When hormone therapy doesn’t work, you may have to have surgery in order to cure the disease.
If you also have fibroids, adenomyosis or more extensive endometriosis, surgery for endometriosis can be very complicated and may require repair of the rectum and bladder.
Laparoscopic surgery
Laparoscopic surgery is a procedure performed with surgical instruments called laparoscopes. The purposes are to.
1. diagnose endometriosis.
2. remove endometriosis lesions.
3. break down the adhesions caused by endometriosis.
The laparoscope is a slim surgical instrument about 30 cm long and resembles a telescope. It is inserted into the pelvic cavity through a small incision in the umbilicus. It has a light source and lens that illuminates the pelvic cavity and has a magnifying effect so that the gynecologist can see the pelvic organs and endometriosis lesions clearly. There is usually a second channel for placing surgical instruments, and the observation reveals that if surgery is needed, then the gynecologist performs the operation through the instruments entered by this tube.
Laparoscopic surgery is not to be confused with open surgery. Open surgery is an operation with a 10-15 cm incision in the abdomen (while laparoscopic surgery has only 2-4 small 1 cm incisions). Currently open surgery is only used to treat very severe endometriosis that cannot be done with laparoscopic surgery.
Diagnostic laparoscopy – used only to diagnose endometriosis. Laparoscopy is the gold standard (the most credible method) for diagnosing endometriosis. If no endometriosis lesions are seen on laparoscopy, then the diagnosis of endometriosis should not be considered. Most gynecologists also insist that a pathological examination should be performed to confirm the diagnosis.
Usually mild – to moderate endometriosis lesions are seen laparoscopically and laparoscopic surgery should be completed at the same time. Surgical laparoscopy is the laparoscopic removal of endometriosis lesions and removal of adhesions. This means that only one surgery is needed and diagnosis and treatment are completed at the same time. For this reason, it is important that you are fully informed and agree before the surgery.
If endometriosis is found to be severe, eroding the bowel or urinary tract, then laparoscopic surgery may have to be postponed because, because of the need to perform adequate bowel and urinary tract preparation and to obtain the patient’s consent for bowel and urinary tract surgery.
Surgery for endometriosis is very difficult and complex, so the surgeon performing the procedure requires special skills and expertise. Many obstetricians and gynecologists are able to treat mild cases of endometriosis. Severe endometriosis, however, requires an experienced and expert surgeon. Very few obstetricians and gynecologists are able to treat severe endometriosis.
Surgical procedure
Endometriosis surgery is performed by removing the visually visible endometriosis lesion and the adhesions caused by endometriosis. The laparoscopic surgical approach may include.
1. removal or destruction of peritoneal endometriosis lesions;
2, removal or destruction of ovarian chocolate cysts;
3, excision of adhesions.
4, removal of deep lesions in the rectal compartment of the uterus
5, removal of the uterus.
6, removal of one or both ovaries.
7, surgery of the intestinal canal and bladder
8, laparoscopic uterine neurectomy (LUNA) and presacral neurectomy (PSN).
Surgical techniques
Endometriosis surgery requires two techniques: excision and coagulation.
Excision: Endometriosis lesions are removed with scissors, an electric knife, or a laser beam to remove the endometriosis lesions extremely surrounding tissue. This technique does not damage the ectopic lining within the lesion so that it can be given to the pathologist for pathological examination to determine that it is endometriosis and not cancer or some other condition. Excision allows the surgeon to separate the endometriosis lesion from the surrounding normal tissue to ensure that the endometriosis lesion is completely removed without residual lesions.
Coagulation destruction.
Coagulation destruction involves cauterizing or vaporizing the lesion with an electric knife or laser beam. When coagulation is performed, the entire lesion must be carefully destroyed to prevent regrowth. Care must also be taken to destroy only the endometriosis lesion and not the normal tissues beneath it, thereby damaging the bowel and bladder. Coagulation on vital organs (bowel and bladder) is frowned upon because of the damage to the underlying normal tissues.
Endometriosis of the ovary
Treatment of ovarian endometriosis varies depending on the type and size of the lesion. Ovarian cysts are called “endometriosis cysts” or “chocolate cysts”.
Ovarian surface implants
Ectopic endometrial implants on the ovarian surface can be destroyed by coagulation or vaporization.
