Surgery | Academic OB/GYN

Grand Rounds at Baylor Dallas – A Few Lesson for the Residents

October 21, 2018 Nicholas Fogelson 2 comments

Reposted from the new blog home at Northwest Endometriosis and Pelvic Surgery:

https://www.nwendometriosis.com/blog/grand-rounds-at-baylor-dallas-a-few-lesson-for-the-residents

This week I had the honor of being invited to give Grand Rounds at Baylor Dallas, under invitation from the chair Dr Anthony Gregg. I spoke to the residents about endometriosis surgery, discussing what we understand about the origins of endometriosis, as well as the rationale for excision surgery. I also showed videos from a number of different excision sugeries, with cases varying from stage I endometriosis, stage IV pelvic endometriosis with bowel resection, abdominal wall endometriosis, and thoracic endometriosis. These sorts of talks are important we are exposing young doctors to something that they otherwise might never be aware of.

I also had the pleasure of working with the residents as we dissected a fresh cadaver, demonstrating the entire retroperitoneal anatomy. I took down the entire side of the pelvic sidewall and identified and demonstrated every named artery, vein, and urinary tract structure. We also demonstrated and dissected the path of the ureter from pelvic brim all the way to the bladder, and replicated technique for a radical laparoscopic hysterectomy.

Finally, I dissected all the pelvic neuroanatomy, including obturator, sciatic, pudendal nerves, as well as nerve roots S1-S4 on each side. We also demonstrated how one performs a pudendal nerve release, cutting the sacrospinous ligaments and coccygeus muscle to open up the pudendal canal to free pressure on the nerve.

I had a great question from one of the residents. She asked how a young doctor can become an endometriosis surgeon. My rather long answer was this:

1. Even at this early stage in your career, resist the urge to think about surgery as a series of steps. Many will do this. That is, when learning to do a laparoscopic hysterectomy many young surgeons will memorize and learn a series of steps that leads from the beginning to the end of the surgery. The problem with this is that while it may work in ordinary situations, one will inevitably encounter variations in anatomy or scarring and adhesions that will make your steps useless. And then you will be paralyzed, and either you will abort your surgery or you may continue and if unlucky, you will injure the patient.

2. Instead of learning a series of steps, focus on learning surgery as three legs to a stool. The three legs of the stool are knowledge of anatomy, knowledge of technique, and knowledge of intention.

Knowledge of anatomy means that the expert surgeon is the master of every anatomical structure in the vicinity of their operative field. Most gynecologists, probably 98% of them, would fail this criteria. The level of mastery required to truly excel means you understand the anatomy of nerves, arteries, veins, bones, and muscle structures, and the relationships between them. When a surgeon has mastered this leg of the stool, no anatomical variation is going to be scary, because they understand where everything is and where they can safely go to complete their task. Knowledge of anatomy does not come from operating under supervision and identifying anatomy as one learns. It instead comes from a specific intention to learn anatomy from all the resources available outside of the operating room, such as books, videos, and cadaver dissections.

The second leg of the stool is knowledge of technique. This means the ability to manipulate tissue and complete one’s tasks without creating undue bleeding or accidentally injuring something, and the ability to successfully stop bleeding when it occurs. It also means a mastery of one’s equipment, such as an deep understanding of the electrosurgical and other energy-based equipment that we use on a daily basis. Just using the settings your attending used is inadequate. One must truly understand why one sets a piece of equipment a certain way, and why one uses that equipment in a certain way, in order to deal with the situations where one might like to change those settings for better effect.

The third leg of the stool is the easiest one. It is the understanding of surgical intention. For example, the surgical intention of a hysterectomy is to remove the uterus from the body while leaving every arterial and venous connection between the uterus and the body secured and sealed, while preserving the support structure of the body. In many ways this is obvious. But in some cases it is more difficult to understand, such as whether or not one should remove a piece of bowel that appears involved in endometriosis. We call this surgical judgement.

