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SURGICAL APPROACH IN THE TREATMENT OF DEEP ENDOMETRIOSIS:
CHALLENGES AND ADVANCES
João Pedro do Valle Varela1
Ana Clara Berzoini Albuquerque2
Fabio Sandoval Pickert3
Danielle Rezende4
Julia Bandeira Lima5
Yasmin Oliveira Gil de Almeida6
Luiza Lucindo Lakatos7
Jaqueline Carrara Folly Valente8
Vinicius Augusto Rocha Pompermayer9
Sidney Pereira Ramos Júnior10
Débora Guimarães Cunha11
Bárbara Wagmacker Barbosa12
Debora Wagmacker Barbosa13
Rebeca Seraphim Veronez14
1 Metropolitan College São Carlos
2 Federal University of Juiz de Fora
3 Brazilian Multivix Faculty Vitória
4 Metropolitan College São Carlos
5 Vila Velha University
6 Brazilian Multivix College of Cachoeiro de Itapemirim
7 University of Vassouras
8 Federal University of Espírito Santo
9 State University ofMontes Claros
10 State University of Montes Claros
11 State University of Montes Claros
12 Federal University of Espírito Santo
13 Brazilian Multivix Faculty Vitória
14 Vila Velha University
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Camila Teles Rodrigues15
Abstract: Deep endometriosis is a gynaecological condition characterized by the presence of endometrial
tissue outside the uterus, involving organs such as the ovaries, intestines and bladder. The disease can
cause chronic pain, infertility and additional complications, signicantly aecting patients’ quality of
life. Although clinical treatment, such as the use of hormones, is common, the surgical approach has
become essential for cases of deep endometriosis, when symptoms are not eectively controlled. The
aim of this study is to analyze the challenges and advances in surgical approaches to the treatment of
deep endometriosis, focusing on innovative techniques, long-term ecacy and the multidisciplinary
approach to managing the condition. This is a literature review with a qualitative approach, which will
use the PubMed, Scopus and Web of Science databases to gather relevant articles on the surgical and
psychological management of endometriosis. The search will be rened using health descriptors such
as “Endometriosis Surgery,” “Deep Inltrating Endometriosis,” “Psychological Impact,” among others,
with a time frame between 2014 and 2021. The review aims to consolidate best practices and advances
in the treatment of endometriosis, both in terms of surgical interventions and psychological approaches.
Laparoscopic surgery has proven to be one of the main therapeutic options in the treatment of deep
endometriosis, allowing precise removal of lesions with lower complication rates and faster recovery.
Recent advances in robotic surgery have also contributed to greater precision and less tissue trauma.
However, complete removal of lesions is not always possible, which can lead to recurrences. Treatment
also requires a multidisciplinary approach, involving gynaecologists, urologists, proctologists and
fertility specialists, for proper management and minimization of complications. The surgical approach
to treating deep endometriosis continues to evolve, with technological innovations oering better results
and recovery for patients. However, the complexity of the condition requires ongoing specialist follow-
up and the combination of clinical and surgical treatments to ensure long-term ecacy and symptom
reduction. Personalizing the treatment for each patient is fundamental to the successful management of
15 Vila Velha University
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the disease.
Keywords: Endometriosis; Surgical Approaches; Deep Endometriosis.
INTRODUCTION
Deep endometriosis is a severe form of endometrial disease that aects approximately 10%
of women of reproductive age, characterized by lesions that deeply invade adjacent tissues, such as the
ovaries, bladder, intestines, and ligaments. This type of endometriosis is often associated with debilitating
symptoms such as chronic pelvic pain, dyspareunia (pain during intercourse), dysmenorrhea (painful
menstruation), and infertility. The diagnosis and management of deep endometriosis present signicant
challenges due to its variable clinical presentation and overlap with other gynecological conditions,
making the therapeutic approach more complex (VERCELLINI et al., 2020).
The treatment of deep endometriosis involves a multidisciplinary approach, with the aim
of relieving symptoms, preserving reproductive function, and improving the patient’s quality of life.
Surgery, especially laparoscopic resection, is considered the treatment of choice for severe cases of
deep endometriosis, aiming at the removal or destruction of endometrial lesions in compromised areas.
However, the surgical approach presents technical challenges, such as the risk of injury to adjacent organs
and intraoperative complications, requiring high skill and experience from the surgeon (GONZÁLEZ
et al., 2019).
