Endometriosis Foundation of America
Endometriosis 2013 / The American Perspective
Improving Your Endometriosis Surgery & Rationale for Excision Surgery - Tamer Seckin, MD
The reason I picked this topic is that I am challenged all the time over my work, why the patient's results? Many times the patient teaches us what to do and we have to review our work. When they come back with your surgery or with others' surgery, with continuous pain or dissatisfaction you do not feel good about your work, and you feel bad about the other guy's work too. When it is the other guy's work you get their operative report to see what he has done. You look at the issues, you screen and you must be as honest as you can to the patient. When it is your work I believe you have to be the same to the patient.
The only thing that shows us is you have to take pictures and you have to videotape. There is no way by just looking at the OR report you can tell every fact. What strikes me though is the issue of burning and lasering. It has really touched me with respect to not developing lesions. I believe it does affect the outcome of these patients.
Excision, the mentality behind excision is removal of all endometriosis and associated scarring with the intention of leaving behind disease-free tissue. The endometriosis lesion by itself and its scarring is a total pathology. It is not only the lesions, the glands, the classics of what you hear and what you read, there is associated scarring and it stains positive with today's immunological stains. As you know this surgery is one of the most difficult surgeries that you can do - it is worse than any cancer surgery and has been known as such for many years.
I do endometriosis surgery. In the last four years the numbers we have done were above 400. We have done 3,500 excisions and in one case we did 34 excisions. In every case we use just scissors and micro bipolar back up, but at times we use cutting current scissors also. There is tenderness of these lesions. We believe these lesions originate from, I personally believe and as it has been written by others, they originate from the endomyometrial junctions, from the basal cell. And it brings this stemness, the character of stemness to these lesions. Stemness is one of the...of this rationale I would say from my talks. That really makes you look for things, the root of inflammation, the scarring and depth of it.
The peritoneum is an organ. It is an organ to be respected. It is clear, it is shiny. It is a beautiful slippery layer of mesothelium and there is underlying basal membrane, extracellular matrix obviously between cells and fibril collagen material with nerves and blood vessels underneath. When it is under the effect of the endometriosis though this peritoneum over the years gets battered and sort of these mesothelial cells separate from each other. Inflammation really starts with the heavy effect of the iron and the body's reaction to...of mass cells. There are hypoxic elements happening in the supra mesothelial lesion and obviously there is an SOS. There is inflammation underneath blood vessels and there is reaction to this oxidative stress. At one point this is how neo-angiogenesis happens and saves this cluster of debris up there. Obviously it is not as simple as that but I just want you to understand how I think and I try to do it through animation.
The last picture that you see is what I call my little mouse. This actually, if you look back, it is actually swimming. If I irrigate with water this folds like that. I have the whole picture not for that purpose, but I believe, and you see how the...anchored by vessels. This is another hello to Dr. Redwine. I showed this to him.
There are micro menstrual sort of vesicles. There is micro menses, and here you are, all these vessels. Whether these have glands or not is yet to be seen but the thing is some of them I really cannot get any pathologist to do a micro-biopsy on. But, I will show you what is happening though in my picturesque presentation.
These little bleedings is a common finding, especially with my underwater blue examination I see these contrasts. As you see, this little bleeding becomes more dense iron deposits, it bled the vessel and then there is fibrosis that follows that. Similarly it gets bigger on the pelvic sidewalls.
This patient I remember very well. This is a bigger lesion than it looks. It is deep and it has a 3D extension envelope. It ends up being, as you see in this rectum, vesicular and can completely glue the rectum and the posterior cervix. You see the lesion on the...the lesions on the upper, under gas pressure. You see some discoloring and some glandular appearance. It is stuck to the surface. However when you put them under blue water you see how they float underneath, they are vegetative lesions, another floating version of this here. Here is a little movie that you probably saw. You can irrigate this with water. You see how these lesions are swimming, they are really projectile lesions. It is interesting to see this as it gives you a real dimension of how much you really have to excise. It becomes these constrictive fibrosis, here it is. So what happens with fulguration? When you apply fulguration to peritoneum this animated video tells you: common sense; the surface tension increases, it brings all the sub-peritoneal tissue more clustered together. It does increase scarring, there is no pathology there, no specimen and you do not know how much of the lesion is left behind. As Dr. Dan Martin explained also you do not know how deep the thermal effect reaches down there.
Similarly, maybe less surface tension, less scarring but again, there is no backstop unknown remaining lesion, no pathology but it leaves a nice, clear, very assuring tissue behind. That does not mean the lesion is out. In excision though it is more humble, an old classic you just see what you treat. You go border free, three dimensional removal; you can go as deep as the lesion invites you to. You may end up in the bowel that is fine. That is what you are doing, you are removing the lesion. In every case you go in, if you are not sure about yourself, suturing is difficult to complete these surgeries because you do not know where you are going to end. You may easily go into the bowel and you have to repair it.
This is basically a simple left uterine vein area. What I want to show you is this classic Wolff scissors that we all learned, I learned, from Harry. Many of the things I do are basically what I have seen from him in the very early 1990s. Wolff scissors have never betrayed me. It makes you feel the tissue, it is cheap, it is always available you just have to sharpen it.
