A wide range of procedures come under the title of endometriosis surgery. The common objectives are to relieve chronic pain while preserving natural fertility. Occasionally the solitary goal of surgery is to improve access for IVF, particularly when the fallopian tubes are absent and when the bowel is stuck to the ovaries.
Surgery for endometriosis is really about restoring anatomy and function to near normal. These procedures involve carefully excising endometriosis deposits from the pelvic walls, bladder, bowel, vagina, tubes and ovaries. When there are cysts (endometriomas) within the ovary, they must also be carefully removed, while preserving as much normal ovarian tissue (reserve) as possible.
When important organs such as the bowel, bladder and ureter are involved, very specific techniques are required to safely remove these nodules. During surgery, nerve pain is very often reduced or stopped completely once the cause of compression by endometriosis is identified and removed. Very often patients with poor capacity bladder pre-operatively find that surgery to relieve the bladder pressure, while also releasing compression of the pelvic (autonomic) nerves, allows them to return to normal function. Occasionally there is a slight delay in bladder function, but this is easily managed in the day or so after surgery with the assistance of a urinary catheter.
In patients seeking to conceive within two to twelve months of surgery, dye testing to prove that the fallopian tubes are open is often undertaken. This is a simple, reassuring test that adds little to the overall time of surgery.
Most patients will have a temporary pain pump as well as a drain tube to relieve gas pressure from the laparoscopy. Dr Gordon is a perfectionist in regard to these surgeries; the average duration for surgery under his care is one and a half to two hours, but there have been extreme examples where surgery has extended to almost nine hours. Dr Gordon only practices state-of-the-art excisional surgery, as opposed to laser ablation or coagulation diathermy. The distinct advantage of excisional surgery is that it allows the entire ‘root’ of endometriosis tissue to be removed.
Hysteroscopy / D&C / Examination under anaesthetic
This means, literally, to look into the uterus. It is often completed at the commencement of surgery to establish that the uterine cavity is normal and that there are no endometriotic nodules growing in the vagina, cervix or uterus. The uterine cavity is measured (using a probe called a ‘sound’), particularly if a Mirena IUD is to be installed at the conclusion of surgery.
Mirena intra-uterine device
This is a simple plastic device that releases a very low dose of a progesterone IUD for up to five years; the progesterone is synthetic levonorgestrel.
The effect of Mirena is:
- relief of uterine cramping pain (adenomyosis)
- reversible contraception
- reduction in period volume (menorrhagia or dysfunctional bleeding).
With his extensive experience over 20 years, Dr Gordon believes it is much better to install this device under a light general anaesthetic. Removal of this device, when required, can easily be undertaken at Dr Gordon’s medical rooms.
Tubal division for a woman with a completed family
When a woman’s family is definitely complete, and the use of a reversible device such as Mirena is deemed unsuitable, then permanent options for contraception need to be considered. The male partner option is vasectomy and the female partner options include tubal division or hysterectomy.
Tubal division is performed during a laparoscopy, and really means that the tube is separated into two pieces by either a mechanical clamp (Filschie clip) or by dividing the fallopian tube with diathermy. Both methods are relatively simple and both are permanent. Dr Gordon prefers to not leave a foreign body within the pelvis and will be guided by a patient’s directions.
Removal of an endometrial polyp or intracavity fibroid
This is a simple procedure undertaken at the time of hysteroscopy. The camera guides the operator to the polyp or fibroid and a wire loop, through which a current is discharged, is then able to cut and seal the base or stalk to which the polyp was attached. The contents are then removed through the vagina and sent to the laboratory for testing.
Endometrial ablation: novasure or rollerball
Endometrial ablation is a procedure used to substantially reduce or even stop menstrual periods by removing the lining of the uterus, for women with relatively normal anatomy and where there are no additional indications for hysterectomy. In this carefully selected group of patients, 90% to 95% will achieve absent periods within six months of surgery. It is not an appropriate procedure in women with a thin caesarean scar, very enlarged or distorted uterine cavities (usually fibroids), or those with confirmed adenomyosis.
Since Dr Gordon completed his first endometrial ablation in 1991, there have been myriad techniques proposed and there are only two that he continues to employ:
- NovaSure ablation
- rollerball ablation.
Occasionally uterine dimensions or the presence of an open cervix (which may not produce a water-tight seal) are such that NovaSure is not feasible and in these situations, the gold-standard and very first technique of rollerball ablation is employed to produce an identical outcome.
Total laparoscopic hysterectomy (TLH)
Hysterectomy is occasionally indicated in women with a completed family who are troubled with intractable pain secondary to adenomyosis, or when there are large uterine fibroids that cannot be simply removed. Hysterectomy is also undertaken for various gynaecological cancers, but this requires a separate discussion with a gynae-oncologist.
The preferred and proven safest technique – and the one which Dr Gordon pioneered in conjunction with several other Australian gynaecologists in 1998-1999 – is total laparoscopic hysterectomy (TLH).
This can be done with preservation of normally functioning ovaries so that menopause does not occur. In patients where the bowel is attached to the uterus by endometriosis, a combined procedure with a colorectal surgeon can be undertaken so that all abnormal tissue is removed, including a small segment of bowel if indicated.
A hysterectomy procedure involves removing the uterine body and the attached cervix; it is strongly advisable to remove the fallopian tubes at the same time. There is increasing evidence that the fallopian tubes are the origin of so-called STIC lesions (serous tubal intraepithelial carcinoma), which are a precursor to developing ovarian cancer.
TLH is a very advanced surgical technique, particularly when removing endometriosis or a limited bowel resection is involved as part of a larger planned procedure. The operating time is between one and a half and five hours, depending on associated pathology. The details of surgery will be discussed in detail by Dr Gordon with each patient. The average in hospital stay is two nights only, a car may be driven within a week, and return to full work (non-manual) will be two to three weeks.
Laparoscopic bowel resection for patients with deep infiltrating rectal endometriosis
In patients with ultrasound, MRI or laparoscopically proven endometriosis, a bowel resection may be required. Patients may experience chronic and increasing bowel pain leading up to their periods, they may have cyclical changes in bowel habit, or the bowel may be stuck across the lower pelvis preventing safe access to future planned IVF.
Combined colorectal/gynaecological bowel surgery is always undertaken in conjunction with a colorectal surgeon. Over the last 20 years, Dr Gordon has been involved in over 500 bowel resection procedures, all with deep infiltrating endometriosis; not one has returned to theatre or had a stoma (colostomy bag) following the surgery. The average in-hospital stay is three to five days. In patients with a completed family, where there is a known risk of the bowel attaching to an adenomyotic uterus, removing the uterus (TLH) may be undertaken simultaneously with appropriate consent.
Bowel function returns within two to four days of surgery, initially sporadic, but by three to four months bowel actions have completely returned to normal. The early bowel actions can be blood stained but this settles within the first week or so. There are many factors to consider regarding surgical removal of rectal endometriosis, and these will be discussed with each patient in the planning stages with both surgeons well before an anticipated procedure. It is the aim of every such surgery to maintain as much bowel as possible and if a lesser surgery will produce the desired outcome, this procedure will be undertaken preferentially.