Choosing Your Battle Against Endometriosis: Understanding Excision, Ablation, and Robotic Techniques

The gold standard for diagnosis of endometriosis, a chronic, debilitating condition impacting millions of women (XX), is minimally invasive surgery with histological confirmation. Due to advancements and understanding of the disease, we now recommend that surgical treatment of the lesions be performed at the same time as a diagnostic surgery. It is well understood and agreed upon that in order to obtain a biopsy, the tissue must be removed and excised for analysis but the type of surgical approach to address the lesions is not consistent among all practitioners. 

If you were to ask someone well versed in endometriosis such as an endometriosis excision surgeon or even a patient advocate who is well up to date on their understanding and research, you’d likely hear that excision surgery is the gold standard for treatment and the preferred approach is minimally invasive. However, there are still those who would provide a counterargument stating that there is a place for ablation, especially, according to some guidelines, in the pediatric and adolescent age group. Those who proffer minimally invasive excision surgery differ in opinion about the adequacy of older technology laparoscopy vs. the technical benefits of robotically assisted enhancements.  

This article aims to provide some insight as to the understanding and nuances behind these arguments, and the limitations in the current research, as well as provide a comprehensive guide on the different treatment approaches for endometriosis, including excision surgery, robotic surgery, and the role of ablation.

Understanding Endometriosis

Endometriosis is a heterogeneous, inflammatory condition where endometrial-like tissue is found throughout the body, typically in the abdominopelvic cavity. While some patients with endometriosis can remain asymptomatic, an estimated 35-50% experience severe pelvic pain, infertility, and other symptoms related to the location of the endometriosis lesions or implants.  Endo is intensely inflammatory and fibrogenic, which often creates huge anatomic distortion, causing infertility and pain.  Tackling endo surgically requires advanced skills for these reasons. 

Current and Future Treatment Approaches for Endometriosis

Today’s treatment options are largely limited to hormonal manipulation and surgery. According to various medical advisory organizations, medical therapies should be offered as first-line therapies to alleviate endometriosis symptoms and potentially treat the endo, and then surgical intervention becomes an option. Sometimes surgery is only offered when pain is not alleviated, potentially allowing the endometriosis and resulting fibrosis to grow.  

There is a strong counterargument to starting with medical/hormonal therapy, which is often initiated based on clinical symptoms and findings that suggest endometriosis may be present.  Leading with medical treatment, which can have significant and lasting side effects, means potentially injurious and ineffective treatment can be prescribed when in fact there is no endometriosis present. In addition, due to relative progesterone resistance, symptoms may be ameliorated but the aberrant endometriotic tissue is not usually eradicated.  Meanwhile, fibrosis from your body’s healing efforts continues to accumulate. Therefore, excision may be considered a cornerstone initial step to remove the macroscopically evident bulk of disease followed by potential preventive strategies to suppress any residual microscopic disease after the diagnosis is pathologically established.  

Excising all visible lesions, associated adhesions, and scarring or fibrosis, is thought to reduce disease recurrence, relieve pain, and enhance fertility rates. However, while this can provide long-term relief, it is not usually curative.   In complex endometriosis cases (stage III or IV according to the revised American Society for Reproductive Medicine classification), achieving the goal of safe and complete excision of visible lesions, especially using conventional laparoscopy can be technically challenging, and requires specialized training. 

While this article is not focused on other treatment options, keep in mind that holistic, nutritional, Eastern and natural approaches have a role in alleviating symptoms and, to a degree, can influence the course of endo as well.   

Future treatments on the horizon will go far beyond surgery and hormonal manipulation.  We already know that there are other molecular pathways that drive endo growth and these will eventually be effectively harnessed for diagnostics, monitoring, and treatment.  Some of these pathways can already be influenced by nutritional and other holistic methods. 

Excision Surgery for Endometriosis

Excision surgery, most often performed via laparoscopy or robotics, has largely replaced ablation and big incision surgery. There is general agreement that minimally invasive surgery is superior to big incision (laparotomy) type of surgery.  However, ablation is still commonly performed, partly because it is simply easier and requires far less skill.   

