For doctors: endometriosis surgery, from mapping to safe planes and referral

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Who this article is for

This article is intended for medical professionals and is shared colleague to colleague. It sets out how Dr Mayur Pai approaches endometriosis surgically, with a few practical pearls. It is not personal medical advice, and it is not a substitute for your own clinical judgement in your own operating theatre, or for your local protocols. If you are a patient, our plain-language guide to endometriosis symptoms and treatment will be more useful.

Map before you plan

Endometriosis is a mapping disease, and every good operation begins before the incision. A typical scenario (a composite, not a real patient) is a woman with cyclical pain, dyschezia, deep dyspareunia and perhaps subfertility, whose imaging shows more disease than her symptoms first suggested.

So map before you plan. A careful history, a focused examination including the posterior fornix, and dedicated imaging, whether expert transvaginal ultrasound or MRI, tell you where the disease is likely to sit. You want to know about:

• the ovaries, including any endometriomas;
• the uterosacral ligaments;
• the pouch of Douglas;
• any suggestion of bowel or ureteric involvement.

Staging systems have their place for documentation and audit, but for the surgeon what matters most is an anatomical map of exactly what you expect to meet. That map also tells you, before the day, whether colorectal or urology colleagues need to be part of the plan. Imaging may show coexisting adenomyosis as well, which is worth knowing when you counsel the patient.

A systematic survey at laparoscopy

Start with a systematic survey before you touch anything. Inspect the peritoneum, the ovarian fossae, the tubes and the appendix, look at the diaphragm where relevant, and run the bowel. Superficial disease can look deceptively minor, so look for the puckering and fibrosis that betray deeper lesions underneath. Recording what you find, with images where possible, gives you the documentation you need whether you proceed or refer.

Excision or ablation?

This is the question asked most often. Dr Pai's preference, particularly for deep disease, is excision, and the rationale is straightforward: endometriosis is frequently deeper than its surface appearance.

• Ablation treats what you can see.
• Excision removes the lesion in full thickness and gives you tissue for histology, which confirms the diagnosis and occasionally reveals something you did not expect.

For very superficial peritoneal disease in a carefully selected case, ablation may be reasonable. Where the disease is infiltrative, excise.

The heart of the operation: the plane

Endometriosis creates a pseudo-anatomy. Fibrosis tents structures out of position, obliterates the pouch of Douglas, and pulls the ureter and bowel medially, closer to danger than you expect.

So do not chase the lesion. Step back into normal tissue, find a healthy plane, and work from known anatomy into the disease, not the other way round. Gentle traction and counter-traction open the plane for you, and the tissue tells you where it wants to separate. If you are tearing rather than developing, you are in the wrong plane.

The ureter and the bowel

Awareness of the ureter is non-negotiable. Before working on the pelvic sidewall or the uterosacral ligaments, identify the ureter. Where the disease is significant, open the retroperitoneum and trace the ureter along its course, keeping the dissection lateral to medial so that it is always accounted for.

For the bowel, respect the muscularis. Shaving disease off the rectum demands patience and a clear plane, and you must have an honest threshold at which this is no longer a solo procedure.

Restore anatomy, do not just remove spots

Restoring normal anatomy is the goal. When the pouch of Douglas is obliterated, the operation is not finished until the rectum has been mobilised off the posterior vagina and cervix and the anatomy is genuinely restored. Ovaries that are adherent in the fossa should be freed and, where you can, the pelvis reconstructed so that the tubes and ovaries can once again relate normally.

Fertility-sparing principles

For patients who hope to conceive, fertility-sparing principles run through everything:

• Handle the ovary as if it were the last one.
• Endometriomas: meticulous stripping, with attention to preserving healthy cortex.
• Energy: be deliberate and sparing near the ovary and its blood supply, to protect the ovarian reserve.
• Adhesions: minimise them with clean haemostasis, gentle tissue handling and thorough irrigation.

Every decision is weighed against the reproductive future you are trying to protect.

When should you refer to a specialist centre?

Perhaps most importantly, know your thresholds for referral. Stop, document and refer if you encounter:

• suspected deep infiltrating disease of the bowel, bladder or ureter;
• an obliterated pouch of Douglas;
• a likely need for a multidisciplinary team with colorectal or urology input;
• disease that is simply beyond your current volume and comfort.

There is no failure in referral. The failure is an incomplete or unsafe operation that leaves the patient worse off than a planned procedure in the right hands would have. Good endometriosis surgery is unhurried, anatomical, and honest about its limits.

About the author

This guide is by Dr Mayur Pai, MBBS, MS (Obstetrics & Gynaecology), a fertility and laparoscopy specialist. He practises at Pai Hospital in Vasco, Goa, and shares this article colleague to colleague. A companion CME article covers laparoscopic myomectomy.

Colleagues with questions, or who would like to discuss or refer a patient, can message us on WhatsApp at +91 77989 73345. Consultations are by appointment; to book one for a patient, call +91 77989 73345, or +91 95459 20817, or +91 75582 52088. This article is for education only and is not personal medical advice; please consult your doctor about your own situation.

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This page is for general education and is not personal medical advice. Treatment depends on your own examination and reports, so please speak to a doctor about your situation. We do not carry out or offer sex determination of any kind.