Surgery

by Ros Wood

Hormonal treatments have no long-term effect on endometriosis, so you may have to undergo surgery in order to treat your disease. Surgery for endometriosis can be very complex, in particular if you also have fibroids and/or adenomyosis, and extensive disease may mean that surgery will involve repair to f.x. the rectum and/or the bladder.

Laparoscopy

A laparoscopy is an operation that uses an instrument known as a laparoscope to:

• diagnose endometriosis
• treat endometriosis
• remove adhesions caused by the disease.

A laparoscope is a thin telescope-like instrument approximately 30 centimetres in length. It is inserted into the pelvic cavity through a small cut near the navel. It has a light source and a lens that light up and magnify the inside of the pelvic cavity, so the gynaecologist can see the organs in the pelvis and any endometriosis present. It usually has a second tube attached along its length. This tube holds the surgical instruments used by the gynaecologist when performing surgical procedures during the operation.

A laparoscopy should not be confused with a laparotomy. A laparotomy is an operation that involves a large (10–15 cm) cut in the abdomen (rather than the small cuts of a laparoscopy). Nowadays, it is used only rarely to treat women with severe endometriosis who cannot be treated with a laparoscopy.

A diagnostic laparoscopy — that is, a laparoscopy performed to diagnose endometriosis — is the ‘gold standard’ (most reliable method) for diagnosing endometriosis [1]. A diagnosis of endometriosis should not be considered unless the endometriosis has been seen during a laparoscopy. Most gynaecologists also insist that a biopsy (sample) of the endometrial tissue be examined by a pathologist before confirming the diagnosis.

Usually, if minimal to moderate endometriosis is found, a diagnostic laparoscopy will be combined with an operative laparoscopy [2, 3, 4, 5]. An operative laparoscopy is a laparoscopy that is performed to surgically remove any endometriotic lesions and adhesions. This means that the endometriosis can be diagnosed and treated at the same time, and only one operation is needed. For this to happen, you must have given your consent to surgical procedures being performed beforehand.

If severe endometriosis involving the bowel or urinary system is found, the operative laparoscopy may be delayed, so the bowel or bladder can be prepared for surgery and specific consent to bowel or urinary surgery obtained.

→ How to survive a bowel preparation

Endometriosis surgery can be complex and difficult, and surgeons need specialised skills and expertise to perform these operations. Many gynaecologists have the expertise to treat minimal endometriosis. However, experienced specialist surgeons are needed for more severe endometriosis, and only a limited number of gynaecologists have the expertise to treat very severe endometriosis.

→ Finding a centre of excellence/endometriosis specialist

Surgical procedures

Endometriosis surgery aims to reduce endometriosis-associated pain by removing all visible endometriosis and any associated adhesions.

The surgical procedures that may be performed during an operative laparoscopy include:

• removal or destruction of endometrial implants
• removal or destruction of ovarian endometriosis (endometriomas)
• removal of adhesions
• removal of deep rectovaginal and rectosigmoid endometriosis
• removal of the uterus (hysterectomy)
• removal of one or both ovaries (oophorectomy)
• surgery of the bowel or bladder
• laparoscopic uterine nerve ablation (LUNA) and presacral neurectomy (PSN).

Surgical techniques

Endometrial implants can be treated using two techniques:

• excision
• coagulation.

Excision
Excision removes endometrial implants by cutting them away from the surrounding tissue with scissors, a very fine heat gun or a laser beam.

The technique does not damage the implants, so the gynaecologist is able to send a biopsy of the excised tissue to the pathologist to confirm that it is endometriosis and not cancer or another condition.

Excision allows the gynaecologist to separate the implants from the surrounding tissue, thus ensuring that the entire implant is removed and no endometrial tissue is left.

Coagulation
Coagulation destroys implants by burning them with a fine heat gun or vaporising them with a laser beam.

When coagulating implants, care must be taken to ensure that the entire implant is destroyed, so it cannot regrow.  Care must also be taken to ensure that only the implant is destroyed, and no underlying tissue, such as the bowel, bladder or ureter, is damaged. The possibility of accidentally damaging the underlying tissue means that most gynaecologists are wary of using coagulation on implants that lie over vital organs, such as the bowel and large blood vessels.

