{"paper_id":"fa482a7a-1c2a-446f-b6f4-c7c7dba1fc91","body_text":"Obstetrics and \nGynaecology Cases - Reviews\nGupta et al. Obstet Gynecol Cases Rev 2020, 7:175\nVolume 7 | Issue 5\nDOI: 10.23937/2377-9004/1410175\nISSN: 2377-9004\nOpen Access\nGupta et al. Obstet Gynecol Cases Rev 2020, 7:175\n• Page 1 of 2 •\nCitation: Gupta N (2020) Value of Minimally Invasive Gynecologic Surgeon in Surgical Management of \nEndometriosis. Obstet Gynecol Cases Rev 7:175. doi.org/10.23937/2377-9004/1410175\nAccepted: September 29, 2020: Published: October 01, 2020\nCopyright: © 2020 Gupta N, et al. This is an open-access article distributed under the terms of the \nCreative Commons Attribution License, which permits unrestricted use, distribution, and reproduction \nin any medium, provided the original author and source are credited.\nValue of Minimally Invasive Gynecologic Surgeon in Surgical \nManagement of Endometriosis\nNatasha Gupta, MD*\n*Corresponding author: Natasha Gupta, MD, Department of Obstetrics and Gynecology, Minimally Invasive Gynecologic \nSurgery, Jackson Madison County General Hospital/Woman’s Clinic P.A, 244 Coats land Drive, Jackson, TN, 38301, USA, \nTel: +1-248-464-0451\nDepartment of Obstetrics and Gynecology, Minimally Invasive Gynecologic Surgery, Jackson Madison \nCounty General Hospital, Jackson, USA\nShort CoMMeNtary\nCheck for\nupdates\nAbstract\nThe quality of endometriosis surgery performed by a Mini-\nmally Invasive Gynecologic Surgeon (MIGS) is significantly \ndifferent from that of a general gynecologist. Their training \noffers them the experience to detect subtle endometriosis, \nexcise deeply infiltrative endometriosis, manage extra pel-\nvic endometriosis and restore normal anatomy in stage 4 \nendometriosis. They are able to preserve fertility in an en-\ndometriosis patient if patient desires fertility. They are also \nable to address or excise endometriosis when performing \nconcurrent hysterectomy, instead of disregarding it.\nIn this article, a unique perspective of a fellowship trained \nMIGS is presented who practices as the only MIGS for that \narea. As a result, there is no dearth of inadequately man-\naged endometriosis patients. This article highlights a unique \nscenario where inability to excise ovary completely during \nan oophorectomy in a stage 4 endometriosis patient will \nlead to ovarian remnant syndrome.\nThe paucity of generalist’s experience in surgical manage-\nment of endometriosis leads to unnecessary hysterecto-\nmies, inability to recognize endometriosis in early stages, \ninappropriate treatments like fulguration and rare conditions \nlike ovarian remnant.\nby GnRH agonists or some form of birth control [1]. \nPredictably, patient has recurrent pain and gets a few \nmore laparoscopies. If lucky, they finally escape their \ngeneral gynecologic surgeon and finally seek help from \na specialist in Minimally Invasive Gynecologic Surgery \n(MIGS). If not that lucky, they end up with a hysterecto-\nmy without any concurrent excision of endometriosis. \nReproductive age females desirous of fertility end up \nchoosing hysterectomy due to persistent pelvic pain, \ndysfunctional lifestyle and psycho-social problems \ncaused by the chronic non-menstrual pelvic pain. Many \nof these patients have subtle, non-text book appear-\nance of endometriosis which gets overlooked by the \ngeneral gynecologists who only acknowledge the typi-\ncal black appearance of endometriotic implants.\nAs a fellowship trained MIGS who joined a general \nobstetrics and gynecology practice, I have seen variety \nof ways in which endometriosis patients are ‘managed’ \n[2]. Most of the times these patients present with per-\nsistent pain despite hysterectomy and bilateral salpin -\ngo-oophorectomy. One of the aftermaths of inadequate \nsurgical management is ovarian remnant [3].