Eendometriosis

Information Sheet for Women Undergoing
Laparoscopic Treatment for Endometriosis

This should be used as an adjunct for the information discussed in clinic. If anything is not clear, please discuss further.

Laparoscopy is a technique by which a thin telescope is inserted into the abdomen to inspect the pelvic organs. A small incision  around 1.5cm) is made within or under the umbilicus (belly button) and the abdomen is filled with gas. This distension allows the surgeon to inspect the pelvic organs to confirm the diagnosis of endometriosis. Another small incision is made close to the pubic hairline or on the side of the abdomen.

If any endometriosis is seen then further incisions (normally up to three more) are made to allow treatment to the affected areas. The surgeon would then either burn out or remove the affected areas.

You may be required to have drugs prior to surgery or if the tissue is very vascular, and your disease is in the aggressive stages, your surgery may entail partial treatment and then drugs and a second planned procedure. In other words, your surgery will be undertaken in two stages to optimise complete removal of disease.

Bowel preparation You may be given medicine the day before surgery to clean out your bowels. This will help with the surgery and may reduce the risk of complications if the bowel is involved (see bowel preparation guideline for further details).

Surgery

Surgery will involve inspection and burning away the endometriosis tissue or spots. The procedure will vary depending on your symptoms and the operative findings. Whilst all surgery should be seen as a major undertaking with the surgical risks detailed below being common to all types of surgery,  surgical treatment aims to balance your treatment aims and the greater risks
associated more advanced surgery. Usually at a “first stage” operation less complex surgery is performed, although it is not always possible to absolutely predict the extent of surgery required :

  • Adhesions (scar tissue) would be divided or removed.
  • An endometrioma or chocolate cyst (cyst filled with endometriotic fluid) will be opened and drained. The cyst will then be treated. Care will be taken to preserve as much normal ovarian tissue as possible and reconstruct the ovary where required.
  • Other areas of endometriosis may be removed from your pelvis to help with your symptoms. Most commonly, but not
    exclusively, this may involve releasing your ovaries if they are stuck in the pelvis, removing disease from the pelvic side walls, near the bladder or from the back of the uterus (the uterosacral ligament), depending on the extent of the disease, as these areas may be implicated in pelvic pain, or pain on sexual intercourse. This may also require dissection around the ureters (tubes that carry urine from the kidneys to the bladder). Whilst it is possible, it is unlikely that significant surgery involving your bowel will be undertaken.
  • If the extent of your disease is noted to be particularly significant, clearly involving significant amounts of the bowel, bladder or ureter, or particularly aggressive and bloody, then only partial treatment may be performed, and you will be further counselled about a second operation (see below) dependent on your symptoms and treatment aims.
  • If you have requested, your fallopian tubes will be checked with dye to see if they are open.
  • You will have a catheter (tube in the bladder) overnight.
  • You may also have a PCA (patient controlled analgesia) overnight where you have the control of pain relief medication
    which you may administer yourself by pressing a button.
  • Usually you would be discharged one or two days after surgery. The duration of stay depends on the extent of endometriosis.

Major complex surgery

Extensive surgery is usually also achieved through the telescope, though a longer duration of stay than stated above may be needed. This is usually for women who are known to have significant disease involving the bladder and/or bowel. Often preoperative preparation with special hormonal medication (usually “GnRH analogues”) is required. This type of surgery will
be undertaken dependent on your symptoms, and the findings of previous laparoscopies and /or ultrasound or MRI reports.

This would involve:

  • Cutting away the endometriosis affected tissue.
  • Releasing ovaries if they are frozen in the pelvis.
  • Releasing adhesions and removing the tissue affected by endometriosis around the back and the side of the uterus, around the bladder and ureter and the space between the rectum and the vagina.
  • Dissecting the ureters to be able to remove endometriosis tissue. Usually during such surgery small tubes are placed
    within the ureters via a camera inserted in the bladder (cystoscope) to help guide during surgery. Occasionally these
    tubes are left in after surgery for a period of time.
  • Treating bladder or bowel disease (see below)

Bladder disease

If severe endometriosis affects the bladder (Anterior disease) or is found close to the bladder then:

  • A cystoscopy (inspecting the bladder with a scope) may be done.
  • The bladder may need to be opened to remove the endometriosis.
  • A catheter may be retained inside the bladder and the bladder will be rested for about 14 days.

