The diagnosis and treatment of endometriosis and its significance with regards to reproductive function, has undergone a major transformation in recent years and care pathways are more established and better understood than ever before. Surgical treatment has now largely replaced medical treatment for this condition, although occasionally, a course of pre-operative medication is recommended.
Endometriosis is classified according to the classification system devised by the ASRM. Stage 1 and 2 disease is where there are small deposits of endometriosis on the peritoneal surface or the ovaries, without any anatomical distortion. Stage 3 and 4 represent more advanced disease, where there are adhesions between the pelvic organs and very often the disease has progressed to the stage where there is an endometriotic cyst in one or both ovaries.
Stage 1 (minimal) and Stage 2 (mild) endometriosis is treated using laparoscopic surgical techniques. The areas of endometriosis can either be destroyed by ablative techniques or excised. My preference is to use ablative techniques and of the modalities available, my preference is to use the helica thermocoagulator. The helica has now largely replaced laser techniques for early stage endometriosis. I have been using it for many years and have been impressed by the results, both in terms of pain relief and pregnancy. If there is any concern about the possibility of post-operative adhesion formation, I instill a litre of Adept. This fluid keeps the tissues apart for a few days post-operatively. It can make the woman feel a little uncomfortable and occasionally small amounts of the fluid can leak out through the laparoscopy incisions.
Stage3 (moderate) and Stage 4 (severe) endometriosis can also be treated by laparoscopic surgery, but occasionally a laparotomy (cutting operation) will be required. For patients with more advanced disease, I usually recommend a course of pre-medical treatment with a treatment course of gonadatrophin releasing hormone analogues injections.
The operative techniques I use for endometriosis are ablation of peritoneal disease using the helica thermocoagulator and divisions of adhesions using the helica thermocoagulator, bipolar diathermy and occasionally the harmonic scalpel. The approach I use for endometriotic cysts is to first of all open the cyst out using the harmonic scalpel; aspirate the cyst contents and wash out the cyst; and then remove the cyst wall using bipolar diathermy. If the cyst wall cannot be removed in this way, I will treat it with the helica thermocoagulator. The ovary can then be repaired using normal suturing techniques if a laparotomy is performed or, if the operation is performed laparoscopically, using intracorporial suturing. To prevent post-operative adhesions formation I use Adept fluid for laparoscopic surgery and for laparotomy, a material called Interceed. I have been using Interceed since its introduction in the early 1990’s and have found it to be effective.
I developed a keen interest in the treatment of endometriosis over a long period of time. I am a member of the British Society of Gynaecological Endoscopists (BSGE) and am one of a group of consultants who have established an endometriosis centre in Croydon, recognised by the BSGE. I am also a member of the Society of Reproductive Surgeons (SRS) whose members include leading experts in the United States.