This is how I do it. After I inspect I put in water and I start to closely scan the peritoneum under blue water. It eliminates light reflection, eliminates red and yellow, eliminates the great gas pressure on the superficial lesions which otherwise by floating you may see. You see different, different pictures. Then I examine. The picture that was shown before was really a different picture in which I excised the peritoneum. Dan Martin showed that picture. That picture was retroperitoneal endometriosis. After I look at the peritoneum I hydro-dissect the peritoneum with blue water again. I use that contrast and see whatever I do not see by other means. You are going to see it right now. This is what happens when you hydro-dissect. The lesion is up there. You see peri-lesions at the peripheral. They are very wide, this portion of the peritoneum pathology. When you look from the back you see these windows. These are all CD10 positive at time endometriosis positive lesions. It is nice to see this fibular network without leaving a lesion. This is the right side of the same patient. Look how the peritoneum is nice and clear, and this side how the peritoneum is with defects.
This is the patient that Dr. Dan Martin showed you. I apologize but I could not send him a text. This is what we saw, this was the lesion and this was the territory I had already cut before. So I am going to lift this up for you. You see more lesions over there. But when I cut, I saw this, so endometriosis even in the early stage of the lesion you can find and...this abnormality and I have been seeing it. There is a light reflection there, and there is a light reflection there and another light reflection. When I look under the water to see what we saw, it is much clearer. This is definitely endo positive. I typically suspend the ovary. This is the same patient after with it. This is what the lesion shows, fibrosis and endometriosis - the same lesion. I had to beg the pathologist. It is so important to go up there and tell them what to do.
I am going to show you one excision case. It is a case that I did a couple of years ago. Basically just to show you how I do this. This is how I suspend the ovary. Simple, one grainy needle, one needle puncture I can suspend the whole, that is one action, go through. Pull the needle back and put a sponge there. I tie from above and I take this out three or four hours later - maybe six.
The same patient, the opposite side you see deformed left ovarian fossa. The case starts with a little bit of blunt dissection. You see how it is, you do the ovariolysis. This ovary is suspended so it is easier to manipulate, right? Basically, this is what you do, this is how it goes. Let's show it here; basically you go retroperitoneum by using bipolar, you gently advance, and lift this whole peritoneum layer up like this. You can go as fine as you can. This whole peritoneum leaf is lifted up. This is the excised specimen of this case. This is what happens when you blow it up. How this lesion and you see the peripheral defects. For me this is exciting, I have not seen anybody reporting this or showing this. In these cases we are really excising all these peritoneums in total and I never regretted it. There were quite a few pregnancies following these cases. When you look back the adhesions, on these sides are so minimal and free, it has to be bone dry - hemostatically controlled underlay.
This is a case I showed yesterday. A hospital worker, I think, that I saw. A 38-year-old who had four laparoscopic surgeries in the past, she has hydronephrosis, loss of kidney function and she has a ten year stent history. She was advised to have a hysterectomy and a nephrectomy. When you look at this case you see the laser work that was done before. The doctor who did the case had described it with "superficial endometriosis over the right ureter was evaporated". He also elaborated and described the chocolate cysts in this area. This is what happens, the chocolate cysts are still staying there. There is no way, by any other means than indurated pelvic exam, you can tell it is there. They are very small. With the first move of the scissors we see the chocolate cyst and as you go around it there is more cyst. There is a picturesque representation of the lesion; it goes all the way to the right pelvic sidewall to the obturators. This case is excised completely by scissors. You see the obturator is on the right side of the ureter, bladder and pubic bone. In the end the ureter is free but superficially the serosa is a little bit on the...we kept the stents in this patient another six weeks. The stent was taken out and following IVF the patient got pregnant and has given birth.
So, this is a little bit of neurolysis of the left side. I remember this patient very well, she had multiple endometriosis surgeries. As you start doing your sigmoid mobilization you have to really pay attention to where you are. This sigmoid, as it was removed, there was a lesion we saw and this patient had significant left side pain. After this she was relieved of her pain.
Many times when you go in you do not really know how deep you will go or what you are going to find in these lesions. This is a patient that we saw the stricture way up. This is a bowel example. As you know, whether it is a hysterectomy or a bowel nodule, it is all excision. Hysterectomy is excision. Bowel resection is an excision. You should think from that concept. Just an incomplete shaving will not help you. When you go in, when you are committed to reap the disease, you will be challenged at one point when you remove the nodule, you will be challenged. In this case you are trying to advance, to direct the probe. It is not going to go above a certain point even though it is very off the rectovaginal septum. We are working on the nodule with cutting it, shaving it; however, the passage is still obstructed so we made an inter-operative decision in this case to remove the segment. The rectal probe is there, you still push it up, there is no way, you see the sheath is there. We remove the nodule and we do after that an anastomosis.
I think that is it. The bottom line is the recognition of lesion is the key. If you do not see it you cannot treat it. Understanding the disease is another aspect of it. The disease is deep and the depth comes from the intense inflammation that we cannot comprehend. There are many mechanisms involved. It is really very behind the scenes even though you lift up a very minimal lesion there are lesions underneath. Remember our...study embolysis, their lymph nodes 34 percent of the time in certain depths of bowel. In 17 cases there was significant lymph node involved. Before you leave the case you really have to make sure you did the whole excision.
Thank you very much.