Endometriosis Foundation of America
Medical Conference – 2012
Excision Surgery that Gives Rather than Takes Away: Merging Microsurgery with Laparoscopy
Charles Koh
Good afternoon. Thank you for your kind introduction. I would like to thank the Endometriosis Foundation of America, particularly Dr. Seckin, for his kind invitation and for this great honor.
Our talk to day is about endometriosis surgery. This beautiful film from nature exemplifies one of the things we like to do. This bird has just performed microsurgery, which is the ability to tap whatever it wants without damaging all that is around it. I have to thank Dr. Seckin for this title, and we do surgery that gives rather than takes away.
Classical microsurgery by laparotomy introduced precision finesse through the use of magnification, fine instruments and sutures. From 1991 we investigated the feasibility of performing true microsurgery through the laparoscope and performed the world’s first in 1992 together with my partner Dr. Grace Janik, whom you heard this morning. Why were we interested in the laparoscopic route? Because data had shown it was less adhesiogenic, there was the closed environment, there was variable magnification which you could get with the laparoscope, and incredible access to the pelvis. Little did I know at the time that this access would be pivotal in the treatment of severe endometriosis.
We did our first workshop with AAGL on microsurgery in 1995. During the development, one of our goals was that laparoscopic microsurgery would be used for all tubal disease, but also having attained that it was to perform surgery beyond the tubes specifically radical microsurgery for endometriosis. We thought that the introduction of microsuturing would enable more advanced operations with preservation of fertility. The micro instruments that we used for tubal anastomosis began to be useful for ureteral anastomosis and repair of the bladder. During development and during all the time that we have been performing surgery, there has always been one compelling objective. And that is, whether it be microsurgery or other forms of surgery, faithful replication of the end result. This requires skills development of the surgeon and knowledge of the disease. The portal through which we do these things and the instruments, whether it be various lasers and so on, will be of secondary importance. Today I would include in this portal, robotics, single side, etc. It does not matter what you work through the end result has to be pristine, precise surgery.
We sort of presumptuously said that laparoscopic micro surgery is the tool in our publication for challenges in the millennium.
I think endometriosis has existed for a long time because we can see in Angkor Wat this poor woman obviously is suffering in pain from endometriosis and being ministered by the holistic doctor, etc. So today, in 2012, have we progressed? This is beautiful artwork by an artist in Paris who personally suffered endometriosis and I think it is very graphic of the kind of suffering we see.
What has crystallized our thinking in the management of endometriosis is really looking at it from a morphological perspective and dividing it into three areas to tackle. The AFS stage score is quite useless and really obfuscates thinking in the management of these cases.
In 1927 we have heard this morning and always retrograde menstruation was advanced as the etiology of endometriosis and the logic from that would be that removal of the uterus and the ovaries was the definitive treatment. This lead to consequences like this, no uterus but endometriosis still present. This is a video I got from Dr. Allen Johns who seems to get all the complication videos in the world. This was his treatment of excision of the endometriosis, which if it had preceded the hysterectomy would have saved this poor lady her uterus. This is the kind of surgery “that takes away” that we should publicize is rarely ever indicated in endometriosis.
Peritoneal endometriosis is very important for reasons other than what we think. A great advance was made in about 1990 when Harry (Reich), David Redwine and others published different appearances of endometriosis other than the classical powder burn. This is an example of an atypical white endometriosis which you would see only with magnification of the laparoscope. Excision by whatever source which does not cause damage, as you can see it is very clean because of the appropriate use of energy, is what is needed. We have also found increasingly that areas of hypovascularity, without any obvious lesion, when excised contains endometrial glands and stroma. It is thought that you can see up to 120 microns with the laparoscope, but that was then. Today, with a high resolution camera, this suture which we used for tubal anastomosis is 45 microns and you can even see vessels smaller than that. There is no reason that endometriosis cannot be seen. As I said, hypovascularity without visible lesions is another problem.
Data is not common unfortunately, but here is one which shows the effect of coagulation and excision at 12 months and importantly, at 24 months. There was better pain free response than by coagulation. Other data, including ours, which followed pain relief after surgical excision, shows high relief persisting up to five years. If we establish that it is effective to perform wide excision of peritoneum do we need to fear the risk of adhesions?
