Excision Surgery for Endometriosis
Excision of endometriosis is the “gold standard” for treatment that requires an expert with considerable ability and experience. Dr. Seckin is a pioneer in this field. He is one of a handful of doctors worldwide who is expertly trained and highly successful in advanced laparoscopic excision surgery for endometriosis. He trained with Dr. Harry Reich, M.D., one of the most celebrated laparoscopic surgeons in the world. Dr. Reich is a pioneer in endoscopy and performed the very first laparoscopic hysterectomy surgery in 1989.
Laparoscopic surgery is the most advanced treatment approach for endometriosis. It offers permanent removal of the endometriomas and the greatest pain relief. This surgery includes the excision of the endometriomas and the scar tissue and adhesions.
Laser surgery is often the first choice of many doctors today. However, it is far less effective because it only burns off the top layer of endometrial tissue. This causes the endometrioma and endometriosis to quickly grow back.
Laparoscopic surgery for endometriosis is an effective, less invasive option. It provides maximum results for the total removal of the whole disease.
Laparoscopic surgery for endometriosis also allows Dr. Seckin and Dr. Goldstein to safely and successfully remove the endometriosis from all areas with minimal risk of damage to underlying vital structures. Using sharp dissection, they are able to thoroughly eradicate all forms of endometriosis, including DIE (deep infiltrating endometriosis) and adhesions.
Surgical excision of endometrial implants provides the best symptomatic relief and long-term results. The result is improved fertility, the reestablishment of normal pelvic anatomy, and the eradication of symptoms.
Excision can be performed with any surgical tool, depending on the surgeon’s preference. Dr. Seckin uses the da Vinci system with its 3D high-definition camera that allows for precise excision of endometriosis. He performs the surgery using cold scissors and bipolar capillary bleed control. This allows him to keep the tissue surface as smooth as possible.
Minimally invasive surgery
The term “minimally invasive surgery” is thrown around quite often in the field of reproductive surgery. As a patient, it is important to ensure that your surgeon is able to determine a form of treatment that is most effective for you, while also ensuring minimal invasion.
We believe that robotic surgery is never the right method to treat endometriosis. Though it may be at the forefront of minimally invasive technological development, we consider it to be the “the most maximally invasive” form of minimally invasive surgery. This is because it typically requires more incision sites that are larger in diameter than in normal excision surgery. There is also a larger rate of robotic error than human error.
In an article published in the Journal for Healthcare Quality in 2011, researchers from John Hopkins University found that promotional materials on robotic surgery listed on hospital websites generally overstated the benefits of the approach. They also ignored the possible risks and may have been under the influence of the manufacturers.
We strongly believe that hand-made incisions and excision surgery are the proper way to ensure patients receive the minimally invasive surgery that they deserve.
Using our patented Aqua Blue Contrast (ABC) technique, we ensure that no endometriosis lesion goes undetected. To a surgeon’s eye, this aqua blue contrast makes endometriosis “shine” like stars in the night sky. By administering ABC during surgery, we are able to clearly identify and thus excise all suspected endometriosis scar tissue.
One of the key aspects of surgically removing endometriosis that surgeons often overlook is the need to remove endometriosis lesions in their entirety.
When surgeons conduct procedures such as laser ablation (use of a laser beam) and fulguration (use of electricity to produce heat) in order to “destroy” these lesions, they are only removing the scar tissue at a superficial level, not the nodule. However, endometriosis lesions usually extend far deeper than just the surface of the tissue. Therefore, it is crucial that the nodule is removed at its root, and in its entirety, for the patient to experience true symptoms relief.
Endometriosis iceberg theory
Dr. Seckin likes to think of endometriosis like an iceberg. The peak is above water, but the iceberg’s bulk remains submerged underwater. “Shaving” off the top of the iceberg would appear to leave behind a smooth surface. What actually occurs, however, is that the largest – and most dense – portion of the iceberg stays behind beneath the surface. This is analogous to the superficial removal of endometriosis implants through the techniques of ablation, vaporization, cauterization, or fulguration. The disease is left to thrive and symptoms will recur.
In contrast, with deep excision, the entire “iceberg” – the endometriosis nodule – is “cored” out, leaving behind no residual disease. This confers low reoperation rates and results in a highly successful outcome for long-term, endometriosis-free relief. This is why we strongly believe there is no better method than deep excision surgery to fully remove endometriosis.