Small ovarian cysts
Ovarian cysts less than 3 cm in diameter can be treated by puncture and drainage, and the lining of the cyst can be examined and coagulated or vaporized.
Large ovarian cysts
Cysts larger than 3 cm in diameter can be removed, coagulated or vaporized.
Removal of large ovarian cysts means that the complete cyst is cut from the ovary and to ensure the integrity of the cyst, some of the ovarian tissue surrounding the cyst is also removed.
When draining and coagulating a large cyst, the cyst is first incised to drain the cystic fluid. The inner wall of the cyst is then coagulated to destroy it.
Which method to choose?
It is recommended that cysts over 3 cm be excised rather than coagulated and vaporized. Complete excision results in better pain relief to promote fertility and a lower risk of recurrence.
Adhesions
Adhesions caused by endometriosis should be removed, either with scissors, electric knife, laser, etc. When the adhesions are removed, there is the possibility of re-adhesions at the new cut edge. But there are many preventive measures. Some women are at higher risk for adhesions and re-adhesions than others. Re-surgical removal of adhesions is also troublesome and not recommended.
Endometriosis in deep utero-rectal septum and sigmoid rectum
If deep infiltrating endometriosis is causing symptoms or is likely to cause symptoms in the future, then surgical treatment is the only consideration. If you have deep infiltrative endometriosis of the vaginal-rectal septum without symptoms, it means that it is solitary and the lesion is small, and such a lesion rarely worsens or causes symptoms. If the lesion invades the rectum and ureter because it can cause obstruction, then this lesion should be removed.
If surgery is necessary, then the lesion should be removed in one operation and a second operation should be avoided. Such an operation is complex, difficult, and may have serious complications. It is necessary to discuss the procedure in depth with your doctor so that you can be prepared and undergo the surgery.
Surgery for deep infiltrative endometriosis may include removal of the ligaments along the deep lesion and removal of the posterior vaginal wall. The uterus and ovaries may or may not need to be removed. Partial resection and repair of the bowel, ureter, and bladder may be performed if the lesion is encroaching on the rectum, bladder, or ureter, causing or about to cause damage.
If the surgery may involve the bowel or urinary system, then the surgeon should discuss and plan and prepare in advance with you. In order to have the surgery, you will need to undergo pre-operative bowel or urinary tract preparation and treatment. This procedure requires close cooperation between the obstetrician and gynecologist and the urologist and enterologist.
Removal of the uterus and ovaries
Removal of the uterus and ovaries should only be considered if nothing else has worked and you have no requirement for fertility.
If the uterus is removed, then all endometriosis lesions should be removed at the same time.
A total hysterectomy + bilateral ovaries provides better postoperative pain relief and lower risk of reoperation than simply removing the uterus while preserving both ovaries.
If the uterus is removed, then the cervix is removed at the same time and preserving the cervix causes persistent pain due to endometriosis in the cervix and sacral ligaments.
Removal of the uterus and part of the descending colon is effective in the treatment of endometriosis in the rectal compartment of the uterus, providing pain relief and improving quality of life.
Laparoscopic uterine neurectomy and laparoscopic anterior sacral neurectomy
Laparoscopic uterine neurectomy (LUNA) and laparoscopic presacral neurotomy (LPSN) are laparoscopic dissection of the nerve from the uterus to the brain to relieve chronic pain.
A retrospective study of both procedures showed limited effect in relieving chronic pain. Uterine neurectomy, in combination with laparoscopic surgery, also provided no additional pain relief, while presacral neurectomy provided more pain relief than laparoscopic surgery alone. Women who have had laparoscopic surgery and anterior sacral nerve surgery may experience complications with constipation. If your doctor prefers to do both procedures, then you will want to ask him what the success rate of the procedure is if this is done.
Surgery
Depending on the size and how many lesions need to be removed, laparoscopic surgery may take half an hour or up to six hours.
Procedures and practices also vary from hospital to hospital. The information below is only a guide to laparoscopic surgery. You can ask your doctor or hospital if they have a patient guide booklet that explains the hospital’s procedures and practices to patients.
You should not eat or drink for 6 hours prior to surgery. Whenever there is any possibility of performing bowel surgery, bowel preparation must be performed before surgery to ensure that the procedure is performed safely. This includes drinking something to cleanse the intestines.
