Duncan Turner, MD, MBBS

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Alternatives to Hysterectomy

Coverage of 36th AAGL Congress November 2007, Washington, DC

Lack of Endometriosis Surgery Reimbursement in the US

 for coverage from last year's AAGL conference from Las Vegas, Nevada.

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Will all hysterectomies be done laproscopically in the future?

: "Again, from the       World Congress of Endoscopy in Israel, I’d like to interview Dr. Duncan       Turner from Santa Barbara. He’s been one of the leading surgeons in the       United States, and the topic I’d like to talk about with him today is       safety in laparoscopy. What has always been an issue that the general       public has had concerns about is if laparoscopy is safe. Can you give us a       little update on exactly where laparoscopy stands today and what measures       there are for safety for the patients?"

:       "Thanks, Larry, it’s nice to be able to talk to you and this is a       subject that’s close to my heart, I think that it’s a really       underestimated problem. Complications of laparoscopy are often not       reported, and I think we have a false impression of the safety of       laparoscopy but if we use good surgical techniques and some new technology       that’s available to us, we can really serve our patients better and make       the whole procedure safer for them. Laparoscopy is certainly advantageous       as a way of operating, and we have to be sure that by giving the patients       particular advantages, we’re not causing them more complications. I       think the vast majority of complications with laparoscopy are on entry,       and most of the malpractice cases are concerning bowel and major vascular       injuries, and about 80% of these happen on entry techniques. Another       particular area of concern is the use of electrosurgery, which most       laparoscopists utilize to coagulate, cut, and dissect. The third thing is       one that is really a little more subtle because we don’t see the       complications of it but that is the gentle treating of tissue. When we do       microsurgery techniques in open surgery, we handle such tissue very, very       gently and make sure that the blood supply is not compromised, and one way       of doing that with laparoscopy is to remove one of the insults. And one of       the insults of laparoscopic surgery is the distension of the abdominal       wall with carbon dioxide. That is moderately harsh on the tissue but if we       can warm that gas as it comes in and humidify it, it’s being clearly       shown that this is advantageous. So going back to the laparoscopic entry       techniques, I think that there are a few really basic principles. There’s       always the question of whether they should be open or closed techniques. I       think we’ve shown that there is no great advantage from an open       technique. There aren’t fewer complications that way so let’s try to       refine the closed technique using the Veress needle. The placement of the       needle is important, I think having the initial pressure up to 20 mm or 25       mm of mercury and creating a much greater safety margin between the       abdominal wall and the major vessels in the bowel is very advantageous. I’ve       had a lot of favorable experience with the radiated expanding axis system       made by a company called Innerdyne which has made some very significant       claims of improved safety which interestingly have been accepted by the       FDA as being the safest way to use. I just can’t conceive of using other       types of equipment than that which is available to us and with shown       safety. With regard to electrosurgery, there’s a new device that’s       referred to as active electrode monitoring which adds dimension of safety       to electrocautery by giving more insulation and overcoming some of the       problems of capacitance of generation of electrical current. We have these       things available to us and we can almost exclude electrosurgical       complications except those due to surgeon error, and we’re not able to       take the human error out of things but we can try to diminish the       technical errors as much as possible. Going back to the carbon dioxide,       one of the problems that we run into with patients is that they get cold       during surgery, and the dryness of the gas has been shown to be damaging       to the peritoneum. There are new methods now of very simply and very       economically warming and humidifying the CO2 as it goes into the abdominal       cavity. And as you know in your experience with an awake patient, when we’re       doing pain mapping under local anesthesia or minimal anesthesia, these       patients can tolerate a much greater distension of the abdomen if the       carbon dioxide is warmed and moistened. It’s really been pretty       remarkable in your experience and I think that this is a very good example       of the decreased damage and trauma to the tissue. So that’s three new       technologies that I think are tremendously helpful to our patients       now."

: "One of       the things that we learned this morning, Duncan, and Dr. Nezhat spoke on       was ovarian cancer and its spread. How do you view this new heated and       humidified gas in this respect? There have been some reports that the       damage of the gas may exemplify or cause further spread of cancer tissue       within the peritoneal cavity. Can you give us your views on that?"

: "I       think one of the concerns about the spread of cancer cells is the       diminished immune response of the body immediately after surgery. I think       if there is less damage to the tissue, the body is going to be able to       withstand further insults. So if we have warmed humidified air and less       peritoneal damage, I think theoretically, we should have fewer incidence       of port metastases and spread of the tumor. This is purely theoretical and       it will be hard to prove I suppose, but we’ve got to sometimes make some       assumptions based on good scientific theory even though we don’t have       the data to support it. You know we’re not able to experiment on humans       and so we have to make some of those decisions just based on theory and on       science."

