Endometriosis

The article "Endometriosis--A missed malady" is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, education program professional, Center for Perioperative Education.

A minimum score of 70% on the multiple-choice examination is necessary to earn 3 contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Feb 28, 2006.

Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to

BEHAVIORAL OBJECTIVES

After reading and studying the article on endometriosis, the nurse will be able to

(1) explain how endometriosis affects a woman's normal menstrual cycle,

(2) identify the stages of endometriosis,

(3) describe the treatment options available to women with endometriosis,

(4) discuss the perioperative course of a patient undergoing laparoscopic excision of endometriosis, and

(5) describe how the ultrasonic scalpel is used to resect endometrial implants.

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

Endometriosis--a missed malady

Many women experience cramping during their menstrual cycle. Often, they are told that the stabbing, cramping pain that can leave some women incapacitated for days, weeks, or longer is all in their head. For many women, however, this debilitating condition can be attributed to endometriosis.

WHAT IS ENDOMETRIOSIS?

Endometriosis is a disease that affects girls and women in their reproductive years. According to estimates from the Endometriosis Association (EA), this disease affects approximately 5.5 million women in the United States and Canada. (1) During the menstrual cycle, the endometrial lining of the uterus thickens in preparation to receive a fertilized egg. If fertilization does not occur, this lining sloughs off in the form of blood (ie, menstruation). Endometrial tissue can migrate out of the fallopian tubes and grow outside of the uterus as endometrial implants (Figure 1). This can result in severe pain that interferes with a woman's activities of daily living. These endometrial implants can migrate to various areas, including the

[FIGURE 1 OMITTED]

* ovaries,

* fallopian tubes,

* outer surface of the uterus,

* pelvic cavity and walls, and

* rectum. (2)

Although uncommon, these growths even have been detected in lung, arm, and other tissues (Figure 2). (3)

[FIGURE 2 OMITTED]

Although the etiology of endometriosis is unknown, the most popular theory suggests the cause is retrograde menstruation, a condition in which menstrual tissue backs up through the fallopian tubes and implants in the abdominal cavity. Endometrial tissue that migrates through the fallopian tubes into the pelvic cavity usually responds to the hormones of the menstrual cycle as if it were inside the uterus. The tissue builds up each month, breaks down, and causes bleeding. Unlike blood from the lining of the uterus, the blood from endometrial growths outside of the uterus has no way to exit the body. Internal bleeding occurs, therefore, as degeneration of the blood and tissue shed from the implants. This causes inflammation to the surrounding areas and formation of scar tissue, which many times results in pain.

Symptoms. According to a 1998 study of 4,000 women conducted by the EA, most participants suffered from endometriosis for an average of nine years before identifying the root cause of their discomfort.

Common symptoms include

* bloating,

* diarrhea or painful bowel movements near the time of menstruation,

* discomfort during or after sexual intercourse,

* dizziness,

* fatigue,

* irregular bleeding,

* lower back pain during menstruation,

* pelvic pain,

* profuse, painful menstrual periods, and

* infertility (ie, in up to 40% of the cases). (4)

An endometrioma (ie, endometriosis inside the ovary) often is present as well. This is sometimes called a chocolate cyst due to the appearance of the fluid in the cyst. This thick, brown fluid is, in actuality, old blood. If ruptured, these cysts can prove difficult to resect because the fluid can obstruct vital structures, such as the ureters or blood vessels. In the case of rupture, copious laparoscopic irrigation is performed with 0.9% normal saline and removed by suction in an effort to maintain optimal visualization. According to the EA, recent research has indicated that women with endometriosis are at greater risk for cancer, particularly ovarian and breast cancer and non-Hodgkin's lymphoma. (5)

Infertility. Infertility, which afflicts one in three women with endometriosis, may be the only presenting symptom; however, it is possible to have endometriosis and still be able to conceive. If no adhesions are blocking the fallopian tubes, the odds of conceiving normally after treatment are more than 80%. Severe scarring lowers the odds to 30%. (6)

Endometriosis is very difficult to detect because most women become accustomed to painful menstrual cycles at an early age. They are, therefore, unaware that these symptoms could be abnormal. Most women do not consult a physician until an average of 4.7 years after symptoms begin. (7)

