Indications for endometriosis surgery
Direct visualisation of endometriosis is considered to be the optimum method of making the diagnosis. This is usually done through laparoscopy, a minimal access surgical procedure. If there is suspicion that endometriosis is in other organs then other surgical procedures may be required such as:
- Cystoscopy to assess the bladder.
- Colonoscopy to assess the lower large bowel.
- Mini-laparotomy (open surgery) for endometriosis in the abdominal wall.
Laparoscopic surgery is the mainstay of treatment for mild to moderate endometriosis. In severe endometriosis laparoscopic surgery may be possible and in other cases open surgery (laparotomy) is indicated. Severe endometriosis often requires a multidisciplinary approach, involving surgeons from different specialities and may include:
- Colorectal surgeons
The approach to surgery is determined by the location of the endometriotic implants, the skill and training of the surgeons involved and the particular circumstances of the woman affected.
Followup surgery has two main indications:
- The need for further treatment based on incomplete management during first procedure.
- Symptom recurrence.
- Initial diagnostic laparoscopy ± biopsy.
- Initial diagnostic laparoscopy ± biopsy + primary treatment with recognition that further treatment required and that extra time ± consents need to be appliedl
- ‘Second-look’ laparoscopy to assess the response of the lower-abdomen and pelvis to initial surgery.
- Not commonly used in treatment regimens.
- Has a more established place in research or in the management of reduced fertility associated with endometriosis.
Cystic endometriosis in Pouch of Douglas as well as the peritoneum lateral to the utero-sacral ligaments.
Pouch of Douglas after cystic endometriosis resected. The peritoneum heals very quickly and does not need to be sutured closed.
Endometriosis on both utero-sacral ligaments as well as peritoneum of Pouch of Douglas.
Resection of the peritoneum on the utero-sacral ligaments thereby obtaining tissue for histology as well as treatment.
Endometriosis on the peritoneal lining of the lower abdominal wall.
Use of a Nottle hook to diathermy abdominal peritoneal endometriosis.
Left endometrioma; not easily identified on visual examination.
Incision of ovarian capsule; revealing and then draining left endometrioma.
Management of endometrioma
Endometriomas can be treated by:
- Partial excision of ovarian capsule.
- Cystectomy (complete removal of the cyst).
Right ovarian cystectomy; ovarian capsule open.
Reconstitution of the right ovary after cystectomy.
Completed reconstitution of the right ovary after cystectomy.
Cystectomy takes longer than drainage or partial resection but achieves the best longterm results in terms of reduction of symptoms and recurrence of disease. Sometimes the ovary can be left open and at other times the ovary will require reconstitution.
Reduced fertility associated with endometriosis
Success rates for achieving a pregnancy after surgery for severe endometriosis is equivalent to success rates for assisted conception (IVF). You will have to discuss with your doctor the associated risks and benefits of each approach and then make your decision.
Surgery performed for both moderate and severe endometriosis increases the chances of achieving a pregnancy.
At present, there is no good evidence that surgery for mild cases of endometriosis improves fertility rates. This might be because mild endometriosis does not have a negative impact on fertility rates in most cases.
Other treatment modalities
Although surgery remains the standard for treatment of endometriosis, there are a number of other therapies that may improve symptoms and thus have positive benefit on quality of life.
Modification of diet