:       "Regarding the complications that we’re now experiencing in       laparoscopic surgery - the initial entry and then there’s the second       group of complications which are the intraoperative trauma or       complication, would you like to talk about the intraoperative rather than       the entry technique, just comment on that?"

: "I       think that’s really largely surgeon dependent if we exclude the entry       techniques and we exclude the unknown electrosurgical problems and the       unknown or under-appreciated problems with carbon dioxide gas. So we’re       really talking about things that are damaging to organs by surgical       technique, and there are so many. Operative laparoscopy is such a new       field that we’re still trying to find the best way to do things. One of       the really good examples of a change of technique of focusing on patient       safety is doing a subtotal or a supracervical hysterectomy instead of a       total laparoscopic hysterectomy when it’s practically possible because       you don’t have to get as close to the ureters, there’s much less       likely to be damage to the bladder, and much less disruption of pelvic       floor support if you do a supracervical hysterectomy as opposed to a total       laparoscopic hysterectomy. So I think there’s an example there of a       change of technique that has really been focused or determined not just by       patient desire to keep the cervix but by our desire to try to cut down on       the risks of complications."

: "I think       this is what these meetings come to and appreciate that we have to start       looking at what we’re doing from many aspects to not only the way we’re       doing it, but how to eliminate complications, and to get the world leaders       together like yourself to express the ideas that you’ve had here today.       I’d really like to thank you very much."

OBGYN.net Conference CoverageFrom World Congress on Gynecologic Endoscopy and The 1st Annual Meeting of the Israel Society of Gynecological Endoscopy, 2000

Safety in Laparoscopy

Click             here for Audio/Video Version

"We're here today at the 10th Annual ISGE meeting in Chicago.  I'm a Clinical Advisor for 		

, and I have the  privilege today of talking to one of the real pioneers of laparoscopic  surgery, Dr. Harry Reich.  The subject today is going to be  endometriosis and Harry is well versed in this problem and has led the  way in terms of treatment.  It's changed very significantly over the  last few years in terms of our ability to diagnose and treat these  patients and a lot of this is thanks to Harry.  I'm going to give the  mike to Harry and see what he has to say about endometriosis."
       
       

"Thank you, Duncan.  I'm Harry Reich, I'm also a Clinical Advisor to       

 and presently I  work in New York City at St. Vincent's Hospital and also in Pennsylvania  at both Nesbitt Hospital in Kingston, Pennsylvania and CMC in Scranton,  Pennsylvania."
       
       

"Harry, we used to think that endometriosis  was a disease of thirty and forty year old women.  I think we've  discovered recently that that's not accurate, that it appears much  earlier in a lot of patients' lives.  Would you comment on that?"
       
       

  "It's my belief that endometriosis is  actually present before birth.  I believe that cells very similar to the  cells that are inside the uterus actually don't quite make it to the  inside of the uterus.  They get close; they get to the area of the  cul-de-sac especially posteriorly, around the rectum, the top of the  vagina, and the back of the cervix in the ligaments that support the  uterus.  Now this disease doesn't then become manifested until the  patient starts to have menstrual periods.  At that time it's almost as  if the patient were to cut her finger at the same time every month and a  chronic inflammatory response occurs.  With time that chronic  inflammatory response stimulates fibrosis in fibromuscular tissue around  it and that's the endometriosis that we see and that's the  endometriosis that we could palpate on a physical exam.  Now in some  people this reaction occurs quite quickly and it could be in their late  teens when we'll see the patient with this problem but in most women our  patients present with symptoms in their late twenties to early forties  and the symptoms become increasingly bad with subsequent periods."
       
       

  "What about the treatment of endometriosis  now?  First of all, the diagnosis can't be made except by visual  inspection and biopsy because there's no non-invasive method, although  we can be very suspicious on examination but once you make that  diagnosis how do you believe it should be treated?"
       
       

  "With the type of patients I see, in  most cases I can make the diagnosis without the usual examination.  I  could make it on a simple rectovaginal examination in the office.  What I  do is I put my finger behind the cervix, I elevate the cervix, then  with my rectal finger I can usually feel the back of the cervix, the top  of the vagina, and the ligaments that hold the cervix in place, and  that's how I diagnose most of my cases.  In some situations where the  patient's having severe pain, I may have a normal exam.  I would think  that would be about 25% of cases and those cases I would laparoscope and  what I would see that would be suspicious for endometriosis I would  remove.  The only way we'd know it's endometriosis is by removing it and  taking a look at it under the microscope in the pathology lab,  otherwise, what we think may be endometriosis often time is products of  the last menstrual period from retrograde menstruation.  So if we were  to biopsy that type of an area, we would get back hemosiderin-laden  macrophages as the diagnosis without endometriosis glands.  Those people  don't have endometriosis and the body in most cases will resorb that  process of what the doctor sees and treats as endometriosis without a  firm biopsy to prove it."
       