The disease often will go undiagnosed because even with extensive endometriosis, it is possible to have minimal symptoms or none at all. Symptoms also vary and may mimic other conditions. The amount of pain is not always related to the size or extent of the implants. If the physician is not listening to the patient's concerns, the disease very easily could go undetected. Many women, however, who have documented endometriosis experience pain upon pelvic examination and during intercourse. (8)

Physicians have few diagnostic tools to detect the scars and growths of endometriosis. Endometriosis cannot be detected by magnetic resonance imaging (MRI), computed tomography (CT) scans, x-rays, or ultrasound. The only way to confirm the diagnosis and stage of endometriosis is by laparoscopy.

STAGES OF ENDOMETRIOSIS

The stages of endometriosis include

* stage I (ie, minimal),

* stage II (ie, mild),

* stage III (ie, moderate), and

* stage IV (ie, severe) (Figure 3).

[FIGURE 3 OMITTED]

The stage depends on the extent of the scar tissue and whether other pelvic organs are affected. (9) A combination of findings allows the physician to determine the stage of endometriosis (Table 1).

Stage I is a minimal case of endometriosis. Shallow implants are seen on the ovaries. These can appear as pink blotches or a reddened area on the ovary. Stage II, a mild case of endometriosis, involves deep endometrial implants not only on the ovaries but also on the pelvic lining. Usually these are brown or coffee-stained in appearance. Mild adhesions also are present within the pelvic cavity. These appear as dense, clear, filmy barriers that seem to be stretched between the pelvic walls and may involve the uterus, ovaries, or fallopian tubes. Stage III is a moderate case of endometriosis. This stage differs from stage II only with regard to the amount of adhesions present and the location of the implants. In this stage, deep endometrial implants are visible on the ovaries, and an increased amount of scar tissue is present in the pelvic cavity. Stage IV is the most severe form of endometriosis. All of the previously described symptoms are present but the extent is increased, and implants also are seen on bowel tissue. Scar tissue may be thick and obstruct the reproductive organs. Bilateral endometriomas also may be present.

There are many treatment options available after the initial diagnosis is made. Physicians may choose medical or surgical treatment and often determine that a combination of treatment interventions is required.

TREATMENT OPTIONS

Regardless of the suspected stage of endometriosis, the physician initially may elect conservative treatment. Medical management with the use of hormone therapy may be attempted. This regimen usually continues until the patient experiences relief from symptoms. If no improvement occurs, the patient, in collaboration with the physician, may elect surgical intervention in an effort to achieve definitive relief. In the case of infertility, often a physician will initiate medical treatment for several months before suggesting surgical intervention. In cases of suspected endometriosis, a physician may initiate hormone therapy.

Hormone therapy. Hormones can be controlled or blocked using several types of hormone therapy that propel the menstrual cycle. This treatment limits the swelling of the endometrium and implants. Hormone therapy may be used by itself or in conjunction with surgery. Often pregnancy is possible very soon after treatment is discontinued. Types of hormone therapy available include prescribing use of birth control pills, gonadotropin-releasing hormone (GnRH) agonists, or progestins.

Birth control pills. Birth control pills contain progestin, which is a form of progesterone, and estrogen. The pills can be prescribed to ensure that a woman has a cycle each month or to discontinue the woman's cycles indefinitely.

Gonadotropin-releasing hormone agonists. These hormone agonists prevent the pituitary gland from producing hormones (ie, follicle-stimulating hormone [FSH], luteinizing hormone [LH]) that send impulses to the ovaries. As a result, estrogen and progesterone are not produced. This results in cessation of ovulation and the menstrual cycle. Ovulation returns after treatment is discontinued. Danazol may be prescribed for patients who have confirmed endometriosis. Danazol is a hormone that blocks FSH and LH at the pituitary gland, keeping progesterone and estrogen levels low and resulting in cessation of ovulation and the menstrual cycle, which can cause implants to shrink.

Progestins. Progestin is a form of progesterone that keeps estrogen levels low. This prevents ovulation and limits implant growth.

