Laparoscopic Surgeries for Endometriosis
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 your 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”. These cysts will keep on growing with each menses. Blood gets accumulated in the cyst with every menses. The accumulated blood undergoes changes and it gets chocolate 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 distorts pelvic anatomy leading to fertility issues.
Symptoms of endometriosis:
- Painful periods (dysmenorrhea). Pelvic pain and cramping may begin before and extend several days into your period and may include lower back and abdominal pain. This pain can increase with every menses as the disease progresses or may remain same. Pain may be disproportionate to the disease, that means women with mild disease may have severe pain or sever disease may cause little or no pain.
- Pain with intercourse. Pain during or after sex is common with endometriosis.
- Pain with bowel movements or urination. If Bowel or urinary bladder is involved by the disease patient may experience these symptoms during period.
- Excessive bleeding. Patient may experience occasional heavy periods (menorrhagia) or bleeding between periods (menometrorrhagia).
- Infertility. Endometriosis is first diagnosed in some women who are seeking treatment for infertility.
- Other symptoms. Patient may also experience fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual periods.
Causes of endometriosis:
Although the exact cause of endometriosis is not certain, several possible explanations include:
The most likely explanation for endometriosis is backward flow of menstrual blood during menses. Normally when a lady is having her period , menstrual blood comes out of the uterus through cervix(mouth of the uterus) but in endomtriosis this blood back flows inside the pelvis/abdomen through the fallopian tubes( Tubes which transport eggs and sperms for fertilization). This menstrual blood contains some live endometrial cells (cells lining inner lining of uterus) and these live cells keep on growing inside the pelvis so as to make disease spread. These endometrial cells stick to the pelvic walls and surfaces of pelvic organs, where they grow and continue to thicken and bleed over the course of each menstrual cycle.
Cells lining inner lining of uterus may get transported to other parts of body through blood vessels of lymphatics(tissue fluid) sometimes immune system may cause transformation of normal tissue cells to endometrial cells.
The cells lining the abdominal and pelvic cavities come from embryonic cells which are having potential to turn in to cells as of cells lining Endometrium. If such transformation occurs at some small or large area endometriosis develops.
After a surgery, such as a hysterectomy or C-section, endometrial cells may attach to a surgical incision.
Abnormal immune mechanisms also lead to this condition.
Risk factors
Lady who has never become pregnant and never given birth, one or more relatives (mother, aunt or sister) with endometriosis, medical condition that prevents the normal passage of menstrual flow out of the body and pelvic infections & uterine abnormalities are some of the risk factors for endometriosis
Complications
Infertility
The main complication of endometriosis is impaired fertility. Endometriosis may obstruct or block the fallopian tubes, may cause changes in internal environment so that egg or sperms get damaged.
Ovarian cancer
Abnormal endometrial cells at abnormal location may turn cancerous in later life. These ovarian cancers are mostly adenocarcinoma variety.
Diagnosis of endometriosis:
• Typical complaints of patient like pain during menses, pain during intercourse, problem to become pregnant.
• Pelvic exam. Pelvic examination of patient may give us clue about endometriosis.
• Ultrasound. A good pelvic ultrasound transabdominal or transvaginal may detect chocolate cysts and other details.
• Laparoscopy. Laparoscopy is the most accurate method to diagnose endometriosis. Usually after failed medical treatment we g for laparoscopy.
Laparoscopy will give us exact picture/extent of the disease at the same time we can remove the decease also like removal or drainage of chocolate cyst. Breaking of adhesions etc.
Treatments
Treatment of endometriosis depends upon symptoms severity of the disease and the fertility status.
Generally patients with mild pain during menses will require simple pain killers. If fertility or pregnancy is not desired then oral contraceptive pills are given. If pregnancy is desired then we do work up for fertility and start fertility treatment.
For patients with more severe disease and obvious sonography finding of chocolate cyst, laparoscopic remoTreatment for endometriosis is usually with medications or surgery.
Hormone therapy
Supplemental hormones are sometimes effective in reducing or eliminating the pain of endometriosis. Hormone medication may slow the growth and prevent new implants of endometrial tissue. Hormonal therapy isn’t a permanent solution for endometriosis. It’s possible that there might be a recurrence of the symptoms after stopping treatment.
Hormonal therapies used to treat endometriosis include Oral contraceptive pills, Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists. Medroxyprogesterone (Depo-Provera). Progesterone containing IUDs,Danazol tablets. Hormonal therapies will cause the changes in natural variations in body hormone levels and will help to limit the disease. Hormonal therapies are not suitable for the patients who desire fertility.
Conservative surgery
For the patients who desire to have a baby and who are having significant endometriosis, surgery to remove as much endometriosis as possible while preserving your uterus and ovaries (conservative surgery) may increase fertility.
We do these surgeries laparoscopically while traditional abdominal surgery may be considered for more extensive cases.
Assisted reproductive technologies
Assisted reproductive technologies, such as in vitro fertilization are indicated in more advanced disease.
Hysterectomy
In severe cases of endometriosis, surgery to remove the uterus and cervix (total hysterectomy) as well as both ovaries may be the best treatment. Hysterectomy alone is not effective — the estrogen your ovaries produce can stimulate any remaining endometriosis and cause pain to persist. Hysterectomy is typically considered a last resort, especially for women still in their reproductive years. You can’t get pregnant after a hysterectomy.
