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Surgical Technique

Strategies and steps for the surgical management of endometriosis

Should endometriomas be simply drained? Drained and coagulated?
Or resected? Should implants be resected, or ablated? And is surgery
a concluding phase of care, or just the beginning?

November 2011 · Vol. 23, No. 11

Endometriosis affects 7% to 10% of women in the United States, mostly during reproductive years.1 The estimated annual cost for managing the approximately 10 million affected women? More than $17 billion.2 The added cost of this chronic disease, with recurrences of pain and infertility, comes in the form of serious life disruption, emotional suffering, marital and social dysfunction, and diminished productivity.

Although the prevalence of endometriosis is highest during the third and fourth decades of life, the disease is also common in adolescent girls. Indeed, 45% of adolescents who have chronic pelvic pain are found to have endometriosis; if their pain does not respond to an oral contraceptive (OC) or a non-steroidal anti-inflammatory drug, 70% are subsequently found at laparoscopy to have endometriosis.3

What is it?

Endometriosis is the presence of functional endometrial tissue outside the uterus, such as eutopic endometrium. The disease responds to effects of cyclic ovarian hormones, proliferating and bleeding with each menstrual cycle, which often leads to diffuse inflammation, adhesions, and growth of endometriotic nodules or cysts (FIGURE 1).

FIGURE 1 Drainage will not suffice
Surgical management of ovarian endometriomas must go beyond simple drainage, which has little therapeutic value because symptoms recur and endometriomas re-form quickly after simple drainage in almost all patients.Symptoms tend to reflect affected organs:

  • Because the pelvic organs are most often involved, the classic symptom triad of the disease comprises dysmenorrhea, dyspareunia, and infertility.
  • Urinary urgency, dysuria, dyschezia, and tenesmus are frequent complaints when the bladder or rectosigmoid is involved.
  • When distant organs are affected, such as the upper abdomen, diaphragm, lungs, and bowel, the patient may complain of respiratory symptoms, hemoptysis, pneumothorax, shoulder pain, upper abdominal pain, and episodic gastrointestinal dysfunction.

The hallmark of endometriosis is catamenial symptoms, which are usually cyclic and most severe around the time of menses. Clinical signs include palpable tender nodules and fibrosis on the anterior and posterior cul de sac, fixed retroverted or anteverted uterus, and adnexal cystic masses.

Because none of these symptoms or signs is specific for endometriosis, diagnosis relies on laparoscopy, which allows the surgeon to:

  • visualize it in its various appearances and locations (FIGURE 2)
  • confirm the diagnosis histologically with directed excisional biopsy
  • treat it surgically with either excision or ablation.

In this article, we describe various surgical techniques for the management of endometriosis. Beyond resection or ablation of lesions, however, your care should also be directed to postoperative measures to prevent its recurrence and to avoid repeated surgical interventions—which, regrettably, are much too common in women who are afflicted by this enigmatic disease.

FIGURE 2 Endometriosis: A disease of varying appearance
Lesions of endometriosis can be pink, dark, clear, or white on the pelvic sidewall (A), bowel (B), and diaphragm (C); under the rib cage (D); and on the ureter (E) (left ureter shown here).

CASE Severe disease in a young woman

S. D. is a 22-year-old unmarried nulligravida who came to the emergency service complaining of acute onset of severe low abdominal pain, which developed while she was running. She was afebrile and in obvious distress, with diffuse lower abdominal tenderness and guarding, especially on the left side.

Ultrasonography revealed a 7-cm adnexal cystic mass suggestive of endometrioma (FIGURE 3).

Two years before this episode, S. D. underwent laparoscopic resection of a 5-cm endometrioma on the right ovary. Subsequently, she was treated with a cyclic OC, which she discontinued after 1 year because she was not sexually active.

The family history is positive for endometriosis in her mother, who had undergone multiple laparoscopic investigations and, eventually, total hysterectomy with bilateral salpingo-oophorectomy at 40 years of age.

