{"paper_id":"0ffc89cf-3b7f-4597-981b-d85419402b92","body_text":"125\nCurrent Role of Minimally Invasive Surgical \nTechniques in the Diagnosis and Management of \nEndometriosis-A Clinical Review\nCopy Right@ Hany Wisa\nThis work is licensed under Creative Commons Attribution 4.0 License  AJBSR.MS.ID.001367.\nAmerican Journal of\nBiomedical Science & Research\nwww.biomedgrid.com\n---------------------------------------------------------------------------------------------------------------------------------\nISSN: 2642-1747\nReview Article\nHany Wisa1*, Aiman Aref1 and A I  Hasib Ahmed1,2\n1Medway NHS Foundation Trust, Kent, UK\n2Canterbury Christ Church University, Kent, UK\n*Corresponding author: Hany wisa , Medway NHS Foundation Trust, Kent, UK.\nTo Cite This Article: Hany Wisa, Aiman Aref, A I  Hasib Ahmed. Current Role of Minimally Invasive Surgical Techniques in the Diagnosis and \nManagement of Endometriosis-A Clinical Review. 2020 - 9(2). AJBSR.MS.ID.001367. DOI: 10.34297/AJBSR.2020.09.001367.\nReceived: \n  May 02, 2020;  Published: \n   June 12, 2020\nAbstract\nBackground: Endometriosis is a very common gynaecological condition associated with chronic pelvic pain and a negative impact on fertility. \nVarious medical and surgical methods have been described to treat endometriosis with varying degrees of success. \nAim: This review examines the evidence behind the current practice of minimal invasive surgery in the diagnosis and management of this \ncondition.\nMethods: The Cochrane database was searched for systematic reviews about endometriosis. The ESHRE guidelines were also included. A search \nof the British Journal of Obstetrics and Gynaecology “BJOG” , and the Journal of Minimal Invasive Gynaecology “JMIG” individual database for articles \nabout surgical management of endometriosis was done.\nFindings: Diagnostic laparoscopy is the method of choice for diagnosis and is best combined with histological diagnosis. Surgical treatment \nof endometriosis is superior to medical treatment in terms of recurrence of symptoms and complete cure of the disease. Medical treatment has no \nrole in fertility related endometriosis. Laparoscopic surgery in general is preferred to the open approach. Conservative surgery includes ablation or \nexcision of the peritoneal lesions. Ovarian endometriomas are best treated with excision of the cyst wall rather than ablation. Laparoscopic uterine \nnerve ablation (LUNA) is not effective in the treatment of endometriosis related pain. Presacral neurectomy (PSN) is effective but requires specific \nsurgical expertise. Deep infiltrating endometriosis affecting the rectum and sigmoid is mainly treated with resection and anastomosis. There is still \nnot enough evidence to support the use of robotic surgery.\nConclusion: Minimally invasive surgical techniques have a well-established role in the diagnosis and treatment of pain related and infertility \nrelated endometriosis. Surgical management is superior to medical management. More trials are awaited to identify the role of robotic surgery in \nthis field.\nKeywords: Endometriosis, Endometrioma, Infertility, Laparoscopy, LUNA, PSN, Robotic surgery, Endometriomas, Ovaries \nAbbreviations: ESHRE: European Society of Human Reproduction and Embryology; LUNA: Laparoscopic uterine nerve ablation; PSN: Presacral \nneurectomy\nIntroduction\nEndometriosis is a very common gynaecological condition \nassociated with chronic pelvic pain and a negative impact on \nfertility. Various medical and surgical methods have been described  \n \nto treat endometriosis with varying degrees of success. This essay  \nexamines the evidence behind the current practice of minimal \ninvasive surgery in the diagnosis and management of this condition \nand explores the recent advances in that field.\n\nAmerican Journal of Biomedical Science & Research\nAm J Biomed Sci & Res                                     Copy@ Hany Wisa\n126\n Background\nEndometriosis is characterised by the presence of tissue similar \nin structure and function to endometrium but present outside the \nuterus, most commonly in the pelvic cavity. The lesions are mainly \nscattered and implanted into the visceral peritoneal surfaces in the \npelvis. The presence of these lesions causes chronic pelvic pain, \npainful periods, painful sexual intercourse and infertility [1].