by drseckin.com | Posted on July 13, 2020
by Tamer Seckin, MDEndometriosis Excision Surgeon / Seckin Endometriosis Center (SEC)
Our endometriosis specialists work with patients to understand symptoms, diagnosis, and treatment options for endometriosis.
Endometriosis is a chronic estrogen-dependent disease which is defined as the localization of endometrial glandular and stromal cells outside the uterine cavity. Lifelong management should be planned with the goal of maximizing the use of medical treatment and avoiding repeated surgical procedures. Therapies for endometriosis-related symptoms including dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility are mainly a combined approach of analgesics, hormonal treatments, and surgical intervention. Due to complications and disadvantages of surgery such as risk of organ damage (especially the bowel, bladder, ureters, and blood vessels), possible reduction of ovarian reserve (eg, after ovarian cyst excision), adhesion formation, possible lack of improvements in pain or recurrence of disease/pain, necessity for the use of postoperative medical treatment to decrease recurrence, and standard surgical risks, surgical management is rarely preferred in clinical practice (1). However, non-surgical management of ovarian endometrioma may have some potential drawbacks and risks such as causing pelvic inflammatory disease or Tubo-ovarian abscesses through rupture or infection, the risk of malignant transformation later in life, and the negative impact of ovarian endometrioma on the ovarian reserve (2). Furthermore, surgical intervention has some advantages over medical treatments that provide a histologic diagnosis, allow assessment of pelvic cysts or masses with features concerning for malignancy, and reduce pain by destroying all endometriotic implants (3). There are also some specific cases where surgical intervention should be preferred, including:
Prior to ascribing a patient's abdominal or pelvic pain to endometriosis, the clinician should consider other important causes of such pain, including ectopic pregnancy, pelvic infection, and ovarian torsion. Patients may also have concomitant endometriosis and inflammatory bowel disease (stricturing Crohn disease). Endometriosis may be a cause for acute abdomen in women, and it should be considered in the differential diagnosis (4). The first step in such emergency cases is taking a careful anamnesis and performing a detailed physical and pelvic examination. Then hemogram and a pregnancy test should be ordered to differentiate the presence of pregnancy and pregnancy-related adverse conditions. Imaging modalities such as ultrasonography, Doppler ultrasonography, and magnetic resonance imaging can be used in differential diagnosis. Other departments such as general surgery and urology should be consulted to rule out the presence of an emergency related to the environmental organs including appendicitis, nephrolithiasis, or acute pyelonephritis.
Especially in the case of endometrioma rupture, early surgical intervention should be performed to reduce the dissemination of endometriotic cyst fluid spread, prevent adhesions, and preserve future fertility (5). If obstruction of the bowel or urinary tract occurs due to infiltration of endometriosis, urgent surgical management plays a vital role in minimalizing the loss of organ function.
Although blood tests such as serum CA125 level are not sensitive and specific for endometriosis, increased blood values of these markers during follow-up, changes in the ultrasonographic appearance of endometriomas, and aggravation of patient symptoms may also require emergency surgical intervention to rule out endometriosis-associated malignant transformation or any other serious conditions.
Deep infiltrating endometriosis is the most severe manifestation of endometriosis, affecting 20% of patients with endometriosis. It is defined as the infiltration of ectopic endometrial tissue under the peritoneum, pelvic structures, and the organ walls such as the uterosacral ligaments, colon, vagina, bladder, ureter, rectovaginal septum, and the lateral parametrium. Lateral parametrium covers the retroperitoneal connective tissue from the uterus to the lateral pelvic wall. If endometriosis spread to the parametrium, surgical intervention plays a major role in management (6). However, preoperative clinical treatment can be applied for the reduction of tissue injury and less aggressive surgical intervention (7). While disc excision is performed for single lesions, segmental resection is preferred for larger lesions or when neoplasia is a concern (8).
