**5. Deep infiltrating endometriosis**

68 Endometriosis - Basic Concepts and Current Research Trends

and health-related quality of life at 24-month follow-up (Zullo *et al.*, 2004). However, this technique presents limitations that must be taken into account: first, it is effective in reducing midline pain only, whereas lateral, adnexal pain is not influenced; second, denervation of bowel and bladder cause *de-novo* constipation (15%) and urinary urgency (5%) (Latthe *et al.*, 2007; Zullo *et al.*, 2004); third, great care must be taken to avoid damaging the right ureter and major and midsacral vessels (Berlanda *et al.*, 2010). Systematic performance of presacral neurectomy cannot be recommended, only in patients with central,

The addition of uterosacral ligament resection (i.e., laparoscopic uterosacral nerve ablation) to laparoscopic surgical treatment of endometriosis was not associated with a significant

Definitive surgery in women with chronic pain is a controversial procedure, especially in young women. However, this factor should be carefully evaluated in order to offer a reliable prognosis to women affected by an oestrogen-responsive disease (Vercellini *et al.*, 2009). The surgical solution in women with recurrent symptoms after previous conservative procedures for endometriosis should be based on the desire for conception, and the preoperative patient assessment must be complete, including testing for bowel dysmotility, urologic disorders, musculoskeletal lesions, and psycho-socio-environmental factors (Berlanda *et al.*, 2010). The risk of depressive symptoms after definitive procedures must be taken into account, particularly in young patients (Vercellini *et al.*, 2009). The definitive therapy for endometriosis is represented by total hysterectomy, bilateral salpingooophorectomy and removal of all endometriotic lesions, in particular deep lesions involving the pouch of Douglas, the anterior pouch or the ureter. The operation mimic radical

When pregnancy is no longer an issue and the woman reveals good psychological stability, hysterectomy with or without bilateral salpingo-oophorectomy may be considered and offers the best outcome. The presence of multiple pelvic symptoms, previous use of a GnRH agonist, and absence of pain resolution predict the likelihood of subsecuent hysterectomy (Learman *et al.*, 2007). Few studies address the advantages of hysterectomy for severe pelvic pain associated with endometriosis. Standard extrafascial hysterectomy is associated with increased recurrence of pain than radical hysterectomy with removal of deep endometriotic

The decision to preserve or remove the ovaries should be based on patient's age and intraoperative gonadal conditions. Bilateral oophorectomy substantially reduces the risk of recurrent symptoms and reoperation due to pelvic pain over the ovarian-preserving surgery (10% vs 62%, and 3.7-8% vs 19.2-31%, respectively). Preservation of both ovaries at hysterectomy for symptomatic endometriosis increased the risk of reoperation by 2.4 to 8.1 (Shakiba *et al.*, 2008). Nonetheless, whenever possible at least one gonad should be preserved in young women, especially in those with objections to the use of oestrogenprogestogens (Shakiba *et al.*, 2008). The effect of postoperative medical treatment on the probability of pain relapse should be taken into account after both conservative and

hipo-gastric pain (Latthe *et al.*, 2007; Vercellini *et al.*, 2009).

difference in any pain outcomes (Latthe *et al.*, 2007).

**4.3 Definitive surgery** 

hysterectomy (Berlanda *et al.*, 2010).

lesions (31% vs 0%) (Fedele *et al*., 2005a).

definitive procedures.

The term deep infiltrating endometriosis (DIE) is used to describe infiltrative forms of the disease that involve the uterosacral ligaments, rectovaginal septum, bowel, bladder, or ureters, but is histologically defined in arbitrary manner when endometriotic lesions extending more than 5 mm beneath the peritoneal surface (Chapron *et al.*, 2009) suggest, regardless of location (bladder, intestine, ureter, etc.) that endometriosis is only considered to be DIE when the muscularis is involved (Yantiss *et al.,* 2001). This entity is responsible for refractory pelvic pain, of which the intensity is correlated with the depth of infiltration, and occurs in 30%-40% of the patients with endometriosis (Chapron *et al.*, 2003).

DIE is thought to arise from several possible mechanisms: (i) The Sampson's retrograde menstruation theory: during menstruation, endometrial tissue refluxes trough the fallopian tubes, implanting and growing on the serosal surface of abdominal and pelvic organs, influenced by local hormones and immune, genetic and environmental factors. This results in peritoneal and ovarian endometrial deposits. (ii) The coelomic metaplasia theory proposes that endometriosis develops from metaplasia of the cells that line the pelvic peritoneum. These cells share a common embryological origin with the germinal endometrium of the ovary and the müllerian ducts. Infectious, hormonal or inflammatory stimuli could result in metaplasia of these cells and endometriosis. This theory is supported by the rare occurrence of endometriosis in men and in prepubertal girls. (iii) The embryonic rest theory proposes that metaplasia of müllerian duct remnants in the rectovaginal septum could result in the rectovaginal nodules. (iv) Another theory implies the migration of cells through the lymphatic system or vía hematogenous spread. (v) The neurologic hypothesis is a new concept in the pathogenesis of endometriosis: the lesions seem to infiltrate the large bowel wall along the nerves, at a distance from the primary lesion (Anaf *et al.*, 2004). It is thought that the growth and invasion of endometrial tissue at ectopic sites is due to a process of neovascularizacion mediated by pro-angiogenic factors such as vascular endothelial growth factor (VEGF) (Taylor *et al.*, 2009). Histologically, endometrial nodules are composed of hypertrophic smooth muscle and endometrial glands, similar in appearance to adenomyosis in the uterus (Brouwer & Woods, 2007).

