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