Surgery for Endometriosis

Surgery is the therapy of choice ; medical therapy follows later.

A careful diagnosis based upon symptoms, clinical exam and investigations will permit an estimation of surgery and risks as can be found in the standard letter

Laser surgery is an advantage :(for a more complete discussion see “Laser Surgery for endometriosis.pdf”)

First a diagnosis based upon clinical symptoms, and Ultrasound

If surgery has been decided upon, additional exams can be considered such as a contrast enema and IVP ; click for a full discussion on diagnosis and additional exams

Before surgery, informed consent should be obtained comprising for endometriosis

The presumptive diagnosis and the planned/proposed surgery. i.e. CO2 laser vaporization/excision with electrosurgery for subtle and deep endometriosis : superficial coagulation or excision of cystic ovarian endometriosis ; discoid excision or bowel resection for deep endometriosis.
What will happen when accidents occur during surgery eg a bleeding , a bowel or ureter lesion. Indeed without experience and adequate equipment a conversion to laparotomy will occur.
The personal experience and the personal results of the surgeon, i.e. how many surgeries for endometriosis he performed and what were his results ( % pregnancies, % recurrences, how frequently were other surgeries performed than initially planned such as the conversion rate from laparoscopy to laparotomy
Confirmation that videoregistration of the complete intervention will be done and/or that the patient will get a copy.
The patient should realize the limits of the surgeon , indeed nobody can operate everything- : when the nodule is bigger than 3 cm or when fixed at the spine and certainly for a sigmoid endometriosis it is reckless to start surgery without sufficient experience.
The biggest problem is that surgery for endometriosis can be unexpectedly difficult including bowel surgery and suturing of the ureter and the bladder and occasionally a nerve dissection

BEFORE SURGERY : what should have been done before surgery starts

If there is no suspicion of deep endometriosis – or severe adhesions
Endometriosis surgery can be planned as day surgery without additional exams.
If deep Endometriosis or severe adhesions are suspected additional exams are necessary
IVP (or other exams) to check for hydronefrosis. To know that there is a double ureter is wise to prevent accidents.
Contrast enema to ascertain less than 50% sigmoid occlusion over less tan 2-3 cm
Ultrasound may have suspected a bladder nodule
Full bowel preparation planned
Full informed consent detailing the risks of muscularis lesion, opening of the bowel and bowel resection
A 2 step procedure should be planned for a cystic ovarian endometriosis larger than 5 cm and infertility
A sigmoid resection should be planned if more than 50% occlusion over more than 2-3 cm
If the surgeon is experienced, other exams as MRI, transrectal MRI and CAT scan do not change the surgical decision and are therefore of limited use. If the surgeon is less experienced bowel resections are performed almost systematically

Why CO2 laser an advantage ?

A CO2 laser is an advantage for superficial and deep endometriosis
The hemostatic properties will prevent capillary bleeding resulting in a cleaner operating field.
Tissue damage is minimal ie of 100 micron only : what you see is what you do. Whenever coagulation is needed depth of destruction is at least a few mm leading to an increased risk of adhesions.
A CO2 laser makes endometriosis surgery faster, something important for deep endometriosis surgery where surgery of 5 hours can be reduced to 4.
For mild endometriosis the CO2 laser permits to have 2 secondary ports only, within bikini limits
Disadvantages of surgery without a CO2 laser
For superficial lesions : excision will cause bleeding necessitating coagulation and thus tissue damage.
For Deep lesions : adding an extra of 1-2 hours to endometriosis surgery of 4 hours can become difficult.
Superficial coagulation only is a mistake since depth cannot be judged.
Why is CO2 laser surgery not performed systematically for endometriosis ? First a CO2 laser is expensive, second it requires additional training and most of all it requires a high flow insufflator as developed by us in the early 90ies

Surgery of Subtle Endometriosis

Subtle endometriosis should not be considered a pathology since there is no (proven) association with pain or infertility.

Since laser vaporization takes a few seconds only without risks, I prefer to treat.

Aggressive coagulation over large areas should be avoided because of the risk of adhesion

The main problem is that subtle endometriosis, which should not considered a pathology often is overemphasised and over-treated, thus causing unnecessary adhesions.

