technique guide - endometriosis - bladder nodule

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GYN Technique Guide Series Volume 3, No. 1 Jan. 2015 xx-xxxx_#

GYN Technique Guide Series PN PB-2003683_Rev B, November 2015

Adhesiolysis, Followed by Excision of Deep Infiltrating

Bladder Nodule, Using the Lumenis FiberLase™ CO2 Fiber

and AcuPulse™ CO2 Laser

Case by: Mariona Rius, M.D. and Francisco Carmona, M.D., PhD, Hospital Clinic, Barcelona, Spain

The main objective of this technique guide is to show how to use the Lumenis

AcuPulse™ CO2 Laser and FiberLase Flexible CO2 Laser Fiber for treatment of

endometriosis. After presenting a clinical case, we describe step by step how

the laser is used in order to perform the excision of a deep infiltrating

endometriosis (DIE) nodule on the bladder.

Preoperative

Patient and Presenting

Complaint

Patient is a 30-year-old nulliparous woman.

Past history of endometriosis, diagnosed in 2013, after a laparoscopy with

bilateral salpingectomy for pelvic inflammatory disease (pathology study

revealed endometriosis in both tubes).

Patient complains of dysuria, hematuria, dysmenorrhea, dyspareunia

and pelvic pain, which increases during and after menstruation, since the

surgery in 2013.

Although the patient is under continuous hormonal treatment, the

symptoms persist. Moreover, the patient has pregnancy desire and

requires IVF for the bilateral salpingectomy.

Relevant Physical Findings and

Diagnostics

Routine physical examination, including a complete pelvic exam, revealed a

vaginal anterior wall nodule that did not infiltrate vaginal mucosa. The

examination was painful.

Ultrasound examination showed a deep infiltrating endometriosis (DIE)

nodule on the bladder (4 cm) and another one on the left uterosacral

ligament and left ureter.

Abdominal ultrasound examination ruled out hydronephrosis.

Cystoscopy revealed a 3 cm endometriosis nodule in the bladder fundus.

Adhesiolysis followed by excision and ablation of endometriomas using Lumenis AcuPulse CO2 laser and FiberLase CO2 fiber

Francisco Carmona, M.D.

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Diagnosis Deep infiltrating endometriosis nodule on the bladder.

Deep infiltrating endometriosis nodule over left ureter and left

uterosacral ligament.

Operative

Surgical

Procedure

Adhesiolysis.

Resection of DIE nodules over the ureter and utero-sacral ligament and

resection of bladder nodule.

Anesthesia Patient underwent general anesthesia by the anesthesia department.

She was intubated and muscle paralysis was used to control

respirations.

Laparoscopic

Instrumentation

Storz HD Endoscope Camera.

Storz (0⁰) laparoscope (Storz, 39301 CS) with 10 mm outer diameter.

Insufflation was accomplished with carbon dioxide insufflator (Storz) set

to 14 mmHg pressure. The insufflator was attached to a 12 mm port for

endoscope camera and kept at high flow rate. A gas warmer was used

(Thermoflator SCB 26432020).

Other major laparoscopic equipment:

▪ Suction and irrigation cannula (Gyrus 60/16/5-1).

▪ Generator for electrosurgery (Valleylab).

▪ Bipolar grasper (Olympus, WA63120 C).

▪ Monopolar scissors and hook (Microline 3904/Olympus A6282).

▪ Forceps, graspers (Storz 33322HM/Olympus 3322F).

Uterine manipulator was placed.



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Patient Set Up Patient Position. Patient placed in semi-lithotomy position on a

standard surgical table. The arms were carefully wrapped for protection

and placed beside the trunk to allow the surgeon to work at the level of

the shoulders.

Limb Protection and DVT Prophylaxis. Protective boots were used to

cushion the feet, ankles and calves. For DVT prophylaxis, a pneumatic

compression device was used on the calves with alternating leg

pressure (ALP) set to 40-60 mmHg.

Patient Prep and Drape. After iodine (10% solution) skin preparation

was widely done over the surgical site, a “laparoscopy” drape

(Hartmann “Laparoscopy Pack”) was used to maintain a sterile

operating field. A disposable instrument organizer was used on the

patient’s left leg to keep the most used instruments within reach.

Placement of Ports. Pneumoperitoneum was accomplished by direct

Veress needle puncture on umbilicus and insufflation of carbon dioxide.

Once the pneumoperitoneum was established, a 12 mm umbilical port

was placed for the endoscope camera (Endopath Xcel, Ethicon Endo-

surgery). Then three (3) 5 mm accessory trocars (ENDOPATH® XCEL®

Ethicon Endo-Surgery) were placed at the following locations: left iliac,

right iliac, and suprapubic midline.

