Surgery for endometriosis


the cardinal sins of surgery

  • wrong diagnosis

  • Lack of skills/experience

  • inadequate follow-up

Before undergoing surgery, Check

  • Which endometriosis is suspected? and which surgery will be performed?
  • information and informed consent: 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 nevertheless.
    • If deep Endometriosis or severe adhesions are likely, surgery can be unexpectedly difficult with 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 before surgery to help with the diagnosis
  • but is rarely useful for surgery

Our surgery principles

Read our principles as recently published

Read how our new understanding changes treatment 

  • surgery is 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 prefer surgery with CO2 laser for superficial endometriosis and hydrosalpinges
    • scissors, and bipolar electrosurgery when dissection is needed
laser incision with minimal tissue damage

Superficial Endo

  • Vaporization with a CO2 laser
  • Aggressive coagulation or stripping of large areas should not be done.
  • A common mistake is exaggerated coagulation with removal of large areas
  • for the diaphragm superficial coagulation 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 fewer recurrences
  • A cystic corpus luteum should not be operated on.
  • 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 decreasing ovarian reserve.  Only video registration can demonstrate mistakes. Surgery for ovarian cysts is erroneously considered ‘easy’.
  • Results 
    • The 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.

  • We perform less than 5%  bowel resection is  (read our reviews) in over 2500 deep endometriosis resections in Leuven, some 300 in Oxford and  250 in Rome.
  • The decision of bowel resection is taken during surgery, not before surgery.  As published, we think that many bowel resections are avoidable.
  • If bowel resections are decided because of Ultrasound images, way to many bowel resections are performed

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 indicated since 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 hydronephrosis
  • all ureter lesions can be treated by laparoscopy with excellent outcomes 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.
Share This

Shiny Trinket

Shiny trinkets are shiny.