Rationale for Choosing Laparoscopic Excision of Endometriosis
Whether you have a confirmed diagnosis of Endometriosis, or you are experiencing pain and there is a concern that you may have Endometriosis, you need Laparoscopy. Endometriosis is a surgical diagnosis. This means that Endometriosis cannot be diagnosed by talking with you, examining you, blood or urine tests, x-rays, ultrasounds, CT, or MRI. The diagnosis of Endometriosis requires the physician to look in the abdomen, Laparoscopy. “Lapar” means abdomen, “scopy” refers to a tube with a light.
When a physician looks in the abdomen and finds Endometriosis, a decision is made how to treat Endometriosis. It is difficult to be in a medical situation. It is even more difficult when different approaches are used. All I can do is to give you my rationale for why I exclusively perform Laparoscopic Excision for Endometriosis.
1. Medical Suppression:
- Lupron is a classic example of medical suppression. Lupron takes Estrogen temporarily out of your system. The rationale for Lupron is that Endometriosis is similar to uterine lining, and the uterine lining is supported and stimulated by the female hormone Estrogen. The hope is that Endometriosis tissue will dry up and go away, and there can be some symptom relief with Lupron, but the side effects of Lupron are awful and often long-lasting, and the endometriosis and pain returns when you eventually go off the medication. If I am going to expose a person to the risks of surgery, I want something accomplished and not just look. Sometimes, doctors will empirically treat with Lupron without laparoscopic confirmation, and this makes no sense to me given how expensive Lupron is, and medication will not get rid of Endometriosis.
2. Destruction of Endometriosis lesions by Electrical Fulguration and/or Laser Vaporization:
- Endometriosis starts superficial the lining of the body cavity and over time will invade progressively deeper into the surrounding tissues. A light application of laser or electrical energy only penetrates to 2mm, whereas Endometriosis invades deeper than 2mm in 61% of cases, deeper than 5mm in 25% of cases. Therefore, Endometriosis will be incompletely treated in close to two-thirds of patients treated with cautery and laser. There is an additional concern. Like many medical conditions, there is the lesion you visualize and there is the subclinical disease in the surrounding normal-appearing tissues. Therefore, it is essential to abstain adequate margins. We know from pain mapping studies there can be perceived pain up to 28 mm beyond the visible border of a lesion. Wherever possible, I try to excise with 2-3 cm margins, to prevent a recurrence. With superficial electrical fulguration and laser vaporization, only the lesion seen is treated and the subclinical disease in the surrounding tissues is not addressed and not treated, so it is a guarantee that the endometriosis and pain will persist and/or recur. Superficial burning of the tissues applies an acute inflammation (the energy used) on top of chronic irritation (Endometriosis), and will often lead to worsening of the pain. The end result is surgery after surgery.
Laparoscopic excision of Endometriosis:
- The definitive treatment of Endometriosis is NOT removal of the uterus, fallopian tubes, and ovaries. The definitive treatment of Endometriosis is the complete removal of ALL Endometriosis and associated Fibrosis, with adequate margins, restoration of normal anatomy, usually while conserving the fallopian tubes and ovaries, and protecting and preserving fertility. With excision, the surgeon dissects down to normal loose areolar tissue to get completely underneath and around all Endometriosis and associated fibrosis. Even after excision, Endometriosis can recur and further surgery could be required. But as opposed to surgery after surgery, the long-term incidence of having a 2nd surgery after laparoscopic excision in my series is currently at 24%, so that 3 out of 4 patients do not require pelvic surgery for pain again. Of the 1 in 4 who require another surgery, there is no residual endometriosis in 61% of patients at 2nd surgery. Therefore, we are able to get complete clearance of Endometriosis in close to 90% of patients at the first excision surgery.
This is why Laparoscopic Excision is the Treatment of Choice for Deep Invasive Endometriosis