The Art of Minimally Invasive Excision Surgery for Endometriosis.
The Seckin Endometriosis Center (SEC) has performed thousands of laparoscopic surgeries for endometriosis, which has also included other gynecological conditions such as fibroids, adhesions, etc. Abiding by several techniques and key instruments, we have mastered the art of minimally invasive excision surgery for endometriosis. By following these principles for nearly three decades now, our practice has become a world-renowned center for all women suffering from endometriosis. Using the expertise we have gathered throughout the years, we are able to perform an extensively thorough and meticulous laparoscopic deep-excision surgery, which removes of all suspected endometriosis lesions throughout the body, ranging from disease in the ovaries (endometrioma), lining of the abdomen (peritoneum endometriosis) and the bowels themselves (bowel endometriosis). Below are just a few key ways in which our separates itself from any other.
Meticulous restoration of anatomy with reconstruction and repair
Endometriosis surgery is not your typical surgery. It is different from an appendectomy. It is different from a single episode of cancer surgery. Endometriosis is characterized by deformation of the normal anatomy and severe scarring of organs, therefore causing organ dysfunction. Because of this scarring, organs can fuse together and not function independently as their motility becomes compromised. This organ disfiguration, in turn, allows for endometriosis to invade into the organ. Because the disease affects multiple organs, mainly nonreproductive organs such as the bowels, ureters and nerves, the most common complaint is pain. Therefore surgery must be done in the most meticulous way, analogous to that of microsurgery such as that used in Ophthalmology surgery. Your surgeon should look to examine every single lesion represented on a monitor, produced through laparoscopy, in the form of pixels. Surgery is thus done in the form of pixel resolution, making endometriosis excision a surgery of high precision.
On top of being precise, the surgeon must also be comfortable with operating on multiple organs. An endometriosis surgeon should also be able to operate on the bowel, bladder, ureter and nerves. They should be capable of both reviewing and treating all of these areas for believed endometriosis lesions, abiding by three major principles: restoration of the anatomy, with reconstruction and repair. All of these ideals are crucial in order to preserve the function of surgically treated organs. In architecture, there is a concept called “form follows function,” which states that any building or object should be made primarily to dictate its function. The same can be said of organ reconstruction in endometriosis surgery. In this way, the surgery is much like plastic surgery, but as opposed to being for physical and visible beautification, it is for internal organs so that they can interact with one another without causing pain. The patient may not see the results, but they certainly will feel it.
One of the reasons why the endometriosis on these organs is often not removed, and why are practice is so different, comes in the ability to suture the tissue and thus reconstruct the organs themselves. Suturing skill under laparoscopic camera guidance is arguably the most challenging aspect of endometriosis surgery, as often times the reason that patients are not fully treated are due to the doctor’s unwillingness to remove tissues from the organs they know they cannot put back together if they were to properly to remove lesions on these sites. Unless this practice is performed with ease and flawlessly, proper endometriosis surgery will not be accomplished, as it would not appropriate to perform if the surgeon does not have the training and skill. Therefore, with the ability to suture tissue, physicians are able to remove the endometriosis tissue that is impeded in non-reproductive organs such as the ureter, bowel, bladder, etc. We have seen that in many cases of endometriosis, reconstruction of these organs will be necessary, and without the ability to suture and repair these organs this procedure endometriosis surgery cannot be fully completed. This is why we have taken the time and practice to master this technique, ensuring our patients their highest chance of recovery with minimal complications.
Laparoscopic deep-excision surgery
Our staple procedure and “the gold standard” for endometriosis surgery is laparoscopic deep-excision surgery. This method combines the standard surgical GYN imaging technique of laparoscopy, with excision, a form of surgical technique derived from that used in the removal of cancer, particularly breast cancer.
During laparoscopy, we make three to four incisions (5mm each) into the abdomen through which we insert the laparoscope, a long thin tube with a light and camera attached to it. This allows us to examine the pelvic and abdominal cavity hands-on, with great imaging provided by our high-quality video monitors. These small instruments allow us to make minor incisions, ensuring that there are nearly scarless results and we accomplish our goal of providing the most minimally invasive surgery as possible.
Excision surgery is modeled after a procedure predominantly used in the removal of cancer, mainly breast cancer. It stresses the importance to remove all diseased tissue in its entirety, in order to ensure all cancerous tissue is removed, while preserving the healthy tissue borders of the lesion removed. Our excision surgery technique in removing endometriosis abides by the same thought: Using laparoscopy for visualization, we are able to navigate throughout the abdominal and pelvic cavity and then “cut-out” suspected endometriosis lesions using “cold excision clippers,” and always make sure the borders are preserved. This laparoscopic deep excision technique makes our surgical procedure very unique in two major ways:
"Deep-excision" ensuring each endometriosis lesion removed completely
First and foremost, deep-excision surgery removes each suspected endometriosis lesion in its entirety, which cannot be said of such procedures as fulguration and laser ablation. A common analogy often used when describing proper surgical removal of endometriosis is that of an iceberg. An iceberg, while appearing very large above the surface of the water, is actually only ⅓ of its actual size, with majority of the solid lying below the surface. An endometriosis lesion can be thought of in the same way. Often times surgeons will perform techniques that will remove this surface region of the disease but leave the endometriosis lying underneath very much intact. This will cause persisting symptoms, infection to surrounding tissue and even further spread of the disease. That is why we stress the importance of “deep-excision” surgery, which means removing the lesion fully, including below the surface. We feel that this is the only way to truly guarantee the removal of each lesion fully, and thus gives patients their best chance of symptom relief and further spreading of the disease.
