Ever Wonder: Was My Endometriosis Surgery Unsuccessful?

Ever Wonder: Was My Endometriosis Surgery Unsuccessful?

Overview

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.

Causes of “unsuccessful” endometriosis surgery

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 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 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 the cervix or entry to the uterus is dilated and the endometrial lining is cleaned out or biopsied. A hysteroscopy or look inside the uterus often will 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? Heavier 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 be 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, 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. 

Symptoms

Complications following endometriosis surgery

Endometriosis surgery can also be deemed unsuccessful if complications—including bleeding, cysts, and fistula— arise after surgery.

Bleeding

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 [2].

Cysts

Cysts can appear following surgery and be indeterminable whether they result from disease recurrence or progression [3]. 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 they may go to fertility doctors or other practices who tell them falsely 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.

Fistulas

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.  [4]. 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.

Factors

The recurrence of endometriosis

Three main factors determine the likelihood of endometriosis returning following surgery [3]. 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

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) [5].

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. [3].

Rate of recurrence of endometriosis following surgery

The rate of recurrence of endometriosis is thought to be between 20 and 40 percent within five years of conservative surgery.

Treatment

What to do to minimize the risk of complications and avoid the recurrence of symptoms following surgery

A skilled surgeon

A skilled surgeon is crucial in minimizing or greatly eliminating 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 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 since the surgeon cannot feel the lesion (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

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.

References

  1. https://www.drseckin.com/after-endometriosis-surgery

  2. https://my.clevelandclinic.org/health/diseases/4551-endometriosis-recurrence--surgical-management

  3. https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1471-0528.2010.02774.x

  4. https://journals.lww.com/dcrjournal/Abstract/2012/09000/Management_of_Deeply_Infiltrating_Endometriosis.1.aspx

  5. https://www.drseckin.com/after-endometriosis-surgery

 

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    Dr. Seckin and his staff spared me from years and years of heavy periods and unbearable endometriosis pain. After having surgery with him (my first) I can now function like a regular human. No more eating NSAIDs like candy and calling out sick from work. Thank you, Dr. Seckin!

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    I underwent surgery with Dr. Seckin in 2017 and have felt like a new woman ever since. If you have, or suspect you have endometriosis, Dr. Seckin and his compassionate team of surgeons and staff are a must-see.

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    I have struggled with endometriosis and adenomyosis since first starting my period at 13. I was diagnosed at 21 and what followed was a series of unsuccessful surgeries and treatments. My case was very aggressive and involved my urinary tract system and my intestines. After exhausting all of my local doctors I was lucky enough to find Dr. Seckin. We…

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    Like so many women who have tirelessly sought a correct diagnosis and proper, thorough medical treatment for endometriosis, I found myself 26 years into this unwanted journey without clear answers or help from four previous gynecological doctors and two emergency laparoscopic surgeries. I desperately wanted to avoid the ER again; a CT scan for appendicitis also revealed a likely endometrioma…

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    Dr. Seckin literally gave my wife her life back. I am eternally grateful to him for his generous, determined spirit to see that Melanie finally live free from the prison bonds of Endometriosis.

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    I am so grateful to Dr Seckin and Dr. Goldstein. My experience was nothing short of amazing. I was misdiagnosed with the location of my fibroids and have had a history of endometriosis. Dr. Seckin was the one who accurately diagnosed me. Dr Seckin and Dr. Goldstein really care about their patients and it shows. They listened to my concerns,…

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    When I think of Dr. Seckin these are the words that come to mind. Gratitude, grateful, life-changing, a heart of gold. I feel compelled to give you a bit of background so you can understand the significance of this surgery for me. I am passionate about Endometriosis because it has affected me most of my life and I have a…

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    Dr. Seckin and Dr. Goldstein radically changed my quality of life. They treat their patients with dignity & respect that I've personally never seen in the literally 25+ doctors I've seen for endometriosis. This summer, I had a surgery with Dr. Seckin & Goldstein. It was my first with them, but my 5th endo surgery. I couldn't believe the difference,…

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    I was in pain for 2 years. I was getting no answers, and because dr Goldstein and dr seckins were willing to see and treat me I'm finally feeling almost back to normal. They were very down to earth and helpful in my time of need. Dr Goldstein was easy to talk to and caring, she took care of me…

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    Dr. Seckin is one of the best endometriosis surgeon. Every time I go to the office, he really listens to me and is always concerned about my issues. Dr Seckin's office staff are a delight and they always work with me. I feel I can leave everything to them and they will take care of it. Thank you to the…

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    Fast forward 5 years to find out incidentally I had a failing kidney. My left kidney was only functioning at 18%. During this time, I was preparing all my documents to send to Dr. Seckin to review. However, with this new information I put everything on hold and went to a urologist. After a few months, no one could figure…

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    I had a wonderful experience working with Dr. Seckin and his team before, during and after my surgery. I came to Dr. Seckin having already had laparoscopic surgery for endometriosis 5 years prior, with a different surgeon. My symptoms and pain had returned, making my life truly challenging and my menstrual cycle unbearable. Dr. Seckin was quick to validate my…