Surgical intervention. If symptoms are not relieved or if the woman is unable to conceive, surgical intervention may be an option. In the past, the most successful treatment was open laparotomy with excision of the endometrial implants. This required a large abdominal incision to resect the tissue and resulted in an extended postoperative period of four to six weeks. Another more recent option is laparoscopic excision of endometrial implants. Some of the pathology seen during laparoscopy includes shallow or dense endometrial implants on the ovaries, fallopian tubes, and surrounding pelvic cavity. Adhesions (ie, scar tissue) can result from endometriosis or retrograde menstrual bleeding. Laparoscopy with carbon dioxide (C[O.sub.2]) laser vaporization of the endometrial tissue is one treatment option. Another option is electrosurgical cauterization of the diseased tissue, which can be performed to treat implants found during laparoscopy; however, the implants can recur after only one or two years. Some surgeons, therefore, prefer to use the ultrasonic scalpel, which makes it possible to resect through the laparoscope and avoid a large incision. Many surgeons believe that this technique offers longer-lasting relief from endometriosis than electrosurgical or laser procedures.

PATIENT SELECTION

A patient usually is selected for surgical intervention when medical intervention has proved unsuccessful. Laparoscopic excision of endometriosis is contraindicated in patients with suspected extensive abdominal adhesions from previous surgeries and those with severe endometriosis. Adhesions can pose a problem in laparoscopic accessibility and also may present insufflation difficulties. A patient who has undergone several previous abdominal surgeries often has extensive adhesions. This is considered when determining whether the patient is a candidate for laparoscopic surgery. The patient must weigh the intensity of her symptoms and pain against the invasiveness of surgery and its potential complications. An open procedure is not indicated unless the patient has undergone multiple abdominal surgeries or the surgeon expects the scar tissue to be so abundant that it may obstruct vital structures, rendering laparoscopy unsafe. The physician has no way of knowing preoperatively whether adhesions are indeed present or their extent. Although obesity does not prohibit surgical treatment, morbid obesity may create challenges in achieving proper insufflation without creating cardiac interference and increasing the risk of pulmonary emboli and thrombosis due to positioning. Adipose tissue may obstruct the surgeon's view of vital structures and render the procedure unsafe via the laparoscopic approach.

Stage IV endometriosis is the most difficult to resect. Although some cases of stage IV have been successfully resected laparoscopically, it is not uncommon for a laparoscopic procedure to be converted to an open laparotomy. The surgeon may believe that the endometriosis can not be safely resected laparoscopically and may, therefore, elect direct visualization.

PREOPERATIVE PREPARATION

Patient education begins when surgery is scheduled. The surgeon explains the indications for surgery and the risks and benefits of the proposed procedure to the patient. The surgeon describes the surgical procedure and the required recovery period. The surgery date and time then are selected.

The office nurse explains the anatomy and physiology of the pelvic organs and what diagnostic tests to expect. The nurse instructs the patient to remain NPO after midnight the night before surgery. If the patient has a history of elevated blood pressure and is being treated for hypertension, the nurse instructs the patient to take her oral antihypertensive medications with a sip of water on the morning of surgery. Patients with insulin-dependent diabetes are permitted to inject one-half their usual dose of insulin, and a blood glucose level is obtained after arrival at the hospital.

The nurse instructs the patient to shower the morning of surgery to decrease skin microbial colony counts. He or she also asks the patient to use a povidone-iodine douche the morning of surgery, in an effort to reduce the possibility of infection. (10) A vinegar and water douche is substituted for patients who are sensitive to iodine.

An RN first assistant (RNFA) provides the patient with verbal and written information about the upcoming surgery during the preoperative interview. The RNFA describes bowel preparation that begins 24 hours before surgery as specified in written instructions. He or she instructs the patient to adhere to a clear liquid diet the day before surgery and to drink 1.5 oz of phosphosoda laxative mixed with 8 oz water followed by 24 oz clear liquid or water. Patients with cardiac disease are given a low-sodium laxative in place of the phosphosoda laxative. The RNFA explains that the patient may experience a mild sore throat postoperatively from the endotracheal tube used for intraoperative ventilation.

