Most know by now that the smaller incision, the less pain. Because pain is sometimes the primary issue, we must learn more about pain, including how to examine patients and choose the right procedure, in order to treat it effectively. Sometimes surgeries are successful; however, the patient may have other underlying organ conditions that generate the pain and that may not be recognized prior to surgery.
When I graduated from Tufts University in 1985, and then went on to my ob/gyn residency training at Albany medical center in New York, my experience taught me to remove the uterus if the patient struggled with the pelvic pain for more than six months. Not only was I trained this way, but my patients often demanded surgery as well, in order to alleviate their suffering. As my practice in Ohio grew in the early 1990’s and my interest in laparoscopy increased, I learned to excise endometriosis, which I thought was the cause of my patient’s pelvic pain. Many of my colleagues continued to perform ablation surgeries, but I noticed I was having much better results. Why?
After many years of laparoscopically excising endometriosis and performing laparoscopic hysterectomies on my patients, many of them would return to my office several months or years later with the same or similar symptoms. As I researched this I discovered that endometriosis usually coexists with painful bladder syndrome (Interstitial Cystitis), which I began to call “the evil twins of pelvic pain.” Research showing that pain may sometimes actually be Painful Bladder Syndrome or other pelvic pain generators such as pudendal neuralgia—were more common than we once thought. This is the “evil family” of painful pelvic diseases, and some require surgery, others don’t.
Before I understood this, I felt very inadequate and was continuously discouraged by the outcome for my patients—because they all had reoccurring pain symptoms. As I traveled around the world, I fortunately had excellent peers in SLS, the minimally invasive medical society, and I was able to ask them, “How many of you have done multiple laparoscopic surgeries for patients with pain and have found little to no endometriosis?” Many experienced surgeons raised their hands in the room. I continued to ask, “How many of you have removed pelvic endometriosis alone or within the uterus for treatment only to have the patient return with pain?” It became obvious from peer feedback that removing the uterus or performing surgeries was not always the answer.
Indeed, a fast-track protocol to relieve pelvic pain is not always the answer. We want to eliminate pain quickly for our patients, and that is understandable. But here is a case in point: A brilliant surgeon from Puerto Rico diagnosed a patient for endometriosis, and was ready to operate. But when he shared the complex case with me, we discussed other options for the patient’s symptoms. He preformed bladder testing and followed my treatment protocols. In the end, the patient’s improvement was immediate and obvious. He is now more open minded about surgery as a result. In this case we avoided surgery, which is sometimes more helpful to the patient, especially one who has dealt with multiple surgeries. After all, we must question, “Why do they keep coming back?”
When all other issues have been ruled out and the problem is endometriosis and surgery is the answer, in that case I turn to the laser or I make the smallest incision possible, using the smallest trocar, in an effort to try to avoid both post-op pain and residual pain for my patients. The outcome also determines the level of pain.
We now know that majority of the time the surgeon is not able to excise the endometriosis because of their skill set, so they turn to ablation surgeries. Hence we fail and we end up with residual disease. Because of this we know that specific training and credentialing is the answer to this common problem. Further instruction for this complex disease is key, for both effectiveness and because we can cause even more pain from continued surgeries and the scaring that inevitably comes with them. This is where learning how to make smaller incisions using smaller instruments is critical. At SLS, we have been committed to teaching these methods and I believe it will pay off. At MIS Week this year we trained hundreds more surgeons in minimally invasive surgical methods.
Of course the least invasive method is no surgery at all. We need to learn more about pelvic and other kinds of pain in order to get it right for our patients. SLS is collaborating with IPPS, the International Pelvic Pain Society, so that we can understand, teach and spread the word about eliminating or lessening pain for our patients and decrease the need for multiple laparoscopies.
We can learn that sometimes we need to dig deeper into the diagnosis.