Conservative surgery for severe endometriosis: should laparotomy be abandoned definitively?

According to current opinion, surgery at laparotomy for conservative treatment of endometriosis is obsolete. The debate on the indications, modalities and results of surgical treatment for the most severe forms has recently been rekindled. Although some expert endoscopists propose advanced techniques to deal with the most problematic pelvic lesions, various authors wonder if such interventions have been demonstrated as efficacious and safe enough to justify abandoning the standard reference treatment. We have reviewed the data, comments and proposals recently published on the topic. The available scientific evidence appears insufficient to recommend laparoscopy instead of surgery at laparotomy, even for the most severe forms of endometriosis. Intestinal, vesical, periureteral, retroperitoneal, and vaginal lesions and large endometriomas associated with extensive dense adhesions may still benefit from classical surgery at laparotomy. However, the lack of comparative studies prevents a correct comparison of the methods in terms of pregnancy rate, resolution of pain and incidence of recurrences.