Surgery of Typical Endometriosis takes 15-30 min only

Go top

Typical endometriosis can cause pain albeit mild and not in all women (50%) ;
Women with infertility have more typical endometriosis, and typical endometriosis is associated with the LUF syndrome.
After surgery some 30 to 50% of women will conceive, but it is still unclear whether the increased fertility is because of the removal of the typical endometriosis, or whether the incidence of LUF syndrome decreases
Typical endometriosis should be vaporized or excised. For this the CO2 laser has specific advantages, especially when used with hydro-dissection. Coagulation only should be avoided since the depth of invasion cannot be judged superficially.

Surgery of Cystic Ovarian endometriosis needs a lot of expertise not to damage the ovary

Go top

How should surgery be done ?
If less than 5 cm in Diameter
Very small lesions can be vaporized. A cystic corpus luteum should not be operated. The method of choice is excision of cyst since the recurrence rate is 5% only.
Superficial coagulation has a recurrence rate of more than 20%. For this reason I stopped vaporization in 1996
If more than 5 cm in Diameter : either a 2 step surgery to preserve the ovary or an adnexectomy should be done since excision will generally cause destruction of the ovary The first surgery is a 10 min day surgery with aspiration and rinsing of the endometrioma. After 3 months of GNRH therapy the cyst has become small and can be excised

Complications of ovarian surgery : why this is delicate surgery

Damaging the ovary with a decreased ovarian reserve should be avoided
Only videoregistration can demonstrate that a plane was missed, or that excessive coagulation, especially of the hilus damaged the blood supply Surgery for ovarian cysts is erroneously considered ‘easy’. Reality is that many women will have after surgery a decreased ovarian reserve, whereas reports from excellent surgical groups do not show any decrease. Only videoregistration can demonstrate that a plane was missed, or that excessive coagulation, especially of the hilus damaged the blood supply. Surgery for cystic ovarian endometriosis therefore is delicate, with superficial coagulation of bleeding vessels only. Since coagulation is done minimally , this carries the risk of some 3-4 % haematomas after surgery.

Deep endometriosis is considered difficult surgery

Go top

We were the first to describe deep endometriosis back in 1989
Surgically 4 Localizations and types should be distinguished
Recto-vaginal
Sigmoid
Bladder
rare presentation : ovarian remnant
As indicated on the left slide I performed over 2000 deep endometriosis resections in Leuven, some 300 in Oxford and some 250 in Rome

What is the problem of Deep endometriosis Surgery
It can be technically very demanding surgery with occasionally surgery of the bowel, the ureter, and the bladder. Especially larger lesions can be technically difficult.Therefore this surgery needs a thorough preoperative diagnosis : occasionally a deep endometriosis can be an unsuspected finding. In this rare case it is important not to operate since the absence of a bowel preparation. This surgery requires a surgeon with the necessary expertise, the right equipment, and a good team (assistant, nurses) to have adequate assistance to deal with any problem of bowel, bladder, or ureter during surgery. Also close supervision during the postoperative period is equally important .

Deep endometriosis : recto-vaginal and rectosigmoid

Most important is to have made or suspected the diagnosis before surgery. Clinically a recto-vaginal endometriosis is palpable in 30 to 50% only ; smaller ones can only be detected during menstruation

In our experience complete discoid excision is almost always possible since we only performed a low bowel resection in 3/2000 women only. . For a more thorough discussion on bowel resections see a recent systematic review discussing this
Difficulty increases exponentially with size. When bigger than 3 cm and when fixed to the spine a lot of experience is necessary.
“Shaving” is often used to indicate incomplete resection, ie leaving some endometriosis on the bowel if necessary. Although not evidence based proven, we believe that incomplete surgery should be avoided although some fibrosis can be left.
Deep Endometriosis invades the muscle of the bowel in 50% whereas 20% are transmural. Complete resection of deep endometriosis thus requires a muscularis resection with one layer suture in some 50% and/or a full thickness resection in some 20% with a double layer suture. When these deep endometriosis nodules are big especially with a low lateral extension, or when attached to the spine the parasympaticus nerve is involved in the endometriosis with a 10-15% risk of temporary bladder retention

A low bowel resection is rarely necessary even not for the large ones. Alow bowel resection should be avoided because of the high complication rate, the 30% live long bowel, 30% bladder and 40% sexual problems. Moreover there is no demonstrated advantage

Deep endometriosis of the sigmoid

Go top
A contrast enema is the best diagnostic method to diagnose sigmoid endometriosis and to judge the degree of bowel stenosis.