\nThe term “Pelvic endometriosis” is used to define implants that \ninvolve the pelvic peritoneum including the anterior cul-de-sac \n(utero-vesical pouch), posterior cul-de-sac pouch of Douglas), pelvic \nside walls and surface of uterus, tubes. Ovarian endometriosis can \npresent as blood filled cysts known as endometriomas. “Extra-pelvic \nendometriosis is defined as endometriotic–like implants elsewhere \nin the peritoneal cavity or other body cavities. Endometriotic \nimplants can involve the bladder, pelvic ureter, sigmoid colon, \nrectum, ileocaecal area and appendix [2]. Bladder endometriosis \ncan present with cyclical haematuria, dysuria, urgency and \nfrequency [3]. Ureteric involvement can end in ureteric obstruction. \nGastrointestinal endometriosis can present with disturbed bowel \nfunction and cyclical rectal bleeding. Less commonly endometriosis \nmay be present in the pleural cavity causing cyclical haemoptysis \n[4].\nEndometriosis is present in about 6-10% of all women of \nreproductive age. Its prevalence can be as high as 35-50% in women \npresenting with pelvic pain, infertility or both [5]. A multicentric \ncross-sectional prospective study demonstrated significant \nimpairment of the quality of life and work productivity across \ncountries and ethnicities in women suffering from endometriosis \n[6]. A significant number of women suffering from pain due to \nendometriosis also show symptoms of depression and anxiety [7]. \nThe negative impact of endometriosis on fertility has been \nattributed mainly to four mechanisms. Distorted adnexal anatomy \ndue to scarring inhibits the capturing the mature ovum by the \nfimbrial end of the fallopian tube. Inflammatory changes in the \nperitoneal fluid can inhibit fertilization of the ovum or interfere \nwith oocyte development and early embryogenesis. Finally, \nreduced endometrial receptivity impairs the implantation process \n[8]. Several European studies have shown significant delay in the \ndiagnosis of endometriosis. This could be explained by several \nfactors including wrong diagnosis and the acceptance of menstrual \nperiod related pain as a normal phenomenon by patients and \ndoctors [9]. The correct diagnosis can be delayed by up to 8 years \nin the UK [10]. \nA wide range of medical and surgical approaches have been \npracticed for the management of endometriosis. Medical treatment \nthat aims to supress ovulation with hormonal agents is effective in \nreducing pain in 80-90% of women; However, pain recurrence is \nfrequent after stopping treatment. Laparoscopy is now considered \nthe preferred management choice for endometriosis owing to \nthe advances in minimal invasive surgery technology and the \nlimitations of medical treatment [11].\nMethods\nThe Cochrane database was searched for systematic reviews \nabout endometriosis. 6 Cochrane systematic reviews were \nidentified, 5 of which looked at surgical treatment of endometriosis \nand these were included in this essay. The ESHRE guidelines were \nincluded in the review. Some references from the ESHRE were \nfurther looked at based on their relevance to the title of the essay \nand date of publication with preference to the last 5 years. A search \nof the British Journal of Obstetrics and Gynaecology “BJOG” , and the \nJournal of Minimal Invasive Gynaecology “JMIG” individual database \nfor articles about surgical management of endometriosis was done.\nResults \nLaparoscopic diagnosis of endometriosis\nThe current guideline of the European Society of Human \nReproduction and Embryology (ESHREE) for the management \nof women with endometriosis, recommends that diagnostic \nlaparoscopy should not be attempted merely for the diagnosis of \nsuperficial peritoneal disease if signs of deep infiltrating disease \nor ovarian endometriosis (endometriomas) were not present on \nphysical examination or pelvic ultrasound imaging. Treatment of \nperitoneal disease has not been shown to alter the natural course \nof the disease. Diagnostic laparoscopy for endometriosis should be \ndone with histology for the lesions to confirm the diagnosis and to \nexclude the rare possibility of malignancy [12].