Taking these three steps together and intentionally seeking mastery of each, one is bound to be an excellent surgeon. Once one is on this path, becoming an endometriosis surgeon is easy. There are a zillion patients with endometriosis around. Follow these principles and operate to remove the endometriosis. If you try to do endometriosis surgery as a series of steps you will fail miserably, because every surgery is different. But if you apply these principles, understanding anatomy, using good technique, and understanding that the goal is to remove all of the endometriotic tissue, you will succeed and your patients will benefit.

3. The third thing I said is that to be a strong surgeon, one should always cultivate a feeling of responsibility for your patient’s outcome. I see too many surgeons experience complications in their surgeries and then strive to prove to themselves that they weren’t at fault in what happened. This is fundamentally wrong. The surgeon is almost always at fault when something goes wrong. Ureters are cut in hysterectomies 1% of the time not because “it just happens sometimes”, but because in 1% of cases the surgeon failed to apply proper surgical principles and to understand the anatomy of the surgery they were performing. Even the apparent faultless complication of a postoperative infection often originates in a failure of antisepsis or sterile technique, which are controllable factors. If one has a misadventure and chooses to externalize the responsibility for this event, one has lost the opportunity to grow from the error. And unfortunately, that means that if one operates enough, one will repeat that error one day again.

It was a pleasure to speak to the residents and faculty at Baylor Dallas and to teach anatomy to the residents, and I hope that a few of them go on to serve women with endometriosis. It all starts with the young.

Categories: Endometriosis, Surgery, Uncategorized

On High Volume Gynecologic Surgery, and How to Pick A Surgeon for Your Hysterectomy

January 31, 2018 Nicholas Fogelson 1 comment

If you had a serious issue with your knee and needed a surgeon to repair it, how would go about picking that surgeon? If you were like most people, you would find the most experienced and best surgeon in your area, at least within whatever in

surance network you might belong to. And that would make sense, as the experience level of your surgeon is a strong predictor of outcomes, including complications of surgery.

So you would assume that this would be similar for all types of surgery, correct? People of reasonable means will seek out the best and most experienced surgeon for whatever type of surgery they need, whether it be neurosurgery, bowel surgery, or in this case, gynecologic surgery.

The troubling thing is that in the case of gynecologic surgery, that would be wrong. In fact, the majority of gynecologic surgery in this country is performed by relatively inexperienced surgeons who research would suggest will have a higher rate of complications than more experienced surgeons.

On Hysterectomies and Hysterectomy Alternatives

June 18, 2017 Nicholas Fogelson 1 comment

Every now and then physicians have a clarifying moment that really helps to define the way we think about how to take care of our patients. I had such a moment when I was a third year resident.

The patient was an HIV positive woman who was somewhat ill, who had problems with severe uterine bleeding. Her workup demonstrated that she had a 3 centimeter submucosal fibroid, meaning that she had a fibroid that was inside her uterine cavity. This type of fibroid can cause severe bleeding, and needs to be removed to resolve the problem. She had tried a number of medical therapies, but not surprisingly they weren’t working for her. At the time I remember thinking that she could benefit from a hysterectomy, but was worried that she wasn’t a very well woman and I wanted to do something less invasive.
I posted the patient for a hysteroscopic myomectomy, which is a procedure to remove the offending fibroid with a scope put up through the vagina and cervix, with no incisions in the abdomen. As we didn’t have the fancy intrauterine morcellators that we now have that make these procedures much easier, it was a fairly challenging case to complete, both because it was a relatively large fibroid to tackle this way and because as a third year resident I was not highly skilled at the procedure. uterus

Ultimately, the procedure was difficult. In fact, we were not able to complete it in a single surgery and had to come back to the OR a second day to finish it (which was not uncommon using the technology available at that time.) In the process of the procedure, my attending physician Dr David Soper was critical of my decision to do the hysteroscopic procedure. He asked several critical questions. “Did she plan on future childbearing?” The answer to this was no, as the patient was
actually quite ill with HIV related illness. “Did she specifically desire to keep her uterus?” The answer to this was also no. With these two answers, he asked “So if you can do this in three hours and maybe not succeed, and she may still have bleeding issues even if you succeed, AND you could do a vaginal hysterectomy in half the time and that would have a 100% chance of solving her problem, why again are we doing this and not the vaginal hysterectomy?” (this was before the age of the laparoscopic hysterectomy.)