S. D. was treated on the emergency service with analgesics and referred to you for surgical management.

S. D. has severe disease that requires aggressive surgical resection and a lifelong management plan. That plan includes liberal use of medical therapy to prevent recurrence of symptoms and avoid repeated surgical procedures—including the total hysterectomy with bilateral salpingo-oophorectomy that her mother underwent.

What is the best immediate treatment plan? Should you:

  • drain the cyst?
  • drain it and coagulate or ablate its wall?
  • resect the wall of the cyst?
  • perform salpingo-oophorectomy?

You also ask yourself: What is the risk of recurrence of endometrioma and its symptoms after each of those treatments? And how can I reduce those risks?

FIGURE 3 Endometrioma
Endometrioma on ultrasonography (A), with its characteristic homogeneous, echogenic appearance and “ground glass” pattern, and through the laparoscope (B). These images are from the patient whose case is described in the text.

Focal point: Ovary

The ovary is the most common organ affected by endometriosis. The presence of ovarian endometriomas, in 17% to 44% of patients who have this disease,4 is often associated with an advanced stage of disease.

In a population of 1,785 patients who were surgically treated for ovarian endometriosis, Redwine reported that only 1% had exclusively ovarian involvement; 99% also had diffuse pelvic disease,5 suggesting that ovarian endometrioma is a marker of extensive disease, which often requires a gynecologic surgeon who has advanced skills and experience in the surgical management of severe endometriosis.

Simple drainage is inadequate

Surgical management of ovarian endometrioma must go beyond simple drainage, which has little therapeutic value because symptoms recur and endometriomas re-form quickly after simple drainage in almost all patients.6 The currently accepted surgical management of endometrioma involves either 1) coagulation and ablation of the wall of the cyst with electrosurgery or laser or 2) removal of the cyst wall from the ovary with blunt and sharp dissection.

Several studies have compared these two techniques, but only two7,8 were prospectively randomized.

Study #1. Beretta and co-workers7 studied 64 patients who had ovarian endometriomas larger than 3 cm and randomized them to cystectomy by complete stripping of the cyst wall or to drainage of fluid followed by electrocoagulation to ablate the endometriosis lesions within the cyst wall. The two groups were followed for 2 years to assess the recurrence of symptoms and the pregnancy rate in the patients who were infertile.

Recurrence of symptoms and the need for medical or surgical intervention occurred with less frequency and much later in the resection group than in the ablation group: 19 months, compared to 9.5 months, postoperatively. The cumulative pregnancy rate 24 months postoperatively was also much higher in the resection group (66.7%) than in the ablative group (23.5%).

Study #2. In a later study,8 Alborzi and colleagues randomized 100 patients who had endometrioma to cystectomy or to drainage and coagulation of the cyst wall. The mean recurrence rate, 2 years postoperatively, was much lower in the excision group (15.8%) than in the ablative group (56.7%). The cumulative pregnancy rate at 12 months was higher in the excision group (54.9%, compared to 23.3%). Furthermore, the reoperation rate at 24 months was much lower in the excision group (5.8%) than in the ablative group (22.9%).

These favorable results for cystectomy over ablation were validated by a Cochrane Review, which concluded that excision of endometriomas is the preferred approach because it provides 1) a more favorable outcome than drainage and ablation, 2) lower rates of recurrence of endometriomas and symptoms, and 3) a much higher spontaneous pregnancy rate in infertile women.9

Although resection of the cyst wall is technically more challenging and takes longer to perform than drainage and ablation, we exclusively perform resection rather than ablation of endometriomas because we believe that more lasting therapeutic effects and reduced recurrence of symptoms and disease justify the extra effort and a longer procedure.

Drawback of cystectomy

A potential risk of cystectomy is that it can diminish ovarian reserve and, in rare cases, induce premature menopause, which can be devastating for women whose main purpose for having surgery is to restore or improve their fertility.

