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- Good morning. I am Dr. Devin Garza.
I'm a private practitioner here at North Austin medical center, Women's Renaissance group, and I've been in private practice for the last 25 years.
I'm here in Austin, Texas, my favorite town.
And today we're going to be talking about endometriosis, pelvic pain.
And what I like to do when the groups are small, and by the way, we're recording this today.
So this will be lots and lots and lots and lots of people will be able to see this for a long time to come.
What I'm hoping to do is to bring some perspectives of awareness of sensitivity, not only to the medical community, which we had a meeting this morning, but we're also to the public and be able to have kind of a increased perspective on what does this mean perhaps for you, or what does this mean for your family member or someone else that you know.
The lecture I'm about to give you, I just gave I'm using the same slide deck.
I'm gonna use some of the same language and some of the lines I'm gonna change a little bit.
So I make sure everybody understands it.
But I'm also going to talk about it from the perspective of a doctor who works with this every single day.
Part of my practice is kind of evolved around the use of robotics.
And that's gonna be a little bit of the lecture.
Really I'm not gonna try to teach you how to use one.
What I'm gonna try to do is let you know why I think it's very helpful and how that particular tool allowed me to do better care for my patients.
That's a lot of what today's going to be about, but we're also gonna talk a lot about endo.
We're going to do question and answers and I can't give you a full consult today or anything like that, but I can help on some of the most common questions that I would hear.
So we're gonna talk about.
We have some videos to watch what we're going to do.
The question and answer session.
We're going to describe and discuss endo and the role of endometriosis in pelvic pain.
How that is, why that is, what we do about it?
And then, how does the robot help that stuff?
Okay, so I always start with this slide because it's my perspective.
So who's giving you the talk.
I've heard your perspective on where you're coming from.
Not to talk a lot about me, but just to let you know, it wouldn't be the same lecture coming from somebody else necessarily.
This is a sunrise in Hawaii.
My wife and I love sunrises, I mean sunsets, and so sunrises typically she may not want to wake up for.
It's the exact same thing I think is beautiful.
And I think it deserves a lot of attention and she doesn't.
So my perspective on endometriosis and, my patients and my tool kit in my clinical skill set, isn't the same as everyone's.
And this is my perspective on how I'll give this talk today from a robotic surgeon and why I do robotics.
We'll talk about that a little bit.
But also as someone who really likes to take care of trying to be a champion and a hero for their patients.
Most of us like that, we want to do that.
It's just a matter of your ability to manage that type of stuff.
So pelvic pain, right?
Pretty much something you guys are familiar with seeing your family members with, or seeing yourself in the mirror, or at some point in time, realizing that there is a lot going on here.
There's so many different possible things.
But the one thing I'll always tell my patients is, I'm not sure why your doctor said this, but I can almost assure you, It is not all in your head.
Raise your hand if you've had anybody ever say that to you or in some form or fashion, look at you like that.
That's what we see a lot of.
And the problem is maybe that they love you fine, they care fine it just as very likely, they don't have a good understanding of this kind of a tip of an iceberg phenomenon that endometriosis can be.
In a patient's mind, they don't know what it is.
Sometimes they can't really describe it.
Well, I mean, doctors and their families we're patients as well, right?
We're also patients.
And so being able to help your doctor with your symptoms is key.
So as other patients or endo sisters ask about how do I talk to my doctor, just say be as articulate as you can.
When does it hurt?
What makes it better?
What makes it worse?
Is there any bowel symptoms involved, anything a bloating, diarrhea, constipation?
Anything with your bladder that's involved, any blood when you empty your bladder, when you urinate?
Does it hurt during your cycle?
All the information is very, very valuable to your physician.
From the gynecologic causes of pelvic pain.
You may have been to the ER.
I bet if you say raise your hand, everybody's gonna raise it.
But going to the emergency room and you're diagnosed with pelvic inflammatory disease, when really the diagnosis doesn't fit that.
Another thing is the bladder issue that we talked about.
But an ovarian cyst, can mimic certain things.
And so your ER doctor may say, well, it's just a ruptured cyst, even though they didn't find a cyst, they didn't see a lot of fluid on the ultrasound to support that.
They're just gonna call it something.
Mittlescmirtz is that kind of pain you get with your ovulation or ovulation pain.
It means pain in the middle.
So mid cycle pain, when you ovulate, that can be, if you're not on something, that's gonna keep your ovulation under control or prevent ovulation like the pill or something like that.
Or they'll say it's just adhesions.
And those things may be true, it's just that you can't just say it's black and white, one thing or another and they all may be to some degree kind of combined.
Plus endometriosis can cause symptoms in all of these areas.
So we never say it's all endometriosis, but always understand that the endometriosis can affect all these other systems.
And it's not easy to tease these diagnoses apart.
When we talk about it endometriosis patients frequently have lots of questions.
I mean they're like, what is it?
How do I, why do I, it, how did I get it?
What am I going to do about it?
How do I get rid of it?
What about getting pregnant?
All those things are valid and they're very important and it's not black and white.
It's not a cookie cutter approach.
Although there are protocols and systematic ways of going through this type of stuff from your doctor's perspective.
Common symptoms of endometriosis are the chronic pain components, right?
Chronic, that means you've had it for multiple months, four, six months.
Definitely painful sex, deep, not kind of entry pain and not the kind of pain that's just once in a while, even though that's still possible, it's that deep pain almost every time.
And honestly your doctor on an examination, if they can reproduce that pain, it's so likely to be endometriosis, so likely.
That's frequently the initiating factor that I will decide to take someone back to surgery for, to actually diagnose it.
And we're going to talk about that in a minute.
Pain with your menstrual cycles, not a couple of Motrin and you're good to go, but debilitating you're out for four hours or you can't make that party or you're out for two days.
There's, variations in how this can look for any woman, but highly, highly suspicious in patients that have this type of stuff.
Painful bowel movements all the time, maybe, but for sure if at your cycle things can get worse and it hurts when you have a bowel movement, stabbing pain, you have to tell your doctor that.
It points in my mind, I see images in my mind because I've seen them so many times of what that's probably going to look like.
And I want to get the appropriate physician, a colorectal specialist, or a general surgeon there to help manage the bowel aspect.
So it's important to let your doctor know as many symptoms as you can possibly detail.
Less common, but not unrelated, but can be certainly endometriosis are going to be nausea with your menstrual cycle, bloating.
Does that mean you have endometriosis on your GI tract?
Maybe. Definitely. Maybe, but it can be a secondary symptom as well.
Bleeding when you empty your bladder, when you urinate, you actually see blood that's really, really important.
Could it be a kidney stone? Sure.
Could it be just a terrible urinary tract infection, a hemorrhagic cystitis we call it? Maybe.
But it needs to work up.
It needs to be evaluated and you need to tell your doctor, all these things.
Rare. Okay.
So people always think once I have endo, they think of it in a former fashion like cancer.
And to some degree, I understand that.
And I treat it kind of in that way, from a perspective of trying to remove all that I can.
That's true, but it's not like cancer spreads as commonly.
I want to make sure to give you perspective on this kind of stuff.
It's not common to have endometriosis on your diaphragm.
It doesn't mean it can't happen, it absolutely can.
I have met those people.
Every month you drop a lung or part of your lung drops.
You can't breathe.
It's really, and it's in the literature.
It certainly is.
It requires not only your gynecologist would typically be very, very unequipped to manage that, but a thoracic surgeon with your gynecologist with lots and lots of preoperative discussion so.
Difficulty breathing, pain breathing your lung drops on a monthly basis, other organs as well.
Not likely that you're going to get endometriosis in your brain, okay.
So a headache if you have endometriosis, you wouldn't think I've got endometriosis in my brain.
It's so rare and uncommon.
It would be very, very unfortunate and it can happen.
Can doesn't mean that it probably will.
So I want to ease some of the tension on that type of stuff.
Yet if the workup has continually been negative and you have endometriosis, you need to present that as a potential, okay.
That's still true.
When we talk about endometriosis from the, what is it exactly?
What is it?
OSIS refers to a condition.
That's just the word that we use for condition, a situation.
And the glandular lining of the uterus is called endometrium.
So endometrium in a condition where it lives outside the uterus is where we get the term endometriosis.
Common sites.
We just kind of mentioned, for the most part, you all know this, but the most common thing is going to be the pelvis.
And why is that?
Because pelvis is shaped kind of like a bowl, okay.
It's the floor and your fluid that lubricates all of the abdominal organs, peritoneal fluid is what that's called kind of rest at the bottom of the bowl for the most part, even when you're on your back, it rests for the most part in the abdominal, I'm sorry, in the pelvic cavity.
So if your intestines are for the most part, moving they peristals, okay, they move a lot.
It's not likely you're going to get endometriosis on your small intestine.
It's not very likely it can.
It's just not likely.
Especially there's rare setups where you have larger intestines are stuck anyways, so your bowel is not really freely moving.
so that can happen.
It's just not likely.
Way more commonly your symptoms are coming from pelvic issues.
And that's going to be the ovaries on the ovaries, in the ovaries, the lining of the sidewalls.
So if we're in the abdomen at this moment, the dry wall here is called peritoneal lining.
There's a lining so that we don't have like the pipes, the electrical, all that stuff showing, right.
Those are your organs that are behind that.
The carpet, same thing, it's a lining to the abdomen.
And that just is place where you'll get most often the implants to occur.
And they cause pain because the peritoneal lining has nerve endings, okay.
They're not real specific.
Like if I close my eyes and pinch my wrist, I know where that is.
Inside if I were to pinch your ovary, you may feel that down your leg.
You may feel that in a very general sense, even in your back.
The back part of the uterus, back part of the vagina, the innervation of the nerves there will be towards your back, okay.
Not specific exactly to where these things are located.
Your hip might hurt if the endometriosis is anywhere near that on the peritoneal lining.
So that can radiate.
We call that not radiation, but it radiates pain.
That's not even where the pain is.
Or the actual inflammatory process.
The inflammatory process is elsewhere, but it feels like it's over here.
Fallopian tubes, bowel, bladder, appendix, make sure who still has an appendix by the way of the endo sisters here?
Okay so, endometriosis can, with advanced endometriosis, you can have upwards of a 30% likelihood of endometriosis on the appendix.
So these are things to kind of talk to your doctor about.
What about my appendix?
Less common areas we talked about, the diaphragm, lungs and brains is much, much, much more rare.
So how many people have that?
Well, everybody in this room for the most part, but it's important to understand the general population, how do they even come up with that number?
Well, it's incidentally at this surgery for a different reason, they saw endometriosis.
I don't know who was making that diagnosis, but what I do know is a lot of people don't recognize endometriosis.
I tend to think it's a lot higher.
It doesn't matter.
What it matters is in patients who are in fertile, the upwards of 40% may have endometriosis.
In patients who have chronic pain, which is the base this whole talk is mostly about upwards of 80% of women with pelvic pain, especially some of the ones I'm going to tell you about chronic painful sex, painful bowel movements, especially at your cycle and debilitating pain with your cycles, right?
Upwards of 80% have endo it's a lot, okay.
It's a lot.
So what some of this stuff really is more, I would call it a bit esoteric, but it's important to understand, where does it come from?
And give me some perspective on that.
Is there a genetic role?
Well, it's complicated, okay.
I think there certainly is.
And there's lots of literature to support that there's a genetic element.
A first degree, relative, by the way, it's your sister you have upwards of about a 30 to 40% likelihood of potentially having it yourself.
You may not respond in the same way, but that's important.
Twins, identical twins, studies on identical twins, high correlation between those, both of them having endometriosis.
Did it come from embryologic tissue as I was forming?
And that's now just being expressed.
