Endometriosis Surgery

The QENDO website is an excellent resource with detailed information specific to endometriosis surgery around what to expect before, during and after the surgery. It also talks about how to prepare for hospital and what to ask the surgeon, which can be useful to think about. 

Endometriosis New Zealand is another great website with more local information. 

Endometriosis surgery has evolved a lot over the years, and what we do now is very different to what was done 20 years ago.

Several international guidelines exist about to approach endometriosis surgery. Dr Scheck practices in line with the international guidelines endorsed by the World Endometriosis Society and the European Society of Human Reproduction and Embryology as outlined here. 

Exactly what is done during the surgery varies a lot depending on what is found, but generally will involve the following steps:

1. A camera is placed through the belly button with 2-3 additional incisions for the laparoscopic instruments

2. The entire abdomen and pelvis are searched for any signs of endometriosis, with photos showing what is found at each of these areas: the diaphragm (under the ribs) on the right and left sides, the appendix, the ovaries and fallopian tubes, the pelvic sidewalls, the uterosacral ligaments (ligaments joining the back of the uterus to the tail bone), the pouch of Douglas (space between the rectum and the uterus), the surface of the bladder, and the surface of the uterus.

3. If endometriosis is identified it is excised (cut out). In some circumstances it may be safer to ablate (apply electrical current) endometriosis rather than excise it, but this is avoided unless excision is not deemed safe. 

Severe forms of endometriosis can cause organs to stick together (for example the bowel to stick to the uterus), which can make the surgery more challenging and increase the risk of injury. Sometimes a lot of time is spent restoring normal anatomy and identifying important structures before the excision can be completed. 

The general risks of laparoscopic surgery include:

• Bleeding - There is a small chance of significant bleeding with any surgery in the abdomen (Less than 1/100)

• Infection - There is a chance of infection in the wounds on your abdomen, inside the abdomen, or in the bladder if a catheter is used

• Damage to internal organs - This is very rare (Less than 1/1000) but can include the bowel, the bladder, the ureters (the connection between the kidneys and bladder) or other structures

• Conversion to open surgery - Very occasionally (Less than 1/100) we would need to convert from laparoscopy (keyhole) to open surgery which can involve a horizontal incision on your lower abdomen (similar to a Caesarean section) or rarely a midline incision

• Blood clots in the legs (DVT) or lungs (PE) (Less than 1/1000) - Surgery increases the risk of blood clots, and we may give blood thinning injections (Clexane) while you are in hospital to prevent this

With endometriosis surgery, some of these risk may be increased depending on the severity of the endometriosis identified. This will be discussed with you in detail before your surgery. 

After the surgery most people will stay one night in hospital. If no endometriosis is found, or a small amount is treated, you may be able to go home the same day. If severe endometriosis is found you may need longer in hospital.

The amount of pain after surgery can be difficult to preduct. While you are in hospital the anaesthetist will offer strong pain relief as needed, occasionally this may involve a button that you control to give intravenous pain relief (PCA - patient controlled analgesia). When you leave hospital you will get a prescription for strong pain relief, and other medications if needed (for example anti nausea medication and laxatives).

Hormonal medication such as the combined oral contraceptive, mini-pill or a Mirena may prevent the development of further endometriosis, but will depend on your individual situation and will be discussed with you.

It is normal to expect that your first period after surgery may cause some pain. This is largely due to the areas that are still healing associated with surgery. Generally, you should expect that after that pain with periods improves.

In the long term, it is not clear why or how endometriosis returns after surgery. We would generally expect that surgery gives relief for at least five years, with the hope that no further surgery is needed. If you do have a return of symptoms in the future you should speak to your gynaecologist around options. Repeat surgery does carry higher risk, and is not always helpful, but this will depend on your individual situation.

We often do endometriosis surgery without knowing exactly what we will find. If there is no endometriosis found this can be quite distressing for people, and can make people feel invalidated.

It is important to know that if endometriosis is not the cause for your pain, this does not mean that the pain is "in your head" or "not real". There are a huge number of causes for pelvic pain, which can involve the uterus, ovaries, bowel/gut, bladder, pelvic floor muscles, nerves and others. Often the problem is not something that can be treated surgically - but rather something do do with the way these structures are functioning, and in addition there is often a complex interplay between the brain, spinal cord, nerves and the end organs. It is important that if endometriosis is eliminated as the cause, other possible causes are explored, and you know what your options are for treatment. If endometriosis is not the cause, there are still treatment options available.

There is always a risk with this type of surgery that there is much more severe endometriosis than what we were expecting. This might be that we identify endometriosis invading into the bowel, or the ureters (connection between the kidneys and bladder) for example. If we found that the level of endometriosis is significantly worse than what were expecting, and that we felt that surgery wouldn't be safely possible without a high risk of injury to the bowel or other structures, we just use the initial surgery as a planning procedure, taking photos and then ensuring that a more detailed discussion is had with you before arranging a definitive procedure. Sometimes more severe disease may need to involve a colorectal surgeon or urologist, and would change the risk profile of the surgery.