Endometriosis Surgery

Endometriosis is a condition in which tissue similar to the uterine lining grows and forms lesions outside of the uterus.

Research suggests that endometriosis affects approximately 10% of women of reproductive age globally, with the most common symptoms being pelvic pain, painful menstrual periods and painful sexual intercourse.

Though there is no absolute cure, surgery can be used to remove endometriotic tissue with the aim of alleviating symptoms and/or improving fertility.

There are a number of factors to consider when deciding whether surgery is the most appropriate treatment for endometriosis, including age, severity of symptoms, fertility issues and any previous non-surgical treatments.

Types of Surgery for Endometriosis

There are different types of surgery for endometriosis with the procedure chosen usually depending on the desired outcome, location and severity of lesions.

The four types of surgery for endometriosis are:

• Laparoscopy
• Laparotomy
• Hysterectomy
• Robotic assisted surgery

Each type of surgery requires general anaesthetic.

Laparoscopic Surgery for Endometriosis

Laparoscopic surgery, also known as keyhole surgery, involves making small incisions into the abdomen and using a very small internal camera. This can be carried out as just exploratory surgery to investigate the presence of endometrial lesions, but is usually upgraded to excision of endometrial tissue to treat underlying symptoms.

For these reasons, laparoscopy is considered to be the ‘gold standard’ for diagnosing endometriosis, and is therefore the most common surgical method used, since the abdominal cavity can be well observed with minimal incisions.

The aims of laparoscopic surgery are usually to remove (excise) lesions including endometriomas (cysts) and divide endometrial adhesions to improve symptoms and/or fertility.

As expected, laparoscopic surgery is carried out under general anaesthetic, with the length of surgery varying between 1.5 to 3.5 hours depending on the type and extent of lesion removal.

In terms of what to expect during laparoscopic surgery for endometriosis, at the beginning of the operation, a catheter is inserted into the urethra to empty the bladder and a very fine needle is inserted into the belly button to fill the abdomen with carbon dioxide to aid visualisation and increase the area for surgery. Usually, 2-3 small incisions are made (around 1cm each) at the belly button and bikini line. There may be further incisions made depending on the location of endometrial adhesions.

For thorough investigation and diagnosis of endometriosis, the uterus, ovaries, fallopian tubes, Pouch of Douglas, bowel, bladder and the surrounding abdomen are all inspected before a severity diagnosis is made.

Next, for endometrial tissue removal, a number of techniques can be used. Endometriosis is usually treated by excision which can be carried out by scissors, electrosurgery, laser ablation (burning-off), diathermy scissors (electrical heat) or harmonic scalpels (devices with a vibrating tip).

Excision can be beneficial over ablation to remove endometriotic tissue as it allows for biopsied tissue to undergo histological examination. Excision is also considered to be more effective for deep infiltrating lesions, especially when combined with near-infrared (NIR) fluorescence technology. However, depending on the type and location of endometriotic adhesions, surgeons often use a combination of procedures during surgery.

It is important to consider that surgery may not find any endometriosis. However, though potentially disappointing, this procedure or information may still aid in diagnosing a different condition.

Lastly, laparoscopic surgery for endometriosis is an outpatient procedure, meaning the patient can usually go home on the same day as the surgery. However, in some cases, an overnight stay in hospital is required.

Laparotomy Surgery for Endometriosis

A laparotomy is a surgical procedure where a large incision (usually up to 20cm long) is made along the bottom of the abdomen, similar to a C-section. Laparotomy surgery is no longer commonly used as it is significantly more invasive than laparoscopic surgery, so is usually only performed when endometriosis is severe (e.g. stage 4) or in cases where it is difficult to get a thorough view from laparoscopic techniques.

Similar to laparoscopic surgery, endometrial adhesions or cysts in the ovaries can be removed in a similar way to the techniques used in laparoscopic surgery, with the aim of improving symptoms and/or fertility.

Hysterectomy for Endometriosis

A total hysterectomy is the surgical removal of the uterus, and is an irreversible procedure. It is usually carried out as a last resort in cases where symptoms of endometriosis are debilitating and other treatments have not worked.

There are different degrees of a hysterectomy including a partial hysterectomy (removal of the uterus but not the cervix), oophorectomy (the removal of one or both ovaries) and a radical hysterectomy (removal of the uterus, cervix, uppermost part of the vagina and the nearby ligaments). The type of procedure carried out depends on a variety of factors, including the severity and location of endometriotic lesions and symptoms.

A hysterectomy is not a guaranteed cure for endometriosis, and it is important to consider the pros and cons associated with the procedure and to discuss these with a healthcare professional. A hysterectomy means that it is no longer possible to get pregnant, so it is a treatment for symptoms associated with endometriosis but does not improve fertility.

As a hysterectomy stops periods, it can relieve symptoms for some women whose symptoms are worsened during menstruation. However, if endometriosis is outside of the uterus, a hysterectomy may not alleviate symptoms. Therefore, it is important to discuss all the available treatment options with a healthcare professional.

Needless to say, endometriosis symptoms can return following a hysterectomy, but recurrence is less likely than other types of surgery such as laparoscopic. The most common symptoms to return following a hysterectomy are pelvic pain and pain during penetrative sex.