Probably there's some degree of that.
We think there are, cause it would explain the patients who don't even have a uterus.
How do they have endometriosis?
That would explain that.
Especially with the background in your genetics of having some predisposition for this condition to develop.
Hematogenous or lymphatic, like it goes through your bloodstream, all these places or through the lymphatics, which drain the kind of the fluid aspect of the blood.
Yeah, there's some degree of that.
Some studies would agree that there's part of that too.
But to be honest, I have so many patients that come in and they just want to throw this retrograde menstruation theory out the window.
I don't think you should, I think it's extremely important.
And it does help us on how we manage you in the future.
Why they put you on the pill, why they want to stop your menstruation, why would a hysterectomy help you in some way, form or fashion?
And why would it not help you in some way form or fashion?
But what retrograde menstruation means is that your uterus is a large muscle.
And as your uterus, squeezes out the menstrual fluid, the tissue also comes off of that, the lining.
So partly blood, partly tissue, but it also squeezes up your fallopian tubes and into your abdominal cavity, mostly there in the pelvis because that fluid generally rests in the pelvis.
We see this.
This is a very typical finding when we go to laparoscopy, especially at a woman's menstrual time.
The fluid from that, that's a laparoscopic picture.
The patient is on her back in surgery and for us to do surgery, we have to put you in a tilt so that if this is your legs, and this is your head, we tilt you back like this so that your intestines fall out of the way up towards the diaphragm, so we can see otherwise it's like looking in a big bowl of spaghetti and meatballs.
And you're trying to look at the meatballs at the very bottom of the bowl, you can't.
So we have to tilt you, and that's what that's for.
With the patient tilted on not on her head, but about 30 degrees, that's still in the pelvis.
And so I'm trying to express to you why that these things affect your pelvis so much is because typically that's where the stuff rests.
And why it implants genetic, sure.
I mean, I can't overestimate how often I've seen patients.
My mom had it, my sister has it, but not necessarily, right.
And then why it hurts some women and other women it's an unknown.
It is an unknown.
But it has something to do with genetics.
So when I try to describe the endometrial lining to patients with the endometrium, what I tell them is it's like this, the inside of a cantaloupe is very different than the part of the cantaloupe, the fruit part that we would eat, okay.
This is the uterine lining, and we always draw it like, it's a big cavity.
'Cause we call it a cavity.
It's not really a cave.
Exactly. It's closed.
It looks more like this most of the time, not that thick, but estrogen causes this to be thicker.
Like if we, this lining here, but progestin or progesterone make it kind of thinner.
So there's this interaction between the menstrual, I'm sorry, the uterine lining, okay, and the hormones.
I know that didn't show up too well, I'm sorry.
But in the earlier phases of the, you just had your menstrual cycle here.
This is the uterine lining and the uterine lining begins to thicken with the estrogen buildup.
Then once you release an egg, it kind of stabilizes.
So the uterine lining is undergoing these changes based on hormones, okay.
This isn't a woman, not on the pill or anything like that.
This is natural.
And then once the body determines you're not pregnant, what happens is all of those hormones essentially fall to a level so low that that uterine lining is no longer supported in the uterus.
What happens?
It comes out.
It starts to come off of the side of the inside of the uterus and the uterus will contract it so the fluid comes out with the blood.
So imagine this happening.
but the endometrial tissue is living outside of the uterus.
It's still responding.
It doesn't know it's in the wrong spot and it doesn't respond normally.
Things happen and things happen to the tissue where it's implanted.
So we know that what happens over the course of time is inflammation.
So I always tell patients think of your eyelash, your eyelash is normal, your eyelash falling onto your cornea, your eye it's two normal tissues, but they don't belong there.
What happens? It becomes red inflammation happens.
So it's inflamed, it hurts.
Now the inside of your pelvis is not as sensitive as your eyes, right?
But think of that process, it's not like a infection.
It's not like cancer tissue, it's normal tissue that implanted.
And if you don't take that out or off, it's always going to cause that.
It's always going to cause some degree of inflammation.
Inflammation leads to fibrosis.
Fibrosis leads to all of these things can lead to in certain patients, a lot of pain.
So what we know these pain mediators, and I'm just going to give you a couple lot of studies on this type of stuff, the prostate gland and cytokines.
Inflammatory chemicals that lead to and cause pain, more blood flow to that area happens that shouldn't be there.
And then the fibrosis that occurs and this hyper vascularity and all of this leads to things, getting stuck.
Adhesions begin to form and they can be very, very dense or they can be very, very filmy.
We know that locally, the estrogen is way out of proportion to what it should be in those areas.
Okay. In those areas.
And that could be the genetic aspect involved with this.
We also know, and this is a very important one for everybody in this room, especially your friends or your family or educating women with the condition.
The nerve, what we call growth factors, certain things that happen, maybe because of your genetics.
I don't know.
And this implant you couple, all those things we talked about, we put them all together, but we know that the density of the nerve itself will thicken, okay.
So I tell patients, it's like, you had dial up speed, right, real slow.
You have some issue going on in the pelvis slowly that tells your brain something's going on down here.
And for example, if you fall and scrape your knee or you land down the steps, funny, what do you do?
You grab your knee, you grab your thigh, you grab whatever it was.
And you put pressure on it and you rub a little bit around it, right.
That's a reflex.
And that reflex happens because what it does is it floods your brain with more, what we call afferent signal, which means I'm doing something here that I perceive here.
And I'm flooding the pain, fiber sensation that are going from that injury to my brain.
But you can't do that in the abdominal cavity.
So it just hurts.
It's like leaving that eyelash on your eye and you're doing nothing about it, okay.
Over time, what happens is this the nerve density, because of this whole situation, you start to develop a T1 line that leads to your brain.
Now it may not be that big a deal.
So let's say stage one or stage two, which I see all the time, but you're incapacitated.
Are you therefore a wimp?
Is it therefore all in your head?
No, it's neurochemical okay.
It's neurochemical, and these have been shown in studies.
It's real, okay.
Why in one person and not another, we do not know, but it has to do something with genetics.
Is it all about genetics? No.
Is it all about the overproduction of estrogen? No.
It's all these things together, okay.
Knowing this helps you to know why we do certain protocols of management.
So you go through this kind of cyclic process where you have this tissue begins to proliferate under your own hormonal stimulation.
And then you get more vascularity.
The vascularity brings in more of these and sends more of these inflammatory signals.
It just, it's a fire that catches on, okay.
This is the kind of the pathogenesis summarize to you in a way I think you can understand it, which will help you kind of make some sense out of it.
Yeah, but you know, I just want to be out of pain, right.
That sounds great Dr. Garza, I just want to be out of pain.
I know.
Just make it go away, whatever.
But management always depends on the diagnosis.
And then knowing that pathophysiology behind it will help you to understand why we choose certain management options.
So we talk about, you guys have all been diagnosed, but we talk about kind of this working diagnosis, a presumption.
Well, I think you might have endometriosis.
Can we mask these symptoms or should we mask the symptoms?
That's another way to look at it.
And there's a couple of instances where I don't mind masking symptoms.
As long as the patients know, that's what I'm doing.
I think we're going to try to talk through endometriosis for a minute.
'Cause I think you might have it.
16 year old, who is losing schoolwork every month because of her pain.
Obviously teenagers, I've had four of them, go through their ups and downs and moods, but there's something different going on here.
And so, unfortunately I don't get to see all those young girls who were suffering through endometriosis until their parents finally bring them in.
And then we start to talk through this and give them an idea of this is a real, it's very possible this is what she has.
But it's the middle of your school year?
I don't think we'd interrupt her to do surgery.
Why don't we at least mask the symptoms of her cycle to get her through?
I think that's very valid, very valuable.
I'm not running away from it, I'm happy to operate.
The thing is, does she need that surgery?
Well, I don't know how bad it is.
I don't know the propensity for that causing infertility or not.
I don't know if she's going to lead to chronic pain or not.
I don't know any of those things, but we talk through it.
We talk through it and now she's got an advocate, a doctor.
And then when is it time for surgery, right?
When is it time for surgery?
We talk through that.
If in her case, the pills not working, it's time to do something.
If she develops chronic pain or somebody comes in with chronic pain.
If there's GI or intestinal or bladder symptoms, we're going to want to work through that stuff.
We've gotta want to kind of make sure I get the right people involved ahead of time.
In case when I get there to surgery, we need an additional type of surgeon to go work.
I'm not telling you the 16 year old is sexually active or anything.
But if someone comes to me with painful sex deep, there's no waiting, there's no necessary wait whatsoever.
If I can reproduce the pain that she's been having, not one time.
I mean, we want to rule out and assist and we're going to go through workup and an ultrasound and imaging, et cetera.
But if the patient is coming and tell me, I just, we can't have sex. It's been getting worse.
I do an exam, I feel that even if my ultrasound is negative, which most of the time it will be because you don't see and know on an ultrasound, unless it's in the ovary and once a blue moon, if it's awful, if it's awful deep, infiltrating endo.
So that person's going to go back 'cause I'm 99.99999.
In fact, I've never seen it where it isn't endometriosis.
And then if imaging, you see someone with pain with an endometrioma, a cyst that looks like there's endometriosis in it.
You're at risk for that ovary twisting on its blood supply and losing that ovary forever.
And it also is an immediate indication that the patient has a higher level of endometriosis.
So those people all will go back for surgery.
What are we going to do?
Well, we're not just going to take a look and buzz, buzz, buzz, buzz, buzz, okay.
We are going in with the ability to see a sensitivity of what it can look like and then wanting to get that eyelash out of your eyeball, right?
We are going to take that inflammatory causing issue out.
That is excision is what that means.
Looking at a laparoscopic evaluation.
So you're under anesthesia.
Everybody here has actually had surgery, I know that.
When you look, not everyone can recognize what endometriosis can look like.
So that is, a skill set that takes some time or surgeons who train under places, where they can help you to see these things adequately.
But, I'm just telling you, from going into residency 29 years ago and moving through residency, most people, most docs don't have the ability to be able to tell the difference sometimes.
And there's ways of doing that.
And the robotic platform going to tell you, I think is a big boost in that.
I always also say you have to believe in the patient's symptoms and believe in everything I just told you about already, which is all of the literature obviously to know that you have to hunt.
You have to look carefully.
You have to look very, very closely at the tissue, but also have a willingness to know that you have to know your anatomy and be able to remove this tissue from wherever it's at.
Okay, so the American Society of Reproductive Medicine has a staging classification, one through four, mild, moderate, severe, there's all these very, very important kind of esoteric for the patient I think.
Value points that give you whether it's mild, moderate, severe stage one, stage two, stage three, stage four.
But for you just to know, stage four doesn't mean more pain.
In fact, for someone to develop stage four means they were probably pain-free for a long time.
If someone has horrible pain and they're 17, I'm pretty sure I'm going to see stage two or three active stage two, stage three is for some people incapacitating, absolutely debilitating.
So for you just to understand, yeah, we do have classifications, but it doesn't mean your symptoms correlate with the severity of your disease.
And we don't know why that is, we don't.
Genetic? It's not because of you.
it's something that's going on at that level.
These are, if you haven't seen it and maybe you've already done lots and lots of research on it by this point, but this is what it kind of looks like to us.
This is a very close inspection with a laparoscope.
And this is not as pretty as it would look even on regular laparoscopy or for sure robotically on 3D high definition visualization.
But these are implants.
They're red, the tissue around here, it looks fairly normal.
It doesn't show up real well, but you could see there's some fibrosis or it's a little bit whiter, thicker around those areas.
Same thing here, a little easier to see.
These are what we typically call powder-burn lesions.
Some of us think that those probably don't even hurt.