During excisional surgery, visible endometriosis lesions are removed, which studies have shown significantly reduces the rate of disease recurrence and associated pelvic pain.  However, not all studies clearly support excision over ablation.  Additional research is required to settle this question and this is very difficult to do because of the extremely wide variance of surgeon skill. Suffice it to say that publications by experts in excisional surgery seem to clearly support this technique over ablation. 

The technical aspects of laparoscopy and robotics, as well as the surgeon’s expertise, dexterity, surgical precision, coordination, and visualization limitations, can cause complications during surgical dissection to vary widely, particularly in severe endometriosis cases. For this reason, it is prudent that a surgeon trained in specialized excision techniques perform these surgeries to minimize complications as well as to ensure adequate removal of all visible lesions. 

Robotic Surgery for Endometriosis

Over the past fifteen years, robotically enhanced surgery has emerged as an additional tool that can help circumvent the technical challenges of conventional laparoscopy. It offers several advanced features, including 3-D and magnified visualization, wristed instruments, motion scaling, and ergonomic positioning for the surgeon. But what does this mean in terms of benefits to you as the patient? 

First, 3-D technology and magnified view mean that the surgeon can see every little detail which conventional 2-dimensional laparoscopy may not allow the surgeon to discriminate, even using so-called “near contact laparoscopy.”  This is because magnified 3-D allows depth perception so that even sub-millimeter irregularities on the peritoneal surface can be identified. Also, in a difficult case with distorted anatomy, it allows the surgeon to better avoid damaging adjacent organs, like the bowel and ureters.  

Second, the instruments at the tips are “wristed”, meaning they behave like tiny human hands.  Conventional laparoscopic instruments are straight sticks with scissors or graspers at the end, which can limit options in tight spaces to cut, push, pull and tear. Robotic wristed instruments can result in more precise motions to excise endo in difficult places and avoid bleeding and other complications.  

Third, the fulcrum of activity during conventional laparoscopy is the abdominal wall.  When the surgeon moves the instruments, because of their straight nature, the abdominal wall is constantly being tweaked and traumatized. In contradistinction, since the surgical activity fulcrum is at the instrument tips during robotic surgery, there is less ongoing trauma to the abdominal wall.  This results in less abdominal wall pain over the first hours and days after surgery. 

Fourth, the risk of needing to convert to a big incision because the surgery is not going well using minimally invasive surgery is higher for laparoscopy compared to robotics.  So, you have twice the risk of waking up with a much bigger incision during a planned conventional laparoscopy.  Big incisions are prone to hernia and infection, not to mention more painful during recovery.  Generally, the more difficult the surgery the higher the conversion risk. Unfortunately, it is not possible with endometriosis (due to its intensely inflammatory and scarring nature) to accurately predict what is going to be an easy vs difficult surgery. This is truly a case of an ounce of prevention (optimal preparedness) being worth a pound of cure (getting caught with inadequate instruments for the job and then trying to scramble and fix it).  

Research Comparing Robotic Surgery with Conventional Laparoscopy

Several studies have been conducted to compare the efficacy of robotic surgery and conventional laparoscopy in treating endometriosis. A meta-analysis by Chen et al. evaluated the safety and efficacy of robotic surgery for treating advanced-stage endometriosis. The study concluded that while robotic surgery was safe and efficient, it was also time-consuming and incurred higher costs compared to conventional laparoscopy.  Studies like this are hard to interpret because it is not possible to know the real skill base of the surgeons involved, which means conclusions about costs and efficiencies are suspect. Also, it’s important to keep in mind that from the patient’s perspective, this cost is irrelevant. The costs are almost all absorbed by the hospital or surgery center and not directly passed on to the patient. 

The bottom line is that an experienced laparoscopic excision surgeon will likely be able to get the right surgery done safely in straightforward and moderately complicated cases.  A robotic surgeon should be vested enough in the newer technology (i.e., does a lot of robotic surgery, if not all robotics) to realize a difference.  In other words, in most cases, the surgeon is the most important part.  However, due to the superior technology, a highly skilled robotic surgeon will likely complete a complicated case safely (e.g., Stage III or IV with multiple prior surgeries), without conversion to a big incision, more often than a highly skilled laparoscopic surgeon, due to the limitations of inferior technology.  