\nA systematic review of literature was conducted to evaluate \nthe accuracy of laparoscopy in the diagnosis of endometriosis [13]. \nThe authors searched the literature for studies where diagnosis of \nendometriosis was verified by histology. Initially 1426 studies were \nidentified but only 27 were included in the review after excluding \nstudies with inappropriate population selection, inappropriate \nintervention or failed procedures. Duplicate work lacking original \ndata was also excluded. Only 4 studies out of these 27 were \ncontrolled studies. However, out of these 4 studies only 2 were \nblinded and only one mentioned the method of data collection. \nIn addition to highlighting the paucity of high quality studies \nin this aspect, the authors concluded that a negative diagnostic \nlaparoscopy was highly accurate for excluding the disease and a \npositive laparoscopy without taking biopsies for histology was of \nlimited value.\nLaparoscopic treatment of endometriosis\nLaparoscopic techniques for the treatment of endometriosis \ndepend on the location of the lesions, the severity of symptoms and \nthe aim of the treatment. Conservative surgery includes excision \nor ablation (destruction by electro-cautery, or laser) of small \n\nAm J Biomed Sci & Res\nAmerican Journal of Biomedical Science & Research\nCopy@ Hany Wisa\n127\nlesions limited to the peritoneal surfaces in addition to division of \nadhesions. Endometriomas of the ovaries have been treated with \neither excision of the cyst capsule or drainage and electrocoagulation \nof the cyst wall. Pelvic denervation to treat endometriosis related \npain has also been described. The most common procedures are \nthe laparoscopic uterine nerve ablation (LUNA) and presacral \nneurectomy (PSN). When preservation of fertility is not an issue, \nthe severity of symptoms can warrant removal of the uterus and \nboth tubes and ovaries as the definitive cure for endometriosis. \nClassically, abdominal hysterectomy was the normal approach \nbut recent advances in Minimal invasive surgery technology and \ntechniques have made Laparoscopic Hysterectomy the preferred \nmethod for radical treatment of Endometriosis [11].\nIn a Cochrane systematic review of randomised controlled \ntrials (RCTs) to assess the effectiveness and safety of laparoscopic \nsurgery in the treatment of pain and subfertility associated with \nendometriosis examined ten RCTs with a total of 973 patients [14]. \nThe quality of evidence was evaluated using GRADE methods. \nLaparoscopic surgery was associated with decreased overall \npain compared with diagnostic laparoscopy alone, both at six \nmonths and at 12 months. Compared with diagnostic laparoscopy, \nlaparoscopic surgery was also associated with an increased live \nbirth or ongoing pregnancy rate and increased clinical pregnancy \nrate. Only two studies collected data on adverse events and \nreported no events in either arm. Other studies did not report this \noutcome which limits the value of this review regarding the safety \nof laparoscopic surgery.\nWhen laparoscopic ablation was compared with diagnostic \nlaparoscopy plus medical therapy (GnRH analogue plus add-back \ntherapy), more women in the ablation group reported that they \nwere pain free at 12 months. Common limitations in the primary \nstudies included lack of clear descriptions of randomisation, \nblinding and incomplete outcome data. The authors confirmed \ndifficulties in meta-analysis of data due to heterogeneity of the \noutcome measures used in the trials, which made it difficult to draw \nclinically relevant conclusions. \nBased on this review, both laparoscopic ablation and excision \nof lesions seem to be similarly effective in the treatment of \npain. However, this is based on one small randomised trial of 24 \nparticipants that did not report blinding [15] and a larger RCT of 178 \nparticipants that lacked explanation of how ablation or excision were \ndone or which method was used to treat ovarian endometriomas \n[16]. An RCT showed that laparoscopic excision of endometriosis \nlesions was more effective than placebo (80% vs 32%) in terms of \nreducing pain and improving quality of life [17]. However this study \nlacked power with only 19 women in the placebo arm vs 20 women \nin the treated arm. The ESHREE guideline for the management \nof endometriosis recommends excision of endometriotic lesions \nrather than ablation to obtain histological diagnosis. Furthermore, \nablation might not be sufficient to deal with endometriotic lesions \ndeeply infiltrating the visceral peritoneum [12].