Perspective in endometriosis—the challenge of conservative surgery

Abstract

EditorialOne of the challenges of endometriosis is the prompt andaccurate diagnosis of the disease, which is of great impor-tance in order to avoid long delay before possible surgicalmanagement.Endometriosis is a progressive disease [1] that does notregress spontaneously and tends to aggravate with time,suggesting early surgical intervention. The appropriate timeto operate is proposed when the symptoms interfere withthe patient’s quality of life.The different symptomatology of pelvic pain has beencorrelated with the anatomical location of deep infiltratedendometriosis [2]. Under experienced hands gynaecologicalexamination can detect severe endometriosis particularly onthe posterior vaginal wall and uterosacral ligaments. It wassuggested [3] that symptom profile questionnaires associat-ed with or without clinical examination may be useful tosuspect endometriosis but need appraisal and validation.New advances in endometriosis physiology demonstratethat endometriotic cells present similarities with tumourcells concerning tissue invasion, infiltration and angiogen-esis. It is crucial to perform a preoperative locoregionalevaluation of the extent of the disease in order to decide ona possible conservative or radical surgical approach.Complementary examination should be systematic includ-ing imaging techniques in order to assess a possiblemultidisciplinary approach. The conservative surgical ap-proach is defined as removal of all endometriotic lesionspreserving normal anatomy and it is possible in cases ofendometriosis-related infertility or pelvic pain (either cyclicor chronic). Different instruments and types of energy areused to excise or ablate endometriotic lesions. Well-designed randomized controlled clinical trials comparingtissue damage, intra-operative risks and depth of localdestruction have not been well elucidated. The choice of atechnique is therefore operator dependent based on patientsafety, hospital cost, availability and the surgeon’s experi-ence. Scoring systems have been used in the past duringdiagnostic laparoscopies; however, it is known that they donot quantify the severity of the patient’s symptoms. Aconsensus about a uniform scoring system for surgery isnecessary in order to assess the method and technique used,the location of a possible recurrence and adhesion forma-tion. The modern advances of medical illustrations can addup to this future evaluation and should be readily availablein all laparoscopic surgical procedures and particularlywhen patients are referred to tertiary centres.The conservative approach has not been clearly evalu-ated concerning the overall patient morbidity and quality oflife in the long term in comparison with radical surgery.Intraoperative and postoperative complications are notalways less severe with conservative surgery. It is abso-lutely important that during the first operative laparoscopy