Because endometriosis can involve various structures, with varying degrees of infiltration, surgery is considered as one of the most challenging surgeries in gynaecology. It is one that not many surgeons are doing. With this in mind, what is the purpose of surgery in endometriosis?
Unfortunately, medical therapy for endometriosis including endometriosis associated pain is only symptomatic and does not remove the endometriosis implants. Therefore, surgery is still in many cases the only way to help stop the suffering of affected women.
One of the biggest controversies is ablations vs excision. Some doctors claim that both procedures are pretty much the same. From a surgical point of view, what is ablation and what is excision?
Excision clearly means the complete removal of endometriosis. Ablation depends very much on the surgeon as well as the condition of the implant or tumor. In many cases small parts of endometriosis might be left behind so that a recurrence has to be taken in consideration.
We know that excision is used in cancer, whereby a piece of tissue with margins is removed in order to fully remove the disease. In endometriosis, how is excision executed? Do we have a margin as well?
Since fortunately endometriosis is not a malignant disease it is not necessary to have a safety margin. However, in a lot of cases endometriosis has no clear circumference and might even infiltrate the surrounding healthy tissue so that a wide excision is advised
What is the youngest and the oldest patient that you have operated on?
The youngest patient was a young girl of 16 years with a family history of endometriosis where her mother knew from the beginning of hearing her daughter complain of severe menstrual pain that this could be endometriosis.
The oldest patient was clearly postmenopausal perhaps in her late 50ies or early 60ies. She had endometriosis before which was not completely removed and as she knew the symptoms came for final surgery.
Gateway Clinics GmbH, Amelia-Mary-Earhart Straße 17, Frankfurt am Main, Germany
Photo source: courtesy of NSSU
Studies and patients’ experience show excision to be the best method for improving symptoms on a long term. However, this depends on if all visible or palpable diseases have been excised. In some cases, results may not be permanent, and endometriosis may return. So, what is the principle of excision? Is it to avoid organ damages, or to save reproductive organs? Is it to remove the source of the pain?
Probably the most important reasons or indications for endometriosis surgery is to remove the source of pain as this is sometimes debilitating for the women affected. Also, vital structures in the pelvis need to be protected from being damaged by endometriosis as for instance endometriosis can strangulate the ureter and thereby cause severe kidney problems including insufficiency of the kidney. Of course, in those women that had not completed their family planning surgery might involve a compromise as maintenance of reproductive organs is of utmost importance.
In endometriosis some say there is no cure, others say excision is the cure. When surgery is done and all the disease is removed, is that person cured, even if it might be temporary? Or only if they have no more symptoms?
As menstruation is in most cases the reason for endometriosis a woman in her reproductive age that wants to become pregnant and therefore menstruates regularly might have a stimulus for recurrence of endometriosis with every menstruation even though the excision has been complete. So in principle, the disease was cured but due to a normal condition (i.e. menstruation) it was reignited.
In some cases, despite surgery being executed correctly, patients have little or no improvements. What can be the cause, or what explanation do we have in this case?
This is the most difficult question as it might be that the initial diagnosis was not correct, and the pain should be linked to other reasons than endometriosis. There are many differential diagnoses including psychological causes like post-traumatic disorders. Therefore, pre-surgical diagnosis must be executed very carefully as it is not easy.
Given your experience, in patients that had 10 or more surgeries, and they are still in pain, will another surgery help them, or it won’t bring them much improvement?
This very much depends! Unfortunately, we see patients that had multiple incompetent surgeries where the disease was only removed superficially. In those cases, a thorough diagnosis with excellent imaging and precise pain mapping following the description of the patient is absolutely mandatory in order to decide whether the patient will benefit from another surgery.
Despite having surgery done correctly, or in some cases, by the same doctor, results are different. Some patients have a higher symptom improvement, and others far less. What can be the reason?
First of all: pain is quite subjective which might already explain the differences. In addition, especially in case of several previous surgeries side effects of these operations might be the reason for continuous pain or discomfort.
We know that excision is a procedure that requires high knowledge of pelvic anatomy and high level of surgical skills in order to remove the disease in a safe and efficient way. From this point of view is ablation easier and why is it inefficient in endometriosis?
Endometriosis is a disease that involves several disciplines in addition to gynaecology. Particularly in deep-infiltrating-endometriosis it is best if the surgeon is experienced in gynecology, bowel surgery as well as in urology. If the surgeon shies away from operating in a different disciplines area than his or her own than incomplete removal of the diseased tissue is very common as we see in many cases of ablation.
The pelvis has anatomical danger zones where there is a risk of damaging underlying structures. When it comes to ablation, they say that it can be used in said zones due to damaging organs, hence why excision is better. What are the basic surgical principles employed in excision in order to fully remove the disease and avoid damage to these organs?
As mentioned above excision means the complete removal of the disease. Even if endometriosis is close or involving important and vital structures or organs excision needs to be performed in order to prevent further destruction of that particular region. This might involve that e.g. autonomous nerves can be destroyed causing bladder dysfunction. In ideal cases the pre-operative diagnosis is so precise that this instance can be suspected and needs to be discussed with the patient. Then it will be her decision whether the unhealthy tissue should be completely removed, or parts should be left behind possibly causing recurrence of the disease already after a short interval. I think it is only fair to the patient to explain not only the procedure but also the limitations of surgery.
Do we have limitations in excision? Meaning are any types of cases where excision can’t be used?
If family planning is a vital issue removal of endometriosis of any reproductive organ has to be performed extremely carefully meaning that sometimes endometriotic tissue has to be left behind. For example, ovarian endometriosis has to obey the ovarian reserve so that production of oocytes is still possible. Another example might be brain endometriosis (which fortunately is quite rare) where the surrounding tissue needs to be protected from radical surgery. In bladder endometriosis implants close to the trigon (i.e. where the ureters end in the bladder) must carefully be respected as otherwise innervation of the bladder might be compromised or even the function of the ureter could be impaired.