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
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.
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.
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
Excision is believed to be the right therapy." http://www.gynsurgery.org/.../end.../types-of-endometriosis/