Which technique?
Of the two techniques, excision is more effective, requires more skill, and is more time consuming.

The skill and time required means that it is not used by all gynaecologists. If your gynaecologist does not have the skill to excise all your endometriotic implants, ask to be referred to a gynaecologist who specialises in endometriosis surgery and is skilled in excision.

→ Finding a centre of excellence/endometriosis specialist

The effectiveness of excising endometriotic implants has been shown in two clinical trials. Women who had their implants excised had fewer symptoms 12 months [6] and 18 months [7, 8] after surgery compared with women who underwent a laparoscopy without excision of their implants.

Ovarian endometriosis

The treatment of ovarian endometriosis depends on the type of lesion and its size. Ovarian cysts are often referred to as “endometriomas” and/or “chocolate cysts”.

Superficial implants
Superficial (lying on the surface) ovarian implants can be destroyed by coagulation or vaporisation.

Small ovarian cysts (endometriomas, chocolate cysts)
Small ovarian cysts less than 3 cm in diameter can be punctured and drained. When the inner lining of the cyst has been examined, the lining can be destroyed by coagulation or vaporisation.

Large ovarian cysts (endometriomas, chocolate cysts)
Large ovarian cysts greater than 3 cm in diameter can be excised, or drained and coagulated.

When excising large cysts, the entire cyst is cut away from the surrounding ovary. Some of the adjacent ovarian tissue may be removed with the cyst to ensure that the entire cyst is removed.

When draining and coagulating large cysts, the cyst is opened up and drained. The inner lining of the cyst is then destroyed by coagulation.

Which technique?
It is recommended that large ovarian cysts greater than 3 cm in diameter be excised rather than drained and coagulated [9, 10], and some surgeons feel that cysts larger than 6 cm need to be treated in two steps. Complete excision results in greater improvements in pain and fertility [11, 12], and a lesser risk of recurrence [13].

Adhesions

Adhesions resulting from endometriosis should be removed. They can be excised using scissors, a heat gun or a laser beam.

When cutting adhesions, there is always a risk that the newly-cut edges will form adhesions again. However, preventive measures can be taken to minimise this risk. This tendency to form and reform adhesions is much greater in some women than others. It may be such a problem that further surgery to cut adhesions is not recommended.

→ Adhesions and endometriosis

Deep rectovaginal and deep rectosigmoid endometriosis

Surgery for deeply infiltrating endometriosis is usually only considered if it is causing symptoms or is likely to cause symptoms in the future. If you have rectovaginal deeply infiltrating endometriosis without symptoms, it is usually left alone and monitored, because such endometriosis rarely worsens or becomes symptomatic [14]. However, if the endometriosis is constricting the bowel or ureter (tube between bladder and kidney) and could later obstruct it, the endometriosis should be removed.

If surgical treatment is deemed necessary, all the deep lesions must be excised in one operation to avoid the need for further surgery [3]. Such surgery is difficult, complex and can lead to major complications [15]. It is essential that you discuss thoroughly with your gynaecologist what surgical procedures may be performed, so you can prepare yourself and give your consent.

If you are contemplating surgery for deeply infiltrating endometriosis, it is strongly recommended that you be referred to a multidisciplinary centre that specialises in endometriosis surgery. Such centres offer the full range of treatments, and highly trained and experienced gynaecological surgeons, bowel surgeons, urinary surgeons and pain specialists.

→ Finding a centre of excellence/endometriosis specialist

Deeply infiltrating endometriosis surgery may involve removal of the uterosacral ligaments and the upper part of the back of the vagina, along with the deep lesions. The uterus and ovaries may or may not be removed. If the endometriosis has infiltrated the wall of the bowel, bladder or ureters and has caused or could cause damage, part of the bowel, bladder or ureters may have to be removed and the area repaired.

If your surgery may involve the bowel or urinary system, the surgery will be discussed and planned beforehand. You will need to undergo preoperative treatment to prepare the bowel or urinary system for the surgery. You will probably also need to undergo additional tests and investigations before the operation. During the surgery, your gynaecologist will work closely with a bowel surgeon or urinary surgeon.

