**2. General indications for surgery of endometriosis**

Indications for surgical management of endometriosis include:


Abdominopelvic Complications of Endometriosis 67

endometriomas or adhesions, and they are more appropriately managed surgically (Kennedy *et al.*, 2005). The growing popularity and widespread diffusion of operative laparoscopy has fostered a spread of surgical procedures in women with endometriosis (Vercellini *et al.*, 2009). However, due to the relapsing tendency of the disease, postoperative recurrences are very common (20-40%), and a further surgical procedure is performed in 15-

Conservative surgery preserves the uterus and as much ovarian tissue as possible. Very limited information is available on the effect of repetitive conservative surgery for recurrent symptomatic endometriosis in terms of postoperative pain relief (Vercellini *et al.*, 2009). Pain relief is achieved in most patients who undergo laparoscopic ablation of endometriosis and adhesiolisis. However, the long-term outcome appears suboptimal, with a cumulative probability of pain recurrence between 20% and 40% and a further surgical procedure

Busacca *et al.* (1998) compared surgical outcomes in patients reoperated either at laparatomy or at laparoscopy. The crude recurrence rates of moderate to severe dysmenorrhea, deep dyspareunia, and pelvic pain were, respectively, 22%, 30%, and 35% in the laparotomy group and 29%, 25%, and 32% in the laparoscopy group. The 24-month cumulative probability of recurrence of dysmenorrhea (34% and 43%, respectively) and non-cyclical pelvic pain was not significantly different in the two groups. However, in the patients operated by laparotomy, the rate of recurrence of deep dyspareunia and the number of

The effect of repetitive laparoscopic surgery on pain is similar to that observed after firstline surgery, with a 5-year cumulative pain recurrence rate of 20% after the first surgical procedure and 17% after the second one and cumulative rates of retreatment of 19% and 17%, respectively. This fact confirm the effectiveness of repeat conservative surgery in the treatment of recurrent pain, which is more likely to be associated with severe disease,

High recurrence rate is the demonstration that surgery alone is a suboptimal treatment for a chronic disease such endometriosis. In order to possibly reduce recurrences of endometriosis, it is important that all surgical procedures including primary surgery are performed by experienced surgeons and that prolonged ovarian suppression is established

In these conditions, one of the clinical dilemmas regards the indication for and the potential benefit of reoperation. In women wishing for conception, uterine denervation may be performed in addition to repetitive ablation of endometriotic lesion to improve long-term antalgic results. Laparotomy or laparoscopy plus presacral neurectomy has better results than surgery only in regard to: recurrence of dysmenorrhea at 1-year follow-up (17% and 25%, respectively), dysmenorrhea relief at 6 and 12 month follow-up (87% vs 60%, and 86% vs 57%, respectively), severity of dysmenorrhea, dyspareunia, non-menstrual pelvic pain

adhesions and deep intraovarian or multilocular cysts (Fedele *et al.*, 2006).

20% of cases (Busacca *et al.*, 1998; Fedele *et al.*, 2006).

patients requiring a third intervention was higher.

postoperatively (Vercellini *et al.*, 2009).

**4.2 Pelvic denervating procedures** 

between 15% and 20% (Fedele *et al.*, 2006; Vercellini *et al.*, 2009).

**4.1 Repetitive conservative surgery** 
