Stephen Gordts

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Articles

AAGL 27th Annual Meeting - Atlanta, GA - November, 1998

QnA on THL Procedure

   “This is the last speaker and I’m pleased now to introduce Tom Lyons  who’s Clinic Professor at Emory University in Atlanta and is Director of  the Center for Women’s Care and Reproductive Medicine.  I’m so pleased  to have Tom participate in our work because I have a high regard for  what he has been doing in introducing and evaluating new techniques such  as supracervical hysterectomy, and he has been assisting us in running  our courses on laparoscopy – Tom.”
     
     

  “Thank you,  Ivo, and I appreciate the invitation to be here.  I think that at the  very least, all of us here should be very appreciative and congratulate  with vigor Dr. Gordts and Dr. Brosens and the people at Leuven.  I think  this work is absolutely fantastic, and they deserve a round of  applause.  To follow them, unfortunately, is me so I really want to give  you our experience and I want to actually tell you my experiences which  is probably going to be similar to yours in that you see this very  impressive work and you see these pictures and videos which I felt were  terribly impressive and immediately begin to think of the ways that you  can possibly use them to help your practice and to help in women’s  healthcare. 
     
     In my opinion, and not being a reproductive endocrinologist although  I do a lot of work with endometriosis, etc., I began to look at  slightly different directions than Dr. Gordts and the people at Leuven.   But again, my experience is still the same, in that we are visualizing a  space in the female pelvis that is really the area where most of the  pelvic pathology resides.  Certainly statistically that is true, and we  are visualizing this with such good accuracy that we’re actually seeing  things now that we’ve not been able to see before, and actually, we’re  now having to sort of re-categorize and re-catalogue some of our prior  thoughts.  Some of the things we’ve seen, some of these very fine  adhesions, we now have biopsied and have found are positive for  endometriosis.  We would not have thought that before and you can’t even  see them in laparoscopy so I think it’s pretty exciting.  What I want  to do is show you a video that gives you our experience the way we’ve  approached this.  It is a bare minimum compared to the lovely video that  you just saw with Dr. Gordts but I do want to go ahead and start this  video, and I’ll talk as we go through this about the things that we can  see on the video. 
     
     Our experiences really started as of the middle of summer, I went  over and visited with Dr. Gordts and his colleagues in April and then  after working through IRV approval and some other things, we began doing  cases around the first of July.  We started our experience - you see us  putting the equipment together here - using it in patients who are  going to have laparoscopy done.  Most of these were patients who were  having procedures performed be that hysterectomy or other procedures  done laparoscopically.  They were being done under general anesthetic  originally, we have done some patients under local at this time and find  that it’s a very do-able procedure under local but again, our  procedures were originally done in patients who we were anticipating  other laparoscopic procedures to follow.  You see this presented quite  clearly, this is the obturator and dilator and the Veress needle set up.   You see our patients are more elegantly draped because we’re about to  do operative laparoscopy on them, but again, it’s a very simple, easy  procedure.  We do place the patients in a pretty steep Trendelenburg as  much Trendelenburg as we’re comfortable with, and again, I think that  helps a little bit.  The angle of the Veress needle is further downward  into the pelvis then you would anticipate.  This is what the needle  looks like coming through under laparoscopy.  We did only a few patients  where we actually had the laparoscope in place when we placed the  needle in the cul-de-sac but we did do that a few times just to become  more comfortable.  It’s a single procedure and I find that I actually  slide the dilator in over the Veress needle with one hand, and I don’t  find it very difficult to do.  Once we assure ourselves that we are in  the abdominal cavity and the peritoneal cavity, we remove the speculum,  and actually, we can even remove the tenaculum if necessary. 
     
     These have been done both on patients with uteruses and without.  I  found that usually I’m further end down then I anticipate when I go in  so I usually have to back out.  Again, what’s on this video is just a  series of pathology that we were able to visualize.  Unfortunately,  since I’m closer than you are, I can barely see this but here you see  some filmy adhesions on this area here.  This is the small bowel that  has been bound down into the pelvis and adhesions are quite clearly  seen.  It’s not hard to visualize at all, I think that, again, the  colors are quite nice.  Actually, it’s not quite as clear on this large  screen as it is in the video in surgery itself.  Again, the pelvic side  wall and you can see both the white sclerotic changes that are  consistent with endometriosis and also you’ll see a little bit of  carbonization in certain cases - this is either carbonization or it may  very well be endometriosis.  In this particular case, it was  endometriosis.  Sometimes you’ll see the same type of pattern in  patients who have had prior laser therapy or ablative therapy with  carbonization left.  But, again, these dense adhesions are quite common  and excellent visualization of the pelvic sidewall.  Systemic evaluation  was seen.  With the fimbriated ends, everyone in the room always sort  of takes a deep breath and sighs when you see this because it really is  gorgeous stuff.  The amazing thing is these very, very fine adhesions  that you see on the ovary, here’s the left     fimbria. 
     
