A growing number of practitioners are beginning to recognize the benefit of conscious pain mapping, a procedure in which the patient helps identify the source of her pelvic pain. The procedure is especially useful when other types of evaluation are not successful in identifying the causes of pain.

According to Andrew Cook, MD, an Endometriosis specialist and Director of the Athena Institute, conscious pain mapping is also referred as Patient Assisted Laparoscopy (PAL).¹ This is a procedure which uses a small laparoscope while the patient is awake, so that she can help the surgeon find the cause of her pain.

Dr. Cook finds that the procedure provides "useful information with minimal discomfort to the patient." However, this was not always the case. There were two major hurdles that had to be overcome before this was a worthwhile procedure: the quality of the instruments and the right combination of anesthesia. Dr. Cook feels that a "procedure that causes the patient a significant amount of pain is unacceptable."

Most experts in pain mapping feel that the procedure should be performed in the operating room with an Anesthesiologist present. Using a combination of local numbing medicine with ultra-short acting general anesthetic, the patient can be put to sleep briefly. While she is under, the microlaparoscope and other necessary instruments are inserted. She is then awoken so she can participate in the procedure.

Dr. Cook stresses that pain mapping should not be performed in-office without an Anesthesiologist, using just local pain medicine and sedation. He says, "this approach hurts! To perform an adequate laparoscopy, the operating table is tilted so that the head is down and the feet are up (Trendelenberg position). This is done to help facilitate moving the bowel out of the pelvis and into the upper abdominal cavity. All of the intestines must be above the belly button to see the entire pelvis. At best this is a difficult procedure while the patient is awake. I feel that performing PAL in the office setting does not provide the necessary support system if and when complications arise. The primary motivation behind performing PAL in the office without anesthesia is cost saving. In my opinion, performing surgery without the necessary backup while subjecting the patient to necessary pain is unacceptable."

Traditional diagnostic laparoscopy performed under general anesthesia can be a very useful diagnostic test. Most of the time, this procedure identifies, and allows treatment of, the disease which is causing the pain. There are, however, situations where the cause of the pain is not visible. The incidence of these "false negative" scopes is reported in the literature to be as high as 33% of all diagnostic laparoscopes. Unfortunately, all too often, these patients are then told that she has no physical cause for her pain. PAL can uncover sources of pain that are not apparent at traditional laparoscopy.

For instance, Dr. Cook's experience has demonstrated, and published studies have shown, that a significant number of normal-appearing appendices are causing pain. When the appendix is removed it resolves the pain and often reveals chronic appendicitis when evaluated under the microscope by the pathologist. "Some physicians believe that adhesions (scar tissue) do not cause pain," said Dr. Cook. "Not long ago I was performing a PAL. The patient had adhesions. As I used the micro-laparoscopic probe to pull on these adhesions, the pain which the patient experienced day to day was reproduced. One of the elder statesman of gynecology was in the operating room observing the PAL. When he saw this he said 'in 35 years of practicing medicine, I never thought that adhesions caused pain, but I can see now that I was wrong.'"

Abdominal wall pain is another source of pain that PAL experts like Dr. Cook have discovered while performing the procedure. "There are a set of nerves known as the ilioinguinal and iliohypogastric nerves located in the abdominal wall near the crest of the hip bone. This nerve can become damaged or entrapped as a result of previous surgery or even pregnancy. Patients usually come in saying that their ovaries hurt. It is difficult for the patient and physician alike to tell the difference between ovarian pain and pain caused by this nerve. This nerve pain can be blocked. Surgical staples can cause pain. While these usually do not cause pain, I had a patient with staples very close to the ureter (the tube that carries urine from the kidney down to the bladder). Every time I pushed on the staples, it duplicated her pain. I removed the staples and her pain resolved," said Dr. Cook.

Without a doubt, this procedure can often help the physician, the patient and her family better understand the cause of her pain.

Dr. Cook further states that "PAL has increased our understanding of Endometriosis and pelvic pain. Endometriosis has many visual appearances. Red and vascular lesions are the most painful, clear and white lesions cause medium intensity pain and the 'classic' black lesions are the least painful. This demonstrates the importance in identifying and treating 'atypical' Endometriosis. We have also learned that the pain associated with Endometriosis extends out beyond the border of the visible lesions of Endometriosis. We know from studies using scanning electron microscopy that 'normal' appearing peritoneum (the tissue that lines the inside of the body on which Endometriosis grows) often contains Endometriosis. From these facts we can conclude that effective treatment of Endometriosis requires excision or vaporization of an area which extends well beyond the visible Endometriosis. If only the visible Endometriosis is removed at surgery, the patient is at an increased risk of having persistent pain (from microscopic Endometriosis) and thus incorrectly labeled as complaining of pain without an apparent physical cause of the pain."

At a 1997 meeting of ACOG in New Orleans, Oscar D. Almeida, Jr., M.D., a Clinical Assistant Professor of OBGYN at the University of South Alabama College of Medicine in Mobile presented a study co-authored by John M. Val-Gallas, M.D., a Mobile OBGYN in private practice, of their first 50 pain mapping cases.² Patients in the study had failed conservative therapy for chronic pelvic pain including oral contraceptives, nonsteroidal anti-inflammatory medications and antibiotics.

Beginning with a standard diagnostic exam, Dr. Almeida and Dr. Val-Gallas systematically probed every part of the pelvic cavity, testing patient response to any lesions identified during the initial examination. After re-probing to confirm painful areas, severe Endometriosis and adhesions were treated with operative laparoscopy under general anesthesia.

