Excision Surgery for Endometriosis: Post-Operative Pain Expectations

Disclaimer: The decision to undergo surgery for endometriosis is a personal one, and outcomes can vary. There are no universal guarantees, and each patient’s experience is unique. It is essential to discuss all treatment options with a qualified healthcare provider. The information provided herein is for educational purposes only and does not constitute medical advice or establish a doctor-patient relationship.

EXCISION SURGERY FOR ENDOMETRIOSIS: POST-OPERATIVE PAIN EXPECTATIONS

Guest Post Author: Ken Sinervo, MD, MSc, FRCSC, ACGE

Endometriosis is a systemic, inflammatory disease affecting an estimated 200 million girls and women (Yi et al., 2021) and unmeasured amounts of gender-diverse individuals globally. Characterized by the presence of endometrium-like tissue found in other areas of the body (Taylor et al., 2021), the disease has been documented in virtually every organ system and commonly presents with a variety of subtypes and clinical manifestations. Endometriosis can lead to significant decline in the quality of life of those affected and carries a heavy financial burden on society. For many, surgical intervention is a pivotal step toward both diagnostic confirmation and alleviating symptoms, particularly Laparoscopic Excision (LAPEX). LAPEX is considered by many to be the ‘surgical gold standard’ of operative treatment. Understanding expectations following LAPEX is vital for managing recovery and setting realistic post-operative goals.

Understanding Laparoscopic Excision

Surgical excision of endometriosis is a meticulous technique that aims not only to alleviate pain but also restore normal anatomical structures and functioning. Utilizing cutting techniques, the excisional method allows for thorough removal of lesions ‘root to tip’ and the subsequent pathological examination to confirm a diagnosis. In our Center, we utilize the laser as a cutting tool to resect and remove the disease from all involved areas, preserving healthy tissue and surrounding structures. This precise approach minimizes damage to adjacent areas, promotes faster healing, and enhances overall outcomes for our patients. Studies have demonstrated that excision is more effective than placebo in reducing pain and improving quality of life in all stages of disease, and is generally preferred for its superior outcomes (Rathod et al., 2024). Others have demonstrated that excision is also perceived as superior to ablation* in most measures (Isaac et al., 2024).

In general, Minimally Invasive Gynecologic Surgery (MIGS) like Laparoscopy involves smaller incisions and may result in less postoperative pain, shorter recovery times, and reduced scarring compared to traditional open surgery. Though MIG surgery is considered ‘minimally invasive,’ it can be quite technically complex and vary significantly in terms of techniques, extent of disease treated, and individual patient circumstances. Pain and recovery expectations following excision surgery subsequently vary significantly among individuals and are influenced by numerous factors. Surgical technique, patient characteristics, pain management strategies, and other dynamics all play a role, and educating patients preoperatively can help healthcare providers set realistic expectations, enhance education, and improve overall satisfaction with outcomes.

To that end, excision of endometriosis can be challenging due to several factors, not limited to:

• Extent of Disease: Endometriosis necessitates careful planning and skilled surgical techniques, often undertaken in an interdisciplinary operative setting with a team from gynecology, colorectal, and other specialties.

• Surgical Precision: The complex nature of the disease means the surgeon(s) must be highly skilled in cutting out the lesion(s) from wherever they are present while simultaneously preserving healthy tissue and adjacent organs. This requires an extremely high level of expertise which can only be gleaned through advanced training and high volume experience.

• Potential Complications: Even ‘minimally invasive’ procedures carry risks, including but not limited to bleeding, infection, and damage to surrounding organs. Patients must be fully informed about the benefits and drawbacks of any surgery, all possible risks, expected outcomes, and potential complications. The surgeon must be fully prepared to address unexpected events during surgery, including those involving the bowel, bladder, or nerves, and ensure that any such occurrences can be managed safely, swiftly, and effectively.

• Individual Variability: Each patient's experience with endometriosis and their response to surgery will differ based on personal and specific factors including disease severity, overall health, previous treatments, and more.

It is essential to recognize the complexities involved in excision surgery and the importance of a truly skilled surgical approach to achieve the best, safest outcomes for patients.

Overview of the Post-Operative Recovery Process

The post-operative phase is a crucial one, and understanding expectations and management, especially of pain, is essential for successful recovery. The process varies depending on the type of surgery, the individual’s general health and underlying conditions, and various other factors which could complicate or lengthen healing. A comprehensive approach to recovery includes effectively managing pain, preventing complications, promoting mobility, and supporting overall well-being.

While recovery is generally quicker versus open surgery, patients will still experience pain and discomfort. The healing process is not linear, and post-operative pain may ebb and flow throughout the days and weeks following surgery. The recovery process involves several stages: 

Immediate Post-Surgery Phase (First 24-72 Hours)

• Hospital Monitoring: Vital signs, pain levels, and any immediate complications (such as bleeding or infection) are closely monitored.

