Skip to main content Surgery to remove endometriosis from both the pelvis and the bowel.
For some people, endometriosis may affect the bowel and the symptoms can be very severe. Surgery to remove endometriosis from both the pelvis and the bowel may be considered in this situation. Specialist ultrasound is very accurate at diagnosing both the presence of disease in the bowel and its severity. This will assist with planning your surgical procedure and deciding which surgical procedures you need.
The most common area of the bowel affected by endometriosis is the rectum. This is the part of the bowel that is just above the anus and disease in this area can cause pain when you open your bowels (called dyschesia) or with intercourse (called dyspareunia). There may be other bowel symptoms such as a feeling of needing to empty the bowels frequently or bleeding from the bowel. These are not as common as pain symptoms.
The bowel has three layers and the type of surgery will depend on which layer is affected and how big the endometriosis lesions are. The outermost layer that can be seen at laparoscopy is called the serosa. The middle layer is called the muscularis and is the thickest part of the bowel (but the bowel wall is very thin and usually only a few millimetres thick in total). The innermost layer is called the mucosa and it is this part that is seen by colonoscopy. Neither the muscularis or the mucosa can be seen at laparoscopy and that is why a scan (usually ultrasound or MRI) is used pre-operatively to help plan surgery.
Any surgery on the lower bowel may involve a colorectal surgeon as well as your gynaecologist. Working in a team means greater experience in specialty areas to improve outcomes from your surgery. If the endometriosis is shallow and only on the serosa of the bowel then it may be ‘shaved’ off. This will usually involve cutting the endometriosis off the surface. The depth of disease means that a stitch may not be needed at all. Where the lesion is larger, a stitch may be put in to help healing, but the bowel heals very quickly in general. This technique can also be used if the lesion is small and invades the second layer of the bowel (the muscularis). Generally, a stitch is used to support the edges of the area that is removed to help healing.
When the endometriosis lesion is larger, or deeper, then a second technique may be used called ‘disc resection’. This uses a stapling device that is placed into the bowel through the anus and placed under the endometriosis lesion. The stapler is extended so that the endometriosis can be drawn down into the device and ensure that the tissue at the edge is free of endometriosis. The device then cuts the tissue off and staples the bowel closed at the same time.
This removes a circle of tissue (why it is called a ‘disc’) with the endometriosis in the middle and a thin area of normal tissue around the outside. Only one part (usually the top surface) of the bowel is removed, with the sides and back of the bowel staying in place. The bowel generally heals well, but additional post-operative steps may need to be taken. This technique can only be used for lesions less than 2-3cm. It does remove all three layers of the bowel, so the risk is greater than with the shaving technique (but is used for a different purpose).
Where there is a large lesion (more than 3cm), or several areas of the bowel are affected separated by a few centimetres, or the lesion is high in the bowel where a stapler cannot reach, then a ‘segmental resection’ is used. In this case a length of the bowel is removed completely with the two ends joined back together – again commonly using a stapling device. In this case, it is like having an area of damage in the middle of your garden hose. The area can be cut away to get rid of the damaged area and a joiner used to bring the two ends of hose together.
The technique used will depend on your endometriosis, the experience of your surgical team and their comfort with different types of approaches. The surgery may be performed by laparoscopy (keyhole) or may need an open approach (a laparotomy) and you should discuss the planned approach and the alternative approaches before your surgery. Your team will also discuss risks and complications with you. Read our guide on preparing for surgery.