→ How to survive a bowel preparation

Removal of uterus (hysterectomy) and ovaries (oophorectomy)

Removal of the uterus or ovaries should be considered only if your endometriosis cannot be treated in any other way, and you do not want to have children.

If the uterus is removed, all the endometriosis should be removed at the same time [16] otherwise your symptoms may quickly recur.

Hysterectomy and removal of both ovaries may result in greater pain relief and less likelihood of repeat surgery than a hysterectomy and retention of both ovaries [17].

If a hysterectomy is performed, the cervix should be removed as well. Retaining the cervix often results in ongoing pain due to endometriosis in the cervix or utero-sacral ligaments [10].

Hysterectomy and removal of part of the lower bowel has been shown to be an effective treatment for women with rectovaginal endometriosis. It led to less pain and a better quality of life [18].

→ Hysterectomy: some definitions

Laparoscopic uterine nerve ablation and laparoscopic presacral neurectomy

Laparoscopic uterine nerve ablation (LUNA) and laparoscopic presacral neurectomy (LPSN) are two procedures that involve cutting the nerves from the uterus to the brain in order to relieve chronic pain.

A review of the two procedures showed that they have limited value for alleviating pain [19].

Uterine nerve ablation did not provide any additional pain relief when combined with laparoscopic treatment of endometriosis. However, presacral neurectomy did provide better pain relief than laparoscopic treatment alone. Complications, such as chronic constipation, were more common in the women who had undergone presacral neurectomies and laparoscopic surgery. Ask your surgeon if they intend performing either of these procedures as part of your surgery, and, if so, what their success rate is.

The operation

An operative laparoscopy can take anything from half an hour to six hours or more, depending on the severity of your endometriosis and how much endometriosis needs to be removed.

Hospital routines and practices vary. The information below is only a guide to what may happen when you have your laparoscopy. Ask your gynaecologist and hospital if they have a patient information brochure that explains the routines and practices of the hospital.

You should not have anything to eat or drink for at least six hours before your operation. If there is any possibility that you may need bowel surgery, you will be asked to have a bowel preparation before your operation, so the surgery can be carried out safely. This involves drinking a solution that cleans out your bowel.

→ How to survive a bowel preparation

You will be admitted to the hospital a short time before your surgery is scheduled. You will be asked about your general health, any medications you may be taking, and any previous operations you may have had. They will also take your blood pressure and pulse, possibly give you a pubic shave, and give you a surgical gown to wear. The anaesthetist will visit you to ask you questions about any allergies and problems you may have had with previous surgeries.

When you go into the operating theatre, a general anaesthetic will be injected into a vein in your arm. A tube will be placed in your throat and connected to a machine that breathes for you.

A small cut of about 5 mm will be made in or near your navel. Carbon dioxide gas will be pumped into your abdomen through the cut. The gas causes the organs in the abdomen and pelvis to separate from each other, so the laparoscope can be safely passed into the pelvic cavity. The laparoscope is then inserted through the cut.

The gynaecologist will make another small cut in the lower part of the abdomen, so that an instrument can be inserted. The instrument is used to move the internal organs around, so the gynaecologist can thoroughly inspect the entire pelvic cavity. Another instrument will be inserted into the opening of the cervix, so the uterus can be moved back and forth as needed during the operation.

The gynaecologist will then carry out a thorough inspection of the pelvic cavity for signs of endometriosis — in the obvious and not so obvious places. The instruments inserted through the lower cut and cervix will be used to lift and move the uterus and ovaries around so all their surfaces can be seen clearly.

If endometriosis is found, the gynaecologist will take a few samples of the endometrial tissue present. The tissue will later be examined by a pathologist to confirm that it is endometriosis. This is necessary because endometriosis can be confused with other diseases.

Once a diagnosis has been made the gynaecologist will mark the location of your implants, endometriomas and adhesions on a drawing or prepared chart. The r-AFS chart is commonly used for this purpose. However, it is generally agreed that the resulting chart does not give a clear picture of the extent of your disease and symptoms. Increasingly, gynaecologists are also photographing and taping women’s endometriosis laparoscopies.