• Mobility: Early movement, such as leg exercises or short walks, helps prevent blood clots and enhances circulation.

• Diet & Hydration: Patients may start with clear liquids before progressing to solid foods as tolerated.

• Pain Management & Realistic Understanding of Pain Expectations: This is crucial for patients undergoing any surgical procedure. It helps patients have a better sense on the level and duration of pain they may experience post-operatively. This knowledge can reduce anxiety and fear, and allows patients to mentally prepare for their recovery journey. Additionally, when patients are well-informed, they are more likely to communicate effectively about their pain levels, which is essential for timely intervention and support. 

Post-operative pain can vary significantly among individuals and may include:

• Incisional Pain: This is localized pain at the site of surgery, typically managed with analgesics.
• Referred Pain: Pain that may occur in areas distant from the surgical site due to nerve pathways.

Pain is typically measured using the Numeric Rating Scale, where patients rate their pain from 0 (no pain) to 10 (worst pain imaginable). However, this can vary based on the type of surgery and individual pain thresholds.

• Immediate Post-Op (0-24 hours): Patients generally experience the highest levels of pain immediately after surgery.
• 24-72 Hours Post-Op: Pain levels typically peak within this timeframe, followed by a gradual decrease. 
• Week 1-2 Post-Op: By the end of the first week, many patients report a reduced pain score, indicating transition from acute to more manageable pain.
• Week Two-Four: Most patients experience marked reduction in pain.
• Total healing can take 90 days or longer even after  a patient has resumed normal activity  levels, and patients may find that they experience painful periods for the first three cycles and/or have fatigue, transient pain, and other post-operatuve effects due to ongoing physical recovery, emotional stress, medication effects, overexertion, or sleep disturbances. It's important to listen to your body and consult your healthcare providers if symptoms seem disproportionate or persistent.

Effective pain management is a critical component of the recovery process, enabling patients to engage in rehabilitation activities and improve their quality of life post-surgery. Prioritizing pain control not only enhances recovery but promotes overall patient satisfaction. Depending on the case, this may involve opioid and/or non-opioid pain relievers, nerve blocks, anti-inflammatory medications and others. Pain levels can be influenced by various factors, including:

• Type of Procedure(s) Performed: The nature of procedures can significantly impact pain levels. More invasive surgeries, i.e., Video Assisted Thoracic surgery for lung endometriosis or bowel resection for invasive GI lesions may result in lengthier and higher pain levels compared to other LAPEX cases that do not involve such procedures.
• Individual Patient Factors: A patient’s pre-existing health and individual pain thresholds cannot be undervalued for their influence on how the patient experiences pain. Younger patients may recover faster, while older patients or those with chronic conditions may face additional challenges.
• Quality of Post-Operative Care & Monitoring: Effective post-operative care, including close monitoring and timely interventions, can significantly influence pain management outcomes and overall recovery. Patients should be educated on recognizing signs that indicate their pain may be excessive or not aligning with expected levels, such as increased intensity or changes in the character of pain. Clear guidelines should be provided to patients on when to reach out to healthcare professionals, including signs of complications or inadequate pain control.

Short-Term Recovery (First Few Weeks)

• Wound Care: Keeping the surgical site clean and dry reduces infection risk. Some patients may require drains, which must be managed properly.

• Activity Restrictions: Heavy lifting, strenuous activities, and excessive bending or stretching are discouraged. Frequent short breaks are encouraged. 

• Non-Pharmacological Approaches (Ice, Elevation): Complementary methods like applying ice/heat or using relaxation techniques can help alleviate pain and swelling. Ongoing assessment of pain levels allows for adjustments in pain management strategies, ensuring that patients receive the most effective care tailored to their needs.
• Monitoring Bowel & Bladder Function: Post-op constipation is common, especially with opioid use. Increased fiber intake, hydration, and gentle laxatives may help. Voiding concerns should be addressed with the surgeon at the post-operative visit, if not before as necessary. 

Mid-Term Recovery (Weeks to Months)

• Physical Therapy & Rehabilitation: Physical therapy plays a vital role in post-operative recovery, aiding in mobility, strength building, and pain reduction, ultimately facilitating a faster return to normal activities. Structured exercises with endometriosis- and pelvic pain-specialized PTs can be very helpful postoperatively to regain strength and flexibility and address secondary pain generators like pelvic floor dysfunction or others.
• Hormonal & Systemic Adjustments: For surgeries that involve post-operative medical therapy, hormonal changes may impact recovery.

Long-Term Recovery & Functional Restoration

• Emotional & Psychological Support: Depression and anxiety may arise post-surgery, particularly if chronic pain has been a longstanding issue. Support groups, therapy, and mindfulness practices can be helpful.

• Gradual Return to Normal Activities: Patients should pace themselves and listen to their bodies when resuming work, exercise, sex, and other routines.

• Always an important consideration, a balanced diet rich in protein, vitamins, and minerals is essential for postoperative healing, as it supports tissue repair, boosts the immune system, and promotes overall recovery.

