Dr Abri de Bruin

Welcome! Please see this website as an educational reference for patients. My practice strives to offer comprehensive and individualized care in minimal access surgery, endometriosis and infertility.


1. What is endometriosis?

Endometriosis is a disease where the cells that are shed when a women menstruates, grows ouside the uterus


2. What does it look like?

  1. vesicular endometriosis
  2. white endometriosis
  3. yellow endometriosis
  4. nodular endometriosis
  5. black endometriosis
  6. red endometriosis

(from left to right) endometriosis on the tube, endometriosis causing adhesions between the ovary and pelvic sidewall, endometriosis in the ovary - endometrioma


3. Are there different stages?

  • there are 4 stages
  • these are derived from scores derived from the laparoscopy
  • the different stages does not correllate with symptoms or infertility.  This means that patients with stage 4 may have few or no symptoms and maybe just infertility
  • some patients with severe pain may have just minimal endometriosis
  • pain may be influenced by the are that the endometriosis is affecting

Affected organs?

Endometriosis usually involves the following organs:

  1. peritoneum
  2. ovaries
  3. uterosacral ligaments
  4. vagina
  5. large bowel
  6. small bowel
  7. appendix
  8. diaphragm

(from left to right) small bowel, diaphragm, vagina, ovary, colon / rectum, peritoneum, uterosacral ligament (kort die laaste image)

What are the symptoms?

  • painful periods
  • pain with intercourse
  • chronic pelvic pain
  • infertility
  • sometimes there are no symptoms at all 

Why does it cause pain?

due to adhesions that the endometriosis cause

  • an ovary can get stuck to the pelvic sidewall over nerves and the ureter
  • deep infiltration of tissue
  • impact on nerves
  • distention of the organ with subsequent pain
adhesions of ovaries due to em.jpg

4. How is it diagnosed?

  • the gold standard is to do a laparoscopy and to take biopsies and to see the lesions.  They are very typical, but can have a variety of presentations
  • the only way to diagnose endometriosis is by sending tissue to the pathologist to examine
  • sometimes one can feel nodules of endometriosis when doing a vaginal examination
  • if the endometriosis is in the ovary, then it can be seen by ultrasound
  • peritoneal endmetriosis cannot be seen by ultrasound
  • the accuracy of any special investigation, depends on the interpretation and experience of the examiner

Adenomyosis

this is a condition where the endometriosis grows inside the wall of the uterus.  It is between the muscle cells

What happens is that it has a few problems:

  1. increasing the size of the uterus with subsequent increase in volume and duration of menstrual bleeding
  2. increased pain
  3. decrease in fertility due to the impact on the implantation due to damage to the uterus's muscle functioning

5. What is the treatment?

The treatment depends on a few factors:

  1. Severety of symptoms
  2. If there is associated infertility
  3. The age of the patient

There are 2 main options

  1. medical treatment
  2. surgical treatment

Medical treatment

WHEN

  • usually when there is no fertility wish
  • usually when the patient is very young
  • as a trial when the diagnosis is not confirmed, especially young girls

WHAT

  • there are different options available
  • current preferred option is Visanne®, or the Mirena® intra-uterine device or a contraceptive pill with the same progesterone as in Visanne® 
  • GnRH-analogues are used in patients following surgery prior to fertility treatment

Surgical treatment

  • Main philosophy is to be aggressive to the disease and conservative to function
  • The aim is to remove as much of the disease as possible
  • it should be operated by laparoscopy in nearly ALL of the cases
  • in the cases with minimal endometriosis one can remove the lesions using at least three incisions 
  • the more severe the cases there will always have to be 4 incisions to operate the patients
  • the reason for this is that the surgeon has to use both hands to operate and the assistant will hold the camera and use his other hand to assist

(images above) Always has to be removal of the disease as completely as possible - This is achieved by doing excision of the lesions

Why excision?

  • You know that you have removed the lesion completely
  • You know that you have not damaged underlying structures like blood vessels and nerves

Can you always remove the lesions completely?

  • No, as you have to weigh up the chance of leaving microscopic disease behind and or causing complications
  • Rather have possibly some lesions behind than no lesions and possible complications 
  • However, this is IMPOSSIBLE to decide perfectly during surgery and sometimes some lesions will be left behind and sometimes there will be some in advertant damage to structures like nerves, or the bowel.

What are the risks of the surgery?

The risks depend on what will be done but are summarised as follows:

1.  General laparoscopy risks

  • Anaesthetic risks - this will be explained to you by the anaethetist, but can include allergic reactions to drugs
  • Bladder infections - just due to the fact that you were hospitalised and in theatre (so called nosocomial infections)
  • Difficulty in passing urine in the first 24-48 hours

 

2.  Risks related to the entry into the abdomen using a laparoscope

  • Bleeding
    • this can be due to damaging blood vessels when inserting the ports or during surgery
    • in nearly all cases of bleeding, it can be managed easily, however, damage to one of the large blood vessels, may lead to conversion to a laparotomy and possibly placing of a prosthesis to repair the damaged blood vessel
    • the incidence of this is reported to be around 0.05 and 0.5%
  • Damage to the bowel during entry
    • usually there will be higher risks when you have had previous surgeries, especially midline surgical procedures
    • care will be taken to prevent this complication at all costs and if it happens, to recognise the damage and to repair the damage
    • in very rare circumstances, a colostomy bag may be performed.  This will be temporary and will be closed after 6 weeks
    • the risk of this complication is aound 0.7%

