Surgical Treatment of Endometriosis

Summary:

  • Surgical treatment is the most effective means of treating endometriosis in terms of a long term reduction in pain and an increase in fertility.
  • Mr. Trehan performs all endometriosis surgery via keyhole surgery as it is associated with a number of advantages for the patient.
  • Mr. Trehan removes all endometriosis from the peritoneum via ‘Total Pelvic Peritoneal Excision’, a technique which he has pioneered and implemented in order to improve patient outcome and reduces the likelihood of future recurrence of endometriosis.
  • Mr. Trehan performs a bilateral oophorectomy (removal of both ovaries) under no circumstances in patients with endometriosis as a a bilateral oophorectomy is not the solution for endometriosis treatment and is associated with not only permanent infertility, but also a variety of adverse, irreversible long term effects on a woman’s health.
  • In patients wishing to preserve fertility, Mr. Trehan under no circumstances removes the uterus to treat endometriosis, as a hysterectomy is not the solution to endometriosis – removal of the endometriosis is the solution.
  • Mr. Trehan removes all endometriosis from the bowel (rectum) without removing any portions of the bowel, which massively reduces the risk of surgical complications.
  • Mr. Trehan removes all endometriosis from other pelvic organs such as the bladder and ureters whilst leaving the organs in tact.
  • Mr. Trehan’s complication rates, reoperation rates, readmission rates and the duration of his patient’s hospital stay are amongst the lowest reported in the medical literature, despite many of his patients having extremely severe endometriosis and operations lasting up to 9 hours.

As discussed on the medical treatments page, only surgical treatment offers the prospect of a long term ‘cure’ of endometriosis in terms of a long term reduction or elimination of pain and an increase in fertility.

On this page surgical management of endometriosis is discussed in depth, beginning with a discussion of how access to the pelvic cavity is gained in order to operate and then moving on to discuss how the endometriosis is treated during the operation once access to the pelvic cavity is gained. In endometriosis, both the peritoneum (the ‘skin’ which covers the pelvic cavity and its organs) and, in more advanced stages, organs of the pelvic cavity may be inflicted with endometrial lesions. It is therefore essential to thoroughly remove endometriosis from all of these locations during surgical treatment. Each of these locations are individually considered below. It is important to note that the effectiveness of the removal of your endometriosis (in terms of effectively visualising and completely removing all endometriosis lesions) is highly dependant upon the surgical skill and experience of the surgeon who is operating on you.

Click the subheadings below in order to expand each section:

Surgical route of entry

All major gynaecological surgery, including surgery for the treatment of endometriosis can be undertaken via two principal means: laparoscopy (keyhole surgery) or laparotomy (open surgery). During open surgery, a very large incision (cut) around 120mm in length is made to the abdomen and the cut made is then physically pulled open to form a large hole through which surgery is performed. In contrast, during keyhole surgery, three extremely small 0.5cm – 1.2 cm incisions are made in the abdominal wall. Through these holes long narrow instruments and a laparoscope (video camera) are inserted.

During keyhole surgery, the laparoscope provides significant magnification and the ability to survey the whole pelvis for patches of endometriosis. Conversely, regions of endometriosis are missed during open surgery as the laparoscope’s magnification and flexibility are not available. Thus when endometriosis surgery is performed via open surgery, the endometriosis is almost impossible to completely remove. All surgery for endometriosis should therefore be performed via keyhole surgery as in this way the endometriosis can be completely removed. Furthermore, as the incisions made during keyhole surgery are much smaller, it is associated with less post-operative complications (such as hernia, infections etc.), a quicker recovery, less pain and a superior cosmetic appearance when compared to open surgery. Perhaps the only disadvantage of keyhole surgery is the greater surgical skill and expertise required by the surgeon. For these reasons, Mr. Trehan performs all endometriosis surgery with no exceptions via keyhole surgery. A common misconception is that if you have severe endometriosis, you must have open surgery as the condition is too complicated to be operated on via keyhole surgery; this is not correct, as in all cases, an endometriosis specialist should be able to complete the operation via keyhole means; indeed, Mr. Trehan has not performed a single case of open surgery for a patient with endometriosis in the past fifteen years.

