William Burke, MD - Surgical approach to a difficult pelvis
Advancing the Science and Surgery of Endometriosis
Monday and Tuesday, April 19, 2016
The Union Club, New York
I wanted to thank Harry for having me come and talk and it sounds like I am catching you guys on the tail end of a great meeting. I was asked to talk about the surgical approach to the difficult pelvis. I am reading a book about how people change the world and there is a big chapter on procrastination and modification of talks until the end. So I am going to modify my talk because a lot of the video you have seen and probably spent the last couple of days watching endometriosis being resected so I wanted to just point a couple of highlights out. In preparation and remind you guys that all these guys that have been talking to you have been doing surgery for endometriosis for years and years. They show videos and they show resections and they say what they do but I want to emphasize the preparation that goes in it and sometimes gets lost in some of their talks and the great videos. I have no disclosures.
I want to start with why I should not give this talk. This is a conference on endometriosis and I am a gynecologic oncologist. Patients often get very scared when they come to see me in the cancer pavilion at Columbia. Harry taught me a lot of what I know and he is here. He should probably be talking. I forgot to tell my staff to move my office hours and I am going to be late. Dennis wanted to switch with me but I cannot because I have patients at 11:30. And, I really dislike endometriosis. It scares me. I am always afraid of it. I have been operating on it for a long time but I never like taking somebody to the operating room for it.
But why is this talk important? Endometriosis as you guys have learned makes women miserable. I believe that aggressive surgical resection of endometriosis is an important part of winning the battle against the disease hence we have been hearing it for 30 years from Harry, since I was at Columbia with him as a resident. And becoming familiar with unfamiliar anatomy and novel techniques fosters surgical innovation and better surgical care for women with endometriosis. We have to continue to believe that if we are going to continue to push the envelope in endometriosis surgery.
And finally, like you just heard, experience in a difficult pelvis ultimately will reduce fear and complications that may occur in young women during difficult surgery. I think this last part is why everybody is afraid of operating on endometriosis and often ask for help.
Like we usually start in the operating room at Columbia just keep calm and anytime you are starting an endometriosis surgery let’s get the party started. But there is a lot of thought that goes into getting the party started. Be prepared to get to know your patient. Take a careful and detailed history. What is the duration of the disease? What have been the medical management successes and failures? What is the pain medication use and abuse, are you really going to help this patient? Is it really endometriosis, is it chronic pelvic pain, is it a mix, right? There is kind of a mix there. Medical co-morbidities and this is my favorite, prior surgical procedures. I have given this talk in different venues. Today the two people here that I love how many surgeries have they had, who did them? I have seen a couple patients, “I’ve had multiple surgeries for endometriosis, the diagnostic wasn’t that big a deal” and I get the operative report and it is from Harry or Farr and I know it is going to be not so difficult as it is going to be a disaster when you go back in because of what they do. Get the operative reports, get prepared for who has operated in the past.
Careful physical exam of the body habitus, do not get fooled by BMI. I will show you a quick slide. Note all surgical incisions. As you know, patients think that C-sections, appendicitis, appendectomy, cholecystectomy are not surgeries and oftentimes they will not report them. Assess the uterine size and mobility. Oftentimes with women with endometriosis what you see is the uterus does not move. On a couple of repeat operations that I have done it has been fused to the external iliac artery and vein. You want to note that. Note any adnexal masses dealing with things and pay careful attention to uterosacral thickening and rectovaginal nodularity. A lot of times we are evaluating things with fellows and the residents have not examined the patients. I do not think they really understand what we are getting into like Harry pointed out with the hot dog coming down the rectovaginal septum and how deep you have to go and how far you have to resect. Do not forget about careful physical exam.
This is just a quick slide on the BMI. These BMIs are the same. I have shown this slide a million times. This is a nightmare. This was fairly straight forward. Just keep it in mind and pay attention the waist/hip ratio.
