Surgical Technique Steps for Open Abdomen Exploratory Laparotomy in Endometriosis
While laparoscopy is the gold standard approach for endometriosis surgery, when open laparotomy is necessary, the procedure should follow systematic exploration with complete excision of all visible disease using techniques adapted from laparoscopic principles. 1, 2
Preoperative Planning
Obtain high-quality preoperative imaging with MRI pelvis or expanded protocol transvaginal ultrasound to map disease extent, identify deep infiltrating lesions, and plan the surgical approach, as this reduces morbidity, mortality, and the need for incomplete surgeries requiring repeat procedures. 3, 1
Review imaging to identify involvement of critical structures including uterosacral ligaments, rectosigmoid colon, bladder, ureters, and appendix. 4, 2
Plan for potential bowel resection, urologic involvement, or other organ-specific procedures based on imaging findings. 2, 5
Initial Exploration and Assessment
Perform systematic exploration, inspection, and palpation of the entire abdomen and pelvis at the start of the procedure. 3
Obtain peritoneal washings for cytology at the beginning of the case. 3
Identify all endometriotic implants, recognizing their variable appearances: powder burns, red, blue-black, yellow, white, clear vesicular lesions, and peritoneal windows. 5
Complete classification documentation using the r-ASRM (revised American Society for Reproductive Medicine) classification for all patients, the Enzian classification for patients with deep endometriosis, and the EFI (Endometriosis Fertility Index) for patients with fertility concerns. 1, 2
Systematic Disease Excision
Perform complete excision of all visible endometriotic lesions rather than covering them with hemostatic agents, as complete removal is essential for deep infiltrating endometriosis. 2
Use sharp dissection techniques to remove adherent endometriotic implants without damaging underlying normal structures. 5
Perform adhesiolysis to restore normal pelvic anatomy. 5
Organ-Specific Techniques
Ovarian Endometriomas
- Remove or perform cystectomy of ovarian endometriomas using conservative surgical techniques when fertility preservation is desired. 5
Rectosigmoid Involvement
For rectosigmoid bowel lesions, choose between surgical shaving, discoid resection, or segmental resection based on depth of muscular wall involvement as determined by preoperative imaging. 2, 4
Superficial lesions can be treated with rectal shaving, while lesions involving the muscular layer require discoid or segmental resection. 2
When endometriosis penetrates through the entire depth of the bowel wall, perform complete resection and reanastomosis. 6
Bladder Involvement
- Perform partial cystectomy with complete excision of visible disease when bladder endometriosis is present. 3
Ureteral Involvement
Dissect endometriotic implants from the ureter using careful technique. 6, 5
When disease penetrates through the entire ureteral wall, perform complete resection and reanastomosis. 6
Appendiceal Involvement
- Perform appendectomy when endometriosis affects the appendix. 5
Critical Technical Considerations
Maintain comprehensive knowledge of pelvic anatomy throughout the procedure, as optimal treatment requires not only surgical skill but also anatomical expertise and understanding of endometriosis progression. 6
Recognize that the depth of lesions correlates with severity of pain, emphasizing the importance of complete visualization and treatment. 2
Ensure complete removal of deeply infiltrating lesions from all anatomical locations. 6
Common Pitfalls to Avoid
Do not perform incomplete excision, as this leads to symptom recurrence and need for repeat procedures. 3
Do not damage underlying normal structures during removal of adherent implants—use meticulous dissection technique. 5
Do not rely solely on visual inspection for non-classical appearing lesions; obtain histologic confirmation when lesion appearance is questionable. 1
Recognize that up to 44% of women experience symptom recurrence within one year after surgery, highlighting the need for postoperative hormonal suppression planning. 3
Postoperative Considerations
Consider hormonal medications such as combined oral contraceptives or progestin-only options after surgery to prevent recurrence. 2
Understand that while surgical excision by a specialist is the definitive treatment, medical therapies effectively temporize symptoms but cannot eradicate the disease completely. 3, 2