Having discussed the surgical route of entry into the pelvis (ie. keyhole surgery versus open surgery), the surgical procedures which are undertaken once the surgeon has gained access to within the pelvis will now be described.

Peritoneum (‘skin’ which covers the pelvic cavity and organs)

In order to remove endometriosis from the peritoneum, two principle methods may be used; excision in which the endometriosis is cut away and removed, or ablative surgery in which the endometriotic lesions are burned away using a laser. Ablative (laser) surgery is less effective than excision surgery in the management of endometriosis as:

  • Deep lesions of endometriosis are not removed by laser surgery which results in poorer outcome in terms of pain and fertility and increased reccurence rates.
  • Thermal damage to internal organs can occur with laser surgery resulting in major surgical complications. Further, in order to mitigate this risk, the surgeon may try and avoid operating close to major organs, thereby resulting in all the endometriosis not being removed.
  • Thermal damage caused by laser surgery may obscure complete visualisation of adjacent lesions of endometriosis and organs.
  • Biopsy samples of endometriosis cannot be taken during laser surgery in order to confirm the presence of endometriosis.
  • There is an increased risk of adhesion formation with laser surgery due to the formation of an ischaemic raw area. These adhesions may cause further pain and infertility.
  • Carbon particles left in the body by CO2 laser surgery may cause further pain.

Excision of endometriosis therefore offers the most effective means by which endometriosis can be removed from the peritoneum. In conventional practice, during excision of endometriosis, only the regions of the peritoneum which appear to contain endometriosis are removed; all areas of so called ‘normal’ peritoneum are kept in tact. However, many patients (20-40%) still fail to see an improvement in symptoms in terms of pain and fertility. Further, conventional excision often results in recurrence of endometriosis; studies have demonstrated that following conventional endometriosis excision, endometriosis recurs in 20% of patients within 2 years and 40-50% of patients within 5 years.

In order to improve outcome in terms of pain and fertility and reduce endometriosis recurrence rates, Mr. Trehan has pioneered, innovated and implemented ‘Total Pelvic Peritoneal Excision’. During Total Pelvic Peritoneal Excision, rather than just removing the region of the peritoneum which visibly appears to contain endometriosis, Mr. Trehan removes the entire pelvic peritoneum. The reason for this is that the so-called ‘normal’ peritoneum is not in fact normal, and therefore may form the basis of continuing pain and infertility even after endometriosis excision:

  • In line with the three prevailing theories on the origin of endometriosis described on the Endometriosis Symptoms & Causes page, the ‘normal’ peritoneum is still likely to harbor endometrial or pre-endometrial cells, all which are removed during Total Pelvic Peritoneal Excision:
    • In the case of the retrograde menstruation theory, regions of ‘normal’ peritoneum may be particularly susceptible to implantation by endometriotic cells.
    • In line with the coelomic metaplastic theory, cells which are present within the peritoneum which may have begun differentiation into endometrial cells but have not yet formed bona fide lesions are likely to be present within the ‘normal’ peritoneum and may form future endometriosis lesions.
    • In line with the Müllerian remnant theory, uterine embryonic cells may still be present within the ‘normal’ peritoneum which may form future endometriosis lesions.
  • Studies have demonstrated ‘normal’ peritoneum in patients with endometriosis contains endometriosis which is not visible. This ‘invisible’ endometriosis is removed during Total Pelvic Peritoneal Excision.
  • Studies have demonstrated ‘normal’ peritoneum in patients with endometriosis contains abnormal neuronal innervation which may be involved in conveying pain and facilitate the development of future endometriotic implants. This abnormal neuronal innervation of ‘normal’ peritoneum is removed during Total Pelvic Peritoneal Excision.
  • Studies have demonstrated ‘normal’ peritoneum in patients with endometriosis contains vascular changes and increased inflammation which may form the basis of pain and facilitate the development of future endometriotic implants. These abnormal vascular changes and inflammation of ‘normal’ peritoneum is removed during Total Pelvic Peritoneal Excision.
  • Studies have demonstrated that following conventional excision, regions of endometriotic lesions are often missed by the surgeon, which results in further pain, infertility and future recurrence. Total Pelvic Peritoneal Excision ensures that all endometriotic lesions are completely removed.