     Of course, salpingoscopy is not the easiest thing to do, it’s easily  done by Dr. Gordts but it’s not always easy unless the tube is really  facing you perfectly but if you can slide into this it can be quite  rewarding.  In this case, the ovary itself is smooth and sclerotic just  what a normal ovary should look like but because of the hydroflotation  you can begin to see some of these very fine adhesive disease.  Again,  most of the patients who we were doing you see these little fine  adhesions on the sidewall.  Most of the patients we were doing were  actually patients who had had pelvic pain and endometriosis was the  prior diagnosis and probably the best for the majority of the patients.   We have not only a 30-degree lens but also a 70-degree lens and  sometimes the 70-degree lens can be helpful in seeing some areas that  are difficult on the sidewall.  See these very fine adhesions on the  ovary, these are invisible at laparoscopy; I will assure you that when  we put the laparoscope in these patients, you can’t see these adhesions.   This is, I believe, the 70-degree lens where you can, again, get a  better appreciation of some of the sidewall structures.  Same thing here  but particularly I find that the cul-de-sac is very easily seen with a  70-degree lens as you’re coming out.  Trying to slide into the fallopian  tube from the side, again, when you look in the abdomen, you will see  plenty of fluid, and this is our laparoscope’s end. 
     
     You’ll also see the site at which we entered the abdominal cavity,  and usually there’s no bleeding.  There’s a typical endometriosis lesion  on the left, on the pelvic sidewall.  Abnormal vascularity is, I think,  better seen because you don’t see the compression of the capillary  structures as you would see it with CO2 at laparoscopy.  We’ve also had  two patients who had obliterated cul-de-sacs and we were successful in  performing the procedure.  I don’t recommend it but it certainly is a  contraindication that you don’t always know.  We’ll slip up and probably  see the appendix here, and the omentum, omental structures down the  center.  Here is a dense vascular adhesion in the ovary to the pelvic  sidewall.  This is an amalgam of different pathologies.  This is again  the sclerotic and/or different changes that you’ll see with  endometriotic lesions.  Most of the pathology that I have is  endometriosis for obvious reasons since these are mostly patients with  pelvic pain.  Again, classic endometriotic changes and abnormal  vasculature surround all of this.  All these patients, of course, had  excisional therapy after these procedures were performed and the  pathology that we obtained a specimen was consistent with what you’d  expect with this visualization.  That was the cul-de-sac.  Again, it’s  not very difficult to obtain a perspective, the first couple of times  that you do it, it just takes a little while to get used to the  visualization and then once you’re comfortable with it, you really tour  around quite easily. 
     
     Tubal from the fimbria, again, you see these fine adhesions on the  ovary; this is of course a normal fimbria.  We see corpora lutea, some  classic endometriotic adhesions superficial on the ovary associated  possibly with some abnormal vascularity.  And now right back to the  cul-de-sac, you’re looking at the uterosacral ligament, little bit of  structures, etc. in the cul-de-sac, left ovary, fallopian tube, etc.   But I think it’s patently obvious that you can see better underwater as  the advertisement says.  I think there’s no question that we really are  seeing more things in this procedure then we have seen before but I  think with that there’s a challenge to us to be able to re-catalogue  these abnormalities because we’re really going to have to go through a  whole new atlas of changes.  We certainly see ureteral activity on the  pelvic sidewall, all of these things that you anticipate seeing.  This  is the ureter, this movement over here, I don’t know if you can see it  clearly.  There’s the ureteral peristalsis.  This is the appendix lying  here.  And again, we obviously work with really one set of equipment  which sort of travels with us.  We can do this at several different  places; it’s not a difficult procedure to perform.  Lateral sidewall  endometriosis, you see this plane lesions that have been cauterized  before.  Here’s the tip of the appendix, you see in the right upper  pelvis, more filmy adhesive disease on the ovary.  Again, these  adhesions when biopsied were, in fact, endometriosis, and some cases  endosalpingiosis. 
     
     In our experience, and I’ll just tell you briefly, we’ve done  twenty-five cases at this time and we’ve had no significant  complications whatsoever, no bleeding.  I think we probably did enter  the bowel in our first one or two cases but no sequela with that and to  this date, I think the procedure has been quite informative to us.  My  feeling is that one of the areas that this procedure can be helpful to  our patients is that it may be a way to do effective screening in  high-risk patients for ovarian cancer.  That’s one of the areas that  we’re going to be looking at over the next several months.  Again, I’ve  been very happy to be associated with working with this.  I really want  to thank Dr. Gordts, Dr. Brosens, and the group in Belgium because I  think it is going to be something that’s important to our patients.  I  appreciate you having me here and we’ll be answering some questions  later.  Thank you.”   

OBGYN.net Conference CoverageFrom American Association of Gynecological LaparoscopistsAtlanta, Georgia, November, 1998

Author | Stephen Gordts

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