Excision of Endometriosis | Dr Iris Kerin Orbuch | LA

Laparoscopic surgery is the definitive method to diagnose and treat endometriosis.  Excision of endometriosis is the gold standard treatment for endometriosis. Ideally all endometriosis lesions should be excised. Unfortunately most gynecologists are not trained in advanced endometriosis cases. Others approach endometriosis with cautery or a laser, 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 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.

Excisional surgery makes sense if one understands what endometriosis is. Normally during a monthly cycle, a woman’s’ endometrium, or uterine lining builds up then is shed as her monthly flow of menses. The endometriosis areas growing outside the uterus go through a similar cycle but because the buildup cannot leave the body, the implants get deeper and deeper. Additionally, endometriosis lesions can irritate nearby tissue causing adhesions, scarring, and pain. Over time, endometriosis can grow into nodules causing scaring to nearby organs. Excision of endometriosis is the only therapy to objectively cure disease and thus improve quality of life. Dr. Orbuch excises endometriosis using Wolf blunt scissors, a technique initially performed by Harry Reich, M.D., a leader in advanced gynecological endoscopic surgery. This technique, along with other advanced laparoscopic techniques, was learned during her advanced laparoscopic fellowship with Dr. Harry Reich and Dr. C.Y. Liu.

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 surgeon’s 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 complications1,3,4,5
  • Low blood loss3, 5, 7, 8& low chance for transfusion3,5
  • Low rate of switching to open surgery (through large incision)1,3,6,7

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

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