They're not active anymore most likely, but remember all those changes going on inside the uterus.
Now the peritoneal lining has covered these lesions and this happening within these little, almost kind of a capsular type of effect.
But this is also abnormal.
Do you see this tension distraction?
So if the endometrial lining has nerve endings and this implant is on my jacket right here, but it's doing this to the rest of the peritoneum, if I was only to vaporize even with a laser or, or whatnot, or cut out just that little bitty segment, I'm not doing anything to the rest of this tension.
And so patients can still be in pain by virtue of that.
These are things that aren't really clear in the literature, but I have seen it so many times over and talked to lots of other docs, et cetera.
That we do a wider area resection, when we see areas that are abnormally puckered, thickened, changes that are due to chronic inflammation, all of those things.
We want to interrupt those afferent pain fibers going to your brain.
Here's a little bit worse, right?
You start to see these kind of pockets form.
You start to see, remember this is normal, right about here.
That's normal stuff, maybe normal right around in here.
This stuff is all abnormal, all of it.
And you have to kind of look back a bit to see where is anything even normal?
Much less, if we look in there and we think that's the only abnormal finding is that big, giant one in your face.
And that this stuff is from some other condition.
Well, what other condition can it be from, right?
Does it hurt?
This would cause somebody to have very painful sex and very painful bowel movements.
That needs to be resected.
But it sounds easy.
It sounds easy.
But when you start looking at stuff like this, here's the uterus and I'm not bringing you the worst things I could possibly find.
I'm just giving you a gradation of what I see all the time.
This can hurt worse than this, okay.
To get that view is a 10 times zoom on a little area, right about right there, okay.
It's not that easy.
Someone with this on the ovary, if you were to ovulate, it would not go very far out of the ovary because of all these adhesions.
This kind of a net around your ovary.
You can't know that until you look.
You can't even begin to treat that until you look.
But when you start finding things like this and this here's your uterus, here's an ovary with big endometrioma in it.
Here's another ovarian cyst.
Or it might even be the fallopian tube.
Here's the bowel, okay.
One wrong move in here, and you can end up with a colostomy the rest of your life, okay.
That's why docs tend to be very careful with you, right.
So I don't wanna throw everybody under the bus.
I just wanna make sure you understand.
It's not as easy as waking up saying, did you get it all?
Most of the time I can say, yes, I got as much as I could find was abnormal.
But when you start having organs connected to each other, the bowel to the ovary, I can separate that.
And then we can take the surface of the abnormal stuff off the side of the peritoneum.
'Cause you don't need that, it'll reform back.
But if we start taking this stuff off of your bowel, you run the risk of serious problems with your bowel.
So just so you know, it's not like we can't do a lot, but there's limits, there's limits to what we can do.
Okay, we direct our management, therefore for the most part.
We're not talking about infertility right now.
We're talking about pelvic pain, pain, pain, pain.
With your symptoms, do you want to get pregnant or do you not want to get pregnant?
I use this little segment to make sure everybody knows that nobody has a cookie cutter.
If I would ask everybody what you've had done, we heard a little bit, but it may not exactly fit for everybody.
And if someone who likes to have a hysterectomy done, because they're done having kids, we're going to talk about that.
What else do you do?
Do you just take the uterus out?
What does that cure?
We'll talk about that.
If they want fertility and you see awful endometriosis, if they don't have pain, it may well be that you don't have to put them at risk of the surgery to take things off of their bowel, to take things off their side wall.
And they will probably get some degree of an infertility assisted reproductive technique, IVF, IUI, that type of stuff.
But for the patient in pain, that's a different thing.
Patient in pain needs to be managed for her pain.
Age of the patient's very critical.
Failed treatment very, very critical.
Severity of your symptoms.
So another time where I kind of say, listen, we have endometriosis, I saw your op note, it's diagnosed.
How bad does this bother you?
Are you losing quality of life?
How much?
And if they're saying a lot, I mean, significant.
It's enough for me to say, let's go back and let's do what we can.
If the other side of the coin as well.
I mean, it hurts a little bit when I do this, it hurts a little bit when I do that, I'm okay to say, well, why don't we just watch and see how you do, you may never need another surgery.
Happy to go in if things get worse and you think it's time, I think it's time, you've got the condition.
That's a difficult conversation for another person to have, who's not that same patient.
So it's unique, your treatment is unique.
Surgical of course is the cornerstone around which you build all the rest of your post-op.
So perhaps we'll talk a little bit about it.
Lupron, we'll talk a little bit about progestin, some form of suppression, pain management, all of these things have a place.
Massage therapy, acupuncture.
We are all holistic people.
We're mind, we're body, we're spirit.
All those things matter.
When you've got one thing affecting you, it can affect everything.
Conversely, if you affect everything, you can help affect that.
But in my mind, it can't take the place of surgical visualization and excision.
That's where you build everything from, okay.
I know this is confusing as it could possibly get.
But when you have that conversation individually, based on what your history has been, then it can make more sense.
So is there a place for all those things?
Yes, of course there is, of course there is.
Is it black and white, all of one and not the other?
No, it's not.
Okay, so if fertility is not desired, you're done, you've had your kids, God willing, or you're 36, you never planned on having kids for whatever reason.
That's all up to you.
What is the hysterectomy cure?
So early on in your diagnosis, you had an emergency hysterectomy, sort of, I'd like to hear a little bit more about that.
Is just it'll take care of your cycle.
I mean, I promise it'll do that, but what it doesn't do is take care of your chronic pain.
Will it prevent new endometriosis?
Well, from what I told you earlier, you won't have retrograde menstruation anymore, but you can never be 100% certain you have every little weed pulled in the garden.
That's what I say.
I always say, look, we'll get the big stuff.
I'll even then go down and get the little stuff.
And I've done this so much that I know how to get the little bitty, bitty, bitty, bitty, bitty stuff, but I can't see below the dirt, okay.
And conceptually, there may always be a little bit of endometriotic tiny little areas that because your system has now been hyper regulated towards feeling and sensing pain, it doesn't take much to cause that pain to be severe.
And that's true.
So ovaries, we talk about, yes, the stimulation from the estrogen will still potentially cause that growth of any residual endometriosis, but you probably won't need surgery again.
That's probably true.
You might, and you might get endometriosis in your ovary.
All those things are true.
But for the most part, most of us don't want to take a 32 year olds ovaries out without a really long discussion that 32 year old will undoubtedly or 28 year old or whatnot will undoubtedly have a lot of hot flashes and night sweats.
And so at some point, trying to help her from, for that whole holistic person, that's still there for Lord knows how long we'll likely be replacing hormones, the same hormones, basically.
So it can cause your endometriosis to recur from a pain perspective.
But these are steps you take a little at a time.
My main thing is to tell you, it's not the absolute Trump card I hate using that word, but it's not the absolute thing to pull out your hat.
Okay, it's time for a hysterectomy I'm done.
So Laura, would you mind sharing a little bit of your history and what we've been through?
- [Laura] Sure well first off thank you for doing this.
And having us all here today because this is really important.
I wish that there had been something like this, or I had known about something like this years and years and years ago.
I would like to say that while we all live different lives, where there is that sisterhood is that our stories are, I think pretty similar for what we go through with this.
And that's where we bond in it.
My journey has started about 20 years ago and it was very frustrating in the beginning because I didn't have anyone listen to me.
I did have doctors kind of try to tell me it was in my head or maybe it was this or that.
And something just didn't feel right to me.
And so I kind of just kept pushing and pushing for answers and finally, I had a laparoscopy and was diagnosed with a stage three.
I believe it was when I was 23 at the time.
And I just knew that the pain that I've been experiencing was not norma, it just wasn't normal.
And you know that in your gut.
So it's been a very long road and I actually did.
It was interesting when you just said that there was a period where you could go without pain, if you have severe endometriosis.
And I think that's what happened with me.
I had my surgeries.
Non-surgical things that we did, the Lupron, birth control, progestin, all of that stuff I did made me feel horrible.
I felt melasma, I had dark spots on my face.
It was just, it was a nightmare.
And so I kind of gave myself a break.
I stopped taking the pill and I wasn't doing anything to manage it, but it was weird, 'cause all of a sudden it's like I had no pain.
I started working out again, I ran, I lost 50 pounds, I felt amazing.
And I thought, I don't know, maybe I've got this under control.
I don't know.
And then slowly but surely not only did the pain come back, but it came back in just a horrifying, debilitating way where there were days before I had my surgery, four weeks ago that I couldn't get off the couch.
I mean, it was like someone hit me with a metal baseball bat over and over and over again.
And it's very hard to explain to your friends and other people that you can't join them for things because you just say you're tired or you're not feeling well.
And so you learn to mask all of this and hide it from everyone because you have to function in life.
You have to go to work, you have to do normal things.
And people don't understand how exhausting that truly is when you're in pain constantly.
And so through my journey, I've been so blessed to have fallen in the hands of Dr. Garza.
And this surgery is, this last surgery has been for me, kind of like a lifesaver because my whole life was at the worst it's ever been.
And I had the hysterectomy, we kept my ovaries and he had sized the endometriosis and I was had Menorrhagia.
Is that how you sat it? - Hmm hmm.
- [Laura] very severe bleeding.
So I would bleed very heavily and I would have cycles two or three times a month.
It wouldn't be like spotting.
It would be like I would start a cycle all over again after being done with it for three or four days.
And so I was experiencing anemia pretty bad.
And I had no energy lifting my legs to go to up the stairs at work, it was just, it was the most excruciating pain on the planet.
And so I think what I'm coming to find is that there is a community of women that can support each other, which I think is amazing.
And that there's so much more that has been learned about endometriosis from when I started my journey.
I felt very, very alone and I have felt very alone through this whole thing.
Even though there's so many of us that are going through it, it's just not something openly talk about.
You don't go to happy hour and say, let's discuss endometriosis.
- Which we could.
(people laughing) - [Laura] We could, absolutely but-- - And how are you feeling now?
- [Laura] Wow, that's I think the biggest thing.
So I got so used to living in pain, that I didn't know what life was without it anymore.
It just, it was my normal.
And so I had no concept anymore of what life was like without pain.
And so after my surgery, which was on four weeks post off, I would say it was about the third day when I was kind of moving around a little bit more that it was just, it was like the clouds parted.
And for the first time in almost 20 years the sun came out.
And I was like, I had an energy that was natural.
It wasn't brought on by coffee and 5-hour Energy and a certain type takes my allergies, like whatever I could take to get my energy, it was normal energy because I felt good because all of that disgusting stuff was out.
It was amazing.
And I feel great, I feel wonderful.
Thank you Dr. Garza.
- You're welcome.
I don't bring someone here with a good story to tell you that everybody has the perfect story.
That's part of this also, but it's educational for this patient and many, but for Laura I wanna show, she said it was okay if I showed you a little segment of her surgery, 'cause I just want to show you a few things that maybe you don't ever really get to see in the context of somebody who just had it done.
And I thank you for that, by the way.
It's always way more powerful.
All right, so we looked at some images of endo.
And I'm just going to skip through this.
This is real time, but I'm just gonna skip through it.
Here's endometriosis all over her ovaries on the left.
Here is chronic longterm scarring and puckering like I was describing to you.
And you can tell I was going to make a teaching video out of this anyway, because I'm pointing to the tissue, but just showing you what's abnormal.
This is pretty normal here.
That tube looks pretty normal.
All of this is abnormal.
That's all endometriosis over on the top of the ovary.
The ovary's stuck to the sidewall here.
But remember what I was telling you behind the dry wall here are electrical and plumbing.
So I can never just take a buzz saw to the wall here and not expect to hurt something.
Same thing in her body.
