The Truth About Surgical Treatment of Endometriosis

Surgical Treatments Used in the Treatment of Endometriosis

EVE Procedure for the Treatment of Endometriosis

Multi-System Disease (MSD)

The EVE Procedure™ is an acronym for Excision and Vaporization of Endometriosis, and is a comprehensive process that effectively removes endometriosis from the body. The EVE Procedure utilizes wide excision of the endometriosis. In the majority of cases, excision alone is used to remove the endometriosis; this technique is used by almost every surgical endometriosis specialist. In select cases, ablative vaporization can be used as a precise secondary tool in critical areas where very precise removal of tissue from vital structures is required. Also, the use of ablative vaporization can be helpful where excision alone may damage an unnecessary amount of normal tissue.

While there is currently no known cure for endometriosis, the EVE Procedure does offer an approach that effectively treats endometriosis and its associated pain with a very low recurrence rate. The successful surgical removal of endometriosis involves several key steps: preparation for laparoscopy, accurate diagnosis of endometriosis, and the complete surgical removal of the endometriosis.

Preparation for Laparoscopy
If the endometriosis has not been identified, it does not matter how proficient the surgeon is at recognizing and removing it. Preoperative preparation will increase the chances of identifying and successfully treating the endometriosis. A detailed history and physical examination are important in identifying the cause or causes of the patient's symptoms, including conditions other than endometriosis. A transvaginal ultrasound just prior to surgery fulfills several functions: (1) it is necessary to identify endometriosis deep in the ovary (endometrioma), which cannot always be seen at laparoscopy, (2) it can identify other causes of the patient's symptoms, such as pelvic varicosities, and (3) if performed by the physician, this procedure can help pinpoint the location of the pain.

The process of Pain Mapping enables the physician to collect a detailed history of all of the different locations and types of pain a patient is experiencing. This includes a maximum, minimum and average level of intensity on the numeric pain scale (0 to 10). Anything that exacerbates or helps reduce the pain will be documented as well. This information can then be used in surgery to correlate physical findings with the patient's symptoms.

The review of previous operative reports can be crucial in predicting deeply buried endometriosis. Sometimes, finding endometriosis is like digging for buried treasure: previous operative reports can be used as a map to help find it. Finally, a preoperative bowel preparation aids in diagnosis and complete removal of the endometriosis, especially when the endometriosis invades the bowel wall. If the bowel is full of stool, it gets in the way of seeing the entire pelvic area, and can interfere with the diagnosis. If the endometriosis is growing on the bowel, it must be removed. Usually, the disease is removed from the surface of the bowel, but occasionally it penetrates through the bowel wall. In this case, it should be removed. In the process, a hole is made in the bowel that must be closed. If the patient has completed a bowel prep (cleansing), the hole can be closed laparoscopically.

When endometriosis completely invades a large area of the bowel, that segment of the bowel must be removed and the ends of the bowel reconnected. Again, the bowel should be clean in order to do this procedure safely. In such cases, if a patient has not completed a bowel prep pre-operatively, the surgery should be stopped and the patient should come back for a second surgery. At that time, a pre-operative bowel prep and a bowel resection can be performed to finish removing the endometriosis.

Laparoscopic Diagnosis
The first step in diagnosing endometriosis at laparoscopy is a systematic evaluation of the abdominal and pelvic cavity. The inside of the body is not like an empty room (where it's easy to see if there is anything on the floor or walls). Instead, there are a lot of folds and nooks and crannies, and the search for endometriosis is more like trying to find a penny amongst a bunch of wadded up, unfolded cloths. The peritoneum (the lining inside the body) covers the pelvis, bladder, bowel, abdominal cavity, appendix and diaphragm (bottom of the lung). It must be inspected systematically for endometriosis, one layer at a time, so that no area is missed.

With endometriosis, very small, difficult-to-see lesions can cause excruciating pain. When the end of the laparoscope is very close to the tissue, the laparoscope magnifies it. But this also decreases the area that is seen, similar to the effect of looking through a telescope or a set of binoculars.

A surgeon must be very thorough and meticulous, and use a systematic approach in looking for endometriosis. He or she also needs to understand the many different appearances of endometriosis, and work with an excellent pathologist who does not overlook mild endometriosis. The visual appearance of endometriosis is highly varied: The lesions can be dark, pigmented lesions, similar to a blood blister, or clear, vesicular lesions, appearing like miniature water balloons. It can also look like specks of salt or even leathery scar tissue. Some endometriosis is hard to see, but if the proper time and magnification are used, it can be found. In addition, scar tissue in an endometriosis patient should be considered and treated as endometriosis until proven otherwise.

The pathologist is an unseen and largely unappreciated member of the endometriosis team. If the pathologist is not meticulous in his or her examination of the tissue, then endometriosis will be missed, and the feedback to the surgeon will be false. Worst of all for the patient, the surgeon will leave endometrial lesions behind because the pathologist has incorrectly told the surgeon that this appearance is not endometriosis, when in fact it is. I work with a physician whom I believe to be one of the best endometriosis pathologists in the country. He has a lot of respect for endometriosis, and is very meticulous in looking for the disease. He takes extra steps in preparing the tissue, which helps to maximize the chance of finding all the endometriosis that is present.

