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Surgery for Endometriosis - Options & Opinions - Amanda Chu, MD

Surgery for Endometriosis - Options & Opinions - Amanda Chu, MD
Endometriosis 2023:
Global Patient Symposium
Together for Tomorrow
March 18-19, 2023 - Einhorn Auditorium, Lenox Hill Hospital, NYC

All righty. I think we're, we're up and running, so I'm just gonna get started so I don't delay us too much. Okay. Ready? Okay, we're up


Um, okay. So again, the, the name of my talk is Endometriosis Surgery Options and Opinions.

Okay. So I wanted to jump right in and just say, you know, when, let me just close this. Um, when would we consider surgical management? So, you know, there are a few indications here. So the most common is persistent pain despite medical therapy, and that's pain that typically interferes with quality of life. When you consider chronic pain, you go through definitions, three to six months, think about delayed to diagnosis. So really six months of persistent pain despite medicine. Another indication, um, is also contraindication to medical therapy or a decision to not take medical therapy because that really is a patient's choice. Infertility is actually a big, a big category here. I put a asterisk next to it because this is, you know, a talk in and of itself. Uh, there are many indications for surgery in the setting of infertility, and of course for emergent issues. So if you have, um, like some of the patients, we, um, saw their stories yesterday, if you have bowel, bowel issues, obstruction of the bowel, if you have ur, uh, if you have endometriosis in the urinary tract, or if you have a collapsed lung. So these are all, um, definitely great reasons to consider surgical management.

Um, I like to talk,

Sorry, I like to talk a little bit about the history of endometriosis and surgery. And this is just a quick slide. So just to see the progression of time. So in 1860, endometriosis was first described as a disease by Von Roski, who's actually a pathologist. And pathologists are very crucial in the diagnosis of endometriosis. In 1925, endometriosis. So about a decade ago, was given the name by Sampson, who also provided us with the first theory of this disease. It really wasn't until the 1980s that we really started performing the first laparoscopic surgery. So the first laparoscopic appendectomy was performed in 1980, the first gallbladder in 1987, and the first hysterectomy in 1988. And I want you to look at that picture on the right. I think it's so interesting. That's one of the first laparoscopes that they used to use. So that's a camera in the abdomen, and you can actually see the surgeon looking inside with his eyes. So there's no fancy screens, there's nothing. And this is sort of the inception of laparoscopy.

So what is laparoscopy? So this is minimally invasive keyhole surgery. Patients come to the hospital, they undergo general anesthesia, carbon dioxide, gas is insufflated into the abdomen to create space. Patients are typically tilted with their feet up. Uh, and so you can, and the bowel will fall back and you can visualize the pelvis. You know, laparoscopic instruments are then introduced to visualized endometriosis lesions and then to perform surgery. So just to show you, um, a picture of the abdomen, a laparotomy versus a laparoscopy. So a laparotomy is an open surgery. On the left hand side, that's, that's a traditional, what we call fan and steel incision. So a c-section scar. You can also have, um, a less traditional, which would be up and down, but one la basically one large incision. If you look on the right hand side, those are very traditional laparoscopy incisions.

And this is typical to our practice, although you may find some other, um, configurations which are surgeon dependent. And these are typically ranging anywhere from five millimeters to, uh, potentially up to about a centimeter. But very small advantages of laparoscopy over laparotomy. I really think in the context of endometriosis surgery, laparotomy is, is, uh, is completely outdated. Um, laparoscopy leads to less postoperative pain, shorter postoperative recovery, smaller scars. This is very important. Decreased adhesion formation, okay? Decreased cost and, uh, reduced risk of certain postoperative outcomes. So fevers wound urinary tract infections, most importantly with endometriosis, and this, this is the big one, is that you have improved diagnosis. We all know how hard endometriosis is to see, and these laparoscopes provide us with that vision. They provide us with a guide. Um, and you can see the, how we've advanced from that first image <laugh>.

