{"paper_id":"61a5b22b-ca23-404c-915a-bd57e0ff1051","body_text":"Kulvinder Kochar Kaur1, Gautam Allahbadia2 and Mandeep Singh3\n1Scientific Director, Dr Kulvinder Kaur Centre for Human Reproduction, India\n2Scientific Director, Rotunda-A Centre for Human reproduction, India\n3Consultant Neurologist, Swami Satyanand Hospital, India\n*Corresponding author: Kulvinder Kochar Kaur, Scientific Director, Dr Kulvinder Kaur Centre for Human Reproduction, India\nSubmission: \n  April 26, 2018; Published: \n   May 09, 2018\nCurrent Role of Surgery in Endometriosis; \n Indications and Progress\nIntroduction\nEndometriosis is estimated to occur in 6-10% of women of \nreproductive age [1], with a prevalence of 38% (range 20-50%) in \ninfertile women [2] and in 71-87% of women with chronic pelvic \npain [3]. In the past symptomatic moderate to severe endometriosis \nwas most commonly treated by laparotomy with the removal of \naffected tissue, with or without hysterectomy and BSO. Recently \nmany women with advanced endometriosis have been treated by \na laparosciopic approach as it results in a shorter hospitalization \nand recovery period as compared with laporotomy. But normal \nlaparoscopy has inherent limitations for the treatment of advanced \nendometriosis because of the adhesive nature of the disease, \nobliteration of the surgical planes, variability of surgical skills and \nnormal mechanics of the human hand.\nIndications of Surgery for Endometriosis Treatment\nThere has been advancement in the management of \nendometriosis associated pelvic pain and infertility. The medical \nand surgical management of choice is mainly a thing of the past and  \n \nnow it is recognized that one needs to integrate both for a patient \npresenting with endometriosis and its associated complications \n.Still circumstance are there when surgery is required, preferred or \nrequested for.\nHence role of surgery in endometriosis is highlighted here \nbesides the articles on medical treatment of endometriosis, \naetiopathogenesis, endometriosis associated pain and role of \ndienogest and GnRH - a in Em treatment described earlier [4-6].\nRole of surgery in diagnosis\nNeed to replace diagnostic Laparoscopy with simultaneous \nexamination cum treatment: Surgery has been considered as \nthe gold standard for the diagnosis of endometriosis as it gives a \nhistological assessment of excised specimens. This is supported \nby the absence of definitive non invasive tests for endometriosis, \nalthough there has been continuing work on this conducted \ninternationally [7]. Hence diagnostic laparoscopy remains the ideal \nroute for diagnosis. Diagnostic laparoscopy for diagnostic purpose \nMini Review\nSurgical Medicine Open \nAccess JournalC CRIMSON PUBLISHERS\nWings to the Research\n1/7Copyright © All rights are reserved by Kulvinder Kochar Kaur.\nVolume 1 - Issue - 5\nAbstract\nEndometriosis is a chronic debilitating disease , which affects women of reproductive age group, although medical therapy may be helpful in \nmanaging pain associated with Endometriosis or infertility, surgery becomes an integral part of managing this disease .Although initially surgery \nwas limited to l aporotomy associated with ovarian cystectomy and/or TAH with BSO. Laporoscopy gradually replaced that. Though diagnostic \nlaparoscopy is used for confirmation of endometriosis by histological examination, it is not acceptable that Laporoscopy be done in multiple steps, \ninitially to diagnose and later for treatment. Recently a lot of advancement has come in the imaging techniques by which one can combine planning of \nsurgery based on the imaging classification. Deep endometriosis involving bowel, genitourinary tract can be dealt by careful dissection in controlled \ntrained hands, in a well equipped set up to achieve the optimum results .Endometriosis associated infertility may or may not warrant surgery as \nwith multiple studies operation on ovarian endometriomas might land up in reducing ovarian reserve - while doing straight IVF may result in better \npregnancy rates ,getting good oocyte retrieval in contrast to poor ovarian reserve resulting from damage to ovarian morphology. Use of laser for \novarian cystectomy helps in getting better outcomes than simple drainage and coagulation procedures. Robotic surgery is the latest addition, which \naids in better dissection and management but its problem is its cost, not accessible to many patients and not many trained personnel available.