Endometriosis is a debilitating, inflammatory condition that affects approximately 5-10% of the female population¹. It occurs when tissue similar to endometrium, which normally lines the uterus, grows outside the uterus. It commonly affects the ovaries, peritoneum (abdominal lining), bladder, and bowel.
This condition can cause pelvic pain, abnormal menstrual flow, pain during sexual intercourse, and infertility. Symptoms can often be controlled through combined oral contraceptives (COCs) or other hormonal-based treatments. However, in some cases, surgery is needed.
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Endometriosis surgery allows the surgeon to see the areas of abnormal endometrial tissue to understand the extent of the disease better and help create an effective treatment plan. The surgeon can also remove the lesions to give the best chance at symptom relief and fertility.
The decision to have surgery for endometriosis should be made by you and your physician while considering the extent of the disease, the severity of the pain, your age, fertility status, and after a review of other treatment options.
Staging of the disease
It is commonly said that surgery is the gold-standard method for correctly identifying endometriosis lesions, their spread, and locations to help determine the extent of the disease and the proper treatment.
Treatment for pain
Pain is a valid reason to resort to surgery if non-surgical options, such as the use of hormonal medications, have failed. Your doctor may recommend surgery if you have ongoing, moderate endometrial pain.
Surgery often allows for the complete removal of the endometriosis lesions and, although they can come back, you should have at least short-term pain relief.
Restoration of normal anatomy
In its more severe stages, endometriosis causes adhesions between organs in the pelvis due to the inflammatory scarring that develops. This will then prevent organs from moving freely in relation to each other, which can result in what is termed “frozen pelvis.”
Additionally, the fallopian tubes can be affected, which impacts the ability of the egg and sperm to meet for conception and can cause fertility issues.
Surgery for endometriosis can remove the scar tissue so that eventually, natural conception may be possible.
Endometriosis surgery can be performed either laparoscopically or involve a laparotomy (both of which find and remove endometriosis lesions). Both surgeries are done under general anesthetic.
Laparoscopy involves minor cuts (“keyholes”) made in the abdomen through which the surgeon can insert scopes (or cameras essentially) that allow for visualization of the internal pelvic cavity and its organs. Your belly will be filled with carbon dioxide gas, which simply helps to gently “inflate” your tummy, separate the structures, and allow for more visibility.
These scopes also have a tool to allow for the removal of abnormal tissue. The surgeons can repair any damage they see due to endometriosis. Because the small incisions are minimal and neat, recovery following laparoscopy is typically the quickest compared to other surgical methods.
Laparotomy is a major abdominal procedure in which one large incision is made to fully visualize and carry out the necessary surgery. It is more invasive than a laparoscopy, although may allow for better visualization without a scope. As a result of it being more invasive, it requires a longer recovery time.
Removal of only endometriosis tissue
Due to the development of scar tissue and inflammation from endometriosis, the borders of organs can become less clear and harder for the surgeon to dissect. To prepare for this, patients are often recommended to have medical treatment prior to surgery to suppress ovulation and reduce the inflammation around the endometriosis patches so they can be more easily removed.
Unfortunately, laparoscopically removed endometriosis has a 30-50% recurrence risk², and more surgeries are often required.
A hysterectomy is a surgical procedure in which the entire uterus is removed. It can be done with or without an oophorectomy (removal of ovaries). This is done in extreme cases where pain caused by endometriosis is very severe and fertility doesn’t need to be maintained.A hysterectomy can be performed via laparoscopy, laparotomy, or vaginally. Following a hysterectomy for endometriosis pain, 80% of people³ in one study reported being very satisfied with their surgical choice even many years.
If the ovaries remain, you can still use a surrogate mother to have children in the future, but you won’t be able to carry the pregnancy yourself.
Depending on the method of surgery, recovery times can vary.
Recovery following laparoscopy is generally quick and straightforward. Often, it is performed as day surgery. You will have one to four small cuts in your abdomen that will heal quickly, although it is still important to take it easy for one to two weeks and refrain from bathing, having sex, driving, lifting, and strenuous exercise. If your surgery was purely diagnostic (no tissue was removed), then you should be able to resume normal activities 48 hours after surgery.
It is important to manage your pain with analgesics and to be prepared for the typical shoulder pain that occurs due to the carbon dioxide gas pressing against the diaphragm. This will improve significantly with time and isn’t anything to worry about, but you may choose to take some analgesics to help with this.
Recovery is far more involved for laparotomy due to the “open” wound, so you must take it easy for two to six weeks, refraining from doing your normal activities, including lifting, exercising, driving, and sex. It is important to be on the lookout for possible complications, including severe bleeding, infections, or blood clots. Keep your wound clean and dry, and make sure you have someone to take care of you while you recover.
Recovery following hysterectomy is dependent on the surgical method. For vaginal or laparoscopic hysterectomies, you should be fully recovered within two to four weeks. If it was an abdominal hysterectomy, your recovery will take between four and six weeks and will be very similar in terms of restrictions to those for laparotomy surgery.
If your hysterectomy also includes removal of your ovaries (called a salpingo-oophorectomy), you may be offered hormone therapy to help after the removal of your ovaries, which will cause an imbalance in your hormones. This can be difficult to adjust to so be kind to yourself and take it easy.
Endometriosis can have life-altering effects for those that suffer from it and, unfortunately, surgery is often the only source of relief. Although surgery is common, it must still be considered carefully in light of your end goal, be it management of pain and symptoms or preservation of fertility. The decision to undergo surgery for endometriosis should be made together with your physician after a full discussion about your particular health issues and a review of other treatment options. If this is something you wish to do, ensure you have adequate support around you as you heal.
Surgery and endometriosis ( 2018)