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Minerva Obstetrics and Gynecology 2021 May 12

DOI: 10.23736/S2724-606X.21.04864-8


language: English

Surgical management of endometriosis-associated pain

Philippe R. KONINCKX 1, 2 , Anastasia USSIA 3, 4, Maria G. PORPORA 5, Mario MALZONI 6, Leila ADAMYAN 7, 8, Arnaud WATTIEZ 1, 9

1 Latifa Hospital, Dubai, Unated Arab Emirates; 2 Obstetrics and Gynecology, KULeuven, Leuven, Belgium; 3 Università Cattolica del Sacro Cuore, Rome, Italy; 4 Gruppo Italo Belga, Villa Del Rosario, Rome, Italy; 5 Department of Maternal and Child Health and Urology, Sapienza University of Rome, Rome, Italy; 6 Endoscopica Malzoni, Center for Advanced Pelvic Surgery, Avellino, Italy; 7 Department of Operative Gynecology, FSBI National Medical Research Center For Obstetrics, Gynecology And Perinatology Named After Academician V.I.Kulakov, Ministry of Healthcare of The Russian Federation, Moscow, Russia; 8 Department of Reproductive Medicine and Surgery, Moscow State University of Medicine and Dentistry, Moscow, Russia; 9 Department of Obstetrics and Gynaecology, University of Strasbourg, Strasbourg, France


Endometriosis and pelvic pain are associated. However, only half of the subtle and typical, and not all cystic and deep lesions are painful. The mechanism of the pain is explained by cyclical trauma and repair, an inflammatory reaction, activation of nociceptors up to 2.7 cm distance, painful adhesions and neural infiltration. The relationship between the severity of lesions and pain is variable. Diagnosis of the many causes requires laparoscopy and expertise. Imaging cannot exclude endometriosis. Surgical removal is the treatment of choice. Medical therapy without a diagnosis risks missing pathology and chronification of pain if not 100% effective. Indications and techniques of surgery are described as expert opinion since randomised controlled trials were not performed for ethical reasons, since not suited for multimorbidity while a control group is poorly accepted. Subtle endometriosis needs destruction since some cause pain or progress to more severe disease. Typical lesions need excision or vaporisation since depth can be misjudged by inspection. Painful cystic ovarian endometriosis needs adhesiolysis and either destruction of the lining or excision of the cyst wall, taking care to avoid ovarian damage. Cysts larger than 6cm need a 2 step technique or an ovariectomy. Excision of deep endometriosis is difficult and complication prone surgery involving bladder, ureter, and bowel surgery varying from excision and suturing, disc excision with a circular stapler and resection anastomosis. Completeness of excision, prevention of postoperative adhesions and recurrences of endometriosis, and the indication to explore large somatic nerves will be discussed.

KEY WORDS: Endometriosis; Surgery; Deep endometriosis; Cystic ovarian endometriosis; EBM

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