Surgical Treatment of Deep Endometriosis

Abstract

In deep endometriosis (DE), clusters of endometrium-like cells penetrate more than 5 mm below the peritoneum: The affected organs and tissue structures can eventuate in an alteration of the anatomy with eliminated organ boundaries, which in some cases can pose a real surgical challenge, even for experienced surgeons. A comprehensive description of the different manifestations of the disease can be found in the #Enzian classification. Since the operation is usually the foundation for the successful treatment of DE, what is important are conclusive indications, appropriate preoperative preparation and, above all, appropriate experience on the part of the surgical team. This article aims to provide a review of the surgical options that are currently available.

Keywords: #Enzian; deep endometriosis; endometriosis; laparoscopic surgery; ultrasound.

Fig. 1

#Enzian – classification. Source: Keckstein J, Saridogan E, Ulrich UA et al. The #Enzian classification: A comprehensive non-invasive and surgical description system for endometriosis. Acta Obstet Gynecol Scand 2021; 100: 1165–1175.

Fig. 2

a #Enzian C3 – Endometriosis: resection of the rectum with the linear stapler. b Same finding after resection; affected area totaling 12 cm (Martin Luther Hospital Berlin, Clinic for Gynecology and Obstetrics).

Fig. 3

Extensive bladder endometriosis after resection: In the foreground, the resected tissue measuring a good 5 cm; view of the urinary bladder with catheter ball and double-J stents on both sides (Martin Luther Hospital Berlin, Clinic for Gynecology and Obstetrics).

Fig. 4

a View of the right side of the chest (with collapsed lung and drain) after resection of extensive, transmural diaphragmatic endometriosis. b Status post laparoscopic suturing of the diaphragmatic defect; the liver is held caudally and dorsally (Martin Luther Hospital Berlin, Clinic for Gynecology and Obstetrics).

Abb. 1

#Enzian – Klassifikation. Quelle: Keckstein J, Saridogan E, Ulrich UA et al. The #Enzian classification: A comprehensive non-invasive and surgical description system for endometriosis. Acta Obstet Gynecol Scand 2021; 100: 1165–1175.

Abb. 2

a #Enzian C3 – Endometriose: Absetzen des Rektums mit dem linearen Stapler. b Derselbe Befund nach Absetzen; insgesamt Befall über 12 cm (Martin Luther Krankenhaus Berlin, Klinik für Gynäkologie und Geburtshilfe).

Abb. 3

Ausgedehnte Blasenendometriose nach Resektion: Im Vordergrund das gut 5 cm messende Resektat; Blick in die Harnblase mit Katheterball und DJ-Schienen beidseits (Martin Luther Krankenhaus Berlin, Klinik für Gynäkologie und Geburtshilfe).

Abb. 4

a Blick in den rechten Thorax (mit kollabierter Lunge und Drainage) nach Resektion einer ausgedehnten, transmuralen Zwerchfellendometriose. b Zustand nach laparoskopischem Verschluss des Zwerchfelldefekts; die Leber wird dabei nach kaudal und dorsal gehalten (Martin Luther Krankenhaus Berlin, Klinik für Gynäkologie und Geburtshilfe).