Laparoscopic surgery for endometriosis

Surgery Overview

Laparoscopy is the most common procedure used to diagnose and remove mild to moderate endometriosis. Instead of using a large abdominal incision, the surgeon inserts a lighted viewing instrument called a laparoscope through a small incision. If the surgeon needs better access, he or she makes one or two more small incisions for inserting other surgical instruments.

If your doctor recommends a laparoscopy, it will be to:

• View the internal organs to look for signs of endometriosis and other possible problems. This is the only way that endometriosis can be diagnosed with certainty. But a "no endometriosis" diagnosis is never certain—growths (implants) can be tiny or hidden from the surgeon's view.
• Remove any visible endometriosis implants and scar tissue that may be causing pain or infertility. If an endometriosis cyst is found growing on an ovary (endometrioma), it is likely to be removed.

Laparoscopy procedure

You will be advised not to eat or drink for at least 8 hours before a laparoscopy. Laparoscopy is usually done under general anesthesia, although you can remain awake if you have local or spinal anesthetic. A gynecologist or surgeon performs the procedure.

For a laparoscopy, the abdomen is inflated with gas (carbon dioxide or nitrous oxide). The gas, which is injected with a needle, pushes the abdominal wall away from the organs so that the surgeon can see them clearly. The surgeon then inserts a laparoscope through a small incision and examines the internal organs. Additional incisions may be used to insert instruments to move internal organs and structures for better viewing. The procedure usually takes 30 to 45 minutes.

If endometriosis or scar tissue needs to be removed, your surgeon will use one of various techniques, including cutting and removing tissue (excision) or destroying it with a laser beam or electric current (electrocautery).

After the procedure, the surgeon closes the abdominal incisions with a few stitches. Usually there is little or no scarring.

What To Expect After Surgery

Laparoscopy is usually done at an outpatient facility. Sometimes a surgery requires a hospital stay of 1 day. You will likely be able to return to your normal activities in 1 week, maybe longer.

Why It Is Done

Laparoscopy is used to examine the pelvic organs and to remove implants and scar tissue. This procedure is usually reserved for checking and treating:

• Severe endometriosis and scar tissue that is thought to be interfering with internal organs, such as the bowel or bladder.
• Endometriosis pain that has continued or returned after hormone therapy.
• Severe endometriosis pain (some women and their doctors choose to skip medicine treatment).
• An endometriosis cyst on an ovary (endometrioma).
• Endometriosis as a possible cause of infertility. The surgeon usually removes any visible implants and scar tissue. This may improve fertility.

When laparoscopy may not be needed

Directly viewing the pelvic organs is the only way to confirm whether you have endometriosis. But this is not always needed. For suspected endometriosis, hormone therapy is often prescribed.

How Well It Works

Pain relief

As with hormone therapy, surgery relieves endometriosis pain for most women, but it does not guarantee long-lasting results.

• Between 70% and 100% of women report pain relief in the first months after surgery.¹
• About 45% of women have symptoms return within the first year after surgery.² This number increases over time.¹

Some studies suggest that using hormone therapy after surgery can make the pain-free period longer by preventing the growth of new or returning endometriosis.³

Infertility

If infertility is your primary concern, your doctor will probably use laparoscopy to look for and remove signs of endometriosis.

• Research has not firmly proven that removing mild endometriosis improves fertility.⁴
• For moderate to severe endometriosis, surgery will improve your chances of pregnancy.⁵
• In some severe cases, a fertility specialist will recommend skipping surgical removal and using in vitro fertilization.

Overall, pregnancy rates are highest in the 6 to 18 months after surgery.⁶

After laparoscopy, your next steps depend on how severe your endometriosis is and your age. If you are older than 35, egg quality declines and miscarriage risk increases with each passing year. In that case, your doctor may recommend infertility treatment, such as fertility drugs, insemination, or in vitro fertilization. If you are younger, consider trying to conceive without infertility treatment.

Endometrioma

There are various ways of surgically treating an endometrioma, including draining it, cutting out part of it, or removing it completely (cystectomy). Any of these treatments brings pain relief for most women, but not all. But cystectomy is most likely to relieve pain for a longer time, prevent an endometrioma from growing back, and prevent the need for another surgery.¹

Risks

Complications from the surgery are rare but include:

• Pelvic infection.
• Uncontrolled bleeding that results in the need for a larger abdominal incision (laparotomy) to stop the bleeding.
• Scar tissue (adhesion) formation after surgery.
• Damage to the bowel, bladder, or ureters (the small tubes that carry urine from the kidneys to the bladder).

What To Think About

The benefits of laparoscopic surgery compared with open abdominal surgery include less tissue trauma and scarring and smaller incisions along with being able to have an outpatient procedure or a shorter hospital stay and a shorter recovery time.

The skill of the surgeon is critical when surgery is used to treat endometriosis that is causing infertility. The use of a laparoscope, lasers, and some of the operative procedures require additional training for a surgeon. Doctors report varying pregnancy rates after endometriosis surgery.

Surgeons disagree about reconstruction of fallopian tubes that have been affected by endometriosis.¹

In vitro fertilization (IVF), an assisted reproductive technology, is an alternative to surgery to correct infertility caused by endometriosis.

Complete the surgery information form (PDF) (What is a PDF document?) to help you prepare for this surgery.

Author:	Kathe Gallagher, MSW Ralph Poore Monica Rhodes	Last Updated: September 19, 2007
Medical Review:	Kathleen Romito, MD - Family Medicine Deborah A. Penava, BA, MD, FRCSC, MPH - Obstetrics and Gynecology
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