Surgical Therapy for Endometriosis

Conservative Laparotomy

The absolute indications for surgery in patients with endometriosis are listed in the Table 1. Medical therapy may reduce the size of endometriomas but surgical therapy is necessary for their ablation.

Table 1. Absolute Indications for Surgery in Patients with Endometriosis

• Endometriomas
• Conditions that Cause Infertility
1. Pelvic adhesions
2. Distortions of reproductive anatomy
3. Fallopian tube obstruction
• Intractable and Incapacitating Pelvic Pain
• Involvement of Other Organ Systems (Bowel, Ureter, Etc.)

The same can also be said for pelvic adhesions or distortion of pelvic anatomy that may result in infertility. Pelvic pain that persists despite more conservative therapy as well as involvement and functional compromise of other organ systems (such as the bowel or urinary tract) are also considerations for major surgery in patients with endometriosis.

The surgical technique for major surgery in a patient with endometriosis, particularly one interested in subsequent fertility, should incorporate all the principles of microsurgery that preserve tissue integrity and reduce subsequent adhesion formation. Endometriotic implants are then excised or vaporized using the laser as previously described. The operating loupe or microscope may be particularly helpful in destroying implants or in lysing or excising adhesions. Peritoneal defects should be closed with fine absorbable sutures or covered with peritoneal or omental grafts. Approximation of the uterosacral ligaments not only helps in reperitonealization but also helps to maintain the uterus in an anterior position. Small ovarian lesions can be cauterized or vaporized but large endometriomas should either be excised or vaporized with a laser followed by plastic closure of the ovarian cortex. Reproductive anatomy should be restored to normal by lysis or excision of adhesions and the fallopian tubes should be examined for patency. Prior to closure a retrodisplaced uterus can be suspended and 100 to 200 cc of high molecular weight dextran (Hyskon) can be left in the peritoneal cavity in an attempt to reduce subsequent adhesion formation and to elevate the tubes and ovaries away from the cul-de-sac. For patients experiencing pelvic pain, a presacral neurectomy can be performed.