Peritoneal Endometriosis Endometriosis lesions can be removed during laparoscopy by surgical excision with scissors, bipolar coagulation, or laser methods (CO2 laser, potassiumtitanyl-phosphate laser, or argon laser). Some surgeons claim that the CO2 laser is superior because it causes only minimal thermal damage, but no evidence is available to show the superiority of one technique over another. Comparable cumulative pregnancy rates were reported after treatment of mild endometriosis with laparoscopic excision and electrocoagulation (290). Ablation of endometriotic peritoneal lesions plus laparoscopic uterine nerve ablation (LUNA) in minimal to moderate disease reduces endometriosis-associated pain at 6 months compared to diagnostic laparoscopy; the smallest effect is seen in patients with minimal disease (1,291). There is no evidence that LUNA is a necessary component, and LUNA by itself has no effect on dysmenorrhoea associated with endometriosis (1,292,293). The effectiveness of surgical ablation of peritoneal endometriosis is convincingly shown in two randomized trials where the control group underwent a laparoscopy without surgical ablations of lesions. The treated group had a significant reduction of symptoms that persisted for 12 months and 18 months, respectively (268,294,295). The effectiveness of surgical treatment by laparotomy was not investigated by a randomized trial, although many published observational studies claim a high percentage of success (1).
Adhesiolysis The removal of endometriosis-related adhesions (adhesiolysis) should be performed carefully. Adhesions lysed at surgery can form again (296). Routine use of pharmacologic or liquid agents to prevent postoperative adhesions after fertility surgery cannot be recommended based on a systematic review, including 16 randomized controlled trials, with the following indications for surgery included myomectomy (five trials), ovarian surgery (five trials), pelvic adhesions (four trials), endometriosis (one trial), and mixed (one trial) (297). No studies reported pregnancy or reduction in pain as outcomes (297). The absorbable adhesion barrier Interceed reduced the incidence of adhesion formation following laparoscopy and laparotomy, but there are insufficient data to support its use to improve pregnancy rates (297). The substance expanded polytetraﬂuoroethylene (Gore-Tex Surgical Membrane, Preclude; WL Gore, Flagstaff, AZ) may be superior to Oxidised regenerated cellulose (Interceed; Gynecare, Somerville, NJ) in preventing adhesion formation, but its usefulness is limited by the need for suturing and later removal (297). There was no evidence of effectiveness of chemically derived sodium hyaluronate and carboxymethylcellulose (Seprafilm, Genzyme Corporation, Cambridge, USA) or sheet-type fibrin sealant (Fibrin sheet, Tacho Comb, Tokyo, Japan) in preventing adhesion formation (297). In a randomized trial in patients with surgically treated stages I to III endometriosis without endometrioma, postoperative adnexal application of Oxiplex/AP (FzioMed, San Luis Obispo, California) gel treatment was superior to surgery alone (control group) with respect to postoperative adhesion formation (defined as secondary outcome) 6 to 8 weeks later in a subgroup of patients with red lesions (298). This observation needs to be confirmed in other randomized trials with postoperative adhesion formation as primary outcome. In the same study, control patients with at least 50% red lesions had a greater increase in ipsilateral adnexal adhesion scores than patients with mostly black or white and/or clear lesions (298).