Douglas E. Ott, MD, MPA

:  “This is Douglas E. Ott from Macon, Georgia at the International Human Reproductive meeting with Dr. Larry Demco from Calgary, Canada for 

.  Larry, I understand from discussions today that there’s some new technology that’s available laparoscopically to help diagnose things in the pelvis that we haven’t seen before.  Could you explain that to us?”

:  “Yes, pelvic pain has really been a complexing problem for most physicians.  We were always taught that we could adequately do a history and physical examination and lead to a laparoscopy as the initial approach for pelvic pain.  Most often or not, we see diseases such as endometriosis or adhesions but we were never able to distinguish what we were seeing was actually causing the pain.  With recent developments, patients have now been able to be kept awake and were really instrumental in bridging the gap from what we saw and heard the patient complain about in the office and what we saw at laparoscopy.  Pain mapping and conscious sedation laparoscopy has really shed some new light.  We would see lesions of endometriosis, the classic black lesions and now the newer ones seen are red or clear lesions, and we’ve traditionally just treated the black lesion.  Patients who were awake told us the black lesions really weren’t where all the pain was; it was somewhere distant.  It actually went quite a ways from the lesion out onto the normal peritoneum, and as a result, when the physician would be looking at this and trying to treat it he would treat what he saw.  This resulted in a poor and very high recurrence rate for patients waking up saying, “What’d you do, doc?  You didn’t touch anything.”  With the patient being awake we are then able to actually treat according to the patient’s guidance.  This was fraught with some difficulties because it was very highly technical work being able to keep a patient awake, and it required certain skills and communicative skills that not all physicians have so they had a lot of difficulties with it.  This was mainly in certain research areas and in pain clinics that were very specialized in dealing with pain and not to the common everyday gynecologist seeing the 40% of patients that enter their offices with pelvic pain.  What has been recently developed is a new system, which actually uses less light than what we’ve used before.  Not so white light contains many colors of the spectrum - blue, red, and green.  We’re finding out that these lesions actually can show up.  When patients were stained when they were in patient assisted laparoscopy and awake, these areas looked totally normal.  We now are able to see the endometriosis under the influence of a blue light that we couldn’t see before.  This has made endometriosis a much larger disease, and we always thought it was a pinpoint disease.  We could touch it with a cautery, we could touch it with a little tiny laser, and we took great care in trying to make sure we didn’t go beyond the border of the lesion because we might damage something.  The pain mapping and the laparoscopic spectral analysis have now showed us that this is a very large disease; it extends well beyond what we can see.  Now with the blue light we can see what these patients were complaining about.  This makes the disease gone from a needlepoint disease to a very large disease, and we have to adapt our techniques of treatment based on the fact that this is a large disease now.  So we have to put away our needlepoint cautery and we have to now look at ways of treating that incorporates a large area.  Historically, the wide excision was used and had great results as we saw today being presented.  We always wondered why excision was a little bit better than electrocautery or laser and it was because they were incorporating a lot of this area of normal peritoneum in order to excise the deeper endometriosis.  What we’ve done here is we’ve now seen that with the aid of a blue light and the laparoscopic spectral analysis we can now treat and scan the entire peritoneum for subtle changes of endometriosis that we didn’t see before.  We’re now using the argon plasma coagulator; this is very fast and rapid to actually blight the area.  It’s much cheaper than a laser system and more capable of being used in any average gynecology practice rather than a specific laser.  As a result, we can now use a system that’s becoming available to do the laparoscopy and scan for areas of endometriosis, be it subtle or very readily visible.  With the argon plasma coagulator we can then vaporize those areas.  The only problem or setback with the blue light is if you cause any bleeding this also shows up as blue so we have to be able to treat so that there’s not any blood, and this is why we can’t really excise using the blue light system.  We are currently developing a marking system so we could see it under the blue light; determine the borders of where the endometriosis end, mark it, and then you have the opportunity to excise.  With excision before, there were no guidelines to tell us where to start our excision or where we should start treatment - it was basically a guess.  With the laparoscopic spectral analysis, we finally do have some guidelines to at least give us an idea where to start the treatment, and in early lesions and also in more advanced disease we can actually know where at least start our excision.”

