prior to excision. “This will better delineate the cyst wall and make the excision more efficient,” she said.

Reference

Fajardo O. 7404 - Tips and Tricks for Diagnostic Laparoscopy for Endometriosis. Presented at: AAGL’s 51st Global Congress on MIGS ; December 1, 2022; Aurora, Colorado.