Diffuse adenomyosis typically involves the myometrium with digitations and irregularly shaped lesions with unclear borders. Consequently, complete excision of adenomyotic tissue is not technically possible and in most instances there will be some loss of healthy myometrium. Excision of diffuse adenomyosis is best performed via laparotomy because digital palpation of the uterus is fundamental to the identification of affected areas. This allows selective and piecemeal removal of lesions whilst sparing unaffected myometrium. A few surgical techniques have been described which differ mainly in the type of uterine incision used and in the approach used for uterine reconstruction. Most cases can be done through a transverse laparotomy. A tourniquet placed to compress the uterine arteries reduces blood loss. Adenomyosis lesions can be exposed by bisecting the uterus longitudinally in the midline from the fundus to the endometrial cavity. The index finger is introduced into the endometrial cavity to protect and guide the excision of the lesion [51]. But whilst some authors reported routinely opening the uterine cavity [52, 53], others count breach of the endometrium as a surgical complication [54]. Adenomyotic tissue is resected with the aid of digital palpation. Preservation of at least 1–1.5 cm of myometrial thickness is needed for uterine reconstruction. The endometrial cavity is then closed with interrupted sutures and the myometrium is re-approximated. Reconstruction following extensive ademyomectomy can be particularly challenging. Multiple layers of interrupted sutures are always required for a good repair and particular attention should be paid to avoid intramural dead spaces which can lead to a weak scar with implications on future pregnancies.

Modification of dysmenorrhea and menorrhagia was evaluated in six studies involving 296 women who underwent excision of diffuse adenomyosis [15, 52–56]. Overall, dysmenorrhea and menorrhagia were reduced in 46 % and 69 % of cases respectively with a mean improvement of 60 %. Symptoms relapsed in 5 % of cases after a mean follow-up of 22 months (Table 12.3). Fertility outcomes were reported in seven studies [15, 43, 44, 52–55] involving 219 women wishing to conceive after excision of diffuse adenomyosis. The conception and live birth rates were 36 % and 28 % respectively over a mean follow up of 25 month (Table 12.4).