Surgical treatment for endometriosis

Diagnostic laparoscopy 

A diagnostic laparoscopy is an investigation for endometriosis. It is the initial step of every laparoscopy, and allows us to ‘map’ where endometriosis is, and the organs that are affected. 

Some women have a diagnostic laparoscopy because initial tests such as a scan or MRI have not shown any definite endometriosis, but their symptoms are very suggestive of it. In these situations, we would usually suggest treating with medicine or other options rather than putting you through risks of surgery. 

However, some women, especially if they have not tolerated medical treatment or didn’t find other options enough effective, prefer to have the laparoscopy despite being aware that the cause of their symptoms/pain may not be found. 

Operative laparoscopy 

If during the diagnostic laparoscopy superficial endometriosis is found, the following procedures can be performed: 

• Burning (ablation) or removal (excision) of endometriosis deposits 
• Removal of scar tissue (adhesiolysis) which often forms web-like bands from one organ to another, restricting their movement. 
• Tissue biopsy 
• Treatment to ovarian endometriomas (by opening and draining, followed by energy treatment (ablation), to try and stop them re- collecting. Alternatively, they may be removed completely (cystectomy) depending on the findings) 

Although we are very careful, surgery may cause a damage to healthy ovarian tissue, especially treatment to endometriomas can have an effect on the rest of the ovary, which may then have implications for your fertility (especially if fertility treatment is required). For this reason, endometriomas may often be treated in two stages: cysts are drained at the first operation, followed by medical treatment to for three to six months, before a second operation is performed. It is important that you consider and discuss your fertility wishes with your surgical team. 

In cases of more severe endometriosis, surgery may involve other specialists such as bowel surgeons and/or bladder surgeons (urologists). Again, this may be done as a single or, more often, a two-stage procedure. 

Procedures include: 

• Releasing ovaries that are firmly attached to each other, to the womb, bowel, or the side walls of your pelvis.
• Cutting away endometriosis-affected tissue from the bowel, bladder or ureters (the tubes that carry urine from the kidneys to the bladder).
• Placing thin tubes (stents) in the ureters to make the surgery safer. Depending on the operation, these may be either be removed at the end of the operation, or six to 12 weeks later.

Removing part of the bowel affected by endometriosis and joining the healthy bowel parts together (anastomosis). Sometimes it is necessary to allow this joined area time to heal, and for this reason you may need a stoma (where a section of bowel is brought to the surface or your abdomen, and your bowel contents empty into a bag). This stoma is usually reversed after three to six months in an additional procedure by the bowel surgeons.

Increasingly, we are recommending the use of “robotic assistance” in surgery for deeply infiltrating endometriosis. A 3D high-definition camera is used for a clear, magnified view of your uterus and pelvis, and the surgeon then sits at a console next to you. Every hand movement your surgeon makes is translated in real time by the robotic system which bends and rotates the instruments so your surgeon can treat the endometriosis.

Advantages of robotic-assisted laparoscopy, compared to standard laparoscopy, are:

• Fewer complications. 
• Less blood loss. 
• Enhanced surgical 3D vision and dexterity of instruments – gives the surgeons high levels of control within the abdomen.
• Lower risk of conversion to open surgery.

The gynaecology cancer team at UCLH have carried out robotic laparoscopic surgery for several years with excellent results. Since July 2023 we have introduced this technique for our non-cancer patients who need an operation for other reasons, because we believe it will improve the outcomes and reduce complications for patients. The surgical team have been trained to use the device and the robot technical team are available to support every procedure. 

Pelvic clearance

This is complete removal of the womb with the cervix, both fallopian tubes and both ovaries and excision of endometriosis. It may be considered for women who have completed their families, and if other treatment options for endometriosis have not been successful. 

Removal of your ovaries immediately leads to the menopause. This means you will need Hormone Replacement Therapy (HRT) until the age of the natural menopause (approximately 52 years). This protects you from the effects of an early menopause, including thinning of your bones, and a higher risk of stroke and heart attacks, and will also treat the hot flushes and night sweats you may experience without HRT.

This is a technique in which a thin telescope is inserted into the abdomen to inspect the pelvic organs. A 1cm incision is made within or under the umbilicus and the abdomen is filled with gas. This distension allows the surgeon to inspect the pelvic organs to confirm the diagnosis of endometriosis. Another small incision is made close to the pubic hairline or on the side of the abdomen. 

If a small amount of endometriosis is found, then it is usually treated at your first operation. 

