Advancing the Science and Surgery of Endometriosis
Monday and Tuesday, April 19, 2016
The Union Club, New York
I tell you I love New York. We went to see Woody Allen last night and it was such a great show. A guy had to wake up every now and again and play his clarinet so it was a good show, we did enjoy it.
I think I would like to start with showing you why I personally feel that endometriosis can be cured and should be cured. I will give you the reasons why but let me just show you a case first and see how it progresses. This is an interesting case from the early 1990s, actually before I was at Columbia. Look at that pelvis. She had extensive vaginal disease and you do not see any evidence of any retrograde menstruation there at all, do you? You say, “Well my gosh, this should be an easy case”. Now this is the early 1990s. As I always do I start with my scissors, the old blunt scissors. I cannot get into much trouble with a blunt scissor. I work away with that. I open up the septum between the rectum and the vagina. I hold the camera in my right hand so I am very close to the tissue all the time. I operate with my non-dominant hand, my left hand because that is closest, closest to my assistant who stands between the patient’s legs in most cases.
Look at this now, I am way down in the septum. That is a CO2 laser, which is for some of you a new device, for us it was great. I am way down in the pelvis. I have opened the septum and I am taking out – you can see how fibrotic that is. It is like she had no retrograde menstruation. She did not have an implant in her pelvis, on her ovaries, on her tubes, anywhere in the pelvis and look at the amount of disease that is present. We can pick it up, grab it and try to excise it in many pieces. It is like a hot dog between the rectum and the vagina is what it was. She was sent to me from – I was in Pennsylvania then – she was sent to me from New Jersey when she was 18 years old. Nobody knew what to do with her. She was in acute pain all the time. Her mother found my name somewhere along the line but she brought her there to me. Again, that is the CO2 laser, trying to develop a shelf. I knew I was going to have to open up the vagina at some point and remove the vaginal disease. I did not know how far I would have to get on the rectum. You can see I use a suction irrigator. Now you who use a suction irrigator have suction irrigators with all those holes in the end. Mine never had holes in the tips so I could get an accurate stream, I could get accurate suction. I could also suction the tissue to hold it upward.
You can see the big sheet of tissue being removed. That is all deep fibrotic endometriosis, it is not D-I-E, it is not DIE, which I do not think exists, it is deep fibrosis, which is what I am operating on. I am not operating on cancer.
(Audience – unintelligible question) You could say that. You could feel it, I said, “Ah” my gosh I knew beforehand I was in trouble but we were going to get it done. Seriously, it was like a hot dog, like a big sausage between her rectum and her vagina. You couldn’t believe that she had – her bowel was clean because of the presentation. There is a moral to this story that I will get to at the end. Bear with me for another few seconds, a few minutes anyway. You see part of it. I just let it lay there. I went back because I knew there was a lot more and I knew at some point I was going to have to open the vagina. That is uterosacral
The uterosacrals can be taken up like big long pieces of tissue. They are elongated ligaments. You put them on tension. The same with hysterectomy, you can use your rectal probe to identify them sometimes. They are very high up. Now I am working on posterior vagina with a laser and I think at this point I enter the vagina. At least I could see where it is on the vaginal epithelium. How do we keep the pneumo? My assistant who is standing between the patient’s legs, just grasp the labia and holds them together and I have a very nice view. No big fancy instrument. No glove. We work on the fibrosis not on normal tissue we work right on the fibrosis. Always with scissors you can feel it well with scissors. You can see it well with a CO2 laser. That is the valve Chaux retractor that is in the uterus hauling the uterus sky high out of the field. Now you can see coming across the vagina with a spoon electrode usually I used to fire that up at about 100 to 150 watts cutting current. I have never used coagulation current. It is not in my surgical armamentarium. I use pure cut current and with a broad electrode like that I get good coagulation. It coagulates. I am taking out portions of vagina and I could take them out through the open vagina and check where the endometriosis is. These were the early days of suturing but even then I had my special instrument on the right, which was excellent for using the suture. I always tied from outside in.
What have we not looked at? Here is the rectum and here I am checking the rectum. How do I check the rectum? Every case I was telling you yesterday I have a rectal probe in the rectum. A big probe, I see it, I know where it is and right now I am lifting it upward and excising endometriosis. If you look close you might even see the rectal probe. Ah, there it is the rectal probe. I told you I use a probe in the rectum. (Audience – unintelligible question). No, no, no. There is too much disease around. I have to resect that. Remember I have been resecting rectum well before the general surgeons got onto the gall bladder around 1990. We were doing rectum well before that. We had a real level of comfort with the rectum. I have had some lawsuits but never for the rectum. It is true. The rectum has been good to me.
