When choosing surgery for endometriosis, there are a number of decisions that must be made. The first such decision point is whether conservative surgery or hysterectomy is desired. If the approach is conservative, there are choices in the method of access, the method of treating implants, and the type of surgery done for endometriomas. Finally, there may be a need for other actions to be taken at surgery such as cutting and removing scar tissue, removing the appendix, and interrupting key nerves that transmit pain from the pelvis. Your surgeon should review all of these issues with you prior to the surgical procedure.
(1) Conservative Surgery vs. Hysterectomy
Most surgeons performing surgery for endometriosis must choose one of two possibilities: conservative surgery, where the patient’s future fertility remains an option, or hysterectomy (generally with removal of the ovaries). The general perception is that hysterectomy is more effective over time than conservative treatment, but it must be reserved for patients in whom fertility is no longer desired.
Unfortunately, hysterectomy and removal of the ovaries do not ensure that you will obtain relief: the incidence of continued or recurrent pain is still about 10%.
(2) Method of Access
When conservative surgery is desired, there are options for how to access the inside of the body. Traditionally, surgery was performed through large skin incisions (laparotomy or open surgery). More recently, though, gynecologists have been able to perform surgery through small incisions with the use of specialized instruments and a telescope (laparoscopy). This latter approach, using laparoscopy, is best for the patient because it is less invasive, less painful, and leads to a more rapid recovery. It also generally results in less scar tissue forming as a result of the surgery. Also, the magnification of the telescope allows the surgeon to see better during surgery and be more accurate in removal of disease. Finally, it is usually far less expensive.
However, laparoscopic surgery is technically much more difficult to perform than open surgery. When the surgery for endometriosis becomes difficult due to the amount or location of disease, many surgeons will opt to perform the surgery through a large skin incision. However, surgeons who have received special training in advanced laparoscopy will generally be able to perform most, if not all, surgical procedures for endometriosis through small incisions. The surgeons at the Wisconsin Fertility Institute have such training as well as considerable experience in performing even the most difficult endometriosis surgeries through the laparoscope.
(3) Method of Destruction of Implants
Surgical destruction of endometriosis lesions can be accomplished in one of two ways: ablation and excision. Ablation of the disease means that the endometriosis is not removed from the body but rather destroyed where it lays. The method of destruction may be by electrical heat or laser. The advantage of this approach is that it is much easier for the surgeon. Also there is much less danger to surrounding structures such as bowel, bladder, ureter, and large blood vessels. However, there is considerable danger that the entire endometriosis implant may not be removed, as such lesions are frequently deep (so that only the top is destroyed) or wider than the surgeon thinks (as the edges are sometimes difficult to see). If endometriosis is left behind, the chance of pain after surgery is much greater.
By contrast, excising the endometriosis is a much more complete procedure. To do this, the surgeon must make an incision around the entire area of endometriosis and dig out all the disease, no matter how deep. This requires considerable skill, as endometriosis frequently lies close to other very important structures in the pelvis that are easily damaged. Thus, there is considerable risk with this type of surgery, and even the world’s best endometriosis surgeons have serious complications on occasion. However, there is no doubt that better pain relief is obtained by excision of disease; unfortunately, there is also a risk of more scar tissue than with ablation, which may damage future fertility.
Surgeons at the Wisconsin Fertility Institute are highly experienced in performing both types of surgery through the laparoscope, and thus are capable of tailoring the surgery to your needs for pain relief and future fertility.
(4) Method of Treating Endometriomas
Endometriomas are cysts of the ovary formed by endometriosis and they can grow quite large and become very painful. A common approach to the treatment of these cysts is to remove the ovary (sometimes even the ovary and fallopian tube). However, this is rarely necessary. The goals of treating ovarian endometriomas are to:
- remove all endometriosis in the ovary
- minimize damage to the ovary
- minimize post-operative scar tissue
When operating on endometriomas, the ovaries should first be freed of all scar tissue. The endometrioma is then carefully removed from the rest of the ovary. It is not acceptable to simply drain the fluid from the cyst and leave the lining behind, as the chance of the cyst reforming is very high. Instead, the entire cyst wall is removed, and the ovary carefully repaired. When repairing the ovary, sewing it closed is preferred to using electrical energy, as the electricity can damage the normal tissue of the ovary.
(5) Other procedures frequently performed
- Lysis of adhesions (cutting and removing scar tissue): When scar tissue is present in the pelvis it can result in pain and fertility problems. Removing this abnormal tissue is important in endometriosis surgery. Also, it is important to try to prevent the formation of new scar tissue after surgery. This is best accomplished with careful surgical technique, but is aided by using special materials that decrease the formation of scar tissue. Most commonly used is a material called Interceed.
- Appendectomy (removal of the appendix): The appendix has endometriosis in it in as many as 1 in 6 cases. It should always be carefully inspected and removed if it appears abnormal, as there is little risk to the procedure and substantial gain if endometriosis is present. Furthermore, in women with pelvic pain, it is advisable to remove the appendix so that future bouts of pain are not confused with appendicitis. Also, if it is left in a future appendicitis might be written off by your doctor as the “usual” pelvic pain with disasterous results.
- Nerve interruption procedures: Two surgical procedures are designed to help reduce pain transmission in the patient with endometriosis-associated pain: the uterosacral nerve ablation/resection and presacral neurectomy. Both involve interruption of the nerves that send pain from the uterus to the spinal cord. Of the two, the presacral neurectomy is far more successful and more difficult to perform. The difficulty lies in the location of the nerves, just below the aorta and vena cava (the largest blood vessels in the body). Surgeons at the Wisconsin Fertility Institute are quite experienced at performing these procedures through small incisions. Our team members at Advanced Pain Management are able to determine if you are likely to get substantial pain relief from these complex but valuable procedures.