The RNFA assesses the patient's physical condition and limitations (eg, previous hip or knee surgery, arthritis) in anticipation of placing the patient in lithotomy position. The RNFA also assesses the patient's psychosocial, religious, and cultural considerations, which can affect a woman with endometriosis. For example, religious, cultural, and psychosocial beliefs often are displayed in the degree of modesty the woman demonstrates upon physical examination, as well as her behavior throughout the surgical experience. These important considerations should be at the forefront of the minds of all caregivers. The RNFA communicates any patient requirements or physical limitations to perioperative staff members in a collaborative effort to ensure patient safety and quality care and to accommodate the patient's desires. The RNFA also discusses preadmission diagnostic testing (eg, complete blood count, pregnancy test, chest x-ray, electrocardiogram), work restrictions, and postoperative home care. He or she explains the possibility of converting to a laparotomy approach if severe adhesions as a result of previous surgery, extensive endometriosis, or uncontrolled bleeding are encountered or if the patient is unable to tolerate C[O.sub.2] insufflation.

The nurse obtains the patient's signature on the informed consent after all the patient's questions have been answered. The consent form includes both laparoscopic excision of endometriosis and possible laparotomy.

PREOPERATIVE NURSING ASSESSMENT

After the patient's arrival in the surgical suite, the perioperative nurse establishes rapport to build a trusting relationship. The circulating nurse properly identifies the patient verbally and by using the patient's medical record and identification bracelet. The nurse also inquires about current medications and allergies, including those to latex, povidone-iodine, or shellfish. The circulating nurse performs a systems assessment, noting skin rashes, bruises, and lesions. The nurse assesses for the risk of malignant hyperthermia. He or she reviews the patient's understanding of pain management options and describes use of the zero to 10 pain rating scale. The circulating nurse determines whether the patient's lifestyle patterns (eg, tobacco, drug, or alcohol use; eating disorders; physical abuse) will affect the perioperative experience. In planning for the placement of the electrosurgical unit (ESU) dispersive pad, the nurse reviews the written history and physical examination performed by the physician, which should be present on the chart, noting previous surgical interventions and the presence of metal implants. The circulating nurse validates the patient's NPO status and that the informed consent form has been signed properly and witnessed before the patient receives preoperative sedation. The circulating nurse documents the information in the patient's medical record and initiates a care plan specific to the patient and proposed procedure (Table 2).

After IV access has been obtained, the preoperative nurse administers preoperative IV antibiotics as ordered by the surgeon and documents this on the patient's record. The circulating nurse then reviews diagnostic test and laboratory results to ensure that all are within normal limits. He or she reports any abnormalities to the surgeon and anesthesia care provider before surgery.

PREPARATION FOR SURGERY

The surgical team consists of a circulating nurse who assumes the role of team leader; scrub person; first assistant (eg, physician, RN); anesthesia care provider; and primary surgeon. The role of the RNFA in laparoscopic excision of endometriosis includes

* identifying anatomy;

* inserting trocars;

* providing good exposure of the surgical site for the surgeon;

* providing retraction and countertraction of tissue, organs, and endometrial implants;

* helping with resection; and

* ensuring homeostasis.

An RNFA also may perform intracorporeal and extracorporeal suturing and knot tying.

The circulating nurse coordinates the room setup and equipment for the operative laparoscopy, anticipating potential problems and preparing to rapidly convert to an open procedure should it be necessary. Supplies should be gathered in advance to ensure rapid availability, if required. The circulating nurse also oversees coordination of the equipment and instrumentation (eg, videoscopic camera, laparoscope, light source cord, insufflation tubing, C[O.sub.2] source, ultrasonic scalpel).

Induction of anesthesia. Upon entering the OR suite, the circulating nurse and anesthesia care provider help the patient move from the stretcher to the OR bed. In most instances, the patient already has received preoperative medication in an effort to lower her anxiety level and promote relaxation. The circulating nurse secures the safety strap just above the patient's knees. The anesthesia care provider then further sedates the patient intravenously.

The circulating nurse or RNFA assists with induction of anesthesia by applying cricoid pressure, if needed. It is important to remain present at the patient's side until adequate anesthesia and maximum ventilation is achieved and the anesthesia care provider confirms tube placement.

