Surgical treatment

Surgical treatment of endometriosis

Surgery is the only method that physically removes endometriosis lesions. Unlike hormonal treatment, which only suppresses symptoms, surgical treatment removes the cause of the problems - bringing longer-lasting relief from pain and improvement in fertility.

At our centre, we perform surgical treatment of endometriosis minimally invasively - laparoscopically. A large abdominal incision is not required.

What is laparoscopy?

Laparoscopy is a minimally invasive surgical procedure performed under general anaesthesia. The surgeon inserts a camera and instruments into the abdominal cavity through several small incisions (5-12 mm), fills the cavity with CO2 gas for better visibility, and views a magnified image of the pelvic organs on a monitor. A video camera transmits the entire procedure to a screen for the whole team.

Advantages of laparoscopy over open surgery:

• smaller scars and better cosmetic result
• shorter hospitalisation - usually 1 to 3 days
• faster recovery compared to open surgery
• lower risk of post-operative adhesions
• more precise work thanks to the magnified image
• diagnosis and treatment occur during a single procedure

What is removed during surgery?

• Superficial lesions on the peritoneum - by burning (coagulation) or cutting out (excision)
• Endometriomas - ovarian cysts filled with old blood; the aim is to preserve as much healthy ovarian tissue as possible
• Deep infiltrating lesions - lesions penetrating the rectovaginal septum, bowel or bladder; the most technically demanding procedure
• Adhesions - scar tissue connections between organs causing pain and restricting fallopian tube function

Excision vs. coagulation

• Excision - cutting out the lesion including surrounding tissue. Considered the more thorough method with a lower risk of disease recurrence. More technically demanding, but produces better results particularly for deep forms.
• Coagulation (ablation) - burning the surface of the lesion. Simpler and faster, but may leave part of the lesion in the tissue depth.

At our centre, we prefer excision where technically possible.

Surgical treatment of endometriomas

The World Endometriosis Society (WES), in collaboration with ESHRE and ESGE, published comprehensive recommendations for the surgical treatment of endometriomas in 2017. Recommended techniques include:

• Cystectomy - removal of the entire cyst wall; considered the most effective approach with the lowest recurrence risk
• laser ablation
• plasma energy ablation
• electrocoagulation

The goal is always to maximise preservation of healthy ovarian tissue - each ovarian operation reduces egg reserve.

Surgery and fertility - an important note

Endometriosis is one of the most common causes of infertility, yet many women undergo IVF without prior laparoscopic evaluation or treatment of endometriosis. Dr Camran Nezhat (Stanford University) notes: "The option of a thorough laparoscopic evaluation and surgical technique may give the patient a greater rate of success."

A Stanford University study following 29 women with previous failed IVF attempts who underwent laparoscopic treatment of endometriosis found that 22 of the 29 women (76%) subsequently became pregnant - some without further IVF. Microsurgical eradication of endometriosis improves not only fallopian tube patency but also uterine receptivity for embryos.

How to prepare for surgery

• pre-operative investigations - blood tests, ECG, anaesthetic consultation
• MRI or specialist ultrasound to precisely map disease extent
• fasting from midnight before the operation
• bowel preparation the evening before if bowel surgery is anticipated

Practical tips for the day of surgery: wear loose clothing without waistbands, bring pads (not tampons), comfortable slip-on shoes. Arrange a driver home - you cannot drive after anaesthesia.

Recovery

Most women go home within 1 to 3 days (hospitalisation may be longer with bowel surgery). Recovery depends on the extent of surgery - doctors sometimes underestimate it and talk of "a few days", when in reality it may take several weeks:

• First 2-3 days - fatigue and drowsiness from anaesthesia, need for help with food and medication
• Shoulder pain - right shoulder pain after laparoscopy is common, caused by residual CO2 gas irritating the diaphragm. Heat and movement help.
• First two weeks - no driving, bathing or intercourse; short walks are actually encouraged
• Emotional fluctuations - may persist for several weeks; a normal part of healing
• First period after surgery - may be more painful, longer or heavier than usual due to internal healing
• After simpler surgery - return to office work in 5 to 7 days, physical work in 2 to 3 weeks
• After more extensive surgery (bowel, bladder) - recovery takes 3 to 6 weeks

When is surgery appropriate?

• hormonal treatment does not provide sufficient pain relief
• ovarian endometriomas are present
• deep infiltrating endometriosis is present
• endometriosis is causing fertility problems
• the patient is considering or has had repeated unsuccessful IVF
• the diagnosis has not yet been histologically confirmed

Global surgical recommendations: World Endometriosis Society - Surgery.