Okay, so this is a, actually a pristine pelvis, okay? So I just wanna give you an example because we're gonna look at other examples that are not so beautiful. Okay? So this is carbon dioxide gas deflated into the, uh, into the, um, abdomen into the peritoneal cavity. If you put your hand on the top of your, uh, on the top of your bladder, you'll fe you'll feel it's gonna be bladder. Right behind it is your uterus. Behind that is the cul-de-sac. I had a patient tell me, I'll, I'm never gonna think about a cul-de-sac the same way again, <laugh>. Um, but that's the cul-de-sac between the rectum, uh, and the vagina. And you can see the rectum there at the bottom on the, uh, the white things on the side laterally are the ovaries, and those are fallopian tubes. All right? All right. So I know most people in this room know this, but let's make sure everybody does.

So the main types of endometriosis, okay? One perial, otherwise known as superficial endometriosis, deeply infiltrative endometriosis, d i e or die, uh, which typically is defined when it reaches a depth of about five millimeters. So that's the depth where you can start to pick it up on imaging. On mri. Uh, and then the last would be ovarian endometriosis. I like to separate this out just because it can have, obviously a lot of fertility implications. You know, you can recognize it as a form of deeply infiltrative endometriosis as well of the bowel, uh, sorry of the, of this disease. But, um, like I said, it's an important ca category in and of its own. So, as we know, peritoneal and deeply infiltrative endometriosis can involve a variety of organs. Okay? Some beautiful examples that I've taken. Um, so this is a typical powder burn lesion. This is what you would find in a standard gynecologic textbook. You can see these lesions very clearly. They're black. You can see a little bit of vasculature here. Uh, and these would be considered superficial. So you see, they just rest on the surface. Um, they don't have a lot of depth.

More commonly, um, what we see, and this is where the disease is, uh, underdiagnosed, is that most superficial peritoneal endometriosis lesions tend to be atypical. So you're gonna find red lesions, white lesions, clear lesions, vesicular lesions. If you look at that picture on the left hand side, you're gonna actually see a patient that has a combination. They have clear vesicular lesions, also in the setting of pigmented typical lesions. And those are all important to, to address. Now, we're moving on to deeply infiltrative endometriosis. These are sort of early d i e lesions. And you can see the difference sort of immediately. You can see a pigmented example, and you actually can see a non pigmented example here, but you can see the retraction of the tissues around it. You can see the scarring, and it, you know, these are things that are starting to look like it hurts, okay? This, this process has probably taken at this time, many, many years,

Okay? And this is sort of what happens when this disease progresses in an unchecked fashion. So these are a couple of examples of advanced endometriosis, and I wanted you to think back to that first image that I showed you. Okay? So what you're seeing in this patient is, you know, I can't see one of the ovaries I make out the uterus in the back, there is a u, there is an ovary that I can see, but that fallopian tube, unfortunately, those fibria, the end, the ends of the fallopian tube look a little dilated. They do look a little bit damaged already. The cul-de-sac, I don't see a cul-de-sac. This is, this is what we consider oblation of the cul-de-sac, okay? And that rectum, you can see there's black, there's already, you know, you can see probably likely, you know, repetitive rupture of endometriosis. There's probably an ovary hiding underneath that, that mess. Another example. So a second example of advanced endometriosis here. So this was a patient well into her thirties. So we can't see any ovaries here. Uh, we see a uterus, and we see the rectum abutting the uterus.

Okay? Lastly, this, these, uh, ovarian endometriosis, otherwise known as chocolate cysts, is actually a very early chocolate cyst. Um, and you can see even at this, even at this stage, it's, it's almost bigger than the uterus, right? So 10 to 15% of endometriosis patients have endometriosis. And I, and I like to tell my patients, honestly, there is nothing good about having an endometrioma, except that some doctors, some sonographers, some tech might pick it up on an ultrasound, and you might actually get a diagnosis at that point. Um, but unfortunately, overall it leads to a decrease baseline ovarian reserve, a greater decline over time, and a decrease in your spontaneous fertility.

