Surgical Treatment of Endometriosis: Excision and Destruction

Endometriosis affects women in two ways: it causes pelvic and abdominal pain, and it is associated with decreased fertility. Although symptoms such as pain and infertility may suggest the possible presence of endometriosis, the only definite way to diagnose it is by performing a laparoscopy.

Endometriosis Surgical Treatment

Diagnosis

Laparoscopy is a surgical procedure performed under general anesthesia that allows thorough visualization and inspection of all pelvic structures including: the uterus, ovaries, fallopian tubes as well as the peritoneal surfaces covering the bowel and bladder. Endometriotic lesions are commonly found in all of these areas. Laparoscopy also allows for treatment of endometriosis lesions during the same surgical procedure.

Treatment

There is currently no cure for endometriosis. The goal of treatment is therefore to improve symptoms, preserve fertility for women who would like to postpone childbearing and infertility treatment for women who desire pregnancy. Medical and surgical treatment options for deeply infiltrative endometriosis are discussed in this web page.

Surgical Removal and Destruction

Surgical treatment for superficial endometriosis (when lesions are just on the surface and don’t go deep into the tissues) should be treated at the time of laparoscopy.

Excision of endometriotic lesions or nodules involves cutting out visible areas of endometriosis (excision), or burning them off. Other medical terms that describe the destruction of endometriosis are “ablation and fulguration” which are used with different kinds of energy sources. Excision of superficial peritoneal endometriosis lesions has a benefit of providing pathological confirmation because the excised tissue is sent to the laboratory for evaluation. However, both excision and destruction/ablation techniques are equally effective with improving pain symptoms. Similarly, research studies have shown that both excision and destruction of endometriosis at the time of laparoscopy improves future fertility compared to diagnostic laparoscopy alone.

  • Burn-off is the treatment of choice for superficial endometriosis. This is accomplished with the application of intense heat. Heat can be generated by a number of sources – electricity (cautery), ultrasound (Harmonic scalpel) or laser. Although each of the energy sources has its own specifications, none has been shown to be better than the other for destroying endometriosis lesions. Ablation/fulguration of ovarian tissue during laparoscopy for the treatment of endometriomas is not recommended as it has been associated with poor fertility outcomes.
  • Surgical excision is typically the treatment of choice for ovarian endometriosis (endometrioma cyst) with removal of the cyst wall instead of drainage and ablation/fulguration of the ovary. Surgical excision at the time of laparoscopy results in greater improvement in pain symptoms and better preservation of ovarian tissue. Maximum preservation of ovarian tissue is of utmost importance for women seeking fertility.
Summary
  • Laparoscopic surgical treatment of superficial peritoneal endometriosis improves both pain symptoms and fertility outcomes.
  • Excision and destruction (burn-off = ablation, fulguration) of superficial peritoneal endometriosis are equally effective in improving pain symptoms and fertility outcomes.
  • Ovarian endometriosis (endometriomata cysts) is best treated with excision techniques in order to preserve fertility potential and obtain effective pain relief.