Our fellow won the Fellowship prize for ASRM/AAGL when she looked at the risk of adhesion formation. These patients not only had peritoneal adhesions but also bowel, ureteral and bladder treatment as necessary. It was a retrospective cohort study but prospective blinded videotape analysis and we used 23 sites to look at adhesions. This was validated for another adhesion study. What was found was that the sites that had no endometriosis and were not treated there was a de novo adhesion rate of five percent. The site where endometriosis was excised there was a de novo rate of 14 percent and between these two it was not statistically significant. On the other hand, the sites which needed treatment of both endometriosis and adhesions had a recurrence rate that was between 50 and 77 percent.
Therefore, the conclusion is wide enbloc excision of endometriosis is associated with de novo adhesion of 14 percent with no difference statistically from the sites that are not touched and therefore the fear that adhesions may be a problem is unfounded. Of course, it needs further studies for those who may choose to verify this. It must, however, be emphasized that laparoscopic microsurgical techniques were employed, which is basically doing it very cleanly.
This is an example of the laparoscopic incision, en bloc incision. We tried to get beyond 1 cm of the last endometriotic lesion so that all peritoneum is included. That is the end result in the patient who also had left ovarian cystectomy. A year later because sigmoid resection was not performed the first time around, because it was unexpected, and no consent was given. This is the pelvis. You can see the line of excision of the peritoneum, and you can also see over here and over here very little adhesion formation. The cul de sac is completely free. This is the right sidewall or right perirectal area and you can see this line of excision and here is the line. The new peritoneum is very distinguishable from the old peritoneum. Interestingly, new endometriosis lesion was outside the area of incision and this is something we have consistently found. This has also been observed by others, so this is a very interesting aspect with regard to this morning’s lectures about formation of endometriosis and endometrium. We think that the peritoneum’s susceptibility has a lot to do with the development of endometriosis.
You do not have to use the laser, you can use monopolar, you can use scissors like Harry (Reich) does but it is important that there is no white thermal damage beyond the area that one is treating. So that is microsurgery. It is a state of mind, it is a goal. It is not the instrument.
The take home message for non-excision surgery: coagulation/vaporization leaves behind persistent disease that was not treated the first time around; therefore, recurrent pain is due to disease not removed the first time. The more severe the disease the faster the recurrence of pain because deep disease is not treated if you do not excise and you do not know the extent of it by just beaming the laser superficially, it does nothing.
For radical en bloc excision it prevents persistent disease because all visible disease is removed. It can be used in young women at first laparoscopy. I was at first hesitant but after we found that adhesions were not a problem then we excised even in young women. Could this be one of the aspects of “tapping the roots” of endometriosis?
We have shown that at five years the recurrence rate is low. We have always thought that when pain recurs within months or a year it is due to left over disease. But if we are the surgeons and we think we have cleared the disease including bowel, rectum, etc. what can explain the recurrence?
Our other fellow looked at symptom recurrence after radical excision. She was looking at it from another angle and an interesting facet emerged. First, there were 441 women and there was prospective longitudinal follow up. What was found was that stage one patients, which means peritoneal endometriosis, had a significantly poorer symptomatic results. The recurrence was faster than those with AFS more severe endometriosis. That is somewhat paradoxical but this is what those who do extreme surgery and extremely effective surgery will find. It is the mild disease that is the problem.
While I was mulling around this while traveling in China I got acquainted with the International Pelvic Pain Society and we have formed the Global Society for Endometriosis and Pelvic Pain just as there has been a union between the molecular biologists, basic science and endometriosis I think we have to look at the other aspects.
Infertility longitudinal studies have shown that endometriosis regresses and as much as 18 percent have no disease without treatment on second look. Sutton found that patients with pain on second look some of them had no disease. So we have something that was alluded to earlier, recurrence of pain after radical excision is not due to recurrent disease. Morris Chung found association of patients with endometriosis and interstitial cystitis. This is one area that we have been looking at but I think today that nobody should be doing repeated endometriosis surgery without first ruling out, or ruling in, all the other aspects of chronic pelvic pain. A lot of work is going on in peripheral, central, sensitization and descending modulation from the brain. It is my feeling with mild endometriosis it may just be an innocent bystander and not the cause of the pain. Therefore, a complete chronic pelvic pain workup must be done. If this pans out, and in association with studying pain and endometriosis, I think in the future we might have a category call, the pain previously known as endometriosis.