The importance of “cold excision”
We believe that “cold excision” is the best way to remove endometriosis lesions. When we say “cold excision” we mean that we do not use electricity or high energy to remove scar tissue. When a surgeon uses heat to remove or destroy lesions, such as in the case of ablation, fulguration, or even some types of excision, it raises the possibility of leaving behind burnt tissue. This usually causes additional pain. A surgeon should always aim to give a patient their highest chance of symptom relief. We believe that “cold excision” surgery is the best way to ensure this.
Acute visualization strategy
One of the key ways to spot endometriosis is through the angiogenesis and inflammatory process that takes place in the peritoneum. Your surgeon should have an understanding of these types of medical nuances to ensure that they can identify both atypical and typical endometriosis lesions. One way to ensure this is by changing the color spectrum of the peritoneum by using hydro-floatation with contrast color and retroperitoneal distention. The surgeon can then visualize endometriosis lesions that they would otherwise not be able to detect by standard laparoscopic inspection. We accomplish this by using Seckin’s Aqua Blue Contrast Technique – ABCT™. Using our trademarked technique, we are able to identify all forms of endometriosis lesions visible to the naked eye, thus ensuring the excision of as many endometriosis lesions as possible.
In cases of advanced endometriosis, where pelvic architecture is deformed and organs are fused in various degrees of adhesions, excision surgery can be more difficult and complicated than most cancer surgeries. However, it can still be successful if an expert laparoscopic deep-excision surgeon performs it. He or she will perform the ultimate reconstructive task of meticulously and painstakingly debulking endometriosis lesions to restore the pelvic anatomy.
The skill of the excision surgeon is most important when it comes to the repair and reconstruction of organs where the deep infiltrating disease was. No surgeon should attempt endometriosis excision surgery if they have not mastered suturing techniques for bowel and bladder repair.
Endometriosis primarily involves the pelvic peritoneum. This is the thin transparent lining that covers multiple organ surfaces of the rectum, sigmoid colon, ureters, bladder, ovaries, tubes, and the uterus. The endometriosis excision surgeon must be comfortable operating on the superficial surfaces and deep layers of these non-reproductive organs. Not infrequently, the intraoperative discovery of DIE lesions of the bowel, bladder, and ureter requires delicate repair of these organs. So, an experienced and skillful endometriosis surgeon and his or her endometriosis team must perform the surgery.
Many surgeons’ preferred method of surgical removal is laser ablation or fulguration. Both of these methods look to “destroy” endometriosis whether by means of laser beam irradiation or heat produced by high-frequency electric currents. However, by conducting these types of destructive surgeries, the surgeon is not fully removing all endometriosis. Moreover, he or she is also jeopardizing the surrounding healthy tissue. In addition, by destroying the endometriosis scar tissue specimen, the surgeon loses the opportunity to formally confirm with pathology that the believed scar tissue does, in fact, contain endometrial tissue, thus confirming endometriosis.
We believe that it is crucial to treat your body with the sensitivity and care it deserves. This includes providing you with a thorough and complete diagnosis along with treatment. Thus, our expertise in excision surgery coupled with our strong sense of teamwork with the pathology laboratory allows us to harmlessly remove all suspected endometriosis lesions and confirm a proper diagnosis.
Post excision outcomes
A patient’s recovery period after endometriosis excision surgery will vary. A woman who undergoes a three-hour surgery will likely recover much more quickly than a woman who has an eight-hour surgery. Our goal with every patient is to have them out of the hospital within 24 hours of surgery. We believe that it is better for patients to be moving around and getting their strength back at home rather than in the hospital.
We never promise a patient that her pain will go down to a specific level. No doctor can guarantee a precise result with any treatment. We do not perform miracles, and there is no magic here. We cannot control a woman’s pain. However, we can promise our patients that we will remove each adhesion and as much endometriosis as we possibly can, while not removing any organs unless it is absolutely necessary.
There are some rare instances where a patient’s symptoms resurface. We videotape all our surgeries so that we can review them if necessary. This is especially helpful if a patient’s pain comes back. Your surgeon will review this videotape step-by-step with their team to discern why you may still be experiencing pain. We always do our best to ensure that patients receive the individual care and treatment that their body needs.
We pride ourselves on having a low rate of patients with symptom recurrence. Our surgeons work tirelessly from the very first time you walk into our office to fully understand your case. However, no one knows your symptoms better than you. Through open communication with our patients, we are able to come up with a proper diagnosis and treatment plan to ensure the highest chance of symptom relief. We cannot tell you how many patients come to us after having multiple surgeries elsewhere, only to have minimal symptom relief. We want to work with you in order to ensure Seckin MD is your final stop in the path towards endometriosis pain management. The first step towards this goal is effective communication.
