What is conservative surgery for endometriosis?

The goal of conservative surgery is to aggressively remove as many endometrial implants and cysts as possible without causing surgical scarring and subsequent adhesions that could hamper future fertility.

The two conservative surgical routes used are either laparoscopy or laparotomy.

Improving Fertility.

Surgery has been shown to improve infertility rates in women with severe endometriosis (stages III and IV). Some physicians recommend conservative surgery even in early-stage endometriosis, because of the progressive nature of the disorder and there is some evidence that it improves fertility. Fertility can often be restored even if the surgery does not remove all the endometrial implants. However, the best fertility rates in such cases occur in the early postoperative period. They decline over time if implants have not been completely eliminated. Subsequent surgeries become less effective in restoring fertility.

Reducing Pain and its Recurrence.

Studies report pain reduction after surgery in more than 60% of women. Conservative surgery, however, can miss microscopic implants that may continue to cause pain and other symptoms after the procedure.

Laparoscopy is now the gold standard treatment for endometriosis.

It is usually done under general anesthetic and involves the following:

• The procedure requires making small incisions at the navel and above the pubic bone.
  
• The laparoscope (a hollow tube equipped with camera lenses and a fiber optic light source) is inserted through the incision at the navel (the umbilical incision).
  
• A probe is then inserted through the second incision allowing the physician to directly view the outside surface of the uterus, fallopian tubes, and ovaries.
  
• One or two additional small incisions can be made on either side of the lower abdomen through these incisions.
  
• Surgical instruments or other devices are passed through these accessory incisions to destroy or remove abnormal tissue.
  
• Implants can be removed by excision (surgical removal) using a laser or scissors or by destroying the area with lasers or with electricity (or electrocautery).

In one study, laparoscopy achieved pain relief in over 62% of women. In addition, pregnancy rates can range from 20% to over 50% after laparoscopy.

Laparotomy

Laparotomy uses a wide abdominal incision and conventional surgical instruments. It is more invasive and requires a longer recovery time. Laparotomy is typically used for infiltrating endometriosis, although the less invasive laparoscopy is showing increasing effectiveness, even for deep implants.

Complications after Surgery.

Many patients experience temporary but severe discomfort in the shoulders after laparoscopy due to residual carbon dioxide gas that puts pressure on the diaphragm.

Nerve Destruction Techniques

There is some evidence that when the pain-conducting nerve fibers leading from the uterus are surgically severed, the amount of pain from dysmenorrhea diminishes.

Two procedures, uterine nerve ablation and laparoscopic presacral neurectomy, are used to block such nerves.

Uterine Nerve Ablation.

Uterine nerve ablation techniques use either laser or cauterization to destroy the nerves leading from the uterus to the lower part of the spine. It has been successful in some cases.

Laparoscopic Presacral Neurectomy.

Laparoscopic presacral neurectomy uses laser techniques to sever the nerves in the lower back that transmit pain from the uterus. The effects seem to be more long lasting than with uterine nerve ablation.

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