Endometriosis Foundation of America 2014
Professional responsibility: An essential dimension in the management of endometriosis
- Victor Gomel, MD
Endometriosis affects women of reproductive age. It is a polymorphic disease in appearance, variability and severity of symptoms. And it is frequently a progressive disease. It is the commonest cause of chronic pelvic pain in women of reproductive age. But it frequently remains undiagnosed as has been repeated so many times today despite the significant progress made in imaging and other diagnostic modalities.
The physician treating such patients must have appropriate knowledge and interest in this field, approach the patient with understanding and empathy and be willing to follow the patient as long as required.
Proper initial clinical assessment and investigation is more likely to lead to a correct diagnosis and management, and thus avoid the patient to enter the vicious circle in which interminable referrals happen often with unnecessary reinvestigations and further surgical interventions.
Surgery is the primary treatment today for advanced endometriosis and the first attempt is usually the best attempt. Surgery, because we do not know what endometriosis is and as I always said performed for other than for trauma, congenital defects and cosmetics, surgery represents the failure of medicine; failure of having discovered the etiology of disease and developed specific and effective preventive and therapeutic measures. I can give you many examples where surgery was employed that today, because we know more about the disease, we can prevent it or treat it medically. Time does not permit me to give you examples.
The principles of surgical approach in endometriosis should be minimal access and the use of an atraumatic technique, microsurgical technique and complete removal of the disease. And again, we have come to excision, excision is very important. You have to know what you are burning so rather than burning, excise. The conservation of fertility potential when that is required and using all the principles of really microsurgical principles, pelvic lavage, adjuvants, etc.
The place of minimally invasive surgery in endometriosis is now well established. MIS offers similar long term outcomes. It results in a shorter hospital stay and recovery period and offers better quality of life postop. We have had impressive progress in operating room set ups, major equipment, surgical instrumentation, energy modalities and video equipment, etc. We even have robots. But at the end of the day when we look at it minimally invasive surgery is a bit like a Friedman's curve in labor. You see you have a long phase and technology has helped us to do better things like the cold light with these people. Then we did do a lot of reproductive surgery looking at the telescope directly. Then there was the mini-camera with high resolution video, which permitted us to do much more surgery. And as you can see in 1986 we have endometriosis surgery that is done to a great degree. Then the surgeons did cholescystectomy and made the gynecologists a little bit more aggressive, adventuresome. We have the first hysterectomy published in 1991 I think or 1989 I do not remember the exact date. And then we went on to even oncologic surgery.
Despite all this development, despite the fact that more than nearly 25 years has gone since the first hysterectomy done laparoscopically if we look at the scene we will see that for example hysterectomies in the United States since 1998 to 2010 - if you look at the upper bar you will see that abdominal hysterectomy is still the kick. And the difference is minimal and I will show you this in a graph. You will see it even better between 1998 and 2010. Look at it. The yellow bars are the abdominal hysterectomy and they have fallen from 65 to 55 percent. Here we talk about now natural orifice surgery and we have had the advantage of a natural orifice in the vaginal route, which is our primary route. Look at this, vaginal hysterectomies decreasing even more and laparoscopic hysterectomies also decreasing, and some of them being done by robot. I just do not see the advantage of a robot in a hysterectomy other than of marketing value.
This is where we are at. Is it our training? Yes! I think in the United States you have made the mistake of making obstetrician gynecologists also general practitioners in some ways. This surgery has to be done by real specialists.
Patient safety and successful outcomes, since we are talking ethics, are dependent upon the presence of good surgical indication; proper selection of patient, procedure and surgical access route; knowledge of prerequisites, respect of principles and application of meticulous techniques by an experienced operator, irrespective of equipment. Despite the impressive progress achieved in surgical instrumentation, major equipment, energy modalities, etc. at the end of the day it is the surgeon that determines a successful outcome. And this we have to remember.