The challenges of endometriosis – clinical examination, surgical
excision, adhesions, and should surgery be videoed?
The challenges of endometriosis – clinical examination, surgical excision, adhesions, and should surgery be videoed?
Harry Reich, MD: “My name is Dr. Harry Reich, I am vice-president of the ISGE, and today I am here with my friend and colleague, Dr. Alan Johns, and we are going to discuss endometriosis and adhesions.”
Alan Johns, MD: “I am Alan Johns, I am the current president of the AAGL; and in private practice in Fort Worth, Texas.”
Harry Reich, MD: “So, Alan, tell me: do you think doctors should videotape their laparoscopic operations?”
Alan Johns, MD: “Absolutely. I believe that if a patient is having a laparoscopy, particularly for endometriosis, that it should always be videotaped in its entirety, and the patient should have a copy of that tape.”
Harry Reich, MD: “Many doctors are a little bit afraid of doing that because of the medical-legal ramifications. What do you think about that situation?”
Alan Johns, MD: “I do a fair amount of malpractice case reviews, and a videotape is worth a thousand words. If a patient has a bad outcome and the videotape shows that the physician was using reasonable technique, then they’re fine. No one, no jury, necessarily believes a written or dictated operative report because the doctor knows something bad happened when they dictated it; however, the videotape shows what the physician did, and I think a videotape has a much better chance of helping a case than hurting it.”
Harry Reich, MD: “We’re talking a little bit about endometriosis here, so let’s ask the major question, which is: Do you think you should ablate endometriosis with a laser beam or should we try to excise the whole lesion?”
Alan Johns, MD: “Well, I think it’s fairly obvious that the lesion should be excised in the vast majority of cases. It depends on the depth of penetration of the lesion. A rule of thumb I use is if an implant is on the peritoneum and I pull the peritoneum and the implant moves with it, then you can spit on it, you can do whatever you want to get rid of that lesion, but if the peritoneum does not move, that implies it’s attached to the structures and should be excised.”
Harry Reich, MD: “I’ve always been impressed that most gynaecologists, who say they treat endometriosis, are really treating old blood from the previous period – retrograde menstruation – which I don’t believe has much of a role in endometriosis because when I do laparoscopy, I can usually scrape these areas off, they are not attached to anything, they have no surrounding fibrosis, so I don’t believe they are endometriosis. What do you think?”
Alan Johns, MD: “I agree. More and more, I think you should excise a lesion, if nothing else for pathologic diagnosis. There’s a very good study that’s presented at the Central Association of OBGYN about a year ago and it was comparing visually normal peritoneum to peritoneum that actually had endometriosis. In other words, if the operating physician thought the peritoneum is normal, was it really normal when they excised it? The answer was 90 some odd percent of the time it was normal. If it looks normal, it probably is. On the other hand, if they thought the lesion was endometriosis, they were only 60% accurate overall, regardless of what the lesion looked like, including the puckered lesions. So just looking at it is not good enough, you need to have a pathologic diagnosis and many of these little hemosiderin deposits that are called stage 4 endometriosis tend to be nothing.”
Harry Reich, MD: “The term our doctors used, when I was in training, was “hemosiderin ladened macrophages” and, believe me, that does not mean endometriosis is present. On the other hand, we have a great marker for endometriosis, namely, if it’s there and it’s causing pain, in almost every case there’s some fibrosis surrounding it. Under the microscope you’ll see fibromuscular tissue, so if we remove that fibromuscular tissue and scar, we will remove the whole endometriosis lesion.”
Alan Johns, MD: “That’s right, that’s right. You have to remove the lesion. That doesn’t necessarily mean that you’re going to cure the patient of her pain because a significant number of these patients with endometriosis actually have chronic pelvic pain that has nothing to do with their endometriosis, and those are the patients who end up having 16 laparoscopies in five years and ultimately a hysterectomy and continue to hurt.”
Harry Reich, MD: “I’m impressed by the office exam before we do surgery. I’m very impressed with a good recto-vaginal examination where the surgeon lifts the cervix upwards: you can usually feel the anterior rectum, the posterior vagina and cervix, and both uterosacral ligaments. If one has a tender area there, and one removes it, in almost 100% of these people the pain will be gone, I believe, permanently.”
