Editing Endometriosis (section)

===Surgery===
{{See also|Endometrioma#Surgery}}

Based on strong evidence, experts recommend that surgery be performed laparoscopically (through keyhole surgery) rather than open.<ref name="John2013">{{cite journal |vauthors=Johnson NP, Hummelshoj L |title=Consensus on current management of endometriosis |journal=Human Reproduction |volume=28 |issue=6 |pages=1552–68 |date=June 2013 |pmid=23528916 |doi=10.1093/humrep/det050 |doi-access=free |title-link=doi}}</ref> Treatment consists of the ablation or excision of the endometriosis, [[electrocoagulation]],<ref name="Vercellini Viganò Somigliana Fedele 2014 pp. 261–275"/> lysis of adhesions, resection of endometriomas, and restoration of normal pelvic anatomy as much as is possible.<ref name="John2013"/><ref name=speroff>{{cite book|vauthors=Speroff L, Glass RH, Kase NG |title=Clinical Gynecologic Endocrinology and Infertility |publisher=Lippincott Willimas Wilkins |edition=6th |page=1057 |isbn=0-683-30379-1 |year=1999}}</ref> When laparoscopic surgery is used, small instruments are inserted through the incisions to remove the endometriosis tissue and adhesions. Because the incisions are tiny, there will only be small scars on the skin after the procedure, and most individuals recover from surgery quickly and have a reduced risk of adhesions.<ref>{{cite web |title=Endometriosis and Infertility: Can Surgery Help? |year=2008 |publisher=American Society for Reproductive Medicine |url=http://www.asrm.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/endometriosis_infertility.pdf |access-date=31 October 2010 |url-status=live |archive-url=https://web.archive.org/web/20101011155943/http://www.asrm.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/endometriosis_infertility.pdf |archive-date=11 October 2010}}</ref> Many endometriosis specialists believe that excision is the ideal surgical method to treat endometriosis.<ref>{{cite web |title=UNC Center for Endometriosis |url=https://www.med.unc.edu/obgyn/migs/our-services/unc-center-for-endometriosis/ |access-date=14 July 2021 |website=UNC Department of Obstetrics & Gynecology |archive-date=14 July 2021 |archive-url=https://web.archive.org/web/20210714043254/https://www.med.unc.edu/obgyn/migs/our-services/unc-center-for-endometriosis/ |url-status=dead }}</ref> A 2017 literature review found that excision improved some outcomes over ablation.<ref>{{cite journal|pmid=28456617 |date=2017 |vauthors=Pundir J, Omanwa K, Kovoor E, Pundir V, Lancaster G, Barton-Smith P |title=Laparoscopic Excision Versus Ablation for Endometriosis-associated Pain: An Updated Systematic Review and Meta-analysis |journal=[[Journal of Minimally Invasive Gynecology]] |volume=24 |issue=5 |pages=747–756 |doi=10.1016/j.jmig.2017.04.008}}</ref> In the United States, some specialists trained in excision for endometriosis do not accept health insurance because insurance companies do not reimburse the higher costs of this procedure over ablation.<ref>{{cite news |vauthors=Muraskin A |title=Endometriosis, a painful and often overlooked disease, gets attention in a new film |publisher=[[NPR]] |date=16 July 2023 |url=https://www.npr.org/sections/health-shots/2023/07/16/1186533247/endometriosis-a-painful-and-often-overlooked-disease-gets-attention-in-a-new-fil |archive-date=17 July 2023 |access-date=17 July 2023 |archive-url=https://web.archive.org/web/20230717173453/https://www.npr.org/sections/health-shots/2023/07/16/1186533247/endometriosis-a-painful-and-often-overlooked-disease-gets-attention-in-a-new-fil |url-status=live }}</ref>

As for deep endometriosis, a [[segmental resection]] or shaving of nodules is effective but is associated with an increased rate of complications, of which about 4.6% are major.<ref name="Dunselman Vermeulen Becker Calhaz-Jorge 2014 pp. 400–412">{{cite journal | vauthors = Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D'Hooghe T, De Bie B, Heikinheimo O, Horne AW, Kiesel L, Nap A, Prentice A, Saridogan E, Soriano D, Nelen W | title = ESHRE guideline: management of women with endometriosis | journal = Human Reproduction | volume = 29 | issue = 3 | pages = 400–12 | date = March 2014 | pmid = 24435778 | doi = 10.1093/humrep/det457 | publisher = Oxford University Press (OUP) | doi-access = free | title-link = doi }}</ref>

Historically, a [[hysterectomy]] (removal of the uterus) was thought to be a cure for endometriosis in individuals who do not wish to conceive. Removal of the uterus may be beneficial as part of the treatment if the uterus itself is affected by adenomyosis. However, this should only be done in combination with the removal of the endometriosis by excision. If endometriosis is not also removed at the time of hysterectomy, pain may persist.<ref name="John2013"/> A study of hysterectomy patients found that those with endometriosis did not use less pain medication three years after the procedure.<ref>Brunes, M, Altman, D, Pålsson, M, Söderberg, MW, Ek, M. Impact of hysterectomy on analgesic, psychoactive and neuroactive drug use in women with endometriosis: nationwide cohort study. BJOG 2021; 128: 846– 855. [https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.16469] {{Webarchive|url=https://web.archive.org/web/20230717173454/https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.16469|date=17 July 2023}}</ref>