\n Pelvic denervation\nLaparoscopic uterine nerve ablation (LUNA) involves making \nan incision in each uterosacral ligament. This divides the sensory \nnerve fibres to the uterus and the cervix. This is considered to be \na simple procedure that can be performed by most laparoscopic \nsurgeons. In contrast, presacral neurectomy (PSN) is associated \nwith significant morbidity as it involves division of the hypogastric \nplexus of nerves at the promontory of sacrum which is in close \nproximity to major blood vessels, therefore requires higher level of \nskills [18].\nA Cochrane review looked at the effectiveness of pelvic \ndenervation for treatment of primary and secondary dysmenorrhea. \nSix out of the eleven RCTs identified addressed the effectiveness \nof the treatment for dysmenorrhea secondary to endometriosis. \nThree out of these trials examined the benefit of LUNA plus \nconservative laparoscopic surgery (i.e. ablation and or excision) for \nendometriosis and three trials examined PSN (one trial examined \nthe laparoscopic approach and two trials the open approach). \nThere was no significant risk of bias in the included studies. LUNA \ncombined with surgical treatment of endometriosis lesions did not \nshow to be of any additional benefit for pain relief compared to \nsurgical treatment alone. Laparoscopic PSN combined with surgical \ntreatment of endometriosis was of significant benefit in terms of \npain relief compared to surgical treatment alone but was associated \nwith increased risk of adverse events like bleeding, constipation \nand urinary urgency. Laparoscopic PSN was also shown to be \nmore specific to midline pain. There was insufficient evidence to \nrecommend the use of LUNA for the treatment of dysmenorrhoea \nregardless of the cause and therefore laparoscopic conservative \nsurgery for endometriosis associated pain should not be combined \nwith LUNA. Laparoscopic PSN is of benefit in the treatment of pain \nrelated to endometriosis but for midline pain only and requires \nvery precise surgical techniques due to the potentially hazardous \nsurgery [19].\nTreatment of endometriomas\nThe pathogenesis of endometriomas is unclear. One possible \nexplanation is the transplantation theory [20] that deposits of \nendometrium cause adherence between the ovary and the pelvic \nperitoneum with progressive invagination of the ovary [21]. \nAccording to this explanation, the endometrioma should be a \npseudocyst and its wall is the inverted ovarian cortex. Surgical \ntreatment of endometriomas has been shown to be superior to \nmedical treatment [22] and when compared to laparotomy, operative \nlaparoscopy is the method of choice as it has been shown to be \nassociated with shorter hospital stay, faster recovery, less costs and \n\nAmerican Journal of Biomedical Science & Research\nAm J Biomed Sci & Res                                     Copy@ Hany Wisa\n128\nlower incidence of developing new adhesions [23]. Laparoscopic \ntreatment of ovarian endometriomas can either be done by excision \nof the cyst capsule or drainage and electrocoagulation of the cyst \nwall.\nA Cochrane systematic review compared the two techniques \nto determine the most effective way for treatment. Two RCTs \nwere identified comparing laparoscopic excision of the cyst wall \nwith drainage and ablation by bipolar diathermy. The primary \noutcome was to measure the improvement in pain symptoms and \ninfertility. The secondary outcome was to measure the recurrence \nof endometriomas and recurrence of symptoms. In both studies, \nrandomisation and allocation of concealment were free of bias. \nAlthough the studies were unblended all patients were followed \nup with no selective outcome reporting. Excision of the cyst was \nassociated with less recurrence of the endometrioma, less painful \nperiods, less painful intercourse, less non-menstrual pelvic pain \nand subsequent