Okay, this is my only slide on laparoscopic ablation. I'm sorry, Dr. SK <laugh>. Um, I couldn't put in yours, um, but this is for a reason. So, laparoscopic ablation. So now we're getting to into the treatment of endometriosis. So this is treatment of lesions by laser vaporization, electrosurgical, fulguration. You're gonna hear a lot of these words, ultrasonic cutting coagulation. Those are, in other words, ablation. Um, and essentially it means burning the surface. Um, and the, and the lasers typically reach a depth of about two to three millimeters. So you can see somebody actually using, they're using argon over here, um, and you can see that they're basically just charring the surface of the tissue. And we have a representative image there on the right. So you can see that sort of the root of the lesion remains the alternative, or, um, what we suggest is laparoscopic excisions. This is removal of lesions, typically my laparoscopic scissors. So you're gonna, so this is clearly an example of an early stage, um, case, but you can see that the tissue has been picked up cleanly, has been excised with cold scissors, and you can see that you have clean borders and that the tissue underneath is healthy, which is the most important.

Okay? So I don't know why this is still a debate, but it is a debate in the medical community. So I wanna address it. So, laparoscopic endometriosis, ablation versus excision. So excision, so two big reasons, uh, you know, why we would support excision. So excision leads to the gold standard. So irrefutable diagnosis for endometriosis. So endometriosis truly is diagnosed by pathologists, so not by us as surgeons, by pathologists who take all of the biopsies, take all of the specimens that we remove, and look at them under a microscope and con and, and confirm for us, hey, this is endometrial glands. This is endometrial stroma from typically found inside the endometrium outside, found outside of the uterus.

And why is this important? So, accuracy of visual diagnosis is mixed, and this has been shown in plenty of studies, okay? A big systematic review, which was done a while ago, but it was conduct, it concluded that the positive predictive value of lesions range from 25% to a hundred. So that means if I pick it up and I say it's a lesion, it's a lesion. So that's not very good. Okay? There, they did a smaller study. They took 90 some patients, and they spread 'em out among three gynecologists. Uh, their individual diagnostic accuracy ranged anywhere from 40% to 76%. Again, not very good. I like this last study in 2013, Fernando did this. He took 400 some patients, he took 1400 some biopsies, and he divided the accuracy by stage. And I think the big one here is that if you look at stage one, the accuracy is only 50%. So you could flip a coin. It really, that's how accurate they were, even in the further stages, stage 2, 3, 4. And where you would think that the endometriosis would be extremely obvious, they only reached an accuracy of about 80%. So this is really why we say excision should be the gold standard.

Secondly, so deeply infiltrative endometriosis. I think for most endometriosis surgeons, we agree that, you know, excision is the best treatment, but for some reason, even among surgeons that consider themselves endometriosis surgeons, there's a debate with superficial endometriosis. So I wanted to go back, look at some of the data that's out there that you, that you know, you might have read. There are seven RCTs that looked at excision versus ablation. And RCTs are randomized control trials. So some of the best evidence that we have so far, two, reported that excision was significantly superior to ablation in terms of chronic pelvic pain. Painful periods, oh, sorry, painful, um, bowel movements, painful intimacy. Only one studied, followed those patients out to five years. Three other studies compared painful periods, painful bowel movements, and painful intimacies on a va, uh, on a visual analog scale. So a, a zero to 10 pain score and concluded that ablation was equivalent to excision.

Unfortunately, the problem with those studies, those last three studies, is that is they really only followed patients out to 12 months. So the idea here is yes, when you burn something, you burn nerves. Nerves, tran nerves do transmit pain. And so for a lot of patients, they do feel relief, especially in that first year. But this comes in, if you're gonna, you know, this comes in that myth that you, you're gonna keep having surgery every single year, and also every time you burn, you seems to get less and less effective. And I think that's where those are driven from. And unfortunately, there are not a lot of studies that are following patients out five years, 10 years.

