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Deep Excision Surgery: The Gold Standard of Endometriosis Treatment

What is the best surgical method to relieve endometriosis?

Removal of endometriosis is most successful with endometriosis deep excision surgery, performed by a skilled specialist, to relieve pain, remove all inflammatory tissue, and to help restore fertility.

Where does the term “excision surgery” come from in medicine?

Traditionally, surgical excision is widely used in cancer-related surgical methods, primarily breast cancer. It stresses the importance in removing all diseased tissue ensuring that no cancerous tissue is left behind. When the cancerous lesions are removed, the borders of surrounding healthy tissue are relieved and the patient is considered disease free. Following this, the anatomy is restored and any affected organs are repaired and reconstructed so that function is retained. Excision also stresses the importance of surgery being performed “cold,” that is without using any energy and at pixel precision for every lesion separately, as each lesion can reveal cancerous inclination. These specimens are then collected individually so pathology can analyze each specimen. While one lesion may cause problem, another lesion from a critical area can. Endometriosis deep excision surgery aims to duplicate the same surgical technique for endometriosis lesions as opposed to cancer lesions, making sure to maintain key elements such as removing all lesions individually, “cold” excision, anatomical preservation and reconstruction, and utilizing pathology specialists for diagnosis confirmation.

Why is excision surgery favored over other forms of surgery?

Endometriosis excision surgery is recommended over other surgical methods that are considered inferior due to their destructive nature. These techniques, namely laser ablation and electrical fulguration, are ineffective because they don’t remove all of the endometriosis. With these surgeries, most patients have their pain return in less than a year. More importantly, these methods do not allow confirmation of visual diagnosis by a pathologist because the tissue is not actually removed, but destroyed. What makes endometriosis excision surgery the most effective way to treat endometriosis is that it doesn’t zap out the tip of the disease, as laser surgery does. It doesn’t burn the tissue either. Rather, it removes the inflammatory tissue down to its roots by bringing deep layers of the body into the surgeon’s view. The surgeon not only removes diseased and damaged tissue but also skillfully reconstructs organs and restores their functionality.

Gold Standard excision surgery

How is pathology used in Excision Surgery?

One of the most critical aspects unique to deep excision surgery is the confirmation of the diagnosis of endometriosis and symptoms by a pathologist. Unlike other forms of endometriosis surgery, excision surgery preserves the removed scar tissue so that it can be given to a pathologist, who views the sample under microscope magnification. The pathologist reports the extent of inflammatory changes caused by the endometriosis including border free status (i.e. whether anything was left behind), and also rules out whether there are cancerous changes of the endometriosis cells. The detailed description of where these excisions are taken from, their size, and the number of specimens removed may reveal the tenacity and skill of the excision surgeon. The pathology review is an important point about the quality of surgery verifying the completeness of the procedure.

endometriosis excision surgery
One of the chief advantages of endometriosis excision surgery is the collection of removed tissue that is sent to pathology. These physicians will then look at the scar tissue under a microscope in order to confirm the diagnosis of endometriosis as well as any inflammatory or cancerous changes observed

Is excision surgery common?

At this time, only a handful of doctors performs endometriosis excision surgery. Learning and refining the procedure requires lots of experience, knowledge, time, precision, dexterity, and patience. And expertise in performing endometriosis surgery cannot be defined without the ability to treat unintended consequences – the complications. It is also imperative that every endometriosis surgeon has the precise skills to suture and tie tissues, and to return an organ to precisely where it should be. The organs must also function well after surgery. In sum, the skills required include not only the excision technique but also meticulous bleeding control, suture repair, and reconstruction and restoration of organs. Because of the great expertise that is required, few surgeons are capable of performing deep excision surgery. Nevertheless, it is still the most successful form of endometriosis surgery and should be sought for patients looking for the highest chance of relief of symptoms.

What is the difference between "excision" and "resection" surgery?

Although both excision and resection are used to describe the removal of diseased tissues, excision is different than resection of a lesion. When a pathology specimen is called “an excision,” this means it is a complete removal of all endometriosis lesions, as opposed to a resection, where cancerous tissue is hopelessly left behind. In other words, while resection surgery is the removal of diseased tissue, it does not confirm that all of said tissue has been removed. Excision surgery on the other hand ensures complete, boarder free (i.e. not leaving anything behind) removal of scar tissue. This element of “boarder free removal” is important to take not of, as often times resection surgeries do not ensure complete removal of diseased lesions because they cannot guarantee that the diseased tissue has not spread to the surrounding boarders. This is one of the main reasons why it is so important to find a surgeon who can ensure complete excision surgery, and not just resection.

What makes excision surgery so successful?

A recent study from Sweden suggests that patients with endometriosis who were treated with excision surgery had a reduced incidence of ovarian cancer compared with endometriosis patients who did not have endometriosis excision surgery. Similarly, controlled studies have proven that, compared to other surgeries, excision surgery offers the best outcome for pain relief and positive impact on quality of life. Whether treating something as significant as frozen pelvis or as small as a single peritoneal lesion, the gold standard is to excise without leaving any endometriosis behind. What is being excised is the inflammatory tissue of the peritoneum with its peripheral and deep scarring extending to small nerves and capillaries. (Increased Peritoneal Surface Tension: Theory on Origin of Pain in Early Endometriosis). Additionally, only the excision technique can address the treatment for all symptoms of endometriosis, including dysmenorrhea (painful periods), dyspareunia (painful sexual intercourse), dyszechia (painful bowel movements), and leg and back pain with menstruation.

