Excision for Endometriosis

Overview
Excision is surgery to cut away endometrial implants. Excision is considered conservative surgery because you retain all of your organs and function, unlike a radical surgery such as hysterectomy. Excision can provide years of pain relief and may improve fertility. Excision does not cure endometriosis. The disease may recur.

What does it involve?
Take time choosing your surgeon and hospital. Ask each surgeon you consider how many excision surgeries for endometriosis they have performed, and what their rates of success are. Find out details about all of your surgical options, the procedures involved, recovery time, and the risks and benefits associated with each. Some surgeons set a goal of removing all endometrial implants, while other surgeons may believe it is better to leave implants in some areas rather than risk damaging reproductive function. Ask the surgeon whether they utilize any preventative techniques to reduce the likelihood of adhesions forming after the surgery.

Prepare yourself mentally and psychologically for surgery. You can prepare physically by being in the best condition possible before surgery. Eat nutritiously and get plenty of sleep and exercise in the weeks leading up to the surgery. Finally, you can make plans with friends, family or church groups to get help with rides to and from the hospital and help with shopping, housework, and childcare while you are recovering. Do everything you can in advance to reduce stress in the period after the surgery.

You will be asked to stop eating a few hours before surgery. If your surgery might involve the bowel, you may need to complete bowel preparation (commonly known as bowel prep) the night before. The bowel prep process can be unpleasant, but it helps prevent complications. Bowel prep involves a few hours on a liquid diet followed by drinking a series of solutions designed to clean out your intestines. You will need to stay near a bathroom and relieve yourself frequently during this process. Consider purchasing soothing wipes or hemorrhoid cream to have on hand during bowel prep.

When you arrive at the hospital, vital signs will be taken, and blood may be drawn. Before surgery, you will receive an intravenous (IV) line and general anesthesia to make you sleep.

Excision surgery may be performed by laparoscopy (through three or four small incisions) or laparotomy (performed through one large incision). Laparoscopic surgeries tend to be less painful and have faster recovery time. During laparoscopic surgery, the surgeon inflates the abdomen with carbon dioxide gas. A small camera and tools are inserted into the incisions to perform the surgery. The surgeon will also insert a probe into the cervix to move the uterus around to examine every surface for implants. Excision surgeries can vary widely depending on the severity, location, and depth of your endometrial implants. During excision surgery, implants may be removed from the walls of the uterus, the ovaries, fallopian tubes, or near the bladder, ureters, rectum or colon. The techniques most frequently used for excision are electrosurgery and electrocoagulation. Excision surgery may take up to six hours, depending on how extensive the endometrial implants are.

People who undergo excision may go home the same day, or recover in the hospital overnight. If the surgery involved the bowel, you might need to stay in the hospital for several days. After surgery, a specialist nurse will teach you how to care for your wound. Recovery at home will require about two weeks. You will feel groggy and tired for the first two or three days. You may experience moodiness, feeling blue, anxiety, or nightmares; these should pass after a few days. While you finish your recovery at home, get plenty of rest. Take pain medications as needed. A heating pad may also soothe your sore abdomen. Carefully monitor your incisions for signs of complications. Call your doctor immediately if you experience swelling or redness in the surgical area. Do not have sex or insert anything into your vagina (also known as pelvic rest) and avoid showers and baths until your doctor has said you can resume your routine. You should be able to resume all of your normal activities after your doctor says healing is complete.

Your surgeon will schedule a follow-up appointment four to six weeks after your surgery. At this appointment, the surgeon will examine your incisions to see how they are healing. They will ask you questions about your recovery and discuss laboratory results for the tissue removed during excision.

Intended Outcomes
Excision can significantly increase your quality of life by relieving pain associated with endometriosis for many years. Excision may improve fertility and increase the chances of successful pregnancy.

Results
Results for endometriosis excision surgery vary between cases and surgeons. One study completed in 2003 involved 254 women with chronic pelvic pain. Those who underwent laparoscopic excision experienced significant improvement in pain and quality of life scores for up to five years. Thirty-six percent of the participants required additional surgeries.

One surgeon cited statistics drawn from hundreds of endometrial excision surgeries from 1991 to the present day. According to his results, endometriosis recurred in only 10 to 15 percent of women who underwent excision.

One study focused on fertility involved 348 women with early-stage endometriosis and no other known cause for infertility. Among those who underwent surgical treatment for endometriosis, 30 percent conceived within 36 weeks following the surgery. In comparison, only 17 percent of those who did not receive surgery for endometriosis conceived during the same timeframe.

Constraints
Any surgery carries risks including blood clots, blood loss, infection, breathing problems, scarring, reactions to medication, and heart attack or stroke during the surgery. Short-term complications of surgery for endometriosis can include pain in the surgical area, constipation, diarrhea, bladder or vein irritation, nausea, vomiting, fatigue, nightmares, trouble sleeping, headaches, and shoulder pain from gas trapped beneath the diaphragm. Long-term complications can include scarring and adhesions, both of which can affect fertility and necessitate additional surgeries. Also, excision of deep endometrial implants from an organ may cause damage or affect function.

Call your doctor if you notice symptoms of infection such as fever, bleeding, swelling, or increased pain at the incision, or severe abdominal cramping and pain. Notify your doctor if you experience chest pain, shortness of breath, discharge from the wound, abnormal or foul-smelling vaginal discharge, pain or swelling in your calves, painful or frequent urination, or vomiting more than 24 hours after the surgery.

Excision surgery may not be effective in relieving your pain from endometriosis or improving your fertility.

Your endometriosis may recur. You may need surgery again in the future to treat new implants.