Laparoscopic (keyhole) surgery for endometriosis

What is endometriosis?

Endometriosis is a common problem affecting 10 in every 100 women. It happens when cells which normally line the womb (endometrium) are found outside the womb. This may be anywhere in the pelvis or abdomen.

Symptoms

• Increasingly painful periods
• Pain during and after sex
• Pelvic pain after your period which may be associated with opening your bowels
• Irregular bleeding
• Difficulty getting pregnant

The surgery

During a laparoscopy you would be given a general anaesthetic so that you will be asleep throughout the procedure. A small instrument is inserted through an incision (cut) in the umbilicus (belly button). Gas (carbon dioxide) is introduced into the abdomen and then a telescope (laparoscope) is inserted. This allows us to look at the outside of the womb, ovaries and the rest of the pelvis and the bowel.

Second and sometimes third and fourth incisions are made according to how much surgery is involved. These cuts are usually less than 1cm long.

There are 2 main types of surgical treatment for endometriosis. If there are multiple tiny spots of endometriosis they can be destroyed by electrosurgical heat treatment using a small wand-like instrument. Deeper deposits of tissue are surgically removed from the body through the same incisions; this is called ‘excision’.

Although we aim to complete your surgery as a keyhole procedure, very rarely open surgery is necessary (laparotomy). If this happens you may also need another surgical procedure at a later date. This will be discussed with you.

Why is endometriosis removed?

Endometriosis can only be diagnosed by a laparoscopy. Excising endometriosis at the time of surgery is considered the best way to treat it and to improve pain and irregular bleeding patterns. These improvements are not necessarily permanent and repeat surgery may be needed. About 50 out of every 100 patients will have recurrence of their symptoms and endometriosis. Some patients will not experience any improvement; this might be because endometriosis may not have been the cause of the pain.

After the procedure

Some abdominal pain is normal after surgery; you will be prescribed suitable pain relief. Patients may also experience discomfort in their shoulder. This is due to the gas used during the operation and is quite common. This will completely resolve within 1 to 2 days. Your body will get rid of the gas naturally.

Bruising around the incision sites may happen.

Most patients will be able to go home the same day. Some patients however, may need to stay in hospital longer. The likelihood of this will be discussed with you before your surgery.

Your gynaecologist will explain before the operation if you will need to have stitches removed. Stitches are usually removed around the 5th day after surgery. Please contact your GP’s surgery for an appointment with the practice nurse.

Your gynaecologist will discuss your surgery with you before being discharged home and you may be given a follow-up clinic appointment.

Risks

During surgery injury can happen to any of the structures inside the abdomen, such as the bowel, bladder, blood vessels and ureters (the tubes passing from the kidneys into the bladder). There is a very small chance of injury happening when the instruments are first inserted into the abdomen, about 1 to 4 per 1,000 patients.

This risk increases according to how severe the endometriosis is and which organs are affected.

If injury to the bowel or the blood vessels happen it may need to be repaired with an open operation.

If a severe endometriotic bowel is removed or if the bowel is injured, a temporary colostomy may be necessary.

Adhesions (internal scar tissue) can happen after any surgery but are reduced with laparoscopic surgery.

Alternative treatment

Hormone therapy can be used as a treatment for endometriosis. This works by making the deposits of endometriosis less active and can help with pain symptoms. However, it is not helpful for fertility problems. Some patients may experience side-effects during hormone therapy. When hormone therapy stops and the normal monthly oestrogen cycles return the endometriosis commonly flares up again. Hormonal treatment does not help endometriosis symptoms caused by scarring or adhesions.

Consent

Your gynaecologist will ask you to sign a consent form before your operation. This will state that you understand the risks of:

• Bowel injury
• Bladder or ureteric injury
• Vascular/blood vessel injury
• Adhesions
• An open operation (laparotomy)
• Temporary colostomy

Great care is always taken to avoid these complications but they can still happen. If you do not feel able to accept these very small risks then you should choose not to have the operation.

At home

You should make a quick recovery from your laparoscopy. However very rarely complications become clear after discharge home.

You should seek medical advice from your GP or NHS 111 if you experience:

• An increase in pain
• Problems with breathing
• Feeling increasingly unwell
• Persistent vomiting