Kevin Audlin, MD, an expert in Endometriosis Care, Co-Director in the Endometriosis Center at Mercy Medical Center, Baltimore, talks about low-impact surgery.
Interview conducted by Ivanhoe Broadcast News in November 2017.
I wanted to start by asking you a little bit about the new tools we will be talking about today, could you describe what they are for, what you have now, and what is new and improved?
Dr. Audlin: Sure, the newest instrumentation is actually something that has been around for years, it is a three millimeter laparoscopic instrument and for the longest time they had just been used for pediatric surgery; small patients, small instruments as you do not want large incisions for the wee little infants. But, the company that started this has gotten to the point where the instruments are as rigid and as strong as traditional five and ten millimeter instruments; so we are taking these very small instruments and we are making them as strong as the larger ones, and I am able to do very complex surgery through very tiny incisions.
Tell me a little bit about the kinds of surgery that these smaller tools are good for?
Dr. Audlin: Anything that I can do laparoscopically, I can do with these instruments. The two most common that I will do are endometriosis surgery; excising endometriosis of very vital organs in the pelvis like the bladder, bowels, or the uterus and we are doing it through two to three very, very small incisions that are virtually indistinguishable. Second, hysterectomies; we can do hysterectomies through the same small three incisions. Tube removals; fallopian tube removals, appendices, you know any sort of ovarian issues. Basically, anything I can do laparoscopically; there are no limitations with these three millimeters instruments.
What is the benefit in using these instruments over laparoscopic surgery?
Dr. Audlin: Well these are laparoscopic surgeries, they are just through small incisions and they are varying degrees of sizes, so they range from 12 to 15 millimeter incisions all the way down to a true three millimeters, a true three millimeters. People talk about external diameter or internal diameter, so external diameter is the actually incision you have to make; internal diameter is the size of the instrument that goes through the port, so some of these three millimeters entrance are actually 3.5, 3.7 or actually 4.0, because the internal diameter is three millimeters. These instruments that I am using are actually true three’s so the internal diameter is actually smaller than three millimeters, so most often prior when I was doing surgery we would suture through the skin and put some glue over top, with these I am just putting a little dab of glue; there is not even a need for a suture because the incision is so small, there is no tension on it.
What is the benefit to the patient, I mean we have laparoscopic surgery we have all heard and we all know that is better because of the tiny incisions, but you have taken this even a step further?
Dr. Audlin: Sure the most obvious is cosmesis. Cosmesis is very important for a lot of these ladies, we have got women that are from the age of 18 to the mid 40’s and 50’s that are very active and if they are exercising and they are in great shape; these incisions are virtually unnoticeable that is an easy answer, the less easy answer is pain. We are less likely to go through nerves, we are less likely to go through vessels, you get a smaller incision through fascia; fascia is the tissue that holds the abdominal wall tight and is the most common reason for postoperative pain, so when the incision in the fascia is virtually zero, the postoperative pain is less as well.
And I want to just make sure that I clarify, because the tools before were not as strong, you did not prefer them, you did not use them as often, it is just the strengthen of the tools that makes them?
Dr. Audlin: Sure, they were semi-rigid, at that at that size the metal required was not able to get good enough tinsel strength so that when we are doing them and retracting or positioning you were not getting good rigidity; so it was not as safe and safety is the most important part. Cosmesis and pain relief is often secondary, but we have gotten to the point now with the rigidity of these instruments are identical to that of the larger, thicker instruments so the safety profiles are identical.
Could you talk to me a little bit about endometriosis for our viewer’s who are not familiar with it?
Dr. Audlin: Sure. It is unfortunate, it is a very common disease and it is an insidious disease, about eight to ten percent of all premenopausal ladies have it. You will find it, unfortunately, in teenagers and travels all the way through 20’s and 30’s and usually by the age of 40 most ladies that have it are well identified, but statistically you will find it takes up to towards five different doctors before a patient finds someone who identifies it and can fix it to a point where they are happy. It is a painful disease, it affects intercourse, it affects work life, it affects social life, it affects fertility, so it is a very large burden on our healthcare, very large burden on our financial well being as a country, we are making a collection of 20-year-old women that are narcotic depended to just function in life; so management of endometriosis is a paramount issue and unfortunately, most physicians are not trained to manage it affectively; which is by them physically finding where it is and removing it, almost as if you were to treat it like you would treat a cancer. You would not want to leave a cancer behind, same type thing; go in find it and get rid of it; so that the source of pain is gone.