Patient positioning. The circulating nurse and RNFA place the patient in the supine position with her arms tucked at her sides. The circulating nurse checks the patient's arm, elbow, and finger positions to avoid injury or ulnar nerve compression. Together the circulating nurse and RNFA raise the patient's legs and place them in padded stirrups. The circulating nurse and RNFA ensure that the patient's circulation is not compromised by evaluating the bilateral posterior popliteal, posterior tibial, and dorsalis pedis pulses. They then secure the patient's legs in the stirrups with padded straps. The circulating nurse documents this on the OR record. The anesthesia care provider lowers the foot piece of the bed. The nurse places the ESU dispersive pad on a nonbony area and cleanses the patient's abdomen, perineum, and vagina according to the surgeon's preference.

SURGERY

The scrub ,person and RNFA drape the patient with sterile towels and impervious drapes. The surgeon makes a supraumbilical incision through which he or she inserts a large trocar assembly. After puncturing the peritoneal cavity, the surgeon removes the trocar, leaving the port in place, and insufflates the patient's abdomen with C[O.sub.2] to approximately 14 mm Hg to 16 mm Hg so that a pneumoperitoneum is achieved. He or she then introduces the laparoscope into the port. The surgeon makes three additional suprapubic incisions and inserts working ports through which additional instruments can be inserted to aid in retraction, resection, and dissection. Upon inspection of the pelvic cavity, the surgeon not only diagnoses the stage of the endometriosis, if present, but he or she also determines the course of treatment. Some surgeons prefer to use the ultrasonic scalpel to resect the endometrial implants rather than using electrosurgery (Figure 4). With the ultrasonic scalpel, cutting and hemostasis can be achieved with minimal lateral thermal damage to other tissue. The scalpel blade vibrates longitudinally at 55,000 cycles per second, transferring mechanical energy to tissue. No electricity is passed to or through the patient. Electrical energy is transferred to mechanical motion. The ultrasonic waves travel to the tip of the blade where maximum motion occurs, cutting and coagulating tissue simultaneously. This is achieved by protein denaturation, which forms a sticky coagulant, resulting in coagulation of vessels. (11) Recently, this has enabled the surgeon to totally excise the affected areas in the anterior and posterior cul de sac and the pelvic wall areas. This also allows dissection of the peritoneum directly over vital structures, such as the ureters, without causing damage to the underlying structure.

[FIGURE 4 OMITTED]

The surgeon grasps the tissue to be resected with blunt grasping forceps and employs the ultrasonic scalpel with the bump and slide technique (Figure 5). The ultrasonic waves assist in establishing the proper plane of dissection, resulting in safer dissection around vital structures. When using any instrumentation through the laparoscope, the tip of the surgical instrument must be visualized at all times to avoid injury. The cutting surface on both sides of the blade is used to resect the implant. When inside the proper plane, the curved blade helps to form a circular incision around the endometrial implant for a more precise dissection. The surgeon can use a laparoscopic kitner (ie, peanut) dissector to bluntly dissect the implant away from underlying vital structures. He or she then can obtain hemostasis by using the tip of the ultrasonic scalpel to coagulate tissue alone or in conjunction with the bipolar forceps. (12)

[FIGURE 5 OMITTED]

Resection of endometrial implants. The laparoscopic appearance of endometrial implants varies depending on the location and the stage of endometriosis. For example, implants that present in the posterior cul-de-sac often appear pigmented, even resembling a herpetic lesion. These usually are the result of extensive disease that has not been treated previously. Often these are found in conjunction with endometriomas. It is possible to resect these using an ultrasonic scalpel, which most often is followed by coagulation of the cyst wall using the bipolar forceps.

Endometrial implants that are viewed on the pelvic walls and the anterior cul-de-sac may resemble that of a nonpigmented scarring or blanched area. Using blunt forceps, the surgeon grasps the tissue and resects it with the bump and slide technique. (13) After grasping tissue near the lesion, the surgeon uses the lip of the ultrasonic scalpel to establish the proper plane of dissection. When in the plane, the bilateral cutting edges of the ultrasonic scalpel facilitate transection while the blunt nose provides coagulation. Char is reduced, and thermal energy is minimized. (14) A laparoscopic peanut dissector then can be used to bluntly dissect the implant away from underlying vital structures.

