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«Dan C. Martin David B. Redwine Harry Reich Arnold J. Kresch Foreword by John A. Rock Laparoscopic Appearance Of Endometriosis Second Edition Web ...»

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of Endometriosis

Color Atlas

Dan C. Martin

David B. Redwine

Harry Reich

Arnold J. Kresch

Foreword by John A. Rock



Of Endometriosis

Second Edition

Web Revision

Color Atlas

Dan C. Martin

Reproductive Surgery and Endocrinology

UT Medical Group, Inc.

Professor, Department of Obstetrics and Gynecology

University of Tennessee Health Science Center

Memphis, Tennessee

Foreword by John A. Rock

Dean, College of Medicine

Florida International University Miami, Florida Published by The Resurge Press • Memphis, Tennessee Notice: Our knowledge in clinical sciences is constantly changing. As new information becomes available, changes in treatment and surgery become necessary. The author and the publisher of this volume have taken care to make certain that the standards of diagnosis are correct and compatible with the standards generally accepted at the time of publication.

The reader is advised to consult carefully new information as it is available. The reader is also advised to consider that diagnosis, therapy and management of endometriosis are separate concepts. Techniques discussed in this publication may have been modified or abandoned by the time of publication.

All materials contained in these volumes are covered by copyright. The textual material may be duplicated for use in local training or educational events as long as proper citation as illustrated below is given. If large-scale reproduction or distribution of any portion of the volume is desired, prior written permission from The Resurge Press is required. If you wish to include any material in any other publication for sale, please send your request and

proposal to The Resurge Press. The following statement must appear on all reproductions:

From Laparoscopic Appearance of Endometriosis, Second Edition, Martin DC, The Resurge Press, Memphis Copyright 1990, 1991 by the Fertility Institute of the Mid-South, Inc, a nonprofit, tax-exempt [501 (c) (3)], educational and research organization.

All rights reserved. No part of this book can be reproduced in any form or by any electronic or mechanical means including information storage and retrieval systems, except as noted above, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review.

Published by the Resurge Press 4416 Minden Road Memphis, TN 38117 Fax (901) 339-0888 First Printing, April 1990 Second Printing, September 1991 Third Printing, First Revision, December 1991 Web Revision September 2007 Library of Congress Catalog Card Number: 90-60383 ISBN: 0-9616747-6-8

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Recognition of endometriosis is necessary for diagnosis, informed consent and therapy. As this volume demonstrates, the diagnosis of endometriosis and differentiation from other diseases of similar appearances can be difficult. Although there will be microscopic lesions which will not be seen and large lesions which are more palpable than visual, most patients can have their diagnosis confirmed and can receive adequate care by removing the lesions that are seen. Removing these lesions requires careful observation not only for dark puckered lesions but also for the subtler varieties which have been documented in the literature.

This volume provides, in addition to descriptions of retroperitoneal disease, unique photographs of various atypical presentations of endometriosis as well as of diseases that may masquerade as endometriosis. It is expected that additional atypical and masquerading lesions will be described in the future. The gynecologist will find the text and slides a valuable addition to his or her library. Careful study of the atlas will help the laparoscopist identify lesions he or she may not have appreciated in the past.

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"The "red raspberry" appearance of the implant is due to a recent haemorrhage" while those with a "purple raspberry" appearance "are larger lesions". "The pigmented areas with "blueberry" coloring are due to an older haemorrhage". John A. Sampson in SURGERY, Gynecology and Obstetrics, March, 1924, Volume XXXVIII, page 287 and 290, by permission of SURGERY, Gynecology and Obstetrics.

Table of Contents

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Introduction John Albertson Sampson (1873-1946) published a series of articles on endometriosis from 19211 to 19402. He described chocolate cysts, blebs, adenomyomatous infiltration in the rectovaginal septum, adherent surfaces,1 red raspberries, purple raspberries, blueberries, deep infiltration, cancer arising in endometriotic implants 3 and peritoneal pockets.4 He changed his definition of small from 2 to 4 cm in 19211 to a few mm in

1924.3 Colorless, amenorrheic lesions were seen by John Fallon5 in 1950 while Karl Karnaky6 published an age dependent appearance of endometriosis starting with an initial water blister presentation in 1969.