Work up and evaluation, you guys have probably had nice talks. I am sorry I missed them but pelvic ultrasound, pelvic MRI, I think the MRIs have been quite helpful for me in terms of endometriomas and some adhesions. You have to work with your radiologist in terms of their reading of adenomyosis and some of the deep infiltrating fibrotic endometriosis that can be missed by some radiologists. Obviously cystoscopy if suspected bladder lesions. I saw a woman who had been bleeding for years and no one looked in her bladder. It was endometriosis. She had every diagnosis under the sun minus endometriosis. Colonoscopy or endoanal ultrasound depending on what your staffs are comfortable with in terms of assessing for bowel involvement. Harry said a lot of times he did not know how deep he had to go. A lot of times with the endoanal ultrasound and MRI now we have an idea of how deep we may have to go.
This is just an example, right? This could be overlooked but this colon was definitely adhered to the posterior portion of the uterus. It was very helpful for me in counseling this patient that it was not necessarily going to be an easy dissection given that she had not had previous surgery.
Preoperative preparation, the most important is this, especially in New York and Harry has never been sued for leaks. I have not yet either, it is usually not the colon it is the ureter and the bladder and the infections, the re-operations, the vaginal cuff, dehiscences and things like that. But prepare your patients. I think that a lot of women with endometriosis are not prepared for the extent of the surgery. I tell them I am glad you are in a cancer office. I am glad you are in a cancer building because this surgery is just as bad or worse and the complications can be just as bad or worse. So you try to set the bar in terms of what they will expect. Type and screen antibiotics if appropriate. Bowel preparation is, I think we used to do it all the time with the enhanced recovery system. It is under question, I do think that if you are going to be doing bowel resection a lot of colorectal guys with oral antibiotics and bowel prep the surgical site infection rate is still lower. If you know you are going to do bowel you might still do the preparation. But again, I think that is up in the air at this point.
Then consideration of ureteral stent placement – I think being a gyn-oncologist we all think that we do not need them. Every time I listen to a lecture “stents never help me” and they never prevent you from making the complication or cutting into the ureter but it certainly helps define them sometimes. My ego does not overtrump the placement of ureteral stents if you really think you need them. Colorectal surgeons use them all the time for their surgeries it helps them find the ureters.
Operative approach – we see a lot of conventional laparoscopy. I think you need to be okay with everything and a lot of times if it is a bad endometriosis case I set up for everything and I start small. I will set it up as a diagnostic laparoscopy, conventional laparoscopic surgery in a robotic room with the ability to convert if I would like to, with the ability to use hand-assisted laparoscopy and ultimately the ability to open. I think if you prepare for all of these, especially when it is an advanced case you are not going to look in and say, “Oh, we can’t do it. I feel uncomfortable, I’m going to get into a situation that I can’t get out of”, and you are going to come back another day. Just be prepared to use all even in one operation.
Surgical preparation, again, proper positioning; I think Harry alluded to this, these are long cases, you need to be prepared, so position the patient, prepare anesthesia for steep Trendelenburg. Gastric decompression is essential when you are operating and entering in the upper abdomen. Three way Foley if you want, now you can retrofill with those single Foleys much easier so it is not necessarily always the case that you need one. Again, do not forget, rectal delineator/manipulator, uterine manipulator, vaginal delineator, ureteral stent, all those things are overlooked. I cannot tell you how many times I have been called into the operating room on a bad endometriosis case where there is no uterine manipulator, there is no EEa sizers, the patient’s arms are out at the side and they are at minimal Trendelenburg. It drives me insane, insane, right? You cannot help those patients. You have to be ready for the worst every time.
I think we learned that at Columbia. There are a lot of people here that trained under Harry. We positioned people the same way. We started the case every time the same way, we use the same port placement, we use the same insufflator, and we use the same suction irrigator. It does not matter what you use, be prepared. I only say this, be prepared for steep Trendelenburg. I do not care whether you use a bag, we cannot use shoulder braces any more. Columbia used to use them for 14 years and never had a complication but there are a lot of substitutes but be able to do that.
Uterine manipulation, again, valve, ___, arch, co-efficient, whatever you want to use good uterine manipulation.
