Accuracy of laparoscopic diagnosis of endometriosis Peter Maher, MD and Liselotte Mettler, MD View the video: RealPlayer | Wi

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Accuracy of laparoscopic diagnosis of endometriosis


Peter Maher, MD and Liselotte Mettler, MD
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Peter Maher, MD: Liselotte Mettler, from Kiel, Germany is joining us today for an interview and we are going to talk about the accuracy of the laparoscopic diagnosis of endometriosis. I know that you have a specific interest in endometriosis; could you tell me what particular features about laparoscopy that you look for in making the diagnosis?

Liselotte Mettler, MD: Peter, it’s my pleasure to answer this question on this level at the AAGL here in Las Vegas.

Endometriosis has always been my particular disease of interest, and we have no other possibility to diagnose it really other than by histological diagnosis with laparoscopy. Because all the visual aspects may or may not be endometriosis, and the tumour markers that we use are really not that specific. So we tried to re-evaluate our visual diagnosis compared to the histological result, and especially we did that looking at red, white and black lesions. Now what do you think; which of the three kinds of lesions, the red, white or black ones, gave a better correlation to the histological findings?

Peter Maher, MD: I would have been looking at the red or the white lesions over the black lesions for specific correlation.

Liselotte Mettler, MD: Well, we found that in the 216 patients, where we took biopsies from and checked for all the different types of lesions, that the physiological outcome in the red lesions was actually 100% in which we could really detect endometriosis. That was surprising to me. And the second most frequent one was, at 67%, the black lesions. Unfortunately for the white lesions, it was only around 50% that were really found it to be endometriosis.

Now, looking to the different types of histology, of course in the white lesions we found many times, fatty tissue in it – fibro-fatty tissue. I was wondering if it was maybe true that we didn’t go deeply enough for the biopsy, because we’ve had some white lesions, rectovaginal lesions, that you don’t even see, and we call them white lesions. So actually I would like to say that the findings brought a security in the red, and a good security also in the black lesions, but not in the white lesions.

Peter Maher, MD: Do you have a view on the place of bringing laparoscope up very close to the peritoneum, and looking at any rough areas on the peritoneum? Do you have any thoughts that may be of value in detecting very, very early lesions of endometriosis?

Liselotte Mettler, MD: We do that always if we want to see if some scar tissue may be endometriosis. But only if you come really close can you see that there’s an alteration. There is also the touching laparoscope idea, like with a contact micro-hysteroscope, to do the laparoscopy. I couldn’t find a very good application of laparoscopy really.

Peter Maher, MD: Well, considering the very close correlation you do have with, as you say, the red lesions and the black lesions, what are your thoughts about some surgeons who treat endometriosis just by ablation of the tissue rather than excision?

Liselotte Mettler, MD: I think that is really not correct. The endometriotic lesions cannot be just superficially ablated, they have to be really excised. Don’t you agree?

Peter Maher, MD: I certainly do. At the Mercy Hospital of Women in Melbourne, we always excise any suspicious looking lesions.

Liselotte Mettler, MD: And it is our custom to do that, and we find also very good causation for treatment after that. If we really go deeply down and excise them as much as we can see, I think that the white lesions, they are sometimes where we are going deeper down, we don’t get enough tissue with the biopsy to verify.

Peter Maher, MD: One of the criticisms of that treatment is that it’s very, very aggressive and may result in scarring post-operatively. It’s been our experience that these patients heal up very, very well with minimal invasions following excision. And I’m always weary about the dangers of deeply coagulating any lesions for fear of damage to underlying tissues.

Liselotte Mettler, MD: In the area where we do these excisions, in the broad ligament area and the Pouch of Douglas, I think is not so dangerous to produce scar tissue there. I think we can be excising in the safe part because there are not organs there that bring about pain later on. There are no nerves really. Of course, if we go deep down to the pelvic wall, then we should be careful.

I think a good excision is still the best treatment that we can give to our patients. We can rely to a certain extent on the aspect that we should try, before we do a very serious medical treatment of six months or longer, and a costly one, and just also very effective in the patient because she is having menopause symptoms and so on, we should be sure it’s endometriosis and not just treat medically without having the diagnosis.

Peter Maher, MD: What’s your view on excision of peritoneal patches? Do you think that there’s a correlation between the peritoneal patch, do you understand what I mean?

Liselotte Mettler, MD: Do you mean a broad area? You mean to take an area 3 x 4 cm and excise it? Like a peritoneal ablation in a way? We would do this with a bipolar coagulation, or argon beam coagulation, or laser beam unit; we use the argon beamer and I think that is quite effective.

Peter Maher, MD: We are doing a trial at the moment and excising two cm around isolated lesions and we’re finding quite a high incidence of satellite lesions that aren’t visually detectable.

Liselotte Mettler, MD: I think that’s very good to go in this so-called safe area, go around even the area where you don’t see it; if you don’t produce scars generally in the place where you go about.

Peter Maher, MD: Do you think we’re any further advanced with our treatment of endometriosis?

Liselotte Mettler, MD: As in the versions of the last century, they settled on excision, and we’re back with excision in spite of all the medical treatment we have tried.

Peter Maher, MD: I think you’re right! Well, I thank you very much indeed.

Liselotte Mettler, MD: Thank you.


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