Treating Endometriosis Surgically

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Endometriosis is a chronic disease

In that sense, there is no cure for endometriosis, but the symptoms can
be reduced with the right treatment. Communication is the key to finding a treatment that fits you.

Surgical treatment involves the elimination of endometriosis lesions, division of adhesions and interruption of nerve pathways. Laparoscopic (key hole) surgery is preferred to laparotomy (open surgery) as it improves visibility of lesions and is associated with better patient outcomes such as less pain, smaller incisions, faster recovery and less risk of infection. Elimination of endometriosis may be achieved by excision, other techniques in use are called ablative techniques (diathermy/coagulation/evaporation). Adhesions are divided to help restore pelvic anatomy, and interruption of pelvic nerve pathways is carried out with the intention of improving pain control.

The evidence showing differences between excision and ablation is lacking, due to poorly performed studies, no randomised control trials, no difference been made between stages of endometriosis and not considering surgeon skill and experience in the reviews carried out. It is hoped that with current research that stronger evidence will be found. In speaking to surgeons who carry out hundreds of endometriosis surgeries annually, their method of choice is excision. There are many ways to excise, but the end results are the same – the physical removal of the endometriosis lesion and surrounding tissue. This is important for a number of reasons – endometriosis lesions can be wide as well as deep – but most importantly the tissue can be sent to the laboratory for histopathology. This examination at microscopic level will show that the lesions removed were endometriosis (or not) and if there are clear margins around the lesion. When ablation is used, the tissue is vaporised and destroyed. There is no tissue to send to the laboratory. Ablation can also lead to localised inflammation and endometriosis being left in place under the charred surface of the peritoneum.

The ESHRE guideline group concluded that “Ablation and excision of peritoneal disease are thought to be equally effective for treatment of endometriosis-associated pain. However, this information comes from one small study and a larger one with suboptimal design; hence their conclusions should be treated with caution. Excision of lesions could be preferred with regard to the possibility of retrieving samples for histology. Furthermore, ablative techniques are unlikely to be suitable for advanced forms of endometriosis with deep endometriosis component.”

ESHRE Recommendations

When endometriosis is identified at laparoscopy, clinicians are recommended to surgically treat endometriosis, as this is effective for reducing endometriosis-associated pain i.e. ‘see and treat’

Clinicians can consider performing surgical removal of deep endometriosis, as it reduces endometriosis-associated pain and improves quality of life

Recommends that clinicians refer women with suspected or diagnosed deep endometriosis to a centre of expertise that offers all available treatments in a multidisciplinary context.

Surgical Interruption of Nerve Pathways

Severing the nerves to the pelvic and uterine area was considered a possible treatment for endometriosis related pain.

LUNA – Laparoscopic Uterosacral Nerve Ablation and PSN – PreSacral Nerve Ablation are the two most commonly used techniques. Both techniques are offered as part of a surgical treatment plan for endometriosis.

It can be concluded that LUNA is not beneficial as an additional procedure to conservative surgery for endometriosis, as it offers no additional benefit over surgery alone (Proctor, et al., 2005).

PSN is beneficial for the treatment of endometriosis-associated midline pain as an adjunct to conservative laparoscopic surgery, but it should be stressed that PSN requires a high degree of skill and is associated with increased risk of adverse effects such as bleeding, constipation, urinary urgency and painless first stage of labour.

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