The Laparoscopic Treatment of Endometriosis

Endometriosis is a condition where cells similar to those of the endometrium (the uterus lining) grow outside the uterus. Some of the most common places this tissue may be found include:

• The ovaries
• The fallopian tubes
• The uterus
• The large intestine
• The appendix
• The bladder
• The uterosacral ligaments (ligaments of the uterus)
• The peritoneum (a fine membrane surrounding the pelvic organs)
• The recto-uterine pouch (between the rectum and the uterus).

There are a number of different symptoms of endometriosis and these can differ in each woman. Some of the most common endometriosis symptoms include:

• Painful periods (dysmenorrhea)
• Heavy bleeding during periods
• Bleeding between periods
• Painful sex
• Chronic pelvic or abdominal pain
• Difficulty falling pregnant.

Laparoscopic surgery is the most reliable way to diagnose endometriosis, and is one treatment option available to women with the condition. During this surgery, patches of endometriosis are removed. This offers more long-term relief from symptoms than other treatments can currently offer.

What is laparoscopy?

Laparoscopic surgery (also known as keyhole surgery) is a method of surgery that uses very small incisions. A thin tube (laparoscope) with a telescope is inserted into the incisions to provide a clear view of the abdomen. This is usually preferred to an open operation, because:

• It provides a clear, close-up view of any patches
• It typically results in faster recovery time, less pain and a shorter hospital stay
• The small incisions lead to smaller scars
• There is a decreased risk of complications, including adhesions (strands of scar tissue which can adhere to organs). These can be painful and can contribute to infertility.
• There is a reduced risk of infection.

The extent of the surgery depends on the reasons for the surgery, along with other factors, including:

• How severe the condition is
• Your age
• Any plans for pregnancy
• Other health concerns or complications.

Laparoscopy is usually performed under general anaesthesia, but in some circumstances may be done with spinal or epidural anaesthesia. Depending on the extent of the laparoscopy, it may be a simple day procedure, or it may require a longer hospital stay.

Why is laparoscopy performed?

A laparoscopy may be performed to diagnose endometriosis, and/or to remove patches of endometriosis from the organs of the pelvis. Laparoscopy is usually recommended in order to:

• Relieve pain, discomfort and other symptoms that have not responded adequately to other treatment
• Improve fertility
• Remove a chocolate cyst (endometrioma) from an ovary

About 80% of women with pelvic pain from endometriosis report a reduction in pain following laparoscopy. Improvement is greater in women whose endometriosis is moderate to severe. 10-20% of women report a return of their pain within a year of surgery.

Improved fertility following laparoscopy has only been proven in women experiencing minimal or mild endometriosis, however many doctors believe that fertility can be improved in the case of moderate or severe endometriosis as well.

Before surgery

Before surgery, your doctor will take your medical history. Inform your doctor of any health issues you have had, particularly any:

• Allergic reaction to anaesthesia, antibiotics or other medication
• Bleeding issues or easy bruising
• Previous surgeries
• Chronic illness
• Recent illness.

Tell your doctor any medications you have recently taken, including prescription drugs, over the counter medicine, illicit substances, and natural therapies like herbs.

Your doctor may recommend that you stop taking the contraceptive pill for a month before the surgery. They will be able to recommend another method of contraception to use during this time. If you smoke, you should stop in the weeks before and after surgery. Ask your doctor if you require further information or help with this.

The laparoscopic procedure

A small incision is made near the navel, and a laparoscope (a thin tube with a light and camera attached) is inserted. Carbon dioxide gas is used to gently inflate the abdomen. This gives the surgeon better access and a clear view by lifting the abdominal wall off the organs.

The pelvic organs may be gently moved for inspection using two instruments: one placed through another incision in the lower abdomen, and another placed inside the uterus (with entry via the vagina). More incisions may be made during the surgery depending on the amount of endometriosis being removed, and its location.

There are a number of techniques that can be used to remove endometriosis, including:

• Excision – removing the patches with small cutting implements
• Cautery – removing the patches by burning the tissue with an electrical probe
• Laser surgery – may be used for excision or cautery.

Your surgeon will choose the best technique(s) based on the location of the endometriosis, the reason for the surgery, and their own preference. Sometimes endometriosis extends deeply into the pelvic organs, so complete removal can be difficult.