From a practical perspective, you can experience/simulate the difference yourself between 2-D and 3-D vision or between straight stick laparoscopic surgery vs wristed robotics technology.  Wear a patch or tape one eye closed and immobilize your elbows and wrists with splints and tape, leaving only two fingers to grasp things with, and go about your daily business (NOTE: please don’t do this without someone assisting you because you will find that you misjudge distances and are unable to carry out tasks safely).  Can you adjust to this handicap over time?  Of course, as can a surgeon.  However, it is certainly not optimal to avoid using your wrists and both eyes if you have a choice. 

Robotic Surgery for Deep Infiltrating Endometriosis (DIE) and Extragential Endometriosis

DIE is a severe form of endometriosis characterized by endometrial tissue growth more than 5mm deep into the peritoneum. Approximately 40% of patients with endometriosis suffer from DIE. DIE can cause dense adhesions and fibrosis, distorting pelvic structures, including genital organs, the bowel, and the urinary tract, causing severe pelvic pain. There is also an overlap of molecular abnormality markers (primarily ARID1A mutations) between DIE and clear cell cancer arising from endometriosis.  This has led researchers to suggest that the DIE  type of endo is pre-malignant.  Removing DIE requires an even higher skill base, and robotics can facilitate far safer and complete surgery for the reasons noted above.  

Ablation for Endometriosis

Let’s consider the technique of ablation, as opposed to excision, in a little more detail.  This procedure involves destroying endometrial lesions using heat or laser energy rather than removing them. This method was introduced in the 70’s but has significant limitations. The issue with ablation is that while it may be adequate for very superficial disease, it does not remove the lesion, and more importantly, you cannot determine how deep the lesion goes by burning the surface and not carefully excising the lesion. Ultimately this can leave behind endometriosis which can continue to wreak havoc on the body.  In addition, the more trauma to your body (ablation via thermal damage is more traumatic than precise excision), the more your body resorts to scarring and fibrosis for healing.  This fibrosis can continue to cause pain and lead to complications like urinary system obstruction.  Finally, the ureters ( tubes that connect your kidneys to your bladder) and bowel are often right underneath endo lesions.  These are thin, delicate structures that are in danger of damage by thermal spread.  If they leak due to damage this can lead to emergency surgery, colostomy (wearing a bag for stool on your belly), urinary reconstruction and even death.  Therefore, it should only be done in circumstances where the risk is low, such as the eradication of tiny endo superficial ovarian lesions when all else (including endometriomas) has been excised.   

Conclusion

Regardless of the approach to excision – robotic or conventional laparoscopy, the need for better research utilizing highly skilled surgeons performing wide-excision is needed to definitively demonstrate the superior overall benefits compared to ablation surgeries. As of now, research is relatively sparse due to flaws in the research process discussed in this article and many more statistical reasons. Again, we are burdened by a lack of superlative surgeons and this is not a surgery for less skilled surgeons to dabble in, whether it be in research study participation or patient care.  As a result, the lack of absolute positive outcome superiority currently impacts the availability and insurance reimbursement for those seeking a safe and effective excision surgery.   At this time, since everyone’s situation is different, the best course of action is to get an expert opinion from the best endometriosis specialist you can find.  

Looking for a specialist? Check out our related blogs:

• Finding an Endometriosis Specialist: Your Guide to Effective Treatment 
• Find an Endometriosis Specialist for Diagnosis, Treatment, & Surgery

N.B. The above is based on a combination of published data and the author-surgeon’s personal experience, spanning over three decades, using both laparoscopy and robotic surgery for advanced excisional surgery, inclusive of advanced endometriosis and radical cancer excision. 