Bowel and bladder endometriosis can also appear following a hysterectomy, but it is not thought that this was caused by the surgery itself, and instead was present but undiagnosed at the time of surgery. Symptoms of bowel endometriosis include abdominal pain, constipation and/or diarrhoea, bloating, blood or mucus in stools, intestinal cramps, nausea and vomiting, painful bowel movements and rectal pain. These symptoms are also likely to be cyclical (occur during the menstrual period) if the ovaries have not been removed.

Robotic Assisted Surgery for Endometriosis

Robotic surgery can be performed using da Vinci technology, where the surgeon uses a console to operate surgical instruments within the abdomen. Robotic surgery is thought to induce less trauma to surrounding tissue and provide a greater range of motion when compared to laparoscopic and laparotomy surgery. However, it is not usually the default treatment option as it is significantly more expensive than the current ‘gold standard’ laparoscopic surgery.

Robotic surgery for endometriosis has similar outcomes to laparoscopic surgery, with no research suggesting increased complication rates. However, it may be recommended over laparoscopic surgery if there is an abundance of endometrial adhesions in challenging locations or there is a high risk of complications. Like laparoscopic surgery for endometriosis, patients can usually go home on the same day following robotic assisted surgery.

After Surgery for Endometriosis

The recovery time following surgery for endometriosis varies depending on the type of procedure, the severity and location of endometriosis, as well as personal factors such as age, weight and surgical history.

Following laparoscopic surgery for endometriosis, it is common to feel tired for a few days. However, the patient should be able to return to normal activities in around two weeks, with a full recovery usually taking 4-8 weeks. As laparotomy surgery is more invasive than a laparoscopy, hospital admission for a few days is usually required. Recovery to normal activities usually takes 2- 6 weeks, but varies between patients. Laparoscopic surgery for endometriosis usually results in relatively small and minimal scars from the incision points. However, laparotomy surgery usually results in a more visible and larger scar along the bikini line, which should fade over time.

It is important to note that there are risks associated with any type of surgery. Risks (and side effects) most commonly associated with endometriosis surgery include spotting, bleeding, pelvic pain, infection of the bladder, voiding dysfunction and organ damage. However, the risks vary greatly depending on the type of surgery and methods used, with laparoscopic surgery associated with the lowest risk. There is always a risk that a laparotomy is required during laparoscopic surgery to repair any injury inflicted. This of course comes with more risks, results in a larger incision in the abdomen, and often has a longer recovery time.

Surgery of moderate to severe endometriosis has also been found to carry higher risks of complications, especially among women with comorbidities (such as adenomyosis). However, most complications from endometriosis surgery do not seem to have a negative effect on pregnancy, live birth rates or time to pregnancy.

When and how much pain improves following surgery for endometriosis also varies between patients. Though surgery is not a guaranteed cure for endometriosis symptoms, studies suggest approximately 2 in 3 women see improvement in endometriosis associated pain 6 months post-surgery. Successful surgery can significantly improve endometriosis symptoms and the quality of life. However, the probability of endometriosis recurrence following surgery (estimated to be between 5% and 20% per year) does mean symptom relief can be short lived.

A long-term follow-up study of 84,885 women who underwent surgery for endometriosis reported that approximately 1 in 4 women who undergo minor endometriosis surgery, and 1 in 5 who undergo major conservative surgery with ovarian preservation, will require further endometriosis surgery in the following 10 years. Therefore, doctors usually prescribe hormone therapy with the aim of slowing down the recurrence of endometriosis.

When (and How Much) Should Fertility Improve

Overall, 30-50% of women become pregnant naturally within 18 months post-surgery. Research suggests this natural fertility window post-surgery varies according to the severity of endometriosis. For example, the natural fertility window is on average 36 months for stage 1, 24 months for stage 2 and 12 months for stages 3 and 4 endometriosis.

The severity of endometriosis is classified by stages based on the extent of lesions and scar tissue, not the severity of pain.

These stages include:

• Stage 1 (minimal) – a few small lesions with little to no scar tissue
• Stage 2 (mild) – deeper adhesions with some scar tissue
• Stage 3 (moderate) – many deep lesions with thick bands of scar tissue
• Stage 4 (severe) – the most widespread with many deep lesions and bands of scar tissue

It is thought that the improvement in fertility post-surgery depends on whether or not active lesions of endometriosis are present at the time of surgery. However, other factors are also involved such as the severity and location of endometrial adhesions.

A previous study, featuring women with minimal or mild endometriosis, reported a significant increase in the cumulative probability of pregnancy, 20 weeks post-surgery, with a probability of 31% post-surgical laparoscopy compared to a probability of only 18% following a diagnostic laparoscopy.

A more recent study including women with moderate to severe endometriosis also revealed improved fertility outcomes post-surgery, with 55% of women conceiving naturally and another 23% conceiving following IVF.

Overall, research suggests that surgery for endometriosis can improve fertility, with differences in success rates depending on the severity of the condition and the type of surgery carried out.

Final Tip from Fertility Science

Unfortunately, there is no easy ‘cure’ for endometriosis, but surgery can be a valid option for many women who have previously tried non-surgical treatments and are still are looking for symptom relief and/or improved fertility.

It is important to carefully assess the risks, recovery time, and potential for the recurrence of symptoms following surgery. Factors such as symptom severity, fertility goals and previous treatments should also be considered.

Although surgery is not guaranteed to treat alleviate symptoms, many women experience significant improvements in their quality of life post-surgery. However, it must also be recognised that there is still the potential for recurrence of symptoms as well as side effects of such invasive surgery, which should all be discussed with a healthcare professional.