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Laparoscopic Excision of Endometriosis

Endometriosis is a condition where tissue similar to the lining of the womb grows outside of the uterus. It is a long-term condition that can affect a woman from her first period all the way to the menopause. For some women, it can cause excruciating pain as well as affect fertility.

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Symptoms of endometriosis include:

  • Painful periods
  • Heavy periods
  • Pain pre or post period
  • Chronic abdominal or lower back pain
  • Pain when urinating or with bowel movements
  • Pain during or after sex
  • Nausea, constipation, diarrhoea
  • Blood in your urine and/or poo during your period
  • Difficulty conceiving

Endometriosis can be hard to diagnose, as symptoms vary and many other conditions, such as IBS, present with similar symptoms.

According to the Royal College of Nursing, Endometriosis impacts 1 in 10 women of reproductive age across the UK. Currently, it takes an average of eight years to receive a diagnosis.

At St John & St Elizabeth Hospital, we want to help women who are suffering with endometriosis, and although there is currently no definitive cure, there are many treatment options available.

These include:

  • Intra-uterine hormones such as the Mirena IUS (coil) can provide pain relief as well as be used as a long-term treatment.
  • Conservative surgery such as laparoscopic excision. This is keyhole surgery to remove sections of endometriosis tissue by cutting it out of the body.
  • Complex surgery. This includes more extensive surgery that involves other organs affected by the endometriosis, such as the bladder or bowel. Depending on the severity of your symptoms, more radical surgery may be considered such as a hysterectomy, where the womb is removed. This can be done with or without removing the ovaries. If both ovaries are removed, this causes an instant menopause. However, leaving the ovaries increases the risk of the endometriosis returning. Going ahead with this type of surgery is a big decision so it’s important to keep in mind that a more radical approach will only be considered when all other medicinal and surgical treatment options have been exhausted.

Before

If you think you might have endometriosis and are worried, or have an existing diagnosis and would like to discuss your treatment options, book an appointment with one of our experienced gynaecologists.

Our gynaecologists aim to provide a one-stop service so you can leave your appointment knowing your next steps. When you come in for an appointment, your gynaecologist will take a detailed medical history and ask about your symptoms, including when they started, if they have been getting worse and where you feel pain.

They will then conduct a pelvic exam, which involves feeling areas in your pelvis to check for any unusual changes, and finish with an ultrasound scan. Whilst the ultrasound will not confirm endometriosis, it will show your gynaecologist whether you have any cysts on the ovary (endometrioma) which are linked to the condition.

If at this point your gynaecologist suspects endometriosis, they may refer you for an MRI, which produces very detailed images of your organs, and can show the exact location and extent of any endometriosis.

In some cases, a laparoscopy may then be recommended. This involves making a tiny cut near your belly button and placing a thin tube with a light and camera called a laparoscope inside. This procedure gives your doctor a direct view of the location, extent and size of the endometriosis growths. In many cases, your doctor can treat your endometriosis during a laparoscopy by cutting it out (excision), so you need only one surgery.

It’s important to note that not everyone with endometriosis requires surgery, and the decision to undergo a laparoscopic excision will be made on a case-by-case basis after thorough discussion between you and your doctor. The severity of your symptoms, impact on quality of life, and reproductive goals are important factors in the decision-making process.

Preparing for surgery

If you do decide to go ahead with a laparoscopic excision, we will help you prepare, but you should also try to eat healthily in the run up and stop smoking if you can.

Preparation will involve having some pre-operative tests, including an MRSA test. We will also give you some specific antibacterial soap and lotions to use in the run up to the procedure, which will help reduce your risk of contracting MRSA.

If you take any blood thinners—for example, Warfarin or aspirin, tell your gynaecologist straight away, as you may need to stop taking these or modify your intake from a week before surgery. Your gynaecologist will give you specific instructions if this is the case. You should also tell them if you take nonsteroidal anti-inflammatory drugs, such as ibuprofen.

You cannot eat for 6 hours prior on the day of your surgery. You can drink water up to four hours prior to surgery. You cannot eat chewing gum and hard candies. Brush your teeth with toothpaste only on the morning of surgery. If you take any prescription medications, bring them to hospital with you. Your doctor will let you know if you can take these with a sip of water before your surgery or if you should wait until after.

On surgery day, it’s a good idea to wear loose, comfortable clothing and bring a small bag with things you might need during your stay. Items to remember include a toothbrush and toothpaste, your phone and a charger, a book, any prescription medications and a change of clothes.

Once you have arrived and are settled in your room, a nurse will help prepare you for surgery by monitoring vital signs and running through your medical history, medications and emergency contacts.

Your doctor will then run you through the procedure once again and ask you to sign a consent form for surgery.

During

A laparoscopic excision is a minimally-invasive surgery. Most people will only need to stay in hospital for one night, but depending on the severity your endometriosis, you may need to stay up to five nights. Your surgery will be done under general anaesthetic, so you will be asleep.

