Treating endometriosis

Choosing a doctor and preparing for surgery

Patient articles & presentations

Talking to your doctor
What types of questions should you ask when selecting a physician to take on your care and provide optimal surgery?

Why don't more physicians advise conservative excisional surgical therapy?
What you read on these pages may stand in stark contrast with what you have been advised by your local doctor. Why is conservative excisional surgery not being routinely offered by the majority of practitioners?

Why is endometriosis surgery so challenging?
Endometriosis surgery is often dubbed the most challenging (and the most rewarding) form of pelvic surgery in the book (and quite possible the most difficult surgery per se). This article explains why so few surgeons are able to excise endometriosis and why even fewer are able to do so from any area within the body.

Scientific articles & presentations

Embracing the challenge of complete excision surgery, the gold standard of endometriosis treatment
This short article intended for physicians serves as a fitting introduction to the various materials contained on this site. It is a calling to think differently about the disease, to ask questions and challenge the concepts that currently underpin our philosophy of the treatment of endometriosis.

Patient preparation
This article examines the various steps needed in preparing the patient for the treatment of endometriosis, from differential diagnosis in the office to the correct identification of disease during laparoscopy and the various surgical considerations that must be borne in mind during and after surgery.

An overview of surgical approaches

Patient articles & presentations

A better approach to the treatment of endometriosis
How did Dr. Redwine develop the ideas and techniques that enabled him to successfully treat thousands of women with endometriosis? What did he do differently from those before him and why?

Why is laser vaporization best avoided in the surgical treatment of endometriosis?
Many surgeons vaporize endometriosis using a laser beam. Unfortunately, there are several reasons why this approach to surgical treatment is less than optimal.

What is monopolar electroexcision of endometriosis and how does it differ from electrocoagulation?
Different surgical techniques are used in the treatment of endometriosis. Two such techniques include electroexcision and electrocoagulation. While both utilize electrical current, the similarities end there.

Should laser vaporization and electrocoagulation of endometriosis be banned?
This may seem like an odd question to ask given these techniques are being used by gynecologists to treat endometriosis all around the world... but what do we know about the efficacy of these techniques and are they an adequate, let alone optimal, mode of surgery in women with endometriosis?

Scientific articles and presentations

Principles of monopolar electrosurgery
Electrosurgery is a useful, inexpensive, and a sometimes misunderstood form of surgical energy. A better understanding of the principles of electrosurgery can lead to more widespread use with greater safety. This article discusses monopolar electrosurgery as used by the author.

Surgical footage

Laparoscopic excision of endometriosis (1987)
This early video, filmed in 1987, demonstrates Dr. Redwine's approach and philosophy on the management of endometriosis. He argues the case for the laparoscopic excision of endometriosis as an effective strategy in the alleviation of pain in patients with the disease.

Electrosurgical resections of endometriosis
This film shows several types of electrosurgical resections of endometriosis, including closure of a small full-thickness hole in the bowel following excision of a rectal nodule.

Laparoscopic excision of endometriosis with 3mm monopolar scissors
In this film you will be introduced to the basic concepts of monopolar electrosurgery in the excision of endometriosis. A concern with the use of monopolar current is the potential for thermal spread and tissue damage. However, when high current densities are used, this problem is avoided. The surgery shown in this footage demonstrates the important relationship between current density and surgical technique (touch cutting versus coagulation) in the removal of endometriosis.

Radical versus conservative surgery

Patient articles & presentations

Endometriosis persisting after hysterectomy and bilateral salpingo-oophorectomy: Removing the disease, not organs, is key to long-term relief
Surgical castration (removal of the ovaries, usually accompanied by removal of the uterus and tubes - "hysterectomy and bilateral salpingo-oophorectomy") is often implied as the definitive cure of endometriosis. It is a drastic step to take in striving for relief of symptoms, especially in women who are yet to fulfill their wish for motherhood. Sadly, however, this radical surgery does not eradicate the disease and is no guarantee against the persistence of symptoms.

Scientific articles & presentations

Endometriosis persisting after castration: clinical characteristics and results of surgical management
Surgical treatment of endometriosis by bilateral oophorectomy with or without hysterectomy is usually regarded as curative therapy, even though residual disease may remain. It is used in patients with sufficient pain who have failed previous therapies and who do not desire future fertility. Despite this therapy, this study demonstrates that endometriosis can remain symptomatic after castration, with or without estrogen therapy. In such patients, there is a 33% frequency of intestinal involvement. Therefore, at castration, consideration should be given to removal of invasive peritoneal and intestinal disease. Symptom improvement occurs in most patients after excision of endometriosis.

Surgical techniques per location and subtype

Patient articles & presentations

Ovarian cysts and emergency surgery
When an ovarian cyst is discovered does this require treatment, and if so does this ever represent a surgical emergency?

Surgical footage

The world's first laparoscopic segmental bowel resection
In this award-winning film made in December 1990 you will see the world's first laparoscopic segmental bowel resection. Invasive endometriosis of the sigmoid colon is segmental resected entirely via laparoscopy. The film won the very first AAGL 'Golden Laparoscope Award' for the pioneering surgical procedure performed.

