Laparoscopic excision of endometriosis | North Bristol NHS Trust

Who is this information for?

This information is for you if you are about to have, or are recovering from, laparoscopic excision of endometriosis. You might also find it useful to share this information with your family and friends.

Laparoscopic excision of endometriosis is a keyhole operation that is offered to you if you have had confirmation of endometriosis in a previous keyhole operation and have symptoms that are not responding to other non-surgical treatments.

Excision of endometriosis is an operation that allows us to cut out all the visible endometriotic tissue in your pelvis. This means that once it has been removed, the tissue does not grow back and this is why your symptoms should improve. Southmead Hospital is a BSGE accredited Endometriosis Centre and you may have been referred to us from other hospitals in the region.

We offer this surgery to people with different amounts and severity of endometriosis:

Mild/superficial endometriosis - this means you have a less severe form of endometriosis. If you are still getting symptoms despite treatment with hormones (pill or coil) then you may be a candidate for excision. If you still have symptoms after the excision, then it is likely that your symptoms are not caused by endometriosis alone. Your operation will last for about 1.5 hours.
Moderate endometriosis - this means you have more widespread endometriosis that is sitting deeper in the tissues. It is likely you are recording higher pain scores. Excision of endometriosis is a good option for you and we would expect your symptoms to improve post-operatively. Your operation will last about 1.5 - 2 hours.
Severe/deep endometriosis +/- involvement of uterus, bowel, bladder, rectum, ovaries and tubes -this is the most severe form of endometriosis. You are likely to have high pain scores and be finding it difficult to achieve symptom control with hormones and pain killers alone. Your surgery will take longer than cases of mild/moderate endometriosis. We often plan to operate with the help of a bowel or bladder surgeon if we know in advance your endometriosis is affecting these areas. Your operation will last for up to 4 hours (and in the most difficult cases, it may take even longer).
Endometriosis affecting the bowel - if you have severe endometriosis affecting your bowel, you will have been counselled before the operation about the potential risk of needing a section of bowel removed or a temporary stoma (where the bowel is plumbed through the skin into a discrete bag to let it heal). This will usually happen as a result of an investigation to look at your rectum and bowel called a colonoscopy, or an MRI scan. If we think you may require a stoma, even if it is a small chance, you will be offered an appointment to see one of the stoma nurses before your operation. We will often recommend you receive an oral bowel cleansing agent (‘bowel prep’) prior to admission to hospital for your surgery. It helps to empty the bowel and reduces the risk of infection if you require any surgery to your bowel during the excision of endometriosis. You will be provided with a separate leaflet all about the bowel prep.
Endometriosis affecting the bladder - if you have severe endometriosis affecting your bladder, you will have been counselled before the operation about the potential risk of needing a piece of bladder removed, called a partial cystectomy. The bladder is then closed with dissolvable stitches and you will need to have a urinary catheter for 2 weeks after the operation. You will be advised how to look after this at home and will be invited back to the ward for it to be removed. You will then require a follow up scan of your bladder in the main hospital. After a partial cystectomy, your overall bladder capacity will be reduced. This means you may not be able to hold as much urine before needing to void (empty your bladder) and may need to void more frequently.

We report that 60% of people have improvements in symptoms/pain scores after excision of endometriosis. This means that 6 out of 10 people that we operate on will have an improvement.

We do not burn/cauterise/laser the endometriosis away, apart from in some rare cases. This is because it does not effectively treat the disease and only offers temporary improvement in symptoms. It has no role in treatment of moderate or severe endometriosis. Excision of endometriosis is considered a Gold Standard, which means it is the best treatment on offer.

You will require a general anaesthetic for your excision surgery. The anaesthetist will discuss this with you on the day of your operation. Feeling or being sick after an anaesthetic is quite common in women. If this has happened to you after a previous operation, talk to your anaesthetist and they will explain what they can do to help limit these side effects for you.

What can I expect after a laparoscopic excision of endometriosis?

Usual length of stay in hospital

In most cases, you will be admitted to hospital on the day of your operation. You will usually require an overnight stay and be able to go home the next morning. If you have had a more difficult operation for severe endometriosis, you may need to stay in hospital for 1-5 nights.

