Review on endometriosis surgery

The indication and technique of endometriosis surgery changed rapidly over the last 50 years since better understanding the disease and an improved diagnosis. This review will therefore include a short discussion of the importance and limits of evidence-based medicine (EBM), the clinical importance and diagnostic value of imaging and the alternative medical treatments. Surgery is the cornerstone of infiltrating and fibrotic endometriosis and useful for minor endometriosis. We suggest redefining the aim of surgery, as the elimination of all endometrium like cells with genetic or epigenetic (G-E) endometriotic changes. Microscopic endometriosis in the peritoneum, in the bowel wall and in lymph nodes at distance from a deep endometriosis nodule does not need surgery since there is no evidence that it causes pain, infertility or progression into more severe forms of endometriosis. Subtle and typical lesions need excision or destruction since some of them might progress because of G-E changes. Excision of cystic ovarian endometriosis is associated with fewer recurrences, probably since more complete, but with more ovarian damage than superficial destruction of the lining of the cyst. However, since endometriotic infiltration in the cyst wall is less than 2 mm deep, the rest of the capsule being fibrosis, chemical superficial destruction might combine completeness with superficial treatment. For the surgery of deep endometriosis, the authors have reached consensus on many aspects. This comprises the prevention of nerve damage, the complete excision from the vaginal fornix, the complete excision from the bladder preserving the intramural ureter, ureter excision and anastomosis for fibrotic stenosis, short instead of large bowel resections when necessary and the liberal use of sigmoid resections. Other aspects remain debated, such as the excision of fibrotic endometriosis surrounding and extending below the ureter risking to damage the inferior hypogastric plexus, the exact indication of rectum resections versus complete excision with eventual suture of muscularis or mucosa versus limited excision completed by discoid excision with a circular stapler. The concept of completeness of excision will be discussed since the outer layers might be metaplastic cells without G-E changes. Also, the treatment of macroscopically fibrotic lesions without endometriosis is not clear.