Treatment of endometriosis: surgery
The cardinal sins of surgery
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wrong diagnosis/indication
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inadequate skills/experience
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inadequate follow-up
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arrogance
First, check the diagnosis
Rule of thumb: Which type of endometriosis is suspected? a laparoscopy is needed to diagnose subtle and typical endometriosis, pockets and ovarian remnants. The diagnosis of deep endometriosis, is overestimated resulting in avoidable bowel resections.
THE PANDORA BOX OF TREATMENT : Click to read the full text
What to check before Surgery,
- is the diagnosis ok?
- are information and informed consent ok?
- are the preoperative exams ok?
- what will be done during surgery? Check the contract.
Preoperative exams to check
- 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 surgery during diagnostic laparoscopy
- only in cases of unexpected severe deep endometriosis, a bowel resection will be performed during a second surgery. This risk is less than 2%
- it is discussed which type of intervention you do NOT want e.g. removal of uterus or ovaries.
Technical aspects
- we perform surgery with scissors and bipolar electrosurgery, rarely ultracision
- we use a CO2 laser
- CO2 laser used to be my favorite during the pioneering years. Today the use is limited to for superficial endometriosis or hydrosalpinges, since the quality of the image is less for technical reasons.
- Tissue damage is minimal i.e. less than of 100 micron with less adhesion formation
Surgery for Subtle Endometriosis
- Vaporization with a CO2 laser takes a few seconds, without risks.
- Aggressive coagulation or stripping of large areas should not be done.
- A common mistake is the exaggerated coagulation because of adhesion formation.
Surgery for typical endometriosis
- vaporization - 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 of surgical treatment
Some 50% of women will conceive and pain will be less
Surgery of cystic Ovarian endometriosis
Less than 3 cm; unclear whether treatment is necessary
3 to 5 cm in Diameter
- A cystic corpus luteum should not be operated.
- The method of choice is excision of the cyst since the 5% recurrence rate is less than after superficial coagulation (20%)
- Alcoholization is actually evaluated
If more than 5 cm in Diameter. 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’. Surgery for cystic ovarian endometriosis is delicate, with superficial coagulation of bleeding vessels only. Minimal coagulation carries the risk of 1-2 % haematoma’s after surgery.
Results of surgery
- Recurrence rate of 5%
- Pain : disappears in over 90%
- Fertility : 70% spontaneous pregnancy rate within 1 year
Deep endometriosis
Types of deep endometriosis
Deep endometriosis can be difficult surgery. A bowel resection is rarely needed (read our reviews). We performed over 2500 deep endometriosis resections in Leuven, some 300 in Oxford and some 250 in Rome.
Surgery requires expertise and preoperative preparation. The decision of bowel resection is taken during surgery, not before surgery. As published we think that many bowel resections are avoidable.
Deep endometriosis of the rectum or recto-sigmoid
In our experience complete discoid excision is almost always possible. For a more thorough discussion on bowel resections see a recent systematic review discussing this. When bigger than 3 cm experience is necessary.
Excision should be complete but a rim of fibrosis can be left. Complete resection 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. Care is taken not to damage the nerves and the risk of temporary bladder retention. A low bowel resection should be avoided because of the high complication rate, 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.
Deep endometriosis : Bladder
If the lesion is big, it is wise to do a cystoscopy to check the position of the ureters. Excision can be radical without hesitation since the bladder heals well The bladder is my friend
Deep endometriosis and the ureter
Deep endometriosis surgery always involves at least ureter dissection. A stent is needed only when hydronefrosis to prevent ureter lesions., Most important is that all ureter lesions can be treated by laparoscopy with excellent outcome as we demonstrated 15 years ago
Complications and Postoperative management
Deep endometriosis surgery requires experience and a team, i.e. an experienced assistant or 2 surgeons, permitting to discuss during surgery. Read our papers, to understand surgical principles such as: complete excision is especially at the level of the vagina, leaving a layer of fibrosis on the bowel, treatment of ureter lesions by laparoscopy, 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,
Fatigue is a cause of complications. As a rule of thumb, surgeons get tired after 5 hours with less attention and precision.
POSTOPERATIVE MANAGEMENT.
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.
- A late bowel perforation occurred (see our publication in 1996) in some 5%. After the introduction of lavage with 8 liters this risk has fallen below 0.5%. Since symptoms are vague a late perforation is easily missed. Immediate recognition permits treatment by repeat laparoscopy. However, if the perforation exists for more than 24 hours a colostomy is necessary because of a 4 quadrant peritonitis
- 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.
Ovarian remnant
This is a rare pathology and easily missed unless experienced.
Peritoneal Pockets
Involvement of Nerves
Nerve dissection needs experience. Knowing that endometriosis causes pain at distance, nerve dissection is performed too frequently
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