Perioperative management - Diagnostic laparoscopy endometriosis treatment

Patients with endometriosis exhibit a variety of different clinical symptoms. These are often initially cycle-dependent and can become cycle-independent and chronic over time. Endometriosis is often diagnosed in the context of infertility evaluation, but it can also occur asymptomatically as an incidental finding.

The structured medical history is crucial for identifying relevant symptoms and risk factors. The assessment can be supported by a specific endometriosis questionnaire. The essential components of the medical history are:

General medical history:

• Menstrual cycle history
• Gravidity/Parity
• Previous therapy
• Previous surgeries
• Medication history
• General (internal) medical history
• Allergies
• Body Mass Index
• Family medical history
• Social history

Symptom-oriented medical history:

• Dysmenorrhea
• Lower abdominal pain (cyclic/non-cyclic)
• Dyschezia/Hematochezia
• Dysuria/Hematuria
• Dyspareunia
• Infertility

• Inspection of the posterior vaginal fornix with split specula
• Bimanual palpation
• Rectal examination for planning operative therapies

Transvaginal Sonography: 

• First choice for the evaluation of endometriosis 
• Assessment of rectal anterior wall movement (Sliding Sign)
• Detection of endometriomas and bowel infiltration

Magnetic Resonance Imaging (MRI): 

• Additional diagnostics for complex findings or deeply infiltrating endometriosis

Renal Sonography: 

• Indicated in suspected ureteral endometriosis or involvement of the rectovaginal septum/sacro-uterine ligaments

other diagnostic procedures depending on symptoms:

• Cystoscopy
• Colonoscopy
• Hysteroscopy
• Chromopertubation

Adenomyosis

The Morphological Uterus Sonographic Assessment (MUSA) group has developed various criteria for the detection of adenomyosis:

• Globular (enlarged) uterine shape: The uterus appears diffusely enlarged.
• Asymmetric myometrial thickening: Differences in thickness between the anterior and posterior myometrial wall.
• Myometrial cysts: Small, anechoic or hypoechoic areas within the myometrium.
• Hyperechoic subendometrial lines and buds: Echogenic areas near the endometrium.
• Fan-shaped shadowing: Radial, indistinct acoustic shadowing.
• Irregular or interrupted junctional zone: Thickened (> 12 mm) or irregular.
• Translesional vascularity: Vascular supply within the myometrium detectable by Doppler sonography.

Differentiation between Adenomyosis and Fibroids

The MUSA classification describes differences between adenomyosis and uterine fibroids:

The junctional zone is an important marker: An irregular or thickened junctional zone strongly suggests adenomyosis​Ultrasound in Obstet ….

Classification of Adenomyosis according to MUSA

The classification considers the location and type of adenomyosis:

• Focal adenomyosis: Clearly defined lesions.
• Diffuse adenomyosis: Widespread changes in the myometrium.
• Cystic adenomyosis: Presence of cysts in the myometrium.
• Adenomyomas: Defined nodules with hypertrophic myometrium.

Pelvic Endometriosis: 

Reference: 

1. Van den Bosch, T., de Bruijn, A.M., de Leeuw, R.A., Dueholm, M., Exacoustos, C., Valentin, L., Bourne, T., Timmerman, D. and Huirne, J.A.F. (2019), Sonographic classification and reporting system for diagnosing adenomyosis. Ultrasound Obstet Gynecol, 53: 576-582. https://doi.org/10.1002/uog.19096
2. Guerriero, S., Condous, G., van den Bosch, T., Valentin, L., Leone, F.P.G., Van Schoubroeck, D., Exacoustos, C., Installé, A.J.F., Martins, W.P., Abrao, M.S., Hudelist, G., Bazot, M., Alcazar, J.L., Gonçalves, M.O., Pascual, M.A., Ajossa, S., Savelli, L., Dunham, R., Reid, S., Menakaya, U., Bourne, T., Ferrero, S., Leon, M., Bignardi, T., Holland, T., Jurkovic, D., Benacerraf, B., Osuga, Y., Somigliana, E. and Timmerman, D. (2016), Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group. Ultrasound Obstet Gynecol, 48: 318-332. https://doi.org/10.1002/uog.15955

The preoperative classification of endometriosis according to #ENZIAN is an essential component of surgical planning and patient education. It enables precise assessment of disease extent and individualized therapy planning. As a result, affected patients benefit from better surgical outcomes, lower complication rates, and optimized postoperative care.

#ENZIAN Classification 

Explanation of Application

• Left/right separation: For paired organs (ovaries, tubes, ureters), the severity is specified separately for left and right (e.g., O2/1 for left 3-7 cm, right <3 cm).
• Missing organs: If an organ is absent or not assessable, this is indicated with m (missing) or x (unknown).
• Coding: The classification can be used for non-invasive (ultrasound, MRI) and surgical diagnostics (e.g., #ENZIAN (u) for ultrasound, #ENZIAN (m) for MRI, #ENZIAN (s) for surgical diagnostics).

Reference: 

1. Keckstein J, Saridogan E, Ulrich U A, et al. The #Enzian classification: A comprehensive non-invasive and surgical description system for endometriosis. Acta Obstet Gynecol Scand. 2021; 100: 1165–1175. https://doi.org/10.1111/aogs.14099