→ Taping endometriosis surgery

The chart and video will be used to provide a record of the severity and extent of your endometriosis that can be compared with charts and videos made during any subsequent laparoscopies. This will enable you and your gynaecologist to monitor the progression of your endometriosis and the effect of any treatments. The video will also be used to record any surgical procedures performed during the laparoscopy, ensuring quality control of the surgeon.

If you are having any surgical procedures, the gynaecologist will make another two or three small cuts in the lower abdomen. These cuts will be used to insert the surgical instruments needed to perform the required procedures.

When the operation has been completed, the laparoscope and other instruments will be removed and the carbon dioxide gas allowed to escape. The cuts will be protected with sticky plaster or tiny stitches, and you will be taken to the recovery room.

Risk and complications during and after surgery

A laparoscopy is a relatively safe operation. Most complications are minor and resolve quite quickly.

Rare and serious complications that may occur during surgery include uncontrolled bleeding; damage to organs such as the bowel, bladder and large blood vessels; and gas embolus (a gas bubble entering a blood vessel and lodging in the lung). An experienced surgeon should be able to manage these complications.

Complications that may develop after the operation include difficulty emptying the bladder, wound infection, urinary infection, infection of the uterus and vaginal discharge. If you experience any of these symptoms, please contact your surgeon immediately.

Effectiveness

It is difficult to provide reliable information about the effectiveness of operative laparoscopy for endometriosis. On the one hand, it is almost impossible to conduct well designed clinical trials to evaluate the results of surgery. On the other hand, the results of surgery are influenced by a woman’s personality, emotional state, endometriosis severity and extent, experience of the surgeon, and so on. The multiplicity of influencing factors makes it difficult to draw conclusions about the overall effectiveness of surgery.

Nevertheless, it is known that the expertise of the surgeon or surgeons is a key factor in determining the outcome of laparoscopic surgery for endometriosis: the more skilled the surgeon, the better the outcome. Therefore, if possible, get yourself referred to a gynaecologist or multidisciplinary centre with expertise in endometriosis surgery and care.

→ Finding an endometriosis specialist
→ Taping endometriosis surgery

The results of a few key clinical trials are outlined below:

• For women with mild and moderate endometriosis, surgical treatment was better than wait-and-see treatment [7]. Of those who responded to treatment, 90% still had relief of symptoms one year later.
• Excision was more effective than placebo (no treatment) in alleviating pain and improving quality of life [6].
• Surgery resulted in pain relief for 80% of women with severe disease who had not responded to hormonal treatment [20].
• Deep rectovaginal and rectosigmoid endometriosis surgery had similar rates of complications as other laparoscopic surgeries [21].

It seems that younger women are more likely to have a recurrence of their endometriosis following surgery: the younger the woman, the more likely she is to have a recurrence.

Follow-up after surgery

You should notify your gynaecologist immediately if you develop any of the following symptoms after your laparoscopy:

• fever
• wound becomes painful, swollen and red
• discharge appears from the wound
• severe abdominal pain or cramps
• frequent urination and scalding when passing urine
• vaginal discharge develops an unpleasant odour
• vomiting develops more than 24 hours after the operation
• tenderness and/or swelling in the calf muscles
• increasing soreness of the calf muscles when walking
• shortness of breath, chest pain or pain when breathing.

You will need to visit your gynaecologist 4–6 weeks after your laparoscopy to discuss your recovery, what was found during your operation, and your future treatment.

