Endometriosis is the modern epidemic of gynaecology. A woman normally sheds the inner lining of the uterus (endometrium) at the end of each menstrual cycle. This manifests in the form of menstrual bleeding. Some of this blood containing living endometrial cells can also reach the abdominal cavity through her Fallopian tubes, blood vessels or lymphatics. According to Dr. Nagendra Sardeshpande
Gynecological Endoscopic Surgeon, Sir HN Reliance Hospital, in a small percentage of women, these cells can implant (stick) on the various organs of the pelvis (ovaries, intestines, Fallopian tubes and surface of the uterus) and grow & bleed inside the abdomen. This irritates the abdominal cavity and causes the various organs (intestines, ovaries, Fallopian tubes and uterus) to stick to one another (adhesions). The important structures passing through the pelvis such as the pelvic nerves, blood vessels and ureters (tubes carrying urine from the kidneys to the bladder) can become encased and constricted in these adhesions.
Endometriosis can lead to the following symptoms:
- Severe chronic pelvic pain worsening during menstruation. Pain during the passing of stools (tenesmus) & blood in faeces (hematochezia) and occasionally intestinal obstruction.
- Infertility by blocking the ovaries and Fallopian tubes due to adhesions and inflammation which can damage the sperm and eggs.
- Occasionally, endometriosis involving the urinary bladder can cause painful passage of urine (dysuria) and passage of blood in urine (hematuria)
- Compression of ureters can lead to dilatation of the ureters (hydronephrosis) causing pain and, rarely, renal failure.
- Adenomyosis is a variant of endometriosis where the lining of the uterus (endometrium) invades and grows into the muscle of the uterus (myometrium). This condition can cause severe pain, especially during menstruation (dysmenorrhea) and heavy menstrual bleeding (menorrhagia).
- Rectovaginal adenomyosis is another entity which is characterised by the presence of uterus-like tissue (endometrium and muscle) in the pelvis. This gives rise to symptoms similar to endometriosis.
Sometimes, in a woman with chronic pain, no pathology can be found except dilated blood vessels around the uterus. This is called pelvic congestion syndrome. The mainstay of management of endometriosis and its associated pathologies is surgery followed by treatment for fertility (getting pregnant) and medication. Laparoscopic surgery has become the gold standard for the management of endometriosis.
The following surgeries can be performed for endometriosis:
Adhesiolysis and excision of endometriosis implants: The adhesions which involve the pelvic organs are cut and any localised nodules of endometriosis are excised. This is an extremely complex surgery involving releasing the intestines from the adhesions, releasing the ureters from the endometriosis and separating the ovaries from the adhesions. The ovaries can be lifted and tied lightly away to the round ligament (cord-like structure arising from the uterus) to prevent the recurrence of adhesions around the ovary (ovariopexy). The goal of the surgery is to restore anatomy to as normal as possible and improve the chances of pregnancy.
Hysterectomy with removal of both ovaries and Fallopian tubes (Salpingo-Oophorectomy): In women not wishing further pregnancies and those with severe symptoms, the uterus and both ovaries along with the Fallopian tubes can be removed. This removes the hormones which support the growth of endometriosis and reduces the possibility of recurrence of endometriosis. This is also a major surgery involving separation of the intestines and ureters from the uterus and ovaries.
Ovarian cystectomy: In a large number of cases of endometriosis, the endometriosis implants on the ovaries leading to the formation of large cysts containing thick chocolate-coloured bloody fluid (chocolate cysts or endometriomas). These cysts can usually be removed completely leaving behind an adequate amount of normal ovary (cystectomy). Rarely, the entire ovary may have to be excised (ovariotomy).
Excision of rectovaginal adenomyosis: Excision of these implants often involves excising part of the vagina and superficial aspect of the rectum and intestine. However, complete excision is necessary since this prevents recurrence and offers a complete cure to the woman.
Adenomyomectomy: Adenomyomectomy involves excision of the adenomyoma out of the uterine wall and stitching up the uterine wall. This procedure is similar to the removal of fibroids.
Laparoscopic uterine nerve ablation (LUNA): This is indicated for women with severe menstrual pain. It involves excision of the which pass along the uterosacral ligaments (cord-like structures at the back of the uterus). It is important to keep the ureters away from the field of surgery since they may get damaged accidentally.
Presacral neurectomy: In women with severe endometriosis and pelvic congestion, the nerves which enter the pelvis over the sacral bone and pass to the pelvic organs (uterus, rectum and bladder) are cauterised and cut. This is a more complicated procedure since it involves dissection around major blood vessels entering the pelvis.
The advantages of laparoscopy in surgery for endometriosis include:
- Better visualisation of important structures during surgery with the possibility of more complete surgery
- Better postoperative recovery with reduced pain
- Better cosmesis
- Reduced post-operative adhesions between important pelvic organs
- Improved chances of pregnancy
- Improved long-term results for chronic pelvic pain and other symptoms
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