:  “Good, so the take-home message is technology will help us diagnose more accurately and treat our patients better.”

:  “Yes, that’s it.  Thank you very much.”

Articles

OBGYN.net Conference CoverageFrom the 11th World Congress on Human Reproduction, June 2002

Laparoscopic Spectral Analysis

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Laparoscopic Spectral Analysis Video

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     "Today I'd like to interview Dr. Paul Wetter who is the Chairman of the     Society of Laparoendoscopic Surgeons, and have him give us an overview of     what the society is, where it's going, and the future of the Internet in     regard to medicine on the Internet. Dr. Wetter, will you please tell us a     little bit about the society?"
     
     

 "Thank     you, Dr. Demco. The SLS - The Society of Laparoendoscopic Surgeons - was     founded approximately ten years ago, at the same time as the tremendous     surge in the advent of new technologies in endoscopic surgery. Along with     that growth, the society has grown itself, and today it's the largest     laparoscopy society in North America, with over 6,000 members. SLS's mission     is to provide information and education in the field of minimally invasive     surgery. And to that end, we publish a peer review medical journal, called     "JSLS," that goes out to over 8,000 surgeons in multiple     specialties - general surgeons, gynecologists, urologists, and other     practitioners of minimally invasive surgery. The idea behind the concept of     SLS is for the various specialties to share information, and there have     already been tremendous benefits to surgeons and patients because of this.     There's been standardization of equipment and technologic areas where one     technology was invented for a specific surgery, but was then adapted to     other surgeries. Each year at our annual meeting we get together and discuss     various topics related to endoscopic surgery - where it comes from, where it     is today, where it's going, and how that relates to the various specialties.     So it's a rare opportunity for surgeons of various specialties to get     together and cross-pollinate with ideas. It's really an exciting time and an     exciting experience for most of the participants."
     
     

 "You     and I are both laparoscopic gynecologists. What could a general surgeon who     also does laparoscopy teach us?"
     
     

 "Larry,     you know, for years when we ran into some problem that was not in the     gynecologic area - for instance, something related to the ureters, the     bowel, or patients with severe endometriosis - we often referred to our     colleagues in other specialties as a resource. So it's not a usual leap of     faith to realize the benefit of being able to discuss some of these issues     beforehand or at international meetings. The exchange has really been     excellent. It gives the gynecologists an advantage of being able to discuss     the kinds of dilemmas they might come across with regard to the ureter or     the bowel or other areas, and get some education right from the experts     rather than gynecologist to gynecologist, from general surgeon to     gynecologist with related to bowel injuries, with urologists to     gynecologists relating to ureter injuries, and the list goes on and on and     on. I think it also gives the gynecologist an extra level of confidence and     understanding to have that type of interaction beforehand, rather than     during an event."
     
     

 "The     SLS has really become user friendly to the Internet. Where do you see the     Internet and the education of doctors and the transfer of communication     between doctors and patients?"
     
     

 "Larry,     the possibilities for the Internet are unlimited, and we recognized this     early on. We're one of the first societies to have an Internet, which we've     had now for approximately four years. As you know, the Internet has really     blossomed within the past year or two. I would say now that well over 90% of     all physicians utilize the Internet, and we're developing new ways for     physicians to interact on the Internet and use that. It's also made this a     very small planet with regard to the advent of medical literature. So we're     working on ways to have our journal and our information more interactive,     and also to relay information from different parts of the world to     gynecologists and to surgeons so that there's more accurate and accessible     information. And the Internet... the possibilities are unlimited for this.     It just allows that type of communication - it eliminates time barriers and     distance barriers."
     
     

     would like to learn more about the SLS, how do they contact it?"
     
     

 "The SLS     website can be contacted in two ways - one is through 

 "Is     there both patient and physician access to your site, or is it just strictly     for physicians?"
     
