Embracing the challenge of complete excision surgery, the gold standard of endometriosis treatment

If you are a gynecologist dealing with endometriosis, you know the trite drill dictated by conventional wisdom: in the office diagnose pelvic pain as a sexually transmitted pelvic inflammatory disease (PID) and treat with antibiotics; diagnose recurrent pelvic pain as recurrent PID in a woman with loose morals and treat again with antibiotics; when the patient (sometimes virginal) re-presents with pain thought to be due to yet another recurrent sexually transmitted disease, perform a laparoscopy and finally diagnose endometriosis; shine a coherent beam of light at the disease or put a metal electrode on the various spots and step on a foot pedal to unleash unseen electrons and pronounce that the disease is treated; after surgery administer powerful and expensive medical agents with multiple side-effects and reassure the patient that this combination of treatment will be the best treatment for her disease since this is what most clinicians use; shuffle the suffering patient to various other practitioners, including psychiatrists and pain clinics; question her about childhood sexual abuse when her pain does not respond well; repeat a laparoscopy; repeat the same therapies which did not seem to work the first time; repeat these a third time to be certain they did not work the second time; perform a total abdominal hysterectomy and bilateral salpingo-oophorectomy; rush off to perform a routine vaginal delivery when the patient returns to the office complaining of pain and vasomotor menopausal symptoms. What is wrong with this picture? Modern therapy of endometriosis has become unimaginative, rigid and dogmatic.

...modern therapy of endometriosis has become unimaginative, rigid and dogmatic...

It is universally acknowledged that endometriosis is a confusing, enigmatic, mysterious disease, but this need not be so. Confusion is an opportunity for change if this confusion is recognized for what it is: lack of accurate information. Whereas the debate about the origin of the disease rages confusingly, the debate on treatment has become quite distilled. The word 'treatment' is used here in the same manner as when one talks about treatment of a urinary tract infection: the disease is gone when treatment is concluded, and symptoms once caused by the disease are gone as well. This use of the word 'treatment' is familiar and comforting to patients and physicians and can be used to summarize modern therapy of endometriosis accurately in one sentence - Since no available medicine eradicates endometriosis, surgery is its only treatment. It thus becomes a question simply of which type of surgical treatment most effectively eradicates the disease.

Most of the confusion regarding endometriosis stems from long-held biases that are rooted in misinformation. Our profession must grapple with the probability that Sampson's theory of origin is incorrect because the facts upon which it was based were incorrect. Sampson did not have all the facts we have today when he devised this theory. It seems unlikely that he would have supported reflux menstruation as the origin of endometriosis if he had been aware of the information that we now possess. Continuing support for his theory of origin is not just an intellectual question, because this theory directly affects the treatment of most women today. If the theory is wrong, then it is probable that most women with the disease are being poorly treated.

Continuing support for his theory of origin is not just an intellectual question, because this theory directly affects the treatment of most women today. If the theory is wrong, then it is probable that most women with the disease are being poorly treated.

Misunderstanding about endometriosis is due to a predictable phenomenon which has a name: Berkson's fallacy. This fallacy has operated from the very beginning of our understanding of the disease. Because Berkson's fallacy has operated unidentified and uncorrected for many decades, its deleterious effects on our understanding have been magnified over time and have become huge. This has led to enormous inertia in understanding, treatment and research because we have been unwilling to give up the past, partly because of the fear that we have been so wrong for so long. Things can be made right by leaving our minds open to new thoughts regarding the disease, with the possibility that we must reject much of what we think we know. Understanding clearly the origins of our current confusion will make it easier to face a future which contains the real truth about the disease.

The practice of medicine is sublimely simple because there are only three choices available for almost any ailment: (1) Do nothing. (2) Treat with medicine. (3) Treat with surgery. The patient with endometriosis will already have tried doing nothing, and that did not work because she is now in your office. This simplifies greatly the care of patients with endometriosis, because once the diagnosis is made surgically, there are only two treatment options: medicine or surgery. (Observation of a treatable disease which has led to surgery is not rational by anyone's judgment. If observation seems rational, then surgery should not have been done.) To decide between these two modalities, more information is needed, which you will find here among the pages of this site. It should be apparent after reading through the various articles that endometriosis is a disease which requires surgery for diagnosis and treatment, and this should be a part of the process of informed consent with the patient.

So... how does one treat virtually any manifestation of endometriosis surgically? Since surgery is a visual as well as a tactile and judgmental art, an effort has been made on this site to provide illustrations of surgical strategies with the hope that if a surgeon sees what is supposed to happen, it can be made to happen in that surgeon's hands. The articles on surgical treatment admittedly place a heavy emphasis on excision, which alone is able to treat both superficial and invasive endometriosis completely anywhere in the body.

Many of the images found among these pages were selected to illustrate what I consider to be important points gained through the surgical treatment of over 3000 patients with endometriosis from around the world. Most of these patients have had multiple surgeries and several rounds of medical therapy. One common thread clearly stands out: their disease has never been completely eradicated. They are dealing not with recurrent disease, but with persistent disease. Everything possible has been done to them and to their disease except one thing: the disease has never been removed from their bodies.

Endometriosis surgery is rightfully considered the most difficult surgery to be done in gynecology, and some cases will seem to be the most difficult surgery possible anywhere in the human body, maximally taxing the mental and physical strength of the surgeon. For those surgeons who relish challenge, endometriosis is the perfect disease.

...endometriosis surgery is rightfully considered the most difficult surgery to be done in gynecology, and some cases will seem to be the most difficult surgery possible anywhere in the human body...