Laparoscopic treatment of endometriosis

Laparoscopy (keyhole surgery) with biopsy of suspected endometriosis tissue is the gold standard method to confirm the presence of endometriosis.

A laparoscopy will be offered by your gynaecologist to treat your endometriosis if medical treatment is not effective in controlling your symptoms, if you have been found to have an endometriotic cyst (chocolate cyst) on an ultrasound scan, or if you have problems getting pregnant and therefore surgical treatment of endometriosis will improve your fertility.

There are two treatment options for pelvic endometriosis:

  • Ablation (thermal destruction of endometriosis)
  • Excision (cutting out the endometriosis)

Ablation

When superficial endometriosis is identified in your pelvis during your laparoscopy, thermal energy can be applied on the spots of endometriosis to evaporate and therefore treat them. Unfortunately, if the endometriosis is deep in the tissues, ablation technique may fail to treat it.

Excision

When superficial or deep endometriosis is identified in your pelvis during your laparoscopy, these areas are cut out and the specimens are sent to the laboratory to confirm the presence of endometriosis. This treatment method is believed to be more effective in treating deep infiltrating endometriosis.

What is endometriosis?

Endometriosis is a chronic inflammatory condition that is characterised by cells from the lining of the womb being deposited in various tissues in the body but mainly in the pelvis (ovaries, tubes, bladder, bowel).

Endometriosis is a hormone-dependent condition. The exact prevalence of endometriosis is unknown but it is estimated to affect 2 in 10% of women of reproductive age and up to 50% of women with fertility problems.* It is a benign (non-cancerous) condition but it can have a great impact on the quality of life of the women affected by it.

Common symptoms of endometriosis

Endometriosis commonly causes pain and occasionally infertility. Woman may experience endometriosis symptoms differently but usually endometriosis is characterised by cyclical pelvic pain that is pain that gets worse before or during the period.

Commonly women complain of the following symptoms:

  • Lower pelvic pain
  • Lower back pain
  • Pain radiating down the legs
  • Pain during intercourse (dyspareunia)
  • Pain on opening the bowels
  • Pain on urination or frequency of urination
  • Tiredness/lethargy
  • Bloating

Various studies have been done to assess the superiority of one technique over the other. They have shown that both techniques have similar benefits in treating pelvic pain. However, there is a concern that with the ablative method, deep endometriosis may be missed or left untreated.

Endometriotic cyst

If you have been diagnosed with an endometriotic cyst, your surgeon may suggest that you have the cyst treated.

Again there are two treatment options for endometriotic cysts:

  • Drainage and coagulation (thermal destruction)
  • Excision of the cyst wall (ovarian cystectomy)

Drainage and coagulation

During your laparoscopy, the cyst is drained and opened and thermal energy is applied on the cyst wall

Excision of cyst wall

During your laparoscopy, the cyst wall is identified, the cyst is then drained and the cyst wall is cut out from the ovary.

Both techniques have been shown to reduce the pain related to the endometriotic cyst but the excision of the cyst wall is associated with a reduced risk of the cyst coming back as well as the endometriosis-related pain coming back.

Risks associated with the laparoscopic treatment of endometriosis

As with any operation there are some risks involved with the laparoscopic treatment of endometriosis. These can be divided to frequent risks and serious risks.

Frequent risks

These risks are usually mild and self-limiting:

  • Bruising of wound sites
  • Shoulder tip pain
  • Infection

Serious risks

  • Bleeding
  • Blood clots in the legs or the lungs
  • Hernia at wound sites
  • Damage to surrounding organs in the pelvis like the bowel, bladder and the ureters (the tubes that connect the kidneys with the bladder).

Because endometriosis can sometimes be deep in the tissues of the pelvis, the bowel, bladder and ureters can be involved and in these cases the risk of damaging these organs is slightly higher than 1-2 per 1000 cases that is the background risk of a routine laparoscopy.**

What is the recovery like?

Most women who undergo laparoscopic treatment of their endometriosis are able to be discharged home on the same day after being reviewed by a member of the healthcare team. Occasionally due to pain or difficulties in passing urine some women may have to stay overnight in the hospital. Women who have extensive excision (cutting out) of endometriosis may be advised by their gynaecologist to stay in the hospital for one night.

In the days following your laparoscopy you will be experiencing some discomfort in your tummy and around the wound sites. Simple pain killers should be sufficient to control these symptoms. Depending on the extent of the treatment undertaken during your laparoscopy, you should be able to return to your normal activities within one to two weeks.

 

* Reference: European Society of Human Reproduction and Embryology Guideline, Management of Women with Endometriosis, September 2013, 2. Eskenazi B and Warner ML. Epidemiology of endometriosis. Obstet Gynecol Clin North Am 1997; 24:235–258, 3. Meuleman C, Vandenabeele B, Fieuws S, Spiessens C, Timmerman D and D'Hooghe T. High prevalence of endometriosis in infertile women with normal ovulation and normospermic partners. Fertil Steril 2009; 92:68–74

**Reference: Kondo W, Bourdel N, Tamburro S, Cavoli D, Jardon K, Rabischong B, Botchorishvili R, Pouly J, Mage G and Canis M. Complications after surgery for deeply infiltrating pelvic endometriosis. BJOG 2011; 118:292–298

Content for this treatment has been provided by Mr Ilias Nikolopolous at BMI The Park Hospital

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