Endofound’s Sixth Annual Medical Conference: Ending Endometriosis Starts at the Beginning
Clinical diagnosis of endometriosis in adolescents using the robot
John Dulemba, MD
Thank you Dr. Seckin, Endofound, Lone and Harry, thank you for the invitation. After all that we have seen so far this is probably going to be actually a pretty boring, not very glamorous discussion because when we talk about teens or adolescents with endometriosis the disease is not very apparent. One of the drawbacks of today is that we are only going to visualize my pictures and any videos that I have here in 2D. As I argued with Dr. Michel Canis he said it was HD that was important for this disease and I went “no it’s 3D”. We argued, he did studies with 3D and he now agrees with me. This is a disease that affects a lot of women.
To begin with you have heard lectures all day, you heard them yesterday, today, you are going to hear more. Pain is not normal. Does that mean we need to operate on every single patient? As a teen probably not but I think what we should do is to begin giving the choice. If their symptoms are interfering with their normal functions let them have a choice, do not just hand, as ACOG is saying now, hand them medical treatment. Sure, if that is what they and their family want to do – do it! But please offer surgery to these patients. Why do we want to wait? Think of this as your sister, your daughter, your wife, anybody. If they are adolescents, well maybe not adolescents as a wife, but what you want to do is you want them to be healthy, lead a nice normal functioning life and too many times I see patients come into my office as late teens, 30s, 20s, 40s and what do we see? We see all the videos we just saw. It is great. We look like great surgeons, we are so proud of ourselves. But we have relegated these patients to decades, decades of suffering! Come on, do not do that! We are out there to help them. If these patients had cancer, a little bit of cancer in their hand, you would cut it out. Do we sit around and say, “You know what, let it spread because I want to see how good of a surgeon I am and then I want to get rid of it”. What is your success rate going to be then? It is going to be a lot less.
Laparoscopic appearance of endometriosis – many of you have probably seen slides exactly like this. We all know it is like fighting the revolutionary war to get past the black/blue lesions, the powder burns – yes, they can hurt but we know that all of these other lesions can cause pain and it is probably endometriosis. But what we have not seen because we are not doing 3D are the terrain changes. I did not believe it.
I happen to do surgery for the AAGL Intuitive one year and when I put the camera in, because it was a patient referred to me who had had robot surgery and said, “I don’t do endometriosis on the bowel”. I said, “Ah, this is the perfect patient for me”. I got her all ready, we are getting ready to transmit, I put the camera in, I am looking at the big HD screen and sweat starts pouring down. I see nothing. It is probably as pristine a pelvis as I have seen in a long time. So what do I do? I start to panic. I am like “Oh my gosh, what am I going to do for an hour?” I took a deep breath, sat down at the console. She had an endometriosis all across the cul-de-sac, across her rectum and the left pelvic sidewall but I could not see it two dimensionally. The problem was that everybody who was watching was watching in 2D. The moderator went, “Great dissection” as he was probably thinking “what are you doing?” And the pathology report came back as endometriosis. It is out there. There are terrain changes. We have tried things like dripping blood or fluid along the surface. Dr. Redwine used to drip the blood. You can kind of see things but until you get in there with the 3D you do not see it.
If you do not think it makes a difference, any of you that have cars? Drive home with one eye. You can do it but you are better with two than you are with three. In 2013 in the Journal of Robotic Surgery, which is not Index Medicus so it is not on Medline I published 280 patients retrospective study looking at standard laparoscopy versus robot laparoscopy. What came out? Eighty percent the specimens endometriosis versus standard laparoscopy 57 percent. The key was here on the appendiceal. I was fascinated on this data because 14 years before I had presented a paper, 85 patients, I had a four percent endometriosis rate in the appendix, 30 percent. I am so embarrassed now that I did not start the robot until early 2007. I had about a year and a half before that I could have started helping my patients more by finding endometriosis. In this study there were about ten patients starting from age 14 up to 20.
This is actually a breakdown. You can see everything was pretty similar between the two groups. I did have 180 patients on the robot side because it was my first 180 patients. I had been doing laparoscopy since I came out of residency in 1986 and I started the robot in 2007. Would it be fair to go 100 to 100 - probably not. So by going 180 that sort of got rid of the newness of the robot. And as you can see, confirmed endometriosis biopsies, appendectomy, the percentage was pretty close. I only took out the percentage of 23 percent versus 30 percent in the standard laparoscopy. But as you can see times were about the same. That is one of the arguments, “Oh my gosh the robot is so much more time”. Yeah, in the beginning. Think back to when you started doing laparoscopy. Was it time consuming? Of course it was. Complications pretty much about the same other than I did have one cystotomy on the robot side.
