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Surgical treatments of endometriosis: explaining conservative laparotomy SURGICAL TREATMENTS OF ENDOMETRIOSIS: EXPLAINING CONSERVATIVE LAPAROTOMY
Conservative laparotomy procedures vary and are changing all the time. The nature of your surgery will depend on a number of factors including the extent and location of your disease, your symptoms, your desire for future childbearing and your gynecologist’s training, experience and preferences.
The procedures, which will be performed as part of a laparotomy, may include any of the following:
• removal or destruction of implants and small cysts
• removal or destruction of large cysts and endometriomas
• removal of adhesions
• removal of an ovary or an ovary and fallopian tube
• removal of the appendix
• surgery on any other affected organs such as the bowel or bladder
• suspension of the uterus
• pre-sacral neurectomy or utero-sacral neurectomy
• any surgery necessary to correct other abnormalities found.
Implants and small cysts
Where possible any superficial implants and small cysts on the ovary and peritoneum will be removed or destroyed by cutting, cauterization or vaporization, provided that there is no danger to any underlying organs such as the bowel or bladder.
Large cysts and endometriomas
Any endometriomas will usually be removed by cutting them out. This often involves removing a small amount of the surrounding ovary as well to ensure that all the endometrial tissue is removed. Sometimes, endometriomas will be destroyed by puncturing them and then cauterizing or vaporizing their lining. Large cysts on the peritoneum will be removed by cutting them out.
Adhesions
Any adhesions will be cut, cauterized or vaporized and separated so that the normal positioning of the reproductive organs can be restored.
Ovaries
Sometimes an ovary will have to be removed because an endometrioma lying within it cannot be removed safely. Similarly, if one ovary and fallopian tube are severely diseased they may be removed, provided that the other ovary and tube are normal. The removal of an ovary and tube on one side does not seem to decrease the likelihood of pregnancy following surgery but does seem to reduce the risk of the disease recurring.
Appendix
Some surgeons routinely remove the appendix during a conservative laparotomy, especially if the endometriosis is extensive, but most will remove it only if endometrial implants are present.
Bowel and bladder
Most small implants on the bowel and bladder are superficial and can be removed or destroyed without any danger of damaging the underlying organs. If the implants have penetrated the wall of the bowel or bladder they must be carefully cut out and the affected area repaired. Occasionally a section of the bowel will have to be removed if the implants have surrounded and constricted it; if there is any possibility of this being done it is highly advisable that a bowel surgeon be on hand to assist.
Suspension of the uterus
Suspension of the uterus involves tightening or shortening the utero-sacral and/or the round ligaments in an attempt to hold the uterus in its normal position. This procedure is not commonly performed by gynecologists in Australia though it is quite common in America.
Presacral and utero-sacral neurectomy
A pre-sacral neurectomy and an utero-sacral neurectomy are two similar procedures which are only occasionally performed by gynecologists in this country, although they are performed much more commonly overseas. Both procedures involve cutting the nerves that transmit pain from the uterus to the brain. The same nerves are cut in both procedures but in the case of an utero-sacral neurectomy the nerves are cut closer to the uterus than is the case with a pre-sacral neurectomy. The two procedures are performed to relieve chronic pelvic pain but they are usually only effective for a maximum of about twelve months as by then the nerves have re-grown.
If you are contemplating a pre-sacral neurectomy or an utero-sacral neurectomy it is worth remembering that pain is one of the body's warning mechanisms. If you cannot feel pain in the pelvic area you may not be aware that your endometriosis could be worsening or recurring. If you go into labour you may not be able to feel the contractions which signal the onset of labour. In addition, both procedures can occasionally interfere with normal bowel and bladder function.
Other
If your fallopian tubes are damaged or if you have any other disease or abnormality of the reproductive organs these will usually also be repaired.
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Fresh materia
Hormonal treatment of endometriosis: the oral contraceptive pill