Endometriosis surgery: indications, technique and recovery
In brief
An operation for endometriosis (surgical removal of the lesions, usually by laparoscopy) is not automatic: it is considered when hormonal treatment fails or is not tolerated, in case of infertility, an endometriotic ovarian cyst, or bowel or urinary involvement. According to the French CNGOF-HAS guidelines (French College of Gynaecologists and Obstetricians and French National Authority for Health), laparoscopy is the recommended surgical approach, and a multidisciplinary team meeting is advised for complex or recurrent forms. A Cochrane review of 14 randomised trials shows that laparoscopic surgery probably increases the chances of an ongoing intrauterine pregnancy compared with diagnostic laparoscopy alone, whereas its effect on pain remains poorly measured in the trials.
When is an operation for endometriosis offered?
The decision is based on the patient's symptoms and plans, not only on how the lesions look on imaging. Endometriosis found by chance and without symptoms does not justify surgery.
The main situations in which surgery is considered are:
- pain that persists despite well-conducted hormonal treatment, or treatment that is poorly tolerated or contraindicated;
- a symptomatic endometrioma (endometriotic ovarian cyst); French guidelines state that surgery may be offered above 20 mm in a symptomatic patient;
- infertility, in certain situations discussed with the medically assisted reproduction team;
- involvement of an organ: narrowing of the rectum or colon, bladder involvement, compression of a ureter that may threaten the kidney;
- diagnostic doubt about an ovarian mass.
French guidelines do not advise routine preoperative hormonal treatment solely to make the operation easier or reduce complications.
Why a multidisciplinary team meeting?
When initial treatment has failed, the disease has come back or several organs are involved, the case is presented at a multidisciplinary team meeting (in France, RCP). It brings together gynaecologists, colorectal surgeons and urologists, radiologists, and specialists in pain and medically assisted reproduction.
This meeting makes it possible to:
- compare imaging (second-line ultrasound, MRI) with the clinical examination;
- choose between medical treatment, surgery and medically assisted reproduction;
- plan a combined operation when several organs are involved;
- discuss fertility preservation before ovarian surgery.
How is the operation carried out?
Laparoscopy in the vast majority of cases
Laparoscopy involves operating through small 5 to 10 mm incisions, under general anaesthesia, with a camera inserted through the navel. The abdomen is inflated with carbon dioxide to create a working space. Compared with conventional open surgery (laparotomy), it reduces postoperative pain and recovery time. For deep endometriosis involving the rectum, French guidelines state that the laparoscopic approach increases the chances of spontaneous pregnancy after surgery compared with laparotomy.
The operation lasts from less than an hour for superficial lesions to several hours for extensive deep endometriosis.
What the surgeon does depending on the lesions
| Type of lesion | Usual procedure | Points to note |
|---|---|---|
| Superficial peritoneal lesions | Excision (removal) or destruction with energy | Trials show no clear difference between excision and destruction on pain |
| Ovarian endometrioma | Cystectomy: removal of the cyst wall while preserving the ovary | Better pregnancy rate and fewer recurrences than destruction with bipolar current, but possible reduction in ovarian reserve |
| Nodule of the rectovaginal septum or ligaments | Excision of the nodule | Proximity of the pelvic nerves: nerve-sparing techniques |
| Involvement of the rectum or colon | Shaving, disc excision or segmental resection | Choice depending on the size and depth of involvement |
| Involvement of the bladder or ureter | Partial bladder resection, release or reimplantation of the ureter | In collaboration with a urologist |
Excision or destruction of the lesions?
Excision removes the lesion and allows it to be analysed under the microscope; destruction (ablation) burns it in place. For superficial lesions, the 2020 Cochrane review found insufficient evidence to choose between the two techniques on pain at 12 months. For endometriomas, however, French guidelines advise against destruction with bipolar current and favour cystectomy.
Bowel involvement
When endometriosis infiltrates the rectum, three procedures are possible: shaving of the wall, removal of a disc (disc excision) or removal of a segment of bowel with the two ends joined together (anastomosis). French guidelines state that segmental resection carries a greater risk of narrowing of the anastomosis than conservative procedures, but that for extensive involvement (more than 20 mm in length), conservative procedures do not improve bowel function after surgery. The choice is made case by case, with a colorectal surgeon.
What about hysterectomy?
Removal of the uterus, possibly together with the ovaries, is considered only in a patient who no longer plans a pregnancy, in case of persistent pain or associated adenomyosis. It does not guarantee a cure if endometriosis lesions remain in place.
What are the risks of the operation?
All surgery carries risks, which increase with the extent of the endometriosis and the number of organs involved. They are explained to you in consultation before the operation.
- Risks common to laparoscopy: bleeding, infection, phlebitis, injury to an organ when the instruments are inserted, temporary shoulder pain caused by the gas.
- Ovarian surgery: reduction of ovarian reserve, especially with bilateral cysts or repeat surgery. French guidelines call for fertility preservation to be discussed before surgery for an endometrioma.