The reality is that I didn’t have a good answer. The bad answer was that I had been taught to be afraid of doing hysterectomies. I had been taught that a hysterectomy is what you do when nothing else had worked. And there were things I hadn’t tried yet, so I didn’t do the hysterectomy that would have worked 100% of the time.

Thoughts on Hemodynamic Instability, Laparoscopy, and Ectopic Pregnancies

February 3, 2017 Nicholas Fogelson 1 comment

As a young physician, I was taught that when a patient presents with a ruptured ectopic pregnancy and was hemodynamically unstable, the cor images rect course was to perform a laparotomy for immediate control of the bleeding. At that time (around the year 2000), complex laparoscopy was not really in wide practice, a
nd a physician who suggested that they could control bleeding laparoscopically as quickly as they could via laparotomy would have been met with skepticism. In some cases, a physician suggesting a laparoscopic approach to the problem might be blocked by the atten

ding anesthesiologist, who often holds veto power over certain surgical decisions. The idea was that the bleeding needs to be stopped quickly, and the way to do that is a laparotomy.

But over time, our ability to do things quickly and effectively via laparoscopy has changed, and I think our understanding of hemodynamic instability in young women has changed as well.

Thoughts on Abdominal Wall Endometriosis

August 28, 2015 Nicholas Fogelson 52 comments

In my first year out of residency I practiced in Honolulu, HI. One day in my outlying clinic in Kapolei, on the west side of Oahu, I entered an exam room to find a woman crying in pain. She said she had pain in her belly wall that had been present for years and no doctor could help her or tell what was wrong with it. She said that several months after her last cesarean delivery she started to feel this hard lump on the side of her belly. Every month right before her menstrual cycle, this lump would become exceedingly painful, both at rest and even more so with any kind of pressure.

She was absolutely distraught, and was really in my office to ask for some narcotic pain medications to treat the severe pain. So many doctors had failed to make a diagnosis on this issue that she thought it was something she would have to live with for the rest of her life.

But, that day was different, because her doctor that day had been fortunate enough to be exposed to this condition in his training. The woman had abdominal wall endometriosis that had been ignored or missed for years. I scheduled her for surgery that afternoon and by that evening she was completely cured of the problem. I asked her as she woke up whether it still hurt, and she said that she felt some pain from the surgery, but the pain from that mass was gone. It felt good to help her, and I was thankful that I had gotten training in the diagnosis and management of this condition in my residency, something that is lacking in the training of most gynecologists in this country.

Since that time, I have been fortunate to be able to help a lot of women with this condition. The first few came randomly, and to my disappointment each one had been missed by at least a few doctors before I saw them. Eventually I became known as a competent manager of this condition, along with my general expertise in endometriosis, and at that point I started to see a lot of referrals and do a significant number of surgical repairs for this problem.

ORIGINS:

Abdominal wall endometriosis is a predominantly iatrogenic condition, meaning that it is the result of something that we are doing – and that something is cesarean delivery. The vast majority of these cases are subsequent to cesarean delivery, presumably via seeding of the abdominal incision with endometrial tissue at some point during the case. We do not know exactly what are the risk factors in cesarean delivery that cause this condition, but we do know from animal models that if you take a little piece of endometrium and stick it in the fascia when you close it after surgery, abdominal wall endometriosis will result – so presumably that is what is happening.

There are a few things I think we can do to reduce the incidence of this cesarean related endometriosis. Thorough irrigation of the wound prior to closure is likely to reduce or eliminate flecks of endometrium that might implant in the abdominal wall. I also believe, based on my experience but lacking data, that closure of the parietal peritoneum will reduce the incidence of this disease. I say this because of multiple experiences where uteri are adherent to the abdominal wall contiguous with masses of abdominal wall endometriosis. In one of these cases a hysterectomy was required to entirely remove the disease.

