As I have been discussing for the past several weeks, endometriosis is a very common condition – affecting anywhere from 25-45% of all women of reproductive age and up to 65% of infertile women. It is well known that endometriosis can cause infertility, as well as many other symptoms, such as chronic pelvic pain, pain with intercourse, and pain with periods.

In last week’s blog, I wrote about the tests that are available to diagnosis endometriosis. Although there is no accurate blood test to use when making the diagnosis, many radiologic studies, especially ultrasound, can be useful. This week I want to write about the only reliable way to definitively diagnose endometriosis, which is for the physician to actually see it, and preferably to biopsy it.

The most commonly employed technique used to find endometriosis is laparoscopy. This outpatient surgical procedure involves the passage of a small surgical telescope through the patient’s belly button and into her abdomen. The procedure is performed in an operating room under general anesthesia, and it generally takes anywhere from 30 minutes to 2 hours to perform. Once the patient is asleep, a 10 mm (less than ½ inch) incision is made in the belly button itself. Although you may be a little squeamish about anything touching your belly button, there are actually several good reasons for the incision to be made here. First of all, this is the easiest place on your abdomen to hide a scar. Most importantly, however, it is one of the safest sites on your abdominal wall through which we can insert the telescope. The likelihood of injuring any of the abdominal or pelvic organs is far lower when the belly button is used for access.

After making this small incision, a needle is passed into the abdomen. Carbon dioxide gas is then gently passed through the needle in order to inflate the abdominal wall away from the organs underneath and create a gas-filled space in which the scope can be safely placed. The telescope is then introduced into the abdomen with a camera attached to the lens. This camera is hooked up to a large TV monitor so that everyone in the operating room can see exactly what the surgeon is seeing. The surgeon then carefully examines all visible abdominal organs, including the liver, the gallbladder, the appendix, the diaphragm, and the intestine for any signs of abnormality. Once this examination has been completed, the operating table is tilted so that the patient’s head is lower than her feet. By doing this, gravity pulls the intestine out of the pelvis, making it easier for the surgeon to see and evaluate all of the pelvic organs.

One or two 5mm incisions are then made just below the top of the pubic hair line (again to eventually hide the scars). These incisions are for the insertion of additional instruments that the surgeon needs to move the pelvic organs around, find, and eventually treat endometriosis, scar tissue, or other abnormalities. Endometriosis has a variety of different appearances and the actual implants can be many different colors – from clear to red, white, blue, or black. There is a lot of controversy as to what the different colors mean. Some studies suggest that red lesions are the most aggressive, while blue or black lesions are older. Other studies suggest that it may not be quite this simple. Regardless, once the surgeon confirms the presence of endometriosis, the next step is to treat it.

There are two basic techniques used to surgically treat endometriosis: destruction or removal. Most surgeons choose to destroy the lesions, using a variety of different types of energy – such as light (laser), electricity (cautery), or sound (harmonic scalpel). Regardless of the method chosen, the basic purpose of the energy is to super-heat the endometriosis cells to the point that the material inside the cell is destroyed, killing the lesion. The same types of energy can be used to actually cut the lesions out. While it may make more sense to actually remove the lesions, the concern is that this removal may create more scar tissue (adhesions) than actually destroying the lesions. There are many scientific studies that have looked at this issue, but there is not yet any definitive conclusion as to which method is best.

The two main purposes of endometriosis surgery are to make a definitive diagnosis and, most importantly, to get rid of all of the lesions. This is often not the end of the story, however. Next week we will discuss what to do after surgery.