Juan Salgado-Morales, MD
Retroperitoneum and cul-de-sac surgery
Advancing the Science and Surgery of Endometriosis
Monday and Tuesday, April 18-19, 2016
The Union Club, New York
This is what I do to relax in winter. After we do these types of surgeries we do this. This is my disclaimer. This is a multidisciplinary condition so we use not only ourselves, we use colorectal surgeons, gyn-oncologists also who work with us. We have friends that go with us to the OR.
I have to talk today about retroperitoneal surgery and endometriosis. After 1921 when Dr. Sampson first described endometriosis there has been much research but no single theory has demonstrated the absolute cause of all the different forms of endometriosis. We know it is multifactorial; immune, hormonal, genetic, environmental and anatomical factors are involved. But when we are dealing with retroperitoneal and endometriosis and we deal with rectovaginal endometriosis I go more with the HOX gene studies that Dr. Taylor did. I think it is a different type of endometriosis than what we have in the rectovaginal septum and what we have in the retroperitoneum that could reasonably describe exactly what this patient has and tell us about the etiology of this patient.
What do we need to know before this type of surgery? They are difficult surgeries and you need to be trained. We need to know the anatomy. When you talk about the anatomy of the retroperitoneal space and the anatomy of the vessels and nerves we need to know all the vessels and where they go typically and atypically, all the ____ that could come due to the inflammatory process that we have in endometriosis. We need to know the nerves. Also there was another good lecture about the nerves and how to avoid damage of the nerves so we do not have complications after the surgery because this is not cancer. I would not do a surgery where I remove an endometriosis nodule and then the patient cannot go to the bathroom and needs to catheterize herself from now on. So we have to know all the anatomy in terms of vessels, organs and nerves.
This is how it looks the normal anatomy of a patient with uterosacral ligaments, round ligaments and everything. This is how it looks when you enter and if you do not do the correct job before you do the surgery what are you going to do if you find this? Or what are you going to do when you find this? Just jump in and start to dig there to see what can I do with this patient? This is how it looks in the anterior part with obliterated umbilical artery. This patient was sent to us with five laparoscopies and she was still with pain. What we see here is obliterated umbilical artery. Nobody saw that. We saw the endometriosis that was in the peritoneum and the bladder because you can see that with a sonogram. But they did the laparoscopy, ablate something, we enter, we removed all the peritoneal of bladder and then we removed the umbilical artery. When the patient woke up the pain was gone. This patient slept with her knee touching her chest every night because the pain was very bad.
What we need to know before we do surgery, we have to evaluate this patient with sonography. We will talk later about the sonography but it is very important to have this tool in your office because it will give you guidance to what you are going to do, what you are going to find. If you are going to do a surgery and you go blind maybe you lose a nodule and you will be there and the person is going to have a lot of recurrence. But if you know exactly and do a mapping of the nodules and lesions that a patient has you will for sure resolve the problem of this patient.
We do endovaginal sonography. I will not talk about the literature because Maurice will talk later about that. This is how it looks. We can see everything, every detail in the bowel, every detail in the retrocervical area, we can see the rectovaginal septum without any, any, any complications. It is a simple office procedure with a water enema. This is a picture of the muscles, outer muscularis, serosa, this is the mucosa and inner muscularis and you can see everything there with a sonogram, so you will not miss.
You have a patient here that has a lesion and the serosa is involved. The muscularis is involved. It does not involve the submucosa or the mucosa. I can say to this patient what I am going to do. I am going to shave this lesion. I would not do a bowel resection on this patient. I can tell this patient that the endometrioma is completely adhered to the sigmoid because of the sonogram. I can tell this patient that I am going to have to do a segmental resection because this involves more than 50 percent of the circumference of the bowel. So she knows why she is going for the surgery. I would not guess in the surgery. I will do the correct surgery for that patient.
For this patient, if the lesion is less than 5 cm from the anal verge I will do an ileostomy to prevent any leakage from the reanastomosis because of vascularity. Five cm to the anal verge is less than ___ vascularity when you reanastomosis so this patient if you have a problem I would notify her before she had the problem and I would follow her closely. I would do a ____ enema three months later and if everything is okay I reconnect the patient again.