\nKeywords: Laparoscopic surgery; Ovarian endometrioma; Endometriosis associated pelvic pain; Ovarian reserve; Deep endometriosis\nISSN 2578-0379\n\nSurg Med Open Acc J\n   \n  Copyright ©  Kulvinder Kochar Kaur\n2/7\nHow to cite this article: Kulvinder K K, Gautam A, Mandeep S. Current Role of Surgery in Endometriosis; Indications and Progress. Surg Med Open Acc J. \n1(5). SMOAJ.000521.2018. DOI: 10.31031/SMOAJ.2018.01.000521\nVolume 1 - Issue - 5\nhas various limitations, which should challenge this practice.\nThough the value of having a histologic tissue diagnosis cannot \nbe argued about here are few points which debate the role of \nroutine Diagnostic laparoscopy.\nUnrecognized lesions of endometriosis: If there are lesions \nhaving an atypical appearance they may not be recognized by the \nsurgeon or they may be so small/subtle that pathological specimen \nmay not be retrieved. Lesions, which are deep, below adhesions, \nattributable to pelvic inflammation from previous surgery or \ninfection may get missed .Also involvement of adjacent organs which \ninclude intestinal, urinary tract and deeper nerve involvement may \nbe missed by a laparosopic evaluation.\nExcised specimens: Peritoneal or deeper lesions at the time \nof Diagnostic laparoscopy may not be excised always or may not \nbe possible .Causes for this include specimen getting destroyed by \ncrush or thermal injury at attempted removal and lack of skill to \nexcise relevant disease areas.\nRisks of surgery:  The complications occurring in diagnostic \nand operative gynecologic laparoscopy overall might be considered \nto be relatively low but still they are important considerations in \ndeciding role of surgery [8]. Various factors determine these namely \nexperience of the surgeon, patients history and co-morbidities \nand the extent of disease are factors which determine the risk of \ncomplications.\nTo optimize patient’s outcome and to minimize exposure to \nmultiple surgeries, at present role of surgery would ideally be \nreserved for diagnostic confirmation and simultaneous treatment. \nThe benefits of an examine and treat approach give the women the \nopportunity to confirm the pathology and address the underlying \ncondition, all during one anesthesia. In ideal situation a single \naccurate surgery would also occur in the proper surgical setting \nwith an experienced surgical team, with the correct equipment, time \nand assistance for the level of disease expected. Although there are \nalways going to be exceptions to the ideal setting (i.e. unexpected \nfinding) which would cause halting a procedure and further \nplanning, one should strive for optimal surgical management based \non a robust preoperative evaluation.\nRole of Surgery in Endometriosis Related Pelvic Pain\nThis needs an individualized approach depending on patients \npresenting complaint and findings on evaluation. Chronic pelvic \npain is complex and involves multiple factors beyond simply a \ndiagnosis of endometriosis [9]. Further the issue gets complicated \nby the pelvic pain being an abnormal exaggerated pain response \nfrom CNS (Central sensitization). One of the prominent features of \nchronic pelvic pain syndrome (CPPS) women with endometriosis is \ndecreased volume and density of the grey matter in regions related \nto nociception like thalamus, insular cortex and cingulated cortex \n.In CPPS women without endometriosis, similar findings are noted \nin the thalamus only while in painful cases of endometriosis, no \nsuch findings are reported [10,11]. Thus surgery for endometriosis \nmight be an appropriate way of treatment but should be only used \nif benefits obtained is much greater than the risk of surgery. Patient \ncentered care should prioritize pain reduction and improvement \nof quality of life versus optimal debulking disease which may \nnot offer these benefits, or may cause harm. It is very difficult to \ndecide whether there are any good effects of surgery regarding \nendometriosis associated pelvic pain (EAPP).