The impact of laparoscopic ovarian cystectomy on ovarian reserve was prospectively studied by Chang and co-workers,10 who measured preoperative and postoperative levels of anti-müllerian hormone (AMH) in 13 women who had endometrioma, 6 who had mature teratoma, and 1 who had mucinous cystadenoma. One week postoperatively, the AMH level decreased significantly overall in all groups. At 4 and 12 weeks postoperatively, however, the AMH level returned to preoperative levels among subjects in the non-endometrioma group but not among subjects who had endometrioma; rather, their level remained statistically lower than the preoperative level during the entire 3 months of follow-up.

Stripping the wall of an endometrioma cyst is more difficult than it is for other benign cysts, such as cystic teratoma or cystadenoma, in which there usually is a well-defined dissection plane between the wall of the cyst and surrounding stromal tissue—allowing for easy and clean separation of the wall. The cyst wall of an endometrioma, on the other hand, is intimately attached to underlying ovarian stroma; lack of a clear cleavage plane between cyst and ovarian stroma often results in unintentional removal of layers of ovarian cortex with underlying follicles, which, in turn, may lead to a reduction in ovarian reserve.

Histologic analyses of resected endometrioma cyst walls have reported follicle-containing ovarian tissue attached to the stripped cyst wall in 54% of cases.11,12 That observation explains why, and how, ovarian reserve can be compromised after resection of endometrioma.

Further risk: Ovarian failure

In rare cases, excision of endometriomas results in complete ovarian failure, described by Busacca and colleagues, who reported three cases of ovarian failure (2.4%) after resection of bilateral endometriomas in 126 patients.13 They attributed ovarian failure to excessive cauterization that compromised vascularization, as well as to excessive removal of ovarian tissue.

It is important, therefore, to strip the thinnest layer of the cyst capsule and to reduce the amount of electrocoagulation of ovarian stroma as much as possible to safeguard functional ovarian tissue.

CASE continued

S. D. was scheduled for laparoscopy to remove the endometrioma and other concurrent pelvic and peritoneal pathology, such as endometriosis and pelvic adhesions. You also scheduled her for hysteroscopy to evaluate the endometrial cavity for potential pathology, such as endometrial polyps and uterine septum, which appear to be more common in women who have endometriosis.

Nawroth and co-workers14 found a much higher incidence of endometriosis in patients who had a septate uterus. Metalliotakis and co-workers15 found congenital uterine malformations to be more common in patients who had endometriosis, compared with controls; uterine septum was, by far, the most common anomaly.

CASE continued

Hysteroscopy revealed a small and broad septum, which was resected sharply with hysteroscopic scissors (FIGURE 4). Laparoscopy revealed a 7-cm endometrioma on the left ovary, with adhesions to the posterior broad ligament and pelvic sidewall. S. D. also had deep implants of endometriosis on the left pelvic sidewall, the posterior cul de sac, the right pelvic sidewall, and the right ovary, which was cohesively adherent to the ovarian fossa.

As you expected, S. D. has stage-IV disease, according to the revised American Fertility Society Classification.

Following adhesiolysis, the endometrioma was resected (see VIDEO 1, at Because of the large ovarian defect, the edges of the ovary were approximated with imbricating running 3-0 Vicryl suture. Deep endometriosis was also resected. Superficial endometriosis was peeled off or coagulated using bipolar forceps.

Note: Alternatively, and with comparable results, resection may be performed with a laser or other energy source. We prefer resection, rather than ablation, of deep endometriosis, but no data exists to support one technique over the other.

FIGURE 4 Septate uterus with deep cornua
Through the hysteroscope, a shallow septum is visible at the fundus of the uterus, dividing the upper endometrial cavity into two chambers (A), with deep cornua on the left (B) and right (C). Normal fundal anatomy is restored by septolysis along the avascular plane (D).

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Vaginal hysterectomy 
with basic instrumentation