If you have endometriosis, you’ve probably already tried a few different medications, hormone treatments and lifestyle changes to help soothe your symptoms. Endo treatments are highly individual, varying from person to person, and it usually takes a combination of methods to get your symptoms under control. This article will focus on surgery as a potential endo treatment, something that might seem intimidating at first, but that for many people has become a vital step towards living a comfortable life with endo.

When should I consider surgery?

You’ll probably try several treatment methods before being recommended surgery. Dr. Karolina Afors, Consultant Gynaecologist at Syrona, considers a number of factors when determining whether or not surgery is the appropriate solution for someone with endometriosis, including whether medical management has been tried previously, symptoms and severity of the pain, a patient’s wishes regarding hormonal treatments, and whether they’ve had surgery before. The extent of the endometriosis is also taken into account. Surgery may be appropriate if your endometriosis is developing scar tissue that interferes with other organs, such as your bladder or bowels, or if your doctor suspects an endo cyst on an ovary (also known as endometrioma).

Laparoscopy 101

The most common type of surgery for endometriosis is laparoscopy, typically known as keyhole surgery. It involves inserting a small, lighted viewing instrument called a laparoscope through a minor abdominal incision. The surgery serves two primary purposes: to better view growths and signs of endometriosis and to remove them. While endometriosis can sometimes be discovered through pelvic exams, ultrasounds or magnetic resonance imaging (MRI), a laparoscopy is often the only way to get an official diagnosis. Laparoscopies are performed under general anaesthesia, so you’ll be asleep during the procedure and won’t feel a thing. Your stomach will be filled with gas to help the surgeon see inside of your abdomen. The surgeon will then make one or a few incisions near your belly button to insert the laparoscope, from which point they’ll remove the endometriosis tissue from your ovaries, bladder, fallopian tubes and/or rectum. Next, the surgeon will close up the incisions, and you’ll most likely be able to go home the same day. For removal of endometriosis growths and lesions, there are a number of different laparoscopic techniques available.

• Ablation: Ablation is a technique that utilises a laser to burn tissue. Due to the precision of the laser, it is able to access tricky spots on the lining of the uterus (endometrium) and produce minimal damage to surrounding areas.
• Excision: This technique uses scissors or lasers to cut down areas with endometriosis.

These are the most common laparoscopic surgeries, but there are other options including:

• Eletrocoagulation/diathermy: This technique is similar to ablation, but uses electrical heat rather than laser. It removes endometriosis and controls bleeding.
• Helica Thermal Coagulator: Through a process called fulguration, helium gas and a small electric current are used to dry out endometriosis.
• Harmonic Scalpel/CUSA (cavitron ultrasonic surgical aspirator): These techniques refer to devices with a vibration tip that can be used in endo treatment.

Choosing an operation comes down to several factors. According to Dr. Afors, the location and depth of the endometriosis should be taken into consideration.“If endo is involving ovaries but the patient wishes to safeguard her fertility, then it is important to preserve organ or ovarian function and perhaps be less aggressive and use ablation techniques,” she says.“If [endometriosis] is deeper and infiltrating, [the patient] is more likely to require excision surgery.”Studies have been unable to prove the benefits of one type of surgery over the other. Because of this, surgical treatment should always be individualised, with the main goal being to eliminate endometriosis lesions and preserve organ function, says Dr. Afors.Like with any surgery, there are some risks involved including infection at the incision site, hernia, internal bleeding, or damage to internal organs. Luckily, the risk is quite low and laparoscopic operations are considered relatively safe.

Other types of surgeries

Laparoscopic surgeries are the most common due to their minimally-invasive nature, but a laparotomy — or open surgery — can also be performed. Similar to laparoscopy, it is performed under anesthesia and involves an incision along the abdomen. Laparotomy is rare in endo cases and only utilised when the doctor is unable to reach endo tissue that cannot be seen well during a laparoscopy, or if the case is severe. Since the procedure is more intensive, you’ll likely need to stay at the hospital overnight.If fertility is not a factor, a hysterectomy is another surgical option for treating endometriosis. The surgeon will remove your uterus and potentially your cervix, ovaries and fallopian tubes. While it means you will not be able to get pregnant, if the ovaries are preserved, you can still use your eggs with a gestational carrier. This surgery is typically reserved for severe endo cases.

