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Dan C. Martin, MD
UT Medical Group, Inc.

University of Tennessee Health Science Center (UTHSC)

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Daniel Clyde Martin, M.D.
UT Medical Group, Inc.
Infertility and Gynecology
Reproductive Surgery
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TN 38138-1733

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Microscopic and Unidentified Endometriosis

Adapted from "Recognition of Endometriosis" in
Martin DC (ed), Resurge
Laparoscopic Appearance of Endometriosis, Lecture Supplement
ress, Memphis, (c)1991

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The first report of recognized microscopic disease was a case of ovarian endometriosis in 1899 by Russell. (Russell, 1899) A parallel finding of deep hidden endometriosis noted on ovarian puncture has been published by Candiani. (Candiani, Vercellini, & Fedele, 1990)  I another early report, Sampson described endometriosis hidden within adhesions. (Sampson, 1921) 

Vasquez, (Vasquez, Cornillie, & Brosens, 1983) Brosens, (Brosens, Vasquez, & Gordts, 1984) and Cornillie (Cornillie, Brosens, Vasquez, & Riphagen, 1986) documented the scanning electron microscopic appearance of polypoid, intraperitoneal and retroperitoneal associated with subtle appearances and nonvisualized lesions at laparoscopy. Murphy (Murphy, Green, Bobbie, Dela Cruz, & Rock, 1986) reported lesions with scanning electron microscopy, which had not been seen on gross observation. Both laparoscopic and microscopic diagnosis of lesions of less than 400 has relied on analysis of the epithelium or stroma as lesions of this size do not commonly have both. (Murphy, et al., 1986; Redwine & Yocum, 1990; Stripling, Martin, Chatman, Vander Zwaag, & Poston, 1988 )

Further confirmation of the presence of microscopic disease has been published by Redwine, (Redwine & Yocum, 1990) Nezhat, (Nezhat, Allan, Nezhat, & Martin, 1991) and Martin. (Martin, 1991) Suspected and invisible lesions noted by thermocolor tests were published by Semm. (Semm & Friedrich, 1987)

In addition to microscopic disease not seen in normal peritoneum, Martin (Martin, Hubert, Vander Zwaag, & El-Zeky, 1989) has described endometriosis hidden behind other findings such as adhesions and carbon. Furthermore, Koninckx has described large retroperitoneal nodules which are not seen at laparoscopy but are easily palpated on clinical exam. (Koninckx & Cornillie, 1993; Koninckx & Martin, 1992) These are similar to the patients with AFS stage 0 score 0 endometriosis discussed by Moore (Moore, Binstock, & Growdon, 1988) with bowel and ureteral compromise. These may be related to clinically unrecognized, but histologically proven, lesions noted in the uterosacrals. (Damario, Horowitz, & Rock, 1994; Nesbitt & Rizk, 1971)

Spuijbroek (Spuijbroek, Dunselman, Menheere, & Evers, 1992) demonstrated aminoterminal propeptides of type III procollagen in patients with early endometriosis. These were also increased in patients with unexplained infertility. It is possible that microscopic endometriosis is responsible for this increase in patients with unexplained infertility.

The microscopic and retroperitoneal position of some endometriosis suggests that we will not be able to recognize all areas by visualization. Conscious sedation pain mapping may be capable of identifying focal lesions and distinguishing patients with focal lesions from those with generalized peritoneal sensitivity. (Palter & Olive, 1996)

Pockets are another source of concern. Endometriosis can be hidden deep within the pocket or in the margins of the pockets. (Batt, Smith, Buck, Naples, & Severino, 1989; Chatman & Zbella, 1986; Martin, 1992; Sampson, 1927) As a surgical concern, pockets are associated with medial deviation of the ureter. (Batt, et al., 1989) This ureteral position can make ureters look like uterosacral ligaments.

