Various levels of surgical treatment are available for endometriosis. The simplest type of surgery and treatment of choice is laparoscopy and various types of procedures may be done down the laparoscope to get rid of the endometriosis or its effects.
A more significant form of surgery is laparotomy, where a large incision is made in the abdominal wall to actually perform a definitive surgical procedure. Obviously, this takes longer, is more painful and the patient is in hospital for longer. The risks and side effects are also greater than for laparoscopy. It is therefore better to almost never use laparotomy a treatment for endometriosis.
Burning endometriosis by diathermy or laser may be used to treat mild endometriosis, or it may be used in the context of a “second look” laparoscopy at the end of the course of hormonal therapy.
Laparoscopy with Laser or Diathermy
Laparoscopy is initially used to diagnose endometriosis. When we visualise areas of endometriosis it is possible to destroy them under the control of the laparoscope by burning or excising it. This can be done simply with the diathermy or using the laser.
The laser is expensive and slow and almost never used now by leading endometriosis surgeons. Simple burning treatment is not always the answer for endometriosis as it is rather like trying to treat a case of measles by burning the spots away. The basic disease process probably still remains or returns quite quickly. It is sometimes better to combine a hormonal (drug) regime with local destructive therapy for extensive mild endometriosis.
Advanced Laparoscopy with excision of Endometriosis
This is now the surgical treatment of choice for endometriosis.
Major surgery, previously performed through a large incision, can now be done laparoscopically. This means short (often one night) hospital stays and quicker return to work and normal life with much less post-operative pain. This is very skilled surgery and often requires extra training.
It often can take one to three hours and involve a lot of dissection of the pelvic structures when the endometriosis has caused severe damage, which must be repaired. The bowel often needs to be freed from the ovaries and uterus. Lumps of endometriosis are removed with great precision due to the improved visibility of the laparoscope.
At these laparoscopies all the scarring and endometriosis (old and new) is excised and removed. The aim is to leave the pelvis completely free of all scarring and endometriosis. Long-term pain relief may be obtained from this level of surgery as the nerve-entrapped scar tissue is removed.
Patients often need a bowel clean out (bowel prep) prior to surgery, as often at this level of severity, the endometriosis involves bowel adhesions.
Often, this level of surgery may involve additional surgeons such as a Colorectal surgeon to operate on endometriosis-affected bowel. When we think such additional expertise is necessary patients may be asked to see a Colorectal surgeon before the operation to plan this. However, sometimes it is not possible.
Data suggests excellent long term results from this surgery.
This is now very rarely used in the presence of persisting very severe endometriosis after other forms of therapy are not possible. It is particularly used where large lumps of endometriosis (endometriomas) form in the ovaries and are difficult to treat with drug therapy or laparoscopic surgery.
A large incision is made in the abdominal wall and the aim of the surgery is to remove as much endometriosis as possible to leave the patient disease-free. Any adhesions that may be present are divided in the most careful way possible. This type of endometriosis surgery is often done to improve an otherwise badly damaged pelvis and enhance a patient’s fertility or at the time of a hysterectomy.
Hysterectomy for endometriosis
The final alternative is hysterectomy with removal of the womb, all the endometriosis and sometimes the ovaries. This is curative in 90% of cases, but only can be used when childbearing is complete.
It must be stressed that hysterectomy is not a cure for endometriosis unless all the endometriosis is removed at the same time. Laparoscopic Hysterectomy with excision of all the disease is the final best treatment for advanced endometriosis.
Risks of surgery for endometriosis
There are significant risks to all surgery; the most important of which is subsequent adhesion formation. Once the patient has surgery for endometriosis she runs a significant risk of having tethering of the ovaries and the tubes to each other, with a subsequent decrease in fertility.
The results of surgery can therefore be somewhat variable and can have, in fact, a deleterious effect on the patient’s fertility status. Surgery should therefore be approached with caution, but has a place to play in the definitive management of endometriosis.
Surgical risks include:
The risk of putting a laparoscope in the abdomen. Bowel or a major blood vessel can be damaged at laparoscopic entry. The risk of this is 1-3 cases/1000.
Other organs in the pelvis and abdomen can be damaged as the endometriosis is removed. This includes the bowel, the bladder, nerves and blood vessels and the ureter (a tube which connects the kidney to the bladder). If such damage does occur prompt repair will usually solve the problem. Rarely, damaged bowel may need resection or very rarely, a colostomy and bag. A catheter or tubes may need to stay in the bladder or ureter if these organs are damaged. The risk of inadvertent organ damage is less than 1:100 cases.
Adhesions can form as the result of surgery, especially with the inflammation of endometriosis. Every attempt is made to minimize this but scarring can still occur.
Infection is a risk of surgery. Major cases will usually have antibiotic cover. Infective complications are uncommon.
Bleeding can occur during or after surgery. Major cases of endometriosis almost never need blood transfusions but these may occur.
Clots can form in veins of the legs or pelvis and travel to the lungs causing a pulmonary embolism. The risk of this is about 1:400 cases.