Is Surgical Excision Optimal for the Treatment of All Areas of Disease?

While excision can arguably be applied to any location, there are situations where it may not represent the best approach in terms of minimizing the risk of surgical complications and preserving delicate pelvic structures.

Endometriosis can involve vital and delicate pelvic structures, removal of an area of tissue via excision may in certain instances result in damage to a delicate structure. In the case of preserving a patient’s fertility, if superficial endometriosis is found to involve the fallopian tubes or the surface of the ovaries, excision may be unnecessarily crude. Given the wall of the fallopian tube is so thin, excising tissue from the outside of the tube would entail cutting right through the tube wall, requiring repair of the damage via sutures. Opening and reclosing/repairing a fallopian tube in the process of excising disease could easily compromise the function of the tube by causing scarring inside the tube at the site of the repair, causing an obstruction. In the case of the ovary, removing a large area of superficial surface endometriosis could well result in unnecessary damage to the delicate ovarian tissue, reducing ovarian reserve and potentially impacting upon the patient’s fertility.

Dr. Cook performing excision surgery
The mainstay of endometriosis surgery is excision and excision should be the primary and very often the sole technique utilized.Dr. Cook

Area vaporization

An alternative to excision in situations such as these is a technique called area vaporization. Instead of using a high-energy heat source to vaporize in a linear fashion, creating a “cut” in the tissue, the surgeon directs the concentrated heat source over the area of diseased tissue, rather than around it, vaporizing the surface cells layer by layer. This enables the surgeon to remove the superficial disease without compromising the underlying structures. The area over which this high intensity heat source is applied is very small, so this technique is only suitable for very specific and limited areas of disease. It is not an effective way of removing large areas of disease quickly and reliably. For this reason, the mainstay of endometriosis surgery is excision and excision should be the primary and very often sole technique utilized. Area vaporization is a special technique for highly specific situations with the aim of eradicating the disease while preserving the patient’s vital organs and structures. Unlike excision, area vaporization does not allow the surgeon to obtain a biopsy specimen to send to the pathologist.

Occasionally if superficial small bowel endometriosis is present area vaporization may prevent the need for a discoid or segmental bowel resection (removal of a disc of bowel or a segment of bowel followed by repair of the defect). The small bowel has a relatively thin wall and so even the excision of superficial disease can result in a hole being created in the wall of the bowel. Imagine if a patient has multiple areas of superficial small bowel disease. If each area was excised, the risk of entering the bowel would increase and with each repaired defect, the risk of post-operative complications again increases incrementally. In such cases it is a fine balance between removing the disease as effectively as possible while minimizing the risk to the patient. Obviously if invasive small bowel disease is present, this requires careful excision, followed by resection, but in select cases this radical procedure can be avoided by use of area vaporization.

In rare cases a nodule of endometriosis has invaded into the space through which the ureters (the tubes that carry urine from the kidneys to the bladder) pass. Sometimes the disease or associated scarring can begin to strangulate one or both ureters, potentially causing damage and even loss of a kidney. In situations where diseased tissue must be removed from the ureter, excision will typically result in damage to the ureter and a need for resection repair of the defect. As in the case of superficial small bowel disease, area vaporization may provide a favorable alternative in select cases, by removing the diseased tissue layer by layer without undermining the ureter itself, sparing the patient the need for a stent and potential long term complications.

Confusion & controversy

“But I thought vaporization was just the same as burning, and that burning is something to avoid!”A common misconception

Use of area vaporization in endometriosis surgery remains somewhat of a controversy in the endometriosis community. Well-meaning lay endometriosis advocates explain to patients that vaporization is the same as burning the tissue and should be avoided at all costs, “vaporization is bad!!!” Few endometriosis specialists publicize or explain their use of this special technique to their patients, perhaps because of the bad press it has received and the resulting misconceptions; perhaps they are concerned that “admitting” to the use of this technique could put off potential patients. On occasion an endometriosis patient who has undergone specialist excision surgery will come across the word “vaporization” in her surgical report, having expected only excision to be used, and feels a betrayal of her trust. The truth is that ALL specialist endometriosis surgeons rely on area vaporization in certain situations even though excision should be the primary mode of surgery.

At Vital Health we recognize the absolute need for complete transparency about the techniques used during our surgeries. We uphold the fundamental principles of trust in the doctor-patient relationship and informed patient consent prior to undergoing treatment. Restoring and upholding trust could not be any more critical than in the case of endometriosis, where patients often come to us after years of feeling misunderstand and mistreated by the medical community.