Endometriosis Foundation of America
Medical Conference – 2012
Deep Fibrotic Endometriosis of Cul de Sac and Bowel
Harry Reich, MD
Before I introduce Dr. Reich just a perspective from the over 50s set. I think to use the camera as a tool I think the trick to advanced laparoscopy is just to make a video. Because if you do that there is no bleeding, the sutures place themselves effortlessly and the ureter appears magically with perfect well choreographed peristalsis. So I think you just press the record button and the case proceeds perfectly.
I have a soft spot in my heart for pioneers. I trained with Dr. Barber who invented the concept of a pelvic exenteration. Advanced cervical cancer can recur centrally, involve the bladder and involve the sigmoid and he just invented the concept of taking those organs out, rather bravely, in the 1940s and 1950s and he cured half the patients. I was in an office with Dr. Decker, Wayne Decker whose father Albert Decker went to the morgue and just invented culdoscopy, where you placed a scope with the patient in a knee-chest position and you placed the scope through the cul-de-sac and you were able to visualize the tubes and ovaries rather well. Dr. Chiara, we all use to up-to-date - the residents go to the internet to get the latest. He invented the concept of knowledge as a dynamic and textbooks as an open dynamic issue. He had updates placed each month and well, this was when I was a kid. There is no better introduction of Harry Reich than to realize that he is on one of the slides that Dr. Chiara plays. Dr. Chiara’s slides go back to the 1800s with the invention of hysterectomy and they proceed into the 1900s. Lo and behold in 1989 Dr. Harry Reich up and invented advanced laparoscopy and the first laparoscopic assisted vaginal hysterectomy. I think that is the best way to place Harry Reich in perspective. So, I invite you to talk.
Thank you very much. I am going to change my order of talk a little bit because Antonio is going to come back and show a lot of hysterectomy indications and what not later and maybe some cases. But what I would like to ask right now – are there any general surgeons in the audience? Are there any urologists in the audience? Because that is going to make me really change my talk because I wanted to show some of the complications in those special fields.
I just recently heard that the American Urological Society is trying to make most urologists doing robotic prostatectomy to get them a way to grant them bowel privileges. Evidently the injuries to the rectum are more than we ever thought and I think I would like to see gynecologists move in that direction. But I would have liked to see that for the last 25 years but still we call the general surgeon to help us in some of those situations. We will show you some of that, some of the early days of general surgery done by laparoscopy in the next 30 minutes.
For the residents these are some handouts that were printed up on a chapter I wrote in 1988. It goes through the basic techniques of laparoscopic surgery through the beginnings. For me, my beginning was laparoscopic oophorectomy in 1976. So I felt very comfortable as a vaginal surgeon doing most things without abdominal incision from a very early time. The idea of doing the whole operation laparoscopically came on a day when (mic went dead from 5:00 – 5:12) two other cases were canceled so I did the whole operation laparoscopically instead of doing the upper part laparoscopically, which would be the oophorectomy part, and then going down below to do a vag hyst. Soon after that we started doing the whole operation through the laparoscope. By the end of 1988 we were doing the whole operation in many cases laparoscopically and not abdominally.
I am just going to show you a couple of important ideas I have about hysterectomy and then we are going right to endometriosis, so that way Antonio will know what he has to correct me on when he gets up here later.
Financial disclosure: I did have some interest in Apple Medical but it was bought by Cooper and I have no idea what they are doing with those nice little show cards that we developed in the late 1980s.