\nBenefits of surgery for EAPP is very difficult to outline because \nof lack of evidence ,with limited RCT , disease presentation, varying \nconsiderably like deep, ovarian, extrapelvic and superficial, besides \nthe variations in surgical approaches and skills of the operating \nteam [12,13]. Extra genital endometriosis in 60 cases showed \nbowel foci in 37(61.7%), while in 13(21.7%) skin, and in 7(11.7%) \nurinary tract along with 3 (5%) having whole pelvis localization. \n2 of these had aggressive malignant transformation [14]. Duffy \net al. [13] carried out a Cochrane review, which said that there \nwas only moderate quality evidence which suggests that surgical \nmanagement of mild and moderate endometriosis decreases \noverall pain, however there is little evidence which can compare \nmedical therapies and very indifferent reporting of adverse events \noccurring during surgery [13]. But, Hirch et al. [15] conducting a \nsystematic review in 2016 found marked variations in outcome \nreporting endometriosis trials which prevents generalizing these \noutcomes [15]. Becker et al. [16] for the World endometriosis \nResearch Foundation collaborative elaborated guidelines on basic \ndata which should be collected for surgical endometriosis research \n[16]. Although not very clear in literature more quality studies \nbeing needed, still surgery has a major role in managing EAPP .\nHidaka et al. [17] investigated the usefulness and risks of radical \nlaparoscopic removal of deep endometriosis in patients diagnosed \nas stage III/IV endometriosis during laparoscopic surgery. (47 \nconsecutive patients undergoing conservative laparoscopic surgery \nalone (adhesiotomy and cystectomy of ovarian endometriosis but \nnot removal of deep endometrioic lesion; non DEL removal group) \nand 151 consecutive patients undergoing radical laparoscopic \nremoval of deep endometriotic lesions combined with conservative \nsurgery (DEL removal group) were compared. Significant pain \nimprovement was obtained in both groups, though the degree of \nimprovement was significantly higher and the rate of recurrence \nwas significantly lower in the DEL removal group. This addition \nof radical laparoscopic removal of deep endometriotic lesions \ncombined with conservative laparoscopic surgery significantly \ndecreases the severity of dysmenorrhea and the rate of recurrence \nof pelvic pain. Though this surgical procedure remains technically \ndemanding, amount of perioperative complications and morbidity \nare acceptable [17].\nWhen can surgery be considered\nPatientsdeclining/not responding/having contraindica -\ntions for medical treatment: Although there are advantages of \nmedical treatment for EAPP , all patients do not respond [18]. Cur -\nrently limited medical therapies remain, like hormonal suppression \nand on stoppage, pain symptoms return in ladies in reproductive \naged group [19,20]. Because of side effects like irregular menstrual \nbleeding, headache or mood changes or incomplete response medi-\n\n3/7How to cite this article: Kulvinder K K, Gautam A, Mandeep S. Current Role of Surgery in Endometriosis; Indications and Progress. Surg Med Open Acc J. \n1(5). SMOAJ.000521.2018. DOI: 10.31031/SMOAJ.2018.01.000521\nSurg Med Open Acc J   Copyright ©  Kulvinder Kochar Kaur\nVolume 1 - Issue - 5\ncal treatment is not always acceptable [12]. Thus surgery is needed \nin women who do not want long term medical therapy, get serious \nside effects or there are contraindications to medical therapy.\nMany surgeons come across situations like pts requesting \nsurgery, what they feel is a failure of medical therapy. Thus one \nneeds to counsel regarding the limitations of surgery by itself. \nThough there is an overall improvement in pain symptoms, risk \nof pain recurrence or persistence exists. Because of this repeat \nsurgery, in women refusing medical therapy or cannot use the same \nmight be essential. Berland et al. [21] showed that repeat surgery \nmight have same results as primary surgery for EAPP , but have a \nchance of 50% recurrence of pain at 5 years, and many women may \nneed repeated intervention [21].\nAcute surgical or Pain event\nRarely patient may present as an emergency admission \nwhen diagnosis is not clear and patient may undergo emergency \nlaporotomy for presumed adnexaltorsion, ruptured haemorrhagic \novarian cyst in a patients whose vitals are not stable. Sometimes \nit may be secondary to ruptured ovarian endometrioma or \nendometriosis might be an accidental finding for which it is \nimportant to documents these revelations and plan for future \nelective care be it medical or surgical.