International Medical Conference Endometriosis 2025:
Endometriosis 2025: Your Mother Should Know, Your Doctor Should Know Better!
How I Became an Endometriosis Surgeon: My Journey and Insights - Juan Salgado, MD
Stage is Juan Salgado, my co-chair of this session. He's an obstetric and gynecologist specialist, is San Juan Puerto Rico. He has contributed significantly advancing minimally invasive gynecology and endometrial surgery and we are awaiting your speech. Thank you so much.
Thank you very much Tamara. And then for the invitations, I'm very happy to be here, already honored. It's like my fifth time here. So when Tamara called me, he said, I want you to tell us how you became an endometriosis surgeon at 52 years old. And he sent me the title. So I add, yeah, the causality or causality because it was by either causality or causality. This is my only conflict of interest today. I am the enemy of endometriosis. I find that every single day of my life and all star. In 2009, when I was 51 years old, I have to refer this patient that she came to the hospital with severe pain. They tried to do two surgeries on her due to severe endometriosis and nobody could do the surgery. I didn't feel comfortable even though I was a very good OB YN with a big practice doing 65 deliveries a month and doing very good general gynecology surgery.
But I was not trained to do endometriosis surgery. So I decide I have to refer you, I refer her, and she almost died from die. She was intensive care unit. She have a lot of blood infusions and then I decide what I'm going to do. Either I go forward and try to improve this or I retire. I could live very well at that time, retired. So here I am 16 years later telling my story. So by Ca Ality, there was a meeting in Puerto Rico and Pedro Covar was there. He was the MIS chair of the Cleveland Clinic in Ohio. He's Puerto Rican. And he asked Elliot Amro about one surgeon that was 50 to 55 years old. That's me that do a lot of open surgery and he was good doing open surgery, general gynecology, but he doesn't do any laparoscopy. So I was selected with another friend and he talked to me and said, you're going to Cleveland Clinic.
We're going to train you in laparoscopy. I want to trade your brain from open surgery to laparoscopy surgery. So I accept. I talked to my family and I said, I'm going to have now a challenge and I will do it. We like challenge and we are going to change this. So I went to the Cleveland Clinic. We start there just in the lab with the pigs, with simulators. We went to the robotic simulation, everything. We did everything for one weekend and then we go for another weekend. And in the next weekend that we went by causality of ality, Mauricio Bra had the meeting with Thomas Alani, that was the chairman of the O-G-B-U-N because they were doing research together, Brazil and Cleveland Clinic. So I met Mauricio. Mauricio told me we click rapidly and he said, you know what? I'm going to teach you endometriosis.
I want you to go to Brazil. So in the next months, you know where I were, I was in Brazil, so I was doing surgeries. The Brazilians, there are some of them here, they wake up very early. They start to do surgery at five o'clock in the morning. So I was in both hospital with Mauricio. I was just observing surgeries from five o'clock to the noon. And then at one o'clock I was going to Manuel Goncalves office, the radiology that did the research of the mapping of endometriosis with Mauricio. And I was just watching sonograms of endometriosis all day until seven o'clock, five days a week, sometimes six days a week for three weeks. Then I come back to Puerto Rico, then I went back to Brazil and I come back to Puerto Rico because I have to work. I have a family, three kids in school, so I have to work sometimes.
And then by casual or causality, there was a meeting of the A GL and I met Tamkin in a table and they were saying that we were brothers and we said we were brothers from another mother. And since that day we become very good friends. And he said, I will help you also. He knew my story. So he said, come to Lenox Hill to watch me doing surgery. So after finished bar Brazil, I came to here to see him doing surgery and he's a great, great surgeon and learned a lot from him. Of those cases he put that day. So this was my training around the world, but I have to train in Puerto Rico because I live in Puerto Rico. So we start to do on training with Pedro Co. He was coming every six weeks to Puerto Rico. I was auto didactic. I watch all the caring step videos of surgery one and the other one and the other one and the other one.