- Deep endometriosis: urinary problems (difficulty emptying the bladder, sometimes temporary and requiring catheterisation), bowel problems.
- Bowel resection: fistula (abnormal connection, for example between rectum and vagina), breakdown of the anastomosis, narrowing. A temporary protective stoma may be offered in some cases.
The Cochrane review points out that adverse effects are poorly reported in randomised trials: complication figures come mainly from published surgical series and vary between centres.
What is recovery like after surgery?
In hospital
As a guide, the hospital stay is as follows: day surgery (going home the same day) for superficial lesions, 1 to 2 days for an endometrioma, up to 7 days when the bowel or urinary tract is involved. The operation is performed at the Hôpital privé Geoffroy Saint-Hilaire (Paris 5th), the Clinique de la Muette (Paris 16th) or the Clinique Ambroise Paré (Neuilly-sur-Seine).
Back home
- Pain: usually moderate, controlled with simple painkillers; shoulder pain caused by the gas may last 24 to 48 hours.
- Tiredness: common for one to several weeks, especially after extensive surgery.
- Activity: walking is encouraged from the next day; sport and heavy lifting are resumed gradually.
- Sexual intercourse: usually resumed after healing, with timing specified according to the procedure performed, particularly after surgery on the vagina or the rectovaginal septum.
- Sick leave: as a guide, 7 to 21 days after endometrioma surgery depending on your work; longer after surgery for deep endometriosis. The length is adjusted at your consultation.
A follow-up consultation is scheduled after the operation, with the operative report and the results of the analysis of the lesions. It generally takes place 4 to 6 weeks after the operation (sooner if needed).
What happens after surgery?
The operation does not remove the disease permanently. To limit the risk of recurrence, French guidelines suggest, when there are no immediate plans for pregnancy, hormonal treatment after the operation: the combined oestrogen-progestogen pill or the 52 mg levonorgestrel hormonal IUD as first-line options.
When a pregnancy is planned, the operation is often followed by a period of trying naturally or by medically assisted reproduction depending on age, ovarian reserve and the state of the fallopian tubes.
When should you seek urgent care?
After endometriosis surgery, contact the team promptly or call 15 (SAMU) or 112 in France, or your local emergency number, in case of:
- fever above 38.5 °C;
- abdominal pain that gets worse instead of better;
- swollen abdomen, vomiting, no passing of wind;
- foul-smelling vaginal discharge, passing of gas or stool through the vagina;
- inability to pass urine or constant urine leakage;
- painful, swollen calf, breathlessness.
Frequently asked questions
Does surgery cure endometriosis?
It removes the visible lesions and, according to French guidelines, reduces pain in mild to moderate disease, but the disease can recur, particularly without hormonal treatment after the operation. That is why the decision to operate is weighed against medical treatments.
Should you have surgery before trying for a baby?
Not necessarily. The strategy depends on age, ovarian reserve, pain and other infertility factors. It is detailed in the article "Endometriosis and fertility: surgery or IVF first?".
Can you be operated on more than once?
Yes, but each repeat operation, especially on the ovaries, increases the risks. A recurrence is therefore discussed at a multidisciplinary team meeting before any further surgery.
Will I have a bag (stoma)?
A temporary stoma is only considered in case of a higher-risk bowel resection, to protect the anastomosis while it heals. It is usually closed a few weeks later; this possibility is discussed before the operation.
How long will I be in hospital and off work after an operation for endometriosis?
As a guide, the hospital stay is generally 1 to 7 days depending on how extensive the disease is (sometimes day surgery for superficial lesions). Time off work is generally 1 to 3 weeks after surgery for an endometrioma and 2 to 6 weeks after surgery for deep endometriosis. These timeframes are tailored to your situation at the consultation.
When can I return to sport and sex, and try for a pregnancy?
Generally, sex and baths can be resumed after 3 to 4 weeks, without tampons during this time, and sport after the post-operative appointment, usually 4 to 6 weeks after the operation. When to try for a pregnancy is discussed at that appointment.
References
- Roman H, et al. [Strategies and surgical management of endometriosis: CNGOF-HAS Endometriosis Guidelines]. Gynecol Obstet Fertil Senol, 2018. doi:10.1016/j.gofs.2018.02.020 — PMID 29526793
- Collinet P, et al. Management of endometriosis: CNGOF/HAS clinical practice guidelines - Short version. J Gynecol Obstet Hum Reprod, 2018. doi:10.1016/j.jogoh.2018.06.003 — PMID 29920379
- Bafort C, et al. Laparoscopic surgery for endometriosis. Cochrane Database Syst Rev, 2020. doi:10.1002/14651858.CD011031.pub3 — PMID 33095458
Dr Olivier KadochObstetrician-gynaecologist and gynaecological surgeon in Paris (16th and 5th arrondissements). Former chef de clinique-assistant (senior registrar) at the Paris public hospitals (AP-HP); individually accredited by the French National Authority for Health (HAS). RPPS 10003957809. Background and practice locations
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