What is Endometriosis? | Iris Orbuch | LA

Endometriosis is a disease in which cells similar to the lining of the uterus (endometrium) are found outside of the uterus. More specifically, it occurs when endometrial glands and stroma are found in locations other than the lining of the uterus.

Endometriosis is common affecting 176 million women worldwide. It occurs in 7-15% of women.

What are the symptoms of Endometriosis?

• Pelvic pain during menses, before menses, after menses and/or anytime during the month
• Constipation
• Bloating
• Painful intercourse usually with deep insertion or certain positions
• Infertility
• Right and/or Left sided pelvic and abdominal pain
• Diarrhea
• Painful bowel movements
• Urinary frequency, and/or urgency, and/or painful voiding
• Fatigue
• Malaise
• Lower back pain
• Heavy or irregular periods

Risk Factors for Endometriosis

It is important to note that while the following risk factors increase one’s likelihood for endometriosis, there are many women who develop endometriosis without any of the following risk factors:

• Family history, especially mother or sister. If your mom has endometriosis, you have a 7 times higher risk of developing endometriosis
• Early menses
• Early onset painful periods
• Short frequent menstrual cycles
• Mullerian abnormalities
• No children
• Autoimmune disorders (thyroid, rheumatoid, eczema, food allergies/sensitivities)

The symptoms of endometriosis are related to the areas where endometriosis invades. Endometriosis of the uterosacral ligaments/cul-de-sac leads to painful intercourse, constipation, diarrhea and painful defecation. Endometriosis on the ovary can lead to left sided or right sided pain. Bladder endometriosis may lead to urinary frequency or urgency. You may have only one of the above symptoms or many. Even one symptom can be suggestive of Endometriosis.  Some women have no symptoms yet only suffer from infertility.  Plenty of women do not have any symptoms listed above, and only discover they have endometriosis when are having trouble conceiving.  If your doctor told you that you have ‘unexplained infertility’, endometriosis is the culprit in 40-50% of cases of unexplained infertility.  Come see Dr Orbuch, as her excision of endometriosis decreases inflammation and will improve your fertility.

Treatment of Endometriosis

Laparoscopic surgery is the definitive method to diagnose and treat endometriosis. Excision of Endometriosis is the gold standard treatment for endometriosis. Ideally all endometrial lesions should be excised. Unfortunately most gynecologists are not trained in advanced endometriosis cases. Others approach endometriosis with cautery or a laser or burning, two modalities shown to be far inferior to excision using scissors, the method performed by Dr. Orbuch. With scissors, the endometrial implants are removed, but with cautery or a laser or the lesion remains and continues to cause pain necessitating more surgery. A doctor utilizing laser may vaporize the surface of the lesion, but still leaves active endometrial tissue below. Deep fibrotic endometriosis usually does not respond well to hormonal suppressive therapy. Adequate surgical excision of endometrial implants provides the best symptomatic relief and long term results. In addition, surgical excision has been shown to improve fertility rates in women. Drug therapy can suppress endometriosis, not eradicate endometriosis. The definitive treatment of endometriosis is NOT hysterectomy or removal of both ovaries; rather it is complete excision of endometrial lesions.

da Vinci Excision of Endometriosis

Advantages of Robotic Surgery

Robotic Surgery is an advanced form of Minimally Invasive Surgery. Minimally Invasive Surgery, which includes laparoscopic surgery, uses small incisions instead of large incisions to perform surgery thus reducing the damage to human tissue. The da Vinci System is a sophisticated robotic platform designed to expand a surgeons capabilities. With da Vinci, small incisions are used to introduce miniaturized wristed instruments and a high-definition 3D camera. This allows Dr. Orbuch to view a magnified, high-resolution 3D image of the surgical site allowing for superior visual clarity of anatomy with up to 10x magnification. At the same time, state of the art robotic and computer technology converts Dr. Orbuchs’ hand movements into precise small movements resulting in extreme dexterity. The robotic ‘wrists’ rotate a full 360 degrees that enable Dr. Orbuch to control the miniature surgical instruments with unprecedented accuracy with a wide range of motion. These technological advancements allow Dr. Orbuch to perform complex surgery with precision, dexterity and control. The da Vinci System enables Dr. Orbuch to perform more precise, advanced techniques and enhances her capability to perform complex minimally invasive surgery.

How the da Vinci Robot Works:

The patient cart is positioned over the patient during surgery and contains the robotic four arms, three which hold different instruments, and one that holds the 3-D camera. These arms are controlled by a computer that replicates Dr. Orbuchs’ movements.  Dr Orbuch often uses only three arms, so the number of incisions in robotic surgery is exactly the same as in traditional laparoscopy.