After effects of general anaesthesia

Most modern anaesthetics are short lasting and well tolerated. You should not experience side effects for more than a day after your operation. During the first 24 hours you may find that you feel more sleepy than usual and your judgement may be impaired. You will need someone to collect you from hospital once you are discharged home.

Catheter

A catheter (tube) is put in your bladder during laparoscopic excision of endometriosis. This is to ensure your bladder does not overfill during the operation, and reduces the risk of bladder injury. In cases of mild/moderate endometriosis excision, the catheter will often be removed at the end of the operation and you will be able to pass urine normally afterwards. If the surgery is more extensive, the catheter has to stay in after the operation, and is usually removed the following morning. If you pass urine normally after it is removed it should not delay your discharge home. If you have had surgery to remove endometriosis from the bladder itself, it is likely you will need a catheter in for longer. This will be discussed with you on an individual basis.

Scars

You will usually have three or four small scars on your abdomen. One scar will be within the tummy button, one on the left side, one on the right side, and sometimes one in the middle at the top of your bikini line. Each scar is 0.5 - 1cm in length. Sometimes we have to extend one to manage the endometriosis. These scars are all much smaller than for ‘open’ non-laparoscopic operations. However, for all cases of excision of endometriosis, there is a very small chance of needing to convert the procedure from keyhole to open (laparotomy). This is routinely included on your consent form. This situation would only arise if we needed more access to your tummy, for example to perform surgery to your bowel or blood vessels in an emergency.

Stitches and dressings

The cuts on your abdomen will be closed with dissolvable stitches and will usually be protected by clear dressings after your operation. You will usually go home with the dressings in place and we would advise you remove them after 48 hours. This is best done during a bath or shower. We would expect the stitches to dissolve within 14 days. If any of the stitches do not dissolve, the practice nurse at your GP surgery will be able to remove them for you.

Vaginal bleeding

You may experience some light spotting after the operation. This is because of routine instrumentation of your uterus and cervix during the procedure. It will settle spontaneously. It should not affect the timing of your next period.

Pain and discomfort

You can expect to feel pain in your lower abdomen for a few days after your operation. The area around your scars may feel particularly sensitive. You may also have pain in your shoulder. This is a common side effect of laparoscopic surgery and will get better over the first 24-48 hours. Gentle mobilising can help.

When you are discharged home from hospital, you will be advised to take regular painkillers. We recommend you have a supply of Paracetamol and/or Ibuprofen at home as these are not supplied by the hospital pharmacy. You may also be advised to take a painkiller that contains codeine; this will be supplied as a prescription from the hospital for you. Please be aware that codeine can cause constipation when taken regularly.

Taking regular painkillers will enable you to feel more comfortable after your operation, get out of bed sooner, stand up straight and be able to walk around easier. This will all help speed up your recovery and reduce the risk of blood clots forming in your legs and lungs.

Starting to eat and drink

You are likely to have a drip in your arm to provide you with fluids after your operation. This will be removed once you are able to eat and drink again. In most cases, you will be offered some water in the theatre recovery area once you have woken up from your anaesthetic. You will be offered more water or a cup of tea when you are back on the ward. You will also be offered something light to eat if you feel hungry.

Washing and showering

You should be able to have a bath or shower the day after your operation. This can help to remove the sticky post-operative dressings over your scars. It is safe for the scars to get wet. We would recommend you gently pat them dry afterwards with a tissue or let them dry in the air. It is important to keep scars clean and dry to ensure they stay healthy and heal well. A nurse will check your scars before you are discharged home. Loose clothing/waistbands are advised for the first week or so after your operation.

Formation of blood clots - how to reduce the risk

Your risk of a blood clot is increased after an operation. Some common additional risks include smoking, being overweight, diabetes or having had a previous blood clot in your leg or lung. You will be offered some graduated compression stockings to wear during your stay in hospital. You will also be prescribed a daily injection of a blood thinning agent (called Clexane) while you are in hospital.

It is important that you continue to try and reduce your risk of blood clots once you go home, until you are back to normal mobility and levels of activity. We would recommend:

Staying as active as possible
Staying hydrated
Performing gentle exercises while you are sitting:
- move foot up and down as quickly as you can for 30sec on each side
- move foot in a circular motion for 30sec on each side
- bend and straighten one leg at a time three times, then repeat on the other side

What will help me recover?

