INTRODUCTION

Laparoscopy is an accepted method of treatment in gynecology, general surgery, urology, and pediatric surgery. It is generally safe, is usually well tolerated by patients, and, when compared to its open surgical counterpart, offers the advantages of less postoperative pain, reduced surgical trauma, and a shortened postoperative hospital stay. However, as with any surgical procedure, laparoscopy has technique-related complications. One of these complications is major vascular injury (MVI), of which consequences can be quite serious. Injuries to the large vessels (aorta, vena cava, iliac vessels, and mesenteric vessels) are commonly referred to as MVI and occur in a variety of laparoscopic fields (see Figure 20.1.1, Table 20.1.1). Many of these injuries occur while inserting the Veress needle and/or trocars through the abdominal wall and, as a result, do not occur in conventional procedures. While the reported incidence may be low, ranging from 0.05% to 0.14%, the mortality arising from these injuries is substantially higher and has been reported to reach up to 17% (see Table 20.1.2). Therefore, the rare occurrence of MVI carries with it the risk of a potentially catastrophic outcome.

INCIDENCE

MVI can occur in laparoscopic surgery during the early maneuvers required to enter the peritoneal cavity, or during the surgical dissection required for the specific procedure.

Endometriosis is classically defined as the presence of endometrial glands and stroma in ectopic locations. Affecting from 6% to 10% of reproductive-aged women, endometriosis may result in dysmenorrhea, dyspareunia, chronic pelvic pain, and/or subfertility. The prevalence of this condition in women experiencing pain, infertility, or both is as high as 50%. Endometriosis is a debilitating condition, posing quality-of-life issues for the individual patient. The disorder represents a major cause of gynecologic hospitalization in the United States, estimated to have exceeded $3 billion in inpatient health care costs in 2004 alone. The significant individual and public health concerns associated with endometriosis underscore the importance of understanding its pathogenesis. The first recorded description of pathology consistent with endometriosis was provided by Shroen in 1690. Despite the passage of time and extensive investigation, the exact pathogenesis of this enigmatic disorder remains unknown.

THEORIES REGARDING PATHOGENESIS

Numerous theories detailing the development of endometriosis have been described. For purposes of review, these theories can generally be classified into those that propose that implants arise from tissues other than the endometrium and those that propose that implants arise from uterine endometrium (Table 10.1.1).

Nonendometrial Origin

Metaplasia of coelomic epithelium represents a distinct pathogenic mechanism for the establishment of endometriotic implants.