Now dealing with the difficult pelvis; I think the main thing is be ready for complications. Be ready in your mind that you may have an enterotomy and you can repair it. Be ready for getting into the bladder and you can repair it whether that is going to be straight sticks or you need to use the robot or you need to used barbed suture, or you need to call somebody to help you, that is fine. Starting your procedure, what I see in a lot of the younger generation and a lot of the MIS they are afraid of the retroperitoneal space and I think you guys have had that talk but you need to take advantage of the retroperitoneal space, open the sidewall, open the paravesical space, open the pararectal space, open the rectal space, open the rectovaginal space. These are all relative safe havens unless Harry has operated on the patient before that you can get in and the endometriosis is not there. If somebody has had a big resection a lot of the time those spaces are obliterated and then it is not so easy to get there. But for the most part, whether it is endometriosis or cancer, those are your safe havens. When you can take advantage of the retroperitoneal space you can own any endometriosis case, you can own any cancer case for the most part.
Take advantage of how you get in there. The best is when we trained at Columbia everybody stitched the round the ligament. You had to stitch it, cut it, open it and so if you got to a place where you could not get to the round, or the patient God forbid had hid a hysterectomy, there is a little stall but it is not that rapid cognition of how you are going to get into the sidewall because they have never done it. Find five different ways to get into the retroperitoneal space. Divide the round ligament, open lateral and parallel to the infundibulopelvic ligament on the lateral. Open over the ureteral fold. Sometimes you can go lateral to the rectum and work your way back up. Do things four or five different ways to get used to when you cannot do it the way you normally get to do it.
This gets into a lot of videos. This is just briefly – a lot of these are robotic videos because when I do endometriosis or one of my cancer cases I just prefer to use a robot, it is faster for me. It is just my preference at the point but it does not take a lot of time to open the right and left pelvic sidewall. A lot of times you go to meetings and people edit their videos and you see these really clean, neat dissections. This was a long time ago. I think this was from 2006 or 2007. Initially when we are just learning and getting comfortable with opening the sidewalls but it does not take a lot of time to open the retroperitoneal space. One, two, three minutes it is fast. You can get access to the uterine artery especially with bad endometriosis you can seal the uterine artery at its origin, you get access to the ureter and you can peel off the medial portion of the broad ligament. Then once the ureter and blood supply is secured you are pretty much in a safe haven except for the rectum, which you can deal with later and you do not have to worry about where you are burning, what you are cutting and what structures you need to look at. That is real time, not that hard to open the retroperitoneal space. You just need to get used to it through repetition, learning and putting the hours in as we just heard.
Again, same thing with endometriosis, all of a sudden you cannot see the retroperitoneal space or the ovary is stuck there and you do not know what to do. Again, just go lateral, you go lateral it is a free space and what you can see here is you just go under the left retroperitoneal space you can identify the ureter and start the case. Whether you want to peel the ovary off where it is stuck to the ureter whether you are going to take the ovary out and prevent ovarian cancer like Farr said depending on your patient’s age. It is a free space, it is a safe haven take advantage of it. I am not going to run the whole video for sake of time because you guys have seen it.
Last again, open over the fold. If you can find the ureter, you can see it, and you do not have to go the side way. I think this technique when again I like to go into a lot of operating rooms as well where they have 25, 26, 27 or all the MIS surgeons at Columbia. When I am done with my case I will usually go harass the fellows or the residents but I am actually watching what the other people are doing in the colorectal surgeons are in the other room and I usually never go back to the office on my operative days. I usually hang around the operating room and watch other people, get involved in their case or just shoot the shit and see what they are doing and what kind of staplers and techniques they are using.
But again, very easy to go in over the ureter, work yourself down into the uterosacral and the rectovaginal space. You do not have to disrupt the retroperitoneal space if you do not want to. You should be able to do that.
You have heard this – beware the external iliac vessels are closer in proximity than you realize. I have seen that external iliac artery injury multiple times, not myself, I have done it myself actually with the spatula coming across on a colpotomy when I slipped by and I was not cognizant of where I was. So everybody can do it. The ureters are not often where they are supposed to be. We are always looking where they should be but you do not realize that it is all crunched up and knuckled up with endometriosis. The rectosigmoid takes very unpredictable turns. I am going to skip that. You never know where it is and that is where the delineator comes in handy. I am going to skip this for the sake of time. This was just opening again from altered pelvic anatomy when the uterus is not there taking advantage of landmarks open over the ureter.