The multifocal distribution of DIE lesions indeed prompted us to cease considering this disease as a single organ pathology but rather, to see it as an "abdomino-pelvic multifocal pathology" (Chapron *et al.*, 2010). The pre-operative work-up (questioning, clinical examination and imaging information) aims to clarify the exact location and likely extension of DIE lesions. This is essential in order to: (i) Specify the surgical procedures required to achieve complete excision of symptomatic DIE lesions, the only way to prevent the recurrence. (ii) Thoroughly describe the surgical risks to the patient. (iii) Obtain the patient's full informed consent, as necessary prior to surgery for a benign pathology responsible for painful symptoms (Chapron *et al.*, 2010). It must take into account that the discovery of a DIE nodule during clinical and/or imaging investigations is not always followed by surgery. Only lesions that give rise to symptoms should be operated on.

Although medical treatment may be effective in some DIE patients, the treatment of choice is surgical excision. The multifocal nature of DIE lesions must be taken into account when defining the surgical strategy (Chapron *et al.*, 2003). Generally, DIE is presented as a pathology with a high risk of recurrence, estimated at around 30%. Often, however, recurrence corresponds to persistence of DIE lesions that were left in place as the result of an incomplete initial surgical removal (Vignali *et al.*, 2005).

Abdominopelvic Complications of Endometriosis 71

magnectic resonance imaging and focuses on assessing the possibility of rectal involvement on laparoscopy and clinical examination under anaesthetic. A significant number of patients have more than one laparoscopy and the number of laparoscopies has been shown to

Treatment consists of surgical excision, or segmental resection. Excision should be complete in order to achieve maximal pain relief and minimal recurrences (De Cicco *et al.*, 2011). When the rectum is involved there are several approaches to be considered. The choice of technique depends on the size, location, degree and depth of involvement of the endometriotic implant. As a general rule, less is better when it comes to removal of rectal endometriosis as long as the implant can be completely excised. The nodule can be shaved off the rectal wall leaving it intact if superficial serosal deposits are present, alternatively if there is a solitary penetrating nodule there may be the opportunity to perform a fullthickness disc resection of the rectal wall, or it may be necessary to consider a segmental resection of the rectum and/or sigmoid colon (Brouwer & Woods, 2007; Wills *et al.*, 2009). All these procedures can be carried out by either a laparoscopic, combined or open approach (Brouwer & Woods, 2007; Dousset *et al.*, 2010; Wills *et al.*, 2009). Robotic assistance may allow more bowel resections to be carried out by laparoscopy (Veeraswamy *et al.*, 2010). An initial laparoscopy is carried out unless the preoperative assessment mandate a laparotomy. It appears that most authors decide to perform a bowel resection before surgery, based on preoperative examinations. This approach seems to result in a very high incidence of bowel resection. The indication reported is based on dimensions of the nodule >2 cm or 3 cm, and/or on muscularis involvement and/or occupation of more than onethird of the rectal circumference (Brouwer & Woods, 2007). The other approach is to decide during surgery based on findings such as the size, localisation and extension of the disease. Laparoscopic conversion rates is from 0% to 13%, due to extent of disease, dense adhesions, bowel perforation, difficulty stapling a bowel anastomosis, bleeding and poor visualisation

Surgery is only indicated in enteric endometriosis in acute or subacute small bowel obstruction that fails to resolve, in endometriotic tumours or when it is impossible to exclude malignancy. In an emergency setting, the main aim of surgery should be to relieve the obstruction, and if the disease is suspected intra-operatively, then as many ectopic deposits as possible should be excised (Bianchi *et al.*, 2007; Del Rey-Moreno *et al.*, 2008). It can be difficult to exclude a malignancy intra-operatively, in such case is appropriate to

Appendiceal endometriosis may present as an incidental finding with or without pelvic disease. Acute symptoms are similar to those of appendicitis. The appendix should be inspected in all patients undergoing surgery for endometriosis and appendectomy is

The overall complication rate after surgery is 22.2%. Major complications occur in 7%-12.6% of women: colorectal anastomotic leakage (3.7%-11%), recto-vaginal fistula (4%-8.5%), severe obstruction (2.7%), haemorrhage (2.5%), pelvic abscess (1-4.2%), delayed ureteral ischemic necrosis (2%). Minor complications occur in 14.7% of women: temporary bowel dysfunction (4%), bladder dysfunction (8%-17%) (De Cicco *et al.*, 2011; Dousset *et al.*, 2010). The combination of systematic diverting ileostomy, interposition of omentoplasty and

correlate to extent of rectal involvement.

(Wills *et al.*, 2009).

carry out an oncological resection.

recommended if it seems abnormal (Veeraswamy *et al.*, 2010).