Less severe Endometriosis lesions and adhesions were successfully treated immediately following diagnosis after applying local anesthetic, according to Dr. Almeida. Endometriosis was identified in 84% of the study subjects, of which 29% were treated under local anesthesia.

Drs. Almeida and Val-Gallas identified the appendix as the source of pain in 13 (26%) of the patients in the study. Following laparoscopic appendectomy, nine of the appendices were shown to have pathologies including acute appendicitis, lymphoid hyperplasias and fecaliths. The remaining four appendices had periappendical adhesions, as did three of the diseased organs.

Dr. Almeida stated that "conscious pain mapping enabled us to thoroughly evaluate the appendix." He encouraged gynecologists to pay greater attention to the diagnosis and treatment of the abnormal appendix.

In a study entitled "Minilaparoscopic Pain Mapping in Women with Endometriosis with and without Pelvic Pain," Drs. Marconi, Zupi, Solima, Santi, Lanzi and Romanini at the University of Rome/Fatebenefratelli Hospital in Italy described pain mapping during minilaparoscopy in women with Endometriosis with and without pelvic pain.³  Subjects were 18 women with (group A) and 21 without pelvic pain (group B). After visualization of the entire abdominal cavity and localization of Endometriosis lesions and adhesions, authors touched and grasped utero-ovarian ligaments, bowel, and omentum; moved the uterus with a manipulator; touched and grasped the tubes, and distended them with dye; touched and grasped round and uterosacral ligaments; and touched, grasped, and took biopsy specimens of peritoneal Endometriosis lesions, adhesions, and normal peritoneum. Patients recorded pain level using a VAS. The highest level of pain was recorded in group A when authors touched and grasped uterosacral ligaments with endometriotic implants or dense adhesions and during chromopertubation. No statistically significant differences in pain level and quality was recorded between groups when authors touched and grasped ovaries, omentum, and bowel and peritoneal Endometriosis lesions. In 14 (77%) women in group A, referred pain was evoked and localized topographically.

Authors concluded that "minilaparoscopy is effective in detecting origin of pain and localizing its origin. Endometriosis lesions are painful when located on the uterosacral ligament and when they cause dense adhesions or visceral stretching."

I spoke at length with a patient of Dr. Cook's, Carey.  She told me her pain mapping experience was "a very positive one. It is an ideal tool to help locate an area of pain." Carey went on to recount her experience: "I was first sedated, then brought back around when the procedure was underway. I awoke in a slight fog to hear Dr. Cook asking me "does this hurt?" He was tugging or touching different areas and organs inside of me. I was able to feel what he was doing and even tell him what I was feeling and the amount of discomfort it was causing. It wasn't really painful, just an uncomfortable feeling. When he got to the left side of my pelvic cavity, the side I was having the nerve pain on, he touched what appeared to be a white patch of tissue on the upper abdominal wall. It was excruciating to be touched, but they gave me more sedation until the pain subsided, and when I re-awakened, I didn't even remember the previous few minutes. He touched it three times to make sure it was the area that was painful, and it was."⁴

Carey said "if he hadn't used the pain mapping procedure, he wouldn't have known how painful that weird-looking area was. It was an educational experience for me, and even though I was afraid that I might feel everything that was done, the pain that I did feel was quickly forgotten after being sedated to make me comfortable again. If it wasn't for watching the video of the procedure, I would not have remembered any of it."

Carey recommends this procedure to pinpoint problems that might not be found otherwise.

According to renowned reproductive endocrinologist, Mark Perloe, MD, "Microlaparoscopy is in its infancy. Its' primary uses are for diagnostic surgery. But, as new instruments become available our capabilities will increase. I am very excited to offer my patients microlaparoscopy and truly believe this technique will simplify and reduce the cost of diagnosing of the cause of pelvic pain and infertility."⁵ Dr. Perloe offers a 2 minute quicktime video demonstrating microlaparoscopic lysis of adhesions on his website at: http://www.ivf.com/microlappg2.html

For more information:
Please visit "Ask Dr. Cook" online at www.drcook.com. Author recognizes with thanks input provided by Dr. Cook, his patient Carey, and the invaluable information found within his website.

References:
(1) http://www.drcook.com
(2) Medical Tribune: Internist & Cardiologist Edition 38(3): 1997. © 1997 Jobson Healthcare Group
(3) "Minilaparoscopic Pain Mapping in Women with Endometriosis with and without Pelvic Pain" by D Marconi, E Zupi, E Solima, K Santi, G Lanzi, C Romanini. University of Rome "Tor Vergata," Fatebenefratelli Hospital, Rome, Italy. Copyright © 1998 - 2000 Imagyn Medical Technologies, Inc.
(4) Carey B., Co-Founder of MENDO. For more information, please visit: http://www.geocities.com/HotSprings/Spa/8449/
and http://www.geocities.com/HotSprings/Spa/8509/
(5) Mark Perloe, MD, Director of Georgia Reproductive Specialists, is a world opinion leader on Endometriosis and infertility. Please visit his award winning infertility website at www.ivf.com or contact his offices at (404) 843-2229.

Copyright © 2001-2003 by Heather C. Guidone.   All rights reserved.  Do not reproduce without express permission.  Publication Date:  June 2001.  Revision Date: February 2003.  Disclosure of financial considerations from sources associated with this publication: none.