• Follow-Up Appointments: Ongoing monitoring ensures healing is on track and complications are addressed.

Having a clear understanding of what to expect can lead to better adherence to pain management strategies, improve overall satisfaction with the surgical experience, and enhance cooperation between patients and their healthcare providers. Remember each patient’s recovery journey is unique, and a personalized plan - often involving a multidisciplinary approach - is essential for optimal outcomes.

Continued Post-Excision Pain: Is Something Wrong?

For many with endometriosis, LAPEX can provide significant relief. Some patients, however, can continue to experience pain long after the standard window of postoperative recovery. It is important to understand that excision is not a universal cure for endometriosis and that even removing all disease may not solve underlying issues for some individuals. It is also true that not all pain is from endometriosis. Persistent pain can stem from secondary pain generators and other factors such as surgical complications or underlying conditions that were not addressed during the procedure. Identifying the root cause for continuing symptoms is essential for effective management.

One major contributor to ongoing pain is secondary pain generators, which develop as a result of prolonged nerve sensitization, musculoskeletal dysfunction, or associated conditions. Central sensitization - where the nervous system remains in a heightened state of pain response even after the initial source is removed - can make post-surgical pain feel disproportionate. Pelvic floor dysfunction is also common, as chronic pain and inflammation from endometriosis can lead to muscle hypertonicity (tightness), which contributes to deep, aching pain, painful intercourse, and bladder or bowel dysfunction. In some cases, pain originates from nearby organs, such as the bladder (Bladder Pain Syndrome) or intestines (Irritable Bowel Syndrome), which can mimic endometriosis symptoms. Surgical complications may also play a role in continued pain. 

Adhesions, or bands of scar tissue that form between organs and tissues, can cause pain by restricting movement and function. While meticulous surgical techniques and barriers can minimize formation, adhesions can still develop and lead to pain or issues.

Nerve-related pain is another potential cause, particularly if surgical dissection involved areas near the pudendal, ilioinguinal, or genitofemoral nerves. Neuropathic pain - described as burning, shooting, or tingling – may result from nerve irritation or injury. 

In cases where incomplete excision occurs, residual endometriosis can continue to provoke inflammation and pain, particularly if deep infiltrating lesions remain in areas like the diaphragm or bowel.

Pain persistence may also be related to underlying autoimmune or inflammatory conditions that can exacerbate pain by amplifying the body's response to perceived threats.

A comprehensive post-surgical plan that includes Pelvic Physical Therapy, pain management, hormonal modulation if necessary, and/or lifestyle interventions including adequate nutrition is often appropriate to optimize recovery and reduce discomfort. Communication with your healthcare team is key. Patients should feel empowered to speak openly with their healthcare teams about their pain levels and any ongoing symptoms or concerns, fostering a truly patient- centered, collaborative approach to ongoing care and management.

In Conclusion

Understanding what to expect throughout the recovery process empowers patients, allowing them to navigate their journeys with greater confidence and a clearer perspective on their path to relief. Through thorough pre-operative education, effective pain and post-operative management strategies, and multidisciplinary, personalized care, healthcare providers can significantly improve outcomes in care. As we continue to explore the complexities of endometriosis management, it remains essential to support our patients in their recovery by providing them with the tools and knowledge necessary to enhance their quality of life, both immediately after surgery and for the long term.

Learn more from Dr. Sinervo and his team at The Center for Endometriosis Care

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Taylor HS, Kotlyar AM, Flores VA. Endometriosis is a chronic systemic disease: clinical challenges and novel innovations. Lancet. 2021;397(10276):839-852.

Yi M, Wang S, Zhang X, et al. Linc-ROR Promotes EMT by Targeting miR-204-5p/SMAD4 in Endometriosis. Reprod Sci. 2023;30(9):2665-2679. 

Rathod S, Shanoo A, Acharya N. Endometriosis: A Comprehensive Exploration of Inflammatory Mechanisms and Fertility Implications. Cureus. 2024;16(8):e66128.

Isaac A, Kapetanakis T, Thibeault E, Chatburn L, Mackenzie M. Patient Perception and Experience of Laparoscopic Excision versus Ablation of Endometriosis: A Crowd-Sourced Comparative Evaluation of Symptom and Quality of Life Outcomes. J Minim Invasive Gynecol. Published online October 26, 2024. doi:10.1016/j.jmig.2024.10.014.

*The terms "ablation of endometriosis" and "endometrial ablation" sound similar but refer to completely different procedures with distinct purposes. Ablation of endometriosis is a surgical procedure often performed by those who are not trained in excision, as it requires less specialized skill and experience. The procedure burns or cauterizes lesions, but leaves deeper disease behind, leading to persistent endometriosis and ongoing symptoms. Endometrial ablation is a surgical procedure undertaken to destroy the uterine lining to reduce heavy menstrual bleeding. It is not among accepted treatments for endometriosis, and the procedures serve different purposes.