     

 "Our site     is open to patients and physicians, and often there are very interesting     questions that are posed by patients or potential patients. All of our     active members are listed on the website, so if a patient poses a question,     it then goes up for discussion on the list, but if they want more     information they can also look on our website for SLS members in their area.     It gives them information on how to contact that particular person."
     
     

     "Thank you, Dr. Wetter, for giving us an overview of the society. We're     looking forward to its growth as the Internet grows. I appreciate your time,     thank you."

OBGYN.net Conference CoverageFrom Society of Laparoscopic SurgeonsNew York, December, 1999

What is the SLS - The Society of Laparoendoscopic Surgeons?

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 "I       have with me the Editor and Chief of the Journal of the Society of       Laparoendoscopic Surgeons, Dr. Michael Kavic. I'd like to ask Michael to       tell us a little bit about his journal, some of the history behind the       journal, and for whom this journal is published."
       
       

       "Certainly, Larry. It's a pleasure to talk with you and your       organization. The JSLS is the Journal of the Society of Laparoendoscopic       Surgeons, and it was founded to promote the scientific interests of our       society and to provide an outlet for creativity. Our society, as you are       aware, is a multi-disciplinary organization, one of the very few       multi-disciplinary surgical societies in the world today, and the journal       represents the activities of the society. We first thought of the journal       about four years ago - it took a year in planning, and we initiated it       three years ago. I'm very proud of the fact that the journal has attracted       a very high quantity of papers of good scientific content. They're       actually of such great merit that when we applied for indexing in Index       Medicus, we were accepted our very first time, we had only been in       existence a year and a half. Even more impressive was the fact that the       journal was accepted, and accepted retroactively - that is to say, all the       articles published in the journal from day one have been and are now       indexed in Index Medicus and MEDLINE. It's really quite a feat."
       
       

       "Does the journal have any connections with the Internet at this       time?"
       
       

       "Yes we do. Through the website of the society - 

       - you can use a hot link to get to the journal which gives abstracts of       all the articles, authors, and biographical material. So that's available       instantly on the Internet."
       
       

       "Are there plans in the future to have access to the actual original       articles through the Internet?"
       
       

       "Yes, there are. We plan, as soon as our website capabilities permit,       to put the entire journal on the web for perusal by any interested       parties."
       
       

       "Why is it important for a journal to be established where we have a       mixture of articles from gynecologists, general surgeons, and urologists,       all reading the same material?"
       
       

       "I'm glad you brought that up, Larry. What we've found with our       society, and in particular with gynecologists and general surgeons, is       that there are important advances in one area that would benefit all       surgeons, and here to for, we just didn't have the time or perhaps the       inclination to read one another's specialty work. To give you an example,       some outstanding gynecological surgeons have done brilliant work with       laparoscopic pain mapping. What they've shown is that people with pain, in       particular in this instance women with pain, the product or the cause of       the pain is usually something different than what you might think using       intuitive reasoning. We're beginning to understand now that pain is much       more complex than we'd noted here to for, and there are different ways to       tackle and to handle this. Gynecologists have taught us general surgeons       the importance of it. Just one of many, many examples of the benefit of a       cross fertilization of ideas and techniques..."
       
       

"Thank       you, Dr. Kavic. We'll be looking forward to reading the journals and       looking forward to you editing some of the leading articles. Thank you       very much."
       
       

       "Thank you, Dr. Demco. It's a pleasure being with you."

What is the Journal of the SLS (JSLS)

 "I'm       Larry Demco from the Society of Laparoendoscopic Surgery from New York,       and we'd like to interview Dr. Jay Redan from Pennsylvania. Dr. Redan has       introduced a new concept here at the meeting on laparoscopy in the       emergency room. Jay, can you give us a little run-down on how we can use       laparoscopy in the emergency room?"
       
       

 "When       patients come to the emergency room they're coming in acutely with pain,       and the patients and their families want to know an immediate diagnosis as       far as the etiology. Therefore, by doing laparoscopy right in the       emergency room, you can identify the problem and initiate treatment right       away."
       
       

       "How does the staff in the emergency room view you doing an invasive       procedure in the emergency room?"
       