Okay? Um, I couldn't do a surgery slide and not talk about this, so I'm going to talk about it. So this is an aqua blue dye contrast technique, uh, that was developed by Dr. Sgk. Uh, this is the same patient. So this is installation of methylene blue, um, in the retroperitoneum. And the retro parem is the area, you know, behind all of the, sort of the structures and the organs that you see. This is, if you look very closely, this patient has areas in the peritoneum that are very, very subtle. There's areas, there's small holes, there's small pores. And it does appear that if you look on that, in that mid medial plane, that there are two non pigmented lesions. And so those would be lesions that we would biopsy. I'm gonna give you a more obvious example.

So here, so again, so this is, you know, prototypically, what we'll see in that early stage endometriosis, and I point out a lesion here, I think this is a beautiful lesion, but because you can see all of the qualities in it that really, um, really generate some of the symptoms that we talk about in endometriosis. So there is a lesion here, and you can see it has a focal point, but you can see there are, there's vasculature running towards it, and underneath that vasculature are nerves. The peritoneum around it has holes in it, and you can see the perial defects and the inflammation surrounding the nerve. So I always say that endometriosis is sort of like a, a hungry disease. It wants to grow. And even in superficial endometriosis, maybe it doesn't spread deeply, but it likes to spread laterally. This is an example of actually after excision has been done, and if you look at this, if you had sort of burned this area, you can see where there was actually almost, you know, the root of a, of a lesion right there in the middle, right? So actually better relief would be to then excise that remaining root.

Okay? I, I just have one slide on ovarian endometriosis, because again, this is, um, I think this is a big topic, but I wanna just talk about general surgical principles for endometrioma surgeries. So if you're gonna ha if you have an endometrioma, you're talking to a surgeon, you wanna ask them these very simple questions, you know, we know that excision of your endometrioma is much, much better than drainage and coagulation. You have a lower risk of recurrence, painful periods, and painful intimacy. Why is this also important? They have looked at studies that said, if you had, if you have two endometriosis and you have bilateral ovarian endometriosis surgery, you have a one in 50 risk of premature ovarian failure. So that means that they have unfortunately burned or taken too much of the ovary if it's done improperly. So in general, you avoid every form of cautery or thermal energy that you can, um, in these types of surgeries. And I think we saw a nice example yesterday.

Okay, what stage am I, I get this question a lot. Um, on the left hand side is a staging system put out by A S R M, which is a fertility society. On the right is one of the newest staging systems. It was put out by A A G L, which is a benign G Y N surgery society. I think that there are multiple, multiple complicated staging systems, and ultimately for practical purposes, it's not, you know, it's honestly not as useful. There are a few that focus on fertility, a few, a few that focus on surgery. For our purposes, I think really to date, and I think we all agree, no single classification system adequately classifies endometriosis. So I do think it's sort of easier to group patients into these sort of general categories. You have stage one, stage two, but I would consider that sort of mild superficial disease.

And this is surgically, right? We, we obviously know that this is not a correlation to symptoms. This is how we would describe them surgically, stage three, stage four patients where you have destruction of anatomy, you have those large endometriosis oblation of the cul-de-sac, a lot of deeply infiltrative nodules. And then stage five, stage five is tough. It can include some of those patients too with sort of, uh, multi-organ disease if you're gonna have a bladder mass and a bowel mass. Um, it also includes our patients, unfortunately, that have endometriosis in the abdominal wall, um, who have pat. We have patients with, uh, endometriosis in their diaphragm. You know, it's hard to classify these patients because we have seen patients with, you know, recurrent, like we said, catamenial pneumothorax and very little pelvic disease. So how does it skip the pelvis, right? So we're sort of missing something there in that diagnosis.

Uh, and in then a classification system. We've had, we've seen patients with large abdominal wall masses and very little endometriosis inside. So again, so I think in general, it's, it's nice, you know, of course you wanna stage, you wanna be defined by something, but I really think that, again, we're still struggling. It's still difficult to define exactly what type of endometriosis every patient has. Okay. How is the appendix involved? Um, I'm sure there are some of you that have lost an appendix in this room. And so on the left hand side, we see what looks like a normal appendix on the right hand side, there is, that is, that is an appendix <laugh>, I promise. But that is complete oblation of the appendix. And that patient actually ultimately required resection of the appendix and part of her ileocecal area. So they actually did a very nice study back a couple of years ago on coincidental appendectomy done at the time of endometriosis surgery.

