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)

In this section I will discuss the pros and cons of the various surgical techniques available for the removal of endometriosis. It is important to remember that the goal in the surgical treatment of endometriosis is the removal of all of the endometrial implants. Realization of this goal is dependent upon the skill of the surgeon, and is true no matter which surgical approach or instrument is used.

Basic Techniques
There are two acceptable ways in which a surgeon can remove or destroy the endometriosis: excision and vaporization. Excision means that the surgeon cuts around and removes. Vaporization is the process by which solids and liquids are turned into a gaseous form inside the treated cells. The surgical laser delivers a very concentrated packet of light energy, which instantaneously boils the water in the cell (remember, cells are mostly water, with some proteins and other goodies). The water turns into steam, and in the process expands the volume over a thousand-fold, resulting in water vapor and cellular proteins literally going up in smoke (actually, it's more like fog from the water vapor – there is no burning).

Coagulation is a burning, or melting of the tissue. Historically this has been a common approach to the treatment of endometriosis. Unfortunately, coagulation is ineffective in removing all of the endometriosis (whether by monopolar electrosurgery, bipolar electrosurgery, some types of lasers, or endocoagulater), and thus is not an appropriate approach for treating endometriosis.

The current surgical tools available to remove endometriosis include (1) scissors, (2) electrosurgery, (3) harmonic scalpel, (4) laser, and (5) the endocoagulater. These tools can be used to excise (1, 2, 3, 4), coagulate (2, 3, some types of 4, 5), or vaporize (Carbon 13 CO2 laser and high pure-cut electrosurgery). Keeping in mind the surgical goal of the treatment of endometriosis (complete removal of the endometriosis while maintaining as much normal tissue as possible), let's examine the advantages and disadvantages of the basic methods of removing endometriosis.

Excision
Excision can be performed surgically in one of two ways: (1) by Mechanical Excision (ME), or (2) by Thermal Excision by Linear Vaporization (TEL-V). Mechanical Excision (ME) uses only the mechanical shearing force of scissors, without the aid of electrosurgery. Thermal Excision by Linear Vaporization (TEL-V) uses electrosurgery, laser, or the harmonic scalpel to create the intense heat that result in vaporization. Even the most die-hard, "excise only" surgeons who use electrosurgery via scissors are, in fact, linear vaporizers.

Both ME and TEL-V Excision offer several advantages, and are the mainstay of the successful surgical treatment of endometriosis. These methods of excision can quickly remove large amounts of tissue, and provide tissue for the pathologist to check under the microscope. Neither method damages or alters the appearance of the underlying tissue.

This is an important point, for the following reason – whenever tissue is removed, the remaining underlying tissue must be assessed to determine if all of the endometriosis was removed, or if deeper disease is still present. Sounds pretty good so far, but what is the disadvantage of excision? The primary disadvantage of excision is that it is fairly non-selective. Endometriosis not only grows on the surface of the peritoneum (inside lining of the body) where it can be easily plucked off; it can also invade the underlying tissue. This invasive endometriosis can send out "fingers" of endometriosis, growing on and around vital organs (e.g. the bowel, blood vessels, ureter, bladder, etc.).

If the endometriosis being removed is separate from vital structures, then excision is a good approach. But if the endometriosis is growing on vital structures, I feel excision is not always the best choice, as it may require the removal of normal vital structures. In my opinion, if endometriosis is aggressively removed using only excision, there will be a higher incidence of bowel resection, ureteral resection, etc. because "the endometriosis was so advanced." But in reality, other techniques could have removed the endometriosis without having to resort to removing normal tissue.

Vaporization
There are two basic types of vaporization: Linear Vaporization and Ablative Vaporization.

Figure 1 – Basic Types of Vaporization

As discussed above, virtually all physicians who excise endometriosis are linear vaporizers. Because vaporization does not conduct heat, it does not distort the appearance of the cells next to or under the cells that are vaporized. Vaporizing in a line results in a cutting effect of the tissue. This is the preferred method of virtually all advanced endometriosis specialists.

The second type of vaporization is Ablative Vaporization. For the same reasons that Excision by Linear Vaporization (TEL-V) is a good and preferred surgical technique, Ablative Vaporization is acceptable as a touch-up tool in limited situations by surgeons who have the necessary surgical skills. The main drawbacks to Ablative Vaporization are (1) the surgeon must be very compulsive to ablate all of the tissue and not leave any islands of endometrial tissue, and (2) the tissue undergoing Ablative Vaporization is gone and cannot be sent to the pathologist for evaluation. For these reasons, Ablative Vaporization should only be used as a secondary tool in select areas.

Ablative Vaporization can be performed with electrosurgery or with the Carbon 13 CO2 laser. This technique offers several advantages: It is the most precise surgical tool available for the removal of endometriosis. Because the packet of light energy is so intense and focused, there is no conduction of heat and no coagulation, there is virtually no thermal damage to the tissue that is left behind (it does not burn tissue!!). This allows the surgeon to remove the endometriosis layer by layer. The surgeon also has the advantage that the appearance of the remaining tissue is unchanged, allowing an accurate assessment as to whether endometriosis is still remaining, or if normal tissue has been reached. This is especially useful when working on the vital structures such as the bowel, ureters, blood vessels, and others.