Interestingly, people with cesarean related abdominal wall endometriosis do not necessarily have typical peritoneal endometriosis, as it is caused by direct deposit of endometrium into the abdominal wall during a surgery. However, women that have abdominal wall endometriosis who did not have prior surgery most likely do have peritoneal disease, and it is probably severe. Papers suggest that only 50% of these cases are post-surgical, but in my experience cases without prior surgery are very rare.

DIAGNOSIS:

Abdominal wall endometriosis is a disease that is easy to diagnose if you know what the condition is and how it presents, and impossible to diagnose if you don’t. This is called availability heuristic – it is impossible to make a correct diagnosis if the disease state doesn’t exist in your brain’s medical knowledge banks.

In almost every case I have diagnosed, the patient came right out and told me they had it. Not literally of course, but rather they said the words that made the diagnosis certain. The disease presents with a hard mass that is painful at all times, but become larger and dramatically more painful prior to and during the menses. It is exquisitely tender to the touch, particularly during the most painful part of the month. With those symptoms, the diagnosis is almost certain. I can tell you that I have heard this story over and over and over, and I come right out and tell the patient what is wrong before I even look at their abdomen, and in each case it is there to be found on abdominal exam, just missed by well-intentioned people who didn’t know what to look for.

Imaging studies are useful in confirming the disease, though in my experience it is useful only to for surgical planning, as history is enough to make the diagnosis. The proper imaging should be an axial cut CT or MRI. MRI is better at showing the depth of invasion into the fascia and muscle, but either modality is adequate. If cost were an issue one could certainly get away without imaging. Some people (mostly general surgeons) will do a fine needle biopsy to confirm that it isn’t a malignant tumor, though I don’t think that is necessary and it drives up costs.

TREATMENT:

There are three things one can do with abdominal wall endometriosis, only one of which clearly leads to lasting cure of the problem.

As AWE is endometrial tissue, it will respond to high dose progestin therapy or continuous birth control pills. It will also respond to Depot-Lupron (leuprolide), and perhaps to aromatase inhibitors (eg letrozole). The upside is that these agents do work. The downside is that the patient is stuck taking them forever, or at least until menopause, and that they are not really treating the problem.

There are some recent trials that suggest efficacy in ultrasound guided injection of phenol directly into the endometrial tissue. These injections destroy whatever tissue they go into, so properly guided this probably does work. It is however something that is still in a research stage and only supported by a few recent papers (in international press.)

The final intervention, which is both curative and reliable, is surgical resection of the abdominal wall disease. In my experience, complete resection of the indurated tissue in the subcutaneous space, including resection of underlying fascia if necessary, is curative of the problem. I have had only one patient who did not experience complete relief, and subsequent imaging showed that she had a satellite area of disease that was not resected in the first surgery. She was cured in a subsequent surgery to remove this additional disease.

SURGICAL TECHNIQUE:

This procedure is performed under anesthesia by opening up the old cesarean scar, identifying the endometrial implants, and resecting them. In some cases the implant is superficial enough that removal does not require entry in the rectus fascia. In other cases the disease is invasive into the fascia or even the underlying rectus muscle, requiring resecting a portion of the abdominal fascia. Small fascial defects can be closed primarily, while larger ones can require mesh reconstruction of the fascia prior to closure.

I have removed quite a number of these, and in my experience about half require some level of mesh reconstruction. There are some studies that show a much lower likelihood than that, though I suspect they had a population with less severe disease than I have seen. My criteria for mesh reconstruction is a lack of ability to reapproximate the fascia without significant tension. I have predominantly used a biologic mesh (either Strattice (porcine dermis) or Veritas (bovine pericardium)) which is reabsorbed and replaced with fibrosis over time. Some operators use a permanent mesh. Permanent mesh is likely superior for large defects, though it comes with a chance of infection requiring removal. Porcine or bovine mesh will not get infected easily (if placed in a sterile field), but there is greater risk of subsequent hernia formation. We lack any randomized trials to direct us on exactly what type of mesh we should use in this diseases state, other than the general surgery literature on general abdominal wall reconstruction.