       

  "There's been a lot of money spent and a  lot of time put into the medical treatment in hormonal therapy for  endometriosis.  Do you feel that that is of any benefit or can cure  endometriosis at anytime?"
       
       

  "Another favorite topic - I believe that  endometriosis isn't cured at all by medical treatment.  I'm not sure  that it has any effect on the endometriosis other than preventing the  chronic inflammatory response that happens with periods in a woman who's  on no suppressive therapy.  Actually, most medical treatments stops  periods and it also stops the endometriosis from becoming inflamed every  month.  But as we well know, as soon as the medical treatment is  stopped the periods resume and the endometriosis glands and stroma are  still present and will in a very short period of time cause symptoms  once again.  Hopefully in the future we'll be able to develop some type  of compounds that could actually treat the endometriosis glands and  stroma to make it necrose away but we're far from that at the present  time."
       
       

  "If we go and think of surgery as being  the only definitive way to treat endometriosis, even within that  there's some controversy as to what sort of surgery - whether  vaporization, fulguration with electrocautery, or excision is  appropriate.  What do you think about each of those methods?"
       
       

  "We all know that endometriosis treated  by laser ablation usually just gets the tip of the iceberg unless the  surgeon is adept at using the laser to undercut the lesion and remove it  totally so in my own practice I remove it using scissors without  electricity.  I use scissors, I pick up the lesion, and I use scissors  to cross underneath the lesion.  I then tent up the lesion and continue  using scissors to remove it because endometriosis does not have a  definitive blood supply, it has a blood supply from what we call  neovascularization - new vessel formation.  When we cut across it with  scissors the bleeding that occurs usually will stop spontaneously.   After removing the major pieces of endometriosis, I then try to identify  what hasn't stopped bleeding with microbipolar forceps.  For that  technique, I use fluid through microbipolar forceps to identify the  exact bleeder and coagulate just there so I would have much less thermo  effect.  Can I excise all the endometriosis - probably not.  There  certainly are microscopic components adjacent to the areas where I've  excised, and I believe that given time those could become symptomatic  again.  Since most patients we operate on are in their thirties, most of  the time they've had this lesion developing from a microscopic stage to  a symptomatic stage over a twenty year period of time.  Most of these  people will not need future surgery if the endometriosis is excised well  down to the point where you can't see it anymore."
       
       

  "Traditionally and ultimately, in very  bad cases, hysterectomies have been recommended to patients but isn't it  true to say that a hysterectomy may not cure their endometriosis or  even sometimes if the ovaries are removed?"
       
       

  "Hysterectomy doesn't cure endometriosis.   The major problem in the United States and many other countries is  that when hysterectomy is done for endometriosis a surgeon avoids the  endometriosis with a false belief that taking out the ovaries will cause  the disease to go away, just like putting them on long-term medical  treatment.  The truth of the matter is, that just doesn't make sense.   If you have endometriosis lesions, they should be excised.  If the  patient's still having pain or if the patient has evidence of  endometriosis in the muscle or the uterus, which we call adenomyosis,  then the uterus in women past childbearing age or not desiring children  should be removed but not a normal ovary.  You remove the disease to  preserve the normal structures but, again, we can't tell if there's  endometriosis in the body of the uterus unless we remove it and the  pathologist searches for adenomyosis of the muscle in the uterus."
       
       

  "I've been surprised when operating on  patients with fibroids to find endometriosis there as well and at a  greater extent than I had ever read in the literature.  I believe that  people generally don't have pain from fibroids unless they're undergoing  some degeneration.  Are the patients that have fibroids and have pain  quite likely to have endometriosis?"
       
       

  "Definitely, that's been something I've  seen over the years also.  If a patient complains that the fibroid is  causing pain and not bleeding and you're doing surgery, almost always  you'll find endometriosis as the cause of the pain, not the fibroids.   Fibroids cause heavy bleeding but pain rarely from degeneration, it's  possible but we rarely see it especially if it's cyclic and it keeps  coming back every month."
       
       

"One last question, what about the concerns of development of malignancy within implants of endometriosis that are untreated?"
       
       

  "I've seen one case and that was back  when I started practice in 1976.  I operated on a patient who was over  sixty years old, had a mass in the pelvis, and had a history of having  had a hysterectomy with bilateral salpingo-oophorectomy.  In that one  case we almost did a hysterectomy operation; when we examined the  specimen we could see endometriosis and a focus of cancer coming from  the endometriosis.  Now that was 1976, I haven't seen another case since  so I think it must be a very, very rare phenomena."
       
       

  "Thanks very much.  I'd like to thank Dr.  Reich for clearing the way and clearing the ideas in a logical and  clinically important manner that will enable us to help our patients  more.  Thanks."
       
       

OBGYN.net Conference CoverageFrom ISGE 2001 Congress - Chicago, Illinois, 2001

Endometriosis

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