Endometriosis is a condition that occurs when cells that normally make up the lining of the uterus develop elsewhere in the body.

Normally the lining of the uterus thickens as additional cells grow during a woman’s monthly menstrual cycle, and break down naturally and leave the uterus if no pregnancy has occurred.

When these cells develop elsewhere, there is no route for them to safely leave the body as part of the monthly cycle. This causes the swelling, pain, and potential internal scarring that characterizes endometriosis.

There is no cure for endometriosis yet, but various treatments can help relieve the pain, including several surgical options. Since any surgery is associated with risks, these procedures are generally only recommended in cases of severe pain.

Surgery can help to locate and remove areas of significant endometrial growth, providing considerable pain relief in the short term.

Types of surgery

Laparoscopy is the surgical procedure most commonly performed to treat endometriosis. It has a relatively low risk of complications, and patients generally have a short recovery time. In rare cases where laparoscopy is unsuitable, a laparotomy may be recommended.

More radical and irreversible surgeries, such as a hysterectomy, where the uterus is removed, or a oophorectomy, where the ovaries are removed, may be suggested in extreme cases or when the patient has not responded well to other treatments. These are not used as first-line treatment, however, and are not generally recommended because they cause permanent infertility and can trigger early menopause. There is also no guarantee that the symptoms of endometriosis will not return.

Surgeries to sever the pelvic nerves were historically used to treat endometriosis-associated pain. However, the American College of Obstetricians and Gynecologists no longer recommends this, since the procedure is permanent and usually ineffective at reducing pain compared with other options.

Laparoscopy for endometriosis

Laparoscopy, also called keyhole surgery, is the most commonly used surgical treatment for endometriosis, and may also be used as part of a diagnosis. It is normally carried out under general anesthetic and involves several small incisions in the abdomen through which surgical instruments can be inserted.

First, a single incision is made, generally near the navel, and carbon dioxide gas is pumped into the abdomen. This gently separates the internal organs to allow the surgeon to see affected areas and more easily insert surgical instruments.

An instrument called a laparoscope is then inserted through the incision. This is a small flexible tube, with a small light and camera at the end, so the surgeon can examine the affected areas on a screen.

Once the endometrial tissue has been identified, another small cut is made so surgical instruments can be inserted to remove the tissue. This may involve different specialists based on what organs are involved.

Tissue removal may be done through one of several methods, including:

• Simple puncture, which drains any fluid that builds up inside the tissue but does not remove the cells. This method may be preferable if tissue removal is likely to damage the ovaries.
• Excision, or cutting away the tissue, for example, with surgical scissors.
• Coagulation/ablation of the cells, using heat from a laser or an electric current (diathermy) to remove the tissue. This can also seal blood vessels and help control bleeding.

Laparoscopy may also be required to remove ovarian cysts caused by endometriosis or remove scar tissue that can cause tissue to stick together (adhesions).

Laparotomy for endometriosis

Laparotomy involves making a much larger incision in the abdomen than in laparoscopy so it is sometimes referred to as open surgery. It is only rarely carried out when the woman cannot be easily treated with laparoscopy, or to perform a larger procedure such as a hysterectomy.

Laparotomy is equally effective in treating endometriosis; however, it is associated with more scarring, as well as an extended and more painful recovery time.

Risks of surgery

Following a laparoscopy, the patient will most likely experience pain, nausea, fatigue, and minor bleeding. The first period following the operation may also last longer and be more painful or heavier than usual.

Although rare, major complications can occur during or after endometriosis surgery and include damage or perforation (a hole) to organs, internal bleeding (hemorrhage), blood clots (thrombosis), and damage to major blood vessels.

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