[[Presacral neurectomy]] may be performed where the nerves to the uterus are cut. However, this technique is not usually used due to the high incidence of associated complications, including presacral hematoma and irreversible problems with urination and constipation.<ref name="John2013"/>

====Recurrence====
The underlying process that causes endometriosis may not cease after a surgical or medical intervention. Even though surgery can improve symptoms, the resurgence of pain is common.<ref name=":9">{{Cite journal |date=2024-12-04 |title=Endometriosis, fibroids and heavy periods: long-term research supports treatment decisions |url=https://evidence.nihr.ac.uk/collection/endometriosis-fibroids-and-heavy-periods-long-term-research-supports-treatment-decisions/ |journal=NIHR Evidence |publisher=National Institute for Health and Care Research |doi=10.3310/nihrevidence_64953|doi-access=free }}</ref> A study has shown that dysmenorrhea recurs at a rate of 30 percent within a year following laparoscopic surgery. Resurgence of lesions tends to appear in the same location if the lesions were not completely removed during surgery. It has been shown that laser ablation resulted in higher and earlier recurrence rates when compared with endometrioma cystectomy, and recurrence after repetitive laparoscopy was similar to that after the first surgery. Endometriosis has a 10% recurrence rate after hysterectomy and bilateral salpingo-oophorectomy.<ref name=updateonrecur>{{cite journal | vauthors = Selçuk İ, Bozdağ G | title = Recurrence of endometriosis; risk factors, mechanisms and biomarkers; review of the literature| journal = J Turk Ger Gynecol Assoc| date = 2013 | volume = 14| issue = 2| pages = 98–103| doi = 10.5152/jtgga.2013.52385| pmid = 24592083 | pmc = 3881735}}</ref>

Endometriosis recurrence following conservative surgery is estimated as 21.5% at 2 years and 40–50% at 5 years.<ref>{{cite journal | vauthors = Guo SW | title = Recurrence of endometriosis and its control | journal = Human Reproduction Update | volume = 15 | issue = 4 | pages = 441–61 | year = 2009 | pmid = 19279046 | doi = 10.1093/humupd/dmp007 | doi-access = free | title-link = doi }}</ref>

The recurrence rate for DIE after surgery is less than 1%.<ref name="Koninckx Ussia Keckstein Adamyan 2018 pp. 360–365">{{cite journal | vauthors = Koninckx PR, Ussia A, Keckstein J, Adamyan LV, Zupi E, Wattiez A, Gomel V | title = Evidence-Based Medicine: Pandora's Box of Medical and Surgical Treatment of Endometriosis | journal = [[Journal of Minimally Invasive Gynecology]] | volume = 25 | issue = 3 | pages = 360–365 | year = 2018 | pmid = 29180308 | doi = 10.1016/j.jmig.2017.11.012 | publisher = Elsevier BV }}</ref>

====Risks and safety of pelvic surgery====
The risk of developing complications following surgery depends on the type of lesion that has undergone surgery.<ref name="Vercellini Viganò Somigliana Fedele 2014 pp. 261–275">{{cite journal | vauthors = Vercellini P, Viganò P, Somigliana E, Fedele L | title = Endometriosis: pathogenesis and treatment | journal = Nature Reviews. Endocrinology | volume = 10 | issue = 5 | pages = 261–75 | date = May 2014 | pmid = 24366116 | doi = 10.1038/nrendo.2013.255 | publisher = Springer Science and Business Media LLC | s2cid = 13050344 }}</ref> 55% to 100% of individuals develop adhesions following pelvic surgery,<ref name="LiakokosPAE">{{cite journal | vauthors = Liakakos T, Thomakos N, Fine PM, Dervenis C, Young RL | title = Peritoneal adhesions: etiology, pathophysiology, and clinical significance. Recent advances in prevention and management | journal = Digestive Surgery | volume = 18 | issue = 4 | pages = 260–73 | year = 2001 | pmid = 11528133 | doi = 10.1159/000050149 | s2cid = 30816909 }}</ref> which can result in infertility, chronic abdominal and pelvic pain, and difficult reoperative surgery. Trehan's temporary ovarian suspension, a technique in which the ovaries are suspended for a week after surgery, may be used to reduce the incidence of adhesions after endometriosis surgery.<ref>{{cite journal | vauthors = Trehan AK | title = Temporary ovarian suspension | journal = Gynaecological Endoscopy | volume = 11 | pages = 309–314 | year = 2002 | doi=10.1046/j.1365-2508.2002.00520.x | issue=1}}</ref><ref name="pmid11821616">{{cite journal | vauthors = Abuzeid MI, Ashraf M, Shamma FN | title = Temporary ovarian suspension at laparoscopy for prevention of adhesions | journal = The Journal of the American Association of Gynecologic Laparoscopists | volume = 9 | issue = 1 | pages = 98–102 | date = February 2002 | pmid = 11821616 | doi = 10.1016/S1074-3804(05)60114-4 }}</ref> Removal of cysts on the ovary without removing the ovary is a safe procedure.<ref name="Vercellini Viganò Somigliana Fedele 2014 pp. 261–275"/>