General surgery, it has been a revolution in laparoscopy, an abrupt and violent change. While in gynecology, as we all know, has been a slow evolution and it is slowly evolving and the robot may have something to do with hurrying our cause. I believe as people get better and better with the robot that they will throw it away and go back to doing the whole operation with the laparoscope, with laparoscopic basic instruments, which we know we can do. Hysterectomy, well we know you can do it abdominally, vaginally or now laparoscopically. If we review the literature quite concisely it says that vaginal hysterectomy is best and should be performed when possible. Where vaginal hysterectomy is not possible, laparoscopic hysterectomy may avoid an abdominal incision. What types of hysterectomies are being done in the United States now? Well, most are being done still by laparotomy, and of the laparotomies it is surprises me that 6.4 percent are supracervical. With laparoscopic we see a smaller number but 9 percent of all hysterectomies today are supracervical. This statistic disturbed me and I will tell you why in a minute. You can check out how vaginal hysterectomy has frustrated many of us practitioners with its acceptance with Dr. Julian’s editorial OBGYN Journal 2008. Supracervical hysterectomy is done 9 percent of cases in the United States but in Denmark it is done in 30 percent of cases. So I asked myself “what is a hysterectomy?” I thought the cervix was part of the uterus but many of you do not think that anymore. Is a hysterectomy simply taking out the uterus or more? Well, does taking out the uterus include prophylactic or indicated vaginal support repair? That is a very important area that I have been interested in for a long time.
Every meeting I go to though there is a big session, sometimes a whole day, on correction of prolapses. Especially now that mesh, which I had trouble accepting in the first place, and never did, now that people are looking at that a little bit more carefully, I suspect that industrial boards sit there and they sit there and they say “what can we do after the uterus is out?” Well, one thing you can do is do not take out the whole uterus, leave the cervix and you can have another operation and then after that you can another operation for the prolapse that will occur in many cases with a hysterectomy with the supracervical approach as I will show in a minute.
Why are we doing total abdominal hysterectomies? The Richardson technique was mentioned by Dr. Chiara. In 1929 it was published and it was written in response to problems created by supracervical hysterectomy. The major changes in technique introduced were extrafascial removal of the entire uterus with anchoring of the anterior and posterior vaginal cuff at the corners to the uterosacral ligaments. Well, what is a supracervical hysterectomy? To me it means take out the top. Leave the bottom where the pathology is, especially when we deal with endometriosis, I will get to in a few minutes. Charge lots of money but please do not call it a hysterectomy if the cervix is considered part of the uterus. Removal of the uterine fundus with preservation of the cervix – the data up to this point is very questionable. For every article we read about speculations regarding loss of orgasmic ability, other articles pretty well indicate that this certainly is not true. We are dealing back to an article from Finland by Kilkuts who dealt with severe hypermenorrhea patients at that time and most of the people in Scandinavia have rejected that concept. When we talk about pelvic support in reality pelvic support is vastly improved over baseline if the uterosacral ligament cardinal complex is attached to the upper vagina and endopelvic fascia is brought together.
Quickly, do we have data on all this? I would like to show you some data – skip through a couple of slides – and get to the most important article on this whole debate that I know about. That is this article if any of you have not read it you should, Pelvic Organ Prolapse Surgery Following Hysterectomy for Benign Indications. So you say how could be get and see what is really going on? This came out of Sweden and in Sweden they have a registry and in that registry they have a list of every single person who had a hysterectomy. And that goes from 1973 to the present. So they could compare 162,000 women with hysterectomy to 470,000 without hysterectomy and look at the modes of hysterectomy in relation to future surgery for prolapse problems from the cervix or the cuff. What they found is overall risk of subsequent prolapse surgery was increased by 50 percent after abdominal hysterectomy with an incision. It was doubled after subtotal hysterectomy and it was quadrupled after vaginal hysterectomy. That does not bear well I do not think for subtotal or especially for vaginal.
If we analyze the data though the last two areas there are on laparoscopic type procedures and we will see that they are going to go along around the same rate as subtotal hysterectomy. Why is that? The bottom line is that people who do laparoscopic hysterectomy in most places today still do not pay enough attention to cuff prolapse and cuff support. By that, I mean with some of our industrial devices that have come out, especially this little device that sews, the sewing machine device from, I think it is from Covidien, no support could possibly be obtained using such a fine little device. The vaginal cuff just hangs there with no support. In many of these cases in the future we will find we have prolapse. The data is there. Supracervical, if you do it, and you talk to people like Tom Lyons who is an advocate, he spends a little time on the uterosacrals bringing them into the cuff. I think it is important if you do this operation do not doom your patient to another procedure down the line for cuff prolapse.