Same thing with your surgeon.
That's the way they would handle it as well.
So I'm not going to take you through the whole hysterectomy.
Just kind of go through this real quick.
I want to show you when we get to the endometriosis part, this is a little bit just vaporization of the surface of the ovary.
So you can't undermine the cortex of the ovary, you can't.
You can resect the stuff that's big off the ovary quickly, but the ovary itself doesn't undermine.
So you can't resect the cortex of the ovary.
So that is something that if your surgeon says, I am resected and vaporized, maybe they vaporized the surface of the ovary.
That would be the only place.
Everything else is resectable and you take it.
This is robotic instrumentation.
You're going to see more videos in a second, just to demonstrate stuff for you.
This is scissors.
And you'll notice that the instruments will articulate like a hand.
They move this way.
And that's, what's different between the robotic platform and the non robotic platform.
This is the bladder taking the bladder down here and scissors, and we also use cautery to get through the tissue so it doesn't bleed.
And I'm going to go to this area here on her, the backside of where her endometriosis exists.
So we are going to have to open this space here, to get down, to find a critical structure called the ureter, which is a tube that goes from the kidney down to the bladder.
And that structure in and of itself is enough to help, to make a lot of doctors, not want to get into that space because they don't want to injure that structure.
I just happened to have had enough.
I teach anatomical cadaveric work to lots and lots of advanced surgeons for many, many years.
And so I've just had that blessing and privilege to be able to have an additional amount of training and practice to do that.
This is doable.
It's just, it requires certain tools.
In my mind, you can do it with a regular laparoscope, but the robotic one gives me better wrists to be able to do that.
So what I'm doing here is I'm going to take this whole segment of that abnormal tissue that I showed you a second ago.
And I'm pushing all of the normal stuff out of the way, carefully.
The robotic tool kit I'm going to show you in a second.
But this is what it looks like to go the extra distance to take this additional endometriosis and scarring with the hysterectomy component.
So this is resecting endometriosis along with doing a hysterectomy, okay.
Very, very delicate work at the end of which we have a large segment that's been removed out here.
Let me see if I can show it to you.
There you go, so this is about to be finished.
All that abnormal cells is going to come with it.
What happens to this stuff, is it heals over very quickly within a day or two, that area will heal over.
We use some materials to help things not get stuck to it.
There's little techniques that we use to help things avoid getting stuck.
So her rectum is right here below all of this, that stuck.
And so you have to open spaces to get these areas that are abnormal removed along with it.
Here's the rectum.
So you gotta be really careful in this area here.
So we're going to open that and then resect it.
So these are things I don't think you get often to have someone kind of just at least give you an overview of how this is not as easy as taking an eraser and erasing this abnormal situation.
It requires really intense care, not to injure structures that are nearby.
This looks fairly normal.
But the other side still had some other things to take care of, which basically looks the same as that.
Close magnification, look at my scissors had a wrist articulate.
It allows me to get very precise movements, very slow and no tremor on the instrumentation.
This is that ureter I'm talking about.
It goes from the kidney to the bladder.
Very careful, right.
But you can be careful and you can be very precise.
Okay, then the rest of it gets done.
So thanks Laura for letting us show that.
I think it helps diffuse a few things in your mind about not just a hysterectomy.
What does that mean?
It's a black box, they take out a uterus, no.
How does everything actually look when you're there?
Okay, so the perspective of management, we talked about this it'll definitely take care of your painful cycles.
It will not manage painful sex.
Doing what I did in that video doctors that will do that, and you talk to them about that, right.
I'm not the only guy that can do this, right.
But you want to make sure and talk to your doctor with this stuff.
How comfortable are they?
Will they have another surgeon available if necessary?
All of that kind of thing.
Excision is also required.
And I think that we made that point pretty well.
Just so you know, if your doctor says something or you hear this or whatnot.
Well, I don't think it's that big a deal.
That resection stuff is still kind of out there.
I don't think everybody really does it. That's true.
Unfortunately, that is true, they should.
And this is data.
Data.
Data.
Data.
Data.
Data.
and that's not all of it, okay.
That's with colorectal literature, gynecologic literature, urologic literature, and fertility literature, lots of studies have been done for quite a while, okay.
So it's a team approach.
The team approach.
If you have terrible bowel movements, stabbing pain, you should make sure your doctor's gonna have a colorectal specialist available.
We have so many people here.
I could call anybody at any point in time, but I usually like you to see the doc ahead of time, or at least know that you could.
And then a colorectal specialist or a general surgeon, at least either on standby or they come in and take a look.
But normally it's your gynecologist that's going to help them know what's abnormal.
Cause they don't, you know, they take care of so many other things related to endometriosis until you prove to them, remember that patient we did this on?
Remember this picture? Pain-free.
Remember this patient you did this? Pain-free.
And they start to believe in it as well.
So a lot of what I'm doing today is to try to help the medical community believe because I hear everybody that comes to see me and other doctors as well not just me.
It's the same thing.
You hear that story over and over and over.
Postoperative management, it depends on who you are, what your symptoms were.
If all you had was painful sex and we black and white resected it, you don't have pain anymore.
You're trying to get pregnant.
Why in the world would I put you on Lupron or hormones?
Lupron unfortunately has a horrible reputation on any blog post.
And people will have all kinds of side effects that they may have had.
So I can almost tell anybody, look, it is the gold standard, but I know it's going to feel bad or there are some side effects.
But it's still in the literature as the gold standard of being able to suppress your ovaries.
So there's no secretion of hormones for a little while.
Is that still the best thing to do?
Are there options? Right?
We always say, well there's options and the options frequently, some of the best ones, if you're not trying to get pregnant, obviously our progestins.
Some form of a progesterone.
Remember I showed you that graph, on that graph that showed you the endometrial lining and buildup.
You want it to be thin and you want it to constantly be thin that lining because that's the same thing as is happening in these other little endometrial implants.
So that's why an estrogen progesterone it's still okay because a low, low, low estrogen dose, by the way, your ovaries are still making estrogen.
So don't think they're not okay.
when you're on a progestin otherwise, you'd get hot flashes and night sweats and stuff.
But a progestin with a low dose estrogen, you're constantly getting the progesterone and that's what matters.
So for some women, if they're on a progestin only they start breakthrough bleeding a lot.
And with a lot of breakthrough bleeding, what happens pain whenever you're bleeding.
Remember, even though we took out the endo, that central nervous system or that nerve fiber development that occurred, okay.
What happens is your master level for many women the way worse than others, but your master level of your brain is set for a sensitivity that you can't undo for a while.
It takes time for that master sensitivity level to kind of start going back the other direction where a little bit of endo can cause severe pain, okay.
You have a T1 line and it's not just the areas that we resect it's hard to express clearly, cause no one knows the answer.
But breakthrough bleeding can cause a little bit of a, I mean a little bit of breakthrough bleeding can cause a lot of pain in these patients because they're very sensitive still.
We still have a uterus, we still have ovaries.
We still have everything in there 'cause they're wanting to get pregnant or not even not wanting to get pregnant yet.
But if we put on a progestin only, and they're bleeding, I will put them on a low dose estrogen because it'll help the breakthrough bleeding and they still get the benefit of the progestin constantly.
So that's why you might see why doctor chooses one thing or another.
Pain management options.
I'm very much opposed to somebody being on narcotics, for the rest of their life if I can do something about that.
And so I will frequently get patients who come in, who have been they're on pain meds forever.
I can't magically, no one can magically do the greatest resection in the world and expect their pain volume level up here in their brain to just shut off and be off of narcotics.
It doesn't work like that, it would be great if it could.
And a lot of patients I've worked on have now come off of narcotics, that's true.
It's a process, okay, it's a process.
But there are, certain types of nerve blockades and making sure where that pain is coming from and all of those things that are very, very helpful that I don't understand the pain pathways well enough to speak into that.
But be mindful if you're going to see a pain specialist that you've heard all this stuff we've talked about and that pain management is something that's going to go on top of the cornerstone of good resective surgery, okay.
And it's not the only thing.
It's not the answer.
It doesn't cure you.
We just want you to be able to function as much as, as well as possible as normally as possible.
For pregnancy, even IVF will have better rates after resection of endometriosis.
And certainly we know that stage four endometriosis your tubes can be so distorted and everything can be so distorted in the surface of the ovary.
As you saw, even on Laura's video can be so covered with endo that you're never gonna ovulate through all that stuff.
But let's say there's none of that.
It's a stage one or two it's still can cause infertility.
Exactly why we don't know.
Maybe the sperm don't function as well.
There's a hormonal milieu, or a neurochemical, chemical, prostate gland and all those things that are in high level and high volume there, can affect the eggs ability to do what it's supposed to do the tube to do what it's supposed to do.
We're not sure studies point to all of these things, but we're not sure, we just know that it's better.
Now let's bring up the robotic platform.
Why does this make a difference in my mind?
Is every robotic surgeon equal? Absolutely not.
Not every artist is the same artist either, right?
Not every singer is a good singer.
It's not really exactly the song itself, right?
There's a study actually called not the song it's the singer, but it can be a tool, a very useful tool to help you navigate very delicate dissections.
What we've all wanted to be able to do is to get away from a big incision to put in these smaller ones on there recovery's faster.
You've all had laparoscopy, basically quick recovery, quick in, quick out.
And then get what's needed to be done, done that you could have done open, but you can do better I think on the robotic platform in these tiny little spaces.
We don't always make tons of incisions.
Sometimes we make one.
For endometriosis frequently, it's at least three.
And we'll talk about that.
Thank you to Intuitive Surgical and thank you to the CONMED people who do things in surgery that allow us to do our surgical work, okay.
So that's very important.
These industry is very important for us to able to get our stuff done and they're hosting today, so thanks.
So with just laparoscopy, regular laparoscopy, most docs find limitations I certainly did.
And I did this for 15 years, at a pretty high level.
But you have a limited angle of approach because your instruments are straight.
So you're coming in at straight angles.
You can do this, but you can't do this, okay.
So you have a limited angle of approach.
It's difficult to suture, if you need to suture.
You can, it's just, it's harder.
The precision is diminished because of these things.
The camera is only 2D, which is kind of like the videos you're watching.
You only see it one way, you don't see depth very well.
All of that decreases the precision.
And the reproducibility on complex cases makes a vast difference in laparoscopic surgeons who do really, really, really, really high end stuff.
Like one of the doctors we had this morning and then kind of the traditional group of the bulk of laparoscopic surgeons.
So it's not very reproducible.
With the robotic approach, what we get is the precision that's made by instruments, having wrists.
And you know, I don't have a tremor in my hand, but when you're on 10 times magnification and you're trying to do surgery with what we call micro instrumentation, up close, what you see is this kind of a movement it's just a heartbeat.
You can see it move with your heartbeat.
That's absent on a robotic platform.
Even when you're 10 times zoom working really, really close.
The camera in this case is high Def, ultra high Def by the way, and it's 3D.
So depth perception is unbelievable.
It literally is as if you're in the body operating and you're up this close or this far, however you want to be.
That's what we call microsurgical ability.
When it's 10 times zoom.
This is what it looks like.
If you're not familiar with it, this is the robotic roll-up carts.
This comes to the patient.
These are the arms you don't use them all every time.
Camera is operated by the surgeon.
So where I want to look, I push my foot in the camera will go.
Where I want to use my right hand, left hand.
I can use two right hands if I want that.
So there's variations in our ability to use the instrumentation.
Again, it's a tool.
It's a toolbox.
The vision cart, this is where the energy is.
This is what the assistant is looking at.
Who's next to you while you're on the table.
And then where the surgeon sits is inside this console.
So what this view here is the 3D of what's going on here.