I the stenosis is less than 50% over less than 2-3 cm we always begin with a discoid resection. Only in 5 % a sigmoid resection will be necessary. It is important always to start with a discoid resection since otherwise a lot of unnecessary bowel resections will be performed because of artifacts.

I the stenosis is more than 50% over more than 2-3 cm we do an elective sigmoid resection since we consider this technically too difficult for a discoid resection.
Sigmoid endometriosis almost always is invasive. in 90% invasion of the muscularis , in more than 50% transmural
We can be more liberal to do a sigmoid resection than for a rectum resection because of the much lower complication rate for a sigmoid resection. In addition a discoid resection of the sigmoid is technically very difficult surgery and should be avoided unless very experienced.
A colonoscopy or NMR is not very useful since it does not change surgery.

Deep endometriosis : Bladder

Go top

Diagnosis should be suspected clinically but sometimes an experienced ultrasonographist can make the diagnosis If the lesion is big, it is wise to do a cystoscopy to check the position of the ureters. In doubt we insert a double J stent in the ureter Excision can be radical without hesitation since the bladder heals well The bladder is my friend since she heals well

Deep endometriosis : Ureter involvement and ureter surgery

Go top

Deep endometriosis surgery can involve the ureter and cause hydronefrosis. Although rather frequent for larger lesions this can even occur in smaller deep endometriosis
Therefore the surgeon should know beforehand whether ureter surgery can be anticipated and he should have the skills to do so.
If hydronefrosis : a preoperative stent is mandatory since associated with an 18% risk for ureter lesion
If no hydronefrosis : a systematic stent is over-treatment and should not be used. First it is not necessary (risk of lesion less than 0.5%), second it causes pain and fibrosis .Most importantly all ureter lesions can be treated by laparoscopy with excellent outcome as we demonstrated in 2 recent reviews a review of the literature in 2007 and personal data 2009

Deep endometriosis : ovarian remnant Syndrome

Go top

Fortunately rare
the ureter is always at the middle of the ovary
always very difficult surgery
fortunately rare

Peritoneal Pockets

Peritoneale pockets are not that well known and often not easy to diagnose. Generally an endometriosis spider is present. As shown in the images below they can be very deep. Excision is the therapy of choice. When infiltrating up to the nerves this can be technically challenging
click for more images of pockets

Deep endometriosis : Complications and Postoperative management

Go top
Deep endometriosis surgery requires experience and a team Not only the surgeon should be experienced, but also the assistant, and preferentially the second assitant, as occurs in the Gruppo Italo Belga. This permits to discuss during surgery when in doubt. Such a team know the following rules

- complete surgery. Indeed incomplete surgery is a serious complication. The surgery not only will have to be repeated, but most importantly the second surgery will be more difficult. Sometimes it is a difficult decision when the lesion is not very clear : without experience the surgeon will refrain because of the risk of bowel perforation, and thus will leave endometriosis behind. To highlight this we did present case reports at several meetings.
- that complete excision is especially important at the level of the vagina since this is the most frequent localisation of recurrences
- that a layer of fibrosis can be left on the bowel.
- that the bladder heals well and that surgery thus can be radical.
- that all ureter lesions can be treated by laparoscopy and that a reimplantation of the ureter ino longer is the first line treatment
- that unnecessary bowel resections should be avoided : indeed in some series up to 14% of women with a bowel resection for endometriosis did not have endometriosis
- that when surgery is too slow or too mutilating, bowel resections become unavoidable.
- that the difficulty increases exponentially with size of the lesion, and when attached to the spine or the sigmoid

COMPLICATIONS DURING SURGERY : these are comparable to other surgery provided the team has experience

- the risk that of an hysterectomy is accidentally performed is zero for our group
- the risk of an ovariecomy also is nonexistent unless no normal ovarian tissue was left. ( in order to be able to check this video-recording is necessary.)
- Complete excision of deep endometriosis involves bowel and urinary surgery. The probability depends on the size of the endometriosis and the localisation. The probability can be predicted from the contrast enema and IVP and should be explained before surgery.
- hydronefrosis is associated with a risk of 18% ureter lesions ; with a normal ureter this risk is less than 0.5%.
- a 2cm nodule in the rectum carries a risk of a muscularis resection and a 1 layer suture of 50% ; for the sigmoid the risk would be 90%
- a 3 cm nodule is associated with a full thickness resection en a double suture of 40 and 95% respectively.