My conclusion: there is some bad laparoscopic surgery being done out there and hopefully we should do better in the future for our patients. Vaginal hysterectomy I think again, you have to grab those uterosacral ligaments and bring them together. My solution has always been, the way I was trained, was to bring the uterosacrals and the vaginal epithelium together across the midline with a high McCall type culdoplasty that you could do vaginally but you can do better laparoscopically because you could see the ureters, you could see where they are, you could really take the uterosacral almost up to the sacral promontory without considering vaginal mesh.
I am going to stop right here and go to endometriosis. We will be discussing hysterectomy a little later on.
I have been assigned laparoscopic treatment; cul-de-sac and bowel endometriosis. When I started treating endometriosis the state of the art was similar to in the 16th century. The art of medicine consists of amusing the patient while nature cures the disease. Unfortunately, with endometriosis that does not occur, if they have endometriosis. I question whether many of the people diagnosed with endometriosis today truly have endometriosis. Remember retrograde menstruation if you look in causes, brown little spots sometimes in the peritoneal cavity. That is not endometriosis. Endometriosis is a diagnosis made, in my feelings anyway, it is a diagnosis that can be made in the office as I put in this slide, with a good exam. But really the sine qua non is endometriosis glands and stroma in the pathology report; under the microscope shall we say.
Let us do a quick slide on diagnosis. A rectovaginal exam should be done routinely in patients with pelvic pain and/or past history of endometriosis despite patient discomfort. I see there are many residents here. I ask you, do you do rectal exams on most of your patients when you see your patients? Does anybody? I see some head shakes this way (negatively). Somebody who is dealing with pelvic pain or endometriosis type patients, or people who are susceptible to it, you have to do a rectal exam. Because if you do a rectovaginal exam you could elevate the cervix with the index finger and feel the whole posterior part of the pelvis, especially the uterosacral ligaments. At least if you are going to do surgery on a patient you could map out where the patient hurts and where at least a biopsy should be taken. I would like to stress that do an exam, do a good exam, elevate the cervix and feel the uterosacral ligaments as far as you can up.
Endometriosis treatment choice: Medical treatment never works. In my 30 years of practicing I do not know of a single case where it worked. I know of not a single case where it eliminated endometriosis. So, if there is endometriosis present you put people on suppression and you come back six months later and it will still be there. Your choices are pelvic reconstruction by laparoscopy or laparotomy. Hysterectomy has always been a poor choice for endometriosis because many of the surgeons when they do these operations they leave the endometriosis behind. They do intrafascial dissection leaving endometriosis on the vagina and especially on the rectum. Again, the supracervical I say supracervical disgrace because, well, you will see in a second when I quote some of the figures that I saw at Columbia.
At Columbia I said, “Well, is the treatment of endometriosis by laparotomy a myth?” When I was at Columbia, and this is what we looked up in 1998-99, we found 424 patients with pelvic pain discharge diagnosis of endometriosis. Laparotomy was done in 108 of these patients. At Columbia, over a 20 month period of time, 76 patients who had laparotomy had abdominal hysterectomies, and 20 of these had supracervical hysterectomy with bilateral salpingo-oophorectomy. Supracervical hysterectomy was typically done for women with extensive cul-de-sac disease that could not be adequately resected at laparotomy despite the presence of a colorectal surgeon for eight of these patients. I hope that is not the situation today. But, that is the way it was back then a little over ten years ago. No laparotomies were done to excise endometriosis at Columbia that we found. Laparoscopy I think mainly when I was there was only excisional cases that would find their way to the pathology lab.