After completion of the procedure, the surgeon ensures that hemostasis has been achieved, and then he or she withdraws the laparoscope. The surgeon then releases the C[O.sub.2] from the abdominal cavity. The RNFA assists by gently pressing on the patient's abdomen. Minimizing retained C[O.sub.2] helps reduce or eliminate postoperative shoulder pain caused by retained C[O.sub.2].

The RNFA closes all skin incisions with a running 4-0 monofilament absorbable subcuticular suture. He or she then may inject a long-acting local anesthetic (eg, bupivacaine) at the port sites to help decrease postoperative pain. The scrub person and RNFA then cleanse the skin of residual prep solution and apply self-adhesive wound approximating strips to the port incisions.

Before the anesthesia care provider reverses the anesthesia, the circulating nurse and RNFA simultaneously lower the patient's legs and ensure the presence of pedal pulses. The circulating nurse removes the ESU dispersive pad and inspects the site thoroughly to rule out skin breakdown and bums. The anesthesia care provider, circulating nurse, and RNFA transport the patient to the postanesthesia care unit (PACU). The PACU nurse assesses and closely monitors the patient's respiratory, cardiac, vascular, and psychosocial status. He or she also coordinates the patient's pain management and antiemetic control on orders from the surgeon or anesthesia care provider. The patient remains in the PACU for one to two hours and then is transported to the day surgery unit where she must pass a voiding trial and tolerate liquids before discharge. The patient is discharged with oral analgesics, oral antibiotics, and possibly an antiemetic. The average time that patient's spend at the hospital is six to 12 hours.

POSTOPERATIVE CONSIDERATIONS

The day surgery nurse reinforces discharge instructions to the patient, including that on postoperative day one she may experience a sore throat from having had an endotracheal tube in place during surgery. He or she also explains that the incisions were closed with absorbable suture material and covered with self-adhesive wound approximating strips. The nurse explains that the patient should report

* bleeding or erythema at the trocar sites,

* fever,

* prolonged nausea, and

* vomiting.

These problems should be reported to rule out postoperative complications, or the surgeon may determine that one or more medications should be substituted or discontinued. Although overnight hospitalization is not anticipated, the nurse explains to the patient that an overnight stay is possible if the patient experiences severe nausea or inability to void or if the surgeon had to convert from the laparoscopic approach to open laparotomy.

Depending on the extent of disease, many women are given an injection of leuprolide postoperatively. This does not affect postoperative recovery but reduces circulating estrogen to menopausal levels, effectively reducing the possibility of new endometrial implants developing, and assists in alleviating pelvic pain. (15) Estrogen levels will return to normal approximately four to eight weeks after the injection. If the patient experiences extreme hot flashes, a small dosage of estrogen may be prescribed during that time. Leuprolide is available in 3.75 mg and 11.25 mg doses. Studies show that leuprolide improves the resolution of endometriosis, and post-operative recovery is the same as for patients who had basic operative laparoscopy. (16)

The nurse discharging the patient provides her with written postoperative instructions and reinforces perioperative teaching. Although recovery time varies, many patients return to sedentary employment in two days. The nurse instructs the patient to avoid lifting anything in excess of 20 lbs until all incisions are healed, which usually is in 10 to 14 days. Pelvic rest, which includes abstinence from intercourse and avoiding the use of tampons or douches, is advised for one week.

CASE STUDY

Ms H is a 34-year-old female gravida one, para one (ie, has been pregnant once and gave birth to one live infant) who presented with complaints of dysmenorrhea, menorrhagia, diarrhea, and painful bowel movement during the time of her menstrual cycle. The patient was referred to the surgeon's office where an RNFA took a thorough history. Ms H reported having had dysmenorrhea as a teenager, stating that she routinely was incapacitated for the first two days of her menstrual cycle, which was accompanied by menorrhagia and clotting. She stated that multiple examinations throughout her youth revealed no abnormalities; however, the pain persisted even after the birth of her child.

The surgeon performed a physical examination and noted extreme tenderness in the posterior uterine cul-de-sac upon pelvic examination. A transvaginal ultrasound was attempted in the surgeon's office, but it aborted because the patient was unable to tolerate the procedure due to severe tenderness. A subsequent CT scan revealed a 4-cm left ovarian mass, consistent with a hemorrhagic cyst or endometrioma.

