International Medical Conference Endometriosis 2025:
Endometriosis 2025: Your Mother Should Know, Your Doctor Should Know Better!
What is Ahead of Us for Surgery? - Harry Reich, MD
He's played a crucial role in advancing surgical techniques for complex procedures. In honor of his groundbreaking contributions, endometriosis Foundation has established a Harry Rich award, which has given yearly since 2010. This recognizes leaders like him who've made significant advancements in endometriosis research, surgery, and advocacy. We're glad to have you here with us this morning. Harry.
Thank you, Dan. Thank you. Thank Dan Martin's been fantastic with the society. Tamir fortunately started this society years ago and it's gone very well since. And I'd like to thank his whole staff, especially SAR pair for SAR pair. I wouldn't be able to do any of this stuff, but I always tell Tamir, never put me at eight in the morning because this is the worst time to get started in any meeting. But anyway, so here goes. What is about, let's see if I can read this. What is the head of us for surgery? Well, I don't know. I don't think very much. I think surgery is the way to treat endometriosis and most of the other speakers that you'll see at this meeting will have very different ideas and hopefully there'll be a magic bullet one of these days where we'll all know what to do.
But what I'd like to do today, first of all, I'd like to start with Tamir's meeting here where he presents. He says, your mother would know. My mother never knew anything about endometriosis, and my mother was a doctor. She was the MD Women's Medical and so was my father. He was a proctologist after he had a problem with his heart when he was 38 after the war, and he studied proctology. So I always say I went in one orifice a little in front of where he was anyway, but my mother should have known better. She did a lot of obstetrics, which I, I'll get into in a few minutes.
Let me tell you a little bit about myself. I'm from a small area in Pennsylvania called Scranton, Wilkes Farra. You might've heard of Joe Biden. He used to be the president and myself, I have to say pledge allegiance to Ukraine because my grandfather came from Kiev and Latvia. And so I have quite a bit about what's going on with Ukraine. Now, I'd like also to say that trying to decide what to do surgery versus medicine when you're in medical school or before medical school, for me was not that difficult because my father, I should say my grandfather was a butcher in Kiev. My father graduated a little from there. Like I said, he became a pathologist and I'm a gynecologist. Anyway, what I'd like to do, having answered a little bit about that, I'd like to first go ahead and talk a little bit about my training.
I trained in Boston and I saw a lot of surgery at Peter. Ben Brigham is a general surgical resident, and we found very few gynecologists. I never saw endometriosis, but very few gynecologists really could operate. And then around my end of my second year, I spent four months with Robert Kissner and Robert Kissner treated only endometriosis. Basically, he saw 46 patients every afternoon. He had three nurse practitioners and his handshake was a rectovaginal exam. And that's pretty much, that's been a guiding principle for me from then on, and I hope for any gynecologist here in this room. Also, a rectal vaginal exam is a necessary part of any exam for pelvic pain. No matter what ACOG tries to tell you, acog, I think now doesn't even know what a pelvic exam was. Anyway, I'd like to switch from this and spend a lot of time on what I did because I came back to this town in 1976 and this is the way we operated for 10 years.
We did not have what you see today with the beautiful videos and other different operations. We had this kind of set up for me. I had my assistant was you could see her in the background there. She's between the patient's legs and she's holding most important, she's holding a rectal probe. And most of my surgery was guided by the rectal probe because when I watch some of the Europeans operate today, I see how they go down each side and they dissect beautiful ureter on each side. We didn't do that. We went for the lesion, which was the endometriosis. So we went right for the endometriosis lesion. And in this position with my right foot, I usually have my be on my heels and I'd use my toe for the pedal for the laser CO2 laser and my back foot, I would have bipolar and I have the possibility to use unipolar cutting current.
We didn't use unipolar coagulation current at all for anything. In fact, it was turned on zero. So in 1976, this is the way we operated. I was very fortunate in that I went back to town where my mother had delivered a lot of babies and most of her population was Polish and Italian. And by Italian, I mean Sicilian. Any of you've seen a movie The Irishman with is about that area. It's about Bino family, and I think Binos played by, anyway, I slipped the names of some of these guys now. But anyway, that was a movie, the Irishman, where they worked their way to Detroit from Wilkesboro, and they stopped at a point where Frank, the Irishman was able to get on a plane and go assassinate a Hoffa. Anyway, that was area I was from. So many of my friends knew Hoffa and they knew that type of area of people, but my mother, I think delivered most of the mafia in our town.
So it was nice for me. Why did she do that? Because Italian men would not send their wife to a male gynecologist. So we had a lot of people from Sicily who my mother would deliver. And then when I came back to town, I came, this is a pretty rural place, so they had very much problems with tubal ligation. So my practice was many, many tubal ligations, and I inherited with my midwife program for which I did for a year, I inherited an infertility clinic that had 100 active patients, none who had laparoscopy. So I had a lot of infertility. So what would I do in those cases? In those cases, I would look in with a laparoscope, make a diagnosis if there was endometriosis, which I have to say was something that very few people knew about or talked about. I certainly never heard about it at the dinner table.
But anyway, endometriosis was not heard of. But in the clinic we did a lot of tubal ligations. In two years, we had close to 400, and in four years, the hospital put me on trial because we did laparoscopic excision of endometriosis instead of hysterectomy. But anyway, we survived and I'm here to talk about it today. Anyway, the main point I'm making here, and what I'm trying to do is trying to show you what it used to be like in surgery. And in surgery, like you see there, it was holding on to the laparoscope. If you're very observant and you really look at that video, you'll see that I am holding the laparoscope with my right hand and I have a beam splitter. A beam splitter is technique that when Cameron came out with a video in 1985, people wanted to see what was going on in the operating room.
