Aims and Methods

Characteristics. Endometriosis is one of the most common benign gynecologic diseases. It occurs in sexually mature women and is hormone-dependent (estrogens). The disease is often called a chameleon. This refers to the nonspecific symptoms, the varying degrees of severity, and the many locations of the disease. One of the most frequent symptoms is pain, for example, chronic diffuse pelvic pain, dysmenorrhea, dyspareunia, or pain on defecation. Other symptoms can be bleeding disorders, contact bleeding, bowel evacuation disorders, and infertility. The most frequent locations are the ovaries and the pelvic peritoneum (peritoneum in the pouch of Douglas, ovarian fossae, uterosacral ligaments). Endometriosis is a benign disease but can infiltrate and interfere with other organs. The bowel is affected most often. The rectum is often infiltrated by pronounced endometriosis low in the rectovaginal septum. The severity of endometriosis is classified according to the Revised American Society for Reproductive Medicine Classification of Endometriosis, 1996, or alternatively by the more recent ENZIAN classification, 2003, and the AAGL Classification of Endometriosis, 2013 (p. 66).

Treatment. The exact etiology of endometriosis is unknown. The hypothesis of retrograde menstruation and implantation contrasts with the theory of local metaplasia. For this reason, the reported reccurence rates of endometriosis range from 5%–20% within five years in menstruating women. The treatment of endometriosis depends on the symptoms, the patient′s age, the severity, the location, and the desire to preserve fertility. Opinions are divided on the usefulness of pre- or postoperative hormone treatment. Gestagens as well as gonadotropin-releasing hormone (GnRH) agonists are used for medical therapy in simple and more severe cases. The Cochrane review of these therapies suggests that the success in similar for these two medications. The aim of endometriosis surgery is to prolong the symptom-free period and, where necessary, restore fertility. Operative removal of the endometriotic lesions is regarded as the most effective treatment. In symptomatic endometriosis, all palpated and macroscopically visible endometriotic lesions should first be completely excised. Depending on the superficial and deep extent of the peritoneal endometriosis, this can be achieved by bipolar coagulation, laser, or monopolar scissors. Accompanying adhesions should be divided to restore the normal anatomy as far as possible. The treatment of symptomatic deep endometriosis consists of resection. Because of the usually marked fibrosis of these endometriotic lesions, the widespread involvement of neighboring organs, and the fusion of the original anatomic layers, these procedures are extremely complex and comparable to cancer surgery. When the rectum, sigmoid colon, bladder, or ureter is involved, an interdisciplinary procedure is reasonable, as complete re-section of the endometriosis is the primary aim in these cases. Technical advances in medicine and the increasing level of surgical training mean that minimally invasive operation techniques are becoming ever more important in endometriosis surgery, compared with the open abdominal approach.

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