This lecture reviews the surgical treatment of endometriosis from an evidence-based perspective focusing on outcomes such as pain and infertility in order to provide practical guidelines and recommendations.
The main endometriotic symptoms are pelvic pain (dysmenorrhea and dyspareunia) and infertility. Randomized controlled trials provide evidence that it is better to perform laparoscopy in patients with pain as compared to a wait and see approach. Regarding fertility, laparoscopic ablation or resection of lesions in minimal and mild endometriosis is significantly better than diagnostic laparoscopy alone. Laparoscopic uterosacral nerve ablation (LUNA) is not effective for relief of pain symptoms, but presacral neurectomy might be useful. In contrast, conservative surgery for rectovaginal septum endometriosis is beneficial for pain improvement, quality of life and sexual life, but do not improve fertility. Regarding radical surgery and bowel resection in endometriosis, there is a clear benefit in terms of pain improvement, but not on fertility. Regarding endometrial cyst treatment, excision is better than drainage in terms of risk of relapse, and the use of anti-adhesion barriers (Interceed®) have demonstrated a decreased risk of adhesion formation after endometriosis surgery.
Keys for surgical treatment of endometriosis should be identification of the disease, restoration of normal anatomy, excision of endometriosis, and finally reconstruction.