       

 "At       first they were quite skeptical. Anytime you're going to do anything       invasive in the emergency room, it does alter the usual homeostasis in the       department. But once they saw how effective it was in identifying and       treating the patients and getting an immediate answer, they became much       more receptive and also very comfortable with the use of conscious       sedation."
       
       

       "How successful are you in starting a procedure versus having to       abort it and go to the operating room?"
       
       

 "Usually       after a careful history and physical, you have a fairly good idea of what       the cause is. Therefore, we're usually about 80%-85% successful in making       diagnoses and feeling safe to send patients home. Then with other 15%,       we'd either admit them to the hospital or take them to the operating room       for a more thorough examination."
       
       

       "What is the advantage of doing a laparoscopy under local in the       emergency room versus an ultrasound or a CT scan?"
       
       

 "Usually       the radiologist cannot give you a definitive pathologic diagnosis after an       ultrasound or CT scan. By doing the scope, you have direct visualization       as to the exact disease process, and you can then initiate exact treatment       as far as empiric therapy, as you would with ultrasound or CT scan."
       
       

       "That sounds like a new place for laparoscopy. Do you think it has       other uses in other parts of the hospital, the ICU for example?"
       
       

       "Absolutely. ICU examination is becoming popular, especially with Dr.       Fowler, with critically ill patients where you don't want to be       transporting these patients to the Cat Scan Department, Ultrasound       Department, or Angiography Suite. We are at the bedside - you can make a       definitive diagnosis regarding their acute disease process."
       
       

       "Jay, it's nice to see that laparoscopy has moved out of the       traditional spot of the operating room and into other areas to help speed       diagnosis, confirm our suspicions, and to direct proper therapy. I'd like       to thank you for your time. See you later."
       
       

Laparoscopy in the Emergency Room

       "Dr. Seckin works here in New York, and I've been a promoter of       microlaparoscopy myself for many years, but this has been mainly in the       diagnostic modalities of microlaparoscopy. Do you find that there's a role       for the use of microlaparoscopic instruments in operative       laparoscopy?"
       
       

       "My answer is absolutely, yes. A microlaparoscopy approach should be       the preferred entrance to the abdominal cavity. It's the first way and the       first step to decrease complications of trocar injuries and to prevent       complications of Veress needle injuries. Apart from that, it is a great       way of diagnosing pathologies. If the surgeon feels comfortable to go       along with the macrolaparoscopy with bigger trocars and so-called 'better       vision' scopes, he's welcome to do so. Yet it's a great way to access       every little corner of the abdominal cavity, rather than using regular       laparoscopy approaches. Today it's possible to do even hysterectomies with       microlaparoscopy. It's the surgeon that counts, not the instruments."
       
       

       "What in the development of microlaparoscopic instruments has changed       the way we do things, such that you're saying we can now use these       microlaparoscopic instruments? What has changed in them that made you       change?"
       
       

       "That's a very good question. I think the resolution of the optics       have come to the stage that you can get almost as close visualization of       the pelvic cavity and peritoneum right now as with the present       instruments. It is more durable; they don't break as much as they used to       break, like the glass rods we used in the past. On top of that, we do have       suturing techniques that we could utilize from ancillary reports with       microlaparoscopy. In other words, we do have other instruments that are       developed along similar lines that we use in macrolaparoscopy cases."
       
       

       "The patient is the ultimate consumer. How do see microlaparoscopy as       an advantage to the patient?"
       
       

       "I think the advantages are tremendous. One of the bigger advantages       is absolutely no scarring or stitching. To start with, that means the same       incision that we use for macrolaparoscopy will have almost no       complications at all. We see hernias, even eviscerations through 1-cm       scars, infected badly, healed scars, and pain - these are absolutely no       occasions for microlaparoscopy cases."
       
       

       "So you say that the ability to have a much smaller scar       cosmetically, as well as reporting no complications of healing, such as       hernias, are more improved for the patient. I think that the patients       themselves are more cosmetically minded. And they are especially looking       at microlaparoscopy as a way of not only doing things better, but from the       patient's point of view, from what she sees, which is the incision itself.       I'd like to thank you very much for your time."
       
       