\n5.2.1. Deep endometriosis: Deep invasive endometriosis is \nthe most severe form of endometriosis involving lot of morbidity \nthat might cause marked organ compromise which might include \ngenitourinary tract obstruction, renal compromise or bowel \nobstruction. Uccela et al. [22] detailed the surgical details, long \nterm follow up and fertility outcomes in laparscopic ureterolysis for \ndeep endometriosis and found it a safe procedure with encouraging \npregnancy rates and found satisfactory long term results. But \nhaving hydronephrosis ≥2 is associated with worse outcomes [22].\nBowel Endometriosis - This occurs in 3-37% cases of \nendomrtriosis. Colorectal involvement causes alterations of bowel \nhabit like constipation, diarrhea, tenesmus and occasionally rectal \nbleeding. On the basis of clinical examination, diagnosis of bowel \nendometriosis can be made by TVS, Barium enema examination \nand MRI. Thus a multidisciplinary laparoscopic treatment has \nbecome the standard of care and depending on size of lesion and \nsite of involvement full thickness disc excision or bowel resection \nis performed by an experienced colorectal surgeon. Anastamotic \ncomplications occur in around 1% cases. Long term resection of \nsevere endometriosis is good with a pregnancy rate of 50% [23].\nThese invasive lesions may limit only to the pelvis but one \nneeds to examine the extrapelvic disease according to symptoms \nlike in catamenial pneumothorax. Though medical therapy might \nbe effective in many cases the surgical approach needed in many \nsituations by treatment by trained personnel in some proper \ncentre/institution is needed [24].\nRole of combining imaging, experience and surgical technique \nhave been described increasingly [25,26]. Further Abrao et al. \n[28] reviewed the various critical factors in managing deep \nendometriosis infiltrating the rectosigmoid, besides emphasizing on \nrole of imaging and importance of discoid and segmental resection. \nThey concluded surgery is not indicated in all patients with deep \nEndometriosis, but when chosen surgery remains the therapy of \nchoice for symptomatic patients when deep lesions do not improve \nwith a medical treatment [28]. At present there is a greater focus on \nadvanced imaging for endometriosis and the management of deep \nand ovarian endometriosis, has seen a major shift in practice [25,26]. \nThe use of imaging for helping in diagnosis and planning any kind \nof surgical intervention is critical to the management of women \nwith signs and symptoms suggesting endometriosis. Exacoustos \net al. [27] carried out a ultrasound mapping system to assess the \naccuracy of TVS in defining size and location of deep infintrating \nendomeriosis (DIE) with laparosocpic/histological confirmation. \nThey accurately mapped 104 women with suspected DIE before \nlaparoscopic surgery. This new mapping system was developed for \nassessing the extent of endometriosis by measuring the size and \ndepth of lesions at the various pelvic locations. Both surgical and \nhistological confirmation of the USG showed that depending on \ndifferent location of the lesions, the accuracy of TVS ranged from \n76-97%. The lowest sensitivity (59%) and accuracy (76%) were \nobtained for TVS in the diagnosis of vaginal endometriosis, whereas \ngreatest efficacy (97%) was shown in detecting bladder lesion and \ndouglas obliteration. Hence, they concluded that this mapping \nsystem is accurate for detecting the extent of DIE and may be useful \nfor preoperative and intraoperative management of symptomatic \npatients with DIE [28].\nSimilarly Manakaya et al. [29] gave an Ultrasound based \nendometriosis staging system (UBESS) to predict the level of \ncomplexity of laparoscopic surgery for endometriosis. They \ndescribed three stages of UBESSI-III and correlated these with the \n3 levels of complexity of laparoscopic surgery for endometriosis. \nFinally, they concluded that UBESS needs to be utilized to provide the \nlevel of complexity of laparoscopic surgery for endometriosis. This \ncan facilitate the triage of women with suspected endometriosis to \nthe most appropriate surgical expertise required for laparoscopic \nsurgery. But, they said that this UBESS needs to be validated \nexternally in multiple centres to assess its general applicability \n[29]. Ferrero [30] gave an overview of deep endometriosis and \nsurgery for pain [30]. A systematic approach in expert hands \nwhich also relies on imaging studies in experienced operator for \ncorrect planning is needed [25]. There was a frame work provided \non advanced ultrasound for deep endometriosis given by Guerriro \net al. [26] of the International Deep Endometriosis Analysis group \ngiven on advanced ultrasound to give a guide for better imaging \nin this field. Whatever the case once surgery is needed ,it is best \ntackled in centres having correct equipment needed for evaluating \n,excising and managing this complex condition.\nSimultaneous Management of Concomitant Disease \nIf patient is having surgery say for uterine fibroids and incidental \nendometriosis is found some of symptoms like dysmenorrhea may \n\nSurg Med Open Acc J\n   \n  Copyright ©  Kulvinder Kochar Kaur\n4/7\nHow to cite this article: Kulvinder K K, Gautam A, Mandeep S. Current Role of Surgery in Endometriosis; Indications and Progress. Surg Med Open Acc J. \n1(5). SMOAJ.000521.2018. DOI: 10.31031/SMOAJ.2018.01.000521\nVolume 1 - Issue - 5\nbe because of this [31]. The correctness of surgical excision in an \nasymptomatic case needs to be thoroughly discussed, considering \nsurgery carefully weighing benefits to risks.\nRole of Robotic Surgery\nTraditional laparoscopy has gained popularity for the \nmanagement of this disease but has limitations in the surgical \ntreatment of the most difficult cases of endometriosis. With the \nintroduction of the robotic surgical platform experience has \ngradually accumulated regarding the application for surgical \nmanagement of deeply infiltrating endometriosis (DIE). It has been \nsuggested that robotic platform enables more complex dissections \nand may be the ideal modality of the surgical management of \nendometriosis. As both experience and technology expand the \nrobotic platform will be utilized by an increasing number of \nsurgeons for increasingly complex minimally invasive pelvic \nsurgery. The literature analyzing the actual performance in the \nmanagement of D IE, however is only just manifesting. Zanoti and \nAbdel bedee [32] described the unique surgical challenges of the \ndisease. They also highlighted the current data of the literature \nwhich analyzes the application of robotic surgery to the various \nanatomic and clinical manifestations of endometriosis and critical \noutcomes as they apply to the safety, efficacy and cost of the \nmodality of the management of endometriosis [32].\nRole of Surgery for Endometriosis Related Infertility\nIn the presence of pelvic pain mostly medical management, \nexcepting analgesics, prevent pregnancy. Surgery may be the only \noption for treatment in this subgroup. Hence, thorough discussion \ncounseling for fertility options vis a vis surgical interventions is \nimportant. On e has to balance pain symptoms with the potential \nrisk of harm to the reproductive organs is a common problem, in \nthe clinical atmosphere. However, in cases where pain significantly \naffects ones quality of life, inability to function, then priority is to \nhelp the patient resolve these issues first. In some cases benefits \nof surgery may get realized through improved pain control as well \nas improved pregnancy rates [13]. Yet if fertility issues persist after \nsurgical management, then appropriate evaluation and intervention \nwill be needed. In the absence of pain, is there a role of improving \nfertility in w omen with Endometriosis via surgical management or \nimproving outcomes of fertility by therapies like IVF.\nMild to moderate endometriosis\nThere are multiple effects which can individually or collectively \naffect fertility like chronic inflammation, with pro inflammatory \nbiochemical milieu pelvic adhesions, which disrupt anatomy and \naffect oocyte or embryo transport and decrease ovarian reserve \n[33]. Surgical treatment of disease may theoretically improve \nthe environment for successful conception. The most recent \nCochrane review on this topic by Duffy et al. [13], gave evidence \nthat laparoscopic treatment of mild and moderate Endometriosis \nincreases live birth and ongoing pregnancy rates. There is need to \nbalance risk of surgical intervention with alternative options for \nenhancing fertility like ART . Repeated surgeries may benefit pain \nsymptoms, although they cause decrease in pregnancy rates.