I stress that it has been a long time coming this concept of excising endometriosis. But we have been doing it for so many years and we have been presenting it to, I sense, deaf ears.
This is a paper I had published in 1991 after submitting it for four years to various different journals who just said this is something that gynecologists should not do. Notice I said Laparoscopic Treatment of Cul-de-sac Obliteration, this was the 100 cases Secondary to Retrocervical Deep Fibrotic Endometriosis. Deep fibrotic endometriosis not deep infiltrating endometriosis. Somebody else I think at an academic center came out with a concept of infiltrating endometriosis. Well, I do not believe it. I do not believe endometriosis is infiltrating. I think it is fibrotic disease surrounding endometriosis glands and stroma. I think deep fibrotic endometriosis is a lot better term than DIE. DIE – it is not DIE, it is not a malignancy, it can involve any pelvic organ including bowel, rectum, bladder. Radical surgery? I think of patients with pain, I think it is mandatory. Unfortunately, it does necessitate advanced training such as for malignancy type surgery. That is happening now. With a robot your oncologists are doing more and more laparoscopically and they are gravitating towards endometriosis as they run out of cancer cases.
These operations have been around for a long time. Thomas Cullen wrote about endometriosis before 1900. In 1914 he said a removal of extensive adenomyoma of the rectovaginal septum is infinitely more difficult than a Wertheim hysterectomy for cancer of the cervix. Endometriosis again, you take chunks of tissue, look at them under the microscope, you see glands, stroma and fibromuscular tissue. Take another specimen inside the septum, you should see that same thing, glands, stroma and fibromuscular tissue.
We will start with some relatively easy situations, like this. You can see not much endometriosis here, a couple of little spots. Whenever you see white, if somebody says there is endometriosis and there is no white, I do not believe it. It is not endometriosis. Endometriosis has to cause some damage to the patient. That damage is chronic inflammatory response. So you get white fibrotic tissue surroundings. Here we are, here is endometriosis. We look. Okay, what do you do? Now, I like my technique, it is called scissors. I use cold scissors with micro bipolar back up. I think Antonio goes more to polar now it looks like in that little picture stuck in your head. But I like cold scissors because I can feel the disease, it is hard. If the tissue is soft when you cut it is not endometriosis. Usually you want to stick at the junction of normal with deep fibrosis. Deep fibrosis you could usually lift up and cut across it and because endometriosis blood supply is a microvascular blood supply you get some oozing. But in most cases it will stop pretty much over the following five minutes. You can cut across it. If you did this with normal tissue there would be a lot more bleeding. But if it is chronic inflamed tissue, engorged tissue, with developing microvasculature you could cut across it, it is okay. And it helps you to see your landmarks better. You know if you cut a uterosacral ligament during hysterectomy surgery it bleeds. If it is filled with the endometriosis nodule the bleeding is minimal and it will stop on its own.
We are going to take out this chunk of the cul-de-sac. As you can see here is the chunk of tissue, this is what was there. Now let us see what is left over. The tissue over the vagina has been removed. But here I come over to the right uterosacral ligament and notice, again, you can cut on the fibrosis and come across, in this case from right to left. The end of it is to get the rectal disease. It is almost always if you have rectovaginal endometriosis which septal area is most common because the rectum is tented up there, there is going to be some disease on the rectum. You have to decide how you are going to handle that. Here we come over to the rectum. The first part of the operation is to separate rectum from vagina down to the loose areolar tissue to the rectovaginal septum. We can then, because it is deep fibrotic disease, lift it up. We could feel it. This is another area why I asked that question about the urologists with a prostate because you are working close to the rectum. We are working very close to the rectum. We can in many cases take these lesions off without getting into the rectum. We will come back and get the rest of that lesion here in a second. In this case it is like a transverse ____ lesion. I can come very close and go right across and stop it.