Thus by performing Total Pelvic Peritoneal Excision, all endometriotic cells, cells with the potential to develop into endometriosis and other abnormal changes within the ‘normal’ peritoneum are removed.

A video on this technique which Mr. Trehan presented at numerous international conferences can be viewed below:

Mr. Trehan has presented this technique at various international conferences. These presentations can be viewed below:

Laparoscopic total pelvic peritoneal excision: a safe surgical procedure for the management of endometriosis (Lisbon, Portugal – 2001; San Diego, USA – 2002; Glasgow, Scotland – 2003; San Francisco, USA – 2004; London, England – 2005; Kuala Lumpur, Malaysia – 2006)

Effectiveness of total pelvic peritoneal excision for the management of endometriosis (Leeds, England – 2009; London, England – 2010; Barcelona, Spain – 2010; Athens, Greece – 2011)

Effectiveness and predictors of outcome of laparoscopic total pelvic peritoneal excision (poster)

Total pelvic peritoneal excision allows conservation of the ovaries in women with endometriosis undergoing a hysterectomy (London, England – 2011)

Mr. Trehan’s technique has also been covered in the media, including BBC News and the Daily Mail:

Endometriosis woman conceives naturally after surgery (BBC news)
Surgery to end monthly pain threatening the fertility of 1.5m women (Daily Mail)

Mr. Trehan has demonstrated that following Total Pelvic Peritoneal Excision, the pelvic cavity heals to a normal appearance and that adhesion (scar tissue) formation does not occur. The peer reviewed journal paper demonstrating this which was published by Mr. Trehan can be viewed by clicking here.

Ovaries

Endometriosis may itself be present on the surface of the ovary. It is not possible to excise the peritoneum on the surface of the ovaries and hence endometriosis on the surface of the ovaries is cauterized (burned). In other instances, endometriosis may be present within the ovary, presenting as a cyst known as a chocolate cyst (endometrioma). In such cases, the cyst itself is punctured in order to drain the fluid it contains, and the cyst tissue is surgically removed from the ovaries, leaving the normal ovarian tissue in tact. It is important that the surgeon removes the cyst itself, and not just punctures and drains it, as otherwise the cyst will simply reform. The eight images below taken by Mr. Trehan demonstrate the process of the removal of an extremely large endometrial cyst (endometrioma):

  • Endometriotic Cyst Removal 1
  • Endometriotic Cyst Removal 2
  • Endometriotic Cyst Removal 3
  • Endometriotic Cyst Removal 4
  • Endometriotic Cyst Removal 5
  • Endometriotic Cyst Removal 6
  • Endometriotic Cyst Removal 7
  • Endometriotic Cyst Removal 8

Thus, no matter how large the cyst, Mr. Trehan treats ovarian cysts via the removal of the cyst and not via removal of the ovary affected by the cyst (unilateral oophorectomy). Although one ovary is left in tact following a unilateral oophorectomy, future problems with this remaining ovary (eg. the occurrence of an endometrial cyst on this ovary too) may occur, which could in turn result in infertility and, in the case of ovarian failure, early menopause, disadvantages of which are discussed below. For these reasons, Mr. Trehan removes the endometrial cyst itself, leaving the normal ovarian tissue of the affected ovary in tact.

In other situations, following ineffective medical and surgical treatment of endometriosis, many patients may be prescribed a hysterectomy (removal of the uterus) and bilateral oophorectomy (removal of both ovaries). The logic behind performing a bilateral oophorectomy is that by removing the ovaries, one removes the hormones secreted by the ovaries which in turn should relieve endometriosis. However, such a means of treatment may be ineffective and is associated with a variety of adverse irreversible and long term effects:

