Laparoscopic excision of endometriosis: what it involves, risks and outcomes

Endometriosis is tissue like the womb lining growing elsewhere in the pelvis, causing pain, heavy or irregular bleeding, pain with sex and sometimes fertility problems. A Gloucestershire leaflet states that it affects 10 in every 100 women. The NHS says medicines, including painkillers and hormonal treatments such as the combined pill, are often the first treatment.

Surgery is offered when those measures fail or the symptoms are severe, or when disease affects the bowel, bladder or ovaries. A laparoscopy used to diagnose endometriosis may allow some disease to be removed at the same time. The NHS is explicit that surgery does not cure endometriosis and that further operations can be needed if symptoms return.

Hormone therapy reduces activity of the tissue and pain, but the Gloucestershire leaflet says it does not address fertility problems or scar-related symptoms, which is one reason surgery is considered.

Excision means cutting out the tissue; the other approach is to destroy it with heat. The Gloucestershire leaflet describes excision as the better way to improve pain and irregular bleeding, though improvement is not guaranteed to last.

Deep infiltrating endometriosis, which the Leeds leaflet defines as a nodule at least 5 mm below the peritoneum, can involve the bowel, bladder and nerves. Planning may involve pelvic ultrasound, an MRI, and a multidisciplinary meeting with bowel and bladder surgeons. The surgery may be one stage, where everything is treated in a single planned operation, or two stages, with a second operation if symptoms persist.

Investigations clarify where disease lies, and for deep disease, extra tests such as sigmoidoscopy or cystoscopy may be requested. Hormonal treatment may be paused or continued depending on your surgeon's advice, and fertility plans are discussed since they influence how much tissue is removed.

Pre-assessment covers anaesthetic fitness and fasting. For complex surgery there may be bowel preparation and a discussion of the small possibility of a temporary stoma.

• Keep a symptom diary so you and the surgeon can measure change later.

• Ask who will operate and whether a bowel or urology surgeon will be present if needed.

• Plan time off and help at home appropriate to the extent of the surgery.

Under general anaesthetic, a small instrument is placed through the vagina to move the womb, and a cut below the belly button allows the camera in, with two or three more cuts for instruments according to the Gloucestershire leaflet. Visible disease is excised or treated, cysts on the ovary are removed, and adhesions are freed.

In deep disease the surgery is longer and may involve shaving a nodule off the bowel, removing a segment or repairing the bladder. The Leeds leaflet says most people go home within 24 hours; the Gloucestershire leaflet describes same-day discharge for standard cases.

The Gloucestershire leaflet quotes 1 to 4 per 1,000 for injury when the instruments are inserted, rising with severity. For deep disease, the Leeds leaflet gives an overall complication rate of 6.8%, or about 7 in 100 operations, with bladder injury at 0.4%, ureter injury at 0.5% and bowel injury at 0.6%, plus conversion to open surgery at 1%. Other risks include bleeding, infection, adhesions, nerve damage and, if the bowel is operated on, a temporary stoma.

The Leeds leaflet reports average quality-of-life scores improving from 55 to 80 out of 100 and bowel and sex pain falling from about 6 to 1 out of 10 in people treated. Against that, the Gloucestershire leaflet states that about 50 out of 100 patients will see symptoms or disease return. Both can be true, because outcomes depend on the extent of disease.

After standard keyhole surgery, pain and shoulder discomfort settle within one to two days in the Gloucestershire leaflet, and stitches are removed around day five if not dissolvable. After deep disease surgery the Leeds leaflet describes return to normal activity within two to four weeks and hormonal therapy for six to twelve months afterwards to reduce recurrence.

Driving depends on being able to control the car and stop in an emergency; the DVLA must be told if you are still unable to drive three months after an operation, according to GOV.UK.

• Fever, increasing pain or vomiting: contact the ward, your GP or NHS 111 promptly.

• Very heavy bleeding, wound discharge or redness.

• After bowel surgery: tummy swelling, being unable to pass wind, or a stoma that changes colour.

• A swollen calf, chest pain or breathlessness: call 999 if severe.

• Is my disease superficial or deep, and what scans support that?

• Will a bowel or bladder surgeon be involved, and is a stoma possible?

• What hormone treatment will I need afterwards?

• How will we judge success, and what if symptoms return?

• What do you advise if I want to conceive?

Deep disease is usually referred to specialist endometriosis centres within the NHS because of the multidisciplinary team required. Private care may offer an earlier date for simpler disease; for complex surgery the more important question is whether the whole team and an intensive care back-up are available, whichever route you choose.