So they weren't a hundred percent sure if they were seeing endometriosis at the time. So coincidental is they're looking, um, they're there doing endometriosis surgery anyway. So about 600 women underwent an appendectomy for early stage endometriosis patients, about 7% at appendic endometriosis. And for advanced stage patients, about 35% had appendic endometriosis. So really significant number. So meaning it might be worthwhile to always investigate this at the time of surgery, it said there is no increased risk of complications. Uh, and quite honestly, sometimes we tell our patients, you know, your lifetime incidence of appendicitis, you know, is about 7%. So we're also saving you, um, some heartache in the o in the emergency department, especially when they tell you every single time, it's probably your appendix. Anyways,

Okay, will I need repeat surgery? And so this is a very, very tough question to answer. So we know that, you know, technically there's no cure for endometriosis. You can look at this statistic. Endometriosis recurrence rates are wildly variable, zero to 89% over a variety of time points. The reason I think this question is tough is really because how are you gonna define success? Or how are you gonna define recurrence? Is it a recurrence of your symptoms? Is it a recurrence, uh, clinically on imaging or is it a return to surgery? Um, what we do know, unfortunately, is that repeat, a surgery is associated with a younger age at first surgery, bilateral or large endometriosis, and also a lack of postoperative medical management, which we'll talk about too. So postoperative medical management, I do think go hand in hand with surgery. We can't just focus on surgery. Um, management decreases the risk of endometriosis related period pain, deep endometriosis, and most importantly, endometrioma recurrence. Okay? And I guess we can't stress this enough, early diagnosis is key. Endometriosis is a progressive estrogen dependent condition. It's progressive. Those stage four pelvis, were not, you know, that was not, uh, those were not those patients at 17, 18, 23 even. Um, studies have consistently demonstrated a negative impact of endometriosis on your quality of life, your education, your workability relationships, social life. So early diagnosis will not only reduce, you know, your risks when you come to surgery, but will hopefully reduce some of these effects.

Okay, I just wanna spend a few minutes on robotic surgery and then I'll finish. Um, and again, I like to start with just a, a history slide because I do think it's interesting. So, robotic surgery was theorized back in the 1960s. It took about 30 years contributions from the Department of Defense to actually realize it. It was actually originally created for remote like battlefield, uh, telepresence. So you'd have like a surgeon sitting remotely and then, you know, you'd have frontline casualties so you could have better access to care. Um, obviously private industry took over. Um, they tried to commercialize the technology. You can see one of the first, you know, operating systems out there. Um, and in the beginning, yes, there were definitely a lot of flaws. So you had bad instruments, you couldn't see, well, it was really, really hard to set up. Uh, now you have sort of the evolution of, uh, one of the most sort of common robotic systems out there.

This is called the Da Vinci EXI system. Previous to that was the SI system. You can see they come out every, you know, five, six years. So the last came out in 2017, I'm sure we're looking at a, probably a new addition, uh, coming soon. Um, so again, let's look at the scars that you get from laparoscopy and the scars that you get from robotic surgery. So, um, traditionally about four incisions for laparoscopy, you can see where they're placed with the robotic arms. The placement does tend to be higher on the abdomen because with the robot, the, you know, a surgeon actually has the ability to control up to forearms. Occasionally there will be a fifth incision, and the, the trocar, um, the incisions do tend to be a little bit bigger, so they're about eight millimeters versus five.

