Transvaginal laparoscopy in the diagnosis and treatment of endometriosis

Hugo Verhoeven, MD: “Good afternoon. My name is Hugo Verhoeven from the Centre of Reproductive Medicine in Germany. I’m reporting from the 12th Annual Meeting of the ISGE, the International Society of Gynaecologic Endoscopy in Cancun, Mexico. 

I have the pleasure of talking this afternoon with my dear friend and teacher, Professor Stephan Gordts, from Leuven in Belgium. Professor Gordts is very famous because he invented the technique of transvaginal laparoscopy. The topic of our talk today will be transvaginal laparoscopy and endometriosis. Let’s start with the question: what is a transvaginal laparoscopy; what are the benefits and what are the advantages for the patients?”

Professor Stephan Gordts: “Well Hugo the first aim of the transvaginal laparoscopy is to have a procedure, which allows us to perform an exploration of the tubes and the ovaries in a minimally invasive way in patients without obvious pelvic pathology meaning having a normal clinical examination and normal ultrasound. So it is a procedure based upon a needle puncture technique of the Pouch of Douglas. It can be performed in an ambulatory setting. Very important is that the distension medium we are using is a watery solution, Ringers lactate, or saline, which keeps the organs afloat. Hydroflotation is extremely helpful in the detection of subtle lesions like early endometriotic implants. In patients without any complaints of pain, transvaginal laparoscopy reveals in about 30% of these patients a presence of minimal endometriotic lesions. One can discuss the value or the significance of these endometriotic lesions but still I believe as in a lot of these patients adhesions are present with these endometriotic lesions and they probably will interfere with the ovulation process and the ova capture at the moment of ovulation.”

Hugo Verhoeven, MD: “So it is important for our listeners to know that there is no other way to detect minimal endometriosis besides the technique of laparoscopy whether you do it trans-umbilically or transvaginally. So you and I prefer the transvaginal way - why?”

Professor Stephan Gordts: “Because it is less invasive for the patients. It can be done on an ambulatory basis, you can even do it under local anaesthesia and at the same moment, if necessary, you can treat these minimal lesions with bipolar coagulation. In contrast, at standard laparoscopy the higher abdominal pressure caused by the CO2 pneumoperitioneum, will mask some of these adhesions present on the ovarian surface in case of endometriosis.”

Hugo Verhoeven, MD: So if you see minimal endometriosis do we need to treat it, and if yes, how do you do this transvaginally?”

Professor Stephan Gordts: “Do we need to treat it”? is really a question at this moment that is not really resolved. We know that we have the Canadian study [Marcaux et al], which proves if you really treat endometriotic lesions, even minimal endometriotic lesions, you will have an increase in the fertility of these patients. But even with this increase of fertility, the fertility will never reach the normal level so you will always face sub-fertility also when you have been treated for endometriosis. And the question of whether we really need to treat all these minimal lesions is not resolved completely. 

I can only tell you what we are doing. Most of these patients we are treating transvaginally because we can detect very early the endometriotic lesions. It’s amazing to see that even small lesions, which are present on the ovarian surface, if you open it up transvaginally under water you, can remark the invagination of the ovarian cortex and a lesion is almost greater than it initially looks. At the basis of these lesions, once they're opened, you have always the typical endometriotic tissue. I believe if you see that, I think it’s worthwhile to treat those lesions by bipolar coagulation and just destroy these endometriotic lesions.”

Hugo Verhoeven, MD: “That means that you are using the technique of transvaginal endoscopy also in patients who have an obvious pathology. You see those endometriomas with ultrasound and then you are going in just for treating that endometriosis cyst. How do you do that?”

Professor Stephan Gordts: “I think there are two kinds of patients. There are patients where first of all we didn’t know that they might have endometriosis, which is not detectable at ultrasound and where we find endometriosis at the moment, we are doing the transvaginal procedure and then we treat them. In the second group of patients some endometriosis cysts were detected at ultrasound and patients were referred for transvaginal operative treatment. 

There are some indications of some rules, which you have to keep in mind. These are that you can never do a transvaginal approach or procedure when the Pouch of Douglas is obliterated or when you have a big rectovaginal induration in the posterior fornix. In all the other cases where the posterior fornix is free, you can try to do this treatment of endometriotic lesions, or endometriotic cysts, and it always consists of three steps, like we’re doing at standard laparoscopy. 

