If you have found this section of our website, you have likely been referred to our facility for expert surgical management of endometriosis or are seeking information or perhaps a second opinion for surgical management of endometriosis. This section should help to educate you on excision surgery, what it means to be a true expert in excision surgery for endometriosis and the importance of a strong “team approach” to the surgical management of endometriosis. If you are not considering surgery at our facility, but need to know what to ask for of your prospective surgeon, this section should be helpful as well.
Excision Surgery - The New "Gold Standard"
In the medical field, a “gold standard” treatment for a disease is one that has been proven through validated clinical trials to have the best long-term outcomes and the least complications when compared to other methods of treatment. It simply means that there is no better treatment. For decades, it was taught to residents in OB/GYN training that surgical thermal or laser ablation of endometriosis and surgical excision of endometriosis provided similar outcomes. Experts in surgical management of endometriosis have known for years that this is not the case. Finally, we now have data from very good clinical trials that excision surgery for endometriosis is far superior to ablation. In the case of surgical management for treatment of endometriosis, the gold standard is now complete and total surgical excision of any and all visible implants of endometriosis with wide margins around all endometriosis and removal of all underlying scar tissue.
What is "Excision Surgery"?
The goal of excision surgery for endometriosis is to remove ALL implants of endometriosis with very wide margins with continued dissection until there is only healthy unscarred tissue left behind. It is only with this approach that surgical excision surgery will provide the best outcomes. If ANY lesions are left behind, then the surgery will result in a sub-optimal outcome. This is true because we have known for many years that the severity or “Stage” of endometriosis does not correlate well with the degree of symptoms that one experiences. In other words, someone can have one cluster of endometriosis and have such bad pain that they miss school or work during their menstrual cycle. Conversely,someone can have undiagnosed “Stage 4” endometriosis and not have any significant symptoms. Therefore, it is absolutely critical that ALL lesions of endometriosis be removed regardless of where they are located.
Traditional "ablation" surgery just eliminates the lesions on the surface and pain recurs within 6-12 months. With the "excision" method, the active surface lesions and the scar tissue underneath, that affects nerves and other structures such as the bowels, is completely removed. This leads to much better outcomes.
What is an "Excision Surgeon"?
T rue“excision surgeons” for endometriosis are considered to be experts in the minimally invasive (laparoscopic or robotic) surgical management of endometriosis. In most cases they have been vetted by their peers and have a long history of good long-term outcomes with minimal complications. There are less than 100 truly expert excision surgeons worldwide. Most excision surgeons are involved in teaching and research in academic institutions and are Involved in some way with fellowship training through the American Association of Gynecologic Laparoscopists (AAGL). Unfortunately, there are not nearly enough true experts in endometriosis excision surgery to cover the millions of women who suffer from this debilitating disease world wide. An excellent resource to find reviews and a list of experts in endometriosis excision surgery are Nancy’s Nook and EndoWarriors on Facebook. The “physician finder” on the AAGL website (AAGL.org) is also a good resource and will help to locate proficient minimally invasive gynecologic surgeons in your area.
Buyer Beware: Not all Excsions Surgeons are Created Equally.
Dr. Furr is considered to be an expert in surgical excision of endometriosis. He is fellowship-trained in this approach by Dr. C.Y. Liu who is one of the most influential pioneers in minimally invasive surgery for endometriosis of our time. True experts in minimally invasive (laparoscopic or robotic) excision surgery typically have 20-30 years of experience with this approach and/or are fellowship-trained in this type of surgery. Fellowship training for minimally invasive gynecologic surgery is governed by the American Association of Gynecologic Laparoscopists (AAGL) and these fellowships are some of the most competitive to obtain in all of medicine. However, graduation from fellowship does not automatically make one an expert in excision surgery. It takes years of post-graduate experience in a high-volume (typically considered to be over 300 cases per year) surgical practice that is focused on this type of surgery. Excision specialists must be able to devote many hours for a single complicated case. They must have extraordinary patience and pay meticulous attention to detail to be able to completely excise all lesions and scar tissue. They must have expertise in laparoscopic suturing and other minimally invasive approaches to repairing tissues and restoring normal anatomy in order to complete complete removal of all affected tissues. Likewise, a true excision specialist should have hospital privileges to excise endometriosis from any organ in the abdominal and pelvic cavities. This includes the surface of the liver and kidneys, diaphragm, bowels, appendix, bladder, ovaries,uterus, Fallopian tubes, ureters, lymph node chains and blood vessels. Lesions located inside the thoracic cavity and lungs or the bronchial tubes require the services of a cardiothoracic surgeon and pulmonologist respectively. For lesions located inside solid organs such as the kidneys, liver,spleen and pancreas, surgeons with privileges to remove lesions from these organs or, in some cases, the organ itself must be on board and familiar with surgical management of endometriosis in these organs. A true excision surgeon is the captain of the ship and will have a surgical team assembled to address any and all lesions of endometriosis in order to provide the patient with the best long-term outcome from a single surgical procedure.
"I treat endometriosis like cancer - I remove all lesions of endometriosis with very wide margins and keep digging underneath until there is only normal tissue left behind. It doesn't matter where it is or what it is on, if it is endometriosis, it's coming out." - Robert S. Furr, MD, FACOG
The Importance of a Team
Dr. Furr strongly believes that it is not just about the excision surgery itself as this is oftentimes just the first step in a long process to achieve the best possible chance at a pain-free life. In addition, to the above-mentioned surgical members of the team, a good excision surgeon should have an experienced pelvic floor physical therapist on board. Likewise, a specialist in pelvic pain management is an absolute necessity if the surgeon is not adequately trained in management of chronic pelvic pain themselves. This is important and oftentimes overlooked because other problems often plague women who have had multiple surgeries for endometriosis. Multiple surgical procedures, in and of themselves, can cause other problems such as pelvic floor dysfunction, nerve entrapment and nerve damage that lead to chronic pain and urinary or bowel dysfunction. These problems must be addressed or the excision surgery will not be an adequate solution. Likewise, an excision surgeon should be proficient in performing the presacral neurectomy procedure for cases of mid-line pain associated with adenomyosis of the uterus and/or complicated painful bladder syndrome (interstitial cystitis). Because these problems are also frequently seen in women with endometriosis, excision surgery alone will oftentimes not solve all of the problems. Dr. Furr is trained in management of chronic pelvic pain and routinely performs obturator and pudendal nerve blocks, laparoscopic pudendal nerve release surgery, laparoscopicpresacral neurectomy procedures and sacral neuromodulation (Interstim) therapy.A provider with expertise in hormone replacement therapy is an extremely important member of the endometriosis excision team. Unfortunately, many women are erroneously led to believe that removal of the uterus and ovaries is a cure for endometriosis. The result of this is the scourge of surgical menopause with little or no resolution of the pain. Women are also led to believe that hormone replacement therapy will cause a recurrence of the endometriosis and lead to heart attack, strokes and blood clots. In general, none of this is true and NO woman should have to suffer the consequences of surgical menopause. Therefore, it is essential to women in these situations to be educated on the benefits, safety and efficacy of hormone replacement therapy as they far outweigh the risks in women under 50 years old who have had their ovaries removed for “endometriosis and pain”. In our facility, both of our Nurse Practitioners have had formal training in traditional andbio identical hormone replacement therapy and has years of clinical experience treating surgical menopausal syndrome with over whelming patient satisfaction.
Finally, it is also a bonus to have available specialists in dietary modifications and Integrative Medicine specialists to augment and maximize life after excision surgery for endometriosis and long-term management of chronic pelvic pain.