 

3.  Risks related to the excision of the lesions in the pelvis

  • damage to underlying structures
  • adhesion formation
    • this is nearly impossible to prevent, and will follow nearly all surgical procedures performed in any way in any location
  • damage to nerves
  • nerves are to small to see all of them
    • the important nerves that I worry about are the ones leading to the bladder and they have a high risk of damage in patients with recto-vaginal endometriosis
    • due to this, it may happen that we will excise deep endometriosis on one side where the nerve is and on the other side, not dissect to deep.
    • this may lead to the preservation of the nerve function, but residual disease left behind.  One has to weigh up the risks vs benefits

  

4.  Risks related to surgery on the bowel

  • unintentional opening of the bowel
    • as the dictum of surgery is to follow the disease and excise as complete as possible, sometimes, I will land in the bowel lumen.
    • this defect will be sutured at the time of the surgery and you may stay a night or 2 longer in hospital and have some extra antibiotics
suture-to-close-hole-in-rectum.jpg
  • shaving on the bowel
    • when shaving is done, the outer layer of the bowel is removed where the endometriosis is
    • very little if any electricity is used on the bowel as this can lead to a perforation after a few days after the surgery
    • I always test the bowel if there is any defect in the bowel wall, but this does not say that it cannot happen after 48 - 72 hours following the surgery
  • discoid resection
    • this is done using a stapling device and testing is done to make sure that there is no leakage following the procedure
    • however, a leakage can still occur after the surgery and that is why you will then stay 5 nights in hospital following a discoid resection
post resection 2.jpg
  • segmental resection
    • this is done using a stapling device and testing is done to make sure that there is no leakage following the procedure
    • however, a leakage can still occur after the surgery and that is why you will then stay 5 nights in hospital following a discoid resection
    • the problem with segmental resection is how low the affected area on the rectum was. ( how lower the affected area, the higher the risk of complications and therefore sometimes a prophylactic colostomy (bag for your bowel) will be placed, but this will be discussed with you before the operation )
    • in all cases of bowel leakage or injury that develops after the initial surgery, the defects will be replaced, but you will have a colostomy (bag) for 6 - 8 weeks after the suregry for the defect and then the bag will be closed and your bowel function will return to normal.
Still_013 (3).jpg

5.  Risks related to surgery to the ovary with ovarian endometriosis

  • ovarian dysfunction
    • as endometriosis in the ovary already affects the ovary itself as well as the oocytes (eggs) in the ovary, this is a very important aspect of surgery to the ovaries
    • you will undergo an AMH test before surgery and this will be to determine the ovarian function prior to the surgery.
    • this test will be repeated after 6 and 12 months
    • in nearly all cases the value will become less, but many ovaries restore their normal function
    • another risk is damage to the main blood supply of the ovary - when there is an endometriotic cyst close to this area, usually a small part of the cyst will be left and just cauterised to protect the blood supply to the ovary and subsequent functioning

6.  Risks related to surgery of the vagina

  • sex should be less painful following the surgery as the diseased area of the vagina will be removed
  • you should not have penetration intercourse for 6 weeks after the surgery to give your vagina chance to heal completely
  • this will not affect your chance of delivering your baby vaginally
  • The biggest and worst complication is a fistula that can develop between the vagina and rectum
    •  This means that there is a connection between the rectum and vagina and you pass stools through the vagina with no control.
    • This risk is increased if surgery is performed on the vagina and rectum.
    • To decrease this risk, we make sure that the suture lines on the vagina and bowel does not lie next to each other
    • We will most of the time also place tissue between the sutures to prevent this complication
    • Another alternative is a temporary ileostomy or colostomy
    • This is temporary for 6 weeks and will more likely be done if the bowel surgery is extremely close to the anus pr there is a risk of infection.

7.  Risks related to surgery on the ureters (kidney pipes)

8.  Risks related to surgery on the bladder

  • you will have an indwelling catheter for 10 days following the surgery
  • after 10 days the catheter will be removed and a procedure called a cystogram will be performed by the radiologist to check that the bladder has healed completely
  • when all is well, the catheter will be removed
  • when there is still a leak, it depends on the size, but mostly another week with the catheter will sort this out
  • increased risk of developing bladder infections due to the catheter - you will thus reveive prophylactic antibiotics
  • the bladder is one of the most forgiving organs in the body and the risk of permanent problems is extremely low


9.  Risks related to smoking and obesity

  • increased risk of DVT (deep vein thrombosis)
  • increased risk of entry complications with obesity
  • decrease in possibility to remove disease optimally due to lack of visualisation
  • decrease in time available to to surgery due to increase pressure on the lungs due to surgery position 
  • decrease in healing of scars - especially in the vagina, rectum, bladder and ureters

Is there a genetic link?

  • Yes there is a link between mothers and their daughters having an increased risk of having endometriosis
  • If one sister has endometriosis, the other one has a good chance of also having endometriosis

Can you get endometriosis if you have had a hysterectomy?

  • Yes you can.
  • this is usually the problem in patients that had endometriosis before they had a hysterectomy.
  • If you had a hysterectomy without having endometriosis your chance of developing endometriosis is virtually impossible.
  • When you do have endometriosis and a hysterectomuy is planned, it is of utmost importance that all visible endometriosis is removed at the time of hysterectomy.
  • remember that the disease is outside the uterus, so if you only remove the uterus and leave the endometriosis, it will just continue to grow.

PROPERTY OF DR ABRI DE BRUIN 2015