Practical Training and Research in Gynecologic Endoscopy
Department of Obstetrics and Gynecology
UNC School of Medicine
Chapel Hill N.C. 27514 USA
University of North Carolina
School of Medicine
Chapel Hill, N.C. USA
The field of chronic pelvic pain (CPP) is in its infancy
as a clinical science. The clinical diagnoses most often made for which
surgery is performed include pelvic adhesions (including chronic PID), ovarian
cysts and endometriosis. The relative ease of laparoscopic surgery has encouraged
compassionate physicians to re-operate in order to relieve recurrent pain.
Although re-operative laparoscopy for relief of pelvic pain has been extensively
reported in the literature, documentation of its efficacy is scant.
In recent years, the explosive emergence of operative laparoscopy
for CPP has created new questions. At what point is surgery indicated? What
is the incidence of recurrence or persistence? When dealing with recurrent
or persistent disease, what is the efficacy of re-operation? Efficacy is
dependent on basic biologic factors such as wound healing, natural history
of diseases and neuro-psychiatric factors as well as surgical techniques.
We will discuss the existing data concerning the need and efficacy of operation
and re-operation in these conditions.
1. General Indications and Caveats
Chronic pelvic pain (CPP) is a major reason for patients
undergoing surgical procedures, often multiple times. It is the diagnosis
10% of office visits to gynecologists2 and
10-20% of all hysterectomies in the United States
40% of diagnostic and operative laparoscopies 1,7
The patient with CPP may be a candidate for laparoscopy
if 6 months have gone by during which more conservative forms of therapy
(e.g., antibiotics, psychotherapy, endocrine suppression) have proved unsuccessful.
Studies of pelvic findings in patients undergoing laparoscopy for chronic
pain have revealed pathology in 70 to 80% of patients.8,9 However,
comparisons of findings in patients with chronic pain to patients with infertility
and no complaints of pain have generally shown no statistical difference
between the nature or distribution of adhesions or other pathology found.10-13
In pain associated with endometriosis, deep infiltrating lesions are causally
related to the symptoms and may require difficult excision.14,15
On the other hand, endometriosis does not consistently cause pain: it has
been found in up to 45% of asymptomatic women.16
Chronic pain persisting over 1 year can alter the nerve
pathways and the spinal pain "gate". In these patients, surgical management
of adhesions found may not cause permanent relief: The pain can be re-established
through the "open gate" pathways after about 6 months17 For example,
hysterectomy for pain with documented pathology was found to result in recurrent
pain in 23% of patients.18 Although some form of psychiatric
pain management therapy is indicated, most patients undergo repeated, temporarily
The placebo effect of diagnostic laparoscopy alone in women
with the absence of pathology on visualization has been reported.19
In this study women with no pelvic pathology and no intra-operative treatment
were returned to their primary physicians with no psychiatric care or other
interventions and remained free of pain 6 months post-operatively. Thus,
we need to be intellectually cautious in the causal relationships between
pathology and pain, as well as the causal relationships between surgery
A suggestion has been made that laparoscopy has no therapeutic
value alone compared to total pain management programmes.10 Most
pelvic pain is relieved after laparoscopy for 3 to 6 months, but pain of
central nervous origin is re-established within one year in 60% of patients.17
These considerations should be taken into account by the operative laparoscopist
before a second or third attempt is made at relieving chronic pain surgically.
A. Prior procedures
All new CPP patients should bring all
operative records, together with the pre-operative description of the indications
and pathologic findings, if any, of previous laparotomies or laparoscopies.
Some patients are given operative photographs or videotapes of prior findings.
These can be time-consuming but rewarding in assessing prior procedures.
During the history taking a note should be made of discrepancies of perception
and fact the patient may have of her prior conditions.
A detailed history as to the time of onset
of the pain, character, location, what made it better, what makes it worse,
relation to functions (menses, coitus, motion) and life events (onset of
coitus, job loss, marriage, divorce, childbirth) will reveal useful patterns
to suggest diagnoses.