Non-surgical ways to treat endometriosis
Primary care physicians will often prescribe medication before referring patients to a referral center. Some patients find relief with medication, while others do not. It is truly a case-by-case basis. Nevertheless, these drugs usually only provide patients with temporary symptom relief at best. But they can be useful when taken following a thorough and successful excision surgery to ensure full symptom relief with a low risk of return. Thus the following medications and methods are additional treatment options that can be helpful pre or post-surgery, instead of substitutes for surgical treatment for endometriosis.
Painkillers are most often the option that many doctors and patients elect to try first to provide temporary pain relief. Nonsteroid anti-inflammatory drugs such as ibuprofen are the most common. Doctors may also prescribe narcotics in more severe endometriosis cases. However, they come with the risk of dependency and addiction and are not suitable for long-term use especially if the patient finds that they have no effect, the pain has gone away, the side effects are worse than the symptoms, or they need to take a higher dosage.
Progesterone antagonist (hormone therapy)
Progesterone, a hormone released from the ovaries, has changing levels that dictate menstrual periods. Because a high rate of retrograde menstruation is one of the primary causes of endometriosis, controlling this process through progesterone agonist drugs can be very useful, especially in cases of fibroids. These hormones can be oral medications, injections, or even as an intrauterine device (IUD) such as the Mirena coil.
Birth control pills, most of which contain the hormones estrogen and progestin, prevent a woman from ovulating. Taking these pills can reduce the heavy bleeding that an endometriosis patient may experience during her period. This will also decrease retrograde menstruation, a probable cause of endometriosis.
Like medication, a diet that works well for one patient may not for another. If your body is telling you that it does not want a certain food, you should remove it from your diet. Generally, endometriosis patients should consider cutting out inflammatory foods from their diet. These include white sugar, dairy products, common cooking oils, trans fats, deep-fried foods, processed foods, red meat, alcohol, and wheat. Instead, you should opt for antioxidant foods (berries, pineapple, etc.) and organic foods.
Acupuncture is a system of medicine based on energy flow concepts and the body’s need to maintain homeostasis (physiological balance). Pain caused by endometriosis produces an imbalance in the body. While we are in no way stating that this method can rid the patient of suspected disease, acupuncture can be useful to relieve symptoms. In fact, several scientific studies showed that this method can be effective in controlling endometriosis-associated pelvic pain and infertility.
Women often discover they have endometriosis when they attempt to conceive. For women looking to have children at some point in their life, it can be very useful to freeze their eggs early if they have a family history of endometriosis or are concerned about fertility.
Drug therapy and endometriosis
Women and girls often have to “manage” endometriosis discomfort with powerful painkillers and hormones. However, both of these merely mask the disease.
Doctors often mislead these patients to believe that by suppressing the symptoms they are treating the disease. This generally results in the disease progressing—the symptoms become worse and no longer respond to medication.
It is true that drug therapy can offer some symptom relief but it does not help correct the underlying problem. Drug and hormone therapy has consequently caused many women a long delay in effective diagnosis and treatment. This has led to many “hit or miss” surgeries with high recurrence rates and, sadly, thousands of unnecessary hysterectomies. The definitive treatment of endometriosis is NOT hysterectomy or ovary removal, but instead the complete excision of the disease.
Why is excision surgery better than other forms of surgery?
Endometriosis excision surgery is better than other surgical methods because other methods are destructive in nature. These techniques, namely laser ablation and electrical fulguration, are ineffective because they don’t remove all of the endometriosis. With these surgeries, most patients have their pain return in less than a year. More importantly, these methods do not allow confirmation of visual diagnosis by a pathologist. This is because the tissue is not actually removed, but destroyed. What makes excision surgery the most effective way to treat endometriosis is that it does not zap out the tip of the disease, as laser surgery does. It does not burn the tissue either. Rather, it removes the inflammatory tissue from its root. In addition, the surgeon not only removes diseased and damaged tissue but also skillfully reconstructs organs and restores their functionality.
Is deep excision surgery common?
At this time, only a handful of doctors perform this type of surgery. Learning and refining the procedure requires extreme experience, knowledge, time, precision, dexterity, and patience. Expertise in performing endometriosis surgery requires the ability to treat unintended consequences and complications. It is also imperative that every endometriosis surgeon has the precise skills to suture and tie tissues and to return an organ to precisely where it should be. The organs must also function well after surgery. In sum, the skills required include not only the technique but also meticulous bleeding control, suture repair, and reconstruction, and restoration of organs. Because of the great expertise that is necessary, few surgeons are capable of performing deep excision surgery. Nevertheless, it is still the most successful form of endometriosis surgery. So patients should seek it out for the highest chance of symptom relief.
