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9. Adhesiolysis. The goal of pelvic pain surgical intervention is 1) restoration of normal anatomy, 2) resection of abnormal tissue, and 3) prevention of recurrence of the conditions that resulted in the pain. The effect of adhesions on pain is controversial and will likely be resolved with laparoscopic pain mapping performed under local anesthesia. From early experience with the technique of Patient Assisted Laparoscopy under local anesthesia, it appears that traction even on filmy adhesions creates a sensation of significant pain and that thickened, more mature adhesions which do not cause twisting or entrapment of intra-abdominal structures such as bowel, frequently are not precursors of pain.
Adhesions overlying the ovary may result in pain at ovulation by restricting the proper growth of the follicular cyst and discharge of the oocyte. Adhesions resulting from infection or endometriosis are sources of noxious stimulation which accompanies the adhesions formation process. Adhesions which have formed or are forming in the cul-de-sac create the opportunity for pain with movement of the uterus and hold of the uterus in retroversion which can then result in increased dysmenorrhea, pelvic congestion, and collision dyspareunia. Complete excisional treatment of pelvic adhesions is recommended as part of the process of re-establishment of normal anatomy. After creation of a completely hemostatic area, the placement of Interceed™ (TC7, Johnson & Johnson Medical, Inc., Arlington, TX) will assist in decreasing recurrence of adhesions. The uterine suspension will stabilize the uterus away from the raw structures to prevent recurrence. Thick adhesions in areas where there is a report of pain should be treated by transection and resection. Thick adhesions in areas far distant to any reported pain are best left untreated unless the possibility of internal herniation or of torsion or obstruction of an organ exists. Again, pain mapping with Patient Assisted Laparoscopy under local anesthesia will assist in identifying those mature adhesions which require treatment.
Adhesions of the bowel resulting in symptoms of intermittent obstruction should be treated by highly skilled laparoscopic surgeons with the capability to repair an inadvertent bowel injury. The principle of adhesiolysis is traction and counter traction with great care taken during coagulation of vessels to avoid dissemination of electrical or heat energy to a focal point which can be injured such as bowel, ureter, or vessels.
Treatment of pelvic adhesions by laparoscopy was effective in relieving symptoms in patients with chronic pelvic pain. Cure or improvement was reported by 65% of patients whose chief complaint was chronic abdominal pain, and by 47% of those whose chief complaint was dysmenorrhea.
In a similar study, 40% of patients with chronic pelvic pain or dyspareunia reported continued improvement or resolution of pain during daily activities, and of those without chronic pain syndrome, 75% were better. Another study reported that 84% of 65 patients with chronic lower abdominal pain who underwent laser laparoscopic adhesiolysis experienced symptomatic relief. In women with previous abdominal operations with significant pain, enterolysis and adhesiolysis resulted in improvement in 67%. Of 35 patients undergoing adhesiolysis for chronic abdominal pain, 18 were asymptomatic and 10 had their symptoms lessened. In a prospective study of 58 patients treated for abdominal pain with adhesiolysis, 45% had complete remission of symptoms, 35% had substantial improvement, and 20% had persistence of the complaint.
The role of adhesions in chronic pelvic pain has been questioned, however. A retrospective study comparing asymptomatic infertile patients with women with chronic pelvic pain did not reveal a significant difference in the density or location of adhesions. A randomized clinical trial on the benefits of adhesiolysis by laparotomy showed no benefit in patients with light or moderate pelvic adhesions. Patients with severe adhesions involving the intestinal tract benefited from this procedure.
10. Laparoscopic appendectomy. Appendicopathy does exist and can be the cause of chronic right lower quadrant pain. In 55 laparoscopic appendectomies performed for chronic right lower quadrant abdominal and pelvic pain the pathologic conditions included entrapping adhesions in 38, chronic appendicitis in 12, and endometriosis in 5. Forty-four of these patients had complete relief, nine satisfactory improvement, and two no relief. Sixty-three patients had appendectomy for chronic lower abdominal pain, 79% of whom had pain localized to the right lower quadrant. All of these women had had previous surgery for pain without relief, and 54% had sought psychologic intervention or pain clinic treatment to no avail. Histologically, 92% of the removed appendixes revealed abnormality, and 95% of these patients were completely cured.