However, if a large amount of endometriosis is found at your initial laparoscopy, and especially if it includes large endometriomas, or if it is affecting your bowel, bladder, ureters, or major blood vessels, it may be felt appropriate to plan a second procedure for more extensive surgery at a later date. This allows time for us to discuss with you in more detail what is involved, time to receive additional hormonal treatment as a preparation for second procedure, and time to do further investigations and plan the safest way to carry out the procedure (this may require other surgeons being available, such as a bowel surgeon or bladder surgeon).

Minor surgery 

Minor surgery will involve inspection and burning away the endometriosis tissue or spots. 

• Adhesions (scar tissue) would be divided or removed. 
• An endometrioma or chocolate cyst (cyst filled with endometriotic fluid) will be opened and drained. The cyst will then be treated. Care will be taken to preserve as much normal ovarian tissue as possible and reconstruct the ovary where required.
• You will have a catheter (tube in the bladder) overnight. 
• You may also have a PCA (patient controlled analgesia) overnight where you have the control of pain relief medication which you may administer yourself by pressing a button.
• Usually you would be discharged the following day. The duration of stay depends on the extent of endometriosis.

Major surgery 

Extensive surgery is achieved through the telescope, though a slightly longer duration of stay may be needed. 

This would involve: 

• Cutting away the endometriosis affected tissue 
• Releasing ovaries 
• Releasing adhesions and removing the tissue affected by endometriosis around the back and the side of the uterus, around the bladder and ureter and the space between the rectum and the vagina
• Dissecting the ureters (tubes that carry urine from the kidneys to the bladder) to be able to remove endometriosis tissue

Endometriosis can sometimes affect organs outside the reproductive system, including the bowel, bladder or ureters.

When this occurs, surgery may involve a multidisciplinary team of specialists working together. This may include colorectal surgeons, urologists and other specialists who are experienced in treating complex endometriosis.

Working as a team allows the surgery to be carefully planned so that all areas of disease can be treated safely during the same operation.

Depending on the extent of the disease, you may need to be seen in the outpatient clinic of these specialties prior to surgery.

Surgical management:

• The bowel may sometimes be involved with endometriosis. The surgical treatment involves dissecting the bowel free and assessing the degree of involvement. At times nothing more need be done, however, at other times the endometriosis may need to be cut away.
• This may require taking off the surface layer of the bowel or taking out a small disc of bowel and sewing up the resulting hole. Sometimes, if the involvement is extensive a small section of the bowel needs to be removed and the bowel rejoined.
• These procedures are done together with the laparoscopic bowel surgeons.
• The surgery may require an additional 3 cm cut in the pubic hair line.
• Occasionally if the bowel join is very low (near the anus) or the operation has been technically difficult then a stoma bag is required (ileostomy). This effectively diverts the faeces into a bag on the abdomen or stomach thus protecting the join down stream and allowing it to heal. The stoma bag is usually left for three months and then requires a smaller operation to return the bowel into the abdomen. This usually requires a hospital stay of two to three days.

The risk of a major complication from a laparoscopy only is about 1-2 per 1000. The risk from the most major type of laparoscopic surgery for endometriosis is up to 1 in 10. All the risks listed below will be discussed in detail by the members of the surgical team when you will sign the consent form for the operation. 

As with all surgery the associated risks may include: 

• Damage to bladder and ureters.  
• If the ureters are involved, then a stent (tube) is passed via a telescope. This is removed as a day case 6 weeks later.
• If the ureter is cut, then it is possible that a cut will be required in the abdomen to rejoin it.
• Extensive surgery in the pelvis may result in delay in return of bladder function. Occasionally you may need to self-catheterise in the short term and very rarely in the long-term.
• Damage to bowel. This can be in the form of a leak from the join leading to an abscess. This may require draining with a small tube, occasionally it will require a larger cut in the abdomen to correct the problem.
• Damage to nerves and blood vessels
• Infection 
• Risk to delayed complications including bowel leak and haematoma (collection of blood in the abdomen) that can occur up to 2 weeks after the procedure. In addition, if a piece of bowel has had to be removed then there may be changes to the way the bowels work in the future. These changes usually resolve over a period of weeks to months. 
• Risk of a fistula (abnormal connection between the bowel (or other organ) and the vagina). 
• Loss of a tube or ovary due to bleeding. 
• Risk of adhesion formation. 

If any of these complications occur, a laparotomy (open surgery through a larger cut) may need to be undertaken to correct the damage or to stop bleeding.

If you experience sudden or increasing pain at home, or have vomiting or feel unwell please seek medical advice immediately.

We want to involve you in all decisions about your care and treatment. If you decide to go ahead with surgery, we will ask you to sign a consent form. This confirms that you would like to have the procedure and understand what it involves. 