After the treatment is finished, the laparoscope is removed and the carbon dioxide gas is allowed to escape. Incisions may be closed with small stitches or with sticking plaster. A catheter may be inserted to drain urine during recovery. The entire laparoscopic procedure can take anywhere from 30 minutes to a few hours. A second surgeon is often present to assist with the surgery.

Recovery after laparoscopy

You may be able to go home the same day as your laparoscopic surgery, however some treatment requires an overnight stay in hospital, or longer. Ask your doctor if you are unsure.

If your laparoscopy was performed under general anaesthetic, you should not drive for at least 24 hours. It is advised that you avoid making important decisions in the days following surgery, and while you may return to work if you wish, most women take a few days off. You should shower and bathe as normal after surgery. You may use tampons, but should ensure they are changed regularly.

Some symptoms you may experience in the days after surgery include:

• Pain and discomfort at the site of the incision and in the area operated on
• Aching muscles
• Tiredness or fatigue
• Mild nausea
• Painful cramping
• A swelling sensation in the abdomen
• Vaginal bleeding, if an instrument was placed in the uterus
• Pain in the shoulders and neck. This is thought to be a response to the carbon dioxide gas, and can last a few days. Lying down may relieve the pain.

Your doctor will prescribe a painkiller to take during recovery. If pain persists, let your doctor know. Laparoscopy recovery time varies from a few days to a couple of weeks. You may resume normal physical activity, including sexual activity,  when these symptoms pass and you are feeling up to it.

It is common to experience constipation following abdominal surgery, and is especially common if endometriosis was removed from the bowel. The use of codeine or pethidine for pain relief can make constipation worse. You can relieve constipation by eating a light diet with a lot of fruit, drinking lots of water, and engaging in gentle exercise like walking. Psyllium husks may be added to cereal, or a mild laxative may be used. Sometimes during laparoscopy, the function of the fallopian tubes is tested using dye. If this is the case, you may experience blue vaginal discharge.

Some symptoms are not normal, and may indicate a problem. Contact your doctor if you experience:

• Worsening nausea or vomiting
• Persistent and worsening abdominal pain
• Pain that is not reduced by painkillers
• Persistent bleeding from the vagina
• Bleeding that is heavier than a normal period, is bright red, or is smelly
• Persistent redness, pain, pus or swelling around the incisions
• A fever of more than 38℃, or chills
• Unexplained fainting or collapse in the days after surgery
• Pain or burning while urinating, or the need to urinate frequently.

If your doctor cannot be contacted, these are good reasons to visit the emergency room.

Possible complications of laparoscopy

There are always risks associated with surgery, but doctors recommend it when they believe the benefits will outweigh these risks. Doctors don’t usually outline every possible side effect or complication of a treatment, but it can be empowering to be fully informed when making decisions about your health.

Some of the risks of laparoscopy apply to all forms of surgery. These include:

• Blood clots, stroke or heart attack
• Infection
• Excessive bleeding or haemorrhage
• A keloid or hypertrophic scar. This can be uncomfortable but is not dangerous to health.

Other risks apply specifically to laparoscopy. These include:

• Unintentionally making a hole in an organ. This can be serious, depending which organ is damaged, whether it is noticed during surgery, and how it is repaired. This occurs once in every thousand diagnostic laparoscopy procedures, and five times in every thousand operative laparoscopy procedures.
• If damage is caused by a surgical instrument during laparoscopy, a laparotomy may be required to repair it. If serious damage has occurred, repairs may be extensive, and may require further surgeries. If the bowel is damaged, a colostomy (an external bag connected to the large bowel) may be performed as a temporary measure until it can be properly repaired.
• A bubble of carbon dioxide, called a gas embolism, can get into the bloodstream and may travel to vital organs such as the heart or lungs. This can be life threatening. Doctors are able to treat a gas embolism if they see the signs that one has occurred.
• If an endometrioma is removed from an ovary, the ovary may not function normally. About 30% of patients who have an endometrioma removed develop ovarian adhesions that can contribute to infertility.
• A hernia can develop from the incision site, sometimes years after surgery.
• Infection can occur inside the abdomen (peritonitis) due to a small hole or burn to the bowel. This may not be immediately clear, and can be life threatening. It requires surgery to repair.

There are other possible complications that are not included here, which may arise due to interacting health issues or risk factors such as smoking or obesity. You may wish to ask your doctor about the risks associated with your particular medical history and lifestyle.