Bladder disease

The bowel may sometimes be involved with endometriosis. The surgical treatment involves dissecting the bowel free and assessing the degree of involvement. At times nothing more needs to be done, however, at other times the endometriosis may need to be cut away.

  • This may require taking off the surface layer of the bowel or taking out a small disc of bowel and sewing up the resulting
    hole. Sometimes, if the involvement is extensive a small section of the bowel needs to be removed and the bowel rejoined.
  • These procedures are usually done together with the laparoscopic bowel surgeons.
  • The surgery may require an additional 3-5 cm cut in the pubic hair line.
  • Occasionally if the bowel join is very low (near the anus) or the operation has been technically difficult then a stoma bag is required (ileostomy). This effectively diverts the faeces into a bag on the abdomen or stomach thus protecting the join down stream and allowing it to heal. The stoma bag is usually left for around three months and then requires a smaller operation to return the bowel into the abdomen. This usually requires a hospital stay of two to three days.

Surgical risks

The risk of a major complication from a laparoscopy only is about 1-2 per 1000. The risk from the most major type of laparoscopic surgery for endometriosis is up to 1 in 10. You should be aware of these prior to signing the consent form for the operation, and if you have any concerns then please ask for clarifications.

As with all surgery the associated risks may include:

  • Infection.
  • Bleeding (that may require a blood transfusion).
  • Developing a blood clot (in your legs or lungs).
  • Damage to ureters. If the ureters are involved then a stent (tube) is passed via a telescope. This is usually removed as a day case 6 weeks later. If the ureter is cut then it is possible that a cut will be required in the abdomen to rejoin it.
  • Damage to bowel. This can be in the form of a leak from the join leading to an abscess. This may require draining with a  small tube, occasionally it will require a larger cut in the abdomen to correct the problem.
  •  Disturbances to bowel and bladder function, particularly if an area of bowel or bladder has been removed.
  •  Extensive surgery in the pelvis may result in delay in return of bladder function. Occasionally you may need to self-catheterise in the short term and very rarely in the long-term.
  • Damage to nerves causing pain, or altered sensation and function.
  • Risk to delayed complications including bowel leak and haematoma (collection of blood in the abdomen) that if present
    usually occurs up to 3 weeks after the procedure. In addition, if a piece of bowel has had to be removed then there may be
    changes to the way the bowels work in the future. These changes usually resolve over a period of weeks to months.
  •  Risk of a fistula (abnormal connection between the bowel (or other organ) and the vagina).
  • Loss of a tube or ovary due to bleeding.
  • Risk of scar tissue /adhesion formation.
  • If there is significant damage to bowel, bladder, ureter or blood vessels or if surgery is unable to be carried out using the laparoscopic instruments, then a laparotomy (open surgery through a larger cut) may need to be undertaken.

When surgery is carried out for pain, it is important to note that whilst we expect significant improvements in symptoms of pain, surgery may not necessarily improve these symptoms, and in a small number of cases may worsen some types of pain.

Following surgery

it is important that you:

  • Take plenty of painkillers -usually regularly for the first 1-2 weeks following surgery and then gradually trail these off.
  • Keep relatively mobile, and ensure that you build up your mobility as time passes.This helps minimise the chances of developing a blood clot. Some women continue to wear their anti-embolism stockings for a few weeks following surgery.
  • Do however make sure you take sufficient rest as most women feel pretty tired following surgery and anaesthesia.
  • Eat a relatively light diet for the first couple of weeks following surgery.
  • Ensure that you open your bowels regularly, attempting to achieve a soft well-formed still on a daily basis. You may  require 1-2 sachets of a laxative to help with this.

If you have any queries or concerns then please contact my PA. and she will  contact me. In an emergency where you are unable to contact me then please visit your A&E or contact King Edward VII’s hospital – sister-in-charge.

You should seek immediate medical advice (contact the hospital or if you are a long way away attend A&E) if you experience:

  • sudden or increasing pain at home.
  • can not pass urine.
  • have vomiting or feel unwell with a high temperature.