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Surgical treatment options for endometriosis

Diagnostic laparoscopy with or without treatment.

This is a technique in which a thin telescope is inserted into the abdomen to inspect the pelvic organs. A 1 cm incision is made within the umbilicus and the abdomen is filled with gas. This distention allows us to inspect the pelvic organs to confirm the diagnosis of endometriosis.

Another small incision is made close to the bikini line to insert a second surgical instrument to manipulate the pelvic organs. If any endometriosis is seen then a further incision is made to allow treatment to the affected areas.

We then remove or sometimes burn the affected areas. Conservative, laparoscopic surgery, depending on the severity of the disease, aims to excise, ablate or vaporize the endometrial tissue. This can be achieved using a number of different energy sources (diathermy/ plasma jet/harmonic scalpel). The endometriosis may be ablated or excised. It is not clear exactly what the best option for treatment is. At OBGYN matters we aim to excise all the endometriosis wherever possible.

Patients may be discharged on the same day, though in some cases an overnight stay is needed. The duration of stay depends on the extent of the endometriosis, the length of the operation (30 mins – 3hrs) and the amount of post-operative pain. It is important to realize that extensive surgery can be achieved through keyhole surgical techniques. 

Endometriosis in the pelvis on the Utero-sacral ligament


 

Endometriosis is excised using mono-polar scissors


 

Endometriosis is fully excised


Endometriotic cysts (endometrioma)

This is the commonest cyst in the ovary that requires treatment. Endometriomas can cause pain as they stretch the capsule of the ovary and often also tether the ovary to the back of the womb or the pelvic side-wall. They damage the ovary thereby decreasing the ovarian reserve and reducing fertility. They may also cause problems during fertility treatment as they often interfere with egg retrieval.


Repeated surgery on endometriomas will further decrease ovarian reserve and thus fertility. These ovarian cysts can either be treated by cyst removal (cystectomy) or cysts destruction (drainage and coagulation).

There is controversy over which type of surgery is better for endometriomas.

The cyst may be drained and the inside coagulated. This destroys less ovarian tissue and may be better for long-term fertility. Unfortunately the risk of the cyst coming back is higher and unless women wish to be pregnant immediately, it is necessary to continue with some form of hormonal treatment to avoid recurrence.

Alternatively, the cyst can be drained stripped away from the ovary and removed (cystectomy). This reduces the risk of the cyst coming back, but there is a possibility of more ovarian tissue being destroyed so this may be worse for long-term fertility.

As yet there is no clear evidence base to guide us.

A pre-operative measurement of Anti-Mullerian Hormone (AMH) may be helpful in assessing ovarian reserve and in planning the type of surgery that is performed. We also feel that the surgery should be individualized to each patient depending on the exact circumstances.

This decision is made in discussion with the patient taking into account their desire for having a baby.

In women with very severe endometriosis the surgery may become very complex. This should only be carried out by surgeons who have a specialist interest in endometriosis. Mr Barnick is the lead laparoscopic surgeon and runs a British Society of Gynaecological Endoscopy (BSGE) registered Tertiary Referral Centre for Endometriosis.

Additional imaging in the form of an MRI will be required to assess the extent of the endometriosis and in particular the severity of bowel or bladder involvement.

Your case will be discussed at a Multi-Disciplinary Team Meeting (MDT). The risk of damage too, or removal of bowel will be assessed. Sometimes it is preferable to perform sutgery together with the bowel surgeons or Urologists or to perform two interval surgeries with medical menopausal treatment in the interim.

Risks of Surgery:

All surgery has some risks. In this particular instance these depend on the type of surgery and extent of endometriosis. The risk of your particular surgery will be discussed with you before the surgery and during the consent process.

All operations have risks associate with:

  • Anaesthesia
  • Bleeding
  • Infection
  • Deep vein thrombosis. 

A laparoscopy involves insertion of instruments into the abdomen. This alone carries a risk o5 1: 5000 of damage to internal organs such as the bladder, bowel or major blood vessels.

Once we start to remove endometriosis then we need to use some form of energy source within the abdominal cavity and we may need to operate in anatomically very difficult areas. The risk of complications goes up.

In surgery for mild endometriosis the risk of major complications requiring a laparotomy occurs in about 1 in 1000 cases.

In surgery for more severe endometriosis the risks may be as high as 1: 10 as there are increased risks of:

  • Damage to bladder and ureters.
  • Damage to bowel.
  • Damage to nerves and blood vessels
  • Delayed complications including bowel injury and haematoma (collection of blood in the abdomen).

If any of these complications occur, a laparotomy (open surgery through a larger cut) may be needed to correct the damage or to stop bleeding.