Protean Appearance

The diagnosis of endometriosis has often been made by observation of puckered black or bluish "typical" lesions. 7-11 These type lesions are common in the patient groups studied. Williams documented a 50% incidence in 968 patients who had an average age of 30.12 Publications since that time have generally had average ages of 28 to 32. In addition, Williams' article excluded patients under 15 and those past the age of menopause. This results in biased data.

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The subtle hue and color changes make diagnosis by direct visualization difficult10 and endometriosis has been diagnosed by taking biopsies of areas of normal peritoneum. 20,21 Lesions can hide in or at the rim of peritoneal pockets.4,22 Goldstein, et al.23 documented that 53% (74 of 140) of his adolescent patients had endometriosis using the magnification of the laparoscope for a

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close-up view. Petechial and bleblike endometriotic lesions were the only finding in 20% (13) of 65 adolescent patients.

Redwine discussed the use of near-contact laparoscopy for better visualization of these lesions.24 Redwine found black lesions in 60% and other lesions in 66% of 137 patients.17 These more subtle lesions were found in 36% of 202 patients by Jansen.13 At the same time Jansen noted puckered bluish lesions in 85% of his patients. Quantitation of histologic confirmation of gross appearances have been reported in studies with up to 20 descriptive types.16

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Martin16,26 sent specimens of abnormal appearing tissue seen at second look laparoscopy in a search for atypical transformation in the remnant tissue following intra-abdominal CO2 laser surgery. Although atypical transformation was not noted, endometriosis was found in association with carbon from previous laser surgery and also in lesions that did not appear to be endometriosis. This was compatible with other studies in Table 1.

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When all patients had excision or biopsy of any abnormal appearing tissue the diagnosis of endometriosis increased (Table 2) from 42% in 1982 to 72% in 1988.14,16 Furthermore, histologic confirmation of endometriosis increased from 62% in 1982 26 to 98% in 1988.16 The largest increase appears to be due to the increased documentation of subtle lesions. This was associated with an increased awareness of these lesions and with use of the intrinsic accuracy of documentation using excisional techniques and the CO2 laser laparoscope.

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This increase in diagnosis and documentation of endometriosis also suggested that the diagnosis was missed in at least 7% of patients and identifiable lesions were not recognized in at least 50% of patients in early

1986.16 This is in spite of a 47% diagnosis rate associated with a 95% confirmation of submitted tissue in 1985. 26 Many of the appearance findings occurred after the histologic confirmation rate was 97% or greater with tissue submitted on all endometriosis patients.16,26 (Table 3)

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In the same period of time, a separate study27 of 55 physicians showed that endometriosis was not documented in 14% to 59% of all cases.

Endometriosis was most commonly missed when it was obscured by adhesions, deep fibrosis, myomata, functional cysts, carbon and psammoma bodies. 16,27 (Table 4) These data are compatible with Fallon's conclusion that experience creates uncertainty. 5

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Scanning Electron Microscopy Vasquez28 and Cornillie29 documented the scanning electron microscopic appearance of polypoid, intraperitoneal and retroperitoneal associated with subtle appearances at laparoscopy. Murphy16 reported lesions with scanning electron microscopy, which had not been seen on gross observation. Both laparoscopic and microscopic diagnosis of lesions of less than 400 µ has relied on analysis of the epithelium11 and associated lesions as lesions of this size do not commonly have a well defined stroma.

Infiltrating Lesions

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Infiltrating and deep lesions may be easier to palpate than to see26,33,34,35 and attempts to develop visual criteria for distinguishing deep infiltration from superficial disease by surface observation have so far been unsuccessful. These deep lesions are associated with increased tenderness.36,37,38 Palpation and removal of all identifiable disease in addition to medical suppression appear important in treating pain and in decreasing the number of repeat surgeries performed.

