Complete PELVIC peritonectomy

Endometriosis is an often painful disorder in which tissue similar to the tissue that normally lines the inside of the uterus (the endometrium) grows outside of the uterus. The endometrial-like tissue acts like endometrial tissue — it grows, breaks down, and bleeds during the menstrual cycle. But because this tissue is not supposed to be there, it can cause pain and inflammation, and ultimately lead to development of scar tissue and adhesions. 

Superficial peritoneal endometriosis describes the endometriosis that grows on the peritoneum of the pelvis. The peritoneum is a thin cell layer of tissue (kind of like plastic wrap) that covers the inside of the pelvis, abdomen, and organs.

Complete pelvic peritonectomy describes a surgery in which ALL the peritoneum of the pelvis is carefully removed: the peritoneum at the pelvic brim, the ovarian fossae (the area underneath the ovaries), the broad ligament, behind the cervix, the posterior cul-de-sac (behind the uterus and over the rectum), and the peritoneum overlying the bladder. 

There is very good evidence that surgeons are not great at identifying endometriosis visually. After all, endometriosis is diagnosed via microscope and can have varying visual appearances in the body. Endometriosis can appear black (“gunpowder”), brown (“chocolate”), red (“flame”), clear (“vesicular”), white (“scar”) or even look normal! Surgeons who just perform biopsies of suspicious areas could be leaving behind disease by accident.

I want to perform the most complete surgery for you and I don’t want to leave any disease behind. I would rather have the pathologist examine all the tissue to make the most well-informed diagnosis. That’s why I perform complete pelvic peritonectomy.

Complete pelvic peritonectomy can be performed via laparoscopy or robotic-assisted laparoscopy. One method of surgery might be better for you depending on the extent and type of endometriosis you have. For example, robotic-assisted laparoscopy might be a preferred option for women who have known endometriomas that need to be removed.

Regardless of the method you choose, you will have four small incisions on your belly: the largest in the belly button, one 5-millimeter incision on the left side, and two 5-millimeter incisions on the right side. 

Recovery after complete pelvic peritonectomy is similar to that of other minimally invasive procedures. Most women are feeling about 75% of their pre-surgery selves at about the 1 week mark. However, recovery will be different for every person. Recovery can take a waxing and waning course, especially as you start to become more active.

One thing to keep in mind is that all of the peritoneum removed during the complete pelvic peritonectomy will grow back in 5-7 days. However, this fresh, new tissue is still healing. There will be a lot of inflammation, which can contribute to the postoperative pain experienced.

The first 1-2 menstrual cycles after surgery will likely be more intense than usual, with more cramping and discomfort. This is likely because of all the associated inflammation impacting the uterus as the peritoneum in the front and back of the uterus heals. 

Total recovery time is about 6 weeks. If returning to a desk job or schoolwork, the earliest I would recommend considering returning to work or school is at 3-4 weeks after surgery. During the 6 week recovery period, you should not lift more than 15 pounds, or perform activities that excessively engage your abdominal muscles.

Overall, there is limited good quality research in the field of endometriosis, which is very frustrating. However, based on my research in fellowship and my experience with patients undergoing surgery at Mayo Clinic, I strongly believe that complete pelvic peritonectomy helps women suffering from endometriosis and chronic pelvic pain.

By the 6 week mark after surgery, most women will be aware of improvements in their symptoms. However, full impact and benefit of the surgery may take up to 6 months.

Surgery is a big part of a treatment plan for endometriosis, but it remains just one part. Most women will consider other concurrent medical treatments such as hormonal management, centrally-acting medications, and pelvic floor physical therapy.