Endometrioziste Cerrahi Tedavi Prensipleri
Özet
Endometriozis, endometriyal dokuların uterus dışında bulunmasıyla karakterize, skarlaşma, kısırlık ve pelvik ağrıya yol açan kronik bir jinekolojik durumdur. Tedavisi medikal ve cerrahi yaklaşımları içermekte olup hastanın yaşı, fertilite istemi ve semptomların şiddetine göre kişiselleştirilir. Cerrahi öncesinde pelvik ultrason ve MR gibi görüntüleme yöntemleriyle detaylı preoperatif değerlendirme ve multidisipliner yaklaşım esastır. Derin infiltratif endometriozis (DIE) varlığında, lezyonlar 5 mm'den daha derine penetre olduğu için genel cerrah, kolorektal cerrah ve ürologdan oluşan uzman bir ekiple multidisipliner rezeksiyon yapılmalıdır. Ovaryan endometriomalarda nüks riskini azaltmak için kist aspirasyonu veya ablasyon yerine laparoskopik kistektomi tercih edilirken; çocuk istemini tamamlamış veya malignite şüphesi olan hastalarda kesin tedavi olarak ooferektomi uygulanabilir. Endometriozis ve DIE'de derin lezyonların tamamen eksize edilmesi ve riskli yapışıklıkların giderilmesi (adezyolizis) ağrıyı azaltmada önemlidir. Günümüzde sinir koruyucu cerrahi standart bakım haline gelmiş, sinir transeksiyonu ise sınırlı vakalarda tercih edilmektedir. Konservatif cerrahi, fertiliteyi ve hormonal fonksiyonları koruduğu için ilk seçenek olarak değerlendirilirken, hayat kalitesi ciddi derecede etkilenen ve diğer tedavilerden yanıt alamayan hastalarda histerektomi ile kesin cerrahi çözüm sunulmaktadır.
Endometriosis is a chronic gynecological condition characterized by the presence of endometrial tissue outside the uterus, leading to scarring, infertility, and pelvic pain. Its management involves a combination of medical and surgical approaches individualized based on the patient's age, fertility desires, and symptom severity. Prior to surgery, a detailed preoperative evaluation using imaging techniques such as pelvic ultrasound and MRI, along with a multidisciplinary approach, is essential. In cases of deep infiltrating endometriosis (DIE), where lesions penetrate deeper than 5 mm, multidisciplinary resection should be performed by an expert team including general surgeons, colorectal surgeons, and urologists. For ovarian endometriomas, laparoscopic cystectomy is preferred over cyst aspiration or ablation to reduce recurrence rates, while oophorectomy can be performed as a definitive treatment for patients who have completed childbearing or have suspected malignancy. In endometriosis and DIE, complete excision of deep lesions and lysis of critical adhesions (adhesiolysis) are important for pain reduction. Currently, nerve-sparing surgery has become the standard of care, whereas nerve transection is reserved for selected cases. Conservative surgery is considered the primary option as it preserves fertility and hormonal functions, while definitive surgical management through hysterectomy is recommended for patients whose quality of life is severely affected and who have failed other treatments.
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