What is the difference between excision and resection surgery?
Resection surgery is the removal of diseased tissue. But the procedure does not confirm that all diseased tissue has been removed. Excision surgery, on the other hand, ensures the complete, border-free (i.e. not leaving anything behind) removal of scar tissue. The phrase, “border-free removal,” is important to take note of, as resection surgeries often do not ensure the complete removal of diseased lesions. This is because they cannot guarantee that the diseased tissue has not spread to the surrounding borders. This is one of the primary reasons it is so important to find a surgeon who can ensure complete surgery and not just resection surgery.
How is pathology used in this type of surgery?
One of the most critical aspects unique to deep excision surgery is the confirmation of an endometriosis diagnosis by a pathologist. Unlike other forms of endometriosis surgery, this surgery preserves the removed scar tissue. This way, that it can be given to a pathologist, who views the sample under a microscope. The pathologist reports the extent of inflammatory changes caused by endometriosis including border-free status (i.e. whether anything was left behind). He or she can also assess whether there are cancerous changes in the endometriosis cells. The detailed description of where these are taken from, their size, and the number of specimens removed may reveal the tenacity and skill of the surgeon. The pathology review is an important point about the quality of surgery verifying the completeness of the procedure.
What does “laparoscopic surgery” mean?
Laparoscopy enables a surgeon to visualize the abdominal/pelvic cavity using an instrument known as a laparoscope. A laparoscope is a long, thin tube with a telescopic lens, multiple light sources, and a miniature video camera. This device is inserted into the abdomen and pelvic cavity through 3-4 small incisions. The video from this device is projected onto a large monitor set-up on the other side of the operating table. This way, the surgeon is able to see a clear image of the abdomen and pelvis while they operate on the patient.
What makes excision surgery so successful?
A recent study from Sweden suggests that patients with endometriosis who were treated with excision surgery had a reduced incidence of ovarian cancer compared with endometriosis patients who did not have excision surgery. Similarly, controlled studies have proven that, compared to other surgeries, excision surgery offers the best outcome for pain relief and a positive impact on quality of life. Whether treating something as significant as frozen pelvis or as small as a single peritoneal lesion, the gold standard is to excise the disease without leaving any endometriosis behind. What is being excised is the inflammatory tissue of the peritoneum with its peripheral and deep scarring extending to small nerves and capillaries. Additionally, only the excision technique can address the treatment for all symptoms of endometriosis. These may include dysmenorrhea (painful periods), dyspareunia (painful sexual intercourse), dyschezia (painful bowel movements), and leg and back pain with menstruation.
Can excision surgery “cure” my endometriosis?
This is a great question for clarification purposes. There is no cure for endometriosis. However, there are treatment options that can help relieve symptoms that many patients report has drastically improved their quality of life. After receiving the proper surgical treatment for their particular case, many patients have found relief from symptoms such as painful periods, GI abnormalities, painful sex, painful bowel movements, and in some cases, infertility. Nevertheless, endometriosis treatment is a field that still requires a great deal of research. That is why there is never a sure guarantee of symptom relief when treating endometriosis.
What else should I look for in a specialist?
In order for an endometriosis excision surgeon to utilize their skills for treatment, they must first be familiar with all appearances of endometriosis. Typical lesions are quickly visualized with varying colors from red to black. However, they are always outnumbered by atypical and microscopic endometriosis, which is not easy to recognize. Inexperienced surgeons who do not practice endometriosis excision surgery may miss these occult and deep lesions. The angiogenesis and inflammatory process that is also taking place in the peritoneum must be recognized in addition to the typical and atypical lesions of endometriosis.
Ready for a Consultation?Our endometriosis specialists are dedicated to providing patients with expert care. Whether you have been diagnosed or are looking to find a doctor, they are ready to help.
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Dr. Seckin is an endometriosis specialist and women’s reproductive health advocate. He has been in private practice for over 30 years at Lenox Hill Hospital with a team of highly skilled personnel.
Dr. Seckin specializes in advanced laparoscopic procedures and is recognized for his expertise in complex cases of deep infiltrating endometriosis of the pelvis. He is particularly dedicated to performing fertility-preserving surgeries on cases involving the ovaries.
He has developed patented surgical techniques, most notably the “Aqua Blue Excision” technique for a better visualization of endometriosis lesions. His surgical techniques are based on precision and microsurgery, emphasizing organ and fertility preservation, and adhesion and pain prevention.
Dr. Seckin is considered a pioneer and advocate in the field of endometriosis.