Of 348 patients treated laparoscopically for generalized chronic pelvic pain, 72% reported complete or significant relief of pain for at least six months. 103 of these patients had chronic right lower quadrant pain and appendiceal abnormality was noted laparoscopically in 62 (60%). These appendixes were removed. Histology was abnormal in 30 of them (48%). After pelvic reconstructive surgery and appendectomy, 60 (97%) of 62 of these women reported complete relief of symptoms.
Visible pathology of the appendix may be less than histopathology. In 85 women undergoing laparoscopy for pelvic pain, pelvic adhesions, and endometriosis, pathology of the appendix was visible in 16.8%, and histopathologic examination revealed pathology in 42.4%. Because of the high frequency of pathology in patients with these conditions, appendectomy at the time of laparoscopy may be both a preventive and a therapeutic measure.
In these five recent reports appendectomy resulted in relief of symptoms of right lower quadrant pain. In addition, there does not appear to be a correlation between visible pathology, histopathology, and complaints of pain relieved by appendectomy. Appendectomy should be performed if right lower quadrant pain is a significant part of the patient's pain profile or if the appendix appears abnormal, that is involved in adhesions, thickened or discolored, or stiff when grasped. Appendectomy can be easily performed according to the technique first described by Semm, modified by the use of bipolar coagulation on the appendiceal artery where Semm uses needle suturing if that is the preference of the surgeon.
11. Ovarian and tubal surgery. The role of ovarian and tubal surgery for treatment of chronic pelvic pain has not been clearly delineated. Torsion and tubo-ovarian abscesses will cause pain although generally not of a chronic nature. A tubo-ovarian abscess encountered must be appropriately drained and affected nonviable tissues resected. While the presentation of these conditions is usually acute the underlying condition may be of a chronic nature, as in rupture of an endometrioma. In the case of the tubo-ovarian abscess, antibiotic treatment can frequently be followed by CT scan guided aspiration of the pus, followed by continued antibiotic therapy, allowing the tissues to recover from acute inflammatory response. Then laparoscopic excision of the affected tissues can be performed with less danger of injury and more likelihood of successful therapy with the removal of the organs localized to the infection. Hematosalpinx or hydrosalpinx may result in chronic pelvic pain and should be drained or excised. Most ovarian cysts may be removed laparoscopically.
Fifty-five benign ovarian cysts were identified in 35 patients treated laparoscopically for chronic pelvic pain. Sixteen women had bilateral polycystic ovarian disease, 12 endometriomas (4 bilateral), 5 simple cysts of the ovary, and 2 benign teratomas. Because of the chronicity of the pain and previous attempts at surgical therapy, 13 patient elected to have the ovary on the side of the pain removed. Polycystic ovaries were treated with laser drilling. Endometriotic cysts were resected from the ovary. The ovarian bed from which the cyst was resected was treated to establish hemostasis. Adhesions overlying the ovary or tubes are treated to re-establish normal anatomy and provide free movement of the fallopian tubes and ovaries as well as unimpeded discharge of the oocyte at the time of ovulation.
12. Laparoscopic myomectomy. The role of leiomyomas in chronic pelvic pain is also unclear. An infarcting leiomyoma will result in an acute episode of pain which if ignored may produce a chronic pain picture. Intramural and subserosal myomas may create pain by compression and distortion of the vasculature as well as lower back pain from pressure. Pedunculated leiomyoma may cause pain with infarction, torsion, pressure on adjacent structures and nerves.
In a study of 100 women with chronic pelvic pain, leiomyomata were found in 11 patients, of whom seven underwent laparoscopic myomectomy. In these patients the myomas were subserosal and intramural and 2-4cm in diameter. Four of the eleven women underwent laparoscopic assisted vaginal hysterectomy, the largest uterus being 321 grams. Two of the patients also had stage II endometriosis which was treated at the time of surgery. Laparoscopic myomectomy for large myomas greater than 5cm, infarcted leiomyomas and pedunculated leiomyomas is an appropriate therapy for patients with chronic pelvic pain. At the same time, all other pelvic pathology should be excised and normal pelvic anatomy re-established. Leiomyomas are the most common pelvic masses, but they are rarely the single cause of chronic pelvic pain. Pelvic pressure may be due to large myomas, especially those compressing the bladder or the rectum. Pain can also be explained by degenerating myomas.