Misconceptions about surgery

One misconception is that surgery is the only treatment for endo. On the contrary, surgery is typically not recommended in mild cases. Even in severe cases, hormonal treatments may be prescribed following surgery to form a more effective, individualised treatment. Another myth is that surgery can cure endometriosis. “The idea that surgery will be some sort of miracle cure where all symptoms will be alleviated — unfortunately that is often not the case,” says Dr. Afors.“I think it’s about addressing expectations. I often state I can improve your pain with surgery but it is unlikely that it will completely resolve. Even despite surgery endometriosis can recur.”For both laparoscopy and laparotomy, endometriosis symptoms return in 15 to 20% of people within five years of surgery, although some studies place those numbers at 50%. With full hysterectomies, symptoms reappear in up to 15% of women. Out of 100 people, 60 to 80 report pain relief in the first months following surgery. Some studies show that using hormone therapy after surgery can extend the pain-free period. For moderate to severe endometriosis, studies show that surgery will improve fertility.

How to prepare for surgery

The majority of laparoscopies are day-case procedures, meaning you probably won’t need to stay the night at the hospital. But as with any operation, fear may be present.“You can feel quite vulnerable and scared prior to surgery and that’s ok and normal,” says Dr. Afors. “In light of Covid, often partners/loved ones are not allowed into hospital — you can ask nurses or doctors to phone them and update.”Prior to surgery, you’ll probably be asked to avoid eating or drinking for around eight hours. Dr. Afors recommends a low residue diet (limiting high-fiber foods) prior to surgery to reduce distension of bowels. It’s a good idea to pack a bag with over-the-counter painkillers such as ibuprofen and paracetamol, as well as peppermint tea to help with bloating, or even glycerine suppositories, which can alleviate constipation. Since you won’t be able to drive right away, make sure to arrange a safe way to get back home.

Tips for recovery

Immediately following the procedure, you may feel a bit groggy or nauseous due to the anesthetic. Your doctor can prescribe medication if nausea persists. The excess gas from the procedure can also cause some discomfort, which is where that peppermint tea comes in handy. Some vaginal bleeding is common, but if you’re bleeding heavily you should let your doctor know. Pain should get better day by day, but the first few days are the most sore. Taking deep breaths, sitting up and gently moving around can help alleviate some of the pain and discomfort exacerbated by the gas. You may struggle to shower for the first couple of days due to soreness of abdominal stitches. These should dissolve on their own, and silicone cream can be used to heal scars. It’s normal to feel weak and fatigued for about 10 days following a laparoscopy — more if you’ve had further treatment — so go easy on yourself and don’t rush into any rigorous exercise for at least two weeks following surgery.“Don’t underestimate recovery time,” says Dr. Afors. Laparoscopy has a reputation for being a minor procedure, but your body and mind will still need time to recover. Surgery can be a highly emotional event, and the connection between physical and mental health should not be neglected. Therefore, caring for your emotional health as you go through pre-surgery worries and post-surgery recovery is important. Your first menstrual period after surgery can potentially be longer, heavier or more painful. Over time, the severity of periods will lessen, but the emotional impact can still be felt. If you’re struggling with your emotional health post-surgery, you can book an appointment with one of our therapists online or through the Sora app. There, we also have an active community that supports each other through the ups and downs of endo

.Any surgery is a big decision. Educate yourself, reach out for help, and if you’re struggling with endo symptoms, remember that there will be a solution for you.

This article was written exclusively for Syrona Health by Emma Olsson

References

• https://www.endofound.org/endometriomas-what-you-need-to-know
• https://www.endometriosis-uk.org/sites/endometriosisuk.org/files/files/Information/laparoscopic_surgery.pdf
• https://www.uofmhealth.org/health-library/hw101171#:~:text=Laparoscopy%20is%20the%20most%20common,laparoscope%20through%20a%20small%20incisionhttps://pubmed.ncbi.nlm.nih.gov/20356588/
• https://www.endometriosis-uk.org/sites/endometriosis-uk.org/files/files/Information/laparoscopic_surgery.pdf
• https://www.mcht.nhs.uk/EasysiteWeb/getresource.axd?AssetID=4628
• https://www.webmd.com/women/endometriosis/surgery-for-endometriosis
• https://www.uofmhealth.org/health-library/hw101171#:~:text=Laparoscopy%20is%20the%20most%20common,laparoscope%20through%20a%20small%20incision
• https://www.endometriosis-uk.org/your-laparoscopy