References

1. Pundir, J., Omanwa, K., Kovoor, E., Pundir, V., Lancaster, G., & Barton-Smith, P. (2017). Laparoscopic Excision Versus Ablation for Endometriosis-associated Pain: An Updated Systematic Review and Meta-analysis. J Minim Invasive Gynecol, 24(5), 747-756. https://doi.org/10.1016/j.jmig.2017.04.008 
2. Kang, J.-H., & Kim, T.-J. (2020). The role of robotic surgery for endometriosis. Gynecologic Robotic Surgery, 1(2), 36-49. https://doi.org/10.36637/grs.2020.00045 

1 year ago Endometriosis , Endometriosis Education 2 comments

Dr. David Redwine Obituary : A Modern Hero in Endometriosis Research and Excision Surgery

The recent death of David Redwine has undoubtedly left many with sadness and devastation. Our thoughts are with his friends, family, colleagues, and the endometriosis community as a whole. The world of gynecology has been significantly influenced and transformed by the groundbreaking work of Dr. David Redwine, a significant contributor to those suffering from this disease. A modern hero in this community in his contributions to endometriosis research, excision surgery, and fighting alongside patients and advocating for better answers and better care. His innovative approaches and relentless pursuit of knowledge have positioned him as a leading advocate for patients with endometriosis, a debilitating condition that affects millions of women worldwide. 

Table of contents

• Who is David Redwine?
• Redwine’s Contribution to the Understanding of Endometriosis
  • Challenging Sampson’s Theory
  • Proposing an Embryonic Origin
  • The Concept of Mulleriosis
• Redwine’s Innovations in Endometriosis Surgery
  • The Importance of Excision Surgery
  • The Concept of Cure
• Redwine’s Advocacy for Patients with Endometriosis
• You Will Be Missed!

Who is David Redwine?

A formidable figure in the medical community, Dr. David Redwine has devoted his career to understanding and treating endometriosis. His profound commitment to research and patient care has made him a renowned authority in the field.

Redwine’s Contribution to the Understanding of Endometriosis

Endometriosis is a complex and often misunderstood condition. Dr. Redwine’s research has been instrumental in challenging established theories and introducing new perspectives on the origins and treatment of the disease.

Challenging Sampson’s Theory

One of the most significant contributions of Dr. Redwine has been his challenge to the widely accepted Sampson’s Theory of endometriosis. The theory, proposed by Dr. John Sampson in the 1920s, suggests that endometriosis is caused by retrograde menstruation, where menstrual blood containing endometrial cells flows back through the fallopian tubes and into the pelvic cavity. Redwine questioned the validity of this theory, arguing that if retrograde menstruation were indeed the cause of endometriosis, there should be ample microscopic evidence of refluxed endometrial cells attaching to the pelvic lining and subsequently proliferating. Yet, such evidence is conspicuously lacking. While modern day understanding by experts support alternative theories and are moving toward more plausible explanations, Dr. Redwine is largely to thank for this movement. 

Proposing an Embryonic Origin

In place of Sampson’s Theory, Redwine proposed that endometriosis originates from an embryonic source. He argued that endometriosis is derived from mesoderm, the middle layer of the three embryonic layers, and is a result of abnormal differentiation and migration of cells during embryonic formation of the female reproductive tract. This theory suggests that endometriosis is a congenital condition that can manifest later in life under the influence of hormones and other factors. 

The Concept of Mulleriosis

To further elucidate the embryonic origin of endometriosis, Redwine introduced the concept of ‘Mulleriosis.’ This term embraces a wider perspective, encompassing all pathologies associated with abnormal development of the Mullerian ducts, the precursor structures to the female reproductive organs.

Redwine’s Innovations in Endometriosis Surgery

Dr. Redwine has not only helped reshape our understanding of endometriosis but also revolutionized its treatment. He is a staunch advocate for excision surgery, a procedure that aims to completely remove endometriosis lesions. While early surgeries also focused on excision surgery, though lacking the precision and advanced technology we have today, the introduction of ablation surgery in the 70’s has complicated research findings, surgical outcomes, and the overall role of surgery in the treatment of this disease resulting in a further push towards hormonal suppression and the fight against Big Pharma. 

The Importance of Excision Surgery

Whereas traditional first-line therapies often rely on hormonal therapy or less thorough surgical methods, Redwine emphasizes the importance of excision surgery in effectively treating endometriosis. Through extensive research and practice, he has demonstrated that excision surgery can significantly alleviate symptoms and improve the quality of life for patients with endometriosis.