\nDeep endometriosis and infertility\nA review by Somigliana and Garcia- Velasco [34] on this topic \nshowed that many case series show very good outcomes of surgical \nintervention, however one must take these series in the context \nof their own individual centres and acknowledge the inherent \nbias of case series. At this point main reason for managing deep \nEndometriosis surgically would be to alleviate pain or visceral \nobstruction in expert hands. Conservative radical excision is \npossible to retain the uterus and ovaries and should be the goal in \nthose wishing to conceive.\nOvarian endometrioma management\nMain indication for managing an asymptomatic ovarian \nEndometrioma in patients with infertility is to improve access \nfor ART . Endometrioma size, location, transvaginal access for \nretrieval may all be factors in determining if patient needs surgery. \nIn a meta analyses carried out by Hamdan et al. [35] it was shown \nthat outcome of IVF/ICSI did not differ in women who had their \nEndometrioma treated surgically vs no surgical treatment [36].\nHydrosalpinges in association before IVF\nBecause Endometrioma Disrupts anatomy, patients may \ndevelop concurrent unilateral or bilateral hydrosalpinges and the \nmilieu of this condition diminishes IVF success rates. At present \nmultiple studies have shown that removal or occlusion of the tubes, \nwhich does eliminate possible natural conception, improves IVF \noutcomes [36].\nSurgical management of ovarian endometrioma\nExcising an Ovarian Endometrioma in those desiring fertility or \novarian function has been shown to be effective in controlling pain \nand has a lower recurrence risk in contrast to that with drainage \nand coagulation alone [37]. Important thing is to consider the \nchances of damaging the ovarian reserve following Endometrioma \nsurgery. One question which needs an answer is how much is the \neffect of Ovarian Endometrioma perse on the ovarian reserve \njust by its mere presence and how much does surgery cause this \nor can it be improve omit be any ovarian reserve. Various studies \nwhich Goodman et al included, demonstrated that women having \nEndometriomas have lower AMH levels as compared to those not \nhaving one [38]. Excising Endometrioma decreased AMH further \nby 1 month, although they do seem to recover by 6 months but \nonly back to baseline. Though this was the first study which used \na control group, that included patients without Endometriosis, but \nin cases of Endometriomas similar results were found by different \nworkers [39-42] regarding AMH levels.\nVarious things which predict more effect of surgery on Ovarian \nEndometrioma management is related to age and presence of \nbilateral ovarian cysts and B/L cystectomy [43]. More harm is \ndone by repeated surgeries on ovarian tissue [44]. The other \nfactors when Ovarian Endometrioma is related to presence of \ndeep Endometriosis, more so in patients having painsymptoms \n[25]. Thus, the surgical procedure complexity is often beyond \nsimple excision of the endometriotic cyst and might need increased \n\n5/7How to cite this article: Kulvinder K K, Gautam A, Mandeep S. Current Role of Surgery in Endometriosis; Indications and Progress. Surg Med Open Acc J. \n1(5). SMOAJ.000521.2018. DOI: 10.31031/SMOAJ.2018.01.000521\nSurg Med Open Acc J   Copyright ©  Kulvinder Kochar Kaur\nVolume 1 - Issue - 5\ndissection and warrant an interdisciplinary approach. If this ovarian \ndisease is not fully dealt with e.g. once oophorectomy is done it \nmay cause an ovarian remnant which might need further surgical \nor medical management [25]. Similarly Keyhan pointed that \nvarious factors which need to be examined before proceeding with \nsurgery or continuing expectant management, included  patients \nsymptoms, age, ovarian reserve, size and laterality of the cyst, \nprior surgical treatment and level of suspicion of malignancy. Most \nrecent evidence is for proceeding directly with IVF. These, include \nsymptomatic infertile patients, especially those who are older, \nthose that have diminished ovarian reserve, those having bilateral \nEndometriomas or those that have had prior surgical treatment. \nSince, surgery can further diminish ovarian reserve and presence \nof Endometriom as per se does not appear to affect the outcome of \nIVF, with surgical removal not improving IVF outcomes, this needs \nto be the primary target. Still proper counseling of infertile patients \nis essential before right option is chosen [45].