Deep disease is a real challenge and something that is very gratifying because these women are cured. The challenge is to remove the disease without doing hysterectomy and oophorectomy. The dysfunction that is suffered by these women include: pain, infertility or organ dysfunction with obstruction of the bladder, bowel and ureter. This is an indication for radical surgery. Here is, from Dr. Periera, a view of the rectovaginal endometriosis but our job is to remove that without removing the uterus. Now there is a swing in the pendulum in the early 1980s and 1990s there was fear of treating bowel adequately for fear it might cause infertility and might cause other problems. However, today, I think we might be over treating the disease. Is there indiscriminate segmental resection because no other type of surgery is being performed? Or are we under treating by shaving? To answer the questions we need a new kind of categorization of disease that looks at the quantity of disease, not a stage.
There is a problem with thinking that if we have multidisciplinary team we have all it takes to treat severe endometriosis. The surgeon is the gynecologist, you cannot outsource the dissection of the disease. If you leave it to the general surgeon you may see things that we have not seen; bladder dysfunction of about 10 percent. There are also real problems with resection and anastomosis including stricture, which of course does not require operative treatment but nevertheless are inconvenient.
We see a kind of explosion of bowel resections in the literature without any intervening kind of treatment full thickness or partial thickness resection. Women who may respond to lesser degrees of treatment may be over treated.
On the other hand this is the kind of ratio we usually see. In about 100 patients 25 percent will need bowel resection and the rest can be treated according to the extent of the disease and you see there are many other authors who are doing the same. We need classification of deep disease in order to know when it is appropriate to do what, which we do not have at the present time. The pregnancy rates following bowel resection of course are not bad at all but this does not mean very much because there are some women with just a sigmoid lesion without very severe disease. Most of the pregnancies will occur in the first two years. In our case of course bowel resection means treatment of the least amount of cases where we think lesser treatment is not appropriate.
We have seen this before and the question of how much disease is left behind by shaving. This is segmental resection with significant bowel disease. And Brouwer from Australia showed that shaving has a higher recurrence rate of symptomatic pain but this may be somewhat selective from the way shaving is done.
Here is an example of how you do partial thickness resection. If properly done it will remove most of the disease – when I say most, I mean all. There we can palpate and visualize. It is important in doing partial thickness resection that you also get rid of all of the peritoneal disease. Now, there is the first shave and this could easily be left behind. Palpation will tell you that there is still endometriosis present and the amount of treatment will depend on how it turns out during surgery. We are not convinced at the present time that you can tell what to do by preoperative triage, whether with ultrasound or any other modality. It is still something you have to decide at the time of surgery. After partial thickness excision we would only use it when the endometriosis does not involve the inner muscularis of the mucosa because I think you will not be able to remove it adequately. We always over sew in order to prevent any sequelae from thermal damage afterwards.
On the other hand, cul-de-sac obliteration does not always mean that there is severe bowel disease requiring segmental resection. The disease has to be treated in layers. The first layer you remove the uterosacral and other thickness until we get to the normal rectovaginal space. Here is the disease on the rectum and there is the disease on the vagina that has been bisected. Our technique is to treat them separately and we attack the disease on the rectum first, always bearing in mind that first we reach the point of normal rectal. You can see normal rectum here and normal rectum here, and this is the residual disease after initially clearing it partial thickness. That is widely excised and then the bowel is closed in two layers continuously.
Outsourcing the disease to a general surgeon will mean that usually the other areas of endometriosis are not removed. Here we see endometriosis of the posterior vagina, the posterior uterus, peritoneal endometriosis, so it is not only bowel resection. The laparoscopic excess allows us to go very deeply down into the rectum which is difficult for the surgeon to perform segmental resection because of instrumental limitations. Here we see, even after removing part of the endometriosis, it is still there and stuck to the levator ani muscle. After complete excision repair takes place in these depths.