To start with, you will have an intravenous (IV) line fitted into a vein. This is usually done in an arm or hand. Through this, your surgical team can quickly give you medications and fluids. The surgical team will also place monitors on you that will help keep you stay safe throughout surgery. After some final safety checks, surgery can start.

Your surgeon will begin by making three or four small incisions in your abdomen. One will be in your belly button, one to the right of it and one to the left. Sometimes, one will be also made in the middle near your bikini line. A catheter (a small tube) will also be placed in your bladder. This prevents the bladder from overfilling during the procedure, which reduces the risk of a bladder injury.

The surgeon will then inflate your abdomen with gas in order to see your organs more clearly, and a laparoscope (a thin tube with a small camera and light) will be inserted into an incision.

The primary goal of a diagnostic laparoscopy is to visually confirm the presence of endometriosis. During this procedure, your surgeon inspects your pelvic organs, looking for characteristic lesions or cysts associated with endometriosis. Your surgeon may also take tissue samples (biopsies) to confirm the presence of endometrial tissue outside the uterus.

If your surgeon has agreed with you in advance that you will be having a laparoscopic excision, they will then begin to remove the endometriosis using specialised instruments. These growths may be situated on the:

  • Uterus
  • Ovaries
  • The fallopian tubes
  • Ureters (tubes that carry urine from the kidneys to the bladder)
  • Back and side of the uterus
  • Bladder
  • Bowel
  • Rectum

Once endometriotic tissue has been removed, it does not grow back, meaning your symptoms should improve.

Endometriosis affecting the bowel.  If endometriosis is also affecting your bowel, your surgeon will have discussed with you in advance of your procedure whether a small section of your bowel will need to be removed or a temporary stoma inserted.  A stoma is an opening made in the abdominal) wall, which connects the bowel to the surface of the tummy. A stoma means poo will not leave your body in the usual way, but will pass into a disposable bag that is attached to the stoma.

Endometriosis affecting the bladder. If you have severe endometriosis that is also affecting your bladder, your surgeon will have discussed with you in advance of your procedure whether a small section of your bladder will need to be removed. The bladder will be closed with dissolvable stitches and you will need to wear a urinary catheter for the following two weeks. As this reduces the capacity of your bladder, you may need to urinate more often after this procedure.

Once all the endometriosis has been cut out, the catheter will be removed, unless the endometriosis was affecting your bladder, in which case it will be kept in for another two weeks.

To finish, the cuts on your abdomen will be closed with dissolvable stitches and covered with a protective dressing.

After

After surgery, your surgical team will take you to our recovery area where specialist staff will monitor your vital signs as you wake from anaesthesia.

Once we’re happy you’re doing well, we will take you to a private room where you can start your recovery.

Depending on the extent of your operation, you should expect to stay in hospital for 1 – 5 nights.

It’s normal to feel some discomfort and pain in your lower abdomen for a few days after surgery. You may also have some light vaginal bleeding. When you get home, you should keep your dressing in place for two days. Don’t worry if you get your incisions wet when you shower. Simply pat them gently dry. We recommend taking regular pain relief to help you remain active post-surgery. The doctor may also prescribe medication to prevent the build-up of new endometriosis tissue. This could include hormone therapy.

In general, recovery from laparoscopic excision takes around four to six weeks. However, if you had a more extensive operation, this will take longer.

You will need to take one to two weeks off work and some everyday activities will also be restricted for around four weeks. This includes:

  • Driving
  • High impact sports
  • Heavy lifting

Although the team will give you post-surgery advice, you should also:

  • Eating a healthy and balanced diet
  • Drink plenty of water
  • Maintain a regular gentle movement practice

After your laparoscopy, you’ll need to have follow-up appointments at two weeks and three months. This is to ensure your procedure recovery is progressing as expected.

Be mindful of your first period following your endometriosis surgery, as it might be more painful than usual. If you are struggling with the pain or are passing too many blood clots, speak with our team.

Medically reviewed by Mr Emeka Okaro - MBBS FRCOG on 17/01/2024

How to pay for your treatment

If you’re… paying for yourself

Did you know you don’t need private medical insurance to come to St John & St Elizabeth Hospital? As a self-pay patient, you can access safe, outstanding quality health care at times to suit you.

For scans and tests, as well as to see most consultants, you’ll still need to be referred by a medical professional like your GP, but as a self-pay patient, the process is more straightforward. You won’t need authorisation from an insurance provider, and you’ll have greater choice of consultant and appointment times.

If you’re… insured

St John & St Elizabeth Hospital is approved by all major medical insurance companies. If you have a personal private health insurance policy, or your company provide it for you, you can use it to pay for your care from your initial consultation through to treatment, surgery and aftercare such as physiotherapy. Not all private health insurance plans cover the same things. It’s very important to check exactly what you are covered for with your insurance provider.