Endometriosis is a disorder in which endometrium-like tissue grows into other organs of the pelvis (or even into organs outside the pelvis). Treatment for endometriosis includes clinical observation with lifestyle modification, medical hormonal treatments, and surgery.
Ablation surgery applies heat, such as laser or electrosurgery to destroy the endometriosis lesions and embedded tissue. The disadvantage of ablation for endometriosis is that the heat either does not fully destroy the lesions, or the heat penetrates and spreads too much and causes thermal damage to the surrounding non-diseased tissue. Furthermore, there is no surgical specimen for pathological identification and confirmation. Ablation treatment for endometriosis does not require advanced surgical skill, and all research studies indicate inferior outcomes and higher complication rates. This is NOT the preferred treatment.
Excision surgery, on the other hand, involves cutting out the lesions, implants, or fibrosis (scar tissue) caused by endometriosis. Although excision surgery is more effective, the procedure is technically more difficult and time-consuming. Complete removal of all visible diseased tissue makes this the best treatment currently available. Furthermore, with this type of surgery, the specimen removed from surgery can be sent to the pathology department where confirmation can be made that it is indeed endometriosis and not a different type of disease.
There is often confusion about laparoscopic and robotic assisted surgery. In actuality, robotic-assisted surgery is still laparoscopic surgery. The robot is simply another surgical tool that is used by the surgeon to perform laparoscopic endometriosis surgery. One of the primary advantages of using the robot for excision of endometriosis is that the surgeon has a 3-dimensional view of the pelvis and surgical field, while having access to a 360-degree rotation of the surgical instruments. Another advantage is that the surgeon is able to sit comfortably while operating, thereby dramatically reducing physical strain and fatigue.
There are also disadvantages to using the robot for excision of endometriosis, one of the biggest being that tactile sensation is lost while operating. Because the surgeon is sitting at a console away from the patient, he or she is unable to feel the diseased tissue. Excision of deep infiltrating fibrotic endometriosis requires a combination of both seeing the disease, as well as feeling the disease and ensuring that all of it has been removed. Throughout the operation for resection of recto-vaginal endometriosis nodules, frequent recto-vaginal examinations by the surgeon are often required to ensure the complete excision of the lesion(s).
Your endometriosis surgery preparation will be individualized to best fit your needs. Detailed instructions regarding what to do in the days leading up to your surgery will be reviewed with you during your office visit. On the day of surgery, you will be asked to arrive at the surgery center or hospital 1-2 hours before your scheduled surgery time. You will meet with the nurses, the anesthesia team, and other members of the surgical staff to review your medical history and medications. When your surgery time arrives, you will go to the operating room where you will be given a medication through an IV to put you to sleep. Once you are asleep, a tube will be placed in your mouth and a machine will breathe for you during the surgery.
The surgical procedure begins with approximately 3-4 tiny incisions on your abdomen below the umbilicus and a 10 mm incision inside the umbilicus. Carbon dioxide is used to inflate your abdomen, and the tiny camera and other surgical instruments will be placed through the incisions. The surgeon will then explore the abdomen and pelvis, looking for any endometriosis. If endometriosis is found, the lesions will be carefully excised with tiny surgical scissors and removed from the body to be sent to pathology.
The surgery may last 1-6 hours, depending on the extensiveness of the endometriosis and the amount to be excised. Upon completion of the procedure, the carbon dioxide and all instruments will be removed. The incisions on your abdomen will be closed with dissolvable stitches, the tube will be removed from your mouth, and you will wake up. In the recovery room and post-operative observation room. You will be carefully monitored for several hours. Typically you will be discharged with instructions the same day or the next day after the surgery.
Your recovery process depends on your baseline health and fitness, plus the severity of your disease. In general, for the first couple of days after surgery, you may experience bloating and discomfort from the gas that was used to distend your abdominal cavity for the laparoscopy. You will also have some cramping and post-operative soreness/tenderness. This should improve by the third day, after which you should be feeling better. It is very important that you call us after surgery if you don’t feel better each day compared to the previous day. Within two weeks, you should be feeling almost 90% back to normal. At this time, you will have a follow-up office visit to ensure all is well and to check your abdominal incisions, which by this time should be almost completely healed. Your surgeon will discuss with you the surgical findings and the follow up treatment plans.
With any surgical procedure, potential risks are involved. Risks include, but are not limited to: bleeding, damage or injury to surrounding structures or organs, infection, and risks associated with anesthesia. Endometriosis often involves growth in multiple locations and organs in the pelvis, such as the bowel, bladder, and ureters (the tube that carries urine from the kidneys to the bladder). Often times, this may be deeply-infiltrating endometriosis (DIE) which invades these organs. In order to completely reset and excise all diseased tissue close to or attached to these organs, the procedure becomes extremely meticulous, and your surgeon must be proficient and experienced in performing this delicate type of surgery.
Although there is no substitute for removing the lesions and implants of endometriosis, hormonal and non-hormonal medications can manage the symptoms of pain and suppress further progression of the disease. Additionally, physical therapy, trigger point injections, and lifestyle modifications can also augment the efficacy of excision surgery.