Surgical Removal of Endometriosis
Unfortunately, there seems to be much misinformation circulating the Internet about the surgical treatment of endometriosis by both physicians and patients. There are well intended but grossly misinformed individuals passing themselves off as experts, when in fact they do not understand what they are talking about. Please read the article about Surgical Techniques Used in the Treatment of Endometriosis to learn the truth about what actually happens in surgery with different tools. Almost every laparoscopic surgeon who excises endometriosis uses vaporization to do so. This technique is actually Thermal Excision by Linear Vaporization (TEL-V), performed with electosurgery, a carbon 13 CO2 laser, or the harmonic scalpel. Vaporization does not burn, it can remove as little or as much tissue as the surgeon wants, and it does not distort tissue. Otherwise, the vast majority of the world's endometriosis experts would not use it.

Removal of the disease (endometriosis) from the body is the core concept in successful treatment. Techniques that remove endometriosis from the body are acceptable; techniques that do not remove the endometriosis from the body are not acceptable. The two techniques that remove endometriosis from the body include excision (cutting the tissue out, either mechanically or with linear vaporization) and ablative vaporization (on which case the endometriosis is vaporized, not burned). Coagulation or cauterization of the tissue with monopolar, bipolar instruments, or underpowered lasers is unacceptable, and is not part of the EVE Procedure. Many endometriosis experts feel that these latter techniques actually result in a high rate of recurrence and/or incomplete removal of the endometriosis.

The primary method required for the treatment of endometriosis is wide excision, which removes all of the endometriosis including the microscopic endometriosis. Just as microscopic cancer cells can spread from the main lesions and require wide excision for successful treatment, microscopic cells can spread up to an inch away from the visible endometriosis.

Excision can be accomplished with scissors, the Carbon 13 CO2 laser, harmonic scalpel, and high-current, pure-cut electrosurgery. When used in a line, the laser acts like a pair of invisible, light scissors and can be used to perform excision. The Carbon 13 CO2 laser has the advantage over the other methods, in that it requires one less incision for the patient, and frees up one of the surgeon's hands to operate more effectively.

The Carbon 13 CO2 laser (and electrosurgery) is a surgical tool that can also be used to perform ablative vaporization of tissue (when the laser beam is moved back and forth over the tissue, rather than in a single line). The energy from the Carbon 13 CO2 laser is so focused that the water in the treated cell is instantaneously turned into vapor, carrying the heat away from the surrounding cells and suspending the solid particles of the cells in the vapor. The vapor appears as smoke, but is more like a fog (it is not smoke as the result of burning). This fog is a result of the solid particulates from the cell being suspended in the water vapor following vaporization. Because the energy of the Carbon 13 CO2 laser is so focused, there is virtually no conduction of heat that could damage the remaining cells surrounding the vaporized cell.

I have heard and read references that laser vaporization burns tissue, and thus should not be used. These claims are not based upon published scientific information. Additionally, physics and the principles of heat and energy delivery tell us that this is simply not true. It is true that a Carbon 12 CO2 laser can coagulate tissue, which does burn it (this is laser coagulation – not acceptable), but laser vaporization (laparoscopically, the Carbon 13 CO2 laser works the best) does not coagulate or burn tissue. An understanding of physics and heat transfer tells us that laser vaporization does not burn tissue.

Excision (mechanical or linear vaporization) and ablative vaporization each have advantages and disadvantages. Excision takes out large amounts of tissue, but is less precise. Ablative vaporization is precise and can remove cells layer by layer from the body, but is slower and works best on a smaller area. Ablative vaporization is especially useful when removing endometriosis from vital structures such as blood vessels, the bowel, ureter and bladder, and the fallopian tubes. The concern about ablative vaporization, which is valid, is that if the surgeon is not careful, areas of tissue and endometriosis can be missed and left behind. This technique should only be used by highly trained endometriosis surgeons for small, refined areas of removal. It is not indicated when removing large areas of tissue. If ablative vaporization is the only technique the surgeon is using in surgery to remove endometriosis, it is unlikely that the required "wide excision" of tissue will be done. Ironically, the Cochrane Collaboration which is an international not-for-profit and independent organization that provides evidence based reviews states that laser ablative vaporization is the only technique in the world's scientific literature that has been proven to reduce pain in endometriosis patients. Regardless, I think based upon our combined experience, most endometriosis experts, including myself, feel that wide excision should be the primary method of surgically removing endometriosis.

The vast majority of endometriosis surgeons currently use the EVE Procedure when surgically removing endometriosis. Use of the Carbon 13 CO2 laser, pure-cut electrosurgery, and the harmonic scalpel all use the technique of Thermal Excision by Linear Vaporization (TEL-V). All are performing excision and vaporization of endometriosis, thus they are employing the EVE Procedure. This can be performed with or without ablative vaporization, depending upon the comfort and skill of the surgeon with this technique. My personal approach is to use EVE without ablative vaporization in >90 percent of cases, with ablative vaporization an excellent technique in a few select situations. In these instances I feel it is better than any other procedure, including excision alone, for the complete removal of the endometriosis, while minimizing the need for removing normal tissue. With the precision of the EVE Procedure, I am able to save normal organs such as the ureter, bowel, ovary and fallopian tube – when the use of excision alone would potentially necessitate removal of all or part of these organs.

The EVE Procedure offers the gentlest, most effective technique for removing endometriosis from the body, with minimal damage to the normal surrounding tissue. I would ask all of the endometriosis community, both physicians and patients, to remember that we are all trying to do the best job possible. As long as we maintain respect for each other, some variation in opinion is, a healthy thing, especially in an area of medicine that has so many unknowns.

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