And with a beam splitter, I could shift somewhere between 50 and 70% of the light to the other people in the or. So that was a great thing. But what I want to point out is that in 19 89, 4 years after Cameron's invention, I still didn't believe in video. I still wanted to see it with my eye. So I operate it really till about 1990 with my eye and with this type of a setup. Now, what I'm going to do is I'm going to show you a video of some of the mistakes that surgeons make at laparoscopic surgery.
Okay, make it full screen, then I could control it with the space bar. Yes. Okay, so now one of the problems that we have in surgery is that sometimes we do exhibition surgery. And this is a case I did in probably around 19 95, 19 96 at Columbia, and it was broadcast to a GL to their annual meeting. So one thing you don't want to do is broadcast a video to a big congregation of people when you have three other people presenting before you, because it goes on and on as you start and you know what you want to do and you know, got to keep it pretty well smoke free. So you have to be very hesitant with a laser. Now this case I'm going to show you is a patient with a fibroid uterus, but also has a four centimeter rectal lesion. Now I'm going to try to show you what we do.
And in this case, again, I always have the rectal probe in, and I always have a val of retractor in the uterus to hold the uterus anterior. And my assistant is the main person in the room holding the rectal probe, not the laparoscope, but the rectal probe. Throughout most of my OR experience, I've used my right hand to hold the camera. And for the times when I need two hands, most of the time my nurse anesthetist would hold the camera. So that worked out really well. Anyway, as you could see here, the uterosacral ligaments have obvious endometriosis in them. They're thickened, and I have the rectum tented upward, and I still can't see the rectal nodule. But normally in a situation like this, I would cut the uterosacral ligaments, but because I'm presenting to A GLI bipolar and then cut the uterosacral ligaments, so I have a little bit better exposure to the cul-de-sac. Again, the rectal probe is a jutting onto the rectal nodule, which you can't even see at this stage, fortunately for laser. But I usually use the scissors.
People say, how do you know it's endometriosis? Well, endometriosis has a crunchy like feeling. So if you cut something and it doesn't crunch, it's not endometriosis, it's normal anatomy. So anyway, in this case, we bipolar coagulate the uterosacral ligaments for the sake of the audience at a LL. And for the sake of not so much smoke and for the sake of not showing too much blood, because as you know, if you just cut a uterosacral ligament without coagulating, it bleeds, but the bleeding will stop. If it's involving endometriosis, it'll stop on its own. If it's normal tissue, it'll bleed and bleed and bleed.
So anyway, in this case, we did use the bipolar, so it would be a little easier to visualize. I would not use the bipolar normally I would just cut right through them and the bleeding would be there, but it would stop. So here you could see the uterosacral on the right, being excised. I stress these are techniques I would not use. I would've just cut it. I would not have used bipolar, and that's why I'm using this tape to show you things I would not do as well as things I would do. So once the uterosacral ligaments are out of the way, I could work on the rectum and work that area down to the looser tissue of the rectal vaginal space. So that is the key to endometriosis surgery. I know where the vagina is because I have the vouch of retractor in the cervix and the uterus. So just so you could see better, we take the uterosacral ligaments like so, and they're full of endometriosis, and that's again the reason it doesn't bleed very much.
So then my assistant Lisa, keeps showing me what's going on with the rectal probe and the answer, do I ever operate without a rectal probe? And the answer would be no. I have a rectal probe in almost every case I do laparoscopically. So in this case, we gradually are able to dissect the rectum out of the rectal vaginal septum until I come to the beginnings of this three to four centimeter nodule. And what I use here is I'm using a carbon dioxide laser and I'm going in ever increasing concentric circles to be able to dissect this mass without entering the rectum.
And in many cases you can do that. If you enter the rectum, you fix the rectum and usually you fix it. I usually use a circular stapler to do that. But as you could see with the carbon dioxide laser, I can see the junction of endometriosis. Endometriosis is not black or brown, it's white fibrosis. There's always fibrosis around the lesion. So I follow the fibrosis junction with what looks like normal tissue. If I'm not sure, I use a scissors and if I feel a crunch, I know I'm in the disease. If I don't feel a crunch, I know that it's normal tissue. So here we keep going, Owen, with the laser, with tension being pulled upward notice I use a lot of suction irrigator. Now I stop this, I stop this video because this is what happens when you're showing at a meeting like a GL. Nobody wants to look in and see out smoke field field. They want to see what looks like normal anatomy. And because of that, they lose the point of the whole case.
So we get the smoke out of the way, we dry everything up. And now you could see most of the nodule has been Ted from inside the rectum. And in all of these cases I use indigo carmine dye in the rectum to see if I could still see it if it's thick or not. If it's very thinned out, I'll usually put a suture in there. As you can see here, I use the scissors at the junction of endometriosis, fibrosis and normal tissue. And we're able to do this without entering the rectum. Notice the device I'm using there that's called micro bipolar forcep. I use very low current cutting current. Again, I never use coagulation. Current 25 years of surgery. We don't use coagulation to current. The cautery turned to zero for coagulation and it's turned up between 50 and a hundred for cutting because cutting is very similar to the CO2 laser. So I could see where I'm at, but with this bipolar I could go there and just touch one area of a bleeding vessel. I call 'em like little tiny red snakes. I look for little tiny red snakes and I just touch one edge of the bipolar and it'll coagulate the vessel so I can get a very clean situation. And we're done time-wise. Okay, I'm just finishing up. Okay, so here after the Indigo Carmine shows no leakage, we decided not to put a suture across that area.
So anything that sort of possibly might be endometriosis in the area, I coagulate with cutting current micro bipolar forceps. Well, Dan is ready to move on to the next speaker. So I'm going to sign out here and I just want to thank you all for we have good crowd for this hour of the morning. Tom is right, but please never again today in the morning. Thanks. Thank you, Harry.
