The way forward in the surgical management of endometriosis – from a third world perspective

Diagnosis When symptoms of pelvic pain, dyspareunia or pelvic mass present, diagnosis of endometriosis is confirmed by laparoscopy. Vaginorectal examination and a sponge forceps pushed upward in the fornix help to delineate the extent of the disease. However, in many third world countries diagnosis is seldom confirmed early by laparoscopy, but later at the time of surgery when a complication has arisen. Treatment Excision is indicated, for minor or moderate disease, or direct ablation of superficial implants with complete excision of endometrial cyst walls, and can involve an oöphorectomy. In some parts of the world this may be performed by means of laparoscopy by a gynaecologist if available, but seldom by a general surgeon. Advanced disease requires complete excision of endometriosis with restoration of normal pelvic anatomy. This requires a highly skilled and experienced gynaecological laparoscopist of whom, worldwide, there are about 10. For the surgeon with little prior skill or experience and with no assistant or consultant, where there is severe pain associated with bleeding, anaemia, malnutrition, no transfusion available, and no chance for second surgery, laparotomy with hysterectomy and bilateral salpingo‐oöphorectomy is the operation of choice. This will change in the future with adequate training in operative laparoscopy and cheaper technology. Results Even in advanced disease with cul de sac occlusion, complete excision of endometriosis by operative laparoscopy, by skilled and experienced surgeons in large centres, gives results which are particularly good with regard to partial or complete absence of pain, as well as significant improvement in fertility. Conclusion Today, this surgical management of advanced endometriosis is available only for the rich few. In the future, pelvic pain and infertility centres will provide advanced training for increased numbers of gynaecological laparoscopists who will be capable of completing surgery for severe endometriosis with supporting groups such as colorectal and urological surgeons, reproductive medical specialists, basic scientists and counselling and support services.