This was a patient that was referred to us from Florida. She went to do the surgery they talked about us and she went to beautiful Puerto Rico. As you can see we saw everything with the sonogram so we decided that we enter laterally. We go laterally here to identify vessels, ureters and you go from the safe part to the complicated part. You do not start in the complicated part. You go through the highway not through the ____ road. Here are the vessels and the ureter is here. We identified everything and then we go to the place where we have to do the surgery that is more complicated.
This is another case that was referred to our center. They tried to do the surgery and they offered to her to open and we said we could do it by laparoscopy. She had a big endometrioma on the left side. We did a sonogram and identified there was adhesion of the bowel to the endometrioma. The right side was completely normal so we entered. This is the IP ligament. We confirmed the sonogram findings with the surgery findings. We are going to publish a preparative staging with sonography to predict the complexity of the surgery and as you can see everything could be done from the sonogram and could be verified. We are exposing here the ureter and when you expose the ureter correctly you have the IP here, the ureter here, uterine artery here so you know exactly what is going on on this side from the safe part and then you can go to the other part. If we cut, dissect here and here we cut all the circulation from the left side of this patient. We know we are not going to have any problems on that side. There is more of the video.
Let us go to another video. This patient was referred to our office. We found that she had an endometriotic nodule in the right ureter close to the right ureter but it was in the peritoneum. You can easily identify the involvement of the ureter or not with a sonogram. We started from the pelvic brim, we went down. You can see how thick the peritoneum is here. We are going to remove all the peritoneum wall, we have to enter retroperitoneally because it is easier for us to identify all the organs. Here is the ureter. You have to be very careful with the vascularization of the ureter so you do not denude the ureter with vascularization. Sometimes we have to do resection of the ureter and reanastomosis but I have a urologist to do the procedure with us. The nodule is here. It is very important to take care of the instrument that you use. I prefer to use this instrument here because the cooling process of this instrument is less than nine seconds and the temperature that it goes up is not as high as other instruments. I will not mention names because I am not promoting any instrument. But, with this one we can easily dissect very close to the ureter. We are removing the nodule here. Since you have done the sonogram you go directly to the place where the problem is. You do not have to go to other places just to look around. This is the ureter moving easily.
Sometimes, even though you know the anatomy this could bleed because you can have vascularization and when you remove a dozen endometriomas from that retroperitoneum it could bleed. The first thing is do not panic. Alert everybody that probably you are going to have an emergency but do not panic. Do not open the patient right away see if you can resolve it with laparoscopy. In this case here we put some pressure, still bleeding, do not panic. Identify your structures do not get crazy burning everything around the uterine artery. This is the ureter so identify everything before you start to coagulate. We put in the recto-probe and we identify also the rectum here. Smooth and easy, slow but firm you control the bleeding. You do not need to open every patient that bleeds. This is the rectum. This patient was discharged the next day no problem whatsoever. Do not forget to remove the gases when you are inside. If you leave them in there the lawyers will charge you in Puerto Rico $30,000 per each gas that you leave inside. So do not forget to remove them. I do not know how it is here, $100,000? There is _____ that you need to have in the OR. I call them the insurance. It is a life insurance. Better to have it and to need it than need it and not have it. Sometimes you have so much bleeding from all the walls where you just did the surgery that if you have a good __ you do not have to go there and do suturing and more suturing and more suturing. It works very, very well. This one it is amazing how it works. We put it with CO2 and we just spread it out and it really, really stops the bleeding.
In conclusion, you have to know the anatomy to do retroperitoneal surgery. It is a very difficult surgery and if you do not know that either you get to serious complications or you will freak out and stop the surgery and not finish the surgery that the patient needs.
Retroperitoneal DIE is a very complicated condition. Even a colorectal surgeon and gyn-oncologists think that it is more difficult than cancer surgery because you have to save the organs. You have to do an adequate preparative evaluation with sonography. If you do that you will save time, problems and complications for the patient.
It is my humble opinion that lack of adequate preparative evaluation with endovaginal sonography is one of the reasons for such a high recurrence rate of symptoms in deep endometriosis perhaps because a lesion was left behind, partially removed and not because they are new lesions. We know that it takes years to have this type of lesion of deep endometriosis. They are not new it is because we left behind the lesion.
Learn the sonogram, plan the surgery, learn your anatomy and you will have success doing this surgery. Thank you very much.