Endometriosis Surgery In NYC | Dr. C.Y. Liu
Over 5 million young women in the United States suffer from endometriosis. Of this number, about 30% have a more aggressive form that tends to infiltrate deep into the pelvic organs, possibly involving the bowels (especially the recto-sigmoid colon), bladder, ovaries, uterosacral ligaments, rectovaginal septum, vagina, cervix, tubes, and even the ureters, forming dense fibrous scarring. Symptoms include chronic or acute, persistent or intermittent pelvic pain, cramps, painful sexual intercourse, painful bowel movement, and other gastrointestinal disturbances, and urinary symptoms. This type of endometriosis, Deep Infiltrating Endometriosis (DIE), generally does not respond well to hormonal suppressive or other medical therapies. The best long-term treatment is the surgical excision of all the visible and palpable lesions.
However, because of the deep invasive nature of the disease and the frequency with which the vital pelvic organs are involved, the gynecologist must be experienced and competent in performing bowel, bladder, and ureteral surgery. If not proficient in handling bowel, bladder, and ureteral defects repair, the treating gynecologist tends to avoid resecting the endometriosis adjacent to and/or on those organs, resulting in treatment failure due to incomplete excision of endometriosis. Laparoscopic surgery, in our opinion, is the best way to excise endometriosis. In view of the complexity of DIE, our advice to those patients suffering from deep infiltrating fibroitc endometriosis is to find an experienced gynecological surgeon who is highly skilled and competent in performing laparoscopic excision of severe endometriosis and is capable of repairing the bowel, bladder, and ureter defects if needed.
Since the 1980’s, I have performed excisional surgery for DIE, with outstanding results. All surgeries are videotaped, and each patient is given a copy of the tape, which shows exactly the extent of her endometriosis, the entire surgical procedure, and its results.
Women with extensive endometriosis often require more than one surgery and suffer from many unfortunate outcomes of poorly performed surgery. It cannot be emphasized enough the importance of enlisting the services of a gynecologist experienced and competent in this meticulous and delicate type surgery at initial diagnosis and treatment of endometriosis.
The definitive treatment of endometriosis is NOT hysterectomy and bilateral salpingo-oophorectomy (removal of both uterus and ovaries). Many gynecologists currently still mistakenly believe that removal of both uterus and ovaries is the cure for endometriosis. At our Center, we are convinced that the correct way of treating endometriosis is the complete excision of all visible endometrial lesions, including those on the pelvic organs, bowel, ureter, or bladder.
The decision to include a hysterectomy or oophorectomy at the time of endometriosis surgery is purely based on whether there are any coexisting uterine or ovarian pathology in addition to the presence of endometriosis and the patient’s desire for future childbearing. For example, if she is known to have severe endometriosis and no longer desires to bear a child, and meanwhile fibroids (benign tumor of the womb which may cause heavy menstrual bleeding and cramps) are found on the uterus, then hysterectomy along with excision of all endometriosis should be considered. Another example is the patient suffering from severe symptoms of adenomyosis (the lining of the uterine cavity invade into the muscle layer of uterus) who no longer desires future childbearing.
Throughout the years, we have performed numerous laparoscopic surgeries for extensive endometriosis with excellent results without removing either a normal uterus or ovaries.
Laparoscopic surgery is the primary and definitive way to diagnose and treat endometriosis. Ideally, all the endometrial lesions should be excised through the laparoscope at the initial diagnosis of endometriosis. Unfortunately, most gynecologists are not well trained in treating extensive endometriosis through laparoscopy. Thus many women with extensive endometriosis often require more than one surgery and end up suffering from many unfortunate outcomes of poorly performed surgery. It cannot be emphasized enough the importance of finding a well-trained, competent gynecologist at the time of initial diagnosis and treatment of endometriosis. My professional background in this subspecialty includes extensive lecturing and teaching in the U.S and abroad, with frequent invitations for teaching and performing live surgery demonstrations of excision of extensive endometriosis at national and international medical conferences (See Dr. Liu’s CV).