The medical team will explain all the risks, benefits, and alternatives, and invite you to ask any questions, before they ask you to sign a consent form. If you are unsure about any aspect of your proposed treatment, please do not hesitate to speak with a member of the team again. 

Medication 

Some medications may need to be stopped before surgery. Hormone replacement therapy (HRT) should usually be stopped 6 weeks before surgery, as oestrogen can increase the risk of blood clots around the time of an operation.

Contraception

It is important that there is no possibility of pregnancy when you have this operation. For this reason, we ask you to either abstain from having sex, or use reliable contraception, in the month before your surgery (from the first day of your last period before your operation).

We advise all patients to stop taking combined oral contraceptive pills 4 weeks prior to surgery, as this can slightly increase your risk of blood clots on the legs or lungs (DVTs or PEs) after surgery. Please change to an alternative method of contraception (e.g. condoms or the progesterone only pill) 4 weeks before the procedure. 

Preparing your body for surgery 

Some changes can have a really big impact on your recovery, for example: 

• Increasing your exercise: try to do 30 minutes of activity which makes you feel out of breath, at least three times each week. 
• Eating a healthy, balanced diet before surgery and planning easy to cook meals for your recovery. 
• Stopping smoking and alcohol can be hard, but quitting or cutting down before surgery can reduce your hospital stay and improve wound healing. 

Preoperative assessment clinic

A few weeks before your surgery you will be asked to attend a preoperative assessment appointment and complete a pre-assessment questionnaire. 

You will be asked questions about your health, medical history and home circumstances. Some tests may also be required, for example blood tests. 

You will be given information about the morning of your surgery: when to stop eating and drinking, and if you need to stop taking any of your regular medications. 

Bowel preparation 

You may be given a medication to take the day before your procedure to empty your bowels. This can make surgery safer, especially when endometriosis is close to, or involves, the bowel. You will be given clear instructions about how to take this. 

The day of your surgery 

You will receive instructions about the time of your admission, and where to go. If you do not receive these, please contact the Endometriosis team: 

Phone: 020 3447 9411 

Email: uclh.admin.endometriosis@nhs.net 

More information about what to bring to hospital, and what to expect once you arrive, can be found in the “Gynaecology Enhanced Recovery Pathway”. 

Detailed information about what to expect in hospital after an operation, and about your longer-term recovery, can be found under “Gynaecology Enhanced Recovery Pathway”. 

When you wake up from the operation, you will have a drip in your arm and a catheter in your bladder. These will usually stay in for about 24 hours. You may also have a drain placed in your tummy to allow additional ody fluids (e.g., blood) to drain out, but this is not common.

You may feel drowsy and nauseous from the anaesthesia. Your abdomen may feel painful and bloated. You may also have pain around the shoulders from the gas that is used within the abdomen for the procedure. This will settle within a few days, and can be improved by moving around and taking pain killers. 

You will be discharged once you are eating, drinking, passing urine and moving around safely, and when your pain is well-controlled with tablets. This is usually after one to three nights. Occasionally your surgeon may recommend that you stay in hospital a little longer, especially if your surgery was difficult, or if there were complications.

It is important that someone is available to help you get home when you are discharged (e.g., to help carry your bag). You will need to plan in advance for the fact that you won’t immediately be able to do things you usually would do at home, including driving. Our section “Gynaecology Enhanced Recovery Pathway” explains in more detail about what to expect, and what plans you may need to make. 

We would suggest that you plan to be off work for up to six weeks, depending on the planned extent of your surgery. You may feel able to go back sooner, or you may need longer if your job is very active, or if surgery was extensive or there were complications. Please discuss this further with your doctor.

Please contact us in case of any further queries throughout your care. 

Phone: 020 3447 9411 
Email: uclh.admin.endometriosis@nhs.net 

Other useful numbers: 

Women’s Health Ward T14 South (if your next of kin wants an update on how you are immediately after the operation, or if you have non-urgent queries when you go home) 
Nurse in charge: 07930 236 122 

Pre-operative assessment clinic (PAC) (if you have questions about how to prepare for the operation) 
Tel: 020 3347 2504 

Surgical reception (if you are running late on the day of your operation)  
Tel: 020 3447 3184 or 07939 135323 

Enhanced Recovery After Surgery (ERAS) (Nurse advice line) 
Tel: 07815 642 930 

For additional information and support please visit: 

• Endometriosis UK 
• Endometriosis NHS 
• Robotic-Assisted Surgery with da Vinci Systems 
• Advice on menopause and HRT