Endometriosis
8 min read

Evidence-Led Approach to the Surgical Treatment of Endometriosis

Table of Contents

Video Description

This video uniquely illustrates a systematic approach to the surgical treatment of both superficial and deep endometriosis, that is based in recent literature and expert consensus recommendations published by ESGE/ESHRE/WES in 2020. We illustrate three surgical approaches in treating superficial endometriosis, namely focal excision, pelvic peritonectomy, and superficial ablation. Based on literature review, we outline the advantages and disadvantages of each technique and when each technique is most suitable. As outlined by expert consensus, when approaching deep endometriosis the pelvis should be systematically prepared by first performing enterolysis, ovariolysis, and ureterolysis. We then summarize and illustrate a 4 step approach to the surgical excision of deep endometriosis in the rectovaginal septum: development of the pararectal space, mobilization of the ventral rectum, shaving disease off the rectum, and confirming integrity of the bowel wall. This routine approach allows surgeons to perform systematic surgery in challenging situations where pelvic anatomy is distorted.

Presented By

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Dr. Erica Pascoal
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Dr. Siddhi Mathur

Affiliations

St. Michael’s Hospital, University of Toronto

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What is Evidence-Led Approach to the Surgical Treatment of Endometriosis?

An evidence-led approach to the surgical treatment of endometriosis emphasizes using the latest scientific research and clinical evidence to guide decisions in managing the condition surgically. Here’s how it works in practice:

  • Patient-Centered Decision-Making: Surgeons consider each patient’s unique symptoms, severity, and quality of life, customizing surgical plans based on proven outcomes rather than a one-size-fits-all approach.

  • Minimally Invasive Techniques: Guided by evidence on effective and less risky procedures, laparoscopic surgery, which involves small incisions and a camera, is preferred for precision and faster recovery.

  • Focus on Comprehensive Excision: Studies suggest that thorough removal (excision) of endometriotic tissue can provide longer-lasting relief from pain and reduce recurrence, so surgeons are encouraged to perform complete excisions rather than superficial removal.

  • Use of Imaging and Diagnostic Advances: Evidence supports advanced imaging techniques, like MRI and ultrasound, before surgery to accurately map endometriosis locations, improving surgical outcomes.

  • Consideration of Hormonal Impact: Surgeons evaluate hormonal therapy options alongside or before surgery, as evidence suggests a combined approach may reduce recurrence and relieve symptoms.

  • Outcomes Monitoring and Adjustment: Post-surgery, outcomes are monitored, and care plans are adjusted based on patient progress and emerging evidence, ensuring long-term relief and minimized risk of further surgeries.

This approach aims to maximize symptom relief, reduce the risk of recurrence, and improve overall quality of life for those with endometriosis.

What are the Risks of Evidence-Led Approach to the Surgical Treatment of Endometriosis?

While an evidence-led approach to the surgical treatment of endometriosis is beneficial in many ways, it does carry certain risks, including:

  1. Complexity of Comprehensive Excision: Evidence suggests complete excision of endometriotic tissue is most effective. However, this can be technically challenging, especially if endometriosis has spread to areas like the bowel or bladder, increasing the risk of injury to these organs.

  2. Possible Recurrence: Even with evidence-led techniques, endometriosis can recur in some patients, particularly if any microscopic lesions are missed, necessitating further surgeries or ongoing treatment.

  3. Anesthesia-Related Risks: Like any surgery, the approach requires anesthesia, which carries risks like allergic reactions, respiratory issues, and, rarely, life-threatening complications.

  4. Surgical Complications: Minimally invasive surgeries still carry risks such as bleeding, infection, and damage to nearby organs or nerves, particularly in advanced cases.

  5. Post-Operative Pain and Adhesion Formation: Surgical manipulation can sometimes lead to post-operative pain or the formation of adhesions (bands of scar tissue), which can cause discomfort or bowel obstruction in severe cases.

  6. Limited Efficacy in Advanced Cases: For patients with extensive or deeply infiltrative endometriosis, even evidence-based approaches may not fully alleviate symptoms, leading to ongoing pain and additional treatment needs.

  7. Long-Term Hormonal Side Effects: An evidence-led approach may involve integrating hormonal treatments to prevent recurrence, which can cause side effects like mood swings, weight gain, and bone density reduction over time.

  8. Financial and Emotional Costs: As a tailored and highly specialized approach, these surgeries may require out-of-pocket expenses and multiple appointments, adding to the financial and emotional burden on patients.

While the evidence-led approach aims to minimize recurrence and improve patient outcomes, a thorough discussion with healthcare providers about these risks is essential for informed decision-making.

Video Transcript: Evidence-Led Approach to the Surgical Treatment of Endometriosis?

Here we present an evidence-based approach to the surgical treatment of endometriosis. In 2020, international gynaecologic societies came together to publish a series of recommendations on the practical aspects of different surgical procedures for the treatment of endometriosis. A routine approach allows surgeons to perform systematic surgery in challenging situations where pelvic anatomy is grossly distorted.

