Treatment of endometriosis—a special skills module only?

with very low morbidity [9]. In some patients, it is possible to remove endometriotic disease from the bowel wall without rupturing the mucosa and with a simple seromuscular repair. A diverting ileostomy or colostomy is never necessary for treating colorectal endometriosis and would represent a significant departure from the standard of care for this disease. Although the patients are young and the initial operative morbidity low, the use of a midline scar and ileostomy is cosmetically objectionable to most women who become aware of simpler minimally invasive forms of treatment and condemns the patient to two unnecessary major surgical procedures: the initial diversion procedure and the follow-up procedure to reverse it. Adhesions resulting from unnecessary laparot- omy can make subsequent surgery more hazardous and could compromise fertility and increase the hazard of egg collection in assisted reproduction techniques. It can thus be seen that endometriosis is one of the most common human diseases, more prevalent even than conditions such as breast cancer, cervical cancer, sexually transmitted diseases and diabetes. It is poorly managed, and there is an overwhelming need to address this. Planned and radical excisional therapy with a view to excising all the identified lesions will cure 50% of patients and lead to good long-term symptom relief for up to 75% of patients with severe lesions and appropriate surgical management [6, 7]. However, this treatment should be carried out by appropriately trained surgeons and subject to scrupulous audit, neither of which exists outside of a very few specialist units. These surgical training needs should be addressed with some urgency, with attention directed toward all the specialties—gynaecology, general surgery and urology— involved in the multi-specialty approach that is common- ly necessary in the surgical treatment of this disease. Endometriosis as a disease has an abysmally low profile in health care circles despite the obvious morbid- ity, and it is time that it was much better placed on the agenda of women’s health care needs. Women should be able to received skilled advice and help with appropriate support to help them deal with this debilitating condition. The need for specialist centres dealing with endometriosis is every bit as real and perhaps more pressing than cancer services, since the morbidity of endometriosis lasts much longer than that of cancer, and endometriosis is much more common than cancer. The surgery is specialist, as specialist as that of on- cology or gynaecological urology, and deserves to be recognised as such with similar proper training—it is inappropriate to regard it as a special skills module only, as is currently planned by the RCOG. The BSGE and the ESGE are realising that laparo- scopic surgery requires special training, and there is finally the possibility of developing proper training on a Europe-wide basis. This, together with an appropriate audit of results, may be the beginning of the recognition of this type of surgery as a speciality in its own right, as it richly deserves to be.

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