I was watching video every single day. I have to relearn the anatomy because the anatomy in the laparoscopy is not the same anatomy. When you do open surgery, there is no depth of perception except if you do robot like RA said before. But with laparoscopy, I didn't have it and I didn't train. I was not a video gamer because I was 52. I didn't born with that. So I did my own pelvic trainer in my house. We bought tons of cows and practiced my kids were better than me because they were video gamers. This is not my perfect dream because my wife throw it away. This is one I took from the internet. But we start to do that and then I start to record, I start to do the surgeries and we were recording all the surgeries, every surgery I recorded so I could review in my house in the afternoon and I start to review and review and do whatever I can so I can improve more.
So then I said, okay, it's time to go. So Pedro start to come to Puerto Rico and we start to do surgeries every time. Bigger surgery, more complex surgeries. So we start to do more sation first with the mechanical morcellation, the manual morcellation. And we were removing big uterus up to five pound uterus by laparoscopy without any previous training in my life. Just open surgery. All these surgeries were done by us there in Puerto Rico. So we said we need to go to endometriosis. This was the first bowel resection, low anterial resection of endometriosis done in Puerto Rico that I convinced a crazy surgeon. And he said, let's do it. He is do it high and assisted with me. And everything went out good. She was an infertility patient that the only explanation of infertility was the bowel endometriosis.
And we did it. We present this at the A GL and was accepted and we were very, very excited at that time. And everything was completely fixed, obliterated, cool. The sac, it was a very difficult, the patient has a night of pulse and we have 200 because we were scared that if something went wrong, it was the first surgery of endometriosis in Puerto Rico and we're going to be kick out from the hospital. So everything came out very, very good. We did an cyst and the surgery did well, the patient became pregnant, but when the pathology came out and it says endometriosis in the bowel, I was called by everybody in the hospital, what are you doing? This is not cancer. And you're removing bowel from people that doesn't have cancer. So it take me time to convince the people that we have to do this because this patient is suffering a lot. So then we start to improve in endometriosis. And then I found this colorectal surgeon, Dr. Marla Torres, who really embraced with me in this journey. And we are doing a lot of great things with the patient. We do the sonogram, we do preparative evaluation, we identify the nodules, we go to the or. We have a neurologist that put the stents and the ICG in the very complex cases. And with the sonogram we can identify everything we do, the bowel resection or the shaving of the deletions.
I have good time. And then we start to put more complex and more complex cases. Some of them blitz a lot, some of them doesn't bleed that much. But if we have a lot of addition, you will see it soon. So we start to do everything by laparoscopy. We remove the lesions by the vagina and then we introduce the amil and do it. And now we are doing what Mario says today. We do everything by laparoscopy. We don't take anything out through the vagina, just the specimens. We introduce the Amil through the vagina and we do everything inside. And this is how it ends.
And this is just learned by us out of didactic and then by ality or by causality. In 2013, I met Mahon from the SLS. We were giving a lecture of mapping of endometriosis in Argentina. And Tamari invited me for the first time here and he took before me in Argentina and after me here. And then he said, I want you to be part of the world team of the SLS. So we started to travel the world. I've traveled more than 2 million miles 10 years giving lectures all over, teaching residents to do surgery, to do endometriosis, to do the mapping all over the world with the SLS and what we do in Puerto Rico. Now we have our protocol, we examine the patient. I dedicate one hour to every patient when they come to our office because they have 1, 2, 3, 4 surgeries. I'm going to show you one with 11 surgeries.
So I have to explain that. Trust me, we're going to cure you. We're going to take this out because we know what you have. We do the mapping and we're not talking about the mapping that much because Alexandra just gave a very good presentation. But we identify all the lesion. So we know if we're going to do a segmental resection or we're going to do a shaving of a lesion or a disco resection, we know if we need to do an ileostomy. If the lesion is so close to the anal verge, we have to do an ileostomy because the anastomosis could leak because the vascular is not the same as is upper to the rectum. Closer to the sigmoid, we identify the bladder lesions very well. The recov septum is very well seen and could be identified. So all that Alexandra said is completely feasible to do is you could do it in the office.