The arms are operated here, fingertips.
So you have fingertip manipulation that will then translate into the tips of the instrumentation they're very small, in the exact same kind of like a puppet.
They're right aligned with that.
So if I do this, my instrument goes like this.
On the floor, that's a camera pedal.
These are energy pedals.
So if you need to touch coagulate with electrical cautery which you saw me do on that video.
I was going to explain it.
I was gonna says wait vaporize.
So that doesn't bleed and then cut it.
Vaporize so it doesn't bleed, dissect it gently lift away from the abnormal stuff, cut it.
Her whole blood loss on your case was less than five CCS.
It's like squirt an eyedropper on your palm of your hand.
This is the, it looks menacing, but it actually, it all comes up.
And at the very tip of all of these, the instruments move with very small, fine movements.
This is the patient on the, I mean, this is the patient here for example, it's not really a patient.
Here are the instruments going in.
None of this moves unless the surgeon moves.
And the only things that are going to move is the very tip of the instrument inside the patient.
These arms move only slightly to get the angle.
There's multiple joints at all of these areas.
It has been around now.
We just came up with a we I get to see it.
The fifth iteration of this, which is phenomenal.
I mean, these things are amazing.
The technology keeps getting better.
There's the console.
There's a surgeon sitting in the console.
I'd love it if they could just put a little coffee holder right there.
So it wouldn't, you know, that'd be the best day, but you can't bring coffee in the OR.
This is what we call single site.
So everything in this case goes through the patient's belly button right there.
So you don't even see the incision.
We can do full hysterectomies on this kind of stuff.
It's amazing.
I was one of the very privileged six people to help develop this for the use of gynecology hysterectomy.
I mean, it's just, it's amazing.
They want the input of experience.
So this is kind of all put together.
It's not fake 3D like your television.
It's literal 3D two cameras, a right eye and left eye.
It's what we would call software enhanced surgery.
So software enhanced means I'm here between me and your tissue, there are certain things.
One of them is software.
And that software allows me to be more precise.
This is true size instrumentation.
That's not, either in the giant's hand or anything like that.
This is some of the most fine tools that we have.
For example, to do a reversal of a tubal.
Somebody had their tubes tied and we want to put their tubes back together.
We call it a tubal reanastomosis it requires suture like your hair, but we're able to do that with these very tiny instruments up close tine, suture, like hair, it breaks in your fingers like this, okay.
If I was to do that with my fingers, this way I could break the suture with this much ease yet we can precisely tie that suture down.
What it looks like in the room when you have a dual console.
So I will frequently have surgeons come in who want to learn how to do whatever it is that we're operating on that day.
And I'll just teach a doc and they can watch, with exactly what I'm seeing.
They're not gonna operate of course, but they can watch.
We train residents.
Or in the case of my sister, she had an enormously awful, massive complex hysterectomy.
Her doctor and I worked together literally together.
Yet we're not at the patient's bedside.
We're in the same room and this is all connected.
And we always have an assistant by the side.
Simulation yeah this is something that will allow your doctor to be able to get like a captain of an airplane.
You have to have certain simulation hours logged in with a verification of what you can accomplish the way it's supposed to be done well.
And so there's validation on how your surgeon can operate.
And these are things that are part of the robot only truthfully.
Alright, briefly, we mentioned this earlier in my, this was mainly for the doctors this morning.
I think probably you would be convinced if I just told you that you look at the technology, it makes common sense, but trying to move from the laparoscopic world to the robotic world, I help train those doctors.
I've done that for many, many years.
I was one, right?
I was one, I don't know, 10 years ago at this point, no 11.
And so I helped them get past their learning curve more quickly.
And so I'm going to go through this more quickly than I did this morning because you guys probably don't care much, but the reality of it is the robot has made a big difference in how women can get minimally invasive approach to their surgery, it has.
We know that it can be complicated in gynecology it can be simple.
But the cases I showed you of that endometriosis to get all that stuff done, that's not simple stuff.
And so what happened over the course of a period of time is the number of cases back in 2000 and kind of four or five, where we had to do surgery through a big open incision, compared to what we do now has plummeted.
In other words, more women have access to a minimally invasive approach than ever before because of the robotic platform.
This is a study I happen to be very privileged to be part of that came out last year in February.
We basically compared seven of us who were high volume robotic users to a massive database of about 10,000 of experienced laparoscopic surgeons.
Traditionally, the way we all used to do it.
And then our vaginal surgeon or an open surgeon and everything we looked at basically was better robotically.
So don't let anybody tell you there's no studies or that it's experimental tons and tons and tons of data.
There's over a thousand studies at this point.
This just happens to be one that I was associated with recently for gynecology.
In our group at Renaissance women's group, the orange is what you want to see.
And over the course of these years, using robotics specifically, we were able to take our rate of opening a woman down to only one out of a hundred or less than that.
We do a lot a surgery, I don't do them all.
I do a lot, but that's a very big thing when we do a lot of complex work.
So the robot has been proven over and over again.
People always ask about, but it's so complicated, it's so costly.
You guys don't care about that.
And you shouldn't the reason you shouldn't is because your insurance covers a robot, the same as it covers a laparoscope.
I don't get paid more to use a robot, I don't.
I can do a better job and I can do more complex work.
The insurance companies don't pay more to the hospital for a robot.
So just know these things, right?
Know these things.
This is just showing you what I used to do.
Complex work compared to robotic complex work.
I'm actually less expensive.
So my data, just things, my perspective, right.
All that stuff.
I do a lot of lecturing on this type of thing that I'm always happy to take questions from any doc any time and especially patients.
This is what it would look like for a robotic port placement.
So don't let anyone ever tell you, well, they're gonna have to put a bunch of dots all over your tummy, it's not true.
It's not true at all.
This is what it normally looks like.
And then sometimes if it's really complicated, we do have to add more, if it's complicated.
Normally we'll use the camera.
We'll use two little what we call cannulas.
That's where the instruments go through.
These are the typical instruments we use.
This is just something to show you that it's only available on a robot it's called Firefly.
And I'm going to just kind of briefly mention what it does, so you understand the technological advances that are available, robotically.
The camera itself, emits a laser.
You can't see it, it's not going to harm you, but that laser will excite certain radio immunofluorescent, isotopes that you're given a couple of CCS or less in surgery.
And then we're able to see endometriosis turn up bright green.
So these are ways of helping other doctors.
This is what I use to help doctors see what endometriosis can look like.
So I don't use this every single time.
If you were to ask me, I did for a while just to get an idea of, wow.
even, I didn't know that it could look like that.
And then when you do enough of that and the biopsies come back, confirming whatever endometriosis fibrosis inflammation, you start, you're a believer and you just do more and more and more and more and more.
I'm going to close with just a little bit of video on resection and then all QA after that, or none.
If you want to go home and eat lunch, okay.
You guys have been great.
You've not fallen asleep.
And that's like my number one thing.
So this patient 24 had a prior laparoscopy was told, didn't have a whole lot and from this area that you're looking at right now, from this depth up real high in the abdomen, it doesn't look like a whole lot.
Although I can already see a little bit going on already.
The goal is to get closer.
And with 3D you're able to get not only closer, but you're able to see these abnormal areas right here, that this is normal tissue.
See that right up there?
Smooth glistening, all of this kind of rough, we call it trabeculated fibrotic tissue, that's not normal.
This little defect right there, that's not normal.
All that's caused by longstanding endometriosis.
This is all very active.
That's pretty normal.
This whole area is not very normal, okay.
So all of this would need to be excised, but behind all that is very important structures, right.
Every structure in your body is important.
But the last thing in the world we want to do is cause you to have a complication.
So what is unfortunate, so many times that your doctor would not have gone after that lesion up there, or much of this lesion right here, because of this structure, which is the ureter coming right in that area.
So what I teach is for doctors to go to the abnormal tissue, assess how much it needs to come out and then assess what structures you could injure, and don't injure them.
It's very simple, right? Not really.
And so what we do is we're going to want to work around the areas that are affected, go to the area where that, for example, that ureter, which leads from the kidney down to the bladder.
And I was going to want to let that run just for a second.
So you kind of watch some of the, the technique, not that you're going to do this, but this is what you should expect, anticipate.
And that's, I think the best thing that we can do for patients.
So what we're doing is you see that wrested movement of my instrument, look how close I am with my camera.
I'm able to undermine this tissue away from the structures and cut just precisely tiny blood vessels.
These movements right here are capable on a laparoscope.
They are, but the angles aren't as readily, easy to manage.
And so knowing when to turn on your cautery, knowing when to turn it off, those are all pretty critical, right.
And so we're able to dissect in these areas to allow for the abnormal stuff, to be undermined and completely resected away.
And this is, debilitating pain for this patient.
The patient's already a ton better, but she may not respond exactly like another patient.
You never know until post-ops over.
This is the cornerstone.
This surgery, is the cornerstone on which we're going to build the rest of her management plan, okay.
You can't do the management plan from the outside and try to work your way back in.
Not in my mind.
It just doesn't work well like that.
This is overlying the bladder I believe.
We want to get just the abnormal tissue and not the bladder itself.
You don't want to then have to wear a catheter for the next two weeks, right.
So, but this is the technique.
And to have somebody kind of show you that there are delicate structures behind that veil of tissue that are literally less than a millimeter microns away at some point in time.
The ease with which you're seeing this done comes with experience.
And it comes with a robotic tool.
Knowing how to use that tool is one thing, knowing your anatomy is another.
And so again, I'm not the only person in the world doing this for crying out loud, but just knowing what you should be able to expect, okay.
I'm gonna show you a couple of cool little things.
This is, well, I'll show you this too.
This particular area here is where you have pain during intercourse.
Cause it's the backside of the vagina.
The uterus has lifted up up here right now, the rectum lives right here.
And so to get this abnormal tissue out, this abnormal tissue out is going to require entering spaces to push the organs out of the way.
Now you remember those other ones I showed you where everything was so stuck together you couldn't tell what was what?
Yeah, that's a lot harder than this.
But to me, this is easy.
Just believe in it, know what needs to happen.
Know your anatomy and take care of that.
The other ones I showed you are going to involve multiple surgeons.
Your difficulty in taking the endometriosis off of the bowel covering without causing injury to you, is it worth it?
All those things have to be weighed and measured at the time of that kind of a surgery.
But this is typically who I see people who are so painful that it's typically not so far gone stage four, because those patients with far gone stage four probably don't hurt as much because they wouldn't have let it go on that far.
At least in the United States, in the US, okay.
So all that comes out, that's what resection is.
It's what it looks like.
I want to show you that a ICG, just so you see that.
And this is again, only something that can be done on the robotic instrumentation at this point in time.
Maybe somebody other company will come up with it as well.
But for now, this is all that happens.
So I'm at the backside of our uterus, the bottom side of her uterus.
I'm really close, as you can tell, my instrument looks huge, right?
But remember it can fit in the Palm of my hand.
It looks so small, very close with the camera.
And all of these abnormal areas are starting to turn green, okay.
This area up here, you're going to see that in a second.
How it can look very subtle.
To me I know it's abnormal just by looking at it right there.
And you guys are pretty sensitive now with your eyesight, you can kind of tell, what looks normal, what looks abnormal.
And so knowing that you have another additional advanced kind of technology always helps to know you've taken all the best tools you can into surgery.
That's kind of the point of what I'm trying to tell you.
Okay, and then it just, it all comes out as well.
The structure right here, by the way, feeds the entire lower leg.
So to put a hole in that could be a very big problem.
The nerve that runs underneath here would cause you the inability to be able to move your right or your right foot inward or together.
So your anatomy and being careful with all that stuff.
