Consultant gynaecologist and endometriosis specialist Mr Ahmad Sayasneh from BMI The London Independent Hospital answers common questions about how the condition is treated with surgery.
Many people living with endometriosis pain and the other difficult symptoms of the condition will undergo surgery as part of their treatment plan. Mr Sayasneh answers some of the most frequently asked questions on the subject.
When is surgery required for endometriosis?
Whether you are recommended surgery will depend on a variety of factors individual to each person.
For example, your consultant will consider your age and whether you are looking to have children either now or in the future. They’ll also consider which treatments you have been prescribed so far.
Of course, your symptoms and the extent of your endometriosis will also be taken into account, as will your personal feelings about having surgery.
How is endometriosis surgery performed?
In general, minimally invasive surgery is preferred – so most people will have a laparoscopic (keyhole) procedure.
This is where small incisions are made in your tummy so that your surgeon can access your abdomen and pelvis without making large incisions.
Laparoscopic surgery for endometriosis is usually done under general anaesthetic.
The benefits of keyhole surgery can include a faster recovery time, less pain and bleeding after your operation, and reduced scarring.
Women wanting to get pregnant soon may be recommended surgery before they start trying to increase their chances. Reduced scar tissue around the ovaries and fallopian tubes encourages better fertility outcomes compared to open surgery.
Open surgery is rarely required and will only be performed when keyhole surgery is deemed not possible (for example if you have severe scarring from previous surgeries).
What types of surgery are available for endometriosis?
There are two different surgical techniques that can be used either to ablate or to excise areas of endometriosis: Laser technology and electrosurgery. Both can be used during a laparoscopy to remove endometriosis tissue.
Neither is better than the other. Which one is used will depend on the individual case as well as on the surgeon’s preference.
What is the difference between ablation and excision surgery?
Ablation is getting rid of endometriosis by burning or destroying it. Excision is removing the endometriosis by cutting it out.
While ablation may remove superficial endometriosis, it may fail to treat the deeper roots of the disease. For this reason excision, which removes the endometriosis at a deeper level, is believed to be more effective.
Often when endometriotic growths or nodules are removed, they’ll then be sent to the laboratory to confirm diagnosis under the microscope.
This is also true for endometrioma, which are cysts in the ovaries (sometimes called chocolate cysts because they contain old, brown blood).
Are different people suited to different surgeries?
Yes. As mentioned above, which surgery you are recommended – if you are recommended surgery at all – will depend on factors personal to you.
For most people, endometriosis surgery is designed to preserve fertility and is done using keyhole procedures. But this does not apply to everyone.
For example, if you are not looking to have children, if your family is complete, or if you are approaching menopause, you may be recommended a more radical procedure. This might involve removing your fallopian tubes or ovaries, or even a hysterectomy (which removes the womb).
In rare cases where endometriosis is very advanced and you have already had multiple surgeries, you may have to have open surgery.
In cases of very advanced endometriosis (also known as deep infiltrative or deep infiltrating endometriosis), the condition can invade organs including the bowel or bladder. You may then need surgery on these organs too.
This might involve just removing small areas from the surface of the bowel or bladder, or it may be more extensive.
Sometimes with endometriosis of the bowel, part of the bowel will have to be removed and patients need a temporary stoma bag before a follow up surgery to repair the bowel. This can still be done as keyhole surgery.
What is the recovery period like after surgery?
Recovery after minimal access surgery is usually fast compared to open surgery.
The exact timeline for recovery will differ for each person, depending on factors such as the extent of the surgery and whether procedures such as bowel resection were required.
In less extensive surgery, for example ablation procedures or excision of endometriosis tissue from the pelvis, the average stay in hospital is about one day. In many cases, a laparoscopy is done as a day-case procedure.1
In cases where the endometriosis is more advanced, and cases where bowel resection is needed, you will need to be in hospital for longer. You’ll need to be monitored until your bowel starts working after surgery.
With an enhanced recovery programme, the aim is for a stay of three to five nights.2 However for some people it will be longer, and in rare cases up to two weeks.
Can surgery cure endometriosis?
In principle there is no cure of endometriosis. However, treatment aims to control the disease, generally in order to reduce pain and help achieve pregnancy.
Often the best way to treat endometriosis is to combine surgery with medications such as hormone therapies.3
Can I get pregnant after having endometriosis surgery?
You should be able to, yes.
After a short period of recovery after surgery (up to six weeks), you will have a follow-up assessment and most likely be encouraged to start trying to get pregnant.
If there are no other reasons to stop you getting pregnant (such as a partner’s low sperm count), you’ll normally be advised to try for around six months before considering further fertility help or treatment.
After six months you’ll normally be recommended to a tertiary infertility centre, where you’ll perhaps be recommended IUI or IVF.
At this time you will of course be given other tests, such as ovulation check-ups, ultrasounds and hormone tests, and your partner will have relevant checks too.
Can endometriosis come back after surgery?
Unfortunately, yes. Especially when surgery is designed with fertility preservation in mind.
This is why this type of conservative surgery, performed to aid conception, is best timed just before you are trying to get pregnant.
Removing fallopian tubes and ovaries, with or without a hysterectomy, is a radical surgical treatment for the condition and for most people won’t be the right option, but it does lead to a lower recurrence rate.
This is because the ovaries will no longer produce oestrogen, the hormone most strongly linked to the growth of endometriosis.4
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