Keep your bowels working

It is common to experience a short term change in your bowel habits after an operation. Constipation, and associated bloating, is the most common complaint. This can happen in women who have had a previously normal bowel habit. There are many reasons why it happens which include laparoscopic surgery, having been starved ahead of the operation, use of constipating pain killers post-operatively. The use of a strong laxative before the operation (in cases of severe endometriosis) may also have an impact. It is not the excision of endometriosis, or the endometriosis itself, that affects the bowel habit.

It is important to try and keep your bowels as regular as possible before your operation. If you already have a tendency for constipation, we would recommend starting some gentle laxatives (Movicol, Fybogel, Lactulose) from your pharmacy before your operation. Drinking plenty of water, eating fresh fruit/vegetables/fibre rich foods and keeping active also helps.

If you do struggle with opening your bowels, it can help to place a small footstool under your feet when you are sitting on the toilet. Leaning forwards and resting your arms on top of your legs can help to avoid straining.

A positive outlook

Your attitude towards your post-operative recovery is an important factor in determining both how your body heals and how you feel in yourself. We would encourage you to be positive about the long term benefits of your operation. It can also be useful to use the recovery time to make positive lifestyle choices, for example starting regular exercising, eating a healthy balanced diet and stopping smoking.

When should I seek advice after a laparoscopic excision of endometriosis?

We would anticipate that the overall recovery from your operation will take up to six weeks. In cases of excision of mild/superficial endometriosis, your recovery may be quicker than this.

You should seek medical advice from your GP if you experience:

Burning/stinging after you pass urine or needing to pass urine more often: this may indicate an underlying urine infection. In most cases this will settle with a short course of oral antibiotics.
Red, painful, oozing skin around your scars: this may indicate a wound infection. In most cases this will settle with a short course of oral antibiotics.
Worsening abdominal pain: this may be constant or made worse by movement. It may be associated with other symptoms including nausea, vomiting, loss of appetite, a temperature, difficulty opening your bowels or pain when you pass urine. If you have severe pain, or pain that is getting worse many days after your operation, it is important that you are seen by a doctor. We would recommend you see your GP on the same day or phone the ward for advice. You may require review and readmission to hospital.
A painful, red, hot swollen leg and difficult weight bearing: this may indicate an underlying deep vein thrombosis (DVT). If you are experiencing pain in your chest, shortness of breath, cough up blood or are finding it difficult to walk around because of these symptoms, you may have a pulmonary embolism (PE). If you think you may have a DVT or PE it is important you seek immediate medical help by calling your GP, calling NHS 111 or attend A+E.

Getting back to normal

Around the house

In the first few days after your operation, you will need to ensure you rest. However, it is important to start doing some of your normal daily activities and build up gradually. You may find the main limitation to activities will be abdominal pain. If you experience pain, you should try doing a little less for a few days. We would advise you to avoid lifting heavy objects, such as shopping bags, a vacuum, or young children for 3-4 weeks after your operation.

Exercise

You will be able to walk around on the first day after your operation. Over the next few weeks, we would expect you to be able to increase your activity levels towards normal again. Swimming can be resumed within 2-3 weeks, so long as you are comfortable and your wounds have healed. Running, cycling, exercise classes or contact sports should not resume until 4-6 weeks after your operation.

Travel plans

It is safe to travel as a passenger in a car, on a bus or train in the first 1-2 weeks after your operation. If you are going on a journey over four hours, we would recommend you keep well hydrated, wear flight socks and try to keep your lower legs moving. If you plan to travel abroad, you will need to contact your travel insurer about potential restrictions.

Returning to work

The length of time you require off work after your operation will depend on the complexity of your procedure and the type of job you have. For cases of excision of mild disease and a non-manual job, it would be reasonable to consider a return to work between 2 and 4 weeks after the surgery. For cases of excision of moderate to severe endometriosis and/or a manual job / job that involves long shifts or periods on your feet, we would suggest you do not return to work for 6 weeks. All decisions about return to work should be discussed with your line manager and occupational health department. They may recommend you have a phased return back to your normal duties. We can provide you with a sick note prior to your discharge from hospital.

