Surgery for endometriosis — structured oral station (12 minutes)

Opening prompt — "How will you map her disease before operating?"

Model response — imaging plus #ENZIAN plus MDT: ^[1][2]

• "I complete her pre-operative mapping before listing her. I repeat the TVUS with bowel preparation and rectal water contrast, and I arrange an MRI to map the DIE in all compartments using the #ENZIAN-structured report — A rectovaginal, B uterosacral, C rectum, plus FA uterus, FB bladder, FU ureter."^[2]
• "I check renal function and image the renal tract for hydronephrosis — ureteric DIE can cause silent obstruction. I check AMH and complete an EFI workup because she wants to preserve fertility."^[1]
• "Crucially, I refer her to a multidisciplinary meeting with colorectal surgery before any operation — DIE involving the bowel is an MDT disease."^[1]

Probe 1 — "Her MRI confirms a C-compartment nodule invading the muscularis. What is your operative plan?"

• "Laparoscopic, nerve-sparing, complete excision. For DIE and fibrotic nodules I excise completely — ablation cannot reach the depth of fibrosis and the disease recurs."^[1]
• "For her bowel disease, the options are shaving, discoid excision, or segmental resection. The Quintairos meta-analysis found conservative surgery — shaving or discoid — had fewer events of constipation and frequent bowel movements than segmental resection, so I choose the most conservative approach that completely removes the disease."^[3]

Probe 2 — "Why nerve-sparing, and who benefits most?"

• "Nerve-sparing identifies and preserves the autonomic pelvic nerves — the hypogastric, pelvic splanchnic, and inferior hypogastric plexus — to reduce postoperative voiding dysfunction without compromising excision completeness, pain relief, or fertility."^[4]
• "Parametrial infiltration is the strongest predictor of postoperative voiding dysfunction, so deep lateral (B-compartment) disease needs the most careful nerve preservation."^[4]

Probe 3 — "She is frightened about a stoma. What do you say?"

This is a scored communication domain — demonstrate it out loud: ^[1]

• Move to her eye level, use her name, acknowledge the fear: "A stoma is possible but not certain — it depends on what we find and on the safest way to remove the disease while protecting your bowel function. I will plan your operation with a colorectal surgeon so we use the most bowel-conserving approach that completely removes the endometriosis. We will talk through every option, including the chance of a temporary stoma, before you decide."^[1]

Probe 4 — "She wants children. How does that change your plan?"

• "I do not delay her fertility workup. I counsel explicitly that bilateral endometrioma cystectomy can lower AMH and risk premature ovarian insufficiency, so I preserve adnexal function. At surgery I complete an Endometriosis Fertility Index to guide expectant vs ART — a high EFI supports a trial of timed intercourse."^[5]
• "Recurrence is common within 5 years, so postoperative hormonal suppression is standard to protect her fertility window from recurrent disease."^[1]

Probe 5 — "How would your plan differ for a 52-year-old with a similar nodule?"

• "In a postmenopausal woman, an endometrioma or pelvic mass is malignancy until proven otherwise. I would arrange tumour markers and imaging with IOTA/simple rules, and involve gynaecological oncology before any operation — the assumption is no longer benign endometriosis."^[1]