The RNFA provided Ms H's preoperative teaching in the surgeon's office. The nurse gave the patient written orders to obtain a preoperative complete blood count and pregnancy test. The RNFA explained to Ms H how to perform a self-bowel preparation and gave her written instructions to ensure accurate compliance. The prep consisted of a phosphosoda enema and a clear liquid diet the day before surgery, and the nurse instructed Ms H to remain NPO after midnight the evening before surgery. Ms H was informed that a hospital staff member would be contacting her the day before surgery with details regarding arrival time to the hospital.

Upon arrival at the hospital, a perioperative nurse greeted Ms H. While shaking her hand, the nurse observed Ms H's hand to be hot and sweating. The nurse commented that the patient's hand was very warm in contrast to her own. The patient admitted being anxious. The circulating nurse then reviewed Ms H's procedure, provided emotional support, and answered her questions. Ms H expressed immediate relief. The nurse placed an IV catheter in Ms H's left forearm and started an infusion of lactated Ringer's solution. Additionally, the nurse infused 1 gm of IV ampicillin sodium.

In the OR, Ms H underwent a diagnostic laparoscopy. This confirmed not only a left ovarian endometrioma but also severe pelvic adhesions involving both fallopian tubes and ovaries. There were a significant number of endometrial implants in the posterior uterine cul-de-sac, bilateral pelvic walls, and rectum. The surgeon diagnosed the patient with stage IV endometriosis. The surgeon performed careful resection of the implants and lysis of adhesions using the ultrasonic scalpel. Ms H was discharged home later that same day after voiding and tolerating liquids without nausea or vomiting. On the first postoperative day, the patient was able to pass flatus and tolerate a regular diet. Ms H explained that her pain was well controlled with prescriptive oral analgesics until postoperative day three, after which over-the-counter anti-inflammatory medications provided adequate pain relief. Ms H's incisions were well healed by her two-week postoperative visit. She returned to her normal routine and activity level, including work as a nurse, belly-dancing, and caring for her five-year-old son. Ms H was treated with postoperative GnRH agonists for six months and returns to her physician's office monthly for the injections. Ms H is pleased with the results of her surgery and is relieved finally to have been diagnosed and treated successfully for endometriosis.

SUMMARY

Endometriosis can be an excruciating disease that often can lead to infertility. It can affect the menstrual cycle, reproductive organs, and other organs in the pelvic area. The resulting pelvic pain can interfere with a woman's ability to perform her activities of daily living. There now are several effective treatments for endometriosis; however, definitive diagnosis is imperative so that a specific plan of treatment can be established to battle this debilitating disease.

Examination

ENDOMETRIOSIS--A MISSED MALADY

1. Endometriosis is a disease that affects

a. postmenopausal women.

b. girls and women in their reproductive years.

c. women experiencing menopause.

d. girls who have not begun menses.

2. According to a 1998 study of 4,000 women conducted by the Endometriosis Association (EA), most women suffered for an average of--years before identifying the root cause of their discomfort.

a. three

b. five

c. seven

d. nine

3. According to the EA, recent research has indicated that women with endometriosis are at greater risk for cancer.

a. true

b. false

4. --, which affects one in three women with endometriosis, may be the only presenting symptom.

a. Breast tenderness

b. Irregular bleeding

c. Infertility

d. Pelvic pain

5. Endometriosis can be detected by

a. magnetic resonance imaging.

b. laparoscopy.

c. ultrasound.,

d. computed tomography scan.

6. Danazol can cause implants to shrink by blocking follicle-stimulating hormone and luteinizing hormone at the pituitary gland, keeping progesterone and estrogen levels low, resulting in cessation of ovulation and the menstrual cycle.

a. true

b. false

7. To achieve pneumoperitoneum, the patient's abdomen is insufflated with carbon dioxide (C[O.sub.2]) to approximately

a. 8 mm Hg to 10 mm Hg.

b. 10 mm Hg to 12 mm Hg.

c. 14 mm Hg to 16 nun Hg.

d. 18 mm Hg to 20 mm Hg.

8. The ultrasonic scalpel is used for dissection because it

a. produces a homogeneous coagulative effect without vaporization occurring.

b. passes electricity safely through the patient.

c. creates maximal thermal damage to fully excise endometrial implants.

d. transfers electrical energy to mechanical motion.