C. The physical examination
Since CPP may well be of non-gynaecological origin the physical
examination should include brief examination of the costo-vertebral angle
(for chronic pyelonephritis), spinal and lateral sacral tenderness (peripheral
nerve compression or sympathetic tenderness), repeated abdominal tenderness
evaluation (consistency of finding, association with a lateral abdominal
scar) with and without distracting the patient, and leg motion range for
hip or peripheral nerve pathology.
The gynecological examination is best begun with a gentle
mono-manual examination, showing the patient that the abdominal hand is
not being used. Introital tenderness or spasm (vaginismus), anterior vaginal
wall tenderness (urethritis or cystitis) as well as uterine tenderness on
motion of the cervix can all be detected without alarming the patient with
bimanual pressure. Patients with long-standing CPP may not be able to tolerate
a standard bimanual examination, and the examination should be discontinued
when exceeding the patient's pain tolerance.
II. Lysis of Adhesions For Pain
Before the introduction of laparoscopic techniques to lyse
adhesions and minimize their recurrence, many surgeons were reluctant to
attempt therapy unless the adhesions caused bowel obstruction. Recent studies
have indicted that adhesions tend to reform less frequently when lysed by
laparoscopy than by open laparotomy.20-22 This is probably due
to less direct trauma from swabbing during laparotomy which results in mechanical
abrasion and desiccation of serosal surfaces. Studies of wound healing and
adhesion reformation have been reviewed in detail.23,24 Peritoneal
surfaces tend to heal from the "bottom up", by a process of peritoneal regeneration
from underlying vasculature. Damage to this underlying vasculature during
laparotomy results in cytokine release and alterations in plasminogen activator
activity which is necessary for endogenous lysis of excess fibrinous attachments.24
In contrast, the ovarian surface is protected by loose cells
derived from the peritoneal fluid and damage to these cells stimulates tubal,
bowel and omental adhesions as the hypoxic cells on the ovary secrete angiogenic
factors promoting "vascular grafts" from nearby viable tissue.25
As a result of this process, the ovary is the pelvic structure most likely
to reform adhesions after attempts at lysis26 Further, the percentage
of ovarian surface covered by adhesions is a major prognostic factor after
adhesiolysis for infertility.27 Most recent animal and human
observations suggest that the ovary heals best (with minimal adhesions)
without attempts at re-approximation by suturing.28-30 The role
of chemical and mechanical adjuvants to prevent adhesion re-formation such
as Hyskon, corticosteroid, Interceed, or Goretex have yielded mixed results
in clinical experience. Thus, the following four points are currently recommended
in adhesiolysis by laparoscopy or laparotomy to minimize recurrence:
Minimal use of absorbable sutures (they provoke an inflammatory
and adhesive response)
Sharp dissection to cause minimal cell destruction
Less meticulous micro-haemostasis to allow normal clotting
and vasoconstriction rather than tissue destruction by excess electro-desiccation
Dilute the angiogenic factors by leaving 1000 to 2000
ml of lactated Ringers in the peritoneal cavity after surgery 31,32
Second Look Studies
Second look laparoscopy studies26,33,34
reveal a surprising amount of adhesion reformation despite good surgical
technique. Since adhesions form immediately after surgery, postoperative
adhesions causing pain usually do so within 1 or 2 months after surgery.
Pelvic pain, especially chronic pain over 6 months' duration and arising
months or years after surgery, is thus seldom causally related to post-surgical
adhesions and more elusive psychological trauma and scars need to be sought
and dealt with.
Adhesions from endometriosis or infection may be progressive
over time and causally related to chronic pain, but these adhesions may
also be incidental findings in a patient with deeper psychological origins
of chronic pain. An emerging observation is that lysis of adhesions of bowel
to the anterior abdominal wall 35 seem to be effective in relief
of CPP. This may be due to the involvement of peritoneal branches of intercostal
nerves in the adhesions on the anterior abdominal wall peritoneum. These
nerves are able to localize parietal pain in fairly specific segmental distribution.
In contrast, the bowel itself is essentially void of pain fibres, and bowel
mesentery has visceral pain fibres of poorly localizing autonomic origin
and distribution 36.
