O&G SAQs · Gynaecological surgery — endometriosis
Surgery for endometriosis — structured SAQ (15 marks)
FRANZCOG-format structured SAQ on the surgical management of endometriosis: pre-operative mapping with the ENZIAN classification, the excision-vs-ablation evidence, bowel DIE surgical options and bowel-function outcomes, nerve-sparing rationale, and recurrence with postoperative suppression. Per-sub-part marking rubric included.
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Prompt
A 32-year-old woman with deep infiltrating endometriosis has cyclical dyschezia and a TVUS showing a rectosigmoid nodule invading the bowel muscularis. She has been referred for surgical management. (a) Outline your pre-operative assessment and mapping, naming the classification used. (4 marks) (b) Summarise the evidence comparing laparoscopic excision with ablation, and state which is preferred for deep infiltrating disease. (3 marks) (c) Describe the surgical options for her bowel disease and cite the evidence on bowel function. (4 marks) (d) State the rationale for nerve-sparing surgery, the outcome it reduces, and the strongest predictor of that outcome. (2 marks) (e) State the recurrence rate after surgery and the role of postoperative hormonal suppression. (2 marks)
How this SAQ is marked
Marks come from the #ENZIAN-named pre-operative mapping, the excision-vs-ablation evidence with the DIE exception, the bowel-DIE surgical spectrum with the Quintairos evidence, the nerve-sparing rationale with the predictor, and the recurrence rate with postoperative suppression. Write in short labelled points. [1]
Reveal model answer and mark schemeShowHide
(a) Pre-operative assessment and mapping (4 marks)
- Structured symptom history (cyclical dyschezia, cyclic rectal bleeding) + bimanual exam (fixed retroverted uterus, posterior fornix nodularity).
- TVUS with bowel preparation and rectal water contrast for the rectosigmoid nodule; MRI to map DIE in compartments A/B/C/FB/FU.
- Use the #ENZIAN classification to stage anatomically (compartments A rectovaginal, B uterosacral, C rectum, plus FA/FB/FU/FI; severity 1a–4) — usable by both imaging and surgeon.[2]
- MDT referral with colorectal surgery; renal tract imaging (rule out hydronephrosis); AMH/AFC and an EFI workup if fertility is a goal; counsel explicitly on stoma possibility and anterior resection syndrome.
(b) Excision vs ablation and the DIE preference (3 marks)
One mark per point. [3]
- Minimal-to-mild peritoneal disease: the Burks meta-analysis of four RCTs (346 women) found no significant difference between excision and ablation in VAS pain reduction at 12 months for dysmenorrhoea, dyschezia or dyspareunia.[3]
- DIE and fibrotic nodules: complete excision is preferred over ablation, because ablation cannot reach the depth of fibrosis — ablating the surface of a deep nodule is incomplete and the disease recurs.[1]
- Laparoscopy is the preferred route over laparotomy — less adhesion formation, faster recovery.[1]
(c) Bowel DIE surgical options and bowel-function evidence (4 marks)
One mark per option, one for the evidence. [4]
- Shaving — superficial removal of the nodule from the bowel surface.
- Discoid excision — full-thickness disc of bowel wall removed and closed.
- Segmental resection — radical; removes the affected bowel segment with re-anastomosis; carries anterior resection syndrome risk.
- Evidence: the Quintairos meta-analysis of 13 studies found conservative surgery (shaving or discoid) had fewer events of constipation and frequent bowel movements than colorectal segmental resection — choose the most conservative approach that completely removes the disease.[4]
(d) Nerve-sparing rationale, outcome reduced, predictor (2 marks)
One mark for rationale+outcome, one for the predictor. [5]
- Nerve-sparing surgery identifies and preserves the autonomic pelvic nerves (hypogastric, pelvic splanchnic, inferior hypogastric plexus) to reduce postoperative voiding dysfunction without compromising excision completeness, pain relief or fertility.[5]
- Parametrial infiltration is the strongest predictor of postoperative voiding dysfunction and therefore of who benefits most.[5]
(e) Recurrence rate and postoperative suppression (2 marks)
One mark per point. [6]
- Recurrence is common within 5 years depending on severity, completeness of excision, and postoperative suppression (check the current reviews for the rate range); repeat surgery increases ovarian-failure and adhesion/organ-injury risk.[6]
- Postoperative hormonal suppression is standard to reduce recurrence — the perioperative period is a critical, often-neglected window.[6]
References6ShowHide
- [1]Becker CM, Bokor A, Heikinheimo O, et al. ESHRE guideline: endometriosis. Hum Reprod Open, 2022.PMID 35350465
- [2]Maciel C, Ferreira H, Djokovic D, et al. MRI of endometriosis in correlation with the #Enzian classification: applicability and structured report. Insights Imaging, 2023.PMID 37405519
- [3]Burks C, Lee M, DeSarno M, et al. Excision versus Ablation for Management of Minimal to Mild Endometriosis: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol, 2021.PMID 33310168
- [4]Quintairos RA, Brito LGO, Farah D, et al. Conservative versus Radical Surgery for Women with Deep Infiltrating Endometriosis: Systematic Review and Meta-analysis of Bowel Function. J Minim Invasive Gynecol, 2022.PMID 36184064
- [5]Choi S, Roviglione G, Chou D, et al. Nerve-sparing surgery in deep endometriosis: Has its time come? Best Pract Res Clin Obstet Gynaecol, 2024.PMID 38981835
- [6]Guo SW, Martin DC The perioperative period: a critical yet neglected time window for reducing the recurrence risk of endometriosis? Hum Reprod, 2019.PMID 31585460