Endometriosis

Surgical Treatment
Only surgery can properly diagnose and stage the disease.Endometriosis in its early stages can be treated at the time of laparoscopic (surgical) diagnosis. During laparoscopy, a thin viewing tube (called a laparoscope) is passed through a small incision in the abdomen. A second incision may be made on the lower abdomen to provide an additional opening for surgical instruments.Using the laparoscope, the surgeon inspects the outside of the uterus, ovaries, fallopian tubes and nearby organs. The laparoscope can also be fitted with surgical devices for taking tissue samples or removing scar tissue.Endometrial lesions (implants of endometrial tissue outside of the endometrium) can be cut away (excised) or burned away using a high-energy heat source, such as a laser (ablation). Treatment with laparoscopy is more difficult with advanced disease that involves large areas of the rectum or larger lesions.An endometrioma is a mass of tissue (noncancerous cyst or tumor) that contains shreds of endometrial tissue. Endometriomas most frequently occur in the ovary, in a part of the peritoneum (sac around the internal organs) between the rectum and uterus, the wall (septum) between the rectum and vagina, and the outside of the uterus.Several surgical treatments are available for endometriomas:
Simple puncture - This procedure is completed by draining the fluid from the cyst. Endometriomas have been shown to recur in about 50 percent of the patients treated with simple puncture. However, a more aggressive surgical approach, such as cutting away the mass, can cause extensive adhesions (scar tissue) that may prevent the ovary from releasing an egg.
Ablation - To drain the cyst and remove its base with laser or electrosurgery. However, heat can also damage the ovary.
Cutting away of the cyst wall - This is the procedure of choice to decrease recurrence of disease. This procedure can also damage the outer layer of the ovary that contains the eggs.
Draining, drug therapy, and surgery - Endometriomas can also be drained, treated with medication, and later removed by surgery. Endometriomas recur in 8 percent of the patients treated with this procedure. Results from several different prospective studies have reported pregnancy rates of 50 percent over 3 years. There are no randomized clinical trials comparing these different treatment methods. The most challenging surgery by laparoscopy or by laparotomy (traditional abdominal surgery, which requires a large incision) is the management of advanced endometriosis within the pelvic cavity and the rectum and vagina. Several studies have reported pregnancy rates over 2 years of 50 to 60 percent of cases treated with surgery. According to several reports, endometriosis may recur in 20 percent of the cases.Please see "Intestinal Endometriosis" by Dr. David Redwine.Adhesions are fibrous bands connecting structures that normally are separate. Adhesions develop as a response of normal tissue to some type of injury or trauma (as in surgery). In most cases, patients who undergo surgery for endometriosis will form new adhesions at the site of the surgery. Adhesion formation may cause infertility by impairing the function of the ovaries and fallopian tubes. Adhesions also may cause pelvic pain and small bowel obstruction.There are some newer preventive treatments that can be used during surgery to help prevent adhesions from forming. These include rinsing the pelvic cavity with special solutions and placing a piece of protective material (such as Interceed) into the pelvic area to serve as a barrier. The barrier keeps the surfaces from rubbing together after surgery, which can lead to adhesion formation. The barrier dissolves and is absorbed when it is no longer needed.In some cases, a woman will have to undergo additional surgery to remove adhesions formed from previous surgery. Fortunately, the advancement of laparoscopic surgery and the development of these new preventive treatments can reduce the chances of adhesion formation.Please see "A Patients Guide to Adhesions and Related Pain" by Dr. David M. Wiseman.
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