Techniques using laparoscopicscissor excision are, however, becoming the most commonly reported methods ofsurgical treatment of endometriosis. Redwine and Wright 84 demonstrated thatsuch an approach can be an effective treatment for deep pelvic endometriosis orCullen’s syndrome. More recently, work from the author’s unit 85. hasdemonstrated that, in a series of 135 women prospectively followed up forbetween 2 and 5 years, laparoscopic excision of endometriosis significantlyreduced all aspects of pelvic pain and improved the quality of life and sexualfunction of women with endometriosis. Some 59% of this group who wished tobecome pregnant after surgery were successful, and 44% achieved a live birth.
However, this study also demonstrated that this type of intervention was notinvariably or permanently effective in all cases. It was calculated that 36% ofthe subjects in the group would require further surgery within 5 years afterthe primary treatment. When reoperated upon, however, some of the patients withsevere recurrent symptoms had little or no visible endometriosis.
We deducedfrom 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 allstages of endometriosis. Repeated observations in the placebo arm indicatedthat the disease progressed over a 6-month period in 45% of patients, remainedstatic in 33% and improved in 22% of cases. This study demonstrated that everysymptom investigated, including all aspects of pelvic pain, quality of life andsexual activity, improved significantly more after excisional surgery thanafter a placebo, irrespective of the stage of the disease. In addition, therewere very significant negative and positive placebo influences of therandomization process on the results, particularly during the mid-trial period.Unfortunately, 20% of the subjects in the group did not improve after optimumsurgery.
The widespread awareness of such a significant failure rate associatedwith these laparoscopic interventions has led to the search both forrefinements to the surgical techniques used and to the development ofsatisfactory adjuvant therapies to complement the surgical effects.