That's what your surgeons are trying to help you with is to how much can we do without causing any harm.
And so we take out these larger heres these large sheets that contain all the abnormal areas.
That's all very hypervascular too much vascularity.
Lots of little tiny dots in here when I looked much closer.
So all of it kind of comes out.
So your surgeon that performs resection surgery, this is what they're trying to accomplish.
And I'm trying to help you to understand it's not as easy as it sounds.
This is the ovary, this is a laser.
We don't always use a laser, but we do when we need to.
It causes less tissue trauma.
It has good uses and certain limitations as well.
Most of the time, that kind of the section is mainly going to be done with scissors and a grasping instrument of some type.
These are endometriomas or endometriosis in an ovary.
What we try to make sure doctors understand is you can't simply drain them.
And what we call that quote, a chocolate cyst you've read about that.
Or you've seen that it's because that fluid looks like that.
It's just, that's what, when people refer to chocolate cysts, they talk about either a hemorrhagic cyst or an endometrioma.
That black stuff coming out like that, that's why it's termed that.
All of this is abnormal.
You can't just buzz, buzz, buzz, and go home.
You have to open this find the normal tissue, take the time, be careful and resect it.
This actually was one of my old nurses who was infertile didn't know she had endometriosis and has since had two kids, regular natural.
That's not everybody's story, but that's lots of stories.
Alrighty, well, the rest of this is, a ton of the same, but I've got hours worth of videos, probably days worth of videos for that much.
But I think the point to take home is that you're not alone in your endometriosis clinical scenario of whether it's pain or infertility.
There's millions, millions out there, and there's millions that have yet to be diagnosed or underdiagnosed.
And so raising awareness is important and making sure that you having these Facebook pages and these associations really that are helping women to know that they have commonality finding good docs.
Like I said, I'm not the only one, there's many good docs.
But someone that believes in it and someone that's equipped to handle it in my mind, it would be uncommon to find somebody that can do this regular laparoscopically, but there are.
I had a good colleague this morning that was there.
Runs the infertility whole thing here in Austin in my mind.
One of my good colleagues.
And he's good with that, but he's way apart from the most surgeons.
So I would think it would need to be probably robotic, very experienced, and then how much of this do you do.
And I'll ask those questions.
It's okay to ask doctors that stuff, even though they might've delivered your first baby, all that kind of stuff, okay.
Questions and answers go ahead.
- I have a question.
What is the best route to expect the physician to be able to properly diagnose the small intestine endometriosis?
- So we would be imaging, of course.
Do you see?
So MRI is not the best way to see endometriosis by, up so that you know that you can, it's just not very often, it's laparoscopy.
It really is going in and taking a look.
- You have to do diagnostic laparoscopy?
- Diagnostic and operative.
So it's not a diagnosis, and then they wake you up and say, Hey, guess what we found?
We found endometriosis.
It wasn't all in your head.
You're like, I knew that, did you fix it?
That's what you should say if that ever happens.
Now that it's okay for a doctor to get, maybe they'd bit off, a little more than they can chew, but what they should do is have the lack of pride to then say, I will now send you to someone else.
Don't be mad if you're in that.
That's the right thing to do.
Sometimes you're good at it, and then I'm not there yet.
And so that's okay, so they don't hurt you and then say, Oh, I got it all.
- I have a question, do you use any kind of dosage for adhesion?
- Absolutely We had a discussion this morning with our infertility specialist as well.
Anything's better than nothing I think.
There are variations in what works well and you have to use them correctly.
Some things like Interceed, you don't put it on there if it's oozy.
'Cause then it'll cause adhesions.
Seprafilm is another one that can be used.
There's one called adept, which is a fluid that has a starch in it.
So the water just stays in there for about three days.
So things don't get stuck because that sidewall is going to cover back over about 24 to 48 hours.
Not fully, but it'll cover over enough that things don't get stuck.
I will, we call peksi or temporarily place the ovaries up real high on a suture that dissolves in about a month so that they don't get stuck.
The bowels typically aren't going to get super stuck if you just do something and it's dry, not a bunch of ooze.
So it's a little oozy, it's not enough to hit me like hemorrhaging.
It's just a little ooze.
I will use a medication that's called a hemostatic.
It's a EVICELL is what it's called, which in other countries has an indication for not forming adhesions, but not in the U S cause the FDA has a lot of rules and guidelines on that.
But it's at least been shown not to promote adhesions.
So EVICELL is I use frequently.
There's another thing called AmnioFix.
And AmnioFix is an amnionic chorionic membrane, literally it's from the placenta.
And what it does is it's got a lot of growth factors in it and it's a physical barrier.
And then it'll cause quicker healing, less inflammation.
And the problem with that is that it's $2,000.
That's a lot of money.
And so do we use it on everybody?
We can't do that.
We can't it doesn't have studies that say it works well.
- You wouldn't use adhesions like laberian on everybody to prevent adhesion or you're just gonna follow the case?
- No, no, you gotta use adhesive barrier.
You should and make sure nothing's oozy 'Cause even laparoscopically, you're not going to form the same kind of adhesions as an open case.
Open case their oxygen getting on the tissue, Tissue you can get dry.
The tissue can get dry laparoscopically with the carbon dioxide as well, but you can just moisten it quickly.
But sponges, hands, gloves, trauma will cause the type of adhesions that people think about in terms of man, that is stuck.
Much less endometriosis can cause horrible adhesions.
I showed you some pictures.
So if I think that most of us use something all the time.
- That's a big one.
If they were to get rid of adhesion.
Or I guess they'd be thoroughly get rid of it I guess.
- You can, and again, if you laparoscopically, you can manage adhesions, but why are the adhesions forming?
So the hard part is when you have bowel stuck to the side like this, and you just take these things that are stuck.
Well, what about that stuff?
You just, you put the Velcro, you just pealed the Velcro part.
The Velcro is going to come back again, hard to take it off the bowel without putting you at risk of a bowel injury, which is a horrible thing, but you can take it off this side.
So if you take part of the Velcro off, hopefully that's going to help lack of a better way of saying that.
What else? - I have a question.
So let's say you have a surgery where the adhesion has formed to your bowels and your rectum, what is the possibility of it continually growing there?
Is there a possibility of that continuously growing there?
- So the question is, if you have endometriosis around your bowels and it's been resected or excised for the most part, if it could be, what's the likelihood that it can come back.
It always comes back to a couple of things.
What people think in terms of management, I forgot to say this treatment management.
And I did say you will base it on symptoms.
The question is, does the endometriosis come back?
And so in your mind, you're thinking if the endometriosis comes back, I'm going back to surgery.
If the endometriosis comes back, I'm going to have pain again.
Well, the endometriosis technically can come back, probably not exactly where it was treated, but whether or not it leads to you needing more surgery, is what we don't know.
Most of the time no, sometimes yes If it's not adequately managed was not adequately removed.
So depending on estrogen and ovaries, no ovaries hormones, no hormones, or even your own adipose tissue secretes, a weak estrogen called estrone.
And that aromatase activity is increased at the level of, of the endometriosis as well as in some patients, it's just the way it is.
So the long-winded reason I'm answering this long-winded is because it's not an easy answer I could have said yes.
But what does that mean to you?
What does that mean to you?
Yes, is the answer and having not been there to see how much was removed resected or left behind, it's impossible for me to say, that you're going to need something again or not need something again.
But to make sure you do understand that removal of the sidewall, sidewall pain, uterus, tubes, ovaries, all that kind of stuff is different than removal from the bowel.
The bowel is a, it's one thing.
Sometimes we, not me, but colorectal people will have to do partial resection of your bowel, because that's how bad it is.
And that's the problems it's causing you.
Same with poor women who don't have endo, but have other conditions.
Diverticulitis and Crohn's disease and stuff like that.
So it's not an easy answer, but the answer is yes, but the easiest, it's hard to say, what does that mean for you specifically?
- Okay its my last surgery, my organs were completely encased my lower intestine was, my rectum was as well There was a urologist, another general surgeon in there.
And you mentioned it, the blunt of the work.
- The what?
- The blunt in the work.
So they did most of the work as opposed to handling the bowel.
- Oh, gotcha gotcha.
- So I guess that was my biggest concern is it grew there it was there.
And that's one more thing I have to, and I guess this just kind of makes me, it confirms what I have endometriosis.
Thank you.
- I think I understand you, but you understand you and that's important.
I'm hoping I didn't throw anybody under the bus, but I feel like I did, so I'm not sure.
I tried to show you those really awful ones, because really there's, some of those are just so bad, you do as much as you can.
And then you regroup and say, listen, this is what's still there.
Cause we were worried that you'd have a colostomy.
And if you say, look, I'd rather a colostomy, get rid of this pain.
Well then you regroup with a colorectal specialist and all that stuff, and then that is possible for some women.
We just don't want to choose that for you.
So that's where we kind of draw the line in certain areas until we know that this has to happen this way because of this pain, we're treating symptom, your symptom has to warrant what our surgical process is.
So patients will frequently ask, what, if the endo comes back and I told you, I'm pulling weeds, right?
I'm pulling weeds, I got the little bitty ones.
I'm really good at finding those little bitty ones and not damaging the rest of the flowers, but I can't see it all.
I can't see the stuff that's below the surface.
And that's the stuff that you just gotta wait and see.
Is it going to come back? Well, it might is.
Do I need surgery? I doubt it.
But we wait and see.
Many patients will need more than one surgery, many.
Yeah Laura.
- [Laura] I have a question seeming a little bit off of hers as far as it growing.
So I know that it can recur.
My question is so when I go back to the very beginning and when I had my first laparoscopy too, and when I had my second one, my doctor at the time was quite amazed at how fast it regrouped.
So is there ever a change in that growth rate, for instance, I'm older now that was 15 years ago.
Could it be that something's changed in my body to where it's not going to go back as quickly if it does recur or that I have to be concerned about the possibility of it being another rapid growth situation.
Like it was way back there?
- Yeah it's a good question.
Only because I was there and I showed you, I really doubt that I was not sure of other ones, it's hard for me to comment.
It may well be the doctor loves you, did his best to take care of you doesn't believe that maybe enough was warranted.
And so to protect you for his good judgment, her good judgment, they just didn't excise everything.
And in that case, which would be a very, very common thing 10 years ago, 15 years ago, then it grew quickly just because it does.
Once it starts, where that cycle I was showing you early on that cycle starts to do this more vascularity, more release of the local hormone is abnormal more release to those prostate glands.
Yeah. I've seen, certainly I have, it's not something you did, didn't do time in your life or anything like that.
Probably just the natural process because of your genetics with the disease process.
- Can I add another one - Yeah of course.
- I can tell you from my own experience, when I first heard my surgery, I went five years between my first and my second.
I went four months between my second, my third, two years between the other two.
And then another one I had 2011 before I got married.
I then had two kids and I just had my last one, 2016.
So that's four years.
So depending on what my body was going through, where I was health wise, really depended on how long I had to go.
I give myself a two year average within that two years, I've been told that my body's down, whether I need surgery in two years, or I can go another year, depends on how I nervous.
- Take good care of yourself.
All those things are very important that whole mind, body spirit there's rest, that needs to be managed.
We didn't talk about it.
A lot of that stuff, but critical, whatever you need to reduce your free oxygen radicals.
I mean, come on, like you don't smoke, but I mean, people eat all of these things matter.
They matter for everything but needing new, surgery.
How many times am I going to need surgery?
It just varies. It really does.
It varies once it gets to a certain level, it's just hard to be final, it really, really is.
So we're always treating symptoms, symptoms, and it's always about the symptoms.
And when the recurrence.
- I have a very good friend.
