Pathology of Complete Cul De Sac Obliteration in Endometriosis and the Treatment Strategy Based on Laparoscopic Operation

Endometriosis is roughly classified into 3 morbid states such as peritoneal lesion, ovarian lesion and cul de sac lesion. Compared with the first 2 lesions, the pathology of cul de sac lesion has yet to be elucidated in detail. The lesion is clinically acknowledged as complete cul de sac obliteration (CCDSO). The incidence of CCDSO is surprisingly high. Of the 2464 cases of laparoscopic operations conducted at this department, endometriosis was noted in 1063 (43%) and CCDSO was confirmed in 304 (29%) of them. Between 1995 and 2002, there were 144 cases of laparoscopic open operation of CCDSO conducted at this department. Though perioperative complications including impaired ureter and rectum occurred in 14 patients (9.2%), it was possible to laparoscopically handle all of them. After operation, dysmenorrhea, coital pain and evacuation pain, etc. markedly improved, and spontaneous conception occurred in 13 (23.6%) of the 55 cases. When a group of 35 patients who received open operation of CCDSO complicated to the chocolate cyst of ovary were compared with another group of 35 patients whose chocolate cyst of ovary alone was extracted without open operation (35 patients), there was no difference in the post-operative conception rate and the severity of pre-operative dysmenorrhea between the groups but the post-operative dysmenorrhea was significantly milder in the former than the latter (p<0.01). SLL was performed in 61 patients. The postoperative r-AFS and the adhesion score of bilateral adnexa significantly decreased in all of them (p<0.01) in comparison with the pre-operative status. Re-adhesion of cul de sac occurred in 26 patients (42.6%) at the time of SLL. However, there was no significant difference in the post-operative pain between these 26 patients and the 35 patients who did not demonstrate adhesion, suggesting that it is simply the post-operative adhesion that occurred in the former rather than the recurrence of cul de sac endometriosis. The MRI jelly method developed by this department was successful in classifying the CCDSO into 3 types that mostly corresponded with the findings obtained during the operation, indicating that this method is highly objective and reproducible. According to the histological examination of the extracted deep lesion, fibrosis and metaplasia of smooth muscle were observed around the endometriotic foci. Based on the result, deep lesion is assumed to be constituted from CCDSO that are formed by the fibrosis in the periphery of endometric foci and sub-seauent metaplasia of its nerroheral smooth muscles.