Radical Endometriosis Surgery
by Charles Koh, MD

In 1921, Dr. Sampson from John Hopkins Hospital theorized that Endometriosis was due to the back flow of menstrual blood and that this blood containing uterine lining material began to grow and embed on the pelvic peritoneum and structures thus forming Endometriosis. The corollary of this theory is that if the uterus is removed, then no further back flow can occur, therefore Endometriosis would be cured. Furthermore, it was believed that the endometriosis implants in the pelvis responded to hormones in the same way as the uterine lining and that the estrogen from the ovaries stimulated their growth. Therefore, it was routine for the ovaries to be removed along with the uterus even in very young women in an effort to cure the pain of Endometriosis. Surprisingly, there were and still remains a large number of women who continue to have pain despite having undergone hysterectomy and removal of tubes and ovaries.

Recent studies have confirmed the following:

• Endometriosis, especially the deep variety, is not related to back flow.
• Many women have cells derived from the early development of the pelvic organs during embryonic life, which under certain stimulation will grow into Endometriosis and deep Endometriosis.
• Endometriosis and deep endometriosis do not react in the same way as uterine lining, nor do they contain estrogen or progesterone receptors in the same quantity.  Therefore, hormone stimulation or deprivation has limited influence on the lesions. This means that in many cases, the use of GnRH agonists (Lupron, Synarel, Buselerin) or removal of the ovaries surgically has minimal impact on some endometriosis.
• Deep Endometriosis proliferates and invades without needing estrogen influence most of the time.

It has become clear that the treatment of Endometriosis can only be effective by radical excision. This term means the removal of wide and large areas of pelvic peritoneum where superficial Endometriosis is present as well as removal of all deep Endometriosis.

Superficial Endometriosis
This is usually found in the peritoneum of the cul de sac, pelvic sidewall, and bladder. It may occasionally be widespread over the whole abdomen even up to the diaphragm. Wide removal of the peritoneum in the pelvis (en bloc excision) requires considerable skill and experience because it is stuck to the rectum ureter, blood vessels of the sidewall, and bladder. However, this is regularly achievable by specialist Endometriosis surgeons.

Deep Endometriosis
These are tumors or implants that are deeper than half a centimeter and typically involves the uterosacral ligament, cul de sac, rectovaginal space, posterior vagina, anterior rectum, cardinal ligaments and ureter, bladder, as well as areas of large and small intestine away from the pelvis. These lesions used to be called fibrosis implying that they were no longer containing active Endometriosis but rather was a fibrotic tissue reaction.  From excision of these lesions and subjecting to pathology, it has been clearly shown in the last few years that these so-called fibrotic lesions are in fact very active Endometriosis that continue to invade.

Radical surgery for deep Endometriosis involves removing all the deep lesions accurately. This includes excision of a part of the bladder with repair if endometriosis has invaded the bladder, excision of the ureter with anastomosis, excision of the rectum with repair or anastomosis, and removal of Endometriosis around deep lateral structures near the obturator nerve and blood vessels. Having a hysterectomy and oophorectomy (ovarian removal) performed without removing deep Endometriosis is the most frequent cause for persistence of pain after surgery. At the Reproductive Center, we frequently operate on such women to remove the deep Endometriosis. Radical excision of Endometriosis is an even more specialized procedure requiring a team of experts from other specialties like urology, general surgery, etc. However, it is important that the leader of the team be the expert gynecological endometriosis surgeon. Hysterectomy is indicated for heavy bleeding and central pain of the uterus usually due to a condition called adenomyosis, which is Endometriosis of the muscle of the uterus. If the ovaries are involved in numerous endometriotic cysts, then oophorectomy can be considered. However, it is important to realize that hysterectomy and oophorectomy is performed only after radical excision of deep and superficial endometriosis has been accomplished. Otherwise, as described above, the operation is ineffective.

Radical Excision of Endometriosis with Fertility Preservation
Frequently radical excision of superficial and deep Endometriosis is successful in alleviating pain without the need for a hysterectomy or oophorectomy. Numerous women consult us for an opinion after they have been informed by many doctors that hysterectomy and oophorectomy is the only course of action for their Endometriosis. In the majority, we find that what is needed is radical excision of Endometriosis rather than hysterectomy. Such women may then conceive through natural means or by assisted reproductive technology.

The Specialist Endometriosis Surgeon
Only the highly specialized Endometriosis gynecologic surgeon is capable of performing radical excision of Endometriosis; following such excision, the general surgeon is called to assist or perform bowel resection and anastomosis. The urologist is called in to assist in the performance of bladder excision and repair or ureteric excision and repair. It is important to realize that a non-expert gynecologist relying on the general surgeon to perform Endometriosis surgery will NOT achieve radical excision.

The Reproductive Center Program for Endometriosis
At the Reproductive Center, we have performed  we have performed over a hundred cases of ureteric dissection of Endometriosis with one resection anastomosis, over 70 cases of partial bowel resection and repair for Endometriosis, over 40 cases of full thickness excision of bowel Endometriosis with repair, and 15 cases of segmental resection (colectomy) and repair of the bowel. We have performed combined hysterectomy with bowel and bladder repair including colectomy in 10 cases.

All of the above procedures have been performed laparoscopically in the last seven years, during which time there has been only one laparotomy (open abdominal incision) when the general surgeon decided that the colectomy part of the operation could not be performed laparoscopically (in 1994).

Dr. Koh regularly performs radical Endometriosis surgery by referral in Singapore and Hong Kong and many patients fly in nationally and internationally for this surgery at the Milwaukee center.  Please visit the center at http://www.reproductivecenter.com/ to learn more about their programs.

MIMIS, The Milwaukee Institute of Minimally Invasive Surgery at Columbia St. Mary's is the Midwest's first multi-specialty minimally invasive surgical center of excellence. Established in 1992 by a group of highly respected leaders in the field of minimally invasive surgery,
the Institute grew out of a strong desire to provide the most innovative surgical care and treatment for patients. In addition to providing excellent patient care, physicians of the Milwaukee Institute of Minimally Invasive Surgery have published books and articles, reported
their results in medical literature, and taught and lectured worldwide. [http://www.mimis.us/]