  • Many patients still experience pain following a bilateral oophorectomy, as a bilateral oophorectomy does not remove the endometriosis itself.
  • Since the ovaries are responsible for producing the ovum (egg), by removing the ovaries, permanent infertility occurs and patients will never be able to conceive.
  • The ovaries are responsible for producing the sex hormones oestrogen and progesterone. Further, even after natural menopause, the ovaries produce significant quantities of the male hormones androstenedione and testosterone which are converted to oestrogen in the female body, and these hormones are important for a woman’s health. Since a bilateral oophorectomy results in a loss of these hormones, it causes:
    • Early menopause resulting in menopausal symptoms (hot flashes, night sweats, lack of sleep, vaginal dryness resulting in painful sex, depressed mood, lethargy/irritability, impaired body self image). Unlike natural menopause, these changes caused by a bilateral oophorectomy are abrupt and dramatic due to the sudden loss in ovarian hormones.
    • A variety of deleterious effects on a woman’s long term health including an increased risk of: premature death, cardiovascular disease, cognitive impairment or dementia, Parkinson’s disease, osteoporosis and bone fractures, a decline in psychological well-being and a decline in sexual function.
    • In order to try and mitigate some of these deleterious effects of a bilateral oophorectomy, Hormone Replacement Therapy (HRT) is usually prescribed, especially in young patients. However, studies have shown that long term HRT use significantly increases the risk of cardiovascular disease, strokes, deep vein thrombosis (DVT – clots in the legs) resulting in pulmonary embolism (potentially fatal clots which migrate to the lungs) and breast cancer. Further, long term HRT use increases the risk of endometriosis recurrence.

For these reasons, in Mr. Trehan’s opinion, under no circumstances should a woman’s ovaries be removed in order to treat endometriosis. By completely excising the pelvic peritoneum and removing endometriosis from all organs affected, Mr. Trehan has not had to remove both ovaries in order to treat endometriosis in a single patient in the past decade.

Another consideration with regarding to the ovaries and endometriosis is that following any pelvic surgery, ovarian adhesions (fibrous bands of scar tissue) are particularly susceptible to forming. These ovarian adhesions are associated with symptoms similar to endometriosis such as pelvic pain, dyspareunia and infertility. In order to prevent the formation of such ovarian adhesions, Mr. Trehan pioneered, innovated and implemented the technique of ‘Temporary Ovarian Suspension’ during which the ovaries are temporarily stitched to the stomach wall. The stitches are removed a few days later using scissors by your GP and the ovaries then move back into their normal position and are much less likely to form adhesions as the pelvic cavity will have now healed from surgery.

A medical journal paper regarding this procedure which Mr. Trehan published can be viewed by clicking here.

Furthermore, a video which Mr. Trehan presented globally at a number of international conferences on Temporary Ovarian Suspension can be viewed below:

Uterus

It is essential to note that endometriosis is not a disease of the uterus – it is a disease of the peritoneum and other organs of the pelvic cavity – and hence a hysterectomy should not be performed in order to treat endometriosis; a hysterectomy only has a place in the treatment of uterine pathologies, not endometriosis.

Endometriosis may, however, be present on the surface of the uterus. Endometriosis on the surface of the uterus is cauterized (burned). Endometrial cells may also be present in the walls of the uterus; this is thought to be a distinct condition from endometriosis and is known as adenomyosis, however the two may occur together in the same patient. Unlike endometriosis of the peritoneum and other organs, endometrial cells can not be removed from the wall of the uterus. Thus the only way to remove adenomyosis is via a hysterectomy (removal of the uterus). Furthermore, other uterine pathologies such as uterine fibroids, pelvic inflammatory disease, cervical pathologies or clinically bulky/tender uteri may be present within patients with endometriosis.