\nCriticality of Addition of Post Operative Medical \nTherapy\nMain role of medical therapy following fertility sparing \nendometriosis surgery in women with EAPP is to prevent the \nrecurrence of symptoms and/or disease. There may not be total \nsurgical excision when post op medical suppression acts like \nadjuvant treatment for symptom control. Wu et al. [46] showed that \nO.C’s and progestin agents showed beneficial effect and there was \nno statistical difference among O.C’s and gestrinone, mifepristone \nor GnRH-a groups, though O.C; had lesser side effects which were \nmore mild, in contrast to other hormonal treatments [46]. Also use \nof progestin intrauterine system has been shown to be effective in \nlong term pain control with surgery [12]. It is important to use long \nterm medical suppression, in contrast to short intermittent courses \nbecause symptoms and disease might return instead of returned \nonce medicine is discontinued in women of reproductive age group \n[47].\nEndometriomas recurrence is the main problem in patients \nhaving pain and wanting to preserve ovarian function. The \nrecurrence rate of Ovarian Endometriomas after surgical excision \nmight be very high-as high as 50% at 5yrs. Using medical therapies \nlike combined O.C’s is effective at decreasing recurrence and related \npain recurrence [46,48-50].\nBut using long term post operative suppression can affect future \npregnancy. Thus those wanting to conceive, there is limited role of \nmedical suppression, as not shown to cause increase in pregnancy \nrates, though some studies showed better implantation rates with \nGnRH -a before IVF [51].\nWomen with deep endometriosis should also receive some type \nof medical treatment following surgery, as those with superficial \ndisease and ovarian Endometriomas [52].\nConclusion\nThus surgery for endometriosis will play a role though medical \nmanagement is progressing. For women having EAPP and or \nendometriosis related infertility one needs to consider multiple \nfactors prior to surgery. One needs to consider how patient presents, \nfinalizing on evaluation, USG findings and assessment based on \ni. Uterus and ovary assessment \nii. Assessment of site specific tenderness \niii. Assessment of ovarian mobility and pouch of douglas \nobliteration \niv. Assessment of the anterior, posterior and lateral \ncompartments of the pelvis for non bowel DIE\nv. Assessment of anterior wall of the bowel for DIE. \nFurther response to therapies, individual treatment \npreferences, all have a role. There needs to be a balance between \nextreme situations like only surgery or only medical therapy based \non patient’s requirement of the disease. \nReferences \n1. Giudice LC, Kao LC (2004) Endometriosis. Lancet 364(9447): 1789-\n1799.\n2. Balasch J, Circus M, Faibergues F, Carmona F, Ordi J, et al. (1996) Visible \nand non visible endometriois at lapariscioy in fertile and infertile \nwomen and in patients with chronic peovis pain:a prospective study. \nHum Reprod 11(2): 387-391.\n3. Leibson CL, Good AE, Hass SL, et al. (2004) Incidence and characterization \nof diagnosed endometriosis in a geographically defined poulatio. 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Vercellini P , Vigano P , Somigliana E, Fedelle L (2014) Endometriosis: \nPathogenesis and treatment. Nat Rev Endocrinol 10: 261-275.\n34. Somigliana E, Garcia-Velasco JA (2015) Treatment of infertility \nassociated with deep Endometriosis: definition of therapeutic balances. \nFertil Steril 104(4): 764-770.\n35. Hamdan M, Dunselman G, Li TC, Cheong Y (2015) The impact of \nendometrioma on IVF/ICSI outcome: a systematic review and meta \nanalysis. Hum Reprod Update 21(6): 809-825.\n36. Johnson N, Van Voorst S, Sowter MC, Strandell A, Mol BW (2010) \nSurgical treatment for tubal disease in women due to undergo in vitro \nfertilization. Cochrane Data base Sys Rev 3: CD002125.\n37. Beretta P , Franchi M, Ghezzi F, Bussaca M, Zupi E, Bollis P (1998) \nRandomized clinical trial of two laparoscopic treatments of \nendomtriomas: cystectomy versus drainage and coagulation. Fertil Steril \n70(6): 1176-1180.