What we use for preoperative triage is MRI with gel in the vagina and the rectum. This shows us a normal rectovaginal epithelium and here is the disease in the rectosigmoid. Here is another one with very elongated rectosigmoid involvement and also posterior vaginal.
This is the story of a 24-year-old girl who developed hypertension and had a recent laparotomy with stents that were performed for hydronephrosis and hydroureter. She had had an oophorectomy done at an earlier age. She was put on GnRHa but was still in pain. The right ureter stops almost here, obviously it is not completely blocked. This is the left ureter. It is important to pay attention to the right ureter. She had laparoscopic surgery and this is what it looks like after a woman has had many laparotomies. Here is the left ovary and left fallopian tube. There is the actual uterus and there is the uterine horn. Surgery begins in layers. First, the bowel is freed from the uterine horn. Here we see the sigmoid is actually lateral to the ovaries rather than medial and this has to be separated. We tend to use a laser simply because we can irrigate and suck at the same time. That is the hydroureter on the left that is exposed. After freeing it laterally we see the ureter and this is where micro-dissection of the ureter allows us to decide what to do. Very rarely have we needed to implant. I do not remember a single case where we re-implanted the ureter. Here we go to the distal part of the ureter where there is no endometriosis and the endometriosis is clearly identified. This would be a case for ureteral transection and anastomosis and we can see that the lesion in between is completely removed. Suturing is by the use of 4-0 or 5-0 suture and it pretty much mimics what we do at tubal anastomosis with suturing at 6:00 o’clock and 12:00 o’clock. After the 6:00 o’clock suture that is when the stent can be placed by the urologist. Then the 12:00 o’clock suture is performed followed by 9:00 o’clock and 3:00 o’clock. Then we have a slide of the knot. Here is the 3:00 o’clock suture being placed. The knot is slid down and the anastomosis is complete after another tension relieving suture is placed.
On the right side we saw on the IVP there was almost complete occlusion. Right ureterolysis begins from the pelvis; again, this dissection method using a back stop or something that we did with micro surgery and it was just serendipitous that we could use the same style in isolating the ureter, without damage to the ureter by thermal or other crude measures. Here we see the ureter stops exactly at the right uterine horn and so the horn is removed, which needed to be removed anyway because it was non-communicating. The final bipolar and incision to separate the horn, after which it is taken out. We find that this actually de-roofs the ureter. All the endometriosis has been removed and the ureter begins to recover. At this point it is clear that no further treatment is necessary.
This patient also had severe bowel disease and it is obvious to those of you who have seen many videos this is the crater we talked about. Whenever the wall of the rectum sinks in like a crater it is deep disease. Only at this point do we bring in the general surgeon to do his part of the bowel resection. The surgeon does not have a role at all in dissecting the pelvis or in making a decision about what to do. A small 3 cm incision is made in the abdominal skin where one of the trocars is and then the bowel is resected and then brought back in for anastomosis. One of the things we find is that with clear view visualization and accurate apposition we do not worry about fistula. We have no problems if there is a repair of the bladder, a hysterectomy and repair of the bowel or repair of the ureter. This patient would have been better treated by in vitro fertilization with her remaining hydrosalpinx but in Wisconsin that is not a covered benefit so being young a neosalpingostomy was performed together with ovarian cystectomy. This was a patient who had a right oophorectomy for ovarian cysts simply because that was what could be done. She would have been much better off from a fertility standpoint had her right ovary been present. That is the end result of surgery. Just to show what the patient looks like after a prolonged surgery with bowel resection on the first day, with her permission. Histology confirms deep endometriosis.
IVP at eight weeks shows hydroureter resolving. At 12 months she is pain free, normal bowel, bladder function, off hypertensive medications and even wishes to attempt pregnancy.
I guess this is an example of surgery that gives.
Hysterosalpingogram showed tubal patency but the tube is really not in good condition. We have had data and presentations of women who have had IVF and failed to have a baby, and one of them was by Camran Nezhat, where after laparoscopic surgery as much as 70 percent of them achieved pregnancy, both by IVF and spontaneously. But I do not think there has ever been a report where multiple IVF cycles have been cancelled so that the patient never went to transfer having surgery to try to correct their problem. Here is one example.