In a report of 30 re-operations for relief of chronic pelvic
pain (defined as 6 months or more duration) due to adhesions,37
previous surgery included 25 laparotomies and 10 laparoscopies. No correlation
between the severity of adhesions and pain was found. Pain was localized
to the area of adhesions in 90% of patients. Although immediate post-operative
pain relief was frequent, symptoms tended to recur in 6-12 months after
surgery. This observation which is consistent with others, makes a follow-up
period of observation of at least 6 months necessary to evaluate efficacy
of treatment for pain. Re-operative adhesiolysis resulted in long-term improvement
of daily pain in 63%, with no improvement in 37%. Among patients with the
chronic pain syndrome (see below), dyspareunia was unchanged or worse in
4 out of 6 patients. Among these chronic pain patients with either pain
and/or dyspareunia, 6 out of 10 showed no long-term improvement.
Confirmed by other studies, the re-lysis of adhesions for
relief of recurrent pelvic pain emerges as a legitimate indication for operative
laparoscopy. Most recently, Steege has explored the use of small diameter
(2 mm) office laparoscopy with the placement of a Tenckhoff catheter in
the umbilicus for re-lysis on four occasions during the first 2 post-operative
weeks.29,37 The average interval between re-operation was 3-4
days. This interval was chosen to optimize outcome by lysing adhesions that
were still filmy and had not been vascularized or collagenized. This study
confirmed the feasibility and safety of re-lysis but appropriate applications
of this particular procedure remain to be defined. Similarly, the development
of miniscopes and office laparoscopy may be used for pain mapping procedures.
III. The Chronic Pain Syndrome
Evaluation of the efficacy of re-operation for chronic pelvic
pain is confounded by the occurrence of important associated psychological
conditions, termed by Steege "the chronic pain syndrome" with symptoms similar
to those of chronic depression. This syndrome includes:
pelvic pain of 6 months or more that lacks apparent
previous treatments unsuccessful in relieving pain
significantly altered physical activity, including work,
recreation, sexual activity, etc.,
disturbance of mood, mostly depression with at least
one vegetative sign (sleep dysfunction, loss of appetite, psychomotor
altered role in the family38
These patients report less benefit from adhesiolysis. Again,
careful preoperative selection, including duration of symptoms, recurrence
of symptoms after previous surgery, and psychological and behavioral assessment
are all important prognostic factors for both primary and re-operation for
chronic pelvic pain. In a prospective study by Peters10 patients with chronic
pelvic pain were divided into one group receiving routine laparoscopy and
one group receiving an integrated approach giving attention to somatic psychological
conditions. In the second group, laparoscopy was not routinely performed.
The integrated approach appeared to improve pelvic pain significantly more
than the standard laparoscopic approach.
The importance of evaluation of the emotional component
in patients with chronic pain was summed up well by a gynecologist trained
later as a psychiatrist who ruefully commented "I have done many laparoscopies
IV. Removal of Adnexal Mass
Ovarian cysts are often found in patients with acute or
chronic pelvic pain. Although the cause and effect relationship between
adnexal masses and acute pain is clear, this relationship is questionable
in chronic pain. Nevertheless, cystectomies and oophorectomies are often
performed for relief of pain, particularly if there are adhesions on the
ovarian surface. Although the relief of acute pain with removal of adnexal
masses has been well documented, there are no data concerning the efficacy
of adnexal mass removal for chronic pelvic pain.
Recurrence of ovarian cysts after cystectomy has been studied.
Hasson40 found that endometriomas recur in 50% of cases if not
completely excised. Fayez and Vogel41 compared recurrence rates
and adhesion formation for different laparoscopic treatments of endometriomas.