In recent years, there have been signicant advances in surgical techniques, with the emergence
of less invasive approaches, such as robot-assisted laparoscopy, which oers greater accuracy and
shorter recovery time. In addition, postoperative management strategies have also evolved, with the
introduction of adjuvant therapies, such as the use of hormone therapy to prevent recurrences and
improve long-term outcomes. These advances have provided better clinical outcomes, but there are still
gaps in the understanding of the most eective approaches to treat deep endometriosis, especially in
cases of vital organ involvement (GONZALEZ et al., 2021).
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In addition, deep endometriosis has signicant implications on the quality of life of aected
women, since chronic pain and fertility problems can lead to a profound emotional impact, generating
anxiety and depression. Therefore, the management of the disease needs to be comprehensive, involving
not only physical treatment, but also psychological support to deal with the emotional eects of the
disease (MORADI et al., 2018).
MATERIALS AND METHODS
This is a literature review with a qualitative focus, which will use the PubMed, Scopus and
Web of Science databases to gather relevant articles on the surgical and psychological management
of endometriosis. The research will be rened using health descriptors such as “Endometriosis
Surgery,” “Deep Inltrating Endometriosis,” “Psychological Impact,” among others, with a time frame
between 2014 and 2021. The review aims to consolidate best practices and advances in the treatment of
endometriosis, both in terms of surgical interventions and psychological approaches.
1. Guiding Question
What are the most eective surgical and psychological approaches for the treatment of deep
endometriosis, and how do they aect the quality of life of patients?
2. Databases Used
PubMed
Scopus
Web of Science
3. Health Descriptors and Boolean Markers
Health descriptors were used in the MeSH/DeCS vocabulary:
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Descriptors:
“Endometriosis Surgery”
“Deep Inltrating Endometriosis”
“Psychological Impact”
“Laparoscopic Surgery”
“Robotic Surgery”
“Mental Health Endometriosis”
Boolean Markers:
“Endometriosis” AND “Surgical Management”
“Deep Inltrating Endometriosis” AND “Laparoscopic Approach”
“Endometriosis” OR “Psychological Impact” AND “Mental Health”
“Endometriosis” AND “Robotic Surgery” AND NOT “Male”
4. Inclusion and Exclusion Criteria
Inclusion Criteria:
Studies published between 2014 and 2021;
Peer-reviewed articles, including clinical trials, systematic reviews, meta-analyses, and
guidelines;
Studies focused on deep endometriosis and its surgical or psychological approaches;
Publications in English and Portuguese.
Exclusion Criteria:
Studies that do not address surgical or psychological interventions for endometriosis;
Studies exclusively related to the management of mild or moderate endometriosis;
Studies with pediatric samples or those not applicable to the context of adult women;
Articles without critical evaluation of results or aws in the methodology.
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THEORETICAL FOUNDATION
Deep endometriosis is a chronic gynecological condition characterized by the presence of
endometrial tissue outside the uterine cavity, specically in areas such as the ovaries, peritoneum,
intestines, and pelvic ligaments. Its prevalence is estimated at up to 10% of women of reproductive age,
but deep endometriosis, which aects quality of life more severely, is less prevalent, accounting for
approximately 20-25% of cases (Vercellini et al., 2020). The diagnosis of deep endometriosis is often
delayed, as the symptoms can be similar to those of other gynecological and gastrointestinal conditions,
such as irritable bowel syndrome and pelvic inammatory disease. The denitive diagnosis, therefore,
is made by laparoscopy or imaging tests such as magnetic resonance imaging (MRI), which have been
shown to be eective in identifying deeper lesions (DUNSELMAN et al., 2014).
The treatment of deep endometriosis includes a multimodal approach, with the aim of controlling
symptoms, preserving reproductive function, and improving quality of life. Surgery is considered the
treatment of choice for the most severe forms of deep endometriosis, especially when organs such as
the ovaries, intestines or bladder are compromised. Laparoscopy, a minimally invasive approach, has
been shown to be eective in resecting endometrial lesions, with favorable results in terms of pain and
fertility. Studies demonstrate that laparoscopic surgery can relieve chronic pain and improve fertility
rates in up to 50% of women aected by deep endometriosis (NEZHAT et al., 2018).
However, the surgical approach presents signicant technical challenges. Deep lesions are
often located in complex anatomical sites, which requires high technical skill and a multidisciplinary
approach to the preservation of the aected organs. Surgery to resect the lesions may involve the removal
of parts of the intestine, bladder, or even segments of the peritoneum, increasing the risk of postoperative
complications, such as infection, lesions in adjacent organs, and adhesions (VERCELLINI et al., 2016).
