OC066: Laparoscopic surgery for endometriosis

The surgical management of endometriosis is controversial. The first consideration is whether the finding is a chance finding and whether fertility or pain is the primary complaint. The justification for treatment of asymptomatic endometriosis is unknown. Whether it reduces the progression of disease and prevents future severe disease is unknown. There is some evidence however that superficial endometriosis may regress spontaneously. With regards fertility, there is clear evidence that the treatment of endometriosis surgically is of benefit. The different surgical treatment options for endometriosis are see and attempted complete treatment or a combination treatment. The later involves an initial partial treatment followed by LHRH analogues and then a second treatment to excise remaining disease. With regard endometriomas, the current debate is whether to ablate or perform a cystectomy. Cystectomy reduces the recurrence rate compared to ablation but there is debate as to whether it results in increased ovarian loss. The treatment of recto-vaginal disease is in its infancy. The principles are to excise all endometriotic tissue. The ureter needs to be dissected laterally and the bowel dissected off the vagina so that the nodule can be excised safely. Initially the ovaries are freed form the pelvic sidewall. Temporary suturing of the ovaries will aid surgical exposure. The ureters are then dissected to lateralise them from the nodule. The dissection should start at an area of normal tissue normally at the pelvic brim. A probe inserted in the rectum will aid opening of the para-rectal and recto-vaginal space. The nodule can then be safely excised. The need for bowel excision is currently controversial. This radical surgery is high-risk major surgery and requires significant laparoscopic skills. However improvements in quality of life scores have been demonstrated although long-term follow up data are limited. There is a need for more long-term data and possibly endometriosis centres with standardised treatment protocols. Only then will the place of radical endometriosis surgery be determined.