What is endometriosis excision surgery as well as why is it different? Or is it different? Let’s take a step back and check out the history of medical techniques to treat endometriosis, including surgery and its advances over the centuries.
Way back in the dark ages before laparoscopy and lasers (although you can get this today in an operating room near you if you don’t watch out), all surgery included big incisions. These were called laparotomies. This method dates back to the 1800s but was a problem without good anesthesia and antibiotics. A surgeon and gynecologic doctor, Dr. Joe Meigs wrote in the 1950s about excision of endometriosis and ovarian cancer. From the turn of the 20th century up until the 1970s, endometriosis was much less often detected than it is now, and was basically ignored as a significant problem.
Then, although discovered long ago, in the 1970s a “new” tool called laparoscopy came to be. This radical new method enabled surgeons to operate on structures deep inside the body using only tiny little openings through which a telescope and operating instruments were positioned. Laparoscopy enabled far better visualization of the undersurface of the pelvis where endometriosis exists and is much better seen than with open incisional surgery. In addition to the improved vision via small little incisions came brand-new instruments such as lasers as well as brand-new strategies such as laser and cautery ablation of endometriosis. Considering that surgical procedure was much less intrusive, it ended up being less dangerous to execute, and the principle of a diagnostic and then therapeutic laparoscopy was born. This allowed medical professionals to identify endometriosis more, yet the methods they were utilizing to treat it had not yet been proven better.
Early research studies of endo and laparoscopy were primarily focused on the inability to conceive as opposed to discomfort alleviation, and also even though no clinical trials showed substantial long-term discomfort alleviation, ablation (burning) of endo implants making use of either cautery (electrical energy) or laser (light energy) ended up being basic therapy. This was combined with hormonal therapies with Danazol as well as later with Lupron. These are pretty potent therapies with side effects, and plenty of them.
Despite little to no proof to validate this combination method, even into the 1990s, laparoscopy with ablation of endometriosis when combined with hormonal therapy was considered the answer. But was it effective? In 2001, Jones, et.al. reviewed 6 year followup of laser ablation for stage 1 as well as stage 2 endo disease and found that 74% of individuals had reappearance of discomfort at approximately 20 months. or less than two years. In 2005, Wright and his coworkers, examined removal of endo implants or excision comparing that to ablation or burning away. After six months post surgery, the outcomes were equivalent. There are no studies to determine if ablation is helpful for stage IV illness, when endo is filling the pelvis with severe scarring. So treatment was going on that was not really very well proven by clinical trials.
Fortunately, there is one more choice. Excision of endometriosis is the technique by which the condition is more strategically and meticulously removed. There are lots of ways to accomplish this- some utilize lasers, some choose cautery, some use cold scissors via minimally invasive surgery. The less trauma the better the outcomes in any type of surgery. Excision allows us to get rid of endometriosis that lies over delicate structures like the ureters (which connect your kidneys to your bladder) as well as on the bowel– locations where it’s not safe to simply burn the disease away. Excision likewise lets us remove the illness and preserve the reproductive organs to both protect fertility and also avoid castration which creates a life time of hot flushes, bone loss, sexual dysfunction, genital atrophy, memory loss … and a whole lot more.
Excision has actually been researched quite thoroughly, and several research studies from around the world have revealed really consistent outcomes. In one study, a year after surgery, about half of the patients had no further discomfort and no factors that led to subsequent surgical procedures. But half did need one more surgery for different indications, including pain and recurrent endometriomas. All in all, there was almost 60% cure in reoperated individuals, and a 19% occurrence of recurrence or perseverance amongst all individuals that had excision surgery. Numerous other studies showed extremely comparable outcomes. Lately there was a landmark research study released by Heaney in 2010 that randomized patients to excision vs ablation. Despite several issues with the study (inadequate patients, non-expert surgeons (trainee residents) performing the excision, higher stage patients in the excision cohort, there seemed to be much better pain relief in the excision patients. They considered reductions in pain scores at 1 and 5 years postop in different categories, and also in almost all locations (pain in the back, rectal and defecation pain, nausea or vomiting, bloating, painful sex) the excision team did much better. Because they designed the study for 75 people in each group yet ended up with only 50 in each group, it was called “underpowered” which is a statistical concept that means the proof is not complete.
In general, when choosing a specialist, experience matters. There is a big difference in the capability to eliminate all endometriosis in between a surgeon who does a few occasional surgeries like this and someone that does a lot of this type of surgery. To be clear, there are many gynecologists who mean well and genuinely believe that excision of endometriosis is the very best way to deal with the disease, and they can usually do a great job on surface condition as well as endometriomas. The challenge is that deep disease is technically far more difficult and dangerous to eliminate as well as requires dramatically higher skill sets. These include gynecologists who are fellowship trained endometriosis excision surgeons and gynecologic oncologists (cancer surgeons) who also do a lot of endo surgery.
The options between laparoscopy and robotic surgery are hotly debated. But you can ask yourself, for a difficult task is it better to have two eyes or one and is it better to have instruments that are like little hands or can you perform your tasks using chopsticks? That is the difference between robotics and laparoscopy. You can get away with most surgery using 2D flat screen chopstick instrument surgery if the surgeon is excellent. But when presented with a difficult situation and distorted anatomy (which is common with endo and one never knows if they will find this until the operation is underway), it may be prudent to have 3D vision that is magnified and the most delicate instruments possible so that less trauma is inflicted and healing is therefore accelerated.
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