Diagnostic laparoscopy endometriosis treatment

• positioned in lithotomy position
• It is recommended to position both arms alongside the body (caution: use cotton wrapping when positioning with a cloth sling), or position one arm on the assistant's side
• The legs should be adjustable in angle via the operating table controls
• if necessary, use shoulder supports to prevent the patient from slipping on the operating table
• if necessary, attach a cervical adapter

Creation of a pneumoperitoneum by inserting a Veress needle, usually infraumbilical. Insertion with the optical trocar infraumbilical.

A thorough assessment of the entire abdominal cavity is essential, as endometriosis lesions can occur not only in the pelvis but also in other regions. The inspection is performed systematically:

Upper abdomen (subphrenic regions, liver, diaphragm, omentum)

• Typical findings:
  • Endometriosis lesions on the diaphragm (often small, brown, or blue lesions).
  • Adhesions between the liver, diaphragm, and stomach.
  • Fibrin deposits or adhesions in the area of the right diaphragm.

Mid-abdomen (small intestine, ascending/descending colon, appendix, greater omentum)

• Typical findings:
  • Endometriotic lesions on the small intestine or colon (usually in the area of the cecum or sigmoid).
  • Involvement of the greater omentum with fibrotic adhesions.
  • Endometriotic changes on the appendix.

Placement of 2 additional 5 mm working trocars under direct vision.

The selection of the number and position of laparoscopic incisions is at the discretion of the surgeon and is based on their personal preferences as well as the specific requirements of the operation. Incisions are often chosen in the left and right lower abdomen or in the left lower and mid-abdomen (left periumbilical).

Procedure for incisions in the lower abdomen: Visualization of the inferior epigastric artery in the lateral umbilical fold. Lateral to this, the superficial vessels are visualized via diaphanoscopy (superficial circumflex iliac artery, superficial epigastric artery). Two fingerbreadths medial to the anterior superior iliac spine, in a vessel-free area, make an incision and insert a working trocar into the lower abdomen.

Procedure for incisions in the mid-abdomen (mostly left): Visualization of the inferior epigastric artery in the lateral umbilical fold. The superficial vessels are visualized via diaphanoscopy. Incision at the level of the navel and approximately 3 cm lateral to it. It is important to ensure that the incision is not too close to the optical trocar or in line with the working trocar of the lower abdomen to avoid collision risk.

Procedure for suprapubic incisions: Preoperative placement of a urinary catheter to empty the bladder. 1-2 fingerbreadths above the symphysis, the superficial vessels are visualized via diaphanoscopy. Make an incision and insert the working trocar under direct vision.

Pelvis (Uterus, Ovaries, Tubes, Douglas Pouch, Rectum, Bladder, Ureter)

Typical Findings:

• Peritoneal endometriosis on the ovaries, tubes, and pelvic wall.
• Deep infiltrating endometriosis (DIE) in the area of the uterosacral ligaments or the rectovaginal septum.
• Ovarian endometriomas with adhesions to the pelvic wall ("Kissing Ovaries").
• Bladder or ureteral endometriosis (risk of hydronephrosis!).

After the complete examination and documentation of the endometriosis foci, the postoperative classification according to #ENZIAN is performed, which allows a detailed description of the disease manifestation.