There is another study, early detection is key and the conclusion is this; endometriosis in adolescents is an important differential diagnosis from pelvic pain ovarian cyst. Ages ranged from 17, almost 18 to plus or minus two years. We know that early detection by all the data that is out there is important. Yang, he had in 53 of his patients in 63 of the ones that received GnRH postoperatively they had no recurrence observed, and a higher recurrence rate of endometriosis 56 percent in young women by Tandoi. What we are seeing is it is important to go in and operate. But we see recurrences. Why do we see recurrences? Could it be that we did not see it? Or it grew back? We do not know. All I know is if any amount of endometriosis causes pain I think most of us would agree that you want to get rid of it.
This is a slide post-op adhesions a problem following wide excision because that is one of the arguments you are going to hear, “Oh my gosh adhesions are going to form if you operate on these young teens”. Complete excision average of 23 months follow up, eight patients were operated on and this is completed excision – was safe, did not have adhesions. And this was Dr. Yeung and actually Dr. Sinervo I think, if I am not mistaken, you were involved in this study also. So you look back in there were no adhesions after complete excision. So yes, you can get adhesions from surgery but we have seen that you can get adhesions from endometriosis. We want to get it out.
Here is a picture of an 18 year old with some endometriosis right in here. I heard you had a lecture this morning, sadly I missed it, on the Firefly and this is a picture of that same view with Firefly. It is a little bright in here but there are some lesions, some abnormal blood vessels that show up with Firefly that you cannot see without that injection. Here are some more in the cul-de-sac. You can see a lesion here. You can some fluffy areas. Those are all areas of endometriosis you cannot visualize without the Firefly, and one more once again, little tiny fluffy areas.
The next few, three, pictures are going to be a 15 year old. You can see some endometriosis right here but there was actually a large amount of endometriosis here on the other side that was on left uterosacral ligament. Then on the right there is endometriosis all along here, all along here, not just in one or two spots but all along there. Then we have the cul-de-sac you cannot see endometriosis in this cul-de-sac – you cannot. I did three dimensionally and this is what the excision looked like at the end, a 15 year old. Wide local excision beyond where the endometriosis was, even on the rectum. What would have happened if I had missed it, if I had just done it two dimensionally? Maybe nothing.
Superficial disease does precede advanced disease. So her disease was probably superficial. This is from, actually Dr. Libby and Dr. Cook’s slides but as you can see Dr. Redwine and a few others all looked at these subtle lesions and then if you do not do anything this is what you end up with! Yes, you can do the surgery, you are great surgeons but do not let them suffer.
I do want to briefly go over disadvantages and cost. I have the next slide I want to talk about that. You have to have a robot. It is a little harder to access quadrant but you can do it! I have been to all four quadrants, longer surgical times, okay, maybe five minutes, ten minutes, decreased staff communication. Advantages? Cost! My fenestrated bipolar hot scissors are less expensive than one harmonic scalpel. Now, it is more expensive than a pair of scissors you are going to have to sharpen that you have been using since the 1960s or 1970s but yes, I want to get all the endometriosis. I want a sharp pair of instruments. Magnified ten times, stable camera. I thought we had great videos? I have to turn my head away because I start to get a little seasick watching these videos. Wrist action, better ergonomics, I am relaxed. Obese patients – we all agree it is difficult to operate on obese patients. Your arms are standing out there. It does not make a difference when you are using the robot. In fact, thin patients are more difficult because your instruments bang together. And I feel that because of the 3D we have better visualization of endometriosis.
Cost? I think it is time to put this to bed, time to quit beating a dead horse. I already talked about that. If you do a lot of cases you are down to about $500 extra a case not counting the instruments. If you do four you are down to $300 a case. Does that cost money? Yes.
In conclusion, data and common sense demonstrate that more endometriosis is visible with 3D. Medical treatment is not the answer. Any amount of disease can cause pain. We need to help these patients, do not let them suffer for decades and we want to give the patients the best opportunity to be symptom and disease free. If anybody has any questions they can…
Harry Reich, MD: Where can I get one of these things?