The Concept of Cure

Contrary to the prevalent belief that endometriosis is incurable, Redwine insists that the disease can be effectively treated through excision surgery. He defines ‘cure’ as the complete absence of the disease, as proven by follow-up laparoscopy. While this topic may be nuanced to a degree and there are cases of regrowth, those of who have undergone a true excision surgery, and those that perform skilled excision surgery understand the difference of persistent pain vs. incomplete technique. 

Redwine’s Advocacy for Patients with Endometriosis

In addition to his clinical and research work, Dr. David Redwine is a passionate advocate for patients with endometriosis. He strongly believes in empowering patients with knowledge about their condition and available treatment options. 

Redwine is committed to educating both the medical community and the public about endometriosis. He regularly delivers lectures and presentations, sharing his insights and the latest research findings. His dedication to education aims to foster a more informed and empathetic understanding of endometriosis.

As a fervent advocate for patient-centered care, Redwine emphasizes the need to listen to patients’ experiences and concerns. He argues that an effective treatment approach should consider not only the physical manifestations of the disease but also its impact on a patient’s mental and emotional well-being.

You Will Be Missed!

Dr. David Redwine’s pioneering work in endometriosis research, excision surgery, and patient advocacy has had a profound impact on the understanding and treatment of the disease. His unwavering dedication to advancing knowledge and improving patient care serves as an inspiration for both medical professionals and patients alike. Dr. Redwine’s contributions will undoubtedly continue to shape the future of endometriosis care and research, despite his recent passing. His name will always be known in this community for the significant contributions he has made and the patients whom he has helped whether directly, or indirectly. 

Rest in peace Dr. Redwine, you will be missed. 

1 year ago Endometriosis , Endometriosis Education , Integrated Care , Pain Management No comment

Complementary Endometriosis Therapy Related to Pelvic Pain

Table of contents

• The Pain Experience in Endometriosis
• Transcutaneous Electrical Nerve Stimulator (TENS)
• Dietary Modifications
• Cannabidiol (CBD)
• Turmeric

Endometriosis, a medical condition that affects nearly one in ten women worldwide, is characterized by persistent pelvic pain that can significantly hamper their quality of life. While we await more research in diagnosing endometriosis and effective non-hormonal treatments, not to mention better research regarding excision surgery and improved access to care, it is crucial that patients have access to effective pain management strategies. Complementary therapies offer promising avenues for managing pelvic pain resulting from endometriosis, providing patients with a sense of control and agency in their own treatment. This article will delve into these natural therapies, offering a comprehensive guide to several popular and easily accessible options.These natural therapies include Transcutaneous Electrical Nerve Stimulation (TENS) units, dietary changes, Cannabidiol (CBD), turmeric, meditation, yoga, and acupuncture. While these therapies show promise, more research is needed to fully understand their efficacy and mechanisms of action.

The Pain Experience in Endometriosis

Understanding the pain associated with endometriosis is complex. It’s believed to be multifaceted, involving nociceptive, inflammatory, and neuropathic components. Endometriosis lesions can cause mechanical pain through compression and infiltration of nerves, and the chronic inflammatory state associated with the condition can lead to elevated levels of inflammatory cytokines and markers. Neuropathic pain can result from damage to neurons, as well as from central sensitization of pain in the central nervous system.

Pain from endometriosis can wax and wane, presenting in “flares” of variable duration that can significantly impact patients’ lives, often requiring increased pain medication. Those with endo may have cyclical or non-cyclical pain, and many people suffer from ovulation pain, which you can read more about here.

Self-management, involving active participation in managing one’s chronic condition, has been associated with improved knowledge and self-efficacy, and can be particularly important during times of isolation and distancing, such as during a pandemic. 

Transcutaneous Electrical Nerve Stimulator (TENS)

TENS units are handheld devices that deliver small electrical pulses to the body, providing a form of pain relief. These units work by the Gate Control theory, inhibiting the transmission of pain through smaller nerve fibers. They offer a patient-controlled, non-pharmacological option for pain management that is readily accessible and inexpensive.

Research has shown TENS units to be well-tolerated, with minimal side effects, and effective in reducing pain. Patients have reported significant decreases in pain scores and reduced need for pain medication with TENS unit use. While most studies have focused on the effectiveness of TENS for primary dysmenorrhea, there is a need for more research to understand its applicability to patients with endometriosis. If you are interested in learning more about TENS therapy, and the Apollo TENS, check out our recent blog here.