The surgeon console is where Dr. Orbuch sits and operates the robotic controls while looking into a stereoscopic monitor which provides her with a 3-D, high definition view of the surgical anatomy.

Robotic Surgery Patient Benefits:

• Less pain
• Less blood loss
• Shorter recovery time
• Less trauma on the body
• Less scarring
• Fewer complications
• Quicker recovery and return to normal activities

Early Clinical Data Suggests:

da Vinci Endometriosis Resection may offer the following potential benefits:

• Ability for surgeon to complete difficult dissections (separating of tissue)^1,2,3
• Low rate of complications^1,3,4,5
• Low blood loss^{3, 5, 7, 8}& low chance for transfusion^3,5
• Low rate of switching to open surgery (through large incision)^1,3,6,7

Endometriosis in Teens and Adolescents

Endometriosis is common in adolescents, especially in those who have a history of painful periods and pelvic pain. Their pain can be either cyclical or non-cyclical.  Other symptoms include painful bowel movements, constipation, intestinal cramps, bladder pain. Teenagers who are already sexually active may report painful sex.

Both early, superficial endometriosis as well as advanced endometriosis are found in adolescents. Many articles have reported that 60% to 70% of teenagers who do not respond to medical treatment for painful periods have endometriosis at the time of laparoscopy.

Many times endometriosis symptoms do improve with nonsteroidal anti-inflammatory (NSAIDs) and/or the birth control pill. However, it is important to remember that endometriosis may progress while the symptoms are masked.

The laparoscopic findings of endometriosis in adolescents or teenagers are different than an adult. Dr Orbuch understands that most lesions in teens or adolescents tend to be clear or red.  The use of the robotic camera with its 3-D high definition magnification allows for better viewing of these clear and red lesions found in younger patients. So better visualization of these early lesions allows for better surgical excision and outcome.

Dr. Orbuch offers support and compassion in dealing with adolescents. Dr. Orbuch has two daughters of her own and can relate beautifully to teenagers and adolescents, and is why many gynecologists refer their teen patients to Dr. Orbuch.

References

1. Collinet P, Leguevaque P, Neme RM, Cela V, Barton-Smith P, Hébert T, Hanssens S, Nishi H, Nisolle M. “Robot-assisted laparoscopy for deep infiltrating endometriosis: international multicentric retrospective study.” Surgical Endoscopy 28.8 (2014):2474-2479. Epub.

2. Nezhat, Camran, Anna M. Modest, and Louise P. King. “The Role of the Robot in Treating Urinary Tract Endometriosis.” Current Opinion in Obstetrics and Gynecology 25.4 (2013): 308-11. Print.

3. Siesto, Gabriele, Nicoletta Ieda, Riccardo Rosati, and Domenico Vitobello. “Robotic Surgery for Deep Endometriosis: A Paradigm Shift.” The International Journal of Medical Robotics and Computer Assisted Surgery 10 (2013): 140-46. Print.

4. Bedaiwy, Mohamed A., Mohamed Abdel Y. Rahman, Mark Chapman, Heidi Frasure, Sangeeta Mahajan, Vivian E. Von Gruenigen, William Hurd, and Kristine Zanotti. “Robotic-Assisted Hysterectomy for the Management of Severe Endometriosis: A Retrospective Review of Short-Term Surgical Outcomes.” JSLS, Journal of the Society of Laparoendoscopic Surgeons 17.1 (2013): 95-99. Print.

5. Ercoli, A., M. D’asta, A. Fagotti, F. Fanfani, F. Romano, G. Baldazzi, M. G. Salerno, and G. Scambia. “Robotic Treatment of Colorectal Endometriosis: Technique, Feasibility and Short-term Results.” Human Reproduction 27.3 (2012): 722-26. Print.

6. Dulemba, John F., Cyndi Pelzel, and Helen B. Hubert. “Retrospective Analysis of Robot-assisted versus Standard Laparoscopy in the Treatment of Pelvic Pain Indicative of Endometriosis.” Journal of Robotic Surgery 7.2 (2013): 163-69. Print.

7. Nezhat, C. L., M.; Kotikela, S.; Veeraswamy, A.; Saadat, L.; Hajhosseini, B. (2010). “Robotic versus standard laparoscopy for the treatment of endometriosis.” Fertility and Sterility. (2010).

8. Nezhat, CR; Stevens, A; Balassiano, E; and Rose Soliemannjad. “Robotic-Assisted Laparoscopy vs Conventional Laparoscopy for the Treatment of Advanced Stage Endometriosis.” JMIG 22.1 (2015): 40-44