There are three distinct patients with both endometriosis and uterine pathologies, each of which require different management:

  • Patients with pathological uteri due to uterine fibroids. In these patients, in addition to removing the endometriosis completely from the peritoneum via total pelvic peritoneal excision (see above) and from any other organs affected by endometriosis, Mr. Trehan performs a myomectomy in order to remove the uterine fibroid from the uterus, resulting in resolution of symptoms related to the uterine fibroids.
  • Patients with pathological uteri due to conditions other than uterine fibroids, who have completed childbearing and are confident that they will not wish to conceive in future. In these cases a hysterectomy may be performed, however, Mr. Trehan also removes the endometriosis completely from the peritoneum via total pelvic peritoneal excision (see above) and from any other organs affected by endometriosis as a hysterectomy alone will resolve only the symptoms associated with the uterine pathology, not endometriosis.
  • Patients with pathological uteri due to conditions other than uterine fibroids, who have not completed childbearing and wish to conceive in future. In these patients, a hysterectomy should not be performed. Here, Mr. Trehan removes the endometriosis completely from the peritoneum via total pelvic peritoneal excision (see above) and from any other organs affected by endometriosis. This may reduce or eliminate the pain associated as well as significantly improve fertility. In such cases, the patient may wish to try and conceive for some time. Following completion of ones family, if patients still have pain associated with their pathological uterus, a hysterectomy may be performed. However, if the patient does not have any significant symptoms associated with the uterine pathology, no further intervention will be required.

A total hysterectomy (in which the entire uterus body and cervix (neck) is removed) should be performed, not a subtotal hysterectomy (in which only the body, and not the cervix(neck) of the uterus is removed), as pain is more likely to continue following a subtotal hysterectomy. Additionally, for the reasons documented above, when a hysterectomy is performed for the uterine pathology, a bilateral oophorectomy (removal of both ovaries) should not be performed at the same time; the ovaries should be left in tact.

It is again important to emphasise that a hysterectomy should not be undertaken to treat endometriosis, it should only be undertaken to treat uterine pathologies.

Bowel (rectum)

Endometriosis is present in the wall of the large bowel in around 10% of cases. It can only be treated appropriately by an endometriosis specialist and requires an advanced form of surgery. Although many treat this form of endometriosis by rectal resection (removing part of rectum and then repairing it), Mr. Trehan always undertakes shaving of the rectum (stripping the endometriosis off the bowel wall) for treatment of this condition. The reasons he undertakes shaving as opposed to resection are:

  • The improvement in endometriosis-related pain is similar following both resection and shaving.
  • In a resection, the removal of a portion of the bowel is associated with a 10-15% risk of severe complications such as faecal leakage, peritonitis, rectovaginal fistula, colostomy, anterior resection syndrome and effects on future fertility.

The video below demonstrates the process of rectal shaving of endometriosis:

Bladder

Endometriosis may be present on the surface of the bladder peritoneum in which case the peritoneum is excised as shown in the short video below:

However, in more advanced cases of endometriosis, the endometriosis may penetrate the wall of the bladder to form an endometriotic bladder nodule or scar. In order to remove this nodule or scar, it is cut out of the bladder wall and the bladder is then stitched back together. The video below which was presented by Mr. Trehan at various international conferences demonstrates the removal of an endometriotic bladder nodule:

Ureters

The ureters are the muscular tubes which carry urine from the kidneys to the bladder. Endometriosis may be present on the surface of the ureters in which case the endometriosis is removed by ureterolysis (shaving the ureters) as shown in the video below:

The endometriosis may also invade deep into the muscular wall of the ureters. In such instances the region of the ureter containing endometriosis is surgically cut and removed and the ureter is then rejoined using stitches.

Complications

All major surgery has potential complications, and major complications of surgery for endometriosis include injury to internal organs (eg. bowel, bladder, ureters, blood vessels), infection, haemorrhage (blood loss), blood clots leading to pulmonary embolism etc. The likelihood of you experiencing such major complications is highly dependant on the surgical skill and experience of the surgeon who is operating on you. Mr. Trehan cannot guarantee that you will not experience any major complications; however based on clinical audits of his surgery over the past 20 years, you are extremely unlikely to suffer from any such major complications as Mr. Trehan’s complication rates, reoperation rates and readmission rates are amongst the lowest reported in the medical literature despite the fact that many of his patients have the most advanced and complicated stages of endometriosis (many of whom have previously been refused surgical treatment or had incomplete/abandoned previous surgeries on the basis of the complexity of their pelvic pathology), with operations lasting up to 8 hours in duration. Approximately 90% of Mr. Trehan’s patients leave the hospital after just an overnight stay following surgery.