Introduction
This page provides information for women who have been offered or are considering laparoscopic surgery for the treatment of endometriosis.
Diagnosis of endometriosis
Endometriosis is best diagnosed and assessed by directly visualising the disease. This is the only means of making a definitive diagnosis. Laparoscopy is an operation in which a small telescope (laparoscope) is inserted into the abdomen to look directly at the tissues. A laparoscopy is carried out under general anaesthetic. At the same time, various procedures can be performed in order to destroy or remove the endometriosis, endometriotic cysts and release scar tissue (adhesions).
Is laparoscopy always needed to diagnose endometriosis?
Laparoscopy is the best investigation to diagnose endometriosis. Endometriosis can sometimes be felt on vaginal examination or an endometriotic cyst seen on an ultrasound scan. A normal vaginal examination or a normal scan does not exclude endometriosis. A blood test measuring a protein, CA 125, may assist, however, is not specific to endometriosis. Elevated CA 125 levels can indicate irritation or inflammation inside the body and can be raised in endometriosis, as well as appendicitis, pelvic infection and ovarian cysts.
The aim of the surgery is to:
1. Destroy or remove areas of endometriosis
2. Destroy or remove ovarian endometriotic cysts, by removing or excising the cyst wall, and draining the cyst contents (chocolate fluid)
3. Divide adhesions to free tissues, which may improve fertility
Laparoscopy
Hospital admission is often just for the day (day case surgery) but takes an overnight bag just in case you are advised to stay. You will be given a general anaesthetic. Before the anaesthetic, you must not have anything to eat or drink for at least 6 hours prior to the surgery. Your hospital will give you detailed information about this prior to your operation.
At the start of the operation, the bladder is emptied (catheterised). A trochar is then inserted inside the belly button (umbilicus) and the abdomen is filled with carbon dioxide gas. The carbon dioxide gas lifts the tummy wall away from the bowel. Two to three other small (approximately 1cm) cuts (incisions) may be made. This is for the introduction of other instruments required for holding tissues, destroying or removing endometriosis, washing/cooling tissues, suctioning blood and/or washing fluid. A careful inspection is made of the womb (uterus), ovaries, fallopian tubes, Pouch of Douglas, bowel, bladder and all surrounding areas and a record of the severity of the disease is made by either drawing, photographs or video. Many different appearances of endometriosis have now been recognised. In some cases, if the tissues are stuck together (adhesions), it may not be possible to see some or all of these organs.
At the end of the operation, the small cuts will be closed with a stitch, tape or glue. The stitches will either dissolve or can be removed after a few days.
Success rates of laparoscopic surgery
Different rates are reported, but studies suggest a 62.5% improvement or resolution of pain at 6 months, with 55% still improved at 12 months. Failure to respond to surgical treatment may be due to incomplete removal or destruction of the disease or because of disease recurrence. If endometriosis is severe and affecting other organs such as the bowel, it may not always be possible to remove all of the endometriosis during one laparoscopy, as other consultant specialists (colorectal surgeon, urologist) may be required.
The recurrence rate of endometriosis is unpredictable but is generally reported to be in the range of 5-20% per year. Women wishing to get pregnant should start trying as soon as possible after surgery. Women wishing to defer conception should consider medical treatment such as continuous combined contraceptive pill, continuous progesterone therapy or Mirena intrauterine device, in order to try and prevent or delay recurrence of the disease.
Risks of laparoscopy and laparoscopic surgery
Laparoscopic surgery does not convert a major operation into a minor one. The surgery is still considered to be major, but the recovery time is quicker.
Although laparoscopy is a common surgical procedure, there are risks associated. Most risks associated with laparoscopy are minor. Difficult laparoscopic procedures may require conversion to open surgery (laparotomy). Three out of every 1000 women undergoing diagnostic laparoscopy will require conversion to laparotomy to repair the injury sustained during laparoscopy. This means any woman undergoing laparoscopic surgery should understand that it is possible to wake after the operation with a larger incision. In this situation, which may be life-threatening, it will not be possible to wake the patient to discuss the options. This will be discussed during consent for the procedure. Recovery from a more major operation will take longer, with possibly up to 1-2 weeks in the hospital and 6-8 weeks rest at home.
• Infection (stitches or bladder) 1 in 20
• Bruise (wound haematoma) 1 in 20
• Perforation of the uterus 1 in 200
• Bleeding inside the abdomen 1 in 200
• Clot in a vein of the leg or lung (thrombosis) 1 in 200
• Bladder perforation 1 in 200
• Bowel perforation 1 in 250
• Damage to a major blood vessel 1 in 500
• Death 1 in 12,000 women as a result of complications
Other complications include failure to gain entry into the abdominal cavity and failure to identify the disease. Surgery is more difficult, and therefore more risky, in women who are overweight or who have abdominal scars from previous surgery.
After the operation
You will feel sore around the incisions and sometimes experience period-like pelvic pain. There may be some swelling or bruising around the wounds. The carbon dioxide gas is removed but may cause a feeling of bloating and referred discomfort in your ribs and shoulders. This is normal and will disappear over a few days as the gas slowly reabsorbs. The discomfort can be relieved by painkillers. You may feel nauseated or have vomiting post operation. This can be treated with an anti-sickness medication.
Some patients feel well enough to go home the same day, but this will also depend on the extent of the surgery. Sometimes patients may be advised to stay overnight. It is essential to be accompanied home and to avoid driving or operating machinery for 48 hours. The time required off work will depend on the amount of surgery performed but will usually be about 2 weeks.
At home, you can take painkillers such as paracetamol if needed. Some patients may be given a course of antibiotic tablets to take home. Slight bleeding from the vagina is normal and is nothing to worry about. You can have intercourse again as soon as you are comfortable. The cuts should be kept clean and dried carefully after a bath or shower. Occasionally, wounds can become infected; if the cuts become red and inflamed or there is an unusual discharge, you should contact your GP or gynaecologist.
Reasons to contact after laparoscopic surgery
√ Severe pain or fever after going home
√ Nausea or vomiting
√ Increased bleeding from the cuts
√ One or more of the cuts become painful
√ Smelly vaginal discharge
√ Smelly discharge from the cuts