“Cold Excision” allowing for a pathology report
The other crucial advantage of excision surgery in removing endometriosis, lies in the fact that it preserves the specimen itself, allowing it to be collected and tested by pathologists. The only true way to formally diagnose endometriosis and the severity of it is through a pathology report. This requires the suspected endometriosis removed to not only be collected, but also preserved to the best of the surgeon’s ability. This is why when we perform excision surgery, we perform “cold excision,” which means minimal to no use of electricity. Surgeons must be mindful to avoid the use of electricity as much as possible, cutting with “cold-excision” scissors and using only micro bipolar devices for hemostatic purposes (stopping bleeding) under copious irrigation. This preserves the specimens for pathology purposes, which are then collected by our team of assistants who are highly trained and with us during every surgery for specifically this purpose. Many other surgeons use techniques such as fulguration and laser ablation, which use electricity and heat to destroy the endometriosis. This is flawed in that it can harm surrounding healthy tissue, does not fully remove the endometriosis lesion and most importantly, destruction prevents the sample from being collecting, and thus no pathology report is obtained. We feel that every endometriosis patient deserves to have a fully extensive surgical case review, and a large component to this is a pathology report. Therefore, we abide by a strict “cold excision” technique whenever we are removing specific endometriosis lesions.
Aqua Blue Contrast (ABC) technique
Another unique aspect of our excision surgery procedure is our use of Aqua Blue Contrast (ABC). We patented this technique specifically for endometriosis patients. During surgery, we make a small incision into the peritoneum (lining of the abdominal cavity), a common site for endometriosis to reside. We then fill this site with an Aqua Blue Contrast solution. This enhances the visibility of lesions that are difficult to see (occult lesions) due to the overpowering brightness of the laparoscope light source. We often compare our use of contrast to that of stars in the sky. During the day these stars are not seen, even though they are still present. However, when the sun’s light disappears in the night, the stars are revealed. In a similar way, Aqua Blue Contrast does the same to eliminate laparoscopic light, allowing the surgeon to discern endometriosis lesions otherwise not visible. Thus endometriosis that would go undetected during normal laparoscopic surgery, are able to be identified and removed using this ABC technique. By doing this we are able to remove more lesions than the typical laparoscopic surgery and identify areas of inflammatory changes in the peritoneum and other areas. Through our clinical practice, we have seen this have seen this have drastic results in terms of symptom relief and lowering a patient’s chances of further endometriosis development.
Sparing no organ or part of the body
Because endometriosis can affect a variety of organs, both reproductive and non, endometriosis is a multi-speciality surgery. For this reason, we strongly believe it should be viewed as a team surgery. Each organ to be reviewed and repaired has its own specialized function and anatomy, and thus the insight of each expert in the organ’s function is highly beneficial. For example, urologists, gastrointestinal specialists and others, are all working together under the direction of the primary endometriosis surgeon, who is a gynecologist specializing in endometriosis. This endometriosis surgeon will still be operating on all the affected organs, from the uterus to the bowels, ureter, etc, but to have these specialists on hand is key when it comes to operating on those specific organs, as well as reconstructing them.
There are two surgical approaches to endometriosis: conservative and definitive surgery. In conservative surgery, the organs are not removed. In other words, the ovaries, ureter, and bowel do not get removed. However, conservative surgery does not mean superficial surgery, as it is always radical to the point that no endometriosis lesions are left behind. Without removing organs, we are able to perform multiple excisions of lesions in the deep fibrotic tissue. Conservative surgery is performed for all patients with well-recognized endometriosis lesions, fibrotic lesions and inflammatory locations where all abnormal peritoneum tissue is removed to provide patients with their highest chance of relief of symptoms. On the other hand, in definitive surgery what is defined as conservative is complemented with the removal of organs. In the case of endometriosis, this is most often thought of to be a hysterectomy as it is removing the origin from where the endometriosis comes from, menstruation. Removal of the ovaries (oophorectomy), bowels, part of the bladder and reimplantation of the ureter all due to deeply infiltrating endometriosis, are all a part of definitive endometriosis surgery. While we always resort to conservative surgery, patients with adenomyosis (endometriosis within the uterus) and deeply infiltrating endometriosis should be aware that most of the time the nerves are involved, which is most likely causing their symptoms of pain (neuropathy). Deep endometriosis tissue in the cul-de-sac with retroperitoneal fibrosis is part of the disease. These surgeries are multiple organ surgeries and take a long time.
