Endometriosis: does surgery make a difference?

Surgery traditionally has been a mainstay in the treatment of endometriosis, one of the most common and debilitating diseases in benign gynecology. Surgeons were the first to attack the disease, and surgery remained the primary therapy through the 1970s. Only recently, with the development of drugs to combat endometriosis and techniques to circumvent the pelvic damage associated with the disease, has surgery begun to take a back seat to other therapeutic approaches.

The magnification afforded by laparoscopy frequently facilitates a more precise technique.

This review discusses the various surgical techniques available, including their advantages and disadvantages. An evidence-based review of the therapeutic value of surgery also is provided, along with recommendations for the application of surgery to different presentations of the disease.

One difficulty in reviewing the treatment of endometriosis lies in the heterogeneity of the disease itself. There are many physical manifestations of endometriosis, ranging from superficial peritoneal implants to deep, nodular lesions. Pelvic adhesions with fibrosis and distortion also are common, as are ovarian cysts (endometriomas) and involvement of organs such as the bladder and bowel. This wide range of presentations results in a variety of symptoms, with pelvic/abdominal pain and infertility being the most prominent. Although I will attempt to subdivide the data among these many “forms” of endometriosis, I would like to emphasize that, to some degree, the disease is unique in each woman. Of necessity, the recommendations here will be painted with broad strokes. Nevertheless, it is my belief that such generalizations retain their value in the quest to optimize therapy for individual patients.

Surgical methods

Conservative versus definitive surgery. When treating endometriosis, the surgeon is confronted with a number of technical considerations. The first is whether conservative or definitive surgery is advisable.

If a conservative approach is taken, the physician should assess the desired method of access, the method of treating implants, and the type of surgery done for endometriomas. The surgeon also should assess the need for ancillary procedures such as lysis of adhesions, appendectomy, and nerve interruption.

In conservative surgery, the patient’s fertility is preserved, while definitive surgery generally involves removal of the ovaries, a hysterectomy, or a combination of the 2 procedures. Definitive surgery is thought to be more effective over time, but must be reserved for patients whose fertility or continued endocrine function is deemed less important than the relief of pain.

Unfortunately, hysterectomy and ooph-orectomy do not guarantee the relief of pain. A study from Johns Hopkins suggests that the incidence of persistent or recurrent pain following hysterectomy and bilateral oophorectomy is 10%¹. One explanation for persistence/recurrence may be the presence of ovarian remnants, a common finding among such patients. One method of checking for postoperative remnants is checking serum FSH levels.

Method of access. When conservative surgery is desired, the surgeon must select a method of access. Although laparotomy traditionally has been used, most surgeons performing extensive surgery for endometriosis now favor a laparoscopic approach. There are several reasons for this. First, laparoscopy is less invasive, with a much more rapid recovery time. In addition, a laparoscopic procedure costs less than major surgery. Finally, the magnification afforded by laparoscopy frequently facilitates a more precise technique.

There are limited data comparing laparoscopic surgery to laparotomy for the conservative treatment of endometriosis, and all derive from observational cohort studies.^2-5 Despite the relatively poor quality of these studies, the evidence suggests little difference in pain relief via major or minor surgery. When the desired outcome is enhanced fertility, 3-year cumulative life-table pregnancy rates for the 2 techniques are equivalent.⁶

Destruction of implants. The surgical destruction of endometriotic lesions can be accomplished in a variety of ways: excision, vaporization, and fulguration/desiccation. Excision is generally thought to be the most complete of these techniques. It can be performed with a variety of instruments, ranging from the laser to monopolar needles to scissors. The technique is straightforward: The lesion margins are identified by close inspection of the peritoneum, and the cutting instrument is used to outline the area to be excised. The implant then is lifted with atraumatic forceps and separated from the underlying normal tissue by careful dissection. This procedure may be simple or extremely difficult, depending upon the location, thickness, and size of the implant. Many surgeons favor hydrodissection, a technique of irrigating under pressure the tissue near the lesion, in an attempt to separate normal tissue from abnormal. However, 2 dangers exist. First, fluid below the peritoneum frequently distorts anatomy, making a difficult dissection even more challenging. Second, structures fibrotically adherent to endometriosis will not separate and can be damaged if care is not taken to ensure their safety during excision of the lesion.