Dr. Dan C. Martin's
Clinical Practice is at:
UT Medical Group, Inc.
7945 Wolf River Blvd
Suite 320
Germantown,
TN 38138
Phone (901) 347-8331
Fax (901) 347-8188
Laparoscopic Appearance of Endometriosis
Dan C Martin, M.D.
©1988, 2004 The Fertility Institute of the Mid-South
The slide links are to slides formatted for Power
Point presentations.
Laparoscopic Excision
1. The specimens in this set were excised in their entirety and sent for pathology. This mid cul-de-sac cluster of lesions is circumscribed with a CO2 laser in superpulse by incising through the peritoneum into the loose connective tissue. Repeat pulse superimposed on superpulse gives better control by slowing the process.
2. After the lesion was circumscribed, it was pulled forward with a grasping forceps and the laser was used to incise the loose connective tissue or fat behind the lesion. With the laser in superpulse, the incision is clean and a distinction could generally be made between loose connective tissue, fat and scarred endometriosis.
Black Lesions
3. Puckered black lesions are the easiest to see and to document by biopsy or excision.
4. These lesions generally have a diffuse mixture of glands, stroma, intraluminal debris, fibrosis and muscle.
5. In these black lesions, fibrosis, stroma, hemorrhage and hemosiderin laden macrophages separate the glands.
White Lesions
6. Scarred white lesions are much harder to see. This lesion involves almost half of the photographic field of the left broad ligament.
7. In these white areas, sparse stroma and glands surrounded by a fibrous tissue and muscle is the predominant picture.
8. Trichrome stain was used to demonstrate the fibrous and muscular components. The muscular portion may be a metaplasia.
9. These white scar areas are easier to see when the glands had debris from intraluminal bleeding.
10. These glands are deep in the fibrotic scar.
Red Lesions
11. Red polypoid areas were most commonly endometriosis when associated with scarred areas and reddish reaction.
12. The red areas were associated with deeper glands and stroma.
13. The red polyps are predominantly glands and stroma.
14. The smallest reddish polyp was a single layer gland of about 150 microns in width and 800 microns in length. This polypoid lesion was identified by observing motion using flotation with Ringer's solution.
15. These red polypoid areas have been as large as 7 mm.
16. Red polyps usually contain glands and stroma with variable degrees of vascularity and hemorrhage. Scarring is uncommon.
17. Some of the red polyps are so light as to assume a pink or yellow appearance. This makes recognition more difficult.
18. In this example, the lesion is predominantly stroma. This lesion was cut 6 times to find glands. The 4 cuts through the top of the lesion are stroma only.
19. On the 5th and 6th cuts, glands are noted in the stroma at the base of the lesion.
20. Teenagers frequently have small red polyps and white blebs as isolated findings. In this 19 year old, the largest lesion was 0.4 mm in size and is the small red polyp toward the center of the slide. The white light reflections toward the left of the slide are 0.2 mm epithelial lesions.
21. The 400 micron polyp in the 19 year old was a polyp with glands and stroma.
22. The small clear areas were epithelial lesions. The epithelial type of these was compatible with endometriosis.
23. The youngest patient in this series was 14 years old and had an isolated red polyp of the left uterosacral ligament.
24. Histology confirmed that this is endometriosis in this 14 year old.
25. Of interest, the same patient (slides 23,24) had a basically healthy right cul-de-sac with a reddish blush.
26. At a one year interval, the right cul-de-sac (same as slide 25) developed pockets and red polyps.
27. The red polyps from slide 26 have glands, stroma and a fibrous stalk.
28. Hypervascularity associated with white appearing lesions is an uncommon finding.
29. In this slide, the hypervascular surface peritoneum is noted and glands seen beneath this. These glands have little or no stroma and a differentiation between endosalpingosis and endometriosis must be made at a histologic level. On a clinical level, there may be no difference in these two diseases.
Clear, White and Brown Lesions
30. A small developing pocket is noted in the right lower cul-de-sac. Immediately above and to the left of the pocket is a small whitish lesion.
31. A section across the whitish lesion and pocket reveals that the whitish lesion is a small area of endometriosis and there may be stroma at the other margin.