\nI have had a flood of referrals for ovarian remnant \nexcisions. The typical scenarios consist of extensive \ndeeply infiltrative endometriosis in the primary surgery \nwhere general gynecologic surgeon naturally unable \nto dissect the pelvic side walls, endometriomas etc., \nplucks the uterus and part of ovaries out. Such patients \nhave persistent pelvic pain due to inadequate excision \nof endometriosis as well as from ovarian remnant syn-\nIntroduction\nI trained in a Minimally Invasive Gynecologic Surgery \n(MIGS) fellowship program where we were referred the \npatients with chronic pelvic pain and endometriosis. \nNeedless to say, these are the patients that have been \ngiven the ‘run around’ for management of pelvic pain. \nThe typical treatment course of these patients consists \nof diagnostic laparoscopy; if fortunate, they may re -\nceive fulguration of endometriotic implants followed \n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410175\nGupta et al. Obstet Gynecol Cases Rev 2020, 7:175\n• Page 2 of 2 •\ndrome [4]. Ovarian remnant is diagnosed typically by \nMRI or ultrasound which shows persistent ovarian tis-\nsue on one or both sides. While performing the ovarian \nremnant excision in such patients, I come across exten-\nsive endometriosis, adhesions, distorted anatomy and \nretroperitoneal fibrosis.\nThe excision of endometriosis, restoration of nor-\nmal anatomy, pelvic side wall dissection, ureterolysis, \nretroperitoneal dissection, uterine artery ligation at its \norigin, dissection of rectovaginal space etc., are all the \ngreat tools that a MIGS surgeon toils to learn in their \nfellowship. However, these are elusive to general gyne-\ncologist and hence follow this suboptimal management \nof deeply infiltrative endometriosis.\nThe lack of proper recognition of MIGS as a board \ncertified subspeciality perpetuates this behavior of gen-\neral gynecologist. As a MIGS practicing in a small town \nwhere I am the only fellowship trained MIGS surgeon, I \nget referrals for extremely complicated pelvic surgeries. \nBut that’s all the referrals I get- only the very challeng-\ning cases... There are no slightly or moderately complex \ncases! Because they are managed by the generalists…\nsomehow... I see cases for fulguration of endometrio-\nsis or hysterectomy for endometriosis being performed \naround me but never a single intraoperative consult for \nmanagement of the same. That is where I could make a \ndifference with my skills but those are lost to me. And \nyet I see countless consults for ovarian remnants after \na hysterectomy for endometriosis or management of \nchronic pelvic pain after 4-5 laparoscopies for endome-\ntriosis. I believe this is due to lack of awareness as to \nthe tricks and tools that MIGS surgeon can employ and \nlack of any standard of care in surgical management of \ndeeply infiltrative endometriosis.\nIn a nutshell, I see three stages of endometriosis in \npatients-\n‘Subtle’ that a generalist will not be able to identify,\n‘Black implants’ that they will fulgurate and,\n‘Stage 4 endo’ that they will do hysterectomy some-\nhow.\nNone of those treatment options are optimal...\nI believe we can help the women suffering due to \nthe ignorance and inability of their surgeons in manag-\ning this particular condition by presenting more updat -\ned data of the MIGS performed endometriosis excision, \nincreased incidence of ovarian remnant due to subopti-\nmal excision of endometriosis and set standard of care \nfor such surgeries to be performed by a MIGS trained \ngynecologic surgeon.\nConflict of Interest\nNone.\nReferences\n1. Roman JD (2010) Surgical treatment of endometriosis in \nprivate practice: Cohort study with mean follow-up of 3 \nyears. J Minim Invasive Gynecol 17: 42-46.\n2. Chopin N, Vieira M, Borghese B, Foulot H, Dousset B, et \nal. (2005) Operative management of deeply infiltrating en-\ndometriosis: Results on pelvic pain symptoms according \nto a surgical classification. J Minim Invasive Gynecol 12: \n106-112.\n3. Wasson MN, Magrina J (2019) Surgical management and \nprevention of ovarian remnant. J Minim Invasive Gynecol \n26: 811.\n4. Kho RM, Abrao MS (2012) Ovarian remnant syndrome: Eti-\nology, diagnosis, treatment and impact of endometriosis. \nCurr Opin Obstet Gynecol 24: 210-214.","source_license":"CC0","license_restricted":false}