The surgical approach to a patient with endometriosis currently leans strongly toward "minimally invasive procedures." In the hands of an experienced laparoscopic surgeon, virtually any endometriosis associated problem that can be treated by laparotomy can now be dealt with via laparoscopy. The performance of more conservative procedures primarily via the laparoscope has benefited women in many ways. The difference in the approach includes:

(1) laparotomy

1. opening the abdomen to perform the surgery directly through a large open incision
2. cosmetically considered "disfiguring" to many younger women
3. requires a stay (usually several days) in the hospital
4. postoperative recovery may be several weeks with significant time out from work
   

(2) laparoscopy

1. minimally invasive same day surgical approach
2. a telescope is entered through an incision about 1 cm long near the umbilicus and one to three smaller incisions are also usually made in the lower abdomen for the entry of additional instruments
3. postoperative recovery usually only a few days with little time out from work.

There are several surgical tools designed to remove (ablate) tissue, each with their own set of operating characteristics. The surgical tools that remove, destroy or incise tissue include

(1) scalpels and scissors,

• a variety of blade sizes and shapes as well as scissor sizes and shapes are available.

• the knife is ideal for cutting the skin, with research documenting greater tensile strength and faster healing in skin cut with a knife as compared to the carbon dioxide laser, harmonic scalpel or electrosurgical devices.

• scissors are ideal instruments for dissection of tissue and can also be used effectively to cut tissues ranging from tough to filmy. These instruments can be used to remove tissue on which endometriosis has grown. Excised tissue will include some normal tissue and any bleeding created needs to be controlled. This has limited the use of these instruments in the routine treatment of endometriosis.
  

(2) electrosurgical devices,

• these can be adjusted to provide different amounts of power (20 to 80 watts is usually used) with different blends of cutting and coagulation.

• a wide range of effects is possible. Pure cutting current has little char (which acts to coagulate). Fulgaration produces a superficial layer of char by holding the electrode a small distance from the tissue and allowing the current to spark. Lateral thermal damage with these instruments due to heating of surrounding tissue limits their use in the ablation of endometriosis, especially when close to other vital structures.
  

(3) thermocoagulation devices,

• these differ from electrocoagulation devices in that they do not deliver high frequency electrical current to generate heat in the tissues.

• these devices deliver heat directly via a hot metal tip that is applied to tissue.

• these devices are adjusted to deliver heat at up to 160 degrees centigrade, and tissue generally turns white when desiccation causes coagulation.

• of course it is necessary to avoid inadvertently touching tissues other than those desired while using this tool and during its cool down period.

• this is an ideal coagulating device but extensive lateral thermal damage has limited its use in the treatment of endometriotic lesions that are close to other vital structures.
  

(4) lasers,

• these devices can deliver fine beams of intense energy to tissue with the power density (watts per square centimeter) at the tissue site determining the effect (vaporization, excision, coagulation).

• there are different laser systems. These include fiber delivery via KTP-532 or Nd:YAG lasers where the energy released from the tip of the fiber diverges to dissipate the energy (highest closest to the tip of the laser fiber). The carbon dioxide (CO2) laser focuses the laser energy with a series of mirrors into differing size spots that help to determine the power density at the tissue.

• the CO2 lasers can deliver power in different wave forms that determine the power density achieved and amount of lateral thermal damage. The most common laser in use for most fertility work during laparoscopy is the CO2 laser and the optimal wave form for fertility work is the ultrapulse wave.
  

(5) the harmonic scalpel, and

• this is a device that incorporates a tip that vibrates at an ultrasonic frequency to rapidly denature proteins and separate tissue with little generated heat.

• conceptually, this is a great tool for ablation of endometriosis and lysis of adhesions.

• experience with the harmonic scalpel has not yet led to widespread acceptance of this tool. Additionally, the results seen on second look laparoscopy several weeks following its use have had mixed findings.
  

(6) the cavitron ultrasonic surgical aspirator (CUSA),

• this is widely used for tumor debulking by gynecologic oncologists. It has a vibrating tip that reacts to an alternating electromagnetic field (alternates 23,000 times per second) and produces significant heat such that cooling is provided by saline liquid solution sprayed over the tip at a rate of 3-10 ml per minute. This is not commonly used for treatment of endometriosis.
  

The decision on whether to proceed with endometriosis surgery includes the following considerations:

1. * reportedly there is a good cumulative long term pregnancy rate with untreated stage I and stage II endometriosis, up to 90% in 5 years (compared to a normal fertility rate of 90% in 1 year);
   
2. * in patients with endometriosis, COH (controlled ovarian hyperstimulation) and IUIs (intrauterine inseminations) appear to improve the fecundity (rate of pregnancy per cycle) but does not clearly improve the overall cumulative pregnancy rates (which are high if viewed over 5 years).
   
3. * endometriosis that causes mechanical interference preventing or limiting the egg and sperm from meeting can be effectively treated surgically. Medical management of endometriosis does not effectively treat anatomic distortions and adhesions;
   
4. * when endometriosis must be removed from the ovary, even when deeply invading or causing nonfunctional cysts (called endometriomas), a goal should be to preserve as much ovary as possible since as little as 10% of one ovary may allow fertility
   
5. * hormonal (medical) management of endometriosis has no proven value in terms of fertility yet can effectively treat some patients with pain due to endometriosis
   
6. * endometriosis tends to recur (return) since the cause (such as retrograde menstruation, vascular or lymphatic dissemination or metaplasia of the coelomic epithelium) of the endometriosis can not be treated. The recurrence rate of endometriosis is unpredictable, but is generally reported in the range of 5-20% per year with a cumulative rate over 5 years of about 40%.
   
7. * progressive severe dysmenorrhea (pain during the menses) is typically associated with deep lesions of endometriosis that are often not adequately treated with medication alone
   
8. * many patients with infertility and endometriosis have absolutely no dysmenorrhea (possibly due to a reduction in nerve endings that register painful stimuli in the peritoneum of the pelvis), incorrectly feel that the lack of pelvic discomfort means that they do not have significant endometriosis, and continue with their fertility efforts without treatment
   
9. * a couple that has not achieved a pregnancy after 2 years of appropriate management following surgical treatment for endometriosis has a poor prognosis in term of fertility
   
10. * the most effective long term treatment of endometriosis is removal of the uterus and the ovaries, an undesirable (or unacceptable) option for women interested in reproduction.
    
11. * if a patient has decided to undergo radical endometriosis surgery (removal of the uterus and some ovarian tissue) and is younger than 40-45 years of age, leaving an "uninvolved ovary" in place appears to increase the risk for recurrence of endometriosis only slightly. The remaining ovary would then be able to supply the patient with hormones that are beneficial to her until menopause.
    
12. * atypical endometriosis has a varied appearance that takes experience to recognize, may be quite active in response to the sex steroid hormones, and should be removed if the decision to treat stage I or II endometriosis surgically has been made. In fact, there is a high rate of endometriosis identified on pathology report in biopsies of normal appearing peritoneum both in women with endometriosis documented elsewhere (up to 40%) and in infertile women without any visible endometriosis (up to 15%).
    
13. * when endometriosis is incidentally found in a young woman who is not immediately interested in fertility, placement on birth control pills may be considered if early stage disease (to reduce the progression of the disease) or ovulation suppressing medications if more advanced disease (to reduce the bulk of disease).