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What questions should I ask my gynecologist before surgery?
Why is videotaping of the laparoscopic surgery important?
Should I insist on the laparoscopic approach to my surgery?
Why does my endometriosis keep coming back?
How do I know that my gynecologist is skilled
and experienced in laparoscopic surgery for endometriosis?
Unfortunately, it is very difficult for you to know about the
surgical skill and experience of your gynecologist. Membership in medical
societies, board certification, and a busy practice have little (if anything)
to do with a surgeon's skill. Generally speaking, the more surgical cases
performed by the gynecologist, the better his or her skill becomes. Particularly
with laparoscopic surgery, it is important to perform a variety of procedures
on a regular basis to build and maintain skill levels. This is particularly
true in the surgical treatment of endometriosis. This can be very challenging
surgery and should be performed by a gynecologist with extensive skill
and experience with this type of laparoscopic surgery. The best chance
at treatment of advanced endometriosis is the very first laparoscopic
procedure.
What questions should I ask my gynecologist
about his/her experience in laparoscopic surgery for endometriosis?
This can be difficult, but is very important. If your gynecologist
is offended by your questions, it might be time to seek another opinion.
* How many of these procedures have you done in the past year? In the past 5 years?
* How many patients have required a laparotomy to complete their procedure?
* Why would you need to convert the procedure to a laparotomy?
* What type of complications have your patients experienced?
* Who assists you in the surgery?
* Do you videotape the laparoscopic procedure? If not, why not? (Fear of malpractice is not a good answer- see the question on videotaping)
* What technique do you use to remove endometriotic lesions.
* What if these lesions are on the bowel, ureter, or bladder. Are you able to remove these?
* What about postoperative adhesions?
What questions should I ask my gynecologist
before surgery?
* What do you expect to find and what will be done during surgery
if the diagnosis is correct?
* If you find endometriosis, are you comfortable removing the implants regardless of location?
* Under what circumstances would you do a laparotomy?
* Under what circumstances would you remove the uterus, fallopian tube, ovary, or other organ?
Why is videotaping of the laparoscopic surgery
important?
Regardless of the detail included in a dictated operative report
(and most from laparoscopic surgery are not particularly detailed), a
videotaped record of the entire procedure is by far the best record of
what was found and what was done. This becomes extremely important if
another physician becomes involved with your care, another surgery seems
possible (the endometriosis "came back"), or symptoms leading to surgery
do not resolve after the procedure. In addition, patients have a much
better understanding of their diagnosis and surgical procedure if they
have had the opportunity to review a video of the surgery. There is no
better record.
Generally speaking, gynecologists with extensive skill and experience in operative laparoscopy have no problem with videotaping a procedure for future review by ANYONE. Virtually every operating room with adequate and up-to-date laparoscopic equipment has the capability to videotape the procedure.
Should I insist on the laparoscopic approach
to my surgery?
You should never insist that your gynecologist perform any procedure with
laparoscopic techniques. If a gynecologist is not comfortable performing
a laparoscopic procedure, it can be dangerous "pushing" them to proceed
laparoscopically. If the surgeon doesn't mention laparosocopy or says
it cannot or should not be done, simply seek another opinion.
Why does my endometriosis keep coming back?
Why do I need repeated laparoscopic surgeries for it?
If endometrial implants are excised (not coagulated, endocoagulated, or
vaporized), those implants are GONE. Too often, the depth to which the
implant penetrates is not appreciated, and only the superifcial portion
of the implant is destroyed. In this circumstance, one can look back in
a few months later and still find endo. It did not "come back", it simply
was not completely removed in the first place. If excisional techniques
are used, it is very unusual to find implants of endometriosis in the
same location a year or two later.
Because of endometriosis, I have been told my hysterectomy
cannot be done vaginally, why is this not necessarily true?
Unfortunately, almost 70% of all hysterectomies performed for benign (non-malignant)
conditions in the United States today are performed by laparotomy. It
is well documented, however, that in the hands of a gynecologist with
extensive skill and experience in laparoscopic and vaginal surgery techniques,
90 to 95% of all such hysterectomies can be completed vaginally. It may
well be that your gynecologist cannot perform a vaginal hysterectomy in
any given patient, but that does not mean that no one else can do so.
In most cases, the choice of vaginal or abdominal hysterectomy (when considering
benign conditions) is solely determined by the skill and experience of
the individual surgeon. Before undergoing abdominal hysterectomy, it can
be advantageous to get another opinion or two. There is probably someone
with sufficient skill and experience to perform the surgery vaginally.
Keep in mind, the purpose of hysterectomy for endometriosis is to remove the endometriotic lesions, not just the uterus and/or ovaries. Removal of these lesions can be difficult at laparotomy.