32. Secretion into this glandular structure is noted.
33. White and brown vesicular lesions were more difficult to note.
34. The angle of light inflection was important in noting these. In this slide, whitish looking lesions are seen at 3 or 4 locations. The next slide shows a different light angle of this same section.
35. When the angle of the view was changed (slide 34), more lesions were seen. It is not uncommon that the angle of light on the lesions needs to be changed in order to see them.
36. These clear vesicles frequently are dilated glands within fibrosis.
37. Other sections in the same patient show both glands and stroma.
38. Other patients have stromal edema in endometriosis presenting as clear lesions.
39. Small whitish inclusions are most frequently psammoma bodies. On occasion these hide endometriosis.
40. A psammoma body is seen on the surface covering up glands and stroma beneath it. The whitish appearance of the calcium deposits is more obvious than the underlying clear vesicles of endometriosis. This generally represents coexistent disease.
Diffuse Infiltration
41. This field shows endometriosis and red adhesions covering the entire left broad ligament underneath the left tube and ovary. The left ovary is seen in the upper portion of the field and the left uterosacral at the depth of the field. Blackish areas of endometriosis are noted to the left. Reddish adhesions are noted in the center. These reddish adhesions hide endometriosis in approximately 40% of the cases.
42. Due to the fact that endometriosis cannot be seen in these adhered areas, the area was excised in its entirety. The entire left broad ligament was excised by first opening the peritoneum away from the ureter and then pushing the ureter off with a blunt probe. Blunt probes protect the ureter. If the ureter will not bluntly dissect away from the peritoneum, it is assumed that the endometriosis may be infiltrating into the ureter and this is not removed unless the patient has been preoperatively prepared for ureteral implantation. However, in the majority of the circumstances the ureter has pushed away easily and the broad ligament has been excised.
43. In this section of the reddish adherent area, endometriosis is seen infiltrating through the entire field.
Deep Infiltration
44. Endometriosis in this case involves the right round ligament and is pulling the tube toward that area.
45. Dissecting this area with the CO2 laser is performed and leaves a clean field. However, it is noted that excision went completely through the broad ligament. When tissue is distorted by endometriosis, surgeons must take care not to do damage to deeper levels of tissue. In this circumstance, this was noted during the course of the dissection. Had this not been noted, it would have been easy to damage the ureter if it had been pulled into this lesion. In addition, closing this defect might decrease the chance of internal hernia.
46. This right uterosacral ligament is interesting in two aspects. The first is that the brownish appearance that may be related to a positive Chlamydia culture from this surface. We can anticipate that the incidence of Chlamydia in endometriosis patients will probably be the same as the incidence of Chlamydia in the rest of our infertility or pelvic pain patients.
47. The second point of this lesion is that it goes much deeper than is apparent.
48. After dissection, it is noted that the dissection plane is almost to the level of the rectum and vagina.
49. The size of this lesion is easily noted and had a depth of 7 mm toward both the rectum and vagina. Bipolar and thermal coagulation would have been inadequate to coagulate this lesion unless wide coagulation forceps had been used to completely enclose this lesion in the grasping jaws. Most bipolar and thermal coagulation jaws are not wide enough to completely encircle this lesion. In addition, lasers which coagulate to a depth of no greater than 0.4 to 4.2 mm would have been inadequate to coagulate this lesion. Destruction of this lesion requires vaporization or excision.
50. Diffuse endometriosis is seen in the cul-de-sac. However, the lesion at the center is the one of note. This is the fibrotic white lesion behind the surface black endometriosis. This lesion was easily palpable on bimanual exam as a 2 cm nodule. This was also seen pushing into the posterior vaginal fornix.
51. The laparoscopic dissection was taken to the level of the vagina. A probe in both the vagina and the rectum was used for recognition of these areas. The rectum was avoided and the probe in the vagina used so that the dissection could be taken immediately adjacent to the probe around the circumference of the lesion. Once this was well developed, an incision was made directly through the vagina. At this time the pneumoperitoneum was lost and the lesion was pulled through the vagina.
52. The left side of the slide is the peritoneum and the right side the vaginal epithelium. Endometriosis is noted infiltrating through the entire fibromuscular scar area.