Okay. And to be completely fair, I would just say there's advantages and there are disadvantages of the robots. Okay? So the advantages include ergonomics. Okay, that's, that may be number one, and that means that your surgeon gets to sit down. Okay? Um, you also have improved 3D visualization actually, in order for them to create that, they actually, the, the visual, the visuals, um, are very, very nice. You can have increased dexterity of your hands. So if you look on the right hand sign, you'll see an image. And actually that's an example of a robotic trocar. So you can actually see how the instrument is wristed. So you are a little bit more able to perform open type surgery in a laparoscopic environment. And finally, you're a less dependent on a skilled team. So I, I know, I really do think that there's, you know, not a lot of, not a lot of things then can, that can be two skilled laparoscopic surgeons working side by side using four ports.

But you know, you have a lot of surgeons in certain places that don't have that luxury, and they're operating alone and they're operating with a team that changes every day, and they're not able to anticipate those needs. And if they come across a patient with advanced endometriosis, they want to be able to have a reliable, uh, instrument to use, uh, disadvantages of robotic surgery. Things that we, that we know there's a lack of tactile feedback, so you can't feel as well, you can't feel as well the, um, the depth of endometriosis, uh, the fibrosis that it causes. It's more, you know, uh, sometimes, um, experience can compensate for that. But yes, it can be more difficult. Uh, you are disassociated from the patients, so if there's an issue at the patient bedside, it does take you, you know, a minute more to get back to the patient. I do think that the instruments, because they're newer, are a little bit cruder. They're, we have very fine instruments for endometriosis surgery, and I don't think that that has been translated yet to robotics. Um, and finally it just, just costs more.

So this is an example of robotic surgery. Okay? You can see the instruments here. You have a, um, you have, um, actually if you look at the bottom, it says 1, 2, 3, 4. So they have the ability to dock forearms, to have four, to, to control forearms. You don't always have to, so you, you don't necessarily need to place a fifth incision. Um, but you can see this is actually aqua eye contrast technique. So trying to replicate the same things that you can see an ovary is lifted in the background. Um, you can see though that, you know, unfortunately the, the forceps is a just a little bit, um, less refined than the image you're about to see. Okay. So this is sort of that traditional, uh, laparoscopic appro, uh, sorry, approach.

Okay, so robotic surgery takeaways. So the robotic system, honestly, I, I tell a lot of patients is just another surgical tool, and your surgical outcome rests in the hands of the surgeon. And I, and I always think, you know, we're in an area of innovation, we're, you know, I think if we're doing the exact same thing today that we're doing 30 years from now, you know, something is wrong with that. Um, robotics has continued to make advancements and, you know, you may start to overcome some of the current limitations that we have. Um, but surgical planning should really just be indiv individualized to your, to the patient, the institution, the surgeon, the assistant, and your multidisciplinary team. Hmm, okay. That's it. My references. Thank you.

Awesome. And if you'll stick around just for a moment, for a couple, can we take a couple of questions from the audience? Okay, great. Uh, yes,

Thank you so much for you. Um, I just wanna say that I feel a lot of anxiety for my daughter because she's still probably had a well catamenial pneumothorax three times. And we're just going on speculation because her pulmonologist did not find, um, endometriosis in her lung. But from what I'm hearing is that it's easily missed. And so now that she's had aple, is it hard to go back in and how do you find it when it's up in the, in the abdominal wall or We don't, I'm, I'm at my wits end, cuz you know, we are just learning this still that it could be a missed and anyway, thank you.


Okay, sorry.

Hello? Okay. Yes. Um, that's heartbreaking actually. And that unfortunately is not an uncommon story, especially with our, uh, thoracic patients. You know, traditionally you're diagnosed in your mid thirties, uh, typically it's at least your third and a lot of patients have had Mies or pleis because you're really seen by a CT surgeon, a cardiothoracic surgeon, and most of them don't ever think to ask you, did this happen on your period, right? So it is actually very difficult to see and it very uncommon to see it on chest x-ray or chest ct or, and we don't even do MRIs. We're looking for a lung collapse. We typically do dual compartment surgery at the time, and so we actually visually inspect the diaphragm at the time of surgery from below in order to inspect for implants. So that would be the appropriate, um, surgical approach.