increased spontaneous pregnancy rate in women \npreviously known to be subfertile. There was insufficient evidence \nas to which technique was better with regards to fertility [24]. A \nmore recent prospective randomized trial evaluated excision of \novarian endometriomas against laser vaporization with a five year \nfollow up for recurrence. The authors reported significantly higher \nrecurrence rate of endometriomas on ultrasound in the group \ntreated with laser vaporization at 12 months compared with the \nexcision group. There was no statistically significant difference of \nrecurrence rate at 5 years follow up [25]. This study was limited by \nthe number of patients allocated to each group (36 for cystectomy \nand 38 for laser vaporization). According to the authors a sample \nsize of 312 patients per group would be necessary to provide a \nstatistical power of 80%.\nDeeply infiltrating endometriosis\nSurgical treatment options for colorectal deep endometriosis \ninclude superficial shaving (superficial peeling of bowel serosal \nand subserosal endometriosis), discoid resection (selective \nexcision of the endometriosis lesion with opening, then closure, of \nthe bowel wall) and segmental resection of the bowel [26]. Donnez \nand Squifflet [27] debated the evidence for better improvement \nwith the bowel resection technique against the shaving technique. \nThey analysed the complication rate of 500 patients treated by the \nshaving technique for deep rectovaginal endometriotic nodules. \nTheir findings showed overall all complication rate with the shaving \ntechnique (1.4% rectal perforation, 0.8% ureteric injury and 0.2% \nsignificant blood loss) and a combined (both spontaneous and \nIVF) post treatment pregnancy rate of 84%. Their argument is that \nendometriosis “is not cancer” and therefore does not require the \nsame treatment approach. Accordingly, they support debulking \nsurgery (shaving) against radical surgery (rectal resection). \nHowever, this study lacked a control group.\nA systematic review concluded that segmental bowel resection \nfor colorectal endometriosis was followed by excellent pain relief \nfor the first year after surgery [28]. Recurrence of pain requiring \nintervention was reported in 61 out of 314 women. Bowel resection \nseemed to be a widely acceptable option possibly because bowel \nsurgeons are used to resections for the treatment of bowel cancer. \nThis review did not specify the type of studies included and \nhighlighted the poor reporting of operative techniques, lesion \nsize, or indication for surgery among the studies. In addition, \nendometriosis was not always confirmed by histology.\nThere is lack of clear comparison of the clinical outcome of \nvarious surgical techniques for the treatment of deep colorectal \nendometriosis. A systematic review examined 49 studies. 71% \nof the patients were treated with bowel resection and primary \nanastomosis, 10% with full thickness disc excision and 17% were \ntreated with superficial surgery [26]. Because of the inconsistency \nof reporting data throughout the reviewed papers, comparison \nof clinical outcome between different surgical techniques was \nnot possible. The authors suggested a checklist to standardise \nthe reports of trials for surgical treatment of deep infiltrating \nendometriosis. \nIn an RCT that compared laparoscopically assisted versus open \ncolorectal resection for deep bowel endometriosis, 52 women with \ncolorectal endometriosis were randomized with 26 patients in each \ngroup. The study showed that laparoscopic colorectal resection \nwas as effective as open technique in terms of improvement in \nsymptoms and quality of life. Laparoscopy was associated with \nhigher spontaneous pregnancy rate compared to open surgery [29]. \nAlthough the authors stated that “this study was not designed to \ntest whether laparoscopic assisted colorectal resection is superior \nto open surgery for endometriosis” , they reported that laparoscopy \nrequired less postoperative analgesia than open surgery and \nis a safe option with overall less severe complications in the \nlaparoscopy group (11 versus 25). There was a 7.7% conversion \nrate from laparoscopic to open surgery. This study lacked power \ndue to small number of patients in each arm and was unblinded.