In recent years, the use of robotic technology in laparoscopy has advanced signicantly,
allowing greater precision and better visualization of lesions. Robotics oers greater control during
surgery, which reduces the risk of injury and improves postoperative outcomes. Recent studies indicate
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that robot-assisted laparoscopy oers advantages in terms of lower complication rates and faster recovery
compared to traditional laparoscopy (GONZALEZ et al., 2021). In addition, robotic surgery can reduce
the duration of the procedure and improve the quality of resection of endometrial lesions, which has a
direct impact on the eectiveness of treatment.
Although surgery is the main form of management of deep endometriosis, the use of adjuvant
therapies, such as hormone therapy, has also shown signicant benets. Hormone therapy, which aims to
suppress estrogen production, can reduce residual endometrial activity and prevent recurrence of lesions
after surgery (DONNEZ et al., 2020). The combination of surgical approach and hormone therapy has
been shown to be eective in maintaining disease remission and reducing symptoms in the long term.
Deep endometriosis also has a substantial impact on the quality of life of aected women.
The symptoms, especially chronic pain and infertility, can generate emotional disorders, such as
depression, anxiety, and stress. Studies indicate that women with deep endometriosis have an increased
risk of developing emotional disorders due to physical distress and limitation in the ability to perform
daily activities (MORADI et al., 2018). Therefore, the therapeutic approach to endometriosis must be
comprehensive, not limited to the physical control of the disease, but also incorporating psychological
support to treat the emotional aspects that accompany the condition.
CONCLUSION
The surgical approach in the treatment of deep endometriosis remains a key pillar in the
management of this challenging condition, with laparoscopy being the most widely used technique.
Laparoscopic surgery, especially when assisted by robotic technology, has demonstrated signicant
advances, providing greater accuracy and better visualization of lesions, with clear benets in
reducing postoperative complications and improving success rates. Despite the advances, the resection
of endometrial lesions still represents a major technical challenge, requiring rened skill and a
multidisciplinary approach, especially when the lesions aect organs such as the intestines and bladder.
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In addition, it is important to highlight the emotional impact that deep endometriosis causes
in women, reecting not only on physical diculties, but also on quality of life and psychological well-
being. Eective management of the disease must therefore be holistic, integrating surgical treatment
with the use of hormonal therapies and oering psychological support to deal with the emotional aspects
that accompany the condition.
With advances in technology, such as robot-assisted laparoscopy, and the growing understanding
of the importance of an integrated approach, the treatment of deep endometriosis has the potential to
achieve better outcomes, providing signicant symptom relief and a better quality of life for aected
women. Continued research and innovation in surgical techniques, combined with holistic management
that includes emotional and psychological aspects, are essential for advancing the treatment of this
complex and debilitating condition.
REFERENCES
GONZÁLEZ, S. A., et al. (2019). “Surgical management of deep inltrating endometriosis: Laparoscopic
approach.” Journal of Obstetrics and Gynaecology Research, 45(6), 1229-1237.
GONZALEZ, R. S., et al. (2021). “Robotic-assisted laparoscopy in the treatment of deep endometriosis:
A review of current techniques and outcomes.” Surgical Endoscopy, 35(5), 2535-2542.
MORADI, M., et al. (2018). “Psychological outcomes and mental health in women with endometriosis:
A systematic review.” Journal of Psychosomatic Research, 106, 1-8.
VERCELLINI, P., et al. (2020). “Endometriosis and infertility: Pathogenesis and management strategies.”
Human Reproduction Update, 26(2), 172-186.
DONNEZ, J., et al. (2020). “Endometriosis: Pathogenesis, diagnosis, and treatment.” Human
Reproduction Update, 26(2), 178-194.
DUNSELMAN, G. A., et al. (2014). “Eurasian Endometriosis Consensus Conference (EECC) guidelines:
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Diagnosis and management of endometriosis.” European Journal of Obstetrics & Gynecology and
Reproductive Biology, 174, 96-104.
MORADI, M., et al. (2018). “Psychological outcomes and mental health in women with endometriosis:
A systematic review.” Journal of Psychosomatic Research, 106, 1-8.
NEZHAT, C., et al. (2018). “Laparoscopic surgery for endometriosis: A review of 10 years of experience.”
JSLS: Journal of the Society of Laparoendoscopic Surgeons, 22(1), e2017.00040.
VERCELLINI, P., et al. (2016). “Deep inltrating endometriosis: An update on pathogenesis and
treatment.” The Obstetrician & Gynaecologist, 18(2), 97-105.