Recovery tracker

First 24 hours

How might I feel:

You are likely to be in hospital.
You will have some pain or discomfort in your abdomen.
You may feel sore moving in/out of bed.
You may have pain in your shoulder tip.
You may feel tired and require daytime naps.

What is safe to do:

Get up and move around.
Go to the toilet.
Have a shower and get dressed.
Eat and drink as usual.

Fit to work?

2-7 days

How might I feel:

You should be at home.
Your bowels should have opened.
The pain will be reducing in intensity and you will be moving more comfortably.
Any vaginal bleeding should have settled.

What is safe to do:

Continue as for day one.
Go for short walks; continue with any exercise that has been recommended to you.
Wash and shower as usual and remove any remaining wound dressings.

Fit to work?

1-2 weeks

How might I feel

You will have less pain as you move around now.
Your skin wounds will be feeling less sensitive.

What is safe to do

It is safe to build up your activity levels gradually.
Go for longer and more frequent walks.
Lift light loads.
Have sex.

Fit to work

Not just yet

2-4 weeks

How I might feel

Your pain should be resolving.
You will be able to reduce or stop your painkillers

What is safe to do

Continue to build up the amount of activity you are doing, towards pre-operative levels.
You can start low impact sports.
Make a plan for returning to work.

Fit to work

Yes (you may require reduced hours or lighter duties at first, depending on what your job is)

4-6 weeks

How I might feel

You should be feeling back to normal

What is safe to do

All regular daily activities, including heavy lifting.
You should be able to start driving.

Fit to work

6-12 weeks

How might I feel

You will be invited back to clinic to review your recovery and symptoms.

What is safe to do

If you are wanting to conceive we would recommend trying as soon as possible, once you have had a period. It is important to take folic acid supplements.

Fit to work

If your surgery was more complex, your recovery may take longer.

Living with endometriosis

Not all cases of endometriosis can be cured and for some women there is no long-term treatment that helps. With support many women find ways to live with and manage this condition.

Support organisations provide invaluable counselling, support and advice:

Best Treatment
www.besttreatments.co.uk/btuk/conditions/13729.html
(This site requires registration and prepayment to view the information it contains)

Endometriosis UK
Suites 1 & 2, 46 Manchester Street, London, W1U 7LS
Tel: 0207 222 2781
Helpline: 0808 808 2227
Website: www.endometriosis-uk.org

Endometriosis SHE Trust (UK)
14 Moorland Way Lincoln LN6 7JW
Tel: 08707 743665
Website: www.shetrust.org.uk
(Also provides specific information for teenagers with endometriosis)

Hysterectomy Association
10a Acreman Close Cerne Abbas Dorset DT2 7JU
Tel: 0871 781 1141
Website: www.hysterectomy-association.org.uk/

Infertility Network UK
Charter House 43 St Leonards Road Bexhill on Sea East Sussex TN40 1JA
Tel: 0870 118 8088
Website: www.InfertilityNetworkUK.com

Pelvic Pain Support Network
PO Box 6559 Poole BH12 9DP
Tel: 01202 604 749
Website: www.pelvicpain.org.uk
Internet forums may be the first place many women turn to for support. The quality of information can be variable

Complementary therapies

Complementary therapies include reflexology, herbal treatments and homeopathy. They may be effective at relieving pain. Some women have found that dietary changes such as eliminating certain food types (dairy/ wheat) may help to relieve symptoms. Therapies such as TENS, acupuncture, vitamin B1 and magnesium help some women with painful periods.

There is currently insufficient evidence to show whether such therapies are effective at relieving the pain associated with endometriosis. Some women find that recreational exercise improves their wellbeing, which may help to improve some symptoms of endometriosis.

Contacting us

If you have any issues during your recovery, please contact us using the numbers at the back of this leaflet.

Please be aware the ward is often busy and does not have a staffed reception late evening or overnight. If you are concerned and cannot get hold of us, please call 111.

If you or the individual you are caring for need support reading this leaflet please ask a member of staff for advice.

How to contact us:

Southmead Hospital
Bristol
BS10 5NB
Cotswold Ward (24hrs)

01174 14 6785