Can excision surgery be performed on advanced cases of endometriosis?

Deep Infiltrating Endometriosis (DIE)
Even in complicated cases of Deep Infiltrating Endometriosis (DIE), excision surgery is the best treatment option when in the hands of a skilled surgeon.

In cases of advanced endometriosis, where pelvic architecture is deformed, and organs are fused in various degrees of adhesions, the difficulty of the excision surgery can be more complicated than most cancer surgeries. However, it is still very much possible when in the hands of an expert laparoscopic deep-excision surgeon, The excision surgeon is expected to perform the ultimate reconstructive task of meticulously and painstakingly debulking the lesions to accomplish the restoration of the pelvic anatomy. Secondly, repair of organs where the deep infiltrative disease is removed, and reconstruction of the remaining organs is imperative and is where the skill of the excision surgeon is most important. No surgeon should attempt endometriosis excision surgery if they have not trained and mastered suturing techniques for bowel and bladder repair. The thin transparent lining that covers multiple organ surfaces of the rectum, sigmoid colon, ureters, bladder, ovaries, tubes, and the uterus is called the peritoneum. Because endometriosis primarily involves the pelvic peritoneum, the endometriosis excision surgeon must be comfortable operating on the superficial surfaces and deep layers of these non-reproductive organs. Not infrequently, the intraoperative discovery of deeply infiltrative endometriosis (DIE) lesions of the bowel, bladder, and ureter, requires delicate repair of these organs and must be performed by an experienced and skillful endometriosis surgeon and his/her endometriosis team.

What else should I look for in an excision surgeon?

In order for an endometriosis excision surgeon to utilize their skills for treatment, they must first be familiar with all appearances of endometriosis. The classical, or typical lesions are quickly visualized with varying colors from red to black, but they are always outnumbered by atypical and microscopic endometriosis, which is not easily recognized. The inexperienced surgeons who do not practice endometriosis excision surgery may miss these occult and deep lesions. However, there is much more than what we see! The angiogenesis and inflammatory process that is also taking place in the peritoneum must be recognized in addition to the typical and atypical lesions of endometriosis.

Our Approach

What is our approach in conducting excision surgery

The instruments we use are extensions of the hands, so your surgeon’s hands will never actually enter the body. It’s kind of like having a set of chopsticks in each hand that we have learned to use with exact precision. As your surgeon watches the monitor, they move pixel by pixel and use cold scissors to cut out every spec of the disease they can find. Organs are manipulated for viewing, biopsies are taken, the diagnosis of endometriosis is confirmed, and diseased tissue is removed. Overall the excision surgery takes three to four hours, and in some cases as much as five to ten hours.

What are the steps of our method of excision surgery

The surgery begins with a small (approximately five to ten millimeter) incision made through the navel, into which a needle is inserted. For better visualization inside the abdominal cavity, carbon dioxide is injected into the abdomen. This colorless, odorless gas swells the cavity, lifting and separating the organs to allow the laparoscope to be safely inserted. Similar incisions will likely be made in the pubic hairline and/or over the ovaries, through which surgical instruments can be inserted.

General laparascopic deep excision set up.
General laparascopic deep excision set up.

Once all the instruments have been strategically inserted, we explore the organs and surrounding tissue, take a biopsy sample , and then remove the endometriosis and adhesions. We begin with the colon; then move to the ovaries, pelvic sidewall, uterus, and other organs. We inspect every inch of the abdominal and pelvic cavities, as well as the liver and diaphragm. We believe every abnormality we see in these areas may pertain to your pain until proven otherwise, and thus we excise any suspected endometriosis scar tissue.

As noted earlier, one of the most critical aspects of endometriosis excision surgery is the confirmation of the diagnosis of endometriosis by a pathologist, who views a sample of the removed tissue under a microscope. We ensure that every specimen we obtain is preserved and sent off to pathology right away in order to ensure that you get your pathology confirmation report as quickly as possible.

Why do we stress "cold excision" surgery?

We believe that “cold excision” is the best way to remove endometriosis lesions. When we use this term, what we are saying is that no electricity or high energy should be used in order to remove scar tissue whenever possible. This is key as when you use heat to remove or destroy lesions, such as in ablation, fulguration or even some excision surgeries, it raises the possibility of leaving behind burnt tissue, which will cause additional pain. A surgeon should always aim to give a patient their highest chance of symptom relief, and we believe that “cold excision” surgery is the best way to ensure this.

How do we ensure we excise all endometriosis lesions?

Aqua Blue Contrast (ABC) technique
Using our Aqua Blue Contrast (ABC) technique, we are able to easily identify endometriosis lesions

As noted before, one of the key ways to spot endometriosis is through the angiogenesis and inflammatory process that takes place in the peritoneum. Your surgeon should have an understanding of these types of medical nuances, in order to ensure that they can on identify both atypical and typical lesions of endometriosis. One way this can be done is through changing the color spectrum of the peritoneum by using hydro-floatation with contrast color and retroperitoneal distention, in order to the surgeon visualize endometriosis otherwise undetectable by standard laparoscopic inspection. We accomplish this by using Seckin’s Aqua Blue Excision (SABE)™. Using our trademarked technique, we are able to identify all forms of endometriosis lesions visible to the naked eye, thus ensuring we excise out all endometriosis as possible.

Our office is located on 5th Ave and 68th NY, NY.
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