For this reason, when a stage four endometriosis case is this complicated with the presence of fibroids, it is not unreasonable to have a second look since your fibroids may not have been addressed during the time of your extensive endometriosis surgery. Remember, it is not realistic or frankly reasonable for a surgeon to clean all of the damage that has been developing and harming the body for a decade or so, in just one go of a two to three-hour surgery. On top of this, also know that we operate with a conservative surgery mindset first. In cases, where there is say diffuse adenomyosis and a hysterectomy may be beneficial we will always tell you and will not do such a treatment unless it has your complete removal. We do not want patients to feel that they do not have options. Even when definitive surgery methods can pose helpful, it is important that they receive the consent and comfort of the patient themselves, on top of receiving the thorough conservative treatment that every patient with endometriosis needs, to go along with it.
A rising field in surgery right now is the use of robotic assistance. Despite being trained in robotic use, we do not use Robots as it is not precise enough for meticulous endometriosis surgery. For our standards of surgery and the high precision it demands, robots fall short of handling tissues with the gentleness and removing the disease with the uttermost precision that is required in laparoscopic deep-excision surgery. Robots do not have the sensitive finesse and finish that can be done in comparison to that of a highly experienced surgeon’s hands coupled with customized equipment, which we go to great care to hand pick for our highly meticulous surgery technique.
It is also to be said that because we have the rare skill of reconstructing and suturing any organ we operate, the need to use robotic assistance becomes redundant and unnecessary. This is because our skill almost overrides the whole purpose and utilization of robotic-assisted technology. Remember a robotic surgery, does not make an average surgeon a better one. While robotic surgery does have its benefits, it cannot replace the many years of experience and skill developed by a great surgeon over a long period of time. On top of this, robotic surgery makes more incisions as instead of the normal three incisions (5mm each), there are five made (0.5inch-1inch). Thus the surgery itself can be more invasive and lead to more scarring than a well performed minimally invasive laparoscopic surgery.
For these reasons, we view robotics as “maximally invasive laparoscopic surgery.” In fact, of the hundreds of patients we operate on, a considerable percent are patients who have had robotic laparoscopic surgery in the past, only to have their symptoms recur. In other words, robotics in a way can set a patient up for a repeat surgery. Here at the Seckin Endometriosis Center, this is our last hope for you. We do not want this to be just another surgery for your endometriosis, we want this to be the last, and we have found that by putting the surgery directly in the hands and trust of our expert surgeons instead of robots, we are able to best achieve these results.
Last, but certainly not least, our surgery separates itself from any other in how we treat our patients. Following surgery, patients must be taken care and not just left alone without a guide to their proper recovery. Our surgeries are often complemented with a pelvic recovery protocol, which may include pelvic floor exercises, regular diet, and even pain management, with diminished use of narcotics. But above all else, the personable key to both the surgery and a healthy recovery is in how the physician interacts with their patients. Endometriosis patients have been through a great deal, whether they are a case that is just discovering the cause of their chronic agonizing pain or have been through multiple failed surgeries. For this reason, we understand that throughout this entire process patients must be handled with tremendous empathy. This is not only what is needed, but quite frankly it is what these patients deserve after all they have been through. A warm stream of communication between doctor and patient must always drive this bond throughout the surgery process, which includes both pre and post surgery. It is a crucial aspect to developing the trust that is established and cemented during the surgery itself, which persists then after ensuring a successful and healthy recovery.
- Meticulous reconstruction, repair, and restoration of every organ and its function that has been affected by endometriosis, thanks to our precise and meticulous tissue suturing ability.
- Complete removal of each endometriosis lesion through “deep-excision.”
Preservation of endometriosis specimens through “cold excision,” allows for pathology testing for each removed lesion.
- Removal of all suspected endometriosis lesions that otherwise would be naked to the human eye, thanks to our patented Aqua Blue Contrast (ABC) technique.
- No expense spared in high-quality imaging, ensuring the finest laparoscopy procedure.
- An extensive medical staff on hand during your surgery, ensuring that all areas infected by endometriosis will be reviewed and treated, including individual organ reconstruction, repair, and restoration.
- A conservative surgery approach to every case, in which we will provide patients with options, perform a thorough and meticulous excision surgery for endometriosis, and finally only perform definitive surgery techniques (such as a hysterectomy) in the rare instances when we see them being highly beneficial and have the patient’s consent and comfort.
- A highly meticulous and sensitive surgery that would be incapable of accomplishing using robotics, due to our decades of expertise in the field.
Insurance that all of these techniques do not come at the expense of the empathy and personalized care that each and every endometriosis patient craves, deserves and needs.
You may call us at 212-988-1444 or have your case reviewed by clicking here.
Meet Tamer Seckin, MD
Expert Laparoscopic Surgeon
Tamer Seckin, MD, is a Board Certified gynecologist and laparoscopic surgeon in private practice in New York City, practicing at North Shore-LIJ/Lenox Hill Hospital. He specializes in…
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Lectures, Presentations, Abstracts, and Publications
World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonisation Project: I. Surgical phenotype data collection in endometriosis research
Christian M. Becker, Marc R. Laufer, Pamela Stratton, Lone Hummelshoj, Stacey A.…
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