9. After the procedure is completed, the surgeon and RNFA evacuate C[O.sub.2] to reduce or eliminate postoperative

a. shoulder pain.

b. hemorrhage.

c. nausea and vomiting.

d. thrombophlebitis.

10. Although recovery varies, many patients return to sedentary employment in

a. two days.

b. two weeks.

c. 10 to 14 days.

d. three weeks.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. AORN recognizes these activities as continuing education for RNs. This recognition does not imply that AORN or the American Nurses Credential Center approves or endorses products mentioned in the activity. AORN is provider approved by the California Board of Registered Nursing, Provider Number CEP 13019.

Answer Sheet

ENDOMETRIOSIS--A MISSED MALADY

Please fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail to:

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Signature--

Event #03049 Session #7232

Contact hours: 3

Fee: Members $15; Nonmembers $30

Program offered February 2003. The deadline for this program is Feb 28, 2006.

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Learner Evaluation

ENDOMETRIOSIS--A MISSED MALADY

The following evaluation is used to determine the extent to which this Home Study Program met your learning needs. Rate the following items on a scale of 1 to 5.

OBJECTIVES

To what extent were the following objectives of this Home Study Program achieved?

(1) Explain how endometriosis affects a woman's normal menstrual cycle.

(2) Identify the stages of endometriosis.

(3) Describe the treatment options available to women with endometriosis.

(4) Discuss the perioperative course of a patient undergoing laparoscopic excision of endometriosis.

(5) Describe how the ultrasonic scalpel is used to resect endometrial implants.

PURPOSE/GOAL

To educate the perioperative nurse about endometriosis and its surgical treatment.

CONTENT

(6) Did this article increase your knowledge of the subject matter?

(7) Was the content clear and organized?

(8) Did this article facilitate learning?

(9) Were your individual objectives met?

(10) How well did the objectives relate to the overall purpose/goal?

TEST QUESTIONS/ANSWERS

(11) Were they reflective of the content?

(12) Were they easy to understand?

(13) Did they address important points?

LEARNER INPUT

(14) Will you be able to use the information from this Home Study in your work setting?

a. yes b. no

(15) I learned of this Home Study via

a. the Journal I receive as an AORN member.

b. the Journal that I obtained elsewhere.

c. the AORN web site.

d. SSM Online.

(16) What factor most affects whether you take an AORN Journal Home Study?

a. need for contact hours

b. price

c. subject matter relevant to current position

d. number of contact hours offered

What other topics would you like to see addressed in a future Home Study Program? Would you be interested or do you know someone who would be interested in writing an article on this topic?

Topic(s):--

Author name(s) and address(es):--

NOTES

(1.) M L Ballweg, The Endometriosis Sourcebook (Milwaukee, Wis: The Endometriosis Association, 1999) 127-129.

(2.) T P Canavan, L Radosh, "Managing endometriosis: Strategies to minimize pain and damage," Postgraduate Medicine 107 (March 2000) 213-214.

(3.) Inner Peace From Endometriosis (Lake Forest, Ill: TAP Pharmaceuticals, Inc, 2000) 120-121.

(4.) Ballweg, The Endometriosis Sourcebook, 141-143.

(5.) Ibid.

(6.) Ibid.

(7.) How Can I Tell If I Have Endometriosis? (Milwaukee, Wis: The Endometriosis Association, 1999) 142-144.

(8.) Ibid.

(9.) "Ultrasonic and electrosurgical products: Harmonic scalpel," Ethicon EndoSurgery, http://www.eesonline.com/ultrasonic.jsp (accessed 10 Dec 2002).

(10.) A J Mangram et al, "Guideline for prevention of surgical site infection, 1999: Hospital infection control practices advisory committee," Infection Control and Hospital Epidemiology 20 (April 1999) 250-280.

(11) Ibid

(12.) Ibid.

(13.) Ibid.

(14.) Ibid.

(15.) "Product information," LupronDepot, http://endofacts.com/expect/productinfo.htm (accessed 10 Dec 2002).

(16.) Ibid.

Marti M. Taylor, RN, CNOR, CRNFA, is an independent practitioner in Houston.

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COPYRIGHT 2003 Gale Group