Endometriosis Surgical ManagementDr Asha S Vijay
The management approach to patients with Pelvic Endometriosis is multidimensional
Current strategies to manage endometriosis aim mainly at
1. Reducing pain
2. The increasing pregnancy rate for women who desire to have children
3. Delaying disease progression and preventing recurrence
Surgical Management of Endometrioma
Conservative surgical treatment consists of resectioning Endometrioma (drainage or Cystectomy), Adhesiolysis, and restoring normal pelvic anatomy as far as possible.
Various Surgical options available are
1. Laparoscopy & removal of Endometriotic lesions, restoring the normal relation of pelvic organs.
2. Laparotomy and surgical excision of lesions.
3. Removal of uterus, ovaries & all Endometriotic lesions.
In women desirous of pregnancy, laparoscopy is advisable compared to laparotomy as it has the following benefits.
• Less invasive, more minors tissue injury
• Lower chances of infection due to smaller incisions
• Quick recovery time
• Better exposure to pelvic organs
Laparoscopy is the most common procedure used to diagnose & treat endometriosis.
Stage I & II Endometriosis
In laparoscopic surgery, CO2 laser vaporization or bipolar fulguration of endometriotic spots & endometriomas is done. Tubal patency and release of adhesions, if any, is done.
According to ESHRE guidelines, laparoscopic surgery and removal of endometriosis are associated with higher cumulative pregnancy rates.
Stage III & IV Endometriosis
According to ESHRE guidelines, in infertile women with ovarian Endometrioma of more than 3cm in size, surgeons should perform excision of endometrioma capsules. Cystectomy increases the post-operative pregnancy rates & reduces symptom recurrence. Excision of endometriomas involves the opening of the cyst (using scissors or electrosurgical energy)
After identifying the cleavage plane between the cyst wall and ovarian tissue, the cyst wall is excised by applying opposite bimanual traction with two grasping forceps. The ovarian edges can be cauterized by bipolar cautery. After the Cystectomy, care is taken to release the adhesions from the ovary & uterus.
In dense adhesions involving adjacent organs like the bladder, rectum and POD, adhesiolysis must be done with great precision. In cases with severe adhesions involving bowel, bladder, uterus & ovaries, careful dissection is done to release ovaries from adjacent organs. This helps in access to ovaries during oocyte retrieval in IVF cases.
Endometrioma drainage & cystectomy risk reduced ovarian function after surgery and possible loss of ovary. Hence the decision to proceed to surgery has to be considered carefully after weighing the benefits and risks. Laparoscopy is recommended in case of Endometrioma more than 4cm in size.
Advantages of Removal of Ovarian Endometrioma
1. Reduces Pain and discomfort (Dysmenorrhoea)
2. Diagnosis of Endometrioma can be confirmed by cyst wall-HPE (histopathologic) examination
3. Ovary becomes more responsive to controlled ovarian hyperstimulation
4. Ovaries become accessible for ovum retrieval
5. Reduces the risk of infection following ovum pick up
Surgical management followed by artificial reproductive techniques (IVF) depending on patient profile help in achieving better pregnancy rates.