Some criticism about post-operative pain after adnexal surgery performed by single-port vs. standard laparoscopy

8 10 2012

To the Editor:

We have read with great interest the article by Hoyer-Sorensen et al. (1), showing no differences in post-operative pain after adenexal surgery performed by single-port vs. standard laparoscopy. There are currently few studies in the literature on this topic. In particular, two retrospective case-control (2, 3) and two prospective randomized trials (4, 1) evaluate pain after treatment of adnexal pathology with different surgical approaches (LESS vs. standard laparoscopy), but their results are conflicting.

Focusing on the two randomized trials, the Norwegian study (Hoyer-Sorensen et al.) is very similar to the Italian one (Fagotti et al.) in structure and patient enrollment. However, there are some differences, which could explain the opposite results: i) the number of patients (in particular, there is a larger number of patients in the Italian study than in the Norwegian one); ii) the routine occurrence of pre- and intra-operative analgesia in the Norwegian study, which was never performed in the Italian series; and iii) the timing and site of pain assessment. Read the rest of this entry »





Endometriosis: a consequence of varying injuries to pelvic autonomic nerves

2 10 2012

To the Editor:

Ectopic endometrium appears in the pelvis following injuries to uterotubal nerves that result in uterotubal dysmotility and retrograde menstruation (1). These neural injuries result from prolonged straining during defecation, difficult vaginal deliveries, excessive traction to the pregnant cervix at surgical evacuation of the uterus, and miscellaneous injuries yet to be fully described (2). Retrograde menstruation enables adhesion of endometrium to contemporary pelvic injuries (1). Some years later laparoscopic findings may include symmetric thickening of the uterosacral ligaments with fusion of the vagina to the rectum and extensive deposits of ectopic endometrium (recurrent straining at stool), asymmetric injuries to uterosacral ligaments with variable deposits (sporadic, difficult vaginal deliveries), minor deposits around the uterosacral insertions (excessive traction to the pregnant cervix), and endometriomas following injuries to the surface of the ovaries at ovulation (1), or combinations of these presentations. Aberrant reinnervation in the respective organs contributes to symptoms of dysmenorrhea (uterus), dyspareunia (cervix, vagina), chronic pelvic pain (uterus and uterosacral ligaments, and subfertility (uterus, fallopian tubes) (1, 2).

Endometriosis is no longer an enigma; it is, for the most part, a preventable condition caused by Western diets and lifestyles and obstetric and gynecologic interventions (3). No single view can account for each and every individual case, nevertheless, injuries to pelvic autonomic nerves may explain many clinical and laparoscopic presentations and failures of medical and surgical treatment. Autonomic denervation, with its remote and wide-ranging consequences, may account for many features of reproductive ill health, and in some cases, later systemic disease (4).

Martin Quinn, M.D.
Xin Mei Zhang, M.D., Ph.D.
Xiu Feng Huang, M.D.
Hong Xu, M.D., Ph.D.
Department of Gynecology, Women’s Hospital, School of Medicine, University of Zhejiang
Hangzhou, China

References

(1) Quinn M. Endometriosis- the consequence of uterine deneration-reinnervation. Arch Gynaecol Obstet 2011; 284:1423-9.

(2) Atwal GSS, Armstrong G, Duplessis D, Slade R, Quinn M. Differences in uterine innervation at hysterectomy for chronic pelvic pain with, or without, endometriosis. Am J Obstet Gynecol 2005; 193:1650-5.

(3) Donnez J. Endometriosis: enigmatic in the pathogenesis and controversial in its therapy. Fertil Steril 2012; 98: 509-10.

(4) Quinn MJ. Origins of Western Diseases. J R Soc Med 2011; 104: 449-56.

The authors declined to respond to this letter.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2012.10.002