Advanced laparoscopic procedures for pelvic pain and dysmenorrhoea

The effective removal of endometriosis is the major aim of physicians treating patients with pelvic pain. This can now be accomplished long-term as effectively at laparoscopy as at laparotomy (Wheeler and Malinak, 1987; Redwine, 1991; Martin, 1994). All successful operative laparoscopists dealing with endometriosis-associated pain should be familiar with and consider offering their patients the operative procedures discussed in this chapter. Adhesiolysis is a well-accepted therapy but uterine suspension and the nerve separating techniques of LUNA and PSN are much more controversial. Pain, being subjective, is difficult to quantify and a poor end point to monitor scientifically. However, there is a significant body of published work to suggest that uterine suspension, LUNA and PSN, which have all been performed for decades, seem effective laparoscopically in reducing pelvic pain associated with endometriosis. Much more data are obviously needed to determine if endometriosis-associated pain can be effectively treated with laparoscopic procedures. Properly designed scientific prospective randomized studies to evaluate some of the laparoscopic operations discussed to treat endometriosis-associated pain have recently been reported (Sutton, 1994). Thoughtful gynaecologists dealing daily with patients with endometriosis should consider discussing with them the advantages and disadvantages of the techniques reviewed in this chapter. From our experience and that of others, it appears that adhesiolysis, uterine suspension, LUNA and PSN can all be safely and effectively accomplished by skilled laparoscopists and result in good patient outcomes. All gynaecologists involved in the care of patients with endometriosis and pain should consider learning and offering these operations to their patients with appropriate discussion of the potential risks and benefits.