Endometriosis Surgery Risks and Obstacles - Reiner, I. & Koninckx, P.
OBGYN.net Conference Coverage
From the 35th Annual
Meeting - Las Vegas, Nevada- November 2006
Endometriosis Surgery Risks and Obstacles
Irvin J. Reiner, MD
Professor Philippe Koninckx, MD, PhD, EndometriosisZone Editorial Advisor
Watch the interview video
Dr. Reiner: Endometriosis surgery. Not only is endometriosis the kind of condition that requires surgery, some endometriosis is a self-limiting condition. I’ve operated on patients twice who had severe endometriosis, and the next time you operate on them, it’s gone.
Dr. Koninckx: This morning I have been talking at one of the courses about severe endometriosis surgery, only the deep endometriosis. The points, in a nutshell, which I would like to transfer here, is that first, before you start the surgery, you should know whether there is a deep nodule so that you are prepared, so that the patient has a stent if necessary, and so that you have a full bowel surgery.
This surgery, as such, is unpredictable, which means that when you go in, and then you say, “Oh, oh, this is too difficult”, don’t do the surgery, refer the patient. The worst thing you can do is do half the surgery. In very severe cases of endometriosis you never know where it is going to lead you. You are going to have rectal surgery, with opening up of the bowel, with suture of the bone. You are going to have a full dissection of the ureter with the hydronefrosis and eventually stitching of the ureter, and eventually resection of part of the ureter. When you go to the sigmoids you have the whole discussion of when to do a resection anastomosis, and when to do conservative surgery. The bottom line of all this is: when you start this surgery you should be in a setting where you can deal with all the things that you should see when you are doing this.
The second point which I made is the discussion about resection of the bowel, which has become very popular these days. I think it has become popular for two reasons, two main reasons. The first thing is the so-called argument that you can have knots of nests of endometriosis at distance. This is a false reason because by just shaving and conservative excision we only have one percent recurrence. The rest is not going to do better.
The second reason why it is very popular is that if you are a slow surgeon you cannot do it. Because, if it takes already five or six hours to do it conservatively, then it is much easier to do a resection.
The third reason is that many gynecologists prefer to have the abdominal surgeon with them at the table for medical legal reasons. The resection of the sigmoid, that’s okay, little complications, little long term problems.
We have an article in the press for the Journal of Minimally Invasive Surgery for the review of the rectum resections. There you have massive complications immediately after surgery between ten and 20 percent, even in good hands. Secondly you have very severe complications long term: bowel problems, urinary problems. And then the surgeons often say, “It’s very well”. Forty percent anorgasmia, you could say, “Who cares about that?” But I think that is a rather serious problem.
The last point, during these kinds of surgery you have to know very well the possibility of follow up where you have to recognize in time the large bowel perforations, which can easily be treated by laparoscopy. If you wait more than 24 hours at that moment you are in trouble. This is the message: early repeat laparoscopy when you do very severe bowel and endometriosis surgery. Thank you.
Dr. Reiner: One comment about the endometriosis surgery, the counterpart is like doing radical cancer surgery. It’s not what you take out, but what you leave that’s important.
Dr. Koninckx: Exactly. You have to do it completely. You have to do complete surgery.
Dr. Reiner: And this is the cardinal problem. This is why lots of times endometriosis surgery meets with some degree of failure because there is always some tissue that you may leave behind. We don’t know how much is going to be viable, how much is going to recur, and how much is going to go away by itself.
Dr. Koninckx: Away by itself? It’s never going to go away by itself.
Dr. Reiner: No, there aren’t too many cases where it goes.
Dr. Koninckx: The subtle ones, the others don’t disappear