\nLaparoscopic Hysterectomy\nHysterectomy with removal of tubes and ovaries has long been \nproposed as the definitive cure for endometriosis. Classically, the \noperation was done abdominally. Recent technological advances \nin minimally invasive surgery has led to the emergence of the \nlaparoscopic approach as the preferred method owing to less \npostoperative pain and faster recovery. Evidence to support \nhysterectomy as the definitive treatment for pain related to \nendometriosis remains controversial. In a non-systematic review of \nliterature [30], 80 references relative to laparoscopic hysterectomy \nfor endometriosis were identified. The author identified 80 \n\nAm J Biomed Sci & Res\nAmerican Journal of Biomedical Science & Research\nCopy@ Hany Wisa\n129\nreferences relevant to the subject and concluded that hysterectomy \nsignificantly improved non-specific pelvic pain associated with \nendometriosis. However, there was of differentiation in the \nliterature reviewed between cyclical and non-cyclical pelvic pain, \nmaking interpretation of the findings difficult. Hysterectomy with \nconservation of ovaries was associated with a six fold increased risk \nfor recurrent pelvic pain and eight times increased risk for needing \nfurther surgery compared to hysterectomy with removal of the \novaries. The Martin review [30] reiterates controversy in considering \ntotal abdominal hysterectomy and bilateral salpingoophorectomy \n(TAH-BSO) as “definitive surgery” for endometriosis. The term \n“definitive surgery” implies that TAH-BSO results in complete cure \nof pain. The assumption is that removing the ovaries will result in \nregression of any remaining endometriotic deposits due to removal \nof estrogenic stimulus. However, requirement for further surgery \nfor endometriosis after TAH-BSO has been described. Radical \nexcisional surgery is more appropriately termed “definitive cure” \nwhere in addition to TAH-BSO, all indefinable endometriotic lesions \nare excised including lesions on the bowel, bladder and ureter.\nThe laparoscopic approach to hysterectomy as a treatment \nfor severe pelvic endometriosis has been compared to the \nabdominal approach in a retrospective analysis of 503 patients \nwho underwent hysterectomy for severe endometriosis [31]. 115 \npatients underwent laparoscopic hysterectomy and 388 abdominal \nhysterectomies. Measured surgical outcomes were operative time, \nblood loss, need for blood transfusion and duration of hospital stay. \nThe results were in favour of laparoscopic hysterectomy in terms \nof the last three parameters but operative time was significantly \nlower with the abdominal approach. There was a 4.3% conversion \nrate from laparoscopic to abdominal approach. With lower \ncomplication rates in those women treated by the laparoscopic \napproach, it is reasonable to consider laparoscopy as the approach \nof choice for patients undergoing hysterectomy for endometriosis. \nThis recommendation needs confirmation by prospective RCTs.\nRobotic Hysterectomy\nA systematic review in 2011 identified only 4 published \narticles about the use of robotic assisted laparoscopic surgery for \nendometriosis [32]. Three studies were case reports, one of which \nis detailed below, and the fourth was a cohort study discussed \nfurther. All the studies showed that robotic surgery seems to be safe \nwith no report of complications. No randomized controlled trials \nexist on this subject.\nA large retrospective cohort study compared robotic-assisted \nlaparoscopy with conventional laparoscopy for treatment of \nadvanced stage endometriosis [33]. Measured parameters \nincluded operative time, estimated blood loss, complication rate, \nand length of hospital stay. 273 patients underwent conventional \nlaparoscopy and 147 underwent robotic assisted surgery. There \nwere no significant differences in blood loss or complication rate \nbetween the 2 groups but the mean operative time was more in the \nrobotic assisted group (196 minutes) compared to the conventional \nlaparoscopy group (135 minutes). Length of hospital stay was also \nsignificantly increased in the robotic-assisted laparoscopy group. \nThe longer duration of the robotic technique was related to several \nfactors. Dealing with large specimens like ovarian endometrioma \nwas more difficult with the robotic method for technical reasons. \nAlso the use of CO2 laser for ablation of lesions is not possible with \nthe robotic method and more time and care is required to achieve \nthe ablation with robotic scissors and monopolar hook. Also the \nlimited flexibility in changing the camera places in the robotic \ntechnique contributed to longer operative time.