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bulletBatt, R. E., Smith, R. A., Buck, G. M., Naples, J. D., & Severino, M. F. (1989). A case series - peritoneal pockets and endometriosis: rudimentary duplications of the Mullerian system. Adolesc Pediatr Gynecol, 2, 47-56.
bulletBrosens, I. A., Vasquez, G., & Gordts, S. (1984). Scanning electron microscopic study of the pelvic peritoneum in unexplained infertility and endometriosis (abstract). Fertil Steril, 41, 21S.
bulletCandiani, G. B., Vercellini, P., & Fedele, L. (1990). Laparoscopic ovarian puncture for correct staging of endometriosis. Fertil Steril, 53, 994-997.
bulletChatman, D. L., & Zbella, E. A. (1986). Pelvic peritoneal defects and endometriosis: further observation. Fertil Steril, 46, 711-714.
bulletCornillie, F. J., Brosens, I. A., Vasquez, G., & Riphagen, I. (1986). Histologic and ultrastructural changes in human endometriotic implants treated with the antiprogesterone steroid ethylnorgestrienone (Gestrinone) during 2 months. Int J Gynecol Pathol, 5, 95-109.
bulletDamario, M. A., Horowitz, I. R., & Rock, J. A. (1994). The role of uterosacral ligament resection in conservative operation for recurrent endometriosis. J Gynecol Surg, 10, 57-61.
bulletKoninckx, P. R., & Cornillie, F. J. (1993). Infiltrating endometriosis: infiltration, retraction or adenomyosis externa? In D. C. Martin (Eds.), Atlas of Endometriosis (pp. 9.1-9.8). London: Gower Med Publ.
bulletKoninckx, P. R., & Martin, D. C. (1992). Deep endometriosis: a consequence of infiltration or retraction or possibly adenomyosis externa? Fertil Steril, 58, 924-928.
bulletMartin, D. C. (1991). Laparoscopic Appearance of Endometriosis. First Revision. Color Atlas (Second ed.). Memphis: Resurge Press. 
bulletMartin, D. C. (1992). Laparoscopic excision of infiltrating pelvic endometriosis. In A. Levensohn (Eds.), OB-GYN Illustrated Slingerlands, New York: LTI Medica (Upjohn).
bulletMartin, D. C., Hubert, G. D., Vander Zwaag, R., & El-Zeky, F. A. (1989). Laparoscopic appearances of peritoneal endometriosis. Fertil Steril, 51, 63-67.
bulletMoore, J. G., Binstock, M. A., & Growdon, W. A. (1988). The clinical implications of retroperitoneal endometriosis. Am J Obstet Gynecol, 158, 1291-1298.
bulletMurphy, A. A., Green, W. R., Bobbie, D., Dela Cruz, Z. C., & Rock, J. A. (1986). Unsuspected endometriosis documented by scanning electron microscopy in visually normal peritoneum. Fertil Steril, 46, 522-524.
bulletNesbitt, R. E., & Rizk, P. T. (1971). Uterosacral ligament syndrome. Obstet Gynecol, 37(5), 730-733.
bulletNezhat, F., Allan, C. J., Nezhat, C., & Martin, D. C. (1991). Nonvisualized endometriosis at laparoscopy. Int J Fertil, 36(6), 340-343.
bulletPalter, S., & Olive, D. L. (1996). Office microlaparoscopy under local anesthesia for chronic pelvic pain. J Am Assoc Gynecol Laparoscopists, 3, 359-364.
bulletRedwine, D. B., & Yocum, L. B. (1990). A serial section study of visually normal pelvic peritoneum in patients with endometriosis. Fertil Steril, 54, 648-651.
bulletRussell, W. W. (1899). Aberrant portions of the Mullerian duct found in an ovary. Johns Hopkins Hosp Bul, 94-96(January, February, March), 8-10.
bulletSampson, J. A. (1927). Peritoneal endometriosis due to menstrual dissemination of endometrial tissue into the peritoneal cavity. Am J Obstet Gynecol, 14, 422-469.
bulletSemm, K., & Friedrich, E. R. (1987). Operative Manual for Endoscopic Abdominal Surgery. Chicago: Yearbook Medical Publishers. 
bulletSpuijbroek, M. D. E. H., Dunselman, G. A. J., Menheere, P. P. C. A., & Evers, J. L. H. (1992). Early endometriosis invades the extracellular matrix. Fertil Steril, 58(5), 929-933.
bulletStripling, M. C., Martin, D. C., Chatman, D. L., Vander Zwaag, R., & Poston, W. M. (1988). Subtle appearance of pelvic endometriosis. Fertil Steril, 49, 427-431.
bulletVasquez, G., Cornillie, F., & Brosens, I. A. (1983). Peritoneal endometriosis: scanning electron microscopy and histology of minimal pelvic endometriotic lesions. Fertil Steril, 42, 696-703.

Adapted from "Recognition of Endometriosis" in
Laparoscopic Appearance of Endometriosis, Lecture Supplement
Martin DC (ed), Resurge Press, Memphis, (c)1991

The color illustrations that accompanied this paper are in the Color Atlas.

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