Pelvic pain can have a number of causes, one of the most common being endometriosis. Evidence of this disease may be seen on an ultrasound or suspected because of symptoms, but laparoscopy is the gold standard for its diagnosis and treatment.
What is this procedure actually like? SheKnows spoke with a number of women who have had endometriosis excised laparoscopically and Oregon-based Dr. Nicholas Fogelson, an obstetrician, gynecologist and surgeon who specializes in minimally invasive excision of endometriosis.
Your pre-op consultation is the opportunity to meet your consultant and ask questions: If endometriosis is found, will it be excised or ablated? (The women we spoke with reported that excision is more effective for long-term pain relief.) What impact will this procedure have on fertility? What complications could arise from this surgery?
“Anesthesia complications are extremely rare,” Fogelson said. “Any surgery in the abdomen has a risk of damage to internal structures. That said, these types of issues are very rare and, in most cases, can be easily repaired.”
According to Fogelson, your surgeon may advise you to stop taking certain medications weeks before surgery, including supplements and hormonal contraception.
Your pre-op is also the time to set expectations. “If we operate for endometriosis and excise all the disease, we can expect substantial improvement,” he said. “At the same time, some women have pain from non-endometriosis sources, and we can’t expect that to get better from endometriosis excision.”
Sue, 23, recommends using the days before surgery to buy your favorite snacks, handle medicine and absences from work and arrange for a family member or friend to look after you. Close to your procedure date, you will likely have a pre-assessment to review your general health.
Fasting and bowel prep
For many patients, the most dreaded aspect of surgery is bowel prep and fasting the day before. Bowel prep entails taking strong laxatives the day before your procedure. Some consultants just ask you to consume a low-fiber diet the day before and to fast for several hours before surgery.
“The bowel prep really wasn’t as bad as I expected it to be,” Sue said. “Just prepare for it with wet wipes and diaper rash cream — you’ll thank me. I was starving, though. I drank vegetable broth and clear juice the day before my surgery. You’ll be low on energy, so I recommend having some easy entertainment to hand.”
Your hospital visit
The time spent in the operating room can vary. Hazel and Sue’s surgeries lasted about an hour. “I was under for 6 hours for my excision,” says Heather, 48, who has had over 20 surgeries for endometriosis.
Nausea is normal upon waking from anesthesia, though it can be prevented. “Before falling asleep, I told my anesthetist that I was highly sensitive to pain and prone to nausea, and he said he would give me medication prevent that, which worked," says Sue.
Tiredness and cloudy thinking are common because of anesthesia combined with pain relief. You may also feel bloated and have some shoulder pain. "Appetite is a little low for a while,” says Fogelson, “and some patients may be constipated for a week or so. In very advanced endometriosis cases, there may be a need for bowel or urinary diversion into an ostomy bag, but this is very rare.”
Hazel woke up with a drainage tube, which she remembers as being more painful than the operative pain, and a catheter to help her urinate.
“Waking up, I felt an immediate difference in pain,” says Heather. “I knew for the first time what operative pain was, and I was missing that chronic endometriosis pain that I had suffered from for so long.”
How long will I stay in the hospital?
Laparoscopies typically allow for quicker recovery than traditional open surgery. They can be offered as an outpatient procedure, or patients may need to stay in the hospital for one to five nights, depending on the severity. “Most of the recovery happens within a few weeks,” says Fogelson. “It can take longer for complex surgery for advanced disease, but in my practice, most people are back to their normal activities in two weeks.”
Amanda, 29, went home the same day as her procedure. Hazel was discharged after a night in the hospital. Heather flew home six days after surgery. “It was brutal navigating the airport and the plane,” she says, “but the airline was very cooperative with patient assistance.”
The time it takes to feel well again after surgery varies. “Patients should follow their surgeons’ advice,” says Fogelson, who generally advises an early return to activity. “On the other hand, some patients set themselves back by jumping into vigorous activity too quickly.”
“I was bedridden for about two days,” says Amanda, “My partner stayed off work and my parents had our children for about four days. It hurt to bend or get up and down. It was uncomfortable sleeping, and I had to sleep upright in bed.” Hazel also relied on her partner for the first few days after surgery.
Your consultant may discuss his or her suspicions about a prognosis with you post-surgery, though nothing is usually confirmed until a pathologist looks at a biopsy. The time this takes varies, depending on the clinic.
“Most women who have symptoms of endometriosis do have endometriosis,” says Fogelson. “At the same time, sometimes women have laparoscopies with surgeons who don’t have much experience with endometriosis and don’t find it, when actually it is there on a repeat laparoscopy with a more experienced surgeon.”
Nothing was found during Sue’s first laparoscopy. “This was obviously disheartening, to go through all that and to get no diagnosis. Then I went to see a more skilled excision surgeon who found endometriosis on my left ovary, on my pouch of Douglas and peritoneum. My consultant told me he suspected this the day after surgery, though it wasn’t confirmed until I received the pathology report — six weeks later!”
How long will it take to see results?
Every patient is different. While many women who have endometriosis excised notice improvements to their quality of life, some might still experience pain. Others may still experience difficulty conceiving. This can be caused by adhesions or by another condition such as adenomyosis, in Hazel’s case. It can also indicate that some endometriosis has been missed.
Symptoms such as tiredness can persist after endometriosis is excised. Of the women we spoke with, a few found that stubborn tiredness and pain could be managed through physiotherapy and diet adjustments.
Six months after surgery, Sue is noticing improvements — she no longer relies on pain relief. After her last surgery, Heather experienced a significant reduction in pain. She also got pregnant weeks later.
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