Dietary Modifications

Diet can play an essential role in managing endometriosis symptoms and is an important aspect when it comes to gastrointestinal symptoms. Certain nutritional deficiencies can contribute to metabolic changes that increase oxidative stress and epigenetic abnormalities, potentially exacerbating the condition. A balanced diet rich in specific nutrients such as folic acid, methionine, zinc, vitamins B12, B6, A, C, and E can help prevent these negative impacts.

Conversely, certain foods, such as red meat and processed foods, have been associated with increased inflammation and the development of endometriosis. Consuming foods rich in omega-3 fatty acids, such as fish oil, and foods containing polyphenols, like citrus fruits, apples, green tea, olive oil, and chocolate, may help prevent and improve inflammatory markers and in turn, modulate disease progression. It is important to note that there is currently no specific guidance on the optimal diet for endometriosis, and more research is needed to establish evidence-based dietary recommendations. Of course, we understand that there may be overlapping conditions that impact the tolerance of these foods in people with endometriosis and it is important to work with a trained provider for individualized recommendations. 

Cannabidiol (CBD)

CBD, a cannabinoid derived from the cannabis plant, has been gaining attention for its potential health benefits and its role in pain management. The endocannabinoid system, which CBD impacts, has direct effects on various physiological functions, including pain perception and inflammation. CBD is generally well-tolerated, with side effects including decreased appetite, fatigue, sleep disturbances, gastrointestinal upset, and hypersensitivity reactions. While there are no published randomized control trials of CBD use in endometriosis, surveys show a positive impact on endometriosis pain, and anecdotal evidence suggests it may be a useful adjunctive treatment. 

Turmeric

Turmeric, a spice derived from the curcuma longa plant, has been used for centuries for its medicinal properties. Its active ingredient, curcumin, has anti-inflammatory properties and has been shown in animal studies to have potential therapeutic effects against endometriosis.

While the benefits of turmeric for endometriosis are not well-studied, no harmful side effects have been reported with supplementation. More research is needed to determine the optimal dosage for managing endometriosis symptoms.

Meditation

Meditation, specifically mindfulness meditation, has been associated with improved outcomes in chronic pain syndromes. It involves focusing on the present and cultivating an attitude of acceptance and non-judgment, which can help manage the stress and psychological comorbidities often associated with chronic pain conditions like endometriosis.

Research has shown that meditation can significantly improve pain catastrophizing scores, suggesting a beneficial effect on pain perceptions. However, more studies are needed to confirm its effectiveness and to understand how best to integrate it into treatment plans for endometriosis.

Yoga

Yoga, a mind-body intervention, has been reported to improve pain and quality of life in patients with endometriosis. While research on the efficacy of yoga for endometriosis management is limited, preliminary studies suggest it may provide beneficial effects. However, more research is needed to understand the specific mechanisms by which yoga may alleviate endometriosis-related pain and to determine the optimal type and duration of yoga practice for maximum benefit. 

Acupuncture

Acupuncture, a component of Traditional Chinese Medicine, involves the insertion of thin needles into specific points on the body. It has been used as a complementary therapy in endometriosis management, with studies showing a small but overall positive effect on endometriosis symptoms. To read more about the impact of acupuncture on endometriosis, read our blog here: Acupuncture: An Underexplored Solution for Endometriosis Pain.

Conclusion

Complementary therapies offer promising options for managing endometriosis-related pelvic pain. While more research is needed to validate and understand their effectiveness fully, they provide patients with accessible, patient-controlled strategies for managing their pain. By incorporating these therapies into their treatment plans, patients can take an active role in managing their condition, improving their quality of life, and gaining a sense of control over their health. You can read more about integrative therapies for endometriosis here. 

References:

1. Li, Linda ; Lou, Kristie ; Chu, Amanda et al. / Complementary therapy for endometriosis related pelvic pain. In: Journal of Endometriosis and Pelvic Pain Disorders. 2023 ; Vol. 15, No. 1. pp. 34-43.

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