Endometriosis presents as three different entities, peritoneal lesions, deep endometriosis and ovarian endometriomas. In this video, we focus on evidence-based treatment of peritoneal and deep disease.

First, we consider the evidence behind approaches to the treatment of peritoneal disease. These include focused excision, complete pelvic peritonectomy, and superficial ablation.

Each method has advantages and disadvantages. Focused excision of visualised disease may be more efficient and confer decreased surgical risk, as fewer structures must be dissected. However, it relies on a surgeon’s visual diagnosis, and microscopic disease may be left behind.

Peritonectomy allows for histopathologic diagnosis of occult microscopic endometriosis. It has also been demonstrated to improve pain and quality of life in patients with chronic pelvic pain with and without surgical evidence of endometriosis. However, it may confer increased surgical risk and prolong operative time.

Peritoneal disease can also be ablated. Based on a 2021 systematic review and meta-analysis, ablation of superficial disease improves dysmenorrhea and dyspareunia, although comparative data is lacking. Ablation is efficient and allows for treatment in areas that are more difficult to resect, such as the diaphragm. Ablation does not allow us to understand the depth of disease, poses a risk of injury to underlying structures which have not been isolated and does not allow for histopathologic diagnosis.

In this focal excision, the lesion in the anterior compartment is visually identified. The paravesical space is opened laterally, and the peritoneum is thinned out. The location of the lesion is confirmed, and the peritoneum is resected, ensuring a margin is obtained.

When performing a pelvic sidewall peritonectomy, first the peritoneum is opened at the pelvic brim at the base of the IP vessels above the level of the ureter. The pararectal space is opened, and the incision is extended, confirming ureter location along the way.

The incision is extended to include the ovarian fossa and is carried medially towards the uterosacral ligament. The ureter is identified vermiculating in the pararectal space and is lateralised off of the peritoneum. The hypogastric nerve, which lies medial and dorsal to the ureter in the medial pararectal space, is also identified and lateralised to ensure a nerve-sparing procedure. Starting cranially, the peritoneum is completely excised.

 Now we will review an evidence-based surgical approach to the excision of deep endometriosis.

At the beginning of the procedure, the pelvis should be systematically prepared. The following evidence-based steps should be used. First, the sigmoid should be mobilised. Starting from the white line of Toldt, physiologic adhesions are lysed to mobilise the sigmoid and its attachments to the abdominal wall and pelvic sidewall. Efforts should be made to avoid entering the retroperitoneum during this step. This exposes the left adnexa, pararectal space and ovarian fossa.

Next, fixed ovaries are mobilised off of medial structures and off of the pelvic sidewall to improve the view of the operative field. Ovariolysis is preferentially done bluntly, although sharp dissection and electrosurgery may be needed. If the ovary is densely adherent to the sidewall, the pararectal space may first be opened and ureterolysis performed to delineate the ureter’s location prior to mobilising with electrosurgery. It is key to divide adhesions and restore pelvic anatomy in addition to completely excising endometriosis.

We then perform ureterolysis. The ureter can be reliably identified in the pararectal space with ureteric vermiculation. Here, a medial approach to the pararectal space is employed. Starting at the pelvic brim in healthy tissue, the ureter is isolated and dissected off the pelvic sidewall peritoneum. Complete ureterolysis should be performed to the anterior division of the internal iliac artery or ureteric canal.

Next, we will illustrate evidence-based steps to follow when approaching deep endometriosis of the rectovaginal septum, as outlined in consensus recommendations.

Access to the rectovaginal septum is often hindered by dense adhesions between the rectum, uterosacral ligaments and the dorsal uterus. Complete dissection of these adhesions is necessary. The pararectal space should be entered in healthy tissue that is free of adhesions. The space is opened longitudinally, medially from the uterosacral ligaments, and as close to the lateral side of the bowel as possible in order to avoid injury to the hypogastric nerves.

Now the aim is to mobilise the ventral rectal wall from the rectovaginal septal nodule. Placement of a uterine manipulator, such as the Valtchev device, allows for palpation of the lateral rectovaginal septum. Working from lateral to medial, a plane is developed in healthy tissue. Now the borders of the rectum can be identified.

The rectum is shaved off of the vagina by dividing the nodule. This is done by mechanical dissection, using cold scissors. The rectum falls dorsally, and healthy vaginal tissue can be palpated. The cul-de-sac is now visualised. The nodule is then shaved off the bowel serosa. Bowel wall integrity is confirmed with rigid sigmoidoscopy, ensuring no bubbles are seen.

Using latest guideline evidence, we present an overarching approach to surgical treatment of superficial and deep endometriosis. Superficial endometriosis can be managed with focal excision, peritonectomy or ablation. There are pros and cons to consider when choosing a method of treatment.

When approaching deep disease, the pelvis should first be prepared with enterolysis, ovariolysis and ureterolysis. Deep endometriosis of the rectovaginal septum should be systematically approached using four key steps. Thank you.