A good example is endometriosis involving the small bowel: It is virtually impossible to excise endometriosis from the small bowel. It's like trying to remove chunks of old dried glue (endometriosis) from tissue paper (the bowel) with a pair of scissors, without damaging the tissue paper. A surgeon who only uses TEL-V or ME excision may be in the position of either having to leave endometriosis on the bowel, or having to perform a segmental small bowel resection because "the endometriosis was so extensive."

Coagulation
Coagulation offers virtually no advantages, and in my opinion is one of the leading causes of under-treatment and "recurrence" of endometriosis. First, coagulation is usually performed using an electrical current that is passed through the body. Coagulation is in essence an electrical "burn" that destroys the appearance of the tissue. As a result, it is impossible to tell what is normal and what is abnormal. Since the surgeon can't tell if all of the endometrial tissue has been destroyed, deep endometriosis can be left behind. In the worst case, normal peritoneum heals over this area, with endometriosis left deep underneath. The next time the patient undergoes laparoscopy (because the pain is not gone, or is back), she is told the laparoscope is normal, and ... well, you know the rest.

Second, I don't care how good the surgeon is; it is virtually impossible to tell how deep the tissue is coagulated (destroyed). The longer the tissue is coagulated, the deeper the damage, but the degree of damage is not apparent for days, or even a week. What this means in real life is that if the endometriosis is growing near a vital structure (say, the bowel), the surgeon will usually err on the side of under-treating. If the surgeon were to over-treat, the thermal damage from the coagulation would damage the normal underlying vital structure, i.e. in this example the bowel. A week after surgery the bowel wall could die off, resulting in a hole in the bowel with the bowel contents spilling into the abdomen, and at the very least the patient becoming very sick. If you were to speak with the nationally recognized surgeons who treat endometriosis, I do not think you would find any who use coagulation as their primary mode of removing endometriosis.

Endocoagulator
The endocoagulator, to the best of my knowledge, is not used at this time. The best way I can describe the endocoagulator is to envision cutting a ¼" diameter piece out of the bottom of a clothes iron and gluing it on the end of a stick. The endocoagulator is a ¼" diameter probe (usually about a foot and a half long) that is heated on the end, much like an iron. It is used laparoscopically to coagulate the endometriosis. This approach has the same pitfalls as coagulation with electricity as discussed above. The endocoagulator was initially introduced as a device to provide laparoscopic coagulation, without the risks associated with electricity.

Harmonic Scalpel
The harmonic scalpel has been promoted as a method for treatment of endometriosis. It is a metal-tipped probe that vibrates at a very high frequency, creating sound waves that can cut or coagulate. This tool has been presented primarily as an alternative to electrosurgery (many surgeons are worried about the electricity arcing to the bowel and causing damage). The harmonic scalpel is another tool that can be used to treat endometriosis. While I have used this device, I do not feel that it offers a significant improvement to the combined use of electrosurgery and the laser.

Summary
I hope my description of the various surgical techniques has helped you gain a better understanding of the surgical treatment of endometriosis. I believe that good technique includes the use of instruments that vaporize or excise, while using instruments that coagulate or cauterize constitutes bad surgical technique. Excision is a primary surgical technique in removing endometriosis laparoscopically, and in many cases is the only method needed to remove all of the endometriosis safely. Ablative Vaporization is an adjunctive treatment that provides the precision necessary in some cases to completely remove the endometriosis, while leaving the normal tissue and vital structures intact. I call this the EVE Procedure (Excision and Vaporization of Endometriosis).

While it is important to understand the various surgical techniques, the real issue is the surgeon's skill in identifying and removing endometriosis. Just because Doc Jones uses technique X does not make him or her a good endometriosis surgeon.

A good share of my practice is devoted to patients who have received treatments from other physicians that failed, so I admit to a certain bias regarding the overall treatment of women with endometriosis. It seems to me that far too many women are not receiving adequate surgical treatment. All too often, endometriosis is under-diagnosed and is not completely removed at the time of surgery. At times, I see endometriosis missed on the videotapes I review – it was that apparent.

On occasion, I operate on patients who have recently undergone surgery elsewhere, but whose symptoms persist. My surgical pathology report usually reveals endometriosis. Either the endometriosis is growing back in a matter of weeks or months, or it was not removed at the time of the previous surgery. Patients and physicians alike want to see endometriosis properly diagnosed and treated.

As a group, women suffering from endometriosis can make a difference in the level of care that is provided by the medical community, by demanding a level of expertise and excellence that will result in effective treatment of their condition. If all patients require that their physician videotape the entire surgery, I believe the level of care will rise, no matter which surgical technique is used. Video documentation of the entire surgery will provide accountability of the facts. If a surgeon states that he/she does not have the equipment to videotape the procedure, you may want to think twice about proceeding with that surgery. "Good surgeons" will be proud of the work they are performing, and will be glad for all to see the "masterpiece" they have created. Others, will not be so inclined. Together you, as patients, can make a difference in the quality of care provided!

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