In women in whom myomas are symptomatic, hysterectomy has always been considered the definitive procedure. However, many women with or without reproductive plans do opt for uterine preservation. For them several surgical options may be considered. Other myomas are removed at laparotomy, laparoscopy, hysteroscopy, or destroyed by myolysis. They may be shrunk and devascularized by the use of GnRH analogs. Especially with intramural myomectomies, the risk of uterine rupture during subsequent pregnancy should be considered.
13. Hysterectomy. Hysterectomy with bilateral oophorectomy was effective in women who failed to obtain long-term relief of pain with medical therapy. These women were diagnosed with pelvic congestion syndrome, although pathology revealed that 25% had adenomyosis.
Of 99 women who underwent hysterectomy for chronic pelvic pain of at least 6 months' duration, and whose disease by symptoms and examination was confined to the uterus, 77.8% had significant improvement and 22.2% had persistent pain. For women requiring hysterectomy that cannot be performed vaginally, LAVH is preferable to TAH. Patients return to normal activity in two weeks rather than eight and their stay in the hospital is reduced 1.5 days. Patients whose pain was intractable to conservative therapies and who rated their pain as a 9 out of 10 underwent LAVH. The source of pain was primarily endometriosis and adenomyosis as well as adhesions and myomas. Six weeks after surgery pain was rated at 1.3 on average.
14. Laparoscopic treatment for endometriosis. When pain is persistent, a thorough examination is required and all potential causes of pain should be investigated. However, endometriosis often is the sole finding in women with incapacitating pelvic pain. A review of the role of laparoscopic surgery in the treatment of endometriosis concluded that laser laparoscopic cytoreduction of ectopic endometrial implants offers a reasonable degree of pain relief in mild, minimal, and moderate disease. Twelve percent of patients who suffered from recurrent disease required repeat laparoscopic surgery. The recurrences arose de novo and rarely occurred at previously treated sites unless the surgeon failed to remove deeply infiltrating disease completely in the uterosacral ligaments or the rectovaginal septum. These implants can infiltrate up to 15mm in depth. Complete surgical eradication of the disease resulted in pain relief in 81% of patients whose pain was due to endometriosis. However, 19% experienced recurrence of new disease in five years.
Ovarian endometriomas are a source of severe chronic pain and their removal by stripping techniques or laser photovaporization of the capsule provides gratifying results in terms of relief.
Conclusion
With application of all currently available laparoscopic modalities, 80% of women with chronic pelvic pain will report a significant reduction in pain which is maintained for up to 3 years.
Individual factors contributing to pain cannot be determined, although the frequency of endometriosis dictates that its complete treatment be attempted. The beneficial effect of uterosacral nerve ablation may be as much due to treatment of occult endometriosis in the uterosacral ligaments as to transection of the nerve fibers themselves. The benefit of the presacral neurectomy appears to be definite but strictly limited to midline pain. Appendectomy, herniorraphy, and even hysterectomy are all appropriate therapies for patients with chronic pelvic pain.
Even with all laparoscopic procedures employed, fully 20% of patients experience unsatisfactory results. In addition, these patients are often depressed. Whether the pain contributes to the depression or the depression to the pain is irrelevant to them. Selected referrals to an integrated pain center with psychologic assistance together with judicious prescription of antidepressant drugs will likely benefit both women who respond to surgical intervention and those who do not.
Recommendation
A maximum surgical effort must be expended to resect all endometriosis, restore normal pelvic anatomy, resect nerve fibers, and treat surgically accessible disease. In addition, it is important to provide patients with chronic pelvic pain sufficient psychologic support to overcome the effects of the condition, and to assist them with underlying psychologic disorders.
Additional Recommended Reading:
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Reprinted with permission from the Journal of the Society of Laparoendoscopic Surgeons (JSLS) 1998; 2: 129-137. Visit the SLS at their web site at www.sls.org