Placement of mesh is does by a simple inlay technique. I use 2-0 PDS suture to secure the mesh. Very large defects may require underlay or component separation techniques, in which case I will involve a general surgeon in the closure.

With the placement of any biologic mesh, drainage is imperative as seroma formation is quite common without it. Drains are left in place until drainage is minimal (10-20 cc a day), which can be as long as a month. My experience with inadvertent (gets pulled out accidentally) or impatient (resident pulls it out thinking that 50cc a day was little enough) has been consistently negative, with seroma reformation being common. While patients dislike drains, they can be managed, and they are preferable to a wound that is draining clear fluid for a period of time.

CONCLUSION:

If you are a physician seeing a patient with the symptoms I mention, please think about this diseases state. If you make the diagnosis you will be doing better than 90+% of people out there.

If you are a patient with these symptoms, tell your physician your own diagnosis. If they are not able to help you with it, consider visiting beautiful Portland, OR and I would be honored to help you.

Also see

https://academicobgyn.com/2017/10/03/academic-obgyn-cases-large-abdominal-wall-endometrioma-with-mesh-reconstruction/

__________________________________________________________________

Dr. Fogelson is a gynecologic surgeon and endometriosis specialist who practices at Northwest Endometriosis and Pelvic Surgery in Portland, OR. Call 503-715-1377 for clinical consultation or email nfogelson@nwendometriosis.com. http://www.nwendometriosis.com

Categories: Endometriosis, Gynecology, Surgery

New Surgical Video: Difficult Robotic Hysterectomy

June 27, 2012 Nicholas Fogelson 2 comments

This video shows a particularly difficult robotic hysterectomy, complicated by severe inflammatory adhesive disease of the left paravesical space. This case demonstrates retroperitoneal anatomy and key strategies for dealing with complicated hysterectomies.

For consultation with Dr Fogelson please call Pearl Women’s Center (503) 771-1883
Copyright 2012 Nicholas Fogelson and http://www.academicobgyn.com

Categories: Surgery, Surgical Videos

On the Surgical Consent Process

June 20, 2011 Nicholas Fogelson 20 comments

Today I saw a patient for a preoperative visit and went through the ritual of “informed consent” and the signing of the surgical permit. We had decided to do a hysterectomy to treat her problematic fibroids, and she very much wanted to proceed. Having discussed the alternatives, we now had to go through the legal ritual of the surgical consent.

As usual, I discussed what we could expect to gain from the hysterectomy. There was a 100% chance that she would no longer have any bleeding, and a very strong chance that any pain that originated in her central pelvis would get entirely or mostly better. Anemia that resulted from the bleeding would improve. Other symptoms, like urinary pressure and frequency, and lateralized pelvic pain, would likely improve though it is not as strong a likelihood as the other symptoms.

We also discussed the risks. “You could have bleeding during the surgery, potentially enough to need a blood transfusion before or after surgery. You could get a communicable disease from a blood transfusion. You could develop a wound infection or abscess, which sometimes is easy to treat and other times quite complicated. Anything in the abdomen could be damaged during the surgery, such as the bowel, bladder, ureters (“which carry urine from the kidneys to the bladder” I always say), blood vessels, or other structures. Anything damaged can be fixed at the time by myself or a consultant. There is a possibility something could be damaged but we do not recognize it at the time, or that there is a delayed injury. If this occurs you might need further surgery, antibiotics, or hospitalization. Though extremely rare, you could die or be injured from an unforeseen surgical complication or complication of anesthesia.”

At this point she looked white as a sheet, as usual, and then I tempered with “but all of this is extremely unlikely, less than 1% of cases for major issues, and I have to explain it all for legal reasons. I am well trained to do this surgery and will do my absolute best for you.” I answered her questions, the consent is signed, and we had our pre-op.
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