The Role of Presacral Neurectomy in Conservative Surgical Treatment for Endometriosis
We sometimes perform presacral neurectomy (resection of part of presacral nerve which is in charge of pain sensation in the midline pelvic area). This procedure excises endometrial implants while reducing pain and cramps in the midpelvic area without affecting sexual sensations or feelings. Preserving the reproductive organs is especially important for patients desiring future childbearing.
Endometriosis Surgery FAQ
Q: Why is so important for me to find a gynecologist who is specialized in endometriosis to do my first surgery?
About 30% of endometriosis is deep infiltrating endometriosis (DIE), which is characterized by invading (infiltrating) deep into tissues and organs in the pelvic area and along the way producing dense fibrosis (scarring). The dense fibrosis eventually may cause the distortion of the anatomy, obstructing and interfering with the functions of the pelvic organs. In addition to the dense fibrosis, DIE frequently invades the bowels, especially the recto-sigmoid colon, bladder, and sometimes even the ureters (tube between the kidney and bladder). When these organs are involved, the patient may not have symptoms in the initial early stage, but eventually significant symptoms will appear.
Most of gynecologists in the U.S are not trained in bowel, bladder or ureteral surgery and, consequently, are not comfortable dealing with endometriosis close to or on those organs. Because of this, the deep infiltrating endometriosis is not adequately addressed and treated. An improperly or inadequately treated endometriosis always creates much more scarring which further complicates the patient’s problem Therefore, it is imperative for patients who are suspected to have endometriosis to find a competent gynecological surgeon who is proficient in complicated laparoscopic surgery and experienced in DIE surgery. Only a handful of gynecologists in the country are trained and experienced in laparoscopic surgery on bowel, bladder, and ureteral endometriosis.
I have been performing laparoscopic surgery for DIE since 1980’s. As one of the most sought after gynecologists for lectures and live case surgery demonstrations for DIE in national and international meetings, I am considered to be one of the most experienced gynecologists in the country for DIE involving bowels, bladder, ovaries and ureters. (see Dr. Liu’s CV).
Q: What about robotic surgery for DIE surgery?
Robot is a surgical tool, just like laser, scalpel or other surgical instruments which are under the command of the surgeon. A poor surgeon with a perfect robot cannot produce successful surgery, but a skilled surgeon without a robot can definitely produce desirable surgical outcomes. Different from other gynecological conditions, such as hysterectomy or myomectomy, DIE always form some fibrotic nodules in the pelvis which many times are difficult to visualize; they must be detected and excised by digital palpation with intraoperative pelvic (vaginal and rectal) examinations. Therefore, we routinely perform many digital pelvic examinations during the course of DIE surgery. Just like any surgical instrument, there are pros and cons, but the greatest advantage of robot is it provides the surgeon with clear 3-D vision of the surgical field and reduces the surgeon’s fatigue by allowing him/her to sit in the console during surgery. However, the disadvantages are that the surgeon is away from the patient and is unable to perform the needed frequent pelvic examination and he/she completely loses his/her tactile feeling of the tissues that are being operated on. This can lead to inadequate and incomplete excision of DIE nodules.
With laparoscopic surgery, however, the modern high definition, high resolution video system produces phenomenal visibility that permits the surgeon to perform all kinds of surgery with smaller and less abdominal incisions. From my own experience in both laparoscopic and robotic surgery, I would recommend laparoscopic surgery for extensive DIE surgery.
Q: For severe DIE cases, do you do the entire surgery by yourself or do you have some other specialists, like urologist or colo-rectal surgeon, help you during surgery?
For patients with severe DIE and suspected bowel or urinary tract involvement, we use the multidisplinary approach in which I perform the actual surgery with the assistance of other specialists. I will be the one performing the bowel, bladder, and ureteral surgery except in rare occasions such as the segmental resection of the sigmoid colon for severe and multiple endometrial nodules on the bowel. Whereas the urologist and the colo-rectal surgeon are experts of the bladder and bowel, endometriosis is neither their area of expertise or interest. I have been using this multidisplinary approach for severe DIE for more than 20 years with favorable outcomes.
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