This is a circular stapler put in through the anus. You can see I have opened up the stapler and I am putting the diseased tissue in the jaws of the circular stapler. So I resect the whole section around the rectum. I push the diseased tissue inside and I take it out. So I have removed it. I saw this patient – you can see I always do the underwater exam 2000 ccs Ringer’s Lactate at least. I leave it in, I check for bleeding. The blood vessels are like little red snakes that I could just go down under water with microbipolar forceps and coagulate. But I do it every case and I have done it in every case for 25/30 years.
The moral of the story is that while I did see her once when I was at Columbia I did a rectal vaginal exam and I felt no endometriosis and then I lost her to follow up. It turned out that my son had bought a home in New Jersey and his next door neighbor came over to him. The next door neighbor with three teenage sons, 14, 12 and I think ten but she came over and asked if I was the father. She was 42 years old, will she ever have endometriosis again? I doubt it. We talked about it in depth. I said really doctors will tell you you might if you have a little twinge here or there because you have periods. All periods do not cause all women to have endometriosis. The truth of the matter is what I believe I do not believe in retrograde menstruation at all. I believe that before you are born some of the cells do not quite make it to the inside of the uterus. They get close. They get onto the rectum, they are in the rectovaginal septum on the outside of the uterus, maybe on the front of the uterus in the bladder area. And they sit there till menarche.
Then probably after menarche they start getting stimulation every month and they get stimulation anytime any of us as endometriosis pay a surgeon sees, what do we see? We see fibrosis. Stimulation causes these cells – you get a little bit of breakdown, you get laying down of fibromuscular tissue. If you have any biopsy without fibromuscular tissue surrounding it or you see any of those things it is not really endometriosis. It is probably the products of retrograde menstruation. If you put off your laparoscope a week or two it will be gone.
Here is our man, I do want to thank him for continually pushing this meeting ahead at the last minute and here we are today.There he is and that is Kurt Semm. He is one of the fathers of laparoscopic surgery. I also want to thank our honoree that is our honoree in the middle with Walter Payton who was a famous football great. We were all having a good time.
(Audience Member: Was Walter having a good time?) No one scoped him. And they may have made a bad diagnosis anyway if they did.
When I started there was no one to learn from. No books, no teachers but there was harassment every inch of the way. Laparoscopic surgery was confined to the operating surgeon. We operated like this. We looked through a scope for my first ten years, if fact, probably that is why I have a new shoulder that I got in December. We operated like that for ten years. Like that, looking through camera with our main assistant between the patient’s legs. All these procedures including a hysterectomy were done with a surgeon’s eye, not a video camera. We videotaped so everybody could see it and the people in the OR could see it. My assistant between the legs could usually operate off the mirror images, which was a great deal.
So we had our three incisions. We used to have lower quadrant, we would have a five and a three and the reason I used a three was because it was so fragile that they could not really hurt the patient if it fell off the lesion. I used basic scissors for the rectum by putting a curette in the uterus and a sponge in the posterior vagina and a probe in the rectum. I could see all my structures. Later on I went over to the valve Chaux retractor, which I still think is one of the best flexors of the uterus and for a long time I thought – we were in the days of Hiscon – and I thought this was ridiculous, that all the patients were dehydrated from sucking out their intravascular volume in to the peritoneal cavity with fluid. I put the fluid right there to start with and it leaked so you had to explain to the recovery room nurses, “Don’t mind the fluid is coming from the inside out, worry about it if it is going the reverse direction. That is where they get the infection. We did not get infections. By and large the technique worked. You could call it like 1980 unconventional operative laparoscopy. These are the many procedures that we did around that time in the small little hospital.
Incidentally I did in 1976 I inherited an infertility clinic with over 100 active patients, none who had ever had laparoscopy. My mother delivered a lot of babies so there was a lot of prolapse in the community for me to work on too. I was a vaginal surgeon first; vaginal surgeon and the midwives helped me get through my ob responsibilities. Early on in 1976 we discovered bipolar oophorectomy. This abstract was rejected by Frank Lawford in the age in 1986 or 1985 when we presented it.
Well, how do you get from this character running the Boston Marathon, which incidentally was yesterday, the last time an American won it was as you see here. It is true actually. I think it was Greg. Greg was in the race in 1982 – first thing was Greg but he won it. The last time an American won it was 1982 and it was not me. So how do you confer a guy like from that to that – simply fucking magic. It is possible.
