I have been asked to explain the differences between excisions of endometriosis vs. ablation of endometriosis for the treatment of this complicated disease.
Excision of endometriosis was first written about by Dr. Redwine of Bend, Oregon about 15 years ago. I started treating endometriosis by excision shortly thereafter based on his publications. Excision is based on the fact that large lesions of endo are deep and extensive and need to be excised, i.e. physically cut out to get the entire lesion and not leave disease behind. The excision may be done with various tools such as a scissors, a knife, the laser used as a knife, or electric excision. The tool is not what is important; the excision is. With excision, you know you are getting the entire lesion.
Ablation is burning away the disease with cautery or laser starting from the surface of the lesion. This works well with very small lesions. However, with large lesions it is difficult to get deep enough or wide enough to destroy the entire area of disease. Large lesions may go several millimeters beneath the surface and leaving part of the lesion behind is a common cause for surgery that does not work (along with inadequate suppression post-op). Many patients have a variety of lesions with excision being done on the large lesions and ablation being done on the tiny ones.
With very severe disease, two other types of excision are important. One is the excision of deep retroperitoneal nodules and the other is excision of endometriosis of the bowel. The deep retroperitoneal nodules are often above the corners of the vagina or in the back of the cervix and uterosacral ligaments. In some cases, these lesions are so extensive that they cannot be removed completely with the laparoscope and need an open laparotomy to completely remove all of the disease. These deep nodules often look like normal tissue but feel very abnormal. It helps greatly to palpate these areas with your hand to be sure you are not missing anything. Endo infiltrating the bowel wall and scarring the Cul-de-sac closed also needs a laparotomy and often a partial bowel resection at the same time.
A word of caution for those considering a hysterectomy: Do not do a supracervical hysterectomy. Leaving the cervix behind usually means leaving the disease behind. Commonly you will need another operation to remove the cervix because of ongoing pain. I hope this explanation is helpful to those of you in the midst of this very difficult disease.
Charles A. Haislet, M.D.
Diamond Women’s Center