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Photographs
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Ten years after a hysterectomy and removal of the left ovary for fibroid tumors, this woman developed bloating and constipation. This barium enema xray shows (in the lower right corner) the bowel wall compressed by endometriosis. She was treated with a laparoscopic bowel resection, was hospitalized for three days and has done well since then.
This patient demonstrates endometriosis in the "cul-de-sac" (the area behind the uterus and in front of the rectum). She presented with painful intercourse and diarrhea associated with the menstrual periods.
A "chocolate cyst" (endometrioma) is formed when endometriosis invades the ovary. A dark, thick fluid fills these ovarian cysts. They are best treated by removal of the cyst and may recur if simply drained or when the inner wall cannot be removed and is burned with a laser.
The most common site for endometriosis is on the uterosacral ligaments behind the uterine cervix. This patient who presented with pelvic pain had involvement extending deep into the space between the vagina and the rectum.
In this patient, endometriosis is seen on the posterior surface of the uterine fundus (just to the right of the metal probe), at the base of the right uterosacral ligament and in the cul-de-sac between the uterine ligaments.
Endometriosis may have many appearances. This photo includes white endometriosis, clear endometriosis, red endometriosis and powder burn lesions.
Powder burns on the right uterosacral ligament causing painful intercourse.
Dissection of the space between the rectum and vagina allows removal of deep endometriosis in patients with severe pain. If preoperative testing reveals narrowing of the bowel, then a laparoscopic bowel resection can be performed. It is important that a thorough cleansing of the bowel be carried out before any surgery for pelvic pain where endometriosis is suspected. Failing to prepare the bowel preoperatively may result in increased risk and limit the surgeons ability to perform a satisfactory resection.
Resection of the uterosacral ligaments and peritoneal surface endometriosis resulted in relief of pain for this patient. But, endometriosis frequently recurs. Therefore, I recommend hormonal suppression for those patients not trying to get pregnant immediately.
Patients with severe menstrual cramps who do not have endometriosis may also benefit from cutting the nerve fibers that run in the uterosacral ligaments behind the uterus. About 60-80% receive some degree of pain relief with this procedure.
Video
Caution, video files are quite large. Your download times may be excessive if you do not have ISDN or T1 access.
As endometriosis can grow below the surface of the peritoneum, I believe that excision of endometriosis leads to better results than laser vaporization.
endo.mov 5.6 meg quicktime video