Challenges in Laparoscopic Management of Adenomyoma (Endometriosis Interna) in Infertility Patient

Intruduction: Adenomyosis, partly understood, is called 'elusive' or 'enigmatic' because of its difficult diagnosis, definition, and because of the vague and ill-defined pattern of symptoms. Patients experience troublesome, heavy menstrual bleeding, troublesome dysmenorrohea, Infertility, B.O.H. and sometimes a tender uterus. The association of adenomyosis with other pelvic pathologies additional (Fibroids, Endometriosis, Rectovaginal Endometriosis etc.) which confuses the understanding of related symptoms. There is no specific combination of symptoms by adenomyosis, although women suffer from very heavy menstrual periods or Dysmenorrohea. Now that moderate to severe degrees of adenomyosis is diagnosed by ultrasound or magnetic resonance imaging (MRI), there is an urgent need for multicentric collaboration to prospectively define symptomatology uniformly, and relate it with findings on imaging (also with surgical and pathological findings. Laparoscopic Adenomyosis Resection :( Author’s technique) :Selection Criteria’s: (1) Localized Adenomyoma can be excised better and likely to give better result. (2) Generalized Adenomyosis with uniform enlargement of uterus of >12-14 size case is not favorable case for Adenomyosis resection. (3) Patient should be counseled about very poor fertility result after adenomyoma resection surgery. (4) Laparoscopic surgeon must do meticulous during suturing of myometrial defect after adenomyoma resection otherwise patient may develop rupture uterus when she becomes pregnant. Laparoscopic Technique: Part of uterus with maximum bulge is incised with scissor or Monopolar needle or spatula is used to excise the adenomyotic tissues. Haemostasis is controlled during surgery with bipolar desiccation. Adenomyotic tissue is grasped with 5 mm claw forcep and pulled and gradually excised till normal healthy myometrium is reached. One should be careful that cavity is not opened and large defect is not formed and then it becomes very much difficult to approximate the defect and suture adequately. Uterine defect should be closed with No.1 Vicryl and by extra corporeal note technique or intracorporeal suturing with slipped note technique or figure of “8 stitch with using extra port for stippling while applying second not. See the stitches on uterus in figure after final repair. Decision Making during Laparoscopy / operation: Surgeon must evaluate carefully the findings of Endometriosis lesions around pelvic organs in all the cases of Fibroid operations. Usually adenomyosis produces a diffuse enlargement of the uterus in contrast to the well circumscribed bosses characteristic of fibroids. After incision on the uterus over bosses it shows typical picture of irregular cut surface with multiple small tarry cysts with no specific capsule anywhere. Look for localized adenomyoma or involvement of all the walls of uterus with adenomyotic changes in advance, as continuing surgery with diffuse adenomyosis involving uterus walls, may result in opening the uterine cavity & very difficult suturing of the defect or hysterectomy. This may be disaster for infertile patient, without any consent for Hysterectomy.