First adhesiolysis, secondly at the place of inversion of the endometriotic lesions we are going to open it up and make a large opening in the ovarian cyst, and then we are rinsing the cyst, and starting coagulating the inside of the endometriotic lesions. For cysts, which are larger than five cm, we are performing a two-step procedure, which means that initially we will try to coagulate as much of the lesion as possible of the endometriotic cyst and we will do a re-intervention about five to six weeks later. With the transvaginal approach this is not a problem because even when the intervention sometimes takes 90 minutes, or even 120 minutes, after two hours the patient has no pain and can go home. So if you suggest to the patient that we have to perform a new intervention six to eight weeks later, the patient will have no big objection to a new intervention. It is completely different if you go with a standard laparoscopy.”

Hugo Verhoeven, MD: “You are using saline as a distension medium. Could that also reduce the formation of adhesions in the abdominal cavity after surgery?” 

Professor Stephan Gordts: “Initially we used saline as a distension medium. For the moment we are using Ringers lactate as the distension medium because there are several experimental studies now proving first of all if you are operating underwater that the formation of adhesions is less than at normal standard laparoscopy. Secondly, there are indications that using Ringers lactate that the adhesion formation is even less than using saline solution. So you will never be able to exclude completely the adhesion formation, but at least you will be able to decrease the number of adhesions which will be formed afterwards.”

Hugo Verhoeven, MD: “There have been continuous improvements of the instruments for performing transvaginal endoscopy. Maybe we should conclude this interview by explaining to our audience where we started, what’s going on now, and what are the future projects are.”

Professor Stephan Gordts: “Well, the instruments we are using for the moment are provided by the Storz company and it’s an amelioration of the initial instrument because now we have the spring load system, which presets the length of the needle to go into the Pouch of Douglas, and because the spring load is going in so quickly the patient doesn’t feel any pain. We are working now on more sophisticated operative instruments which will enable us to do more interventions within a few years from now.”

Hugo Verhoeven, MD: “That means that classical trans-umbilical laparoscopy will be completely out for the early diagnosis of pathology in patients without obvious pathology.”

Professor Stephan Gordts: “Yes, in the case of endometriosis I think minimal endometriosis can easily be treated by the transvaginal approach and we don’t need the standard laparoscopy anymore for that specific indication. On the other hand I like to say that the transvaginal laparoscopy will never replace the standard laparoscopy. The standard laparoscopy has the advantage to do major surgery, which we will not be able to do with the transvaginal approach.”

Hugo Verhoeven, MD: “But wasn’t your initial idea to develop transvaginal endoscopy for patients with extensive adhesions and extensive endometriosis?"

Professor Stephan Gordts: “No. The initial idea was to develop a system or procedure which is as minimally invasive as possible for having a complete and accurate diagnosis in sub-fertile patients without obvious pathology.”

Hugo Verhoeven, MD: “That is the perfect conclusion.”

Professor Stephan Gordts: “Thank you very much.”

Hugo Verhoeven, MD: “Thank you.”

Feedback/Questions:

Question: 
I would like to express my great appreciation for that good piece of work. But here are some inquiries: The idea of transvaginal laparoscopy is an old invention, the so-called culdoscopy, was practiced 50 years ago. However, what is the positioning of the patient, and how risky is the procedure risky for the patient, especially intestinal injurie? Please, inform me about the exact amount of fluid to be installed inside the peritoneal cavity to keep the organs afloat. Also, would you expalin how many entries through the posterior vaginal wall are required for manipulation of the pelvic viscera for such manipulations like bipolar coagulation of an ovarian endometriomata etc. Finally, I would like to know whether the instruments of standard laparosocpy could be used tranvaginally? Thank you.

Dr. Khaled Aly Zahran, MD

Answer:
The difference between culdoscopy and transvaginal laparoscopy, is that in the latter a watery solution is used as a distension medium with the patient in a dorsal lithotomy position like for a normal gynaecological examination and not in the knee chest position. For a normal diagnostic procedure about 500cc of fluid is used.

Concerning complications: the failure rate is around 4% due to initial learning period and obese patients. 
Obliterated cul de sac and retroverted uteri are contraindications. The complication rate is 0.9% in a series of about 3000 procedures, these were rectum perforations all except one treated conservatively with antibiotics during 5-6 days.There is no delayed diagnosis of rectum perforation and after conservative treatment there were no further complications.

Exact data can be found in our publications in Fertil Steril and Human Reproduction.

Professor Stephan Gordts