\nCurrently no papers exist in the literature to compare \nlaparoscopic hysterectomy with robotic hysterectomy specifically \nfor endometriosis; however, several studies have compared the two \ntechniques for hysterectomy for different indications. A retrospective \nstudy comparing total laparoscopic hysterectomy versus robotic \nhysterectomy in terms of operative time, complications and hospital \nstay does not support the widespread use of robot for hysterectomy \n[34]. 77 patients underwent total laparoscopic hysterectomies \nand 47 patients underwent robotic hysterectomies. The authors \nfound no justification to favour the routine use of robotic assisted \ntechnique for hysterectomy compared to conventional laparoscopy. \nThe results of this study lack generalisation as only two surgeons \nperformed all the operations included. Robotic technique might \nbe a way for less experienced surgeons to change faster to more \nminimally invasive approach to gynaecologic surgery, however, \nwith surgeons skilled in conventional laparoscopic hysterectomy, \nthe robot rarely improves the outcome.\nConclusion \nEndometriosis is a very common gynaecological condition \ncharacterised by the presence of ectopic endometrial tissue \noutside the uterus that causes chronic pelvic pain, pelvic adhesions \nand impaired fertility. It can adversely affect the quality of life of \nthe sufferer and may cause depression and anxiety. Up to 50% of \nwomen suffering from pelvic pain are found to have endometriosis. \nDiagnostic laparoscopy is the method of choice for diagnosis and is \nbest combined with histological diagnosis.\nSurgical treatment of endometriosis is superior to medical \ntreatment in terms of recurrence of symptoms and complete cure \nof the disease. Medical treatment has no role in fertility related \nendometriosis. Laparoscopic surgery in general is preferred to the \nopen approach due to fewer complications, less postoperative pain, \nshorter hospital stay and faster recovery.\n\nAmerican Journal of Biomedical Science & Research\nAm J Biomed Sci & Res                                     Copy@ Hany Wisa\n130\nConservative surgery which aims to spare fertility includes \nablation or excision of the peritoneal lesions with comparable \noutcomes. Excision adds the benefit of histological diagnosis so it \nis the recommended method for mild to moderate disease. Ovarian \nendometriomas are best treated with excision of the cyst wall rather \nthan ablation to avoid recurrence. Laparoscopic uterine nerve \nablation (LUNA) is not effective in the treatment of endometriosis \nrelated pain. Presacral neurectomy (PSN) is effective but requires \nspecific surgical expertise owing to the higher risk of complications \nand higher morbidity. Deep infiltrating endometriosis affecting \nthe rectum and sigmoid is mainly treated with resection and \nanastomosis. There is insufficient evidence to support such radical \nsurgery compared to shaving or excision of the lesions without bowel \nresection. Definitive surgical treatment of endometriosis requires \nradical excision of all identifiable endometriotic deposits. Recently, \nrobotic assisted laparoscopy has been used in endometriosis \nsurgery. There is still not enough evidence to support its routine \nuse. It can help less experienced surgeons to do more minimally \ninvasive surgery due to the shorter learning curve but it has its \nown limitations compared to conventional laparoscopy in terms of \nlonger operation time and high cost. \nAcknowledgements\nNone\nConflict of Interest\nNone\nReferences\n1. Burney R O, Giudice L C (2012) Pathogenesis and pathophysiology of \nendometriosis. Fertil Steril 98(3): 511-519.\n2. 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