by Tamer Seckin, MD | Posted on July 13, 2020
The post-operative experience following endometriosis-related surgery can vary wildly from one person to the next. 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, when there is no decrease in pain level. However, there are a number of factors to consider when assessing post-op pain. Though the surgery itself may be a success for the surgeon (in that all visible abnormal tissue was removed and pelvic anatomy was restored to optimal state), this is no guarantee that pain will be eliminated. No surgeon can guarantee this 100 percent as everyone responds differently to pain. Some causes for pain after endo surgery include:
“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 can be very painful due to certain procedures performed during surgery. Typically during endometriosis surgery, your surgeon will dilate the cervix or entry to the uterus and clean out or biopsy the endometrial lining. Your surgeon will often perform a hysteroscopy inside the uterus 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. This can cause a heavier cycle which may or may not be more painful than before. Your first period is also often heavier and longer than usual and may contain blood clots. Typically this resolves within a few cycles after surgery.
However, the recurrence of symptoms several months after surgery could be caused by an unsuccessful or incomplete endometriosis surgery.
There are two 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, the lesions are removed by lifting and removing them in their entirety 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 entirely 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 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 over two weeks, or a heavier than normal period accompanied with fever, nausea, vomiting, or increasing pain, they should contact their doctor immediately .
Cysts can appear following surgery, but it is difficult to detemine 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 often experience a small and normal hemorrhagic follicle due to ovulation. Often they may go to fertility doctors or other practices who incorrectly tell them that their endometriomas have returned. We advise patients to return in 2 weeks and 8 weeks to observe the normal ovulation and ultrasound follow up. These typically resolve spontaneously 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 serious 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 include:
The severity of the disease at the time of surgery.
The completeness of endometriosis surgery.
The use of medical suppressive therapy following surgery.
The risk of endometriosis recurrence 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) .
If every endometrial lesion was not removed during surgery, the symptoms of pain associated with the disease are likely to return following the operation. This is highly dependent on the skills of the operating surgeon.
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 of endometriosis is thought to be between 20 and 40 percent within five years of conservative surgery.
A skilled surgeon is crucial in minimizing or greatly eliminating unsuccessful endometriosis surgery. Most gynecologists do not receive adequate training on endometriosis, and therefore may not be qualified or experienced enough to manage the disease and operate on multiple organs.
Choosing the right type of surgery is key towards 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 (the inner lining of the abdomen), which can cause further retraction of tissue and scarring; similar to a cigarette burn on skin.
Using robotic surgery may also increase the risk of endometriosis recurrence because the surgeon cannot feel the lesion (no haptic feedback from the instruments) and this can increase the likelihood of lesions being left behind.
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 ensure the success of endometriosis surgery and preventing the disease from returning. The sooner the disease is diagnosed, the sooner it can be correctly treated. Early daignosis will aid patients in avoiding both the unnecessary use of other treatments and long, stressful periods of uncertainty.
Endometriosis: Recurrence & Surgical Management, ClevelandClinic.org
Complications after surgery for deeply infiltrating pelvic endometriosis, by W Kondo, N Bourdel, S Tamburro, D Cavoli, K Jardon, B Rabischong, R Botchorishvili, JL Pouly, G Mage, M Canis
Management of Deeply Infiltrating Endometriosis Involving the Rectum, Koh, Cherry E. F.R.A.C.S., Juszczyk, Karolina M.B.B.S., Cooper, Michael J. W. F.R.A.N.Z.O.G., Solomon, Michael J. F.R.A.C.S
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