Lectures

notes Prof. Resad Pasic

Endometriosis

Types of endometriosis: superficial, ovarian endometrioma, DIE

Locations of DIE (in decreasing order): uterosacral ligament (more commonly
left), vagina (anterior, posterior pouch), intestinal mucosa, bladder

Laparoscopic appearance: old lesions, new lesions, vesicular
Lesions must be confirmed by pathological verification

Which is better: medical or surgical treatment: UNKNOWN (no RCT to answer
this question)

Does the use of LNG-IUS improve pain after surgery; Yes (10% vs 45%)

Surgical management:
1. Identification of disease
2. Restoration of normal anatomy: ureterolysis, dissection of rectovaginal
septum
3. Excision of disease
4. Reconstruction

Eksisi bisa dengan hydrodissection sebelumnya (terutama pada lesi
retroperitoneal dekat ureter)

Uterolysis à start from pelvic brim, then follows the ureter downwards. Start by
grasping the peritoneum over the ureter.

Medical
- Presurgical GnRHa 3-6x à reduce AFS score
- Postsurgical GnRHa 6x à reduce recurrence of pain
- Postoperative COX-2 inhibitors, OCP, LNG-IUD à reduce pain and
recurrence


Complications of Laparoscopy
1/3 occur during trochar entry

Risk factors for complications: previous abdominal surgery, complex procedures,
low/high BMI

Timeline of complications
- Immediate / first 24 hours : vessel/vascular injury à vital signs, lab
- 48-72 hours: ureteral injury à creatinine, IVP
- Days to week: bowel injury à clinical signs

Always keep the tips of instruments in center of screen when performing
electrocoagulation.

Alternative insufflation techniques:
1. Transumbilical (Veres)
2. Direct
3. Open laparoscopy (Hasson technique)
4. Transuterine insufflations (Veres)
5. Subcostal insufflations (Palmers point) à one of the safest

Thin patients: insert 45 degress, overweight 45-90 degress, obese 90 degrees

Tidak boleh insersi troker pasien pada posisi Tredelenburg, dapat cedera
pembuluh darah terutama retroperitoneal (distorsi anatomi).