Endometriosis is the condition in which inner lining of uterus grows outside uterus (endometrial implant). Endometriosis most commonly involves ovaries, bowel or the tissue lining pelvis in some patients endometrial tissue may spread beyond your pelvic region like diaphragm, lungs, skin etc.
In endometriosis, ectopic Endometrium (the Endometrium which has grown outside uterus) is hormone dependent and it behaves exactly like normal Endometrium. That means whatever changes are occurring inside the inner lining of uterus same changes are occurring in ectopic endometrial tissue also. Ectopic endometrial tissue thickens, breaks down and bleeds with each menstrual cycle. Because this ectopic tissue has no way to exit your body, it becomes trapped. Trapped endometriotic tissue along with the blood gets collected in pelvis. The endometriotic tissue gets enclosed containing blood within to form a cyst and these cysts are called as “Endometriomas”. This cyst will keep on growing with each menses. Blood gets accumulated in the cyst with every menses. The accumulated blood undergoes changes and it gets chocholate like consistency, hence these cysts are called as chocolate cyst or endometriomas. Endometriomas are generally formed inside or over the surface of the one or both the ovaries. Presence of ectopic Endometrium, blood in pelvis irritates the surrounding tissue which leads to scarring and adhesion formation. Due to adhesions different organs get stuck to each other leading to various symptoms, usually pain. Adhesions distort pelvic anatomy leading to fertility issues.
As a treatment for endometriosis, surgery can be used to alleviate pain by removing the endometriosis, dividing adhesions or removing cysts and also as a fertility preserving/enhancing procedure.
We do laparoscopic surgeries for endometriosis. Open method of surgery is not done at all for such cases.
During Laparoscopic surgery for endometriosis, main incision is taken at or near the umbilicus-navel from which laparoscope goes inside. Carbon di-Oxide gas goes inside the abdominal cavity to distend/ bloat the cavity. We call it as a pneumoperitoneum. Once pneumoperitoneum is created, three or four more incisions are made on either of the sides. Various instruments go inside the abdominal cavity and surgery is performed.
There are three options of surgery for treating endometriosis:
Conservative surgery aims to remove or destroy the deposits of endometriosis and is usually done via a laparoscopy (keyhole surgery). We can either cut out the endometriosis (known as excision) or destroy it using heat or any other energy source. We generally use bipolar energy source to fulgurate (superficial Burning) although surgery can provide relief from symptoms, they can recur in time. Once conservative surgery is done, we give hormonal suppression to many such patients so as to suppress the remnant of the diseases, and then we start fertility treatment (if patient desires fertility).
Laparoscopic excision of endometriomas / chocolate cyst is also done frequently. Largest size of endometriomas which removed laparoscopically was 20cm at Yashadaa.
As discussed previously the endometriosis surgeries are not straight forward one. There is lot of adhesions (sticking of bowel, uterus, tubes, and ovaries together) these adhesions make surgery difficult. Sometimes all the structures are so much stuck to each other that surgery is not possible at all or there is more risk of damage to normal structures.
While removing endometriomas, we generally puncture it; drain all the chocolate colored fluid. We separate cyst wall from normal tissue. Separated cyst wall is then brought out through sterile, specially designed endo bags.
Depending on the severity of endometriosis, Patient may need to undergo more complex surgery that involves different organs within the body, such as the bowel or the bladder. These types of surgery will often include a multi-disciplinary team such as a colorectal surgeon, and are usually carried out via laparoscopy.3. Radical surgery
More radical surgery can be considered if a woman has not responded to drug treatments or conservative surgery and is not planning to start a family. Radical surgery refers to a hysterectomy or oophorectomy.
Hysterectomy is the removal of the womb, and is performed under general anaesthesia. It can be done with or without removing the ovaries. If the ovaries are left in place then the chance of endometriosis returning is increased. Some women need a further operation to remove the ovaries at a later date. Hysterectomy is not the right operation for everyone and not a decision to make lightly.
Oopherectomy is the removal of the ovaries. When both ovaries are removed, the surgical procedure is called “bilateral oopherectomy,” whereas the removal of only one ovary is called “unilateral oopherectomy.” When both ovaries are removed, a woman will experience an instant and irreversible menopause.
Laparoscopic endometriosis surgeries are gold standard and also safe, less painful. Patient recovery is very fast as compared to traditional surgery. Patient can be discharged practically on same or very next day of the surgery.
Laparoscopic endometriosis surgery may have some complications, such as injury to urinary bladder, intestines or ureter or major blood vessels. Rate of such complications is as low as 1 % but such complications can also occur in traditional open surgeries.