Surgical treatment

Options include:

• conservative surgical treatment
  • principles of conservative surgical treatment include
    • ablation, vaporization or excision of peritoneal lesions
    • cystectomy for endometriomas
    • interruption of nerve path ways
    • excision of uterosacral and/or rectovaginal septum deep endometriosis
    • restoration of pelvic anatomy by adhesiolysis
  • laparoscopic approach is generally used
    • small lesions can be treated via laser; adhesions may be divided
    • there is evidence that combined laparoscopic ablation of endometrial deposits and uterine nerve is likely to be a beneficial intervention in the management of endometriosis compared with diagnostic laparoscopy (2).
    • laparoscopic helium plasma coagulation is another minimally invasive option (3)
    • laparoscopic cystectomy is more suitable for ovarian endometriomata than drainage and coagulation (4)
• radical surgical treatment
  • hysterectomy and bilateral salpingoophorectomy
    • usually reserved for women who have completed their family
    • often medical treatment is used prior to surgery
  • if hysterectomy is indicated (for example, if the woman has adenomyosis or heavy menstrual bleeding that has not responded to other treatments), excise all visible endometriotic lesions at the time of the hysterectomy (5)
  • perform hysterectomy (with or without oophorectomy) laparoscopically when combined with surgical treatment of endometriosis, unless there are contraindications (5)

Surgical management if fertility is a priority (5)

• offer excision or ablation of endometriosis plus adhesiolysis for endometriosis not involving the bowel, bladder or ureter, because this improves the chance of spontaneous pregnancy
• offer laparoscopic ovarian cystectomy with excision of the cyst wall to women with endometriomas, because this improves the chance of spontaneous pregnancy and reduces recurrence - the woman's ovarian reserve must be taken into account

Reference:

• (1) Amer S. Endometriosis. Obstetrics, Gynaecology and Reproductive Medicine 2008;18(5):126-133
• (2) Clinical Evidence (March 2005). Endometriosis
• (3) NICE (May 2006).Laparoscopic helium plasma coagulation for the treatment of endometriosis
• (4) RCOG (2006) The investigation and management of endometriosis. Royal College of Obstetricians and Gynaecologists.
• (5) NICE (September 2017). Endometriosis: diagnosis and management