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What does excision surgery involve in endometriosis treatment?

<div><p><span style="font-family: helvetica;">​<img src="/nairobi/PublishingImages/Excision%20endometriosis%201.jpg" alt="" style="margin: 5px;"/></span></p><p><span style="font-family: helvetica;">The ultimate treatment of endometriosis is removing the
abnormally located tissue, known as excision surgery. This is a delicate
operation that aims to balance restoration of normal function and minimisation
of risk due to inadvertent damage to normal organs.</span></p><p><span style="font-family: helvetica;">Endometriosis has gained much prominence in both the lay and
professional discourse over the past three decades. This has seen formation of
patient advocacy groups and development of treatment guidelines by professional
associations across the world whose culmination are the World Endometriosis
Organisation (WEO) and World Endometriosis Society (WES) respectively. Locally,
Endometriosis Foundation of Kenya sits on the steering committee of the WEO.
The unique partnership between patient and professional bodies in endometriosis
discussions guarantees that a common agenda in the management of endometriosis
is pursued for the betterment of endometriosis patients.</span></p><p><span style="font-family: helvetica;">As more understanding of endometriosis is gained through
continued research and observation, recommendation for the type surgical
management also changes. Presently, it is recommended that treatment of
endometriosis is accomplished by excision, meaning to remove visible disease
through an operation. It is also the recommendation that this type of surgery
is performed by trained specialists to reduce risk of complications that may be
associated with an operation and reduce the risk of multiple surgeries. Where
available, patients with severe endometriosis must be treated in a centre with
a multidisciplinary team of specialists. This team comprises of a gynaecologist
trained in endometriosis surgery, bowel surgeon and urologist. Other members
include a radiologist with special interest in female reproductive imaging,
pain management specialist, fertility specialist, counselling psychologist and
physiotherapist.</span></p><p><span style="font-family: helvetica;">Whereas the extent of endometriosis may vary and dictate
complexity of the disease and the surgery, inadequate preoperative assessment
of a patient may result into unexpected finding of severe disease at surgery
which was not be anticipated. This could result in inadequate treatment as the
patient may not have been adequately counselled and consented to a complex
surgery, or the surgeon may be untrained to handle this.</span></p><p><span style="font-family: helvetica;">Patients present to doctors with various symptoms, more
commonly with pain or infertility. A thorough assessment with particular
attention to the pain character, examination to pick out areas of disease
involving the bowel, ovaries and roof of the vagina will guide the clinician to
extent of disease. An initial test tends to be a pelvic ultrasound scan. This
is best performed using a transvaginal probe preferably by the gynaecologist if
trained. Focus should be on detecting disease on the ovary which presents as a
cyst (fluid filled sac), disease behind or in front of the uterus and between
the rectum and vagina. Often an ultrasound assessment is adequate, however, a
more sophisticated test known as magnetic resonance imaging (MRI) may be
requested.</span></p><p><span style="font-family: helvetica;">Findings of severe disease on MRI require that a
multidisciplinary team meeting is convened to carefully plan the surgical
operation combining guidance from the radiologist and surgical expertise. The
decision of the multidisciplinary team will usually be communicated to the
patient by the lead gynaecologist who ensures that the patient fully
understands the planned surgery including benefits, risks or alternatives to
treatment. Only a well-informed patient should proceed to surgery.
Understanding may be enhanced by using a patient information leaflet that
distils complex medical information into clear and easy to understand language.
Patients are encouraged to bring a relative or trusted friend to the
appointment when discussing with the doctor and must never be hurried to decide
going into surgery.</span></p><p><span style="font-family: helvetica;">Generally, laparoscopy is preferred to open surgery as it
confers added benefits such as better visualisation and access for surgery,
less pain and quicker recovery for the patient and if well done, economical in
the long-term. Laparoscopy involves passing a special operating telescope
through the belly button (navel) and using long instruments through small
incisions in the abdomen to operate. The image is usually projected on to a
high definition television screen. Some equipment is enabled to record the
operation which can be reviewed later. Often this type of operation takes long
to complete as it involves taking away disease that may be near or onto vital
organs such as bladder, ureter (tube connecting kidney and bladder), or the
bowel.  When the ovary contains a cyst,
this has to be removed with meticulous attention to detail ensuring that normal
tissue is not destroyed that may result in ovarian failure. An ovarian cyst
also signifies presence of severe disease and this must be emphasised as removing
the cyst and leaving disease elsewhere means symptoms are likely to persist.</span></p><p><span style="font-family: helvetica;"> Accomplishing a
complex operation is not enough and a careful follow-up plan must be drawn by
the specialist keeping the wishes of the patient at the centre of discussions.
Evidence is now accumulating that a competently done operation achieves high
pain relief scores and improved fertility outcomes. Working closely with other
specialists such as counselling will improve outcomes as often the patient may
have struggled for long before getting the correct diagnosis or proper surgery.</span></p><p><span style="font-family: helvetica;">Dr Charles Muteshi

Endometriosis and Fertility Specialist, Aga Khan University Hospital

Member, European Society of Human Reproduction and Embryology: Endometriosis
Guidelines Development Group


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