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Severe Endometriosis...

 

Information for patients undergoing radical surgey for severe endometriosis

Endometriosis is a gynaecological disease where some of the tissue which lines the inside of the womb (the endometrium) lies outside of the women and may involve the walls of the pelvis, the bowel, the bladder and the ureters.

 

The aim of radical surgery is to remove completely all endometriosis from the pelvis regardless of where it is located. This does not mean hysterectomy or oophorectomy although these may be advised additionally. Your operation may include surgery to bowel, bladder and ureters depending on what is involved.

 

Risks of surgery

The surgery involved is major even if, as is usual, it is all done by laparoscopy. Occasionally, the abdomen must be opened for safety reasons. All surgery carries risks some of which are relatively minor but fairly common and others which are more serious but fortunately relatively rare. Bleeding and infection may occur during or following any surgery and antibiotics are routinely given to reduce the risks. 

 

DVT or pulmonary embolism may occur following pelvic or abdominal surgery and the risk may be reduced by the use of compression stockings and prophylactic heparin use.
Surgery for advanced endometriosis may also carry a risk of injury to the bladder or ureters and may be unavoidable if the disease is to be removed completely. Small tubes (stents) may be inserted into the ureters at the start of the operation in order to identify and protect them and similar tubes may be left in place for up to 6 weeks (rarely longer) after the operation; these are easily removed under sedation.


The main risks of radical endometriosis surgery pertain to bowel surgery. It is often impossible to determine before an operation to what extent the endometriosis involves the bowel. It may just be in a single site or in many. It may be on the surface or may penetrate right through the wall of the bowel. Sometimes the bowel lumen may become severely narrowed due to scarring. If possible we try to shave the endometriosis off the surface of the bowel; if this is not possible or is unsafe we then proceed to either remove a small disk of the bowel wall or more commonly a segment of the bowel, the length depending on the degree of involvement by the endometriosis.

 

We try to avoid performing an ileostomy or colostomy at the time of operation but this is necessary in a small number of patients such as when multiple segments of bowel have to be removed. About 1 in 20 patients who have a segment of bowel removed develop a leak from the join. Should this happen, you would need to be brought back to theatre and have an ileostomy performed. You would then require a gastrografin enema 6 weeks later to confirm that the bowel wall has healed before coming in for reversal of the ileostomy.

 

Women sometimes find that they have to empty their bowels several times daily after the operation and this may take a year or more to settle as the bowel learns to accommodate. Sometimes a stricture may form at the point of the join in the bowel; this is relatively easy to stretch up under sedation. A further potential and relatively rare complication is the development of a fistula. Fistulae sometimes heal on their own but at other times require further surgery for correction.

 

Success rates

Based on our own experience and analysis of our data we expect a cure rate of about 85%. By this we mean that about 85% of patients undergoing this type of surgery will end up either pain free or experience great improvement in the pain experienced. Endometriosis is responsible for many different types of pain and some respond to surgery better than do others.

 

In particular, painful periods may persist after surgery if the womb is left intact. Some patients require further surgery over time. Our experience to date suggests that women who experience recurrent pain are likely to have adhesions or else have endometriosis in the ovaries. Recurrence at the site of the original surgery does not appear to be a problem.

 

What to expect after surgery

You are likely to have a catheter to drain urine from your bladder as well as a drain going into your pelvis. There will be intravenous lines to give you fluids. Most of these will be removed within 3 days and you will be encouraged to mobilise. If your have had an anterior segmental rectal resection, you may also have a catheter placed in the rectum to allow air to escape. If so, it is usually left in place until passed spontaneously as the bowel starts to work. Antibiotics are given routinely in theatre to reduce the risk of infection and sometimes continued after the operation for a short time. They will also be given at the time of catheter removal. Heparin is administered and special stockings provided to minimise the risk of DVT.

 

Pain relief may be provided in a number of ways: some women may be advised to have an epidural and if so will be managed on the High Dependency Unit (HDU); otherwise women may be provided with a pump to enable them to give themselves appropriate doses of painkillers, or may have injections or tablets. Women who have had bowel removed are kept in the hospital until their bowels have opened and we are convinced that there is no significant risk of any leak. This is usually between 5 and 8 days.

 

Energy levels are typically reduced for several months after surgery and a minimum of six weeks is required off work is required by those who have had a bowel resection.

 

Pregnancy after surgery

It is expected that fertility would increase after surgery so long as the womb and ovaries and tubes are relatively intact. This is also likely to be true of women who require IVF; however, it is difficult to give precise figures for this and the area is one of development. For women who become pregnant after rectal resection we believe that delivery should be by Caesarean section. This is because of the potential for disruption of the scar in the bowel during labour.

 

Glossary of Terms...

 

Anterior Rectal Resection

The removal of a segment or length of the lower large bowel or rectum, the amount removed depending on the extent of disease

 

Colostomy

The drawing out through a small hole on the left side of the abdomen of a loop of large bowel or colon; the bowel contents are allowed to drain into a bag attached to the abdominal wall

 

DVT

Deep Venous thrombosis: a clot in a deep vein in the legs, pelvis or abdomen which may be associated with surgery

 

Endometriosis

A condition where some of the endometrium exists outside of the womb and typically causes pain and scarring

 

Endometrium

The tissue lining the womb which builds up and breaks down in response to stimulation by ovarian hormones and which is shed at menstruation

 

Fistula

A connection between different tissues or organs such as between the bowel and vagina or the bladder and vagina. They are a complication of very major surgery where different pelvic organs are operated upon. They sometimes close on their own but frequently require further difficult surgery to repair

 

Gastrografin enema

The instillation of a radio-opaque dye into the rectum to see if there is any leak from the bowel

 

Heparin

A drug given to prevent or treat abnormal clotting such as DVT

 

Hysterectomy

Removal of the uterus or womb

 

Ileostomy

The drawing out through a small hole on the right side of the abdomen of a loop of small bowel or ileum; the bowel contents are allowed to drain into a bag attached to the abdominal wall

 

Laparoscopy

The insertion of a telescope into the abdomen to enable the surgeon to visualise the organs within and, if necessary, to operate on them

 

Oophorectomy

Removal of ovaries

 

Pulmonary Embolism

The passage of a clot from a vein (DVT) elsewhere to a vein in the lungs

 

Ureters

Tubes which run through the abdomen and pelvis carrying urine from the kidneys to the bladder

 

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