Tuesday, March 4, 2014

Laparoscopy in the Diagnosis of CPP

Laparoscopy in the Diagnosis of Chronic Pelvic Pain

Deborah A. Metzger, PhD, MD

(From Chronic Pelvic Pain: An Integrated Approach, eds Steege, Metzger, Levy)

"Clear documentation of the laparoscopic findings will allow the operator to plan the surgical procedures to be performed.   Photographic and written documentation in the operative record allows the surgeon to refer back to the procedure, when planning additional treatment or if another  laparoscopic procedure is performed subsequently.

             It is important that the exam be conducted in a standardized and thorough manner.  Soon after the laparoscope and accessory trocar are inserted, the omentum and bowel directly beneath the trocar should be inspected for Veress needle and trocar injury.  First, a general survey of the pelvis is undertaken so that all of the pelvic structures are in view of the laparoscope.  The blunt probe is used to gently manipulate the organs of interest, in particular areas with scarring or areas which correlate with pelvic tenderness.    The laparoscope is then moved closer to the left adnexa and the ovary is lifted, if possible, and the pelvic sidewall is carefully inspected.  The ovary is then released and the laparoscope then directed over the anterior cul de sac and swept over to the right adnexa.  Again the right ovary is elevated and the pelvic sidewall is carefully inspected.  The posterior borad ligaments and cul de sac are then carefully evaluated.  The surface of the bowel should be examined next, followed by an inspection of the appendix, liver, and diaphragm. 

            The examiner’s efforts should be concentrated primarily in the region of the patient’s pain.  For example, when a pelvic examination suggests that there is tenderness in the right adnexa, most of the laparoscopic effort should be concentrated there.  However, the examiner should also be receptive to other possible abnormalities that could contribute to the pain or
which may be one of several pain sources of the patient.

            Visual records via still photographs or video will aid your post-operative discussion with the family. Patients often benefit immensely when they can “see” what was responsible for their pain or, alternatively,  may be reassured if their pelvis is normal.  Many surgeons give the patient a copy of the photographic and written record.

Specific conditions commonly found in women with chronic pelvic pain will now be reviewed.

While typical endometriosis implants appear as blue-black “powder-burn” implants often surrounded by stellate scarring, the atypical lesions are less apparent visually but more active physiologically as determined by their production of prostaglandins (15).  Atypical implants may  appear as reddish vesicles, clear vesicles, slight irregularities on the surface of the peritoneum or white patches.  Detection of subtle non- pigmented lesions requires laparoscopic inspection at close range (1-2 cm) or inspection of the surface at moderately close range utilizing different lighting angles.

Teenagers are more likely to have atypical implants, particularly the nonpigmented type (16).  Sometimes an extraordinary effort may be required to make a diagnosis including re-cuts of peritoneal biopsies that are negative for endometriosis at first glance.  Early detection of endometriosis has an important impact on treatment selection.

            Sometimes endometriosis implants are buried under scar tissue that develops as a result of the natural progress of the disease or from previous superficial attempts at ablation.  Palpation of these areas with the manipulating probe will allow detection of occult nodules.  Resection of the overlying scar tissue may be necessary in order to discover and remove underlying implants and fibrosis.

            Bowel endometriosis may be difficult to diagnose preoperatively even in the presence of rectal bleeding, dyschezia or deep dysparunia.  Only 20% of women with bowel endometriosis can be identified by either colonoscopy and/or barium enema (Redwine and Sharpe, unpublished). However, if a patient has suspected bowel involvement, there are several techniques which may be helpful in improving the diagnostic yield.  Since most of bowel endometriosis is found associated with the rectosigmoid, a careful examination may yield evidence of scarring and distortion of the serosa of the bowel.  Palpation of any abnormalities with the manipulating probe allows assessment of the extent of the lesion.  Inserting ring forceps or a rectal probe into the rectum and gradually withdrawing it, may disclose retroperitoneal nodules that would otherwise go undetected.  Similarly, the pelvic floor tissues can be palpated in detail using a recto-vaginal examination a blunt laparoscopic probe.   Finally, the diagnosis of significant bowel endometriosis may require a laparotomy in order to run the bowel.         


            Not all adhesions which are found at the time of a laparoscopy for CPP are responsible for the patient’s pain.  In general, filmy adhesions are not associated with chronic pelvic pain, although it is tempting to use their presence as an
explanation.   In contrast, dense adhesions which distort anatomy and/or function may be a significant source of pain.  Careful pelvic mapping prior to the laparoscopy as well as a correlation of laparoscopic findings with a description of the patient’s pain characteristics may allow a certain degree of discrimination.  When the patient has localized pain and the only findings are adhesions limited to the anatomic location of the pain, it is highly probable that the adhesions contribute significantly to the pain.  In other patients, the judicious use of laparoscopy under conscious sedation will allow a more definitive diagnosis.


            Direct inguinal, indirect inguinal and femoral hernias are seldom visible in women at the time of laparoscopy as indentations or defects of the peritoneum.  Moreover, hernias may be difficult to palpate externally, making diagnosis in women problematic (17).  The presence of hernias is suspected on the basis of a vaginal exam associated with inguinal tenderness which reproduces the patient’s pain.  A retroperitoneal laparoscopic examination by an experienced general surgeon confirms the diagnosis and allows treatment at the same time.  

Pelvic congestion

            Dilated ovarian and pelvic veins, when present in the patient with ovarian tenderness and postcoital ache, are diagnostic of pelvic congestion.  However, laparoscopy is not a definitive method of diagnosing pelvic varicosities since Trendelenberg positioning enhances venous drainage and minimizes the size of the veins.  Transvaginal ultrasound and transcervical venography are less invasive and a more definitive means of diagnosing this condition.  Testing should be preferably performed prior to the laparoscopy so that appropriate treatment can be instituted.

Pathology which is rarely associated with CPP

            Some pathology is often encountered during laparoscopic examinations for CPP but is only rarely responsible for chronic pelvic pain.  Findings such as functional ovarian cysts, cysts of Morgagni, filmy adhesions and peritoneal windows (Master-Allen syndrome) should be viewed as “red herrings” which may distract attention from the real reason for pain.  More widespread use of laparoscopy under conscious sedation (Chapter 34) will provide additional information regarding the
spectrum of sources of pelvic pain."     http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=51&cad=rja&ved=0CCYQFjAAODI&url=http%3A%2F%2Fwww.harmonywomenshealth.com%2F.%255CDocuments%255CConditions%255CChronic%2520Pelvic%2520Pain%255CLaparoscopy%2520in%2520the%2520diagnosis%2520of%2520CPP.doc&ei=A3IWU-_xDoKTkQeP1oGgBA&usg=AFQjCNGPToQuhV18bDT6hwaTZpg8uCe_mg&sig2=0dxGzSt39tTC99yxWZ9u5A          

***Please note that ovarian cysts can rupture and cause pain and endometriosis is often found behind peritoneal windows. "Peritoneal pockets are an unclear pathology Pockets in the peritoneum. They can be large and deep. Peritoneal pockets are believed to be associated with endometriosis
Excision is believed to be the right therapy." http://www.gynsurgery.org/.../end.../types-of-endometriosis/