Surgical resection can be conservative (treatment of endometriosis by ablation or resection) or definitive (removal of all visible implants). The main objective should be therapeutic and effective surgical intervention. The potential benefits and complications should be discussed with the patient based on her age, obstetric history, desire for pregnancy, symptoms, and the characteristics and localization of the endometriotic lesions (9). Ablation is aimed to completely destroy endometrial epithelium surrounded by stroma. Excisional surgery results in a more favorable outcome than drainage and ablation regarding the recurrence of disease and symptoms, and obstetric outcomes. Ovarian cystectomy using stripping technique or combined excision/ablation technique is the preferred surgical technique compared with ablation in terms of endometrioma recurrence, pain symptoms, and increased spontaneous conception rate among subfertile patients (10). In the case of ovarian torsion due to the presence of endometrioma, detorsion of the ovary and cystectomy of the endometrioma is the most appropriate approach. Clinicians can consider hysterectomy with oophorectomy and removal of all visible endometriosis lesions in women who do not have fertility desires and have no response to other conservative therapies. It should be shared with the patient that hysterectomy is not a definitive treatment for endometriosis. Laparotomy and laparoscopy are equally effective in the treatment of endometriosis, but laparoscopic surgery appears to be superior to laparotomy due to less postoperative pain, a shorter hospital stay, and a quicker recovery and better cosmetic outcome (11*). In the case of emergency surgery for endometriosis, if the vital signs of the patient are stable, laparoscopy may be preferable. Postoperative use of hormonal therapy is recommended in patients who do not desire to become pregnant immediately after surgery (12).
Despite extensive research, the optimal management of endometriosis still remains unclear. The decision for treatment should be patient-centered and in consideration of her clinical presentation and age, symptom severity, disease extent and location, reproductive desires, other comorbidities, side effects and complications related with medical treatment and surgery, and cost (13). Relief of pain, amelioration of infertility, prevention of progression of the disease, restoration of normal anatomy, and delay of recurrence should be a priority in the management of endometriosis, even in emergency situations (14).
As a result, all women with endometriosis should be evaluated with a multidisciplinary approach considering all possibilities in differential diagnosis (15). The final decision for treatment of urgent cases should be made in a short time based on tolerability, therapeutic effectiveness, the physician’s experience, the patient’s preferences and needs, and cost.
Some questions to consider asking your surgeon before undergoing laparoscopic surgery for endometriosis:…Read More
by Tamer Seckin, MDEndometriosis Excision Surgeon / Seckin Endometriosis Center (SEC) Nonsurgical Endometriosis…Read More
There aren’t enough stars for Seckin Endometriosis. They deserve 100/ 5. I want to make sure every woman right now who is looking for help, who is looking for a doctor and is scared and confused knows this is where you need to be. It doesn’t matter if you have to come from the other side of the United States or from the other side of the world, I can guarantee it will be worth it. Every member of their…
I’ve seen many obgyns over the years explaining my monthly symptoms during my period...but eventually it became a daily struggle with these pain. It feels like a poke here and there near my right pelvic region. I was given birth control pills for the past ten years but honestly, it didn’t help at all. I was in bed whenever I had my period. I was previously sent to GI doctors for possible appendicitis but it was ruled out from imagings…
Dr.Seckin is so much more than a surgeon. His passion for helping endometriosis sufferers and determination to improve the quality of life in all of his patients is undeniable. I remember when my gynecologist first told me I needed a laparoscopy. Her exact words were "I can do the surgery, but if you were MY daughter- I'd send you to him." From the first day I met him he took the time to explain endometriosis to me since I knew…
I was there for hysterectomy but then I found out that I also had endometriosis.My both surgeries went excellent and I feel great!.I am so thankful to Dr.Seckin and all his team for making my journey smooth!
I am a physician who suffered from deep infiltrative endometriosis. I needed laparoscopic surgery, so I went to see my former gynaecologist and he performed the procedure (a surgery which he supposedly does hundreds of times a year) last November. I had severe pain again when I had my period in January and was advised to go on taking a low hormone dose anticoncipient pill. My symptoms came back quickly and got worse in a few months’ time. I went…
After years of excessively painful periods, a serious loss of quality of life, and a series of uninformed and uninterested doctors, Dr. Seckin and Dr. Goldstein turned my life around. I was told I woke up from my surgery almost a year ago with a smile on my face, and I haven't stopped since. Before I heard of Dr. Seckin, I was experiencing almost daily terrible pain to the point where I had difficulty walking, inability to eat, inexplicable weight…
Dr Seckin and his team gave me back my life! Tomorrow will be 1 month since my surgery and I feel great. Dr. Seckin, Dr Liu, and Dr Goldstein are not only beyond words talented and amazing Doctors, but they are also genuinely wonderful and caring people. I cannot say enough great things about Holly, Asiye and Kim as well. They were all caring, kind, patient, and took the time to listen to me and explain anything I needed to…