Techniques using laparoscopic
scissor excision are, however, becoming the most commonly reported methods of
surgical treatment of endometriosis. Redwine and Wright 84 demonstrated that
such an approach can be an effective treatment for deep pelvic endometriosis or
Cullen’s syndrome. More recently, work from the author’s unit 85. has
demonstrated that, in a series of 135 women prospectively followed up for
between 2 and 5 years, laparoscopic excision of endometriosis significantly
reduced all aspects of pelvic pain and improved the quality of life and sexual
function of women with endometriosis. Some 59% of this group who wished to
become pregnant after surgery were successful, and 44% achieved a live birth.
However, this study also demonstrated that this type of intervention was not
invariably or permanently effective in all cases. It was calculated that 36% of
the subjects in the group would require further surgery within 5 years after
the primary treatment. When reoperated upon, however, some of the patients with
severe recurrent symptoms had little or no visible endometriosis. We deduced
from this that not all post-excision pain was due to recurrent or persistent endometriosis.
More recently, our group has more clearly defined, in a placebo-controlled,
randomized trial 86, the effectiveness of laparoscopic excision for all
stages of endometriosis. Repeated observations in the placebo arm indicated
that the disease progressed over a 6-month period in 45% of patients, remained
static in 33% and improved in 22% of cases. This study demonstrated that every
symptom investigated, including all aspects of pelvic pain, quality of life and
sexual activity, improved significantly more after excisional surgery than
after a placebo, irrespective of the stage of the disease. In addition, there
were very significant negative and positive placebo influences of the
randomization process on the results, particularly during the mid-trial period.
Unfortunately, 20% of the subjects in the group did not improve after optimum
surgery. The widespread awareness of such a significant failure rate associated
with these laparoscopic interventions has led to the search both for
refinements to the surgical techniques used and to the development of
satisfactory adjuvant therapies to complement the surgical effects.