I give a soft diet the day before and the day of the sonogram we give three fleet ene animals and with that we can see everything. The most difficult part is the area of the appendix, but we can figure it out. We do the sliding test because we're doing now three cases, two to three cases per week. So we have to identify which are more difficult. And with the lighting test, I will know if everything is fixed there in the anterior or the posterior compartment or if everything is frozen. And I don't have any cool sac because it's completely obliterated. So I not put three cases like that for one day. This patient was a case that was referred to us. She was septic, 40,000 white blood cells. She have pyro, nephrosis, hydronephrosis in the left side because she have a huge two ovarian abscess and she have five surgeries before nobody could do the surgery because everything was completely fixed there.
So we cannot put the double J through the bladder. So we put it with interventional radiologist, we cool down the patient and we took it to the or and then we cannot put the manipulator. So we start to do the lysis of addition. First identify the abscess. As you can see, we can found it easily. And then we put manipulator stand, IC, g and everything to go farther and start to do the surgery on the patient. We use a lot of ICG because it give us guidance when we are lost in surgery that we cannot find anything because everything is completely fix it. And it's helped us a lot. This patient, we have to dissect all the masks from the ureter down to the bladder. We did it easily with ra, identify all the time.
And just to go a little bit here, we are doing very, very complex cases now. We are number one referral center in Puerto Rico and we are very, very pleased that our outcomes are very good and we have patient coming from all Ian Islands. We have patient coming from the states because as you can imagine, the surgeries is more cheaper in Puerto Rico than in any place. And this is how this patient finished after that mess. She was discharged two days after and she was doing excellent. And I have followed her in the office and she have a normal life without pain, without nothing. And this is a patient that had 11 surgeries because she have hydronephrosis of the right ureter, 11 surgeries. The first one was remove the uterus and hysterectomy patient continue with the problem. The second one was the right ovary patient continue with the problem.
And the other nine was to clean. I don't know what type of detergent they use, but they cleaned the patient for nine times. So we identified that she have a big nodule obstructing the ureter and doing the surgery, we found that she also have a band that I'm going to show it to you soon. Here is the van. So I put it in slow motion. So you see the effect of cutting that van in that ureter and look now how it looks without the band, with the ICG. And then we go to take the mass out. You can see it here. So we check if it goes coming close to the rectum, to the vagina or to the bladder and we remove it.
And then after remove, we light on the ICG and we could see the complete the ureter down to the bladder. So this is our patients 24 next day, seven o'clock in the morning. I do rounds very early. All of them have bowel resection. They allow me to show you the pictures. I don't use narcotics. I only use pain medications on steroidal and acetaminophen and gabapentin. We got diet the next day. We ambulated the same day. If we do the surgery early in two days, two, three days, if they have bowel movement, they go home. And the last one we did, she was from Toola and we did the surgery on Wednesday. We did B resection appendectomy, total laparoscopic hysterectomy, bilateral salpingectomy. And on Saturday she was in Toola. That is like a 35 flight from Puerto Rico to Toola. And she was doing good and she's doing excellent now.
So what we have to do is an next generation. I think that mixed fellowships are very good to treat general gynecology, but we have to train fellows in endometriosis because it's different in monster to deal with general gynecology, do atherectomy, do a myomectomy than do endometriosis. It's more difficult. It took me a couple of years of a lot of traveling and self-study, but it is doable. I have the opportunity to meet many, many great people around the world and learn from them in this journey. And I teach a lot of people in the world also and have a lot of friends that I have made in the world with this great opportunity that I have by ality or by causality. I don't know. But either of each one is worth it. I was elected, elected as a secretary treasury of the SLS. I'm the first Puerto Rican ever to going to lead a society, an international society.
So we were very happy. I was all over the news in Puerto Rico because it was a good thing for the gynecological societies and the medicine in Puerto Rico. But I could not do that without my team. My team is colorectal surgeon and another gynecology and a neurologist. They are at the OR with me all the time. There could be another or doing surgery. But when I need them, they jump to the or and we prepare the patients and we do the cases and the outcome are very good. And now we have the new kid in the block in Brazil. They put him Dr. Huci, which is my son. I'm Dr. Juan the senior, and we are doing the great team. And I am pretty sure that I could give the baton in a couple of years and he will be a great, great endometriosis surgeon as well. This is my family that backed me up when I decide that in 2010 that I was going to start to travel and do things to improve my practice and to accomplish my dreams. And I dream very, very high and I did it. So thank you for the opportunity.