Assistants Two residents assisted by holding the camera and bringing in graspers

and suction/irrigation cannula.

Laser, Accessories and

Purge Air

AcuPulse 40WG CO2 Laser

FiberLase flexible CO2 laser fiber, OD 1.04 mm, minimum spot diameter

500 µm

FiberLase GYN Lap-R Handpiece

Purge air for fiber was supplied by low-flow internal pump on laser

(with bacterial filter), set to flow only when lasing.

Smoke Evacuation and

Insufflation

Smoke evacuator (Buffalo Filter) was connected to one of the 5 mm

ports and used only when lasing.

The carbon dioxide insufflator was kept at high flow.



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Laser

Parameters

The laser parameters for the major surgical steps for which the laser was used

are provided in the table below.

Step Mode and

Power

Exposure

Mode

Time On

Time Off

Distance to

tissue from

tip

Adhesiolysis and

resection of DIE nodules

on left ureter and left

utero-sacral ligament

SuperPulse

10-12 Watts

REPEAT On: 0.3 sec.

Off: 0.3 sec.

1 mm

Dissection and resection

of deep endometriosis

nodule on the bladder

SuperPulse

13-14 Watts

REPEAT On: 0.3 sec.

Off: 0.3 sec.

1 mm

Laser Technique

After macroscopic inspection of abdominopelvic cavity, adhesions

between the left ovary, posterior wall of the uterus and bowel were

identified. Adhesiolysis was performed by resecting with laser, cold

energy (scissors) and electricity (hook). The decision to use one or the

other was based on risk to nearby structures (bowel, ureter, etc.). CO2

laser was used when the risk was greater. Scissors and electricity were

used when the risk was low.

Resection of the DIE nodule on the left ureter and left uterosacral

ligament was performed by grasping the nodule and using SuperPulse

laser energy to dissect and resect from healthy tissue and then

progressing towards the disease. Previously, the left ureter was

identified and dissected in order to prevent accidental lesion of this

structure.

Resection of the DIE nodule on the bladder was performed by

dissection with scissors and laser in SuperPulse mode.

Hemostasis The laser beam automatically controlled the mild bleeding.

Bipolar coagulation was used to control the moderate bleeding, which

could not be controlled with laser beam.



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Operative Photos

Fig. 1 Visualization of pelvic cavity,

multiple adhesions between bowel, uterus

and left adnexa.

Fig. 2 Adhesiolysis

Fig. 3 Endometriosis bladder nodule

Fig. 4 Laser ressection of endometriosis bladder nodule

Technique Tips

Prevention of ureteral lesions

In order to prevent ureteral lesions, it might help to identify and dissect ureter

trajectory across the pelvic cavity.

Dissection and Identifying Pelvic Structures

Starting the dissection from healthy tissue and moving to the

fibrotic/endometriotic will help to identify pelvic structures.



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Postoperative

Discharge and Instructions

Patient discharged from the hospital 3 days after surgery.

Post-operative care is routinely coordinated between surgeons, nurses and

office staff.

Painkillers such as NSAIDS are prescribed in case of pain during the

postoperative first week.

Bladder catheter is maintained from 10 to 15 days. Before discharge, nurses

give patients an informative leaflet describing normal recovery period and the

steps to take in case of any problems.

Patients are seen 10-15 days after the surgery in order to remove the bladder

catheter. Then 3-4 weeks after the surgery in the outpatient clinic in order to

assess the recovery. After it, routine follow-up is planned.

Recovery and Outcome Recovery is expected to be progressive over a 2 to 3 weeks period. NSAIDS are

required for not more than 7 to 10 days. Patients usually resume all activities

within 3 to 4 weeks.

Patient will undergo IVF treatment in the coming months.

Discussion

The procedure described above is another technique to surgically treat endometriosis. It is a reproducible technique

with a fast learning curve (6 weeks), making it a wide spread technique for all gynecologists who are specialized in

endometriosis. The margin of safety provided by CO2 laser is high, since the laser penetrates just micrometers in the

tissue. (During the procedure, when the bladder was already opened, the laser hit the Foley catheter balloon by mistake

and it didn’t break! It just broke a thin layer of it!). This is the reason why we use the laser when the risk of injury to

nearby structures is high. Having the opportunity to use the fiber (and its handpiece) simplifies the procedure since it’s

easier to imagine the direction of the laser compared to the free beam -- and the fiber produces less smoke. Finally,

using the laser for treating endometriosis opens a new field characterized by safety and easily reproducible techniques.

WARNING

In order to protect the patient and the operating room personnel, operator manuals including the

Clinical, Safety and Regulatory sections, should be carefully read and comprehended before laser operation.

technique guide - endometriosis - bladder nodule

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