Transvaginal segmental bowel resection
The transvaginal segmental bowel resection is a sleek technique in patients in which both the vaginal cuff needs to be opened and a segmental resection needs to be performed during the same surgery. The technique can reduce surgery time and avoids the need to extend one of the laparoscopy incisions to accommodate the bowel during anastomosis.

Obliteration of the cul-de-sac
This film shows several types of electrosurgical resections of endometriosis, including closure of a small full-thickness hole in the bowel following excision of a rectal nodule.

Frozen pelvis
This film shows excision of severe endometriosis, including resection of endometrioma cysts, complete obliteration of the cul-de-sac, and mucosal skinning of the rectosigmoid colon.

Gastrointestinal endometriosis
Endometriosis of the intestines can sometimes be superficial. This video shows resection of superficial disease from the colon and small bowel

Umbilical endometriosis
Umbilical endometriosis is a rare manifestation of the disease. It is the result of embryological patterning of the distribution of endometriosis. Umbilical endometriosis can exist without any pelvic endometriosis. The best treatment is local excision. This video shows local excision of umbilical endometriosis.

Diaphragmatic endometriosis
Diaphragmatic is a rare presentation of endometriosis and is commonly associated with widespread pelvic disease. This film examines the diagnosis and surgical treatment of diaphragmatic disease in Dr. Redwine's practice in the early 1990s. Nowadays diaphragmatic disease may be excised via laparoscopy and thoracoscopy rather than requiring laparotomy.

Surgical complications

Scientific articles & presentations

Complications of laparoscopic presacral neurectomy
Presacral neurectomy is a procedure that denervates the uterus and some bladder sensation. This article examines the indications for the procedure, how the procedure is performed, and the possible complications that may result.

Surgical footage

Repairing ureteral injuries
The ureter is the tubular structure which carries urine from the kidney down to the bladder. Most of us have only one ureter on each side. Some patients have two ureters on one side, which can lead to an increased chance of injury during difficult pelvic surgery. This video shows damage to and repair of a duplicate ureter which occurred during a difficult pelvic surgery.

Arterial haemostasis
Arterial haemostasis is an important part of any surgery. This video shows a variety of areterial bleeders and how they are controlled.

Colposuspension mesh removal
Women who have undergone removal of their pelvic organs in the 'definitive' treatment of endometriosis may later experience prolapse. Surgical mesh is used increasingly to try to 'fix' pelvic support problems in women. Mesh problems requiring reoperation are the dirty little secrets which can follow the use of mesh. This video shows laparoscopic removal of mesh which had been causing pain.

Monarc mesh removal
Women who have undergone removal of their pelvic organs in the 'definitive' treatment of endometriosis may later experience prolapse. Surgical mesh is used increasingly to try to 'fix' pelvic support problems in women. Mesh problems requiring reoperation are the dirty little secrets which can follow the use of mesh. This video shows laparoscopic removal of mesh which had been causing pain.

Surgical audits, digital documentation, evidence-based endoscopy, and controlled surgical studies

Patient articles & presentations

How should the effectiveness of a specific treatment be measured?
When measuring the efficacy of a treatment it is important to consider how reflective the outcome measure is of the underlying disease. Typical measures of treatment efficacy in endometriosis include fertility, pain, and disease at reoperation.

Medical therapies

Patient articles & presentations

Generic flaws of studies of medical therapy
What are the pitfulls in the studies examining the efficacy of medical therapy in the treatment of endometriosis? What impact do these flaws have in terms of the clinical utility of medical therapy in patients presenting with pelvic pain due to endometriosis?

Should medical therapy be used for endometriosis?
Many medical therapies are being used in patients with endometriosis but are they effective in treating this disease?

Is a medically-induced pseudomenopause an effective treatment of endometriosis?
Powerful and expensive hormone therapies are often prescribed in the treatment of endometriosis whereby the patient is placed into a medically-induced pseudomenopause, often resulting in severe side-effects. Are these therapies actually effective in treating this disease or best steered clear of?

Scientific articles & presentations

Berkson's fallacy and the medical 'treatment' of endometriosis
When a disease is studied only in patients in a hospital, the symptomatic and morphologic features seen in those hospitalized patients may not accurately reflect the wild type disease which is prevalent in the population as a whole. This may result in an inaccurate picture of the disease. This is called "Berkson's fallacy". So what role has Berkson's fallacy played in our beliefs and understanding of endometriosis?

Pregnancy and menopause

Patient articles & presentations

Does pregnancy protect against or cure endometriosis?
Endometriosis has often been characterised as a diasese of middle-aged career women who have put off having children. Pregnancy is often cited as both preventative and curative of this disease. Is there any truth in these beliefs?

Does menopause cure endometriosis?
It is often assumed that endometriosis is a disease limited to the reproductive years and that menopause (either natural, medical, or surgical) will bring the disease to an end. Is there any truth in this belief?