Could you give me some of the signs and symptoms, you said it that is takes a while; are they vague?
Dr. Audlin: Well they are similar to painful cycles, so ladies that have lower back pain, and painful cycles, painful intercourse, one of the most common symptoms that most gynecologist do not look at is the GI symptom; diarrhea with your cycle, lower back pain with your cycle, it could even be constipation with your cycle, painful bowel movements with your cycle. The blood from endometriosis sits on top of the colon, it irritates the colon and it causes some sort of GI symptom. Often the primary care sends the patient to a gastroenterologist thinking that the GI symptoms are related to the organ and it actually is the endometriosis over lining it that is irritating the bowel not inside the bowel that is being irritated.
And what happens if it is not addressed?
Dr. Audlin: Infertility is a big issue, so essentially it ascends, and when it ascends it can irritate the fallopian tubes. The majority of infertility of a 20-year-old woman, or a 25-year-old woman that is not related to a sexual transmitted disease, it is very likely to be endometriosis; it is upwards of 10 percent of all infertility.
And last question, about endometriosis, standard treatments?
Dr. Audlin: Often you start with birth control pills, some sort of menstrual regulation because that is part of the way that you just kind of tease out whether it is a true dysmenorrhea or something more pathologic like endometriosis. Dysmenorrhea is painful cycles and often times can be pain-managed with birth control pills. Endometriosis in the very beginning is often treated the same way; but within the first year of treating it, it tends to not respond any longer, so at that point you either move up to stronger medications like Lupron, which is a medicine that basically shuts the ovaries off, because the ovaries are the source of the pain for endometriosis or in my opinion the more appropriate management plan is, identification and treatment, and then suppress the natural cycles of birth control with pills, or some sort of menstrual hormonal management like IUD’s.
I want to talk a little bit about Mallory; can you speak to this situation?
Dr. Audlin: Yeah, Mallory is that patient; she is a young, thin, type a personality and ended up with endometriosis unfortunately, and she was one of those young ladies that benefited significantly from the three millimeter experimentation. We were able to get her in and get her out quickly; we were able to get her back to full function rather quickly. The down time related to this instrumentation is not the same and I have seen young ladies that have had extensive endometriosis to bulking with an appendectomy and then back to their high school sports within a week; you know it is truly an eye opener, not only how well they do afterwards, but when you look at their belly it is even hard to figure out exactly where your incisions were.
If you can describe for our viewers how you perform the surgery, it’s laparoscopic?
Dr. Audlin: Yes, I make three small incisions, one in the bellybutton, and that ranges variably from a three millimeter incision. It could be a little larger, it could be as large as the one centimeter incision base off whether we do need to remove an appendix or n fallopian tube, an ovary or anything else. But if it is a straight laparoscopic procedure we can go in at a small three millimeter, which is virtually in distinguishable and then two other small three millimeter incisions at right around each hip. You try to hide it in the underwear line, in the bikini line, so it is impossible to see, but even if there was a situation where it would be visible you would see it is almost nothing there.
And you said, no, very little down time?
Dr. Audlin: Most of these patients have described, first of all feel better after surgery then they did before surgery because the source of pain gone, but even that the discomfort is mostly soreness with coughing or sneezing, or sitting up or going up and down stairs because of the bellybutton incision; but they are often back to work in three to five days.
Okay, how should I refer to this surgery, is it a three millimeter laparoscopic surgery?
Dr. Audlin: We call it low impact; low impact, because of the small incisions and less intra-abdominal pressure, so we usually insufflate the abdomen to 15 millimeters of mercury pressure; so you can get visualizations everywhere, but the system that we use for three millimeters port you do not need that, it is usually eight or ten. It is almost half the gas, so less retained gas to less pressure, less pain in the shoulder, and less bowel stunning because intra-abdominal pressure can put pressure on the bowel and the vessels; so in that situation if you are using less pressure there is better venous return to the heart, there is better profusion of the brain, it is less stunning of the bowel; so it is less in all. The theory is, there is no data approved this yet; the theory is less post-operative nausea, and less post-operative stay in the recovery room, less narcotic usage and it kind of puts the patient in the right step.
END OF INTERVIEW
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