The post-operative experience following endometriosis-related surgery can vary wildly from one person to the next, but why? While laparoscopic excision surgery remains the most effective surgical treatment for endometriosis, in some cases, patients may experience the return of pain and unpleasant symptoms within a year.
A patient may characterize their endometriosis surgery as unsuccessful for a number of reasons, namely, no decrease in pain level when comparing pre-op and post-op. However, there are a number of factors to consider when accessing post-op pain. It is important to remember that even though the surgery itself may be successful for the surgeon—in that all visible, abnormal tissue was removed and pelvic anatomy was restored to an optimal state—this is no guarantee that a patient's pain will be completely eliminated. No surgeon can 100 percent guarantee a pain-free post-op experience as everyone responds differently to pain. Post-op pain can occur due to:
“Surgical insult” where the organs swell as a normal inflammatory response to surgery. (This should go away as the tissues heal with time.)
Local anesthesia, which can relieve all pain during surgery, but gradually wear off three to five days post-op.
The first post-op menstrual cycle, which can be very painful due to certain procedures performed during surgery. Typically, during endometriosis surgery, the cervix or entry to the uterus is dilated, and the endometrial lining is cleaned out or biopsied. A hysteroscopy, or procedure during which a surgeon will look inside the uterus will often be performed with a small camera. This causes the lining to regenerate a new lining and the cervix to stay dilated for a short time after surgery. How does this translate for the patient? A heavier menstrual cycle which may or may not be more painful than before. This first period is also often heavier and longer than usual and may contain blood clots. Typically this resolves within a few cycles after surgery.
Still, the recurrence of symptoms several months after surgery, could, however, indeed be caused by an unsuccessful or incomplete endometriosis surgery.
Pain as a result of unsuccessful or incomplete endometriosis surgery
There are two main types of endometriosis surgery that may be used to remove endometrial lesions: ablation and excision. In ablation surgery, the endometrial lesions are destroyed with heat or a laser beam. In excision surgery, they are removed by lifting and excising them away from the surrounding tissue. Excision surgery is more effective than ablation, but it requires more skill and is more time-consuming.
Surgeons may not always remove, or be able to remove, all lesions during surgery, which can continue to cause unrelenting pain following the operation.
This may be because:
The endometriosis lesions were not adequately excised due to the surgeon’s lack of skill
The lesions were only superficially removed and not wholly excised
The surgeon intentionally left part of the lesion behind because the risks of complications following surgery outweighed the benefits. For instance, if the scar tissue involves intestine/bowel and the patient does not want a bowel resection, or the surgeon isn’t skilled in this type of removal the damaged bowel may be left as is. This also applies to endometriotic lesions on the bladder, major blood vessels and any other areas which may result in a major complication.
Endometriosis surgery can also be deemed unsuccessful if complications—including bleeding, cysts, and fistula— arise after surgery.
Vaginal bleeding for up to two weeks following endometriosis surgery is normal. However, if patients experience bleeding that lasts for more than two weeks, or that is heavier than a normal period and is accompanied with fever, nausea, vomiting, or increasing pain, they should contact their doctor immediately .
Cysts can appear following surgery and be indeterminable whether they result from disease recurrence or progression . It is important to remember that cysts and follicles do develop every month as a part of normal healthy ovulation. Patients many times will ovulate and have a small normal hemorrhagic follicle from ovulation. Often patients may go to fertility doctors or other practices only to be wrongly advised that their endometriomas have returned. We advise patients to return in two weeks and eight weeks to observe the normal ovulation and ultrasound follow-up. These cysts typically resolve in a few months. It is also an option to suppress ovulation following surgery in order to lessen the chances of recurrence and give the patient time to recover.
One of the most severe complications of endometriosis surgery is intestinal and urinary fistulas or an abnormal, tube-like connection that forms between two organs in the intestines and the urinary tract. . It is important to remember this is not considered “unsuccessful” surgery; this is a complication which can occur whether or not the surgery is a success.
Three main factors determine the likelihood of endometriosis returning following surgery . These are:
The severity of the disease at the time of surgery
The completeness of endometriosis surgery
The use of medical suppressive therapy following surgery
The severity of endometriosis at the time of surgery
The risk of recurrence of endometriosis following surgery can be higher in patients with less severe disease (Stage I or II) compared to those with advanced disease (Stage III or IV) .
Incomplete endometriosis surgery
If all the endometrial lesions were not removed during surgery, the symptoms of pain associated with the disease are likely to come back following the operation. This is highly dependent on the skills of the operating surgeon.
Use of medical suppressive therapy
Research has shown that the use of hormonal suppressive therapy, following endometriosis surgery, may reduce, and prevent the return of, painful endometriosis symptoms. .
The rate of recurrence
The rate of recurrence of endometriosis is thought to be between 20 and 40 percent within five years of conservative surgery.
Minimizing risk and recurrence after surgery
A skilled surgeon
A skilled surgeon is crucial in minimizing or greatly eliminating the outcome of an unsuccessful endometriosis surgery. Most gynecologists do not get adequate training on endometriosis, and therefore may not be qualified or experienced enough to manage the disease and operate on multiple organs.
The right type of surgery
Choosing the right type of surgery is also key to a successful treatment of endometriosis. Ablation is usually not as effective as excision surgery and can often leave carbon deposits on the surface of the peritoneum, or the inner lining of the abdomen, which can confuse surgeons at future surgeries. These deposits can cause further retraction of tissue and scarring; similar to a cigarette burn on the skin.
Using robotic surgery may also increase the risk of endometriosis recurrence since the surgeon cannot feel the lesion (there's no haptic feedback from the instruments) and this can increase the likelihood of it being left behind.
A multi-disciplinary approach
It is essential that the healthcare team treating a patient with endometriosis is a multi-disciplinary team comprised of a minimally invasive gynecologic surgeon, a colorectal surgeon, a urology surgeon, and any other surgical specialty involved. Many centers may also collaborate with dieticians and pelvic floor therapists or acupuncturists to complement care. It is therefore important for patients to be referred to a multidisciplinary center, like Seckin Endometriosis Center, with expertise in endometriosis surgery and care if possible.
Early intervention is also key to ensuring the success of endometriosis surgery and preventing the disease from coming back. The sooner the disease is diagnosed, the sooner it can be correctly treated. This can help by avoiding the unnecessary use of other treatments and allow patients to avoid long and stressful periods of uncertainty.
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