Is There More Than Meets the Eye? Pattern of Visible and Occult Peritoneal Endometriosis in Patients with Pelvic Pain

Abstract

Study Objective

Pattern of visible and occult peritoneal endometriosis in patients with pelvic pain undergoing complete peritonectomy(CP).

Design

Retrospective observational.

Setting

Academic medical center.

Patients or Participants

Patients with chronic pelvic pain undergoing a laparoscopic or robotic CP between 2018-2024. Patients with stage four endometriosis were excluded. A pilot analysis of 56 patients are included in this study.

Interventions

Minimally invasive CP with documentation of intraoperative location of endometriosis performed by fellowship-trained surgeons experienced in endometriosis excision. CP was defined as excision of left and right pelvic brims, pelvic side-walls, ovarian fossae, uterosacral ligaments, posterior cul-de-sac and bladder peritoneum.

Measurements and Main Results

Records were coded as 1(surgeon positive) or 0(surgeon negative) and 1(pathology positive) and 0(pathology negative). Discordance was calculated (surgeon positive-pathology negative=1; pathology negative-surgeon positive=-1). 89.3% of patients (28.7% of total regions) had at least one instance of discordance. In 61.6% of those cases, the operative report identified areas of suspected endometriosis, but the pathology showed no endometriosis. Of those cases 47.8% showed evidence of fibrosis or chronic inflammation. Hormonal medication and history of previous surgery were not related to surgeon positive/pathology negative discordance (chi-square, p = .07). In the other 38.4% of discordant cases, the operative report did NOT identify areas of suspected endometriosis, but the pathology report DID identify endometriosis. The area with the most identified endometriosis was the left ovarian fossa (80% positive pathology).

Conclusion

Evidence for surgical excision of endometriosis for improving pain is robust. Debate regarding the optimal technique continues. Our findings further support the emerging data suggesting the role of CP given that even with expert, well-trained eyes, microscopic endometriosis can be missed. Furthermore, presence of fibrosis or chronic inflammation in nearly half of the cases where the pathology report did not show endometriosis is an intriguing finding. Studies are needed to assess the role of CP in reducing the risk of repeated surgical interventions.