Endometriosis: Employing Minimally Invasive Surgery for Maximum Results
The endometriosis program at Columbia is the only such program in the tri-state area spearheaded by three fellowship-trained gynecologic surgeons with subspecialty training, background, and expertise in the management of complex endometriosis pathology.
While endometriosis was first described in the early 1800s, the disease, albeit fairly common, continues to be a very challenging condition to diagnose. “It can actually take up to seven to 10 years or so for the ultimate diagnosis of endometriosis to be made,” says Jeannie Kim, MD, a gynecologic surgeon in the Division of Gynecologic Specialty Surgery at NewYork-Presbyterian/Columbia University Irving Medical Center. “This is due, in part, to the diversity of symptoms that patients experience. Many of these symptoms are vague and overlap with other conditions. And imaging, such as pelvic ultrasound, MRI, or CT scan, is not going to necessarily detect endometriosis. The confirmation of a diagnosis relies on a pathology test of a tissue sample.”
Hye-Chun Hur, MD, MPH, a minimally invasive gynecologic surgeon at Columbia, concurs. “Patients are typically referred to gynecologic surgeons from their OB/GYN provider or primary care physician,” adds Dr. Hur. “They generally present with pelvic pain or infertility. When there are clinical symptoms that suggest endometriosis, we will do a laparoscopic evaluation and excise visible lesions to make a histologic diagnosis. Unlike fibroids and other gynecologic pathology that can be diagnosed with imaging, endometriosis really requires a surgical diagnosis.”
Dr. Hur cautions, however, that even a surgical diagnosis poses a challenge concerning accuracy. “Frequently, the diagnosis is either overcalled or undercalled. Some of the endometriosis implants can be very subtle, atypical, or almost look normal, and therefore may be missed in the preliminary surgical survey,” explains Dr. Hur. “Other times, the disease can be so severe the pelvic or abdominal cavity is full of adhesions and is completely obliterated, obscuring the visible lesions and resulting in some providers to miss the actual diagnosis. Making the diagnosis is contingent on surgical experience, which enables a more accurate recognition of the variety of the types of implants.”
Dr. Hur emphasizes that if the condition is diagnosed visually, i.e., the lesion is just looked at and not excised, this too could lead to a misdiagnosis as the lesion can present in a variety of ways. “This is also why a surgical diagnosis is critical and requires excision of the lesion. This is so tissue can be sent to pathology for histologic confirmation,” she says. “This is usually done laparoscopically, which is the ideal method for making the diagnosis, particularly as the laparoscope magnifies your visual field. When you do open surgery, you don’t have the benefit of magnification.”
“Treatment of endometriosis can involve many different specialties and so I think it is crucial for patients to be treated in a program where those resources are available,” notes Dr. Kim. “If we suspect the disease involves other organ systems then we work very closely with either colorectal specialists or urologists. Sometimes you can find endometriosis in the lungs, in which case we will discuss appropriate treatment with a thoracic surgeon. When patients come to us with pain or seeking care for fertility issues, their major concern is how the disease and its course of treatment may impact their fertility. Endometriosis affects about 10 percent of all reproductive age women and is higher in the infertility population. Our Endometriosis Treatment Program helps these patients navigate these complex issues.”
The Endometriosis Treatment Program is led by Arnold P. Advincula, MD, Chief of Gynecology, Chief of Gynecologic Specialty Surgery, and Vice Chair of Women’s Health at NewYork-Presbyterian/Columbia, and Zev Williams, MD, PhD, Chief of Reproductive Endocrinology and Infertility at Columbia.
“Being able to work together as surgical specialists and infertility specialists allows us to manage the patient through the continuum of her reproductive years,” says Dr. Advincula. “We have cultivated an ability to comprehensively manage deep infiltrative endometriosis, a classification of endometriosis that tends to involve organs in the abdomen and pelvis. Working with other specialists, we are able to confidently address and manage endometriosis patients who desire fertility sparing surgery and those who have extensive endometriosis involving organs such as the bowel, the bladder, and the ureter. These are significant manifestations, and we are one of the few places in the city that have been managing these patients.”
According to Dr. Hur, endometriosis, in particular, is a disease in which minimally invasive gynecologic surgery (MIGS) shines. “This specific mode of surgery is not just about the incision size,” she says. “In this kind of pathology, magnification is invaluable, enabling us to look around the corners of the disease process, providing superior views that an open incision wouldn’t be able to offer. Enhanced visibility offers a more accurate diagnosis and an opportunity for more thorough excisional treatment.”
Dr. Advincula plays a leading role in furthering robotic applications in MIGS. “Robotic surgery today is already minimally invasive, but it requires several punctures in the abdomen for placement of four to five trocars for deploying instruments,” says Dr. Advincula. “We are in the process of helping to bring to market a newer generation of surgical robotics with a single port robotic platform. This will allow us to be even less invasive. The game changer is the fact that all the instrumentation deploys out of one single port.”
The endometriosis program at Columbia is the only such program in the tri-state area spearheaded by three fellowship-trained gynecologic surgeons with subspecialty training, background, and expertise in the management of complex endometriosis pathology. Dr. Kim, Dr. Hur, and Dr. Advincula have each been in practice a minimum of 15 years and have some 50 years of surgical experience and thousands of cases among them.
“For the Columbia team, minimally invasive gynecologic surgery doesn’t mean that we are using a robot, or we are using laparoscopy because you don’t have to have those modalities to be minimally invasive,” adds Dr. Advincula. “It could involve using a small open incision for a procedure in which other surgeons might use a much larger incision. Our philosophy is how can we offer the best treatment through the least invasive method? We are constantly looking at how to innovate the way in which we do surgery. While we are often are referred to as minimally invasive gynecologic surgeons or specialists in minimally invasive gynecologic surgery, ultimately what we have become are specialists in advanced pelvic surgery.”