Endometriosis surgery: What to expect and 5 risks of surgery
Understanding endometriosis surgery and its implications
Dr. Geoff Zeni joins us on EP08 of My Fertility Podcast. He is a minimally invasive gynaecologic surgeon currently practicing at Markham Stouffville Hospital with a particular interest in fertility-sparing surgery. He currently does complex gynecologic surgeries involving endometriosis, fibroids and Mullerian anomalies. He also has a particular interest in advanced gynaecologic ultrasound, including endometriosis mapping, fibroid mapping and the evaluation of Mullerian anomalies. Outside of this, he also has an interest in surgical education and the advancement of fertility specific endometriosis research. We thank Dr. Zeni for the work he does for the endometriosis community.
If you are new to the topic of endometriosis, learn about what endometriosis is.
This article Endometriosis explained: What is it?, the 3 types, how it affects fertility and diagnosis talks about endometriosis diagnosis and fertility.
Endometriosis surgery: what to expect and related risks
Let’s discuss the two types of endometriosis surgery:
- Laparoscopic surgery for diagnosis and
- Laparoscopic surgery for treatment
1. Endometriosis surgery: diagnostic laparoscopy
Laparoscopic surgery for diagnosis will usually incorporate putting two laparoscopic ports in the abdomen: one in the belly button and one somewhere else on the abdomen. Surgeons take a look around, taking pictures and potentially take a biopsy.
A biopsy is referred to as the gold standard when it comes to making a diagnosis of endometriosis. A pathology diagnosis involes a pathologist looking at the biopsy samples from the surgery under the microscope, examining for features of endometriosis and then making a final conclusion. But interestingly, that is also not 100% accurate. They can miss lesions because it all depends on where things get cut; for example, cautery artifacts can be present, which can destroy parts of the lesion. And in this case, it is not possible to identify all the markers required, therefore it’s not a perfect method.
In summary, the diagnostic laparoscopy is about taking a look at the area and potentially taking a biopsy or two.
2. Endometriosis surgery: treatment laparoscopy
Laparoscopy for treatment: is what Dr. Zeni endorses. Essentially we are talking about going in and treating your endometriosis. There are two broad categories of surgical treatment of endometriosis:
- Ablation surgery
- Excisional surgery
Ablation surgery
Ablation surgery is essentially burning the endometriosis deposits. This can be limited to superficial endometriosis; read more about endometriosis fertility treatments.
The biggest issue with ablation surgery is the surgeon does not know how deep the deposits go, hence they are unable to know how much of the endometriosis was destroyed. Also, surgeons don’t necessarily want to “burn things” adjacent to/on top of other structures: they DON’T want to cause injury. There are many structures inside the pelvis that are right underneath where the endometriosis loves to live – this includes the ureters (the tubes between the bladder and the kidneys) as well as large blood vessels and nerves inside the pelvis, the fallopian tubes and the ovaries. Ablation surgery is limited in its ability to treat deeply inifltrating endometriosis and comes with risks of damaging important structures in the pelvis.
Excisional surgery
Dr. Zeni really only performs excisional surgery because of how the disease works and it makes a lot more sense to actually remove the disease. Our goal is complete excisional surgery to remove every bit of endometriosis. And this comes with risks.
5 risks of endometriosis surgery
With these risks, the details will change, but those risks are always going to be present in every surgery. There are 5 risks to (every) surgery:
- Damage to surrounding structures inside the pelvis: the bowel, the bladder, the ureters (the tubes between the bladder and the kidneys), blood vessels, the uterus, ovaries, fallopian tubes and then the nerves inside the pelvis in general. In the hands of a really skilled surgeon, those risks are extremely low. With more complex disease, those risks may be increased.
- Infection: the risk can change a little bit, especially with bowel involvement
- Bleeding: can vary depending on the complexity of the disease
- Having a blood clot (most commonly in the leg) around the time of surgery
- Anesthetic risks.
In general, these are all pretty low risks, but we really do need to be able to have that good consent process beforehand.
Endometrial surgery: the process
The patient arrives at the hospital for day surgery, they come into the operating room, and an anesthesiologist will put them to sleep. The surgeon performs the surgery through tiny little incisions.
Typically, a one centimeter incision is buried in the belly button and then a five millimeter incision is made on one side of the abdomen and one five millimeter incision on the other side. These are all the incisions required to remove all of the endometriosis (most of the time).
In super complex disease, it may be required to extend some of these incisions. Sometimes there’s an incision in the back of the vagina if the actual lesions go from the abdomen all the way through the back of the vagina. In general, this is are pretty uncommon circumstance.
Once the surgery is complete, the patient goes home with these tiny little holes and they have a really big surgery on the inside, but very small holes to show for it on the outside.
Patients generally tolerate the surgery well. There will be some soreness for a couple of weeks and they can expect to feel totally back to normal, likely in four to six weeks. A lot of the time this surgery actually improves a patient’s pain so much and they’re so happy.
How often does endometriosis come back after an excisional surgery?
The thought about recurrence is changing. Modern evidence is talking less about recurrence and more about residual disease. Meaning, what we used to think was recurrent disease, is likely a factor of disease that was left behind in a prior surgery.
There’s microscopic disease that sometimes is not possible to see at a given time, even with a, really, really good look and expert eye.
But, this is becoming less and less common with better excisional techniques. The biggest recurrence risk is in the ovaries because surgeons are trying to maintain the best ovarian health by causing the least amount of damage, which can mean that sometimes some cells of endometriosis are left inside the ovary.
Recurrence risk inside the ovary is the highest. But recurrence outside of that – in the pelvis, is much, much lower than was previously expected with good excisional surgery.
With ablation surgery, obviously, the recurrence rate is going to be higher for all the reasons previously discussed.
As a concluding thought on endometriosis surgery, choosing your surgeon is really, really important. Do your research, choose somebody who is well trained, specialized and has specific training in endometriosis, in order to give yourself a much better end result.
Endometriosis surgery: Endo surgeons and surgery waitlists
Simply put, there’s not that many endo surgeons and the wait lists for surgery are horrible. Dr. Zeni states that his waiting list for surgery right now (as of April 2024) is about a year. He tries to mitigate that as much as possible by picking up extra OR days to try and minimize wait times.
But there are not many surgeons. However, there are more and more people being trained, which is fantastic.
Dr. Zeni explains that patients are looking at between eight months to two years for surgery and that’s really horrible, especially for a fertility patient.
In general, society needs to reevaluate how it approaches fertility and pelvic pain. And we need to have a lot more grace when we talk with people. It makes a huge difference in people’s lives when they’re, first of all, taken seriously and secondly, when they are listened to.
Fertility is really difficult. We know there’s so much good evidence in terms of the toll fertility takes on people’s mental health over time.
And, pelvic pain is the same. When you put both those things together in the same patient, it’s horrible. These people suffer and it really hurts when I hear these stories of people whose pain and suffering has been underplayed their entire lives.
Since I’ve gone into this field, I think this is a population that has been so marginalized for such a long period of time that it’s really important that people take them seriously. And you guys at Markham Fertility do such an amazing service. And I want to thank you for what you do for your patients because I think that you treat them with the empathy and the care that these women and these families deserve.
-Dr. G. Zeni
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