What Does It All Mean? Excision, Ablation, and Robotic Assistance for Removal of Endometriosis

Endometriosis is an estrogen-dependent disease that affects five to 10 percent of women in the United States, reaching around 40 percent of the sub-fertile women. Its defining feature is the deposit of tissue outside the uterus. This tissue can be present in different sites like the peritoneum, ovaries, bladder, and bowel. It can be classified in three main forms: superficial Endometriosis, ovarian endometrioma, and deep infiltrating Endometriosis. This disease can present itself with a lot of different symptoms going from asymptomatic to debilitating.

The most common symptoms being chronic pelvic pain, pain during intercourse, dysmenorrhea, and infertility.

Different from what many people think, Endometriosis can impair a woman’s quality of life significantly.

The treatment approach to this disease can vary from medication to surgery, the last being the gold standard treatment – which is laparoscopic surgery. (All treatments must be individualized and discussed between doctor and patient to see what fits best the patient’s needs and what is medically possible.)

When thinking about the surgical treatment we are also presented with different options, different surgery modalities (laparotomy, laparoscopy and robotic-assisted laparoscopy). Robotic-assisted laparoscopy was developed to overcome limitations of conventional laparoscopy and laparotomy (open surgery). There are many studies proving the feasibility, safety, and efficacy of robotic-assisted laparoscopy. This type of procedure offers advantages such as reduced blood loss, better exposure of the operative field, 3D vision, shorter hospital stay, and lower rates of complications. The robot-assisted manipulation of the instruments is much easier for an experienced surgeon, reducing work fatigue and tremor. This minimally invasive surgery allows the surgeon to operate with precision even in complex advanced stage endometriosis cases.

The ultimate goals of surgical management in Endometriosis are to prevent the progression of the disease, avoid or delay recurrence, restore normal anatomy, alleviate symptoms, and restore fertility.

These goals can be achieved with two different types of procedures: excision and ablation. Excision is the removal of the entire lesion with clear margins and ablation is the destruction of the lesion by burning its surface.

It has been noted that gynecologists with particular interest, superior knowledge, and experience in Endometriosis are more likely to use techniques to achieve full surgical excision of lesions. There are also studies that have shown greater symptom reduction with excision rather than ablation. Each surgeon will have different preferences and techniques and this is a reflex of their own experience and surgical skills.<

Another important goal of Endometriosis surgery is to remove and prevent the formation of adhesions, as these can be related to chronic pelvic pain.

Different types of energy sources and instruments can be used to perform excision of lesions and adhesiolysis like high-frequency radio wave electrosurgery (monopolar, bipolar) and laser dissection (CO2 laser). There are studies comparing all the different types of energy sources and we can see that the CO2 laser provides great precision and virtually no blood loss when compared to others. Another innovative treatment that has been used during Endometriosis surgery is the dehydrated human amnion/chorion membrane. This membrane modulates inflammation and reduces scar tissue formation acting as an adhesion barrier, accelerating and improving the healing process.

Endometriosis has been gaining a lot more attention nowadays. What used to be considered a “mental” disease is now getting more and more understanding from both patients and doctors.

It is imperative that the scientific society study more and more about this disease. Patients should be listened to and should feel reassured that their treatment will be performed by an experienced doctor with knowledge, skills, and understanding of this complex disease.

This post was written by Aileen Caceres, MD and Daniele Fuhrich, MD. Carceres is a board-certified gynecologist who specializes in minimally invasive gynecologic and robotic surgery.