What did we do? We started figuring out what could we do to get like more advanced? We developed the GIFT program. But the GIFT people said what are you doing with the GIFT program? That is a crazy program when you could be doing laparoscopic surgery. At that point the state of the art was as you see here, “The art of medicine” (or the art of endometriosis surgery in many cases today also) “consists of amusing the patient while nature cures the disease” (Voltaire). It is not new.
Back in 1985 Camran, you can see, Camran Nezhat presented, I presented my oophorectomy and endometrioma work all of which was promptly forgotten but we are still at it. These are slides from 1985. These were not just tiny little endometrioma cases. They were big endometriomas which were excised. I finally did get that published. But anyway I said I thought that was the key endometrioma and gradually these people were not getting pregnant so we gravitated into the cul-de-sac.
With the cul-de-sac we presented in 1987 when I debated at the Endometriosis Association. I debated Robert Franklin on using the laparoscope as a technique and I had 100 cases of cul-de-sac obliteration, and that was my paper, “Laparoscopic treatment of cul-de-sac obliteration secondary to retrocervical deep fibrotic endometriosis – DFE”. We had 100 cases, very poor pregnancy rate as you see. We had a second look, most of them – 33 percent. That was back in 1987. Like 20 years later I am sure the pregnancy rate now that we are much more aggressive with the rectum would be more like 87 percent not 33 percent. That is just my opinion. But we did clean out the cul-de-sac and we were able to put a sponge behind the cervix and dissect all the endometriosis from the sponge. Here is a case where we took down a lot of endometriosis but not enough. We went at her again and you can see we took out a lot more but you can see all the stuff on the rectum. We were not doing the right operation. We were not taking that area on the rectum out which was necessary to get the really high results.
In 1987 I submitted the paper to all the journals. We had a lot of journals in our specialty with the Green and the Grey the Red, forget it. I finally got it accepted at Journal of Reproductive Medicine in 1991 after many years. From that point on these were some of the comments that I received. From that point on I have not read the Green Journal ever, especially ever since then. The AAGL has a journal I have not read that either. Why should I read it? There is nothing I am going to learn from it to tell you the truth. They are not going to accept this kind of work, they never did. But here are the kind of comments I got. “The author is known for his aggressiveness in endoscopy and is to be commended…however the average gynecologist with typical skills of endoscopy (which were none back in the 1980s)…” He did comment that he thought they were not going to operate for eight hours. You have got to operate till the job is done. That is the way our philosophy was. Fortunately I was in a small hospital and I did not operate under the tyranny of time that many of you do. I do not apologize for it. I could go to the OR when I wanted to and my poor wife would tell you dinner was very cold and late in those days. We survived.
The other journals were like that. “Despite the extensive and noteworthy experience, I feel that the article should not be published”. “The aggressive surgical approach could be better depicted in a movie…than in our journal”, that kind of thing. These were all of them. I have all kinds of rejections. But we did get it into the Journal of Reproductive Medicine and that was in 1991. I threw Dr. Salvat’s name on it but he was a friend of mine from France at the time who wanted to be a professor so I said, “We’ll put your name on my paper it’s okay”. That was the way we worked. Again, I had a good operative permit here, I said the patients exactly what you can see in this permit. I would advise you how to use it. It is a good permit, works every time. Early on we were doing lymphadenectomy, we were doing peri-aortic lymphadenectomy, we were doing anything and everything. Our criteria was pretty nil I am sad to say. You read about when you should operate and when you should not operate. With endometriosis we operated on pretty much everything.
This was a great discovery. In the early 1990s I started using the circular stapler. I would take a specimen, push it down in and take it out that way instead of sewing with my hands. I never had a leak with that technique. Test the rectum afterwards, not with air or gas that they talk about. Blue dye is the best. Blue dye will show you thinned out areas where the muscularis is not quite covering the mucosa and you see those areas and you can put a stitch in to reinforce those areas. But the blue dye test, I am not going to show you videos of that. I have them here but you can see the areas that you are too close to the rectum and could end up with a late delayed perf.
The surgery itself it is easy or difficult but the hardest part sometimes is taking down all the small bowel adhesions and correcting for what somebody else did. But after that it is pretty straightforward. We can get into the deep cul-de-sac and do those operations.
Present problems; this will be 30 seconds and we are over by the way. This is the present problem. This was back in 1989 and as you can see there if any of you can read what they say there. Let me see if I can read it here, “Our valuation is completed. Based…” Well, you know it is investigational. Almost everything you do with endometriosis is investigational, “We won’t pay”. So that is a major problem, probably number one. And major problem number two are people like Roy Pitkin, the editor of the Green Journal who felt that operative laparoscopy was certainly a technical gimmick.
But here we are, thank you for giving me a chance to vent out here. It is almost like that.