A 26 year old from New Jersey who had a laparoscopy in 1997 with stage four endometriosis and bilateral endometrioma, which was drained. I left the treatment of ovarian endometriosis because it was quite clear that we do cystectomy. The first IVF was attempted, the estradiol dropped and the cycle was cancelled. There was further surgery to drain the endometrioma. The second IVF now oocytes were retrieved and five were fertilized, however, did not develop, so no embryo transfer. Another laparoscopy but by this time there were a lot of adhesions and so she was given long term Lupron but there was no pain relief. The plans were for a donor oocyte cycle but this was cancelled when it was found she did not have a property integrin expression. So, with a lot of pain and no other hope, hysterectomy is offered and this mirrors patients everywhere. I think this is the message that has to go around; you can seek a surgeon who knows how to treat endometriosis before resorting to this. She had surgery in 2000 and this was the finding. A lot of adhesions, ovaries, tubes and bowel were freed; plenty of endometriomas too. This was mainly an exercise in adhesiolysis, freeing the fallopian tubes and removing each ovarian cyst because there were many small, multiple ovarian cysts. The smallest ones are difficult to remove and it is permissible to vaporize the cyst wall without damaging the ovary. The rectum is checked and found to be supple. There is no actual rectal disease but certainly thickened uterosacral ligaments on the side which I excised.
So the plan of treatment and the progress of treatment depend on what shows up. Here is a ring forceps in the rectum revealing no rectal endometriosis and after removal of the thickened area above the rectum no more is performed. Bilateral ureterolysis and this is using a micro grasper designed for tubal anastomosis. This is the only way that you can really expose the ureter. Ovarian cystectomies are performed. Now this is the kind of case where common _____ . There is really no hope, she has too many adhesions, she is never going to transfer and so on. She went back to New Jersey, had an IVF and delivered a male baby and another one two years later and has been pain free for a long time. A very interesting thing is she called her sons Zachary Koh and Lucas Charles.
Is that just a flash in the pan? During this period of about two years we had multiple patients who had cancelled. So this is not IVF, no pregnancy; this is IVF cancelled, no transfer and some of them had as many as six and these were all done in reputable centers. And not in our centers, so there is no bias. They underwent surgery at various times during these two years. IVF was performed after the radical surgery and, other than one, all of them had live births. This was ongoing because we did this somewhere in two of four and had a baby. One of the patients had a second baby normally, spontaneously after IVF. This is the patient that we showed from New Jersey.
So, there may be a place, certainly the place is there for radical excision for pain but one may be surprised that cases that are thought to be hopeless from a fertility standpoint may actually improve.
In summary, women with severe endometriosis who suffer from infertility, pain or organ dysfunction should be treated by a radical endometriosis surgeon. The word reproductive means the surgeon also has to have some idea of advances in assisted reproduction so you know that even retaining one ovary or retraining the uterus may be useful. At the present time a reproductive endocrinologist is not an automatic reproductive surgeon. A laparoscopic surgeon who is fellowship trained is not an automatic endometriosis surgeon. An endometriosis surgeon is one who has really spent the time and can be from either class.
Radical surgery with uterine and ovarian sparing should be performed and symptom relief can be expected, spontaneous pregnancy or successful IVF, all failing all of which a surrogate uterus or donor egg can be performed. The default movement is always to IVF without doing any surgery, that is fine because a proportion of the women get pregnant. But for those who fail, because of poor oocyte, embryo quality etc., these women can be given a chance at radical endometriosis surgery.
In conclusion, the greatest contribution of endoscopy to endometriosis is the preservation of fertility while achieving functional correction of effects of disease. It is a tribute to the pioneers of extreme laparoscopic surgery who have been honored by your foundation that this paradigm has come about. Laparoscopic microsurgery extends the radicality but with finesse, precision and accuracy to allow maximum recovery of fertility function.
Again, I wish to thank Tamer and the Endometriosis Foundation for the wonderful job they are doing. Thank you.