Alan Johns, MD: “That’s true. That’s a specific area of pain that’s identifiable on exam and reproducible on exam, whereas a patient with generalised pelvic pain and the first question I ask is where do you hurt? If a patient spreads her fingers out and says, I hurt here, then the odds of you curing that patient surgically is pretty close to zero. That’s that absolutely classic sign of chronic pelvic pain. If they can’t put their finger on where it hurts, then it’s unlikely that you’re going to cure it in surgery.”
Harry Reich, MD: “I agree. It’s so nice when you can actually elicit the pain before the operation and then you can really tell them that when they come back for their post-operative examination, that pain won’t be there any more.”
Alan Johns, MD: “What about adhesions? How do you prevent adhesions?”
Harry Reich, MD: “Well, I prevent adhesions by limiting the use of thermal energy during my surgical procedures. So, what I do is I use cold scissors dissection. I don’t use cautery. I don’t use laser. I excise it with scissors, and then if there are small bleeders at the end, I’ll coagulate these tiny little bleeders. With endometriosis its blood supply is what we call neovascular-type blood supply. These are tiny, little newly formed vessels and you don’t have to stop for every single little bleeder during the operation. How about yourself?”
Alan Johns, MD: “The bottom line is the patients who have significant endometriosis probably produce more adhesions post-operatively than any other patient population we deal with; and having done close to 500 second looks, I’m convinced that almost all of them get adhesions. I don’t know which ones will and which ones won’t, and we have absolutely nothing on the market right now that is approved for use in laparoscopy, or even usable in laparoscopy, that works, so we are out of luck as far as adhesion formation product goes in laparoscopic surgery. We have to use good surgical technique and even that, it is amazing the adhesions you can end up with using good surgical technique afterwards.”
Harry Reich, MD: “I agree. But I also believe that many of the adhesions that we see after endometriosis surgery are because the endometriosis is partially removed, so you still have some of those little active cells present. They are more active than ever after partial removal and I think that they contribute a lot to adhesion formation. But haemostasis is the key, also. If at the end of the operation there’s no bleeding. If we try to separate the organs with simple fluid (I use Ringers lactate), I think it’s as good as any of the presently available adhesion preventive medications in the United States, although we hope there will be some new ones developed that will be tested in other countries in the near future.”
Alan Johns, MD: “I’d agree. I use hydra floatation simply because there’s nothing else available. It doesn’t work, either, but it makes me feel good. And, the patient doesn’t get nauseated and they don’t get dehydrated afterward, so it has a benefit regardless of whether it works for adhesion prevention or not.”
Harry Reich, MD: “And of course you have less
CO2 retained because you get almost all the CO2 out.”
Alan Johns, MD: “There are a lot of benefits to leaving that fluid in the pelvis and they are real benefits and the adhesion prevention is imagined, but it makes us feel good.”
Harry Reich, MD: “Great.”
I am and adhesions sufferer of 7 years. I find your information quite useful. I do have a couple questions though.
1) My uterus and bladder are severly adhered to each other and the omentum. Is it possible to seperate these two organs without causing damage to either one?
2) Since the uterus and bladder are adhered around the navel is it possible to still have a laparoscopy?
3) I was told that i need a hysterectomy to seperate these two organs, is that true in your opinion, I was also told that to have the hysterectomy and seperate the organs it would have to be done by laparotomy, is this true in your opinon?
I thank you so much for your response, I have so many questions but I will post more later.
It should be possible to separate the uterus, omentum, bladder, and anterior abdominal wall by laparoscopy (as long as the gynecologist has extensive skill and experience with this type of laparoscopic procedure). Hysterectomy might not be necessary.
Alan Johns, MD
It is possible to take care of adhesions laparoscopically almost 100% of the time. It is not necessary to have a laparotomy or a
hysterectomy for this, although it may be necessary to remove the uterus if it is the source of pain or bleeding or to reduce the
possibility of adhesions reforming.
David Redwine, MD