They found stripping of the lining, laser ablation of the lining and drainage
with irrigation, all had a recurrence rate of 20%. When complete excision
was accomplished there were no recurrences but there was 100% adhesion formation
compared to 30% with the other three methods. In contrast, more recent studies
have indicated a rate as low as 2% for the recurrence of functional cysts
after laparoscopic fenestration. However, when pelvic adhesions were seen
at the time of laparoscopy, the recurrence rate increased to 11%. Post-operative
hormonal therapy with a progestogen or combined oral contraceptive pill
demonstrated no protective effect. Follicular cysts had a recurrence rate
of 2%, while corpus luteum cysts recurred in 14%. With both functional cysts
and endometriomas, caution must be exercised weighing the significance of
the finding of an ovarian cyst and contemplating its removal for relief
of chronic pelvic pain.42
The patho-physiology of endometriosis is such that a significant
percentage of patients treated for pain experience recurrence of symptoms.
Success therefore can be defined as the length of the pain free interval
and the percentage of patients that experience recurrence. The technical
objectives of laparoscopic surgery are to restore normal pelvic anatomy
and resect, coagulate or vaporize all endometriotic implants. These objectives
can be accomplished with mechanical excision, thermal, electrical or laser
energy and there are no objective data that one is better than another.43
The surgeon's knowledge, familiarity and competence with the energy sources
are far more important than any differences between them1. Full
depth resection of all implants including atypical lesions is necessary.
Based on studies to date, approximately 67% of women treated laparoscopically
for pain with documented endometriosis, will note an improvement in pelvic
pain that will last for at least one year. There is no consensus on combined
medical and surgical treatment of endometriosis in CPP.
The advantages suggested by other studies include:
Suppression of ovulatory activity to eliminate the confusion
of functional cysts with endometriomas.
Decreased inflammation and size of endometriosis implants
Decreased pelvic vascularity43,44
The disadvantages of medical therapy are:
Decrease in size or change in appearance of implants
may lead to sub-optimal excision or ablation.
Cost and side effects
n patients attempting conception, medical therapy results
in time delay.43
Laparoscopic Uterine Nerve Ablation
and Pre-Sacral Neurectomy
CPP may present as severe dysmenorrhoea and at laparoscopy
the nerves to the uterus and pelvis can be interrupted by the LUNA procedure
or pre-sacral neurectomy. The efficacy of LUNA was recently supported in
a prospective study where 62% of patients undergoing LUNA (and ablation
of endometriotic implants) had improvement of relief of symptoms, compared
to 23% of non-surgical controls 45. The risk of venous or ureteric
injury in this area can be reduced with relatively simple methods and the
procedure should be abandoned if the position of the ureter is not completely
Pre-sacral neurectomy can be performed laparoscopically
with more significant risks of injury to the vena cava, and though one study
reported a significant improvement in midline dysmenorrhoea,46
a similar study showed no relief with endometriosis 47. The risk-benefit
aspect of this procedure remains controversial and in areas where there
is not immediate availability of a vascular surgeon to assist in the repair
of an injured vessel, the greater risk is not justified by proven efficacy.
Since Howard C. Taylor,Jr. first proposed pelvic congestion
(varicosities of the adnexal venous plexus) as a cause of CPP 48the
theory has been met with indifference despite the wide respect for the author.
Most recently Prof. Richard Beard in London has activated modern interest
in the condition and has reported significant improvement in patients treated
with medroxyprogesterone acetate 50 mg daily49 or 30mg50.
Nevertheless, the existence of this cause of CPP or its medical management
has again not yet been widely accepted. Surgical intervention with scarring
of the overlying peritoneum has been suggested but there is significant
risk of injury to the underlying vessels and this technique has not been
When dyspareunia is the dominant component and retro-version
of the uterus the only physical finding at laparoscopy, uterine suspension
has been suggested. There are no published prospective studies documenting
Sixty percent of women with CPP have a pathologic or anatomic
abnormality. In patients with CPP with documented endometriosis or pelvic
adhesions to the bowel or stretching the peritoneum, re-operation offers
a minimally invasive method for treatment with clinical improvement afterwards
in 65 to 80%. In patients with CPP and previously normal pelvis, CPP syndrome,
or functional cysts, less than 50% will report improvement in pain following
re-operation1. These patients require an integrated comprehensive
pain management program to optimize their pain relief rather than re-operation
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