It can be difficult if they did an apical meaning at the top. Okay, just at the top. Um, you typically can, but you might not need to. Occasionally we use a hepato biliary surgeon, you can resect the disease from below because you imagine that, you know, we had a slide yesterday about the, the way that the perial contents move, you typically implant from below. It's, this is an abdominal pelvic disease, right? It's not, this is coming from below. So we should be able to see those implants and resect them from, from the laparoscopic approach.

One more.

So would you recommend her, her situation that that gets

Rechecked or

Something? Yeah, it would also be done with a cardiothoracic surgeon at the time. So they would have to go back in and look at the lung. Exactly. And she may need a chest tube, unfortunately. And you know, it, it, it's gonna be a, it will be a a a long surgery. It'll be a tough surgery. But


I just, it's okay. We could talk, yeah, we could talk after.

I just want to comment. I I understand the dilemma. It's very difficult situation, especially thoracic endometriosis. It depends, there's two issues here. Are the symptoms synchron or, uh, catamenial, in other words, monthly coming, uh, or when the OV ovulation is suppressed, are the symptoms persisting? What are the symptoms? Is it pain with breathing or shoulder pain? Neck pain, or there's recurrent pneumothorax that comes and goes. So these are such how it, every individual is different. So it has to be dealt with. A team who really understands it is generally 99% of the time thoracic surgeons have no idea about endometriosis. That's why they do pleis. Do you, do you know what pleis is? So let me tell you what pleis is. So they go in, they can't find anything, or they find something, they just do whatever they have to do, uh, and then they scratch the ribs.

They basically scratch the whole perial layer of the rib. So the lung would come and stick there. So doing repeat laparoscopy on these, uh, thoroscopy on these patients are not something every thoracic surgeon would go forward with. So they drag their feet on this good ones, they can go in with small scopes and they can break those and look for additional lesions and find them, but rarely implants on the inside, the, um, inside the chest cavity cause pain, unless it is on the ribs or associated with a small hole on the diaphragm. So main problem is on the diaphragm. So diaphragm has to be inspected from above and below. Sometimes there's a disease below it. The, uh, lesion, uh, the hole opens up and closes, as I mentioned yesterday. So it has to be done by, you know, team of doctors. You need a laparoscopic surgeon who can recognize the lesions.

Like she said, where there are lesions are comes in different colors and most of the lesions are subtle. They're off, off, white, off. They're not pigmented, they're white, they're vesicular, they're very difficult for other people to recognize if they haven't seen these. So from the dhr, from approach from the belly, we can see a lot of things above the liver dome. It needs to be pushed down and really looked very meticulously, even with a liver surgeon most likely. So they can mobilize the, so it's a, it is a, it's a team thing, not a single, not a single. I can't do it myself. I have done many, many of these, but in every, every attempt I had either thoracic surgeon with me or hetic surgeon with me too, because you, you may need extensive liver mobilization. Um, yeah, that's what I'm gonna say. It needs a team effort to approach your daughter's problem and it could be addressed if there is consistent pain, there is something going on, she's not making it up.

That's, that's the bottom line. I like to comment on the word superficial image use. I, I have a serious stand against using the superficial on perial enemy users. Perial enemy users is not to be used with an adjective of superficial. Your pain is not superficial. And it's a, it's an approach to demean again, to suppress your, your complaints and bringing it nothingness. And I'm, I stand very firmly against it. If you have waves of struggling and resisting the this term, please do so. And many of the time peritoneal uses as, as she explained, has components of deeper it, it's irrelevant. There is three millimeter versus five millimeter. So what mri, of course MRI there, there is missing. It's the main culprit why users name the bad disease. It's named main reason why endometriosis is not dying. It's the perial image uses. All right, so from from our angle when we sayit uses is 10% 15 chocolate cis.

