Video - Medical Conference - Harry Reich
I have the privilege of introducing Dr. Harry Rich who is well known to anyone who has studied endometriosis or have been involved in laparoscopic surgery. He is truly a pioneer and has helped catalyst surgeons learn these skills and through his techniques, innovative and daring boldness, I think the specialty has evolved. He is a founding member of the Society of Laparoendoscopic Surgeons and he is the foundation of the American Association of Gynecologic Laparoscopists and he is past President of the International Society for Gynecologic Endoscopy and he is very special and we are quite honored to have him speak this morning.
Dr. Harry Rich
Thank you very much Michael and thank Tamer for organizing such a great event. I mean hope first part was pretty much above me but I learnt a lot and I hope so I have to digest it but it was quite an experience. Now Tamer just wanted me to talk about some of the things that I do not like about the treatment of endometriosis and the treatment of endometriosis to me is a surgical treatment of endometriosis. So I just put together a couple of questions and some of them have their answers that are pretty obvious as you could see.
Why are ovaries removed in hysterectomy? Well if you look at our quotes from American College of OBGYN you always get more money if you take out the ovaries, it is true and if you do a difficult operations to take out the ovaries by vaginal route, you get less and if you do it with a big open incision, we have a lot of problems in our specialty but you know, it is a big specialty Obstetrics goes along with the Gynecology. I do not understand that we should change that some day but it is still with us. Why is present day total laparoscopic hysterectomy a rip off? Well it is simple, I will mention that at the end but it is a rip off because of present day codes for the operation do not include pelvic support which is the original operation did so as a result the operations that are being done in many centers, I believe, will lead to prolapse problems in the future.
Why do so many patients with endometriosis have no endometriosis? I always am suspicious when a patient comes in and they have been laparoscope many times and they do not have a pathology report to show if they had endometriosis and we could almost always tell in the exam and if it feels relatively normal, most of the time you are not going to find endometriosis. In my practice, most of the time if I examine the patient and do a good rectovaginal exam which I guess some doctors do not even do rectal exam but if I do a good rectovaginal exam, I should have a very, very good idea where the patient hurts and be able to fix that during surgery.
So I would like to thank you all for the opportunity to express my views about endometriosis. I do believe we need proper guidelines for the diagnosis and treatment of this disease. Please realize that extensive endometriosis surgery can be very difficult surgery probably much more difficult than oncological surgery. I am convinced to this day that what is excised does not come back and we will talk more about that in a few minutes but I want to show you the state of the art when I was at Columbia where I started the department of advance laparoscopic surgery in 1995 through 2000 and this was some, we pushed through the sea. What was really going on with endometriosis at that institution so we looked about a two-year period of time and we found it was a 20-month from 1998 to 1999, 424 patients with pelvic pain had a discharged diagnosis of endometriosis, laparotomy was done in 108 of these patients. But look at the operations that they had, 76 had abdominal hysterectomies, 20 of these had supracervical hysterectomies with bilateral salpingo-oophorectomy. Supracervical hysterectomy was typically done for women with extensive endometriosis that could not be adequately resected at laparotomy despite the present of a colon and rectal surgeon present in 8 of these cases. I found this quite embarrassing because I mean it has same concept of you a patient with endometriosis, you take out the top easy part of the uterus. The uterus and cervix are one organ and you take out the top easy part, sometimes take out the ovaries which is really, I think criminal in some cases and you leave the disease behind. So what is this disease do after that? Well a disease without a uterus, fundus is on the cervix, it has a free route to grow from rectum to the ureters, and to the bladder so some of those cases where we do cervical stunt operations are very, very difficult. Well anyway, well I do find is that no laparotomies were done to excise endometriosis of the deep cul-de-sac, anterior rectum, posterior vagina, rectovaginal septum, and ureters. The only thing that showed that was excised or the only excisional surgery was my laparoscopic surgery. Well anyway, I hope it has gotten better but that was the state of the art in 1998.
My diagnostic approach, well I believe that endometriosis surrounded by scar tissue can be palpitated most of the time in the office. I diagnosed endometriosis by positive specimen. We usually try to excise the specimen. We do not look and say it is endometriosis, we have show that it is. So when we look at the whole literature of endometriosis surgery, many of the operations have no pathological diagnosis, so where we going, what this literature mean. Probably not much, again like I said most women with a diagnosis of endometriosis without biopsy do not have endometriosis and I do not believe in Sampson's theory. If it occurs, no one has ever seen it and I have been with Seckin and he is sure that it occurs so fast that you cannot see it but, I mean, no one has seen it like going through the peritoneum starting to develop that, anyway so onward I am not going to go through the operation of how we take this old part but I will say point to the bottom part there where I said I have no use, would you talk about this for your opinion with different size with different situations. Within our country we have two distinct groups doing laparoscopic surgery, very large cluster doing it for diagnosis and minimal treatment, and a much smaller ureteric segment doing it for optimal treatment instead of open abdominal laparotomy. There persists a poor level of surgical training even with endometriosis, poor reimbursement certainly has contributed. There is still as of 2010 are no codes for excising these different areas of endometriosis. So actually the practicing gynecologist is penalized financially for spending too much time in the operating room instead of the office. Office patient visits and procedures pay approximately 20 times or can be made by operating therefore few gynecologists want to get stuck with complex endometriosis surgical cases involving the rectum, ureters, and frequently the small bowel.
Many women again like I said with endometriosis by multiple operations, I call it, for some doctors, I think they look in as very little, they say there is a little bit of blood from the old period, that is endometriosis. It is really hemosiderin like macrophages where they went in a week later be gone but then they put the patient on Lupron and then a year later they come back and they do another laparoscopy and keep going in that fashion. So I call that simple cashectomy. I think if you do it 20 times that would be complex cashectomy, the extraction of the cash from the patient without ever curing the condition because I did hear some of the comments earlier from I think about some people have gone through multiple operations. If you have ever gone through more than two operations, I would really search for another doctor.
Endometriosis consists of endometriosis glands and stroma surrounded by fibromuscular tissue as accumulated over many years in response to cyclic monthly activation of the endometriosis. It is like when you cut your finger; you get a chronic inflammation around where you cut your finger. I am going to move pretty fast because my time limit is coming close. I want to say that the laparoscopic surgery for endometriosis a lot of it was first presented by myself and Camran Nezhat, this was back in 1985 when Camran did his surgical treatment and that is when he really introduced video to us all. You know at that point I was still looking down the telescope at laparoscopic surgery but I have my endometrioma work presented at that time.
So nice to see a Camran, nice to see you far, you see the guy in between us, was a very famous football player he was from the Chicago Bares, Walter Payton, right? Anyway, so we were doing this work in 1985 where we would excise the endometriosis and I just want to say another thing, this is another pet peeve of mine and that is this idea of deep infiltrating endometriosis, I never see deep infiltrating. I do not see cancer, I see fibrosis, I call it deep fibrotic endometriosis and I believe it makes more sense to call it DFE instead of die. It is not die; it is not a malignancy, but far might give us a little bit more of an idea about that a little bit later. These chunks of tissue as you could see that we removed are all full glands and stroma and always fibromuscular tissue so when we ____.