As recently as 1987 whilst a registrar at King George V Hospital working under Professor Robert Jansen who founded Genea, initially as Sydney IVF, I had the pleasure of being involved with some of his laparoscopic surgery for endometriosis. At that time he published a paper illustrating the myriad appearances that endometriosis may have. Around that time he also demonstrated the impact on fertility in people with endometriosis using donor sperm when compared to a group without endometriosis. Since then laparoscopy has expanded to enable operative procedures to be performed rather than just simple diagnostic cases.
It strikes me that there is significant inter-observer variability in relation to the laparoscopic assessment, diagnosis and staging of endometriosis. It is commonly considered that laparoscopy is the gold standard but I believe there are wide discrepancies depending on the operator and his or her experience. Simple issues such as the absence of using secondary ports or uterine manipulators to gain clear access to the cul-de-sac and failure to aspirate fluid within the cul-de-sac may mean the diagnosis is missed. There also seems to be a range of opinions in recognizing both minor disease and even substantial disease with significant adhesion formation. The former may be regarding as minor burnt out disease of no consequence whilst the latter can at times be considered possibly to be consistent with pelvic infection or adhesions. Even in the hands of people with great experience in managing endometriosis it can be exceedingly difficult at times to determine if an area is in fact involved with endometriosis or not. This is particularly problematic in the rarer areas where endometriosis may be involved. These sites include such areas as the sigmoid colon, caecum and appendix and diaphragm in particular. Palpation of these areas is difficult with laparoscopic instruments and we have at times been surprised to find the extent of disease after removing a specimen. In my own series almost 100% of the bowel specimens that we remove for example have endometriosis involved. Whilst this may sound good I believe it simply represents the fact that we are under-estimating and under-treating disease and that areas of endometriosis remain. By way of comparison the rate of histologically proven appendicitis for cases where appendicectomy is performed is not uncommonly only about 60%.
These issues illustrate that imaging, including both still images and video is of critical importance when a laparoscopy is considered.
Like all things in life all laparoscopies are not the same.