She had her appendix ruptured when I never had a single symptom for endometriosis this entire time she's been working, we've worked together.
She saw everything I went through.
We didn't cover it up - Stage four.
- Never had an issue since.
(people laughing) I'd love to do that.
- I have a chocolate cyst, the size of Ruby red and I was working out twice a day.
Every day I'm talking, this was me 60 pounds ago.
And I was really going for it an hour, hour and a half.
Like I'm going to get that separate body, no pain.
And then all of a sudden I go to put my laundry halfway through the basket.
I couldn't stand up my stomach like that is it I'm sure something is rupturing, something is wrong.
I went to the ER and I was in the hospital for 13 days because I was fighting an infection.
I was up with that mask and that was how my hysterectomy came about.
- What was the hysterectomy for?
Why did he say you need to get it?
- My uterus was completely shut.
In my doctor's words it fell apart as she was trying to get it out my body, it was a regular surgery.
So she went to remove it because it was just, she said it was the point that it looked like, sorry, but it looked like raw meat.
Like ground beef like that, it was rotting.
- A lot of ventrilation.
I certainly don't have any details on that.
But that's a very dark case.
- She said it was definitely the strangest scenario she's seen.
- Yeah yeah I believe you.
I never said your case was the worst thing I've ever seen I've probably seen worse.
What else?
Good comments.
- I recently heard and obviously we're in touch with people around the world.
Everybody's getting their own information really.
Recently were grumblings of round endometriosis creating it's an estrogen.
- Yeah. That's that kind of odd.
What I would sum up on this slide is saying the endometrial implants outside the uterus don't function the same as inside the uterus.
Local production of estrogen is aberrant in those endometrial implants.
It's not normal.
It's under the stimulation of hormones.
And then the hormones come from the ovaries, of course, but there is some abnormal metabolism of that.
And so, what does that mean?
It always still kind of points towards dampen down the estrogen effect.
We know that already.
Where does some of these studies lead?
They're tiny little pieces of puzzles.
That one day may be something awesome.
I don't think it really is gonna, and there's markers.
There's markers for the endometriosis I think they've isolated something like, I don't want to say 350 plus markers that could be useful for endometriosis, but what do you do with that?
I just did blood test on you, you have endo.
Oh, what'd you do about it?
Well, you go in, you take it out.
So it's us still clinically.
We talked about that this morning and it was like, where are the snow and all that wonderful, cool, clear water comes out.
You're like, man, this is beautiful.
That's data information.
Some stuff that's just like, that's very important.
But then where it meets the salt water, like the patient, that whole brackish area there, that's where I live.
It's this is information, but this is what I have to take care of.
And it's not all pretty all the time.
You just go with what we know and what we know now is resection and a counter estrogen because of that, it just it's proving that now even more.
And then when they started looking at these nerve fibers, those studies that's what really is important.
In my mind those things are very important too.
But to help somebody know that you physically have different neuro mapping, well, what do we do about that?
That's, it's way over my head, but that's what pain specialists can now start to manage rather than narcotics.
- And that was probably one of the most interesting things that I've heard today.
Because when I went in, when I got pregnant with my first kid, I went into the emergency room.
I knew I was pregnant.
I was doubled over in pain.
I could barely breathe.
It was then my thought went to the pregnancy.
I need to get in and get seen.
Everything was fine and she came to me and she said, you are so in touch with your body.
And you're so in touch with what your body's doing, that what you're actually feeling is the implantation.
She said you just feel it to such an extreme that it's causing you so much pain where most people would go about their daily business not knowing as well.
And so when you said that, I was like, okay, wait a second that makes a lot of sense to me.
- I'm really looking forward to more of that kind of work being done along with what we're doing and gene if you know, for that matter, how do we turn somebody's gene off for endometrial that's just so far.
I don't think any of us will be alive at that point.
But there's also anti progestin effect in the implants.
So not just like the progestin effect that we try to give you progesterone, but the area itself has been shown to produce an anti progestin.
It's even harder.
It's like it's protecting itself to make this horrible vortex of abnormal, inflammatory process and nerve growth and all this kind of stuff.
It's fascinating obviously, but that's, it's not, it doesn't matter if anybody's fascinated you want to get them out of pain.
- [Laura] I did want to make a comment too I know I said this earlier, but as part of the robotic surgery itself, I have to say, I mean, I didn't know, going into it, I'd never had a robotic surgery or anything, but it was incredible how I felt just a few days after.
And I mean, I've had other surgeries unrelated to endometriosis and all that.
And it's a rough thing to go through when you have surgery, it's a big deal, but it was amazing.
I wouldn't really notice when they say like the least invasive or whatever they do, it really is.
I mean, it was phenomenal.
I'm still in shock.
- The reason it's different, to be honest with you.
So and I did laparoscopy for 15 years.
I mean, I dealt with it.
The instrument and I mean, it's not this big.
But this is your skin, here's the laparoscopic instrument, regular non robotic.
So for me, for example, to pick up that piece of paper, I have to torque this entire thing to that piece of paper.
Notice what's going on up here. Okay.
I'm torquing on the skin.
Robotically you do this, it stays there, and I go like this.
So there's less torque on your abdominal wall.
Now you're going to get better, quick from a laparoscopic surgery anyway.
But it's just these little things, I just, I love it.
I don't know, probably 1400 cases in by now, something like that.
And it's just to me, it's a new way of doing surgery.
How it helps endo though is very simple.
Precision excision by precision.
Ooh, that's a good one I wanna remember it.
(people laughing) That will be my new website.
Any other questions or comments y'all?
- [Audience member] I have one more question - Yeah, of course.
- How bad does your endometriosis have to be to have adenomyosis?
- Okay, that's a great thing, okay, so.
Adenomyosis, I thought I had a picture, maybe I didn't.
Remember the cantaloupe?
So when those little seed particles, for lack of a better way of saying this are outside the uterus that's endometriosis.
When those little seed particles are in the part that you would normally cut as fruit that's adenomyosis.
So glandular within muscle.
Endometriosis has nothing specifically to do with adeno meiosis.
They're equally for whatever reason, the endometrial lining is not where it belongs.
We think about 70% of women probably have adenomyosis.
They're not all symptomatic, which is a super common cause for heavy bleeding, a little bit prolonged bleeding, bad cramps.
You can have concomitant at the same time processes such as endo, adeno for that matter, interstitial cystitis.
if your bladder, we didn't talk about that.
It's just we didn't have that much time.
We call it the evil twin syndrome, right?
The evil twin syndrome means you have a condition of your bladder that has nothing to do with endometriosis, but you hurt from it because the lining inside the bladder is not fully present.
And so certain metabolic things potassium type of things will cause pain.
So adenomyosis is not anywhere really related specifically to endometriosis, but their commonality is in the endometrial tissue being in the wrong place.
Does that make sense?
- Yes. - Okay.
- I have a question on that.
So you speak to how you can surgically treat endometriosis.
Can you surgically treat adenomyosis?
- Why would you be treating it?
- Let's say if you wanna have children.
- Right, so number one, why is there symptoms?
You look at symptoms and management of symptoms.
And adenomyosis you can't specifically tease that out of the uterus, the muscle.
At this point in time, it's, it's impossible.
What you can do if you're trying to treat heavy bleeding in the presence of adenomyosis you can't always see it, but an MRI is pretty good to see if it's there.
It's not a hundred percent, but out of like, say for example, you're only treating heavy bleeding, adenomyosis can be treated for example, the adenomyosis isn't treated, but the heavy bleeding is treated by doing an ablation of the uterine cavity.
The problem is and I'd had researched on this a long, long time ago in women with adenomyosis, your endometrial ablation has higher chance of failure.
Now, are you trying to cure bad painful cycles?
Well, if you have to do a look to see if there's endo and adeno.
And so you can't physically manage the adeno only like surgically.
So you would aim that at removal of the endometriosis and then some form of suppression, so the uterus is just quiet.
Are you trying to treat infertility?
Well, is adenomyosis.
It would have to be pretty significant to be the only cause of your infertility.
But you can get past infertility, of course, by going to assisted reproductive technique.
- All right. - Makes sense?
- Outside of the medical aspects of surgery, birth control, Lumon pain medication more from listening to like if you had a patient who came to you and said, I want to try to treat this outside of the doctor's office, what would you suggest?
- She's been diagnosed? - Hmm hmm.
- We're postop? - Hmm hmm.
- Okay, postop I'd say, here's what I suggest here's are you trying to get pregnant?
No, I'm not trying to get pregnant.
Well, I have a lot of patients.
They just don't want to do anything.
And a lot of them do wonderfully fine, but I wouldn't be the guy suggesting nothing.
You end up having another surgery.
Absolutely proven in the literature, unsuppressed, you have a higher chance of needing another surgery.
You have another chance of needing surgery anyway, once we diagnose endo, but suppression is going to keep you twice as far out from needing another surgery.
So studies basically said you were twice as likely to need surgery if you don't use suppression, that's the easiest way to say that.
So I tell them if you want to, that's what you can do, but it's not my advice.
Low, polly, what was I gonna say?
Saturated fat, low saturated fat diet.
There's been associated study, a big study that had some associated decreased risk of endo.
I mean, but they had surgery.
So it, it's not black and white, but yeah, anything you can possibly do after you've had surgery, but not going to prevent it if you don't have surgery.
- Why do we have more endometriosis now than we did 50 years ago?
- The literature on that said that the incidents is probably not increasing.
It's the diagnostic and awareness.
That's why that 15% I showed you the beginning.
I don't think that's true.
I don't know specifically who was making the diagnosis, what their experience level was, all that kind of stuff.
And, those were in patients that they were doing surgery on for some other reason.
So that's already a bias group of people, but all I know is in patients with pain, it says upwards of 80%.
And that's probably even a low guess.
- I don't remember growing up knowing a person that I had it.
There was the occasional person that had bad menstrual cramps, but I don't remember people living with pain like I do now.
- All I can tell you is I don't think the incidence of it has changed so much as the discussion and the narrative around it.
And I for sure knew the people that trained me didn't know any of that like, we know now that's 30 years ago, but-- - And obviously uber aware of it because of her.
- That's what I would think.
But the jury's out on that.
- What 15 years ago, January, 2002, we'd never heard of it.
I went in to my doctor and knew I first I was pregnant, so I saw him then I had asked for your thoughts, I mean never I'm having horrible periods.
Never was it menstrual related.
I know I had acid reflux.
And it took for you to Google for the word to come up.
We researched it originally.
But then I went and sat there and said, okay, here's my history.
This is what we think it is.
And she goes with endometriosis doesn't exist.
There's nothing I can tell you, this is a fake disease.
- That was an OBGYN?
- That was an OB and I went to a woman - What state? - Austin.
I went to a woman, I was 16 or 17.
- Don't mention any names.
- And I wanted a woman doctor and we went in that's exactly what she told me.
When we left I went to my mother and I said, I don't care, man or woman find me, somebody that has common sense because she wasn't-- - Common sense that's great.
- I've heard every possible Forrest word and what a doctor will tell you.
How is it that we make it?
How is it that we make it easier for doctors to point us in the direction we want?
I mean, if you've got somebody who's got chronic pain, their friends are going like you need to go see a doctor.
What is the best thing for them to go in and say to the doctor to get the doctor to lead to and reach out to get us to the hospital.
- Number one, if you have to do any convincing, find another doctor.
I'm telling you that is exactly the best way to tell you.
The second thing is what we talked about earlier, every articulation of your disease process, memorize it, or have a piece of paper doctors don't typically like seeing your handwriting and a big wad of paper.
Just summarize for me, my pain is getting worse.
My pain hurts here, my pain hurts here, it's right here.
Do your best to be as articulate as you can about describing your pain.
