Endometriosis Foundation of America 2014
Outsmarting Endo - Juan Salgado-Morales, MD
State of the Art Surgical Procedures for Endometriosis
I will be talking about state of the art laparoscopy for endometriosis. This is my disclosure.
I am going to take you through a journey of how I do this at my office with my patients to convince them of the best surgery to do. Let us just talk a little about this that you have been reading about. Prevelency is ten percent; one of every ten women is diagnosed with endometriosis but we think it is underreported. The average diagnosis is around 28 years old, either because the patient thinks there is too much pain or because the physician is not looking for what is causing that pain. The fertility association is about 30 percent and the pelvic pain is around 70 percent.
The only definite diagnosis for endometriosis is by laparoscopy but what else could be done before doing surgery so the patient can have state of the art laparoscopy? When I used to do laparoscopy I would see a lesion that looks something like this and I always asked myself, ‘how deep does this go'? When I look at a patient with endometriosis lesions I did not know how far I could go down because I did not have any tools that helped me to do the precise laparoscopy that that patient needed.
Does every patient need surgery? Of course not; most of the common complaints are fertility that we have talked about with Jeff, pain or sometimes they have both things. The treatment should always be individualized and management should be initiated after careful analysis of symptoms and imaging examinations. We have to do a thorough examination, we have to do pelvic exams, rectovaginal exams, we have to do all the history of this patient and listen to the patient. It takes me about an hour to be with the patient and do imaging examinations. There are different types of endometriosis that cannot be diagnosed by sonography but there are some that can be diagnosed very well this way. We have to discuss with the patient the consequences of the procedure; what are the benefits and what are the risks; what she is going through and the reason for the treatment and for what reason is she having laparoscopy. Is it for pain, for infertility or both?
I explain to my patients that you can have different types of endometriosis. I tell them about superficial endometriosis that I can see with laparoscopy or there are areas where there could be endometriosis that cannot be seen without the help of sonography studies before I go to surgery.
What imaging tools do we have available for DIE (deep infiltrating endometriosis) now? We have sonography and MRI. These are some pictures I brought from my patients. I showed this patient that she had a lesion where the circumference of the lesion was more than 50 percent of the bowel. This patient was oriented of the precise surgery that she needed because of the pain was a bowel resection. I have to get there, go down to the nodule, remove that nodule, remove that part of the bowel and reconnect the bowel. With this patient we knew with a sonogram exactly how far the lesion was from the anal ¬¬¬¬___. We knew before we got to surgery if this patient was going to have an ileostomy, a little bag that we put because if it is less than four centimeters there is high probability they could have some leakage. We have to risk reanastomosis for at least three months with a ____ enema and if everything is okay we go back, reconnect again and we put everything inside.
In this patient we knew she had a bladder lesion so she knew from the very beginning that she would go into the O/R and we were going to do a laparoscopy. We were going to go to the bladder, we were going to cut that bladder and remove that lesion from the bladder, we were going to suture and that she would go from the O/R to her house with a Foley catheter for a couple of days until the suturing absorbed and she was healing.
I could tell with a sonography how many layers of the bowel was involved in this lesion, if it is the serosa, the muscularis, the submucosa or the mucosa and help us to decide what type of surgery this patient would have.
For ureters, which is the tube that brings the urine to the bladder the best study is MRI. There are no good studies in sonography that can help us to identify the lesions in the ureters so when I have lesions in the ureters I prefer to use MRI to identify the lesions and do the correct surgery for the patient.
Many patients come to my office and say that the other physician said that open surgery is much better and safer for the patient than laparoscopy. I believe in God but everyone else has to show me data. So, I show them data. This was a study done by Chapron that minor complications were 40 percent lower in laparoscopy versus laparotomy and that major complications were the same. I convinced them that if I have less minor complications and the same major complications why would we do a laparotomy? Is that because your other physician does not know how to do it by laparoscopy? Let us try a laparoscopy to give you the benefit of this type of surgery.
Then I show what laparoscopy provides; better visualization of the pelvic cavity, it is like if we have our eyes inside. We have cameras with high definition. We can see very well inside, we know exactly where we are going to cut and what we are doing. We have less formation of adhesions and we have faster discharge of the patient to home. If I do a hysterectomy for severe endometriosis my patients go home the next day. I know that here in the States there are some doctors that discharge the patient the same day to their homes. There is also less postoperative pain. I guarantee that many of the physicians here that do laparoscopy go to the recovery room and ask their patients how they are doing to find they only have throat pain because of the tube for the anesthetic, but no pain in the abdomen.
The indications for laparoscopy: Pelvic pain refractory to pharmacologic treatment, severe disease with anatomic distortion, large endometriomas, bowel involvement, urinary obstructions, contraindications for hormone therapy and potential malignant disease as well. The objectives for laparoscopic surgery for endometriotic lesions include; eelieve the pain of the patient, improve the fertility of the patient and most important, improves the patient's quality of life.
But it is very important - yesterday we were talking with Arnie and Jon that there is a high recurrence rate. We have to advise the patients before we do the surgery that there are microscopic endometriosis that we do not see and that she will probably have a recurrence in the future. But if we remove the large lesions that are in the bowel the pain relief is going to take a while until another lesion that big grows again. So we can resolve the problem but we cannot promise that we can cure the patient of endometriosis.
There are two laparoscopic approaches for endometriosis, which are conservative versus complete. Conservative consists of maintaining the uterus and as much of the ovarian tissue as possible in order to preserve fertility. This is from the Fertility Society, a review they reported in Fertility and Sterility in 2012. The benefit of laparoscopic treatment in minimal or mild endometriosis is insufficient to recommend laparoscopy solely to increase the likelihood of pregnancy.
They reviewed and stated that stage three and four endometriosis without no other identifiable infertility factors conservative surgical treatment may increase fertility.
This was a patient I would not ______that was referred by the infertility doctor because he could not reach the obvious when he was doing the IVF so she was referred for a cystectomy of the chocolate cyst, which was the endometrioma and we just went in and removed the it. We identified that she had water in the fallopian tubes that is __hydrosalpinx. We removed the fallopian tubes and resolved the problem. She went back and the patient was pregnant. When we remove the endometriomas it is very important to orient the patients about ovarian reserve that we talked about earlier before.
As you can see on this table these are patients that have surgery for ovarian cystectomy and look here at how the anti-mullerian hormone went down in six months from 1.78 to .72 so we have to orient this patient and do an anti-mullerian hormone before we do the procedure. We inform the patient that your anti-mullerian hormone is low, your ovarian reserve is low, if we do the procedure it could go lower.
The complete surgery is characterized by total removal of the uterus with or without removal of the ovaries. The indications for complete surgery are; recurrent conservative surgeries where the patient continues with the pain, disabling pain without reproductive desire, associated uterine diseases that must be treated with hysterectomy.
In conclusion: State of the art laparoscopy is the one that the patient really needs. State of the art laparoscopy is the one that is well planned and well discussed with the patient. The patient has to be aware when I do orientation with the patient I show videos, I show all the studies. I go with the patients. I give my phone number and I say that after the surgery we are going to be together and that we are going to have a great, great surgery but you have to be together with us. State of the art laparoscopy is the one that is done by an expert surgeon doing the surgery; by Dr. Tamer Seckin, like Dr. Harry Reich, like many, many surgeons around. And state of the art laparoscopy is the one that you do only once. We work very hard to prepare the patient and only do one single surgery to resolve the problem.
Thank you very much.