Surgery for endometriosis

The cardinal sins

  • wrong diagnosis/indication

  • Lack of skills/experience

  • inadequate follow-up


Surgery for endometriosis



The cardinal sins

  • wrong diagnosis/indication

  • Lack of skills/experience

  • inadequate follow-up



you should know

  • Which endometriosis is suspected? 
medical treatment

THE PANDORA BOX OF TREATMENT : Click to read the full text

  • information and informed consent 
  • preoperative exams 
  • which surgery will be done
  • Check the contract.

 Preoperative exams

  • if probably no deep endometriosis or severe adhesions,  surgery can be planned as day surgery without additional exams. Check what will be done if severe endometriosis is found
  • if deep Endometriosis or severe adhesions are not excluded, surgery can be unexpectedly difficult, e.g. bowel surgery, suturing of the ureter, bladder surgery or nerve dissection.  Therefore it is needed to
    • exclude hydronephrosis by IVP or other exams.
    • exclude bowel stenosis  of less than 50%  over less than 2-3 cm by contrast enema

Medical therapy before surgery?

  • medical therapy can be given for a short time to help with the diagnosis
  • is not useful before surgery

Our principles 

  • all surgery needed will be performed during diagnostic laparoscopy
  • 1% unexpected severe deep endometriosis requiring, a bowel resection will be operated during a second surgery. 
  •  important to know which type of intervention you do NOT want e.g. removal of uterus or ovaries.
  • we perform surgery with scissors and bipolar electrosurgery, rarely ultracision
  • we use a CO2 laser  for superficial endometriosis or hydrosalpinges.

Subtle Endo

  • Vaporization with a CO2 laser
  • Aggressive coagulation or stripping of large areas should not be done.
  • A common mistake is the exaggerated coagulation

Typical endo

  • vaporization  or excision takes only 5 min
  • coagulation only should not be done, since the depth of invasion cannot be judged.
  • for the diaphragm superficial coagulation is used in order to prevent perforation
  • Results :Some 50% will conceive and pain will be less

Cystic Ovarian endo

cystic ovarian endometriosis

  • Less than 3 cm:  unclear whether treatment is necessary
  • 3 to 5 cm in Diameter  excision since less recurrences
  • A cystic corpus luteum should not be operated.
  • Alcoholization is being evaluated
  • If > 5 cm  To preserve the ovary, a 2 step surgery is needed. After a 10 min day surgery intervention with aspiration and rinsing of the endometrioma, and 3 months of GNRH therapy the cyst can be excised. The alternative is to remove the ovary
  • Without the necessary skills, surgery risks to decrease ovarian reserve.  Only video-registration can demonstrate mistakes. Surgery for ovarian cysts is erroneously considered ‘easy’.
  • Results 
    • Recurrence rate of 5%
    • Pain : disappears in over 90%
    • Fertility : 70% spontaneous pregnancy rate within 1 year

Deep endo

Types of deep endometriosisDeep endometriosis can be difficult surgery.

of the rectum or recto-sigmoid

  • In our experience complete discoid excision is almost always possible. see a recent systematic review discussing this.
  • When bigger than 3*3*3 cm experience is necessary.
  • Excision should be complete but a rim of fibrosis can be left.
    •  a muscularis resection with one layer suture in some 50%
    • a full thickness resection in some 20% with a double layer suture.
    • Care is taken not to damage  the nerves and the risk of temporary bladder retention.
    • A low bowel resection is very rarely indicatedsince the 30% live long bowel, 30% bladder and 40% sexual problems.
  • Deep endometriosis of the sigmoid: A contrast enema is the best diagnostic method to judge the degree of bowel stenosis.  I the stenosis is more than 50% over more than 2-3 cm we do an elective sigmoid resection is performed. As published, over the years sigmoid resections were more liberally used since easier and  a low complication rate.

Of the bladder

  • If the lesion is big, a cystoscopy is needed to check the position of the ureters.
  • Excision can be radical without hesitation since the bladder heals well The bladder is my friend

the ureter

  • Deep endometriosis always involves at least ureter dissection.
  • A stent is needed only  when hydronefrosis
  • all ureter lesions can be treated by laparoscopy with excellent outcome    as we demonstrated15 years ago

Ovarian remnant

This is a rare pathology and easily missed unless experienced.

Peritoneal Pockets

As recently described these cause pain and need surgery. A small hole hides a big defect,  which is easily missed


Complications and Postop management

  • Deep endometriosis surgery requires experience and a team,  Read our papers, to understand the principles such as:   leaving a layer of fibrosis on the bowel,  why re-implantation of the ureter is the past, how to avoid bowel resections (  up to 14% of women with a bowel resection for endometriosis did not have endometriosis,
  • As a rule of thumb, surgeons get tired after 5 hours with less attention and precision.
    • A 1 layer prophylactic suture requires an hospitalization for 4 days; a double layer suture for 7 days. An hydronefrosis with ureter wall resection and suture requires a double J stent for 6 weeks.A  bladder deep endometriosis with a full thickness bladder wall resection, requires a bladder catheter for 7 days.
    • Video-registration permits the early diagnosis of complications and repeat laparoscopy.
    • Management of Complication
      • late bowel perforation (see our publication in 1996) :  after the introduction of  lavage with 8 liters this risk has fallen below 0.5%. Since symptoms are vague Immediate recognition by repeat laparoscopy is needed.
      • 1-2% recto-vaginal fistulas. 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.
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