SURGICAL TREATMENT OF ENDOMETRIOSIS
The medical treatment of endometriosis is very effective in reducing the associated pain, but it does not eradicate the disease. With the passage of time they become less effective and surgical treatment becomes necessary.
Laparotomy is an operation to gain access to the abdomen through a 5-10cm long incision at the bikini line (like a Cesarean section). Today, its use is limited only to those cases in which laparoscopy can not be performed. The disadvantage of a laparotomy, is a hospital stay of 4-5 days and the a recovery of 4 weeks.
A laparoscopy requires a hospital stay of one night and general anesthesia. The recovery is fast, because the abdomen is not opened. The duration of the procedure depends on the findings. It usually lasts about an hour, but in difficult cases, it can take much longer.
Hospital admission takes place early on the day of the operation, unless special investigations are needed. The patient stops drinking and eating from midnight prior to the operation. You should inform your doctor of any health problems, allergies or medication taken.
The laparoscope is a surgical instrument, 30cm long and 1cm wide. It is inserted into the abdomen through a small incision at the belly button. The abdomen is filled with carbon dioxide gas prior to the insertion of the laparoscope. This way, injuries to the abdominal organs are avoided and a good view of the abdominal cavity is obtained.
The laparoscope is connected to a light source and a camera.
All intra-abdominal organs, such as liver, gallbladder, stomach, bowels, uterus, ovaries and tubes can be examined thoroughly.
The surgeon can inspect the areas above or below the uterus and the ovaries. The endometriotic lesions can be seen and destroyed. Adhesions between the organs can be identified and removed.
The number of abdominal incisions depends on the findings and the kind of the operation (usually 2-3 small incisions 0,5-1cm). These incision are closed with a stitch and covered with a plaster. At end of the operation the gas is allowed to escape from the abdomen.
A video recording of the operation is very useful because it allows the comparison to future findings, as well as the monitoring of the disease.
It is widely accepted as the gold standard for the diagnosis of endometriosis.
Today, the diagnosis of endometriosis is only accepted, after the laparoscopic visualization of the disease.
The lesions of endometriosis are not always typical, therefore taking biopsies for its histologic confirmation is mandatory.
When endometriosis stage I or II is identified during laparoscopy, the procedure can be converted into an operative laparoscopy. The surgeon can remove or destroy the endometriosis spots and clear any adhesions, thus avoiding a second operation.
If the disease is very extensive and involves adjacent organs, such as the bowel, the bladder or the big pelvic vessels, the surgeon must remove as much endometriosis as he safely can. If symptoms persist, then a second operation can be organized, with the cooperation of other specialists, as required (Urologist, General or Vascular surgeon).
Removing Endometriotic lesions
The removal of endometriotic lesion can be achieved in two ways:
- Surgical excision of the lesion with fine scissors. The tissue is not subjected to thermal damage and the histology examination is easier.
- Vaporization of the endometriotic lesions. In this case the surgeon burns the lesion with a diathermy or a laser.
The aim is to destroy the endometriotic lesions, to avoid recurrence of the disease. At the same time extreme caution is required, in order to avoid damage to the underlying organs, such as the ureter, the bladder, the bowel or the big vessels.
When the endometriosis is located on these organ, the surgeons are very careful and conservative.
These surgical techniques are very effective against the pain of endometriosis.
The location and the size of endometriosis lesions of the ovary, will dictate the kind of operation performed.
Endometriotic cysts of the ovary are called endometriomas or chocolate cysts.
Superficial spots of ovarian endometriosis are destroyed easily with a laser or a bipolar diathermy.
The endometriomas or chocolate cysts are first drained, to reduce their size.
Their content is sucked out as much as possible, in order to avoid spillage into the abdominal cavity, as well as the spread of the disease. The abdominal cavity is repeatedly washed. The lining of the cyst is removed and sent for histological examination.
Special attention is needed during the operation, in order to remove as little as possible, of healthy ovarian tissue, so as not to compromise ovarian reserves. The complete removal of the ovarian endometriosis is associated with reduced chances of recurrence, significant reduction of pain and higher chances of a pregnancy.
The body, in its effort to limit inflammation, creates adhesions. These can be treated laparoscopically. Adhesiolysis can be performed with the use of a laser, a diathermy or laparoscopic scissors. They recur very often.
Some women are prone to adhesion formation and are subsequently subjected to many attempts at adhesiolysis. It is better to avoid this vicious circle of adhesion formation and operations.
Deep infiltrating endometriosis between the bowel and the vagina
The surgical treatment of deep infiltrating endometriosis between the bowel and the vagina, is only indicated when symptomatic. If it is asymptomatic, it is best not to intervene. In cases that endometriosis is strangulating the ureter or the bowel, it should be removed surgically.
The operations of deep infiltrating endometriosis are difficult, complicated and have significant complications, even in the hands of world re-known surgeons. They require careful preoperative assessment, more than usual investigations (barium enema, MRI, Pyelogram) and multidisciplinary teams of surgeons.
The aim is, to remove as much endometriosis as possible, in order to avoid a recurrence of the disease. Sometimes, a part of the vaginal wall and the uterosacral ligaments must be removed, together with the endometriosis. When a ureter or the bowel are so deeply infiltrated by the endometriosis, a part may be removed, with surgical reconstruction at the same time.
This kind of heavy operations, are best performed by multidisciplinary medical teams, in specialized tertiary centers.
Hysterectomy with or without removal of the ovaries
If a woman has completed her family and the endometriosis has not responded to any other treatment, an hysterectomy may be indicated.
The reduction of the pain is greater, when the cervix and the ovaries are also removed. The endometriotic implants should also be destroyed in order to avoid recurrence.
In cases of deep infiltrating endometriosis between the vagina and the bowel, a total hysterectomy can be combined with the resection of a small part of the bowel.
This will improve the woman’s quality of life.
Dangers and complications of laparoscopy
Laparoscopy is an overall safe operation. However, as with all operations, there are surgical and anesthetic risks. Most complications are very light and temporary.
Serious complications rarely occur during the operation. Trauma to the big vessels can cause significant bleeding. The bowel, the ureter and the bladder can be traumatized during surgery. Pulmonary embolism is very rare.
An experienced surgeon can safely deal with all these complications. The only surgeons, who do not have any complications, are those who never operate. You do not want one of these, to do your operation.
After your exit from the hospital, you should inform your doctor, if you have any of the following symptoms:
- Wound infection
- Severe abdominal pain or cramps
- Frequency of urination
- Smelly vaginal discharge
- Pain or swelling of the legs
- Pain of the legs when you walk
- Chest pain or dyspnoea
Effectiveness of surgical treatment
It is very difficult to measure the effectiveness of the surgical treatment of endometriosis. Many factors are involved, from the patient’s side (personality, psychology) and from the doctor’s side (experience, surgical skills, hospital setting).
The following studies and their conclusions are generally accepted:
In women with endometriosis stage I and II, surgical treatment is better than waiting. A year later, 90% of those who responded to surgical treatment, were pain free.
In those women diagnosed with endometriosis during laparoscopy, the removal of the endometriotic lesions resulted in better quality of life and better pain relief, than in those where no lesions were removed.
Surgery was effective in relieving the pain in 80% of women with failed medical treatment.
Laparoscopy for deep infiltrating endometriosis, has a similar complication rate to other laparoscopic operations, in expert hands.
In general, a younger woman carries a greater chance of disease recurrence over her life time.