Radical Endometriosis Surgery
In
1921, Dr. Sampson from John Hopkins Hospital theorized that endometriosis was due to the
back flow of menstrual blood and that this blood containing uterine lining material began
to grow and embed on the pelvic peritoneum and structures thus forming endometriosis. The
corollary of this theory is that if the uterus is removed, then no further back flow can
occur, therefore endometriosis would be cured. Furthermore, it was believed that the
endometriosis implants in the pelvis responded to hormones in the same way as the uterine
lining and that the estrogen from the ovaries stimulated their growth. Therefore, it was
routine for the ovaries to be removed along with the uterus even in very young women in an
effort to cure the pain of endometriosis. Surprisingly, there were and remains still a
large number of women who still continue to have pain despite having undergone
hysterectomy and removal of tubes and ovaries.
Recent
studies have confirmed the following.
- Endometriosis, especially the deep variety, is not related to back flow.
- Many women have cells derived from the early development of the pelvic organs during embryonic life, which under certain stimulation will grow into endometriosis and deep endometriosis.
- Endometriosis and deep endometriosis do not react in the same way as uterine lining, nor do they contain estrogen or progesterone receptors in the same quantity. Therefore, hormone stimulation or deprivation has limited influence on the lesions. This means that in many cases, the use of GnRH agonists (Lupron, Synarel, Busarellin) or removal of the ovaries surgically has minimal impact on some endometriosis.
- Deep endometriosis proliferates and invades without needing estrogen influence most of the time.
It
has become clear that the treatment of endometriosis can only be effective by radical
excision. This term means the removal of wide and large areas of pelvic peritoneum where
superficial endometriosis is present as well as removal of all deep endometriosis.
Superficial Endometriosis
This is usually found
in the peritoneum of the cul de sac, pelvic sidewall, and bladder. It may occasionally be
widespread over the whole abdomen even after the diaphragm. Wide removal of the peritoneum
in the pelvis (en bloc excision) requires considerable skill and experience because it is
stuck to the rectum ureter, blood vessels of the sidewall, and bladder. However, this is
regularly achievable by specialist endometriosis surgeons.
Deep endometriosis
These are tumors or
implants that are deeper than half a centimeter and typically involves the uterosacral
ligament, cul de sac, rectovaginal space, posterior vagina, interior rectum, cardinal
ligaments and ureter, bladder, as well as areas of large and small intestine away from the
pelvis. These lesions used to be called fibrosis implying that they were no longer
containing active endometriosis but rather was a fibrotic tissue reaction. It has been
clearly shown in the last few years that these so-called fibrotic lesions are in fact very
active endometriosis that continue to invade.
Radical
surgery for deep endometriosis involves removing all the deep lesions accurately. This
includes excision of a part of the bladder with repair if endometriosis has invaded the
bladder, excision of the ureter with anastomosis, excision of the rectum with repair or
anastomosis, and removal of endometriosis around deep lateral structures near the
obturator nerve and blood vessels. Having a hysterectomy and oophorectomy (ovarian
removal) performed without removing deep endometriosis is the most frequent cause for
persistence of pain after surgery. At the Reproductive Center, we frequently operate on
such women to remove the deep endometriosis. Radical excision of endometriosis is an even
more specialized procedure requiring a team of experts from other specialties like
urology, general surgery, etc. However, it is important that the leader of the team be the
expert gynecological endometriosis surgeon. Hysterectomy is indicated for heavy bleeding
and central pain of the uterus usually due to a condition called adenomyosis, which is
endometriosis of the muscle of the uterus. If the ovaries are involved in numerous
endometriotic cysts, then oophorectomy can be considered. However, it is important to
realize that hysterectomy and oophorectomy is performed only after radical excision of
deep and superficial endometriosis has been accomplished. Otherwise, as described above,
the operation is ineffective.
Radical excision of endometriosis with fertility
preservation
Frequently radical
excision of superficial and deep endometriosis is successful in alleviating pain without
the need for a hysterectomy or oophorectomy. Numerous women consult us for an opinion
after they have been informed by many doctors that hysterectomy and oophorectomy is the
only course of action for their endometriosis. In the majority, we find that what is
needed is radical excision of endometriosis rather than hysterectomy. Such women may then
conceive through natural means or by assisted reproductive technology.
The specialist endometriosis surgeon
Only the highly
specialized endometriosis gynecologic surgeon is capable of performing radical excision of
endometriosis following such excision, the general surgeon is called to assist or perform
bowel resection and anastomosis. The urologist is called in to assist in the performance
of bladder excision and repair or ureteric excision and repair. At the Reproductive Center
we have performed over a hundred cases of ureteric dissection of endometriosis with one
resection anastomosis, over 70 cases of partial bowel resection and repair for
endometriosis, over 40 cases of full thickness excision of bowel endometriosis with
repair, and 15 cases of segmental resection (colectomy) and repair of the bowel. We have
performed combined hysterectomy with bowel and bladder repair including colectomy in 10
cases.
ALL OF THE ABOVE PROCEDURES HAVE BEEN PERFORMED LAPAROSCOPICALLY IN THE LAST SEVEN YEARS, DURING WHICH TIME THERE HAS BEEN ONLY ONE LAPAROTOMY (OPEN ABDOMINAL INCISION) WHEN THE GENERAL SURGEON DECIDED THAT THE COLECTOMY PART OF THE OPERATION COULD NOT BE PERFORMED LAPAROSCOPY IN 1994.
In
addition, Dr. Koh regularly performs radical endometriosis surgery by referral in
Singapore and Hong Kong and many patients fly in nationally and internationally for this
surgery at the Milwaukee center.