Management of endometriosis has always been based on relief of symptoms.
Despite the fact that voluminous research has been performed in order to
find a noninvasive cure, management remains centered around the use of
surgical removal with medical placation.
Although extensive efforts have been made in
attempts at improving prospects of pregnancy for patients with the
disease, results remain marginal. Neither medical therapy nor surgery
alone or in combination produces significant improvement in pregnancy
However, for relief of pain both medical and
surgical therapies have been employed with success although cure rates are
not available. For invasive (Type III) disease and large endometriomas,
surgical therapy appears to be the only solution as medical therapy has
demonstrated no efficacy in these areas.
Surgical therapy revolves around three basic
Of these techniques, excision is by far the
most appropriate. If the surgeon has significant expertise in the
recognition of endometriosis, at times vaporization or coagulation can be
used but in most cases excision is the wiser choice. Excision offers two
- Pathologic Confirmation
- Adequate removal of the lesion
Because endometriosis may extend several
millimeters into the tissue and because epithelial cancers can mimic this
disease it is always wise to have a histologic confirmation of the
Laparoscopy has been defined as the gold
standard in surgical treatment of endometriosis for several reasons:
- Minimally invasive approach
- Superior visualization - microscopic
- Superior access - posterior pelvis
- Microsurgical accuracy of excision
- Less scarring
- Ability to repeat the surgery without
The surgical approach to endometriosis should
be aggressive. Most patients should be bowel prepped and counseled
appropriately preoperatively. A single stage approach is preferable if the
clinical picture warrants this type of surgery.
Pain mapping ( i.e. determining the location
of the pain) should be performed preoperatively using a systematic
Intraoperative mapping may be used under
conscious sedation in order to better target excisional therapy. Ovarian
preservation is possible in a large percentage of patients and, despite
using an aggressive surgical approach, hysterectomy is rarely necessary.
If significant adenomyosis or uterine corpus disease is present, however,
uterine removal is required.
Laparoscopic surgery seems to be the most
appropriate method of therapy for individuals with pain, rectovaginal
disease, or bowel involvement secondary to endometriosis. Risk is low with
this approach although the technical demands are prodigious. Surgical
therapy of invasive endometriosis remains one of the most difficult tasks
for the gynecologic surgeon.
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Stefil 1980, 33:411-414.
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time for acceptance. Fertil Steril 1989; 52: 1-11.
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