Was My Endometriosis Surgery Unsuccessful?

The post-operative experience following endometriosis surgery can vary wildly from one person to the next. While laparoscopic excision surgery remains the most effective method of treatment for endometriosis, in some cases, the surgery may be unsuccessful and patients may experience the return of their symptoms within a year.

Causes of “unsuccessful” endometriosis surgery

A patient may characterize their endometriosis surgery as unsuccessful for a number of reasons, especially when there is no decrease in their pain level. However, there are a number of factors to consider when assessing post-op pain. Though the surgery itself may be a success for the surgeon (in that they have removed all visible abnormal tissue and restored pelvic anatomy to n optimal state), this is no guarantee that pain will disappear. No surgeon can guarantee this 100% as everyone responds differently to pain. Some causes of pain after endometriosis surgery include:

• “Surgical insult” where the organs swell as a normal inflammatory response to surgery. This should go away as the tissues heal with time.
• Local anesthesia, can relieve all pain during surgery, but gradually wear off three to five days post-op.
• The first post-op menstrual cycle can be very painful due to certain procedures performed during surgery. Typically during endometriosis surgery, your surgeon will dilate the cervix or entry to the uterus and clean out or biopsy the endometrial lining. Your surgeon will often perform a hysteroscopy inside the uterus with a small camera. This causes the lining to regenerate a new lining and the cervix to stay dilated for a short time after surgery. This can cause a heavier cycle, which may or may not be more painful than before. Your first period is also often heavier and longer than usual and may contain blood clots. Typically this resolves within a few cycles after surgery.

An unsuccessful or incomplete endometriosis surgery could be the cause of recurrent symptoms several months after surgery.

Pain as a result of unsuccessful or incomplete endometriosis surgery

There are two types of endometriosis surgery that a surgeon may use to remove endometrial lesions: ablation and excision. In ablation surgery, the endometrial lesions are destroyed with heat or a laser beam. In excision surgery, the lesions are removed by lifting and removing them in their entirety from the surrounding tissue. Excision surgery is more effective than ablation, but it requires more skill and is more time-consuming.

Surgeons may not always remove, or be able to remove, all lesions during surgery, which can continue to cause unrelenting pain following the operation.

This may be because:

• The endometriosis lesions were not adequately excised due to the surgeon’s lack of skill.
• The lesions were only superficially removed and not entirely excised.
• The surgeon intentionally left part of the lesion behind because the risks of complications following surgery outweighed the benefits. For instance, if the scar tissue involves the intestine/bowels and the patient does not want a bowel resection or the surgeon does not have the skills necessary for this type of removal, he or she may choose to leave behind the damaged bowel. This also applies to endometriotic lesions on the bladder, major blood vessels, and any other areas, which may result in major complications. 

Symptoms of unsuccessful endometriosis surgery

Endometriosis surgery can also be unsuccessful if complications—including bleeding, cysts, and fistula—arise after surgery.

Bleeding

Vaginal bleeding for up to two weeks following endometriosis surgery is normal. However, if you experience bleeding that lasts for over two weeks, or a heavier than normal period accompanied by fever, nausea, vomiting, or increasing pain, you should contact your doctor immediately.

Cysts

Cysts can appear following surgery, but it is difficult to determine whether they result from disease recurrence or progression. It is important to remember that cysts and follicles do develop every month as a part of normal healthy ovulation. Patients often experience a small and normal hemorrhagic follicle due to ovulation. Often they may go to fertility doctors who incorrectly tell them that their endometriomas have returned. We advise patients to return after two weeks and eight weeks to observe the normal ovulation and an ultrasound follow-up. Cysts typically resolve spontaneously in a few months. It is also an option to suppress ovulation following surgery in order to reduce the chances of recurrence and give the patient time to recover.

Fistulas

One of the most serious complications of endometriosis surgery is intestinal and urinary fistulas or an abnormal, tube-like connection that forms between two organs in the intestines and the urinary tract. It is important to remember this is not considered “unsuccessful” surgery. It is a complication that can occur whether or not the surgery is a success.

Factors affecting the success of endometriosis surgery

Three main factors determine the likelihood of endometriosis returning following surgery. These include:

• the severity of the disease at the time of surgery
• the completeness of endometriosis surgery
• the use of medical suppressive therapy following surgery

Severity of endometriosis at the time of surgery

The risk of endometriosis recurrence after surgery can be higher in patients with less severe disease (stage I or II) compared to those with advanced disease (stage III or IV).

Incomplete endometriosis surgery

If the surgeon has not removed every endometrial lesion during surgery, the symptoms of pain due to the disease are more likely to return following the operation. This is highly dependent on the skills of the operating surgeon.

Use of medical suppressive therapy

Research has shown that the use of hormonal suppressive therapy following endometriosis surgery may reduce, and prevent, the return of painful endometriosis symptoms.

Rate of recurrence of endometriosis following surgery

The rate of recurrence of endometriosis is thought to be between 20 and 40% within five years of conservative surgery.

Minimizing the risk of complications and avoiding endometriosis recurrence

A skilled surgeon

A skilled surgeon is crucial in minimizing unsuccessful endometriosis surgery. Most gynecologists do not receive adequate training in endometriosis. Therefore, they may not be qualified or experienced enough to manage the disease and operate on multiple organs.

The right type of surgery

Choosing the right type of surgery is key to the success of endometriosis treatment. Ablation is usually not as effective as excision surgery and can often leave carbon deposits on the surface of the peritoneum (the inner lining of the abdomen), which can cause further retraction of tissue and scarring, similar to a cigarette burn on the skin.

Using robotic surgery may also increase the risk of endometriosis recurrence because the surgeon cannot feel the lesion due to the lack of haptic feedback from the instruments. This can increase the likelihood of leaving behind lesions.

A multi-disciplinary approach

It is essential that a multi-disciplinary team comprised of a minimally invasive gynecologic surgeon, a colorectal surgeon, a urology surgeon, and any other surgical specialist that is necessary treats a patient with endometriosis. Many centers may also collaborate with dieticians and pelvic floor therapists or acupuncturists to complement care. It is therefore important for patients to be referred to a multidisciplinary center, like Seckin Endometriosis Center, with expertise in endometriosis surgery and care if possible.

Early intervention

Early intervention is also key to ensuring the success of endometriosis surgery and preventing the disease from returning. The sooner the disease is diagnosed, the sooner it can be correctly treated. Early diagnosis will aid patients in avoiding both the unnecessary use of other treatments and long, stressful periods of uncertainty.

Author
Tamer Seckin, MD
Date: July 13, 2020

Dr. Seckin is an endometriosis specialist and women’s reproductive health advocate. He has been in private practice for over 30 years at Lenox Hill Hospital with a team of highly skilled personnel.

Dr. Seckin specializes in advanced laparoscopic procedures and is recognized for his expertise in complex cases of deep infiltrating endometriosis of the pelvis. He is particularly dedicated to performing fertility-preserving surgeries on cases involving the ovaries.

He has developed patented surgical techniques, most notably the “Aqua Blue Excision” technique for a better visualization of endometriosis lesions. His surgical techniques are based on precision and microsurgery, emphasizing organ and fertility preservation, and adhesion and pain prevention.

Dr. Seckin is considered a pioneer and advocate in the field of endometriosis.