John Dulemba, MD: One of the robots?
Harry Reich, MD: Looks too good to be true.
John Dulemba, MD: One of the robots too good to be true? Well, we have a physician owned hospital, 52 beds. We have two robots. If it was not going to make some money we would not have them. Trust me, the physicians would say no. It is multi-specialty. Urologists use it, general surgeons, colorectal – you name it, they all use it. It helps
Audience Member: (Unclear)
John Dulemba, MD: That was the cul-de-sac. Now we are on the left sidewall. It is a little light in here but there are some abnormal blood vessels in there. You only have a window of about a minute. I only use Firefly on patients that are under 20 because after that I am going to start seeing adhesions. If there is any blood in the pelvis at all it is useless. I am just showing a picture of some dissection with the robot. The wrist action, once you start using wrists you do not want to give it up. The first probably 25 to 50 cases you are still acting like you have straight instruments but as you see I am just cutting across the rectum because my magnification is so great. I see so much. You can see I am just dissecting out and it is like I said it looks like benign tissue here. What is he cutting out? Trust me there is endometriosis it comes back, maybe not in every single cell. By the way I have a voice activated manipulator so it was moving to the side. So you can see that I use the same techniques as I use laparoscopically that everybody else uses here. Hot scissors, I am just cutting. You can see the ureter off here on the right and then you just dissect the same as you would do with standard laparoscopy, it is just easier, I am not saying it is easy, it is easier. I personally think it is safer. You are more comfortable. You can see more and you can access more.
Audience Member: What do you think the learning curve is?
John Dulemba, MD: Well, if you are an expert at laparoscopy, which not everybody is, and that is the thing, laparoscopy is really hard; you do not realize it until you start watching other people. I did 25 easy cases before I started doing any endometriosis cases. I would say probably in the 25 to 50 range and then you might, your skill levels in laparoscopy are going to decrease and your robot skills are going to increase and then you have to decide am I going to stick with standard laparoscopy or am I going to go? That is what I would say.
Ken Sinervo, MD: How about the extra cost of the Firefly, is it not about $800 a case?
John Dulemba, MD: Yes, it is from the injection, right. That is why I limited how many people I do and who is going to get it.
Ray Wertheim, MD: I would just like to make a couple of comments. I think that cost is an issue and I am giving a talk later. I should have brought a football helmet because I am going to create some controversy. But my point is most of the people using the robot today do not have your skills. I have seen it used for simple ovarian cysts and things that can be done quicker, cheaper and easier with traditional laparoscopy. So if the robot is going to be used it should be used to full advantage with someone that can do dissections like you can.
John Dulemba, MD: Should not that be said for laparoscopy also?
Ray Wertheim, MD: Absolutely.
John Dulemba, MD: Because you go out there and you would be shocked at what is going on.
Ray Wertheim, MD: I am going to show those statistics later.
John Dulemba, MD: It is so, so hard for people to do standard laparoscopy. It is easier for them to do this. I taught somebody, a nurse who had never been in the operating room, in 20 minutes how to suture and tie 8 0 vicryl. You cannot do that with standard laparoscopy.
Ray Wertheim, MD: I beg to differ. I think that you need to learn the anatomy and how to dissect tissue first.
John Dulemba, MD: I agree.
Ray Wertheim, MD: Before you need to become an expert traditional laparoscopist before you even think about going to the robot.
John Dulemba, MD: Then that would eliminate a huge portion of the world.
Harry Reich, MD: Oncologists who knew their anatomy went to the robot without laparoscopy because it is very, you really have to know your anatomy I think. And laparoscopy is probably harder to learn your anatomy than the robot, right? Is that fiar?
John Dulemba, MD: I agree.
Harry Reich, MD: One observation I have is that most people when they go to laparoscopy today they sew the same as they would at laparotomy. They have somebody holding the camera and they do that kind of stuff. Very few people use their hand like this and this, back hand. Now I stand on the patient’s left and I have always sewed, even though I am totally right handed, I have always sewed with my left hand by going backhand. Nobody does that and these are basic tools of regular laparoscopic surgery. If you are stuck in an OR with an assistant who has trouble holding the camera and doing all that kind of stuff…
John Dulemba, MD: Dr. Liu taught me back in 1993. I was not as good as him but I could suture.
Harry Reich, MD: We have another robotic talk coming up.