In terms of bladder endometriosis and doing difficult anterior resection, do not be afraid to fill the bladder. I cannot tell you how many times I have walked into the OR and heard, “I don’t know where the plane is, I can’t get the shelf going. I figure I’m going to make a hole” and as soon as they fill the bladder, we use methylene blue all the time, maybe it is in my subconscious from way back when, and you can see the plane and you can see how much it thins out and build that shelf when you are resecting the bladder nodule. Vasopressin sometimes injection will help the bleeding if you do not want blood in your field. Do not be afraid of resecting the bladder. I think with barbed suture and some of the suturing techniques and robotics and you know if you practice a lot it is easy to fix the bladder, it is just a nuisance for the patient because they have to wear a catheter for three to 14 days depending on how much you resect and whether or not you re-implant the ureter. This is the expectation. I usually tell my patients it is easy for me to fix your bladder it is just a nuisance for you and then when they wear the catheter for seven to ten days they are no so angry at you.
This was just a shelf – I think I can show you the blue – that you can get. It is not so much the dissection but we retrofilled the bladder, we can kind of build the shelf that Harry was talking about on the bladder but – I think if I speed it up – you start to see the blue and you kind of get a hint there you know where you are. It really aids in your dissection.
Rectovaginal endometriosis, again, take advantage of the uterine manipulator. A lot of times the colorectal guys it is awesome to help them. When they are operating on women they have take the colon out. They do not use a uterine manipulator and they are like, “I can’t get the uterus out of the way. I need you to come and do a hysterectomy because they have one fibroid that’s four centimeters and I can’t get it out of my way” and I say, “Why don’t you just put her instead of this split leg ridiculous table, put her up in Allen’s or yellow fins, I’ll put a manipulator in and I will drag the uterus right out of your way”. Like, “Oh my goodness this is wonderful technology!” Oh my goodness! So anyway, take advantage of the uterine manipulator to get in the rectovaginal space. Do not hesitate to check the rectosigmoid for injury. The worst part of a rectosigmoid injury is not doing it; it is failing to recognize it. Again, I use three ways, I do water, air and then I will do blue. I have got to say I do like the methylene blue because you will miss small leaks sometimes unless you have a really good air seal and sometimes the water you do not see it. I do use methylene blue on all my rectal checks as well. If you are really worried just go get one of the colorectal guys to put a scope in and have them scope them. Always be prepared for potential rectosigmoid resection.
Last video, because I told Dennis I would get him up here so we could bake it, is practice opening the rectovaginal space on some of the easier cases where you are doing a hysterectomy. You do not have to go nuts, just peel it back. It is right under the ____ ring if you have it or under your sponge stick and should open very quickly, no bleeding in the right plane. I always tell people, remember I think Rosanne talked here, but anyway when people are up in stirrups and up in lithotomy the pelvis is straight ahead. People have this tendency to dive down and keep going, they go right into the rectum but I say just kind of do the breaststroke into the levator region. You just want to do the breast stroke straight in here and you want to keep working this way or you will get into the rectum.
Last, I think I want to show you the turning thing and I will be done. When you are using the manipulators – this is a similar case that Harry showed not quite the sausage but really just the rectum was tacked up and a lot of pain with defecation. ______ you can open laterally. If you cannot go in medially you can push the ureter laterally and build between the ureter and the uterosacral ligament, create a nice space, come up and get your delineator. I was about to cut but I was like let us just check really quick and see how close to the rectum it is. It is right there. Normally I would be like, “Gah, I really shouldn’t be twisting and coming up there”. It helped me realize where we were and I think we were able to cut it down eventually so be prepared for those twists. This is kind of the same thing. You can do that too.
In summary I do not want to belabor, preparation, be prepared, expect the worst, take advantage of the pelvic safe havens and again, do not be afraid to ask for help. Ultimately, my final comment is really listening to these guys sometimes we get lost in the videos but everything that they have said and everything that we have learned I still use in my practice today and I build on them. So, repetition, observe, I tell my fellows all the time, “I’m sorry I’m doing this case” and honestly, it is good to watch sometimes. Watch your colleagues, go into the operating room, do not expect to operate all the time. Sometimes you learn a lot more by watching and listening. Thank you very much.