You are asked to be admitted to the hospital in advance of surgery to learn about your general health, any medications you have taken and any surgeries you have had, to take your blood pressure and pulse, to remove pubic hair, and to give you a hospital gown. The anesthesiologist will also discuss with you if you have any drug allergies or other problems from previous surgeries.
You enter the operating room and are given general anesthesia and tracheal intubation with a ventilator to maintain your breathing.
A 5mm incision is made in the umbilicus, through which carbon dioxide is passed into the abdominal cavity. The carbon dioxide separates the organs in the pelvic and abdominal cavities from each other so that the laparoscope can safely enter the pelvic cavity. The laparoscope then passes through this incision into the pelvic cavity. The gynecologist also makes another small incision in the lower abdomen and places another surgical instrument with which to move the organs in the pelvic cavity so that the surgeon can fully examine the entire pelvis. Another instrument is placed into the open pelvic cavity to move the uterus back and forth as needed for the procedure. The gynecologist then thoroughly examines the pelvic cavity to find those features of endometriosis that are obvious or not so obvious. The uterus and ovaries are elevated or swung through instruments inserted into the lower incision and cervix in order to fully examine their surfaces.
If an endometriotic lesion is found, the gynecologist will usually take some endometrial tissue samples and send them to the pathology department for examination to determine if it is endometriosis. This is because endometriosis can often be confused with other diseases.
Once diagnosed, the gynecologist will fill out a chart indicating the location of the lesions, coeliacs, and adhesions. rAFS scoring chart is a common scoring method.
If laparoscopic surgery is to be performed, then the surgeon makes 2-3 small incisions in the lower abdomen which are used to insert the instruments needed for the procedure.
After the surgery is completed, the laparoscope and surgical instruments are removed and carbon dioxide gas is released. The incisions are glued or closed with fine needle stitches. You will also be sent back to the recovery room.
Intraoperative and postoperative risks and complications
Laparoscopy is a fairly safe procedure, and most complications are mild and recovery is fairly quick.
More serious complications include uncontrolled bleeding, organ damage such as bowel, bladder and large blood vessels, and gas embolism (gas entering the blood vessels and lungs). Experienced surgeons are able to manage these complications.
Postoperative complications can also occur and include: impaired bladder emptying, wound infection, urinary tract infection, uterine infection, and increased vaginal discharge.
Results
It is difficult to provide reliable information on the efficacy of laparoscopic surgery for endometriosis. On the one hand, it is impossible to design elaborate clinical trials to assess the outcome of the procedure, and on the other hand, the outcome of the procedure is influenced by individual patient differences, the degree of agitation, the severity of endometriosis, the breadth of invasion, the experience of the surgeon, etc. The influence of multiple factors makes it difficult to arrive at an assessment of surgical outcomes. Having said that, the experience of the surgeon and the surgeon are key factors in determining the outcome of laparoscopic surgery for endometriosis. Therefore, if possible, you will want to seek surgery and recovery with an experienced surgeon or center that treats endometriosis.
An overview of the results of some key clinical trials.
In patients with mild to moderate endometriosis, surgical treatment was superior to expectant treatment. At follow-up of treatment, 90% were still able to have pain relief after one year.
Excision was better than comfort treatment in terms of pain relief and improved quality of life.
In severe patients for whom hormonal therapy was ineffective, surgical treatment provided pain relief in up to 80% of cases.
The incidence of surgical complications for deep infiltrative endometriosis in the rectal compartment and sigmoid colon is similar to that of other laparoscopic procedures.
It seems that young women are prone to recurrence after surgery: the younger they are, the more likely they are to recur.
Postoperative follow-up
If any of the following symptoms are observed after laparoscopic surgery, the surgeon should be notified immediately.
Fever.
Redness, swelling, pain and oozing of the wound.
Severe abdominal pain or intestinal cramps.
Unpleasant odor of vaginal discharge.
Vomiting 24 hours after the operation.
Swelling and tenderness in the lower legs, with increased pain in the lower legs when walking.
Shortness of breath, chest pain or painful breathing.
Follow-up visits 4-6 weeks after laparoscopic surgery to discuss recovery from surgery, intraoperative findings, and follow-up treatment.