And the doctor that you want is who's going to say it's endometriosis unless we prove otherwise.
So that's really important.
In my mind, someone comes in, I'm going only because of my perspective, right?
It's skewed.
So I'm going to basically either have patients who come in, who already have the diagnosis or are they going to come in because they think they have the diagnosis.
And so I'm so sensitive to think that, no, I don't think it is, you know, I don't think you need surgery after all.
Not yet, let's try this.
That's going to be my default stance isn't to say, let's do everything in the world prior to your surgery.
That is what the American College of OB-GYN, we don't want to hurt people.
But then again, there are certain things where you don't operate immediately.
But then again, there are things where probably we're not going to make a lot of progress, but we can try this.
But you gotta start kind of the relationship building to say, I'm thinking it's endometriosis and these symptoms aren't gonna go away unless I take that eyelash out of your eye, I just can't see it yet.
So it's a sensitivity that your doctor will have it.
I think if anybody says they blow it off, that's just, you absolutely need another place to go.
If someone says it could be, but let's try to work around surgery as much as possible.
That's okay, I mean, that's valid.
And then assess whether they feel very comfortable, how comfortable they are with the amount of things that may be needed.
Or if your trust them that much, at least say, if it's over your head and your skillset, would you send me somewhere else or call somebody else in?
That's just assessing a doctor's, pride factor for lack of a better reason.
So there's a lot of people that believe strongly as I do.
I'm certainly not the only person, but there's a lot of people who really believe strongly.
They may not be well equipped yet but are working on being equipped to be able to manage it.
Good docs, that's a good doc to have someone to advocate for you.
- And listen to your records.
- For the benefit of the world, who is to do a better job of informing or teaching about the-- - UT Dell is the only med school I'm associated with.
And I will tell you that because the information is growing, I would only hope so.
I would only hope so, but you just, you, I don't know here yeah, absolutely.
And the residents here that rotate through mine and one of the other, a few of my colleagues, we do a lot of this.
They're going to be highly aware.
Way more than what I ever saw when I was getting through training.
- Why do you think we have the 10 year average to diagnose?
- I think for all the reasons we've been talking about.
Not everybody believes in it and that's sad.
They just are maybe ill-equipped.
And since they haven't seen the light bulb go off on somebody, getting out of pain very quickly.
Even though, they may need to come back again cause it's a process.
It's a condition that you are set up for.
It's like a forest with just dry trees all the time.
We're putting out fires, but it's a set up for another one depending on what you do, postoperatively, are you ready?
Are you trying to get pregnant?
Did you get pregnant by the way?
Pregnancy doesn't cure endo, how could it?
how could it possibly cure it?
What it can do though is interrupt those nerve fiber afferent fibers to your brain, give your brain a chance to cool off, so to speak, just to have that reset down a little lower and then maybe you don't need surgery in the future.
Maybe things are a little better in the future.
You stretched out all that peritoneum and all that kind of stuff.
And maybe it doesn't register.
I don't know, but it helps some patients symptoms.
It does.
But I think it's because of all that anti estrogenic, that huge amount of progesterone, the whole pregnancy and then stuff that we haven't discovered yet.
But anyway, the, the question, I think I forgot it at this point, but why is there a 10 year, window in diagnosis?
This is why I did the seminar.
Awareness let people understand what we do.
- So do you think, cause you go through the stages.
Do you think that women who have taken longer to be diagnosed are more likely to have that stage four?
- So that's a good point.
Most stage fours and from my own experience, most stage fours, they didn't have a lot of problems, pain issues.
Most women who have a lot of pain problems issues early on are going to get diagnosed early on because they force someone to make a diagnosis.
And typically you're going to end up no matter how much somebody doesn't want to do surgery, somebody is going to have to look.
And ultimately any gynecologist knows this person.
I mean, we just gotta look and then they can help make the diagnosis.
- 'Cause I already ranged around stage two or stage three and weeks coming in since I literally, I was fine, woke up January, 2002, my first periods that I carried that month pained so bad that I was literally blacking out.
I mean, it was an overnight transition for my body.
And so we've been on it from day one and I always reserve that to, okay, I'm able to function and know how to manage it and I've been able to have kids.
And I say, it's stage two, stage three.
But I'm on it compared to somebody who's not somebody who maybe ignore the pain or just have those people brush them off eight, 10 years down the road finally gets to where they know.
Somebody mentioned the word endometriosis to them.
- I get that, all the time.
And that's why I showed my perspective slide because I can't answer for everybody.
I train enough doctors to know, of course it's a bias group.
I'm getting doctors who are trying to get better at robotics and I can assess skillset even while I'm training them.
And so when I present the endometriosis, while I'm doing that, how to manage these different gynecologic conditions, I, you know what I mean?
And so those are my chances to raise awareness in those settings as well.
But I'm not saying that they're not good surgeons.
They don't care that just haven't had the equipping surgically or the equipping if they believe in it educationally.
- I think probably I always go, well, it hasn't affected them yet.
They haven't seen their loved one live on pain meds.
- That's a really good point.
- I think that once you do that.
My four year old, five year old I was having a really bad couple of days, and he said, mama, I've got to grow up and I'm sure you're going to be affected by it your entire life because of me you're going to have it and I think that is my hope for some sort of better treatment or here down the road is that we now have so many people who are qualified.
- Speaking of not just sitting there keeping it hush hush 'cause in my household we didn't talk about any kind of blood. - Taboo.
- It was completely.
Mom I'm not feeling good.
Mom I'm not feeling good.
I wouldn't go to school.
I was the last to school in the morning too so I couldn't get up.
And that's when I realized just go through your day.
It's just mind over matter.
Just think you mind, you'll wake up tomorrow-- - Tougher.
- Yeah like grow that thick skin.
- Pull up those big girl panties.
- Exactly.
- [Laura] But also its you on that same thing.
It's just like with your friends and other people that you don't talk about it with.
And so for me recently, I think because I just kind of hit that ceiling where I was like, I've had it, people need to understand what I'm going through because I can't do this alone anymore and I had conversations actually at happy hour, and I explained to them what I've been going through.
They had no idea.
And that's because I got so good at hiding it.
I mean, I could be in horrifying pain and wincing a smile and acting fine, and you become a very good actor because you have to in so many situations.
But I explained to my friends, some of them knew a little bit about it.
Some of my male friends have no clue.
And I was like, okay, let me pull this up online and you read it and I'm sorry, that it's kind of, maybe a little gross, it's happy hour, but just, we're talking candidly so.
And what came out of that was interesting is that some of my guy friends said, well, my ex girlfriend, I'm pretty sure this is what she had.
It opened up a conversation that people didn't want to have before didn't even think about having.
And it opened their minds to a better understanding of what a lot of women go through and maybe their wives, their ex girlfriends, whoever.
And I think that's what was a very profound thing for me in all of this.
This feeling like I opened a door for myself and for others to start talking about it more because for so many years I just didn't talk about it.
- And that's why me personally, when I joined the group, I was like, I don't know if I should talk about this.
I'm a lady, ladies don't talk like that.
The more I got talking to the girls, the more we really kind of brought it in me and just got me out there and got me to talk about it.
And as in doing so we have a girl in the group that, her father was the one that kind of brought her into it.
And he was like, you need to talk to her, just go talk to her, go talk to her and go talk to her.
And I think that's just what we need to keep doing because men will listen and they register.
I work predominantly with men.
They're registered what you're saying, and then keep it in.
And a lot of them are smart enough to not talk about it.
(people laughing) But that information is there and they don't speak about that.
Until, Oh, this is happening to her.
Well, you're not going to talk to this girl.
You don't want to talk to this girl.
You don't want to talk to the doctor and tell them that this is happening.
And I just feel that we've gotten to the point now that we're speaking up enough and now hopefully we'll just continue to do it.
- [Laura] Well, it's empathy that we all need.
We need that empathy where someone doesn't just hear what we're saying, but it's like, they empathize with what we're going through.
And cause then that makes us feel not so alone in the situation.
And it makes us feel stronger to know that someone can empathize.
And that's I think all of us being here together, supporting each other frames that.
- Well, and you talked about the toll it takes to hide it.
I mean, we can talk about the medical aspect of endometriosis all day.
There's that mental, that is and that emotional.
And I can tell you some days that it's worse for me than the physical I can push through the physical, I can't get out of bed for the mental and emotional.
And without the support groups and without the ability to step up and say something about it.
And I, I don't know, five, six, seven years in, I got blunt and I had no problem walking to my doctors and my boss's office, and tell them you know?
And they're looking at me, and telling me you're always.
No I'm not always in pain.
I have my good days, I have my bad days, but I have a disease and you need to know about it if you're going to deal with me.
Because you've gotta understand, I'm going to push through it, I'm going to work harder than 99% of your staff.
But when I say I can't do it, I can't do it.
And you go to stand up for yourself because if not, you're going to be pushed around and it's going to make the emotional and the mental that much worse.
- So you'll exhaust yourself.
- Going off of that I do want ask the last year, when you, tip it.
the last year, my life has been a serious struggle.
I have two surgeries in year span to many procedures to try and tolerate my pain.
During this time, my workload got overwhelming and it was high stress.
And I was work friends of I would take a lot of his.
So I feel my personal theory.
And I guess I'm looking to see, you would agree the higher, the stress, the more stressed I was the worse my endo got because before my second, the last surgery, I got maybe two weeks of relief and that was it.
And my stress factor skyrocketed the second I got back to work.
Does a significant amount of stress affect your endometriosis?
- I mean, you'd have to, even from a common sense perspective, say yes.
I mean, any degree of anxiety, remember that kind of spiraling medical neurochemical thing.
Well now think of it, the whole body system.
Let's say you're not sleeping.
You're stressed out about something you're at work.
You're constantly in that your adrenaline, those are up higher.
Well it's certainly going to make everything register worse.
I mean, people with skin sensitivity.
I mean, all of these things that you hear about read about things that hurt chronic pain, amputation, Phantom limb pain.
I mean, anything that has to do with an increase in your stress.
You'll, I mean, just kind of anecdotal things at sometimes, but they will always lead to a little bit more perception, recognition of pain, all the other things we talked about, kind of any relaxation technique, it always help you go through some.
For example, the operation procedure.
Relaxing breathing, I got birth, you know, the birthing process, think of how much stress is going on there.
And whether you have an epidural or not, I sometimes the epidurals don't work all that well.
And so natural labor, you're always doing so many other things to try to keep that stress level down, Even though there's massive physical stress and physical hormones, stress, hormones being released.
But yeah, I would.
- So it may not, it may not make it a grow more, but it's going to make you more sensitive to essentially growing those though experience.
- Well, I would say at the very least that lovely ultimate central nervous system, your brain, the perception area whatever's going on down here will be heightened.
The neural pathways will be heightened.
This can be turned up slightly, so to speak.
And your perception of that would be better.
I don't know that actually neuro physically neurochemically makes it worse, but that T1 line is just added to, because there's so much stuff going up there.
Well, good I just want to say thank you again for coming.
And the good discussion that we had.
I hope that, sparks a better awareness, some degree of hope, at least in information and clarification and perspective on a lot of stuff.
And I'm seeing different women from different areas and backgrounds, kids, and, I know you're young and all that stuff, but life, life goes on.
Thanks guys.
Appreciate it. - [Audience] Thank you.
Devin M. Garza, MD, FACOG, discusses the role of endometriosis in pelvic pain and the robotic advantages to surgical management.
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Devin Garza, MD, FACOG is a gynecology surgeon with a special interest and extensive experience in minimally invasive robotic surgery to treat gynecologic conditions. He earned his medical degree at the University of Texas Health Science ...