In some instances keyhole (laparoscopic) surgery may be indicated, either to manage your endometriosis, or rule it out. The blog below will explain in detail the many different aspects to this surgery, so you can be better prepared when discussing this with your gynaecologist.
How do I know when I need surgical excision?
There are several reasons why your gynaecologist may suggest that keyhole surgery is appropriate. For example:
- Significant symptoms (e.g. severe period pain, despite trying some of the hormonal
suppressive medications or pain medications outlined in this previous blog post) - Excision of endometriotic ovarian cysts
- Separation (or ‘division’) of suspected internal scarring and normalisation of anatomy
- Subfertility or infertility, with the suspicion of endometriosis as a contributing cause
- A specialised deeply infiltrative endometriosis (DIE) ultrasound that has shown signs of moderate to severe endometriosis, with / without bowel endometriosis
If evidence of endometriosis is demonstrated on a specialised DIE scan, your gynaecologist may recommend surgical excision of these deposits.
By excising these nodules, we hope to:
- Reduce the regular irritation of nerves with the repeated swelling and hormonal
stimulation of these nodules - Reduce overall inflammation in the pelvis
- Reduce the chance of progression and development of adhesions
- Improve fertility and the chances of falling pregnant
It is not advised to have a laparoscopy just to make the diagnosis of endometriosis, as a laparoscopy comes with many inherent risks: the risks of a general anaesthethic and possible damage to other organs within the abdomen with the instruments used. If, however, you have significant symptoms that are not resolved with medical options, you may request a laparoscopy to complete the diagnostic process.
We do know that superficial deposits of endometriosis are not generally seen on imaging, even with the use of high quality DIE scanning, and removal of these deposits can improve pain and fertility. There is a significant chance that no endometriosis will be seen on such laparoscopic surgery, and this risk should be explained by your clinician prior to the procedure. In the event that endometriotic deposits are not found at laparoscopy, it is important to know that this does not mean your pain isn’t real, and impacting your life.
Studies have shown that over five years, up to 70 percent of women will have no evidence of endometriosis returning. This does mean that there is a risk of recurrence of endometriosis with symptoms in 30 percent of women, which is important to keep in mind.
What is does ‘laparoscopic excision of endometriosis’ involve?
A laparoscopy is an operation where a tiny telescope is inserted through a small incision in your belly button, to see the abdominal cavity and pelvis. A few more small incisions (‘cuts’) are made, so that other surgical instruments can be used to perform the operating part of the procedure. The incisions are closed with a suture, glue or tape at the end.
Panoramic photographs of the pelvis are taken to see if there is any evidence of endometriosis deposits. Endometriosis can appear as blue / purple / black / white spots, with or without thickening and scarring of the tissue around them. Adhesions (internal scarring) may be seen causing different organs of the pelvis to stick together.
Your surgeon will systematically remove each of these deposits of possible endometriosis, and send them to the pathology lab for diagnosis. These deposit specimens are labelled specifically to describe where in the pelvis they have been removed from. Any adhesions will be divided, to try to normalise the organs back to their original positions. Endometriotic cysts in the ovaries will be drained and managed: the type of management will depend on your age, the size of the lesion and your fertility desires).
If endometriosis is found growing into the wall of your bowel, bladder or obstructing your ureter (the tube draining urine from your kidney to your bladder), your surgeon may need to leave this severe endometriosis inside you, and perform further investigations before deciding how to proceed at a later date. This later surgery may require the expertise of a colorectal surgeon (such as Maven Centre’s Dr Fiona Reid), or a urologist.
What’s the difference between ‘ablation’ and ‘excision’?
‘Ablation’ is the burning of possible deposits in the hope that this will deactivate their cells. ‘Excision’ means cutting these deposits out completely and in full.
Studies suggest excision of these deposits is better than ablation, as it removes the root bunch of cells that caused the deposit to grow in the first place. Excision is the gold standard of endometriosis surgery.
Does hysterectomy cure endometriosis?
Unfortunately the answer is not that simple.
Endometriosis is a disease that is driven by hormones. The hormones our ovaries produce, stimulate the endometriotic deposits to grow and become inflamed. A hysterectomy will remove the organ (the uterus) that cramps and results in visible bleeding, which may help some aspect of your troublesome symptoms. However, hysterectomy alone will not stop the hormonal processes that drive endometriosis, and hormonal suppression medications will still be needed to stop the cycling of hormone production.
In addition, a hysterectomy is a major surgery, with more risks than a simple laparoscopy. Every surgery can cause internal scarring and nerve injury / assault, which may result in ongoing pain.
In some cases a hysterectomy may be indicated. Whether or not this is right for you requires a comprehensive discussion with your gynaecologist, who can weigh up the risks and benefits, and
consider this option in the context of your history, and what you have tried previously.
Topic area frequently asked questions (FAQs)
My mother had keyhole surgery every year for 10 years when she was my age. Do I need to do the same?
As time goes on, we are learning more and more about endometriosis, and are getting better at managing it. Regular laparoscopies (as above) are not recommended. We do know that
repeated surgery will cause recurrent scarring and nerve injury / assault, which can actually worsen pelvic pain. We also know that five years after surgical excision, 70% of women will have no evidence of their endometriosis returning.
If you are worried your endometriosis is returning, discuss this with your gynaecologist, who can discuss your options with you.
How quickly does endo grow back, after it’s been cut out?
The rate of growth / re-growth is unique for everyone and so very difficult to predict. It depends on a number of factors; your genetics, what kind of surgery you hard (ablation or excision), whether or not all the visible endometriosis was able to be removed and whether or not you use hormonal suppression. Studies have shown that over five years, up to 70 percent of women will have no evidence of endometriosis returning.
I’ve been diagnosed with endometriosis at keyhole surgery. What can I do to stop it coming back?
A good laparoscopic gynaecological surgeon can look for and completely excise any endometriotic deposits that are growing on and around your pelvic organs. This gives you a ‘clean slate’, in that all of the endometriosis has been removed, and any internal scarring sticking your organs together has been separated.
There is good evidence that taking hormones to suppress your period after such an operation slows down the regrowth of the
endometriosis. The best hormonal option for you should be discussed with your gynaecologist as this will depend on your preferences and other medical issues.
I want to fall pregnant. When should I have my endometriosis cut out, in relation to wanting to conceive?
Our next blog post will discuss in detail the relationship between endometriosis and fertility and will answer this question in detail, so keep your eyes peeled for this!
Can any gynaecologist do keyhole surgery to cut out endometriosis?
While all gynaecologists are trained in performing basic laparoscopies, not all of them will feel comfortable, or have the skills, to manage endometriosis surgically. Some gynaecologists (such as Maven Centre’s Dr Sneha Parghi and Dr Alison Bryant-Smith) complete fellowships and further training in advanced laparoscopic surgery, so they can be equipped with the skills to manage complex endometriosis.
Conclusion
When it comes to endometriosis, surgery is not a silver bullet, but surgical excision of visible endometriotic deposits has been shown to improve symptoms in some women. Whether or not surgery is suitable for you depends on many factors. Talk to your gynaecologist to discuss what might be right for you.