Let us continue. Three techniques we have for the rectum; shaving, which you just saw. We could put a probe underneath inside the rectum and shave across it. We could excise it in a disc excision, and more and more you see people doing the segmental resection today.
Here is a nodule. First part of the operation is to separate the rectum from posterior vagina down to loose areolar tissue of the rectovaginal septum. Here is the loose areolar tissue of the septum. This is what the rectum looks like after you separate. There is a lot of endometriosis in that. What I do is I use a circular stapler. This is a technique I developed in the early 1990s. The year 1995 I did 35 of these bowel resections. The technique is basically to take the lesion, invert it into the jaws of the stapler, as you can see and fire it. Here we insert the stapler, we can put the whole lesion into the jaws of the stapler. Bring the stapler together anteriorly. Usually my assistant will hold the handle far down so I do not get posterior wall rectum and I fire it. Then we check it under water with blue dye. This so-called flat tire test does not really work. It will not show you very thinned out areas. You will think there are no leaks but if you have blue dye, as I hope to show you in a few minutes, you will see the thinned out areas of the rectum.
In this case we then take the stapler, separate it, take the specimen out. You see it takes a nice specimen. Here we look under the microscope and one can see in the muscle wall the endometriosis glands, stroma and fibromuscular tissue, and also in this case coming through the mucosa.
Again, I said medical treatment never works. If you look at cure rates with Lupron in almost all studies they are near zero regardless of disease. Staged surgery, most reports are over 50 percent – they say cure. I do not think so. I did not have 50 percent cure, what do we mean by cure rate? The only way you find a cure rate is by doing another laparoscopy at some interval in the future. That is what I feel anyway. This was presented in 1988 and basically we presented 100 cases, 67 percent persistent endometriosis after extensive excision. Remember this is 1983 to 1988. Our cure rate, I would think then, was 33 percent. With more modern techniques I am sure today it would be, I get up to where my colleagues around the 50 percent range, maybe more.
The other thing is the concept of interval laparoscopies. You can look at that too. I think that the endometriosis exciser in most cases will, should maybe consider a second procedure, rarely more than two. You should be able to get the job done then and does it come back? I do not believe so. My experience if you remove the disease, it is gone.
Let us go to the technique. Basically I use sharp scissors. I operated with my eye for the first two years of video, and I switched over to just using video in the early 1990s. In the early days we used a curette in the uterus, sponge behind the cervix and a probe in the rectum. I like the Valtchev manipulator because I can move the uterus up and down and around and see the cul-de-sac well. These are some early cases, you can see a lot of disease down there. We would free the rectum and clear these areas. Again, cases like this I just show you this to say we have been doing this a long time. It is not something just new at this point.
The surgery, as you see with all that disease, first off you usually have to take down adhesions, usually from other surgeries, mainly other laparotomy surgeries. We take down the disease, we separate the rectosigmoid, find the ureters if they are connected, most of the time they are not. Most of the time if you take a uterosacral ligament and pull it toward the midline the ureter sort of goes away. But if not, you have to dissect it out in rare cases. The cul-de-sac dissection part of it just really means separating the rectum from the posterior vagina. Once all that is done we excise the disease.
These were some of the earlier cases. This is one of the first times that we started using the robot. And I said that some of these cases came to two laparoscopies. This is one such case. Look at that – the rectum is fused to the back of the uterus and I am using a carbon dioxide laser. I wanted to show you how we did it with cutting current electrosurgery but that slide misfired. We were able to use the carbon dioxide laser, hard to see much with the cameras in those days. This lady had extensive disease and we excised a lot of cul-de-sac disease. When we looked at her again, this was two years later, you can see the cul-de-sac is still free but she has a rectal nodule. This was a case back in 1989. I believe this is the first rectal resection and this was back in 1989. I had to resect that and that did the trick.
I think I better say thank you at this point. Antonio is going to talk about hysterectomy a little bit more and we will talk more about endometriosis for the next two days. Thank you very much for your attention.
Endometriosis Foundation of America