Laparoscopic treatment of endometriosis utilizes the techniques of laparoscopic surgery (Pic. 1) to remove the foci of endometriosis. Endometriosis is defined as the existence of functional endometrium outside the uterus. Endometriosis lesions (Pic. 2) are mainly located in the pelvis. However, they can be found almost anywhere in the body.
Laparoscopic surgery has been considered as the gold standard for the diagnosis of endometriosis as it gives a histological assessment of excised specimens. This is supported by the absence of definitive non invasive tests for endometriosis, although there has been continuing work on this conducted internationally. Hence diagnostic laparoscopy remains the ideal route for diagnosis.
Laparoscopic procedures are performed via small incisions in the abdominal wall. Long and thin instruments are then inserted into the abdominal cavity through trocars, hollow tubes inserted into the incisions. The laparoscopic technique utilizes a laparoscope, an optic cable connected to a video camera and a light source that enables viewing the area (the abdominal cavity) without opening it with a large incision. During the operation, the abdomen is usually insufflated with carbon dioxide(CO2). This technique presents major advantages such as reduced recovery time (due to the smaller incisions), reduced hemorrhaging, less pain and shorter hospital stay (in some cases, the patient can leave the hospital on the same day).
Diagnostic laparoscopy for diagnostic purpose has various limitations, which should challenge this practice. To optimize patient’s outcome and to minimize exposure to multiple surgeries, at present role of surgery would ideally be reserved for diagnostic confirmation and simultaneous treatment. The benefits of an examination and treat approach give the women the opportunity to confirm the pathology and address the underlying condition, all during one anesthesia.
Debate and controversy still exists as to how radical surgery should be when excising deep infiltrating endometriosis and its long-term benefits and complications. Thorough assessment and preoperative planning is essential, especially in complex cases of severe endometriosis. Firstly full staging is imperative to allow thorough patient counseling as to the extent of the radical surgery and potential short-term and long-term complications. Secondly it is essential to ensure adequate surgical time is allocated and the correct expertise is available especially with regards to colorectal and urological input.
The diagnosis of endometriosis on laparoscopy is highly dependent on the experience and skill of the surgeon performing the procedure; the depth of infiltration of endometrial deposits can often be misjudged and retroperitoneal and vaginal endometriosis often missed. Surgical treatment and the complete excision of endometriosis appears to offer good long term symptomatic relief, however this may involve significant bowel surgery and the potential for major complications.
Conversely less invasive surgery is associated with fewer complications, but incomplete resection carries a higher risk of disease recurrence and generally does not confer the long-term symptomatic benefits seen with complete resection. Risk factors and disadvantages of laparoscopy include damage of organs adjacent to the affected areas and postoperative complications, such as adhesion formation or infection. Symptom relief is achieved in most patients after successful ablation/resection of endometriosis and adhesiolysis (surgical removal of adhesions). Nevertheless, the recurrence rate is as high as 40% after a 10-year follow-up.
Surgical treatment of endometriosis implies a risk of complications, mainly the formation of adhesions (scars attaching organs together and often causing pain) in the abdominal cavity. Surgery for endometriosis could entail a higher risk because of adhesions to the bowel and the urinary tract caused by the nature of the disease, or due to repeated surgery. The formation of adhesions can be prevented to a certain degree by proper surgical technique with minimal damage to the surrounding tissues and by minimizing the number of surgeries, ideally by combining diagnostic and curative surgery into one step. Other possible risks of laparoscopic surgery include direct damage to surrounding organs and postoperative infection.
Laparoscopic surgery has an important role in the management of endometriosis. Because of the lack of non-invasive tests for endometriosis, diagnostic laparoscopy is still considered gold standard in the diagnosis of endometriosis. The outcome of therapeutic removal of endometriosis lesions using laparoscopic approach depends on the severity of the disease, location and number of the lesions and previous operations undergone by the patient. Although radical excision shows good short-term results in relieving endometriosis-related pain, recurrence rate after a longer period of time is still relatively high. Studies show that best results are achieved by a combined approach of medical therapy followed by laparoscopic surgery, which significantly reduces the recurrence rate.
Fertility-related prognosis of patients undergoing a laparoscopic surgery for endometriosis depends mainly on two factors – severity of the disease and location of the endometriosis foci. Endometriosis directly affecting reproductive organs carries a higher risk of impairing fertility by itself and following the surgery, especially in cases of a more radical resection. In cases of endometriosis affecting the adjacent organs but not the reproductive system itself, the prognosis concerning fertility is generally better. However, post-operative complications, mainly formation of adhesions, may also negatively affect the function of reproductive system in the future.