Surgical management of endometriosis

Key content: Advances in laparoscopic surgery have made the surgical management of endometriosis an effective treatment that offers advantages over medical therapy. The majority of gynaecologists readily perform laparoscopic ablation of superficial disease. Excision of deeper disease and management of rectovaginal disease require more expertise and should be managed in tertiary centres. Hysterectomy should not be necessary in the majority of cases. Although some women may benefit, extrauterine disease should also be excised. Evidence suggests that laparoscopic uterine nerve ablation (LUNA) has no effect on long-term symptoms. There is no consensus as to the optimal surgical approach for rectal disease. A multicentre, randomised controlled trial is urgently required to resolve the issue. Learning objectives: To understand the role of surgery in the management of endometriosis. To be aware of the best available evidence so that the optimal approach can be used when performing surgery. To be aware of the preoperative care of women with advanced disease and when to refer them for further management. Ethical issues: What should be regarded as an acceptable complication rate for women undergoing surgery for advanced endometriosis? What level of training should gynaecologists reach if they are to be judged competent in the surgical management of endometriosis? Given that the surgical management of endometriosis is a developing skill, where is the boundary between accepted and acceptable practice?