The rest is mostly peritoneal image uses. But when you look at from infertility angle for them image uses chocolate cis, they don't want hear about perial endometriosis. So they don't even question how much pain you have. That's not in their questionnaire much no painful period. They stop there. How about painful intercourse, painful ovulation. How about leg pain with periods? How about other many things? So every, everybody touches this elephant from different, uh, point and they, they name whatever they wanna name. So including ourselves, we are also little bit may, maybe surgically oriented. For example, I don't like to use the word medical treatment, right? You don't treat endometriosis. You, you treat the symptoms, you stop ovulation, you stop menstrual cramps by eliminating uterine contraction during period. But you don't get rid of the endo as soon as you stop the, the boy and girls, they come immediately.

The treatment is unfortunately surgery, but it should be timed well. And so, you know, you can't jump on everybody because they have painful view. You have to do laproscopy a young girl. So you have to give this medical management trial at least six months and follow, build your trust and transparency with the patient. So there is, they should know that they can trust you. You could give the care after surgery really, as I told you yesterday, the surgery is the easier part for us. The care is difficult because you lose the patient, you know, we have to really focus on the patient again and again. So that trust and your setup should be structured AOR accordingly. Many things could be said, but thank you for the question. It allows us to, allows us to make any more comment. Yeah. Dr. Lewis, you have any comment? <laugh>? He will be speaking soon, bud.

Probably. So I'll, I'll just, um, echo what you had said. Dr. Kin, we had cases of a thoracic endometriosis at our hospital as well. I'm over in Brooklyn and it's, it's always a multidisciplinary approach. Uh, the cardiothoracic surgeon obviously, or anybody that you're gonna be working with, you wanna make sure it's someone that you communicate well who understands the disease, who understands the length of the procedure and is accommodating to you. And I think again, the most important for your daughter would be laparoscopy at the same time with a cardiothoracic thoracic surgeon. But, um, this is very difficult disease and this is why also it's important to survey when you're having laparoscopy to survey the entire pelvis, the abdomen, you know, I go through the same routine for every single case just to survey to find any other evidence of endometriosis. And that's what you have to, to teach future surgeons.

Are most, are most the surgeons using that die to see the white lesion?

I don't, I don't, I don't. Most cases I experience probably you think that very,

But it would be highly recommending

Every, everyone has the whole technique. I think the most important thing is back important that disease, but also treat <inaudible> showed on her slides. It's usually starts at one point, but expand.

Hi. Um, sorry to shift, but I have two questions actually. Um, so is endometriosis more likely to recur with cervical stenosis? Um, and if so, would you treat cervical stenosis during surgery? <laugh>,

<laugh>, interesting question. Um, I have another one. So, right, so that will lead back to samson's theory, right? So the idea of retrograde menstruation, so women that have cervical stenosis and peripheral at hymen, um, things that lead to more reflux. So you would think yes, there is a correlation. Um, interestingly at the time of surgery, uh, we do actually typically do cervical dilation and we'll dilate it a little bit beyond what we need for a his hysteroscope, you know, beyond what we actually need for that procedure at hand. Um, in order to sort of ease that passage,

What is cervical stenosis?

Oh, okay, I apologize. Cervical stenosis. Um, cervical stenosis is, um, uh, you know, think about your cervix in is at the, is at the bottom of the uterus. Okay? So the uterine corpus, we have a cervix below. Uh, typically the cervical canal, you know, is a few millimeters wide. It opens, you know, during menses to allow passage of menstruation. So cervical stenosis is really, uh, that whole, that opening is very, very small, right? So there isn't a lot of lux. So you may have, you may still have bleeding. Um, but you would imagine that with that cramping and the uterine contractions that the other passageways are a little bit, uh, more open. So does that make more sense? Sorry about that <laugh>.

Um, and then my second question, um, is what would or what could be done for someone who continues to exhibit symptoms such as irregular bleeding or spotting, um, postoperatively either with endometriosis, surgery and myomectomy?

Um, so just irregular

Continued symptoms of

Irregular, right? So then irregular

Then we're symptoms happens irregular bleeding. Irregular, yes.

Irregular bleeding is, is not alone. And the endometriosis


By pain, the pain continues after bleeding. So there is mm-hmm there, there's uh,