\n38. Goodman LR, Goldberg JM, Flyckt RL, Gupta M, Harwalker J, Falcone \nT (2016) Effect of surgery on ovarian reserve in women with \nendometriomas, endometriosis and controls. Am J Obstet Gynecol 215: \n589.\n39. Uncu G, Kasapoglu I, Ozerkan K, Seyhan A, Yilmazlepe OA, Ata B (2013) \nProspective assessment of the impact of endometriomas and their \nremoval on ovarian reserve and determinants of the rate of decline in \novarian reserve. Hum Reprod 28(8): 2140-2145.\n40. Chen Y, Pei H, Chang Y, Chen M, Wang H, Xie H, et al. (2014) The impact \nof ovarian endometriomas and laparoscopic cystectome on ovarian \nreserve and the exploration of related factors assessed by serum anti-\nMullerian hormone: a prospective cohort study. J Ovarian Res 7: 108.\n41. Raffi F, Metwailly M, Amer S (2012) The impact of excision of \nendometriomas on ovarian reserve: a systematic review and meta \nanalysis. J Clin Endocrinol Metab 97: 3146-3154.\n42. Somigliana E, Barlanda N, Benaglia L, Vigano P , Vercellini P , Fedele L \n(2012) Surgical excision of endometriomas and ovarian reserve: a \nsystematic review on serum anti-Mullerian hormone level modifications. \nFertil Steril 98(6): 1531-1538.\n43. Alborizi S, Keramati P , Younesi M, Samsami A, Dadras N (2014) The \nimpact of laparoscopic cystectome on ovarian reserve in patients with \nunilateral and bilateral endometriomas. Fertil Steril 101(2): 427-434.\n44. Muzli L, Achilli C, Lecce F, Bianchi A, Franceschetti M, Marchetti C, et al. \n(2015) Second surgery for recurrent endometriomas is more harmful to \nhealthy ovarian tissue and ovarian reserve than first surgery. Fertil Steril \n103(3): 738-743.\n45. Keyhan S, Hughes C, Price T , Muasher S (2015) An update on surgical \nversus expectant management of ovarian endometriomas in infertile \nwomen. Bio Med Research International Article ID 204792.\n46. Wu L, Wu Q, Liu L (2013) Oral contraceptive pills for endometriomas \nafter corrective surgery: a systematic review and meta analysis. Gynecol \nEndocrinol 29: 883-890.\n47. Busacca M, Somigliana E, Bianchi S, De Marinis S, Calia C, Candiani M, \net al. (2001) Postoperative GnRH analogue treatment after conservative \nsurgery for symptomatic endometiosis stage III-IV:arandomized \ncontrolled study. Hum Reprod 16(11): 2399-2402.\n48. Vercellini P , de Matteis S, Somigliana E, Buggio L, Frattaruolo MP , Fedelle \nL (2013) Long term adjuvant therapy for the prevention of post operative \nendometrioma recurrence :a systematic review and meta analysis. Acta \nObstet Gynecol Scand 92(1): 8-16.\n\n7/7How to cite this article: Kulvinder K K, Gautam A, Mandeep S. Current Role of Surgery in Endometriosis; Indications and Progress. Surg Med Open Acc J. \n1(5). SMOAJ.000521.2018. DOI: 10.31031/SMOAJ.2018.01.000521\nSurg Med Open Acc J   Copyright ©  Kulvinder Kochar Kaur\nVolume 1 - Issue - 5\n49. Muzli L, di Tucci C, Achilli C, Di Donato V, Musella A, Palaia I, et al. (2016) \nContinuous versus cyclic Oral contraceptives after laparoscopic excision \nof ovarian endometriomas: a systematic review and meta analysis. Am J \nObstet Gynecol 214(2): 203-211.\n50. Vercellini P , Somigliana E, Vigano P , de Matteis S, Barbara G, et al. (2010) \nPost operative endometiosis recurrence: a plea for prevention based \non pathogenetic, epidemiological and clinical evidence. Rprod Biomed \nOnline 21(2): 259-665.\n51. Sallam HN, Garcia-Velasco JA, Dias S, Arici A, Abou Setta AM (2006) Long \nterm pituitary down regulation before in vitro fertilization(IVF) for \nwomen with endometriosis. Cochrane Data base Sys Rev 1: CD004635.\n52. Somigliana E, Busnelli A, Benaglia L, Vigano P , Leonardi M, et al. \n(2016) Postoperative hormonal therapy after surgical excision of deep \nendometriosis. Eur J Obstet Gynecol Reprod Biol 209: 77-80.\nFor possible submissions Click Here \n Submit Article\nCreative Commons Attribution 4.0 \nInternational License\n   \nSurgical Medicine Open Access Journal\nBenefits of Publishing with us\n• High-level peer review and editorial services\n• Freely accessible online immediately upon publication\n• Authors retain the copyright to their work \n• Licensing it under a Creative Commons license\n• Visibility through different online platforms","source_license":"CC0","license_restricted":false}