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Due to this, careful palpation of the posterior vagina, cul-de-sac, uterosacrals, rectovaginal septum and rectosigmoid junction is needed preoperatively. When endometriosis is seen in the posterior vagina, this almost uniformly represents extension from peritoneal disease.35 Deep infiltrating endometriosis is hard to dissect with it's irregular infiltration and indistinct planes. Palpation at laparoscopy was most helpful in localizing lesions beneath the peritoneum and around the uterosacral

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ligaments where visualization could not differentiate between the fibrotic white of scarred endometriosis and the white of the uterosacral ligaments.

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Visualization is adequate to differentiate loose connective tissue and fat from the appearance of endometriosis in most other areas.39 The histologic presence of adequate healthy tissue at the margins of these lesions confirmed the ability to make this distinction.

Manual palpation at laparotomy increases recognition of deep lesions, subperitoneal nodules, epiploic fat nodules, appendiceal nodules and infiltrating bowel lesions. The distribution of penetration depth of lesions in the patients who had laparotomy (6 to 30 mm) and the laparoscopic appearance of patients with proven, probable or possible bowel involvement suggests that some patients have penetration in the 1 mm to 10 mm range unrecognized at laparoscopy.32 This is, to some degree, confirmed by patients with 6 to 20 palpable nodules at laparotomy which had not been seen at laparoscopy.

When nodularity is noted on preoperative exam, this exam should be repeated before finishing surgery. This is in order to rule out persistence of deep nodules.33 In addition, other deep infiltrating areas have been noted in the process of excising what appeared to be superficial lesions.

Age Related Changes Sampson noted a change from a red raspberry appearance to a blueberry appearance as lesions aged.3 Karnaky stated that it required 4 to 10 years for water blister lesions to progress to scarred blue-domed cysts.6 Redwine quantitated these changes and demonstrated a change in the observed appearance from clear to red to scarred black lesions over 7 to 10 years.17 This change was also noted by Koninckx, et al. in documenting an increase from 23% to 63% in the occurrence of scarred black lesions over a 20-year age change.37 Koninckx' study also demonstrated a decreased occurrence of red and polypoid lesions and an increased occurrence of deep infiltration over the same time span.

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Leiomyomatosis Peritonealis Disseminata Decidualization of foci of endometriosis may result in death of the cells and replacement with muscle metaplasia. This is associated with a variety of unusual histologies. Of these, the most dramatic is leiomyomatosis peritonealis disseminata. In this, the appearance is one of disseminated smooth muscle nodules throughout the pelvis.41 Infiltrating and clear fibrotic lesions have a similar appearance and contain both fibrous and muscular components.14 This may represent a local tissue reaction to an infiltrating process or the end appearance of decidualization, death and metaplasia of the stroma of endometriosis.

Peritoneal Fluid Studies Peritoneal fluid studies of macrophages,42 peritoneal fluid lysozyme activity,43 and endometrial epithelial cells44 suggest that these are related to infertility. The appearance of polypoid red lesions shows that these tend to be within the peritoneal cavity and have an increased likelihood of either secreting or desquamating directly into the peritoneal cavity than scarred retroperitoneal lesions. In addition, these polypoid forms appear to be more active than the retroperitoneal forms in the production of the ability to synthesize prostaglandin F.18,19 Recent publications demonstrating a decrease in polypoid red areas with age37 and a decrease in cell counts with rAFS scoring45 open new areas for further study.

In that much of the published data is based on endometriosis being diagnosed from black or bluish "typical" lesions,7-11 there may be significant bias in the results of these studies. Many of these "typical" lesions are retroperitoneal as opposed to clear vesicles and red polyps which are more frequently on the surface.28,29 Lesions on the surface have a more direct anatomic route to the intraperitoneal environment than those which are retroperitoneal. A lack of differentiation between these various types may be responsible for some of the dissatisfaction with the various staging systems and some of the variation in studies of the intraperitoneal environment. Until

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