Surgery for Endometriosis: Benefits and Caution

Surgical removal of endometriosis lesions is a common treatment that has shown significant benefits for patients.  However, there are some important factors to keep in mind to make sure that surgery is right for you. 

 

 

First, seemingly complete surgical removal fails to alleviate pain for at least a year in up to 50% of carefully selected patients"  

- Dr. Pamela Stratton and Dr. Karen Brekley

 

The only definitive method of diagnosis for endometriosis is laparoscopy -- surgery and analysis of the extracted tissue to identify whether or not it is endometriosis. MRI's, ultrasounds, and other testing or imaging can help to rule out other potential causes of symptoms but cannot identify endometriosis. To minimize scar tissue from repeated surgical procedures, it is helpful to both identify endometriosis and excise (remove) all of the endometriosis in one procedure. This excision process is the gold standard for endometriosis treatment.

 

Ablation surgery should be avoided at all costs. It is important to know the difference between excision surgery and other forms of surgery, including ablation surgery, where the surgeon burns or cauterizes the tissue. Burning or vaporizing the tissue means there will be no tissue to examine in order to verify that it is endometriosis. Ablation also has much higher rates of regrowth in the same regions, likely because the method is not able to completely remove all of the endometriosis. Excision surgery allows the surgeon to cut out all of the involved tissue and test it to confirm the diagnosis.

 

Your surgeon's skill matters. Most gynecologists do not have as much training in surgery as surgeons in other fields, so not every gynecologist has the necessary skills to perform excision surgery well. Excision surgery can be very complex, depending on the areas that endometriosis is located and how deeply rooted it has become. The location of the lesions may even require surgeons of other disciplines to work together to remove it. Some surgeons will use lasers or robotic assistance to improve their accuracy, but they still require an innate level of skill to use these tools well. If your surgeon is unable to excise all of the endometriosis there is a greater chance for regrowth. If they are not as skilled, they may also leave greater amounts of scar tissue which can lead to similar symptoms of endometriosis. Yet even with the most talented surgeon...

 

 

It's important to have reasonable expectations regarding the procedure. While minimally invasive laparoscopic excision surgery has been shown to improve both pain and fertility, it is not always a perfect solution.  For most patients, pain can gradually begin to re-occur after surgery.  Approximately 20% of patients don't see an immediate benefit, and up to half of patients note their pain returns within a year of the procedure.  It appears that patients with greater endometriosis growth have better outcomes than those with mild or moderate growth.  

 

It's also important to have proper post-surgical care.  Any surgery creates scar tissue and inflammation.  In the abdominal and pelvic region, these scars can adhere - or stick - to the surrounding tissue and muscles underneath.  When this happens, they put a strain on the system and can generate pain or other symptoms.  A scar should move freely and feel as much like the tissue around it as possible - if the scar is tender to the touch or doesn't move freely, it may actually be causing additional symptoms.

 

"Second, even in patients whose pain was alleviated by surgically treating lesions, pain often returns, sometimes without evidence of new lesions"

- Dr. Pamela Stratton and Dr. Karen Brekley

 

 

Recurrence of pain does not always mean that endometriosis lesions have returned. In one of the more interesting results, researchers have found that only half of patients who experienced a recurrence of pain after surgery actually had endometriosis regrowth. For the rest, other factors like central nervous system up-regulation, peripheral nerve sensitization, pelvic floor dysfunction, scar tissue adhesions, or other factors seem to be the primary cause of pain. 

 

This is perhaps the most perplexing thing we've learned about endometriosis - the amount of pelvic and abdominal pain or other symptoms are not correlated with the progression (sometimes graded in stages) of the condition. Again, this indicates that proper post-surgical treatment to address these other factors may be crucial in preventing recurrence of pain.

 

Third, severity of pain  does not correlate with extent of disease."

- Dr. Pamela Stratton and Dr. Karen Brekley

 

While this can challenge our views about endometriosis, it can also be beneficial to patients to know that they have some control over their symptoms.  Treatments like physical therapy, stress reduction, yoga, dietary supplements, acupuncture, and other methods can reduce endometriosis symptoms, regardless of the progression of growth.

 

Takeaway

 

Endometriosis is complex and requires multidisciplinary treatment.  Surgery can provide major benefits for patients, but it may not be a permanent or complete solution.  Proper post-surgical care may be able to improve outcomes, reduce pain, and prevent additional surgeries.  

 

Additional Resources

 

 

Dr. Nicole Cozean is the founder of PelvicSanity physical therapy, Orange County's premier pelvic floor physical therapy clinic.  One of only 270 PTs to be board-certified in the pelvic floor, and the first PT to serve on the ICA Board of Directors, Nicole is the author of the acclaimed and best-selling book The Interstitial Cystitis Solution (2016).  She is an adjunct professor at her alma mater, Chapman University. The PelvicSanity blog focuses on presenting practical, positive information to help patients beyond the walls of Nicole's clinic. 

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