- Other potential complications and fatigue Complications are those of severe surgery and the risk is mainly dependent on the expertise of the surgeon and his team. We consider it important to implement a risk management system. We published as recognizable risk factors an inexperienced assistant, inadequate equipment, and fatigue. Clearly all 3 factors relate to the duration of surgery. As a rule of thumb I consider that for surgeons get tired after 5 hours and that attention and precision decreases. Since severe deep endometriosis surgery can require 4-5 hours, I consider it important not to add an extra 1-2 hours because of the absence of a CO2 laser, or to add 1-2 hours because of equipment or assistance.

- without an experienced team the risk increases that surgery is converted to laparotomy or bowel resection. This thus will give information about the experience of the group .
POSTOPERATIVE MANAGEMENT.
50 and 90% muscularis invasion of rectum and the sigmoid respectively, with a 1 layer prophylactic suture and nil by mouth and an hospitalization of 4 days.
30 and 50% full thickness resection of rectum and the sigmoid respectively, with a double layer suture and nil by mouth and an hospitalization of 7 days.
In women with a hydronefrosis 18% ureter wall resection necessitating a suture and a double J stent for 6 weeks. In the absence of an hydronefrosis the risk of ureter lesion is less than 0.5% and a routine stent is not required. A bladder deep endometriosis requires in some 30% a full thickness bladder wall resection, necessitating a suture and a bladder catheter for 7 days. In some women an additional ureter stent is required for 6 weeks.

Risk management and videoregistration Since videoregistration of entire procedures is systematically used we do analyze each complication of surgery. Moreover we discuss and publish this analysis as a training of the team and in order to help others not to repeat the mistake.

POSTOPERATIVE COMPLICATIONS

A late bowel perforation occurred in some 5% – since we introduced massive lavage this risk has fallen below 0.5% We recognized and published this as early as 1996 This complication is severe and requires a close supervision of the patient for 5 days since the symptoms are vague and since a late perforation is easily missed if not experienced. The importance of immediate recognition is that a late perforation can be treated by a repeat laparoscopy and a suture of the perforation. If however the perforation exists for more than 24 hours a colostomy is necessary because of a 4 quadrant peritonitis
1-2% recto-vaginal fistulas In order to avoid this we prefer not to associate an hysterectomy with surgery of deep endometriosis
Bleeding and infection
Bladder retention occurs in some 10-15 % especially in big nodules with lateral extension. This complication rarely last longer than 3 months.
Provided early repeat laparoscopy all complications can be managed by laparoscopy.

Results of endometriosis surgery

Go top

Subtle endometriosis
No effect upon pain or infertility since it is not a cause of pain nor of infertility. Endometriosis surgery is probably not useful and will not prevent recurrences. Since, endometriosis surgery takes a few minutes without risks, superficial vaporization with a CO2 laser is performed
Typical endometriosis
Pain : After excision , a significant reduction in pain occurs in 50% of the women only as demonstrated in the RCT of Sutton.
infertility : Endometriosis surgery is believed to increase fertility rate during 6-12 months. The data however are not clear.
Recurrences : 20% over 10 years.
Cystic ovarian endometriosis
pain severe pain will decrease by 90%
infertility the cumulative fertility should be around 60% after 12 months.
Recurrences : less than 5% after complete excision.
The biggest risk is (partial) destruction of the ovary. This occurs rather frequently if the surgeon is not sufficiently experienced. Therefore quality control should be introduced
Deep endometriosis
PainEndometriosis surgery will cure pain in over 85%. In the remaining 15% the difficult question whether surgery was incomplete cannot be answered without videoregistration
infertility is still unclear whether deep endometriosis causes infertility, since some 50% of the women with deep endometriosis have children. Anyway the cumulative fertility should be around 60% after 12 months
Recurrences is some 1% if completely excised. There is no advantage when a bowel resection is performed