Why see a specialist?

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The skill of the surgeon can affect the ability to accurately identify endometriosis in order to diagnose as well as to remove all disease (Jose, Fausto, & Antonio, 2018; Fischer et al., 2013). Also, endometriosis is not confined to the pelvis and can involve areas such as ureters, bowel, or diaphragm that require a higher level of care.

Why See A Specialist for surgery?

“A multidisciplinary team approach (eg, gynecologic endoscopist, colorectal surgeon, urologist) can reduce risk and facilitate effective treatment. Likewise, advanced surgical skills and anatomical knowledge are required for deep resection and should be performed primarily in tertiary referral centers. Careful preoperative planning, informed consent, and meticulous adherence to “best practice” technique is requisite to reduce morbidity and ensure effective management of potential complications. Although excisional biopsy and resection offers a higher success rate in treating the disease, surgical excision also requires a higher level of surgical skill. As a result, many patients receive incomplete treatment, which in turn may lead to persistent symptoms and recurrent disease. It should be noted that many women who have undergone repeated surgeries and had a hysterectomy still suffer. The need to improve surgical approach and/or engage in timely referrals is unquestionable. Surgery to debulk and excise endometriosis may be “more difficult than for cancer”. Complete removal of implants may be difficult due to variation in appearance and visibility. True surgical resection and treatment poses formidable challenges, even the hands of experienced clinicians. In particular, deep disease is often difficult to treat due to close proximity of and common infiltration in and around bowel, ureters, and uterine artery. Potential adenomyosis should also be included in the preoperative workup, as it can influence postoperative improvement patterns of pain and symptoms associated with endometriosis. Lesions may present as “powder burn” implants, foci of inactive disease containing glands embedded in hemosiderin deposits and stroma; nonpigmented lesions appearing as clear vesicles; and as pink, white, red, brown, yellow, and blue implants. Microscopic disease may be identified in otherwise normal-appearing peritoneum by light and electron microscopy. “Blood painting” or use of staining agents such as indigo carmine or methylene blue may also improve detection. Cellular activity is believed to be greater in superficial or deep implants versus intermediate lesions. Upon visual diagnosis, laparoscopy is usually extended to an operative procedure, beginning with adhesiolysis between bowels and pelvic organs in order to expose the pelvic cavity. Ovaries may then be dissected from the cul-de-sac or pelvic sidewall, tubes freed from adhesions, and implants resected or otherwise destroyed. Bowel and genitourinary lesions should be removed. If appropriate, presacral neurectomy or laparoscopic uterosacral nerve ablation may also be performed to treat central pelvic pain. Removal of endometriomas on the ovaries may also be performed. Peritoneal implants should be destroyed using the most effective, least traumatic manner to minimize and reduce risk of postoperative adhesion formation.

“Complete excision of endometriosis, including vaginal resection, offers a significant improvement in sexual functioning, quality of life, and pelvic pain, including in those symptomatic patients with deeply infiltrating nodules of the posterior fornix of the vagina. As well, the technique offers good results in terms of reduced bladder morbidity and bowel symptoms. However, in that this kind of surgery requires advanced skills and anatomical knowledge, again, it should be performed only in selected reference centers. Randomized controlled trials also demonstrate that excision is associated with a higher pregnancy rate and lower rate of recurrence, though it may cause injury to the ovarian reserve. Improvements to this aspect may be represented by a combined excisional-vaporization technique or by replacing coagulation with surgical ovarian suture. In general, laparoscopic excision significantly improves general health and psycho-emotional status at 6 months from surgery without differences between patients submitted to intestinal segmental resection or intestinal nodule shaving. Pain, sexual function, and quality of life were demonstrated to improve significantly in at least one study, and these symptoms were associated with a good fertility rate and a low complication and recurrence rate after a CO2 laser laparoscopic radical excision of endometriosis with colorectal wall invasion combined with laparoscopic segmental bowel resection and reanastomosis.”

References

Jose, C., Fausto, A., & Antonio, L. (2018). Laparoscopic Enhanced Imaging Modalities for the Identification of Endometriosis Implants a Review of the Current Status. MOJ Womens Health7(1), 00160. DOI: 10.15406/mojwh.2018.07.00160