→ Post surgery ailments

References

1. Kennedy S, Bergqvist A, Chapron C, et al. ESHRE guideline for the diagnosis and treatment of endometriosis. Human Reprod 2005;20(10):2698-2704.
2. Abbott JA, Hawe J, Clayton RD and Garry R. The effects and effectiveness of laparoscopic excision of endometriosis: a prospective study with 2-5 year follow-up. Hum Reprod 2003;18:1922-1927.
3. Chapron C, Fauconnier A, Vieira M, Barakat H, Dousset B, Pansini V, Vacher-Lavenu MC and Dubuisson JB. Anatomical distribution of deeply infiltrating endometriosis: surgical implications and proposition for a classification. Hum Reprod 2003b;18:157-161.
4. Fedele L, Bianchi S, Zanconato G, Bettoni G and Gotsch F. Long-term follow-up after conservative surgery for rectovaginal endometriosis. Am J Obstet Gynecol 2004a;190:1020-1024.
5. Redwine DB and Wright JT. Laparoscopic treatment of complete obliteration of the cul-de-sac associated with endometriosis: long-term follow-up of en bloc resection. Fertil Steril 2001;76:358-365.
6. Abbott J, Hawe J, Hunter D, Holmes M, Finn P, Garry R. Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. Fertil Steril 2004;82:878-884.
7. Sutton CJ, Pooley AS, Ewen SP, Haines P. Follow-up report on a randomized controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal to moderate endometriosis. Fertil Steril 1997;68:1070-1074.
8. Sutton CJ, Ewen SP, Whitelaw N, Haines P. Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertil Steril 1994;62:696-700.
9. Chapron C, Vercellini P, Barakat H, Vieira M and Dubuisson JB. Management of ovarian endometriomas. Hum Reprod Update 2002;8:6-7.
10. ESHRE Guideline, 2006.
11. Saleh A, Tulandi T. Reoperation after laparoscopic treatment for ovarian endometriomas by excision and by fenestration. Fertil Steril 1999;72:322-324.
12. Beretta P, Franchi M, Ghezzi F, Busacca M, Zupi E and Bolis P. Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation. Fertil Steril 1998;70:1176-1180.
13. Vercellini P, Chapron C, De Giorgi O, Consonni D, Frontino G and Crosignani PG. Coagulation or excision of ovarian endometriomas? Am J Obstet Gynecol 2003b;188:606-610.
14. Fedele L, Bianchi S, Zanconato G, Raffaelli R, Berlanda N. Is rectovaginal endometriosis a progressive disease? Am J Obstet Gynecol 2004b;191:1539-1542.
15. Koninckx PR, Timmermans B, Meuleman C, Penninckx F. Complications of CO2-laser endoscopic excision of deep endometriosis. Hum Reprod 1996b;11:2263-2268.
16. Lefebvre G, Allaire C, Jeffrey J, Vilos G, Arneja J, Birch C and Fortier M. SOGC clinical guidelines. Hysterectomy. J Obstet Gynecol Can 2002;24:37-61.
17. Namnoum AB, Hickman TN, Goodman SB, Gehlbach DL and Rock JA. Incidence of symptom recurrence after hysterectomy for endometriosis. Fertil Steril 1995;64:898-902.
18. Ford J, English J, Miles WA, Giannopoulos T. Pain, quality of life and complications following the radical resection of rectovaginal endometriosis. BJOG 2004;111:353-356.
19. Latthe PM, Proctor ML, Farquhar CM, Johnson N, Khan KS. Surgical interruption of pelvic nerve pathways in dysmenorrhea: a systematic review of effectiveness. Acta Obstet Gynecol Scand 2007;86:4-15.
20. Sutton C, Hill D. Laser laparoscopy in the treatment of endometriosis. A 5-year study. Br J Obstet Gynaecol 1990;97:181-185.
21. Varol N, Maher P, Healey M, Woods R, Wood C, Hill D, Lolatgis N, Tsaltas J. Rectal surgery for endometriosis — should we be aggressive? J Am Assoc Gynecol Laparosc 2003;10:182–189.

Thank you to the following for reviewing this article prior to its publication

Philippe Koninckx, Professor of Obstetrics and Gynaecology, Leuven University Hospital, Belgium
Peter Maher, Associate Professor, Mercy Hospital for Women, Melbourne, Australia
Marc Possover, Professor of Obstetrics and Gynaecology, St Elisabeth Hospital, Köln, Germany
Tamer Seckin, Chief of Gynaecology, Kingsbrook Jewish Medical Centre, New York, USA
Anastasia Ussia, Villa Giose Clinic, Crotone, Italy