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Help! More surgery? Help! More surgery?

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Unread 04-12-2003, 07:59 PM
Help! More surgery?

This may be a rerun- I'm new to this & tried to post before but lost it...
I had a partial abdominal hysterectomy & one ovary removed 13 weeks ago. At 8 weeks, I had all the symptoms of my period - a little spotting and pain, pain, pain like before. My remaining ovary HURTS - all the time, really takes my breath away. The dr says it's endo or adhesions, wants to do more surgery, and frankly, I want it gone & outta here!
Meantime, he gave me a lupron shot to induce menopause & that has made it worse - 3 weeks so far of pain flares.
My questions: Does this happen often? I'm in agony and on pain pills all the time just so I can make it through the workday.
Also, I have always trusted this dr., but should I go to someone else. He said he removed the one ovary because it had "exposed blood vessels". What the heck is that?!
I know things could be worse, but I thought surgery would solve my problems & it seems like it created more. It's tough to keep smiling.
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Unread 04-12-2003, 10:40 PM
Help! More surgery?

Hmmm. What's a partial hysterectomy? And did you have endo?

At this point, if you have any doubt at all, a second opinion would be something I personally would recommend.
Unread 04-13-2003, 06:53 AM
Help! More surgery?


Sorry to hear you are in pain. Sounds like you are saying that you kept your cervix and had your uterus and one ovary removed. Is that accurate?

I did not keep my cervix, but some ladies say that they will have a mini period each month. Some have also said that docs can fix that by a treatment to the cervix.

Sometimes on Lupron your pain will get worse before it gets better. Your doc should have warned you. However, I would give his/her office a ring and let them know.

As far as "exposed blood vessels" (don't you hate it when they don't use the proper medical terms, I do) he might mean some type varicose veins or something else (hard to know when they talk slang). Also a good question to raise when you make that call.... what exactly did he mean by "exposed" blood vessels.

If overall you trust your doc, think he is competent and can talk to him then I would try to work it out with him. Otherwise, I'd consider switching.

Hang in there and let us know how you are doing. In the meantime... here's a
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Unread 04-13-2003, 08:13 AM
Help! More surgery?

I'm soo sorry you are having continuing pain & problems
I understand your frustration of having this surgery for relief & only to be left w/ more pain & problems..There are several ((Sisters)) here suffering from recurring Endo, even more battling Adhesions
My Chronic Pelvic & abdominal pain is caused by exstensive Adhesions & Neve Damage. I underwent 2 additional surgeries Post-Hyst for complications from Adhesions, each surgery only worsened the pain & damage..Here is some good info I have researched on both of these conditions:

These links contain info on available products used for Adhesion Prevention:[email protected]

2nd look Lap:

Can Adhesions be prevented?
The only way to treat adhesions is to remove or separate them surgically. This procedure is called adhesiolysis. Studies have shown that patients with pelvic pain and severe adhesions can experience a marked reduction in symptoms after adhesiolysis.

However, even following adhesiolysis, adhesions reform more than 70 percent of the time. That’s why adhesion prevention is so important.

Meticulous surgical technique – Careful surgical technique can help minimize trauma, minimize the interference with the blood supply, prevent the introduction of foreign bodies, minimize bleeding, lessen the incidence of raw surfaces and decrease the incidence of infection - all of which help reduce adhesion formation.

Although adhesions often form after gynecologic surgery, they are not inevitable. And, even if adhesions do form, they usually don’t cause pain or other problems.

Although there is no way to eliminate the risk of adhesions completely, there are steps your surgeon can take to reduce the likelihood of adhesion formation. The most effective methods of adhesion prevention involve meticulous surgical technique and the use of a physical barrier to separate tissue surfaces while they heal.

Surgeons have developed minimally invasive techniques such as the laparoscopy, that are designed to minimize trauma, blood loss, infection, and the introduction of foreign bodies, all of which can lead to inflammation and adhesion formation. Good surgical technique involves minimizing tissue handling, using delicate instruments, and keeping the tissues moist when they are exposed to the air.

While good surgical technique is important, it is often not sufficient to prevent adhesions. There are also other preventive steps that can be taken:

Can Adhesions be prevented:

Barriers – Fabric or liquid barriers create a physical separation between raw tissue surfaces while they heal. Thin tissue-like fabric barriers may be used to try to reduce adhesion formation at specific sites, while liquid solution barriers can help prevent adhesions over broad areas of the abdominal and pelvic region.
GYNECARE INTERCEED Barrier is a lightweight, tissue-like “fabric” that can be placed at the surgical site. The fabric protects and separates the surfaces where adhesions are likely to form. The fabric slowly dissolves as the surgical incision heals. Studies demonstrate that GYNECARE INTERCEED Barrier significantly enhances good surgical technique in reducing adhesion formation.

GYNECARE INTERGEL Solution is a liquid that can be poured into the pelvis after surgery to separate and protect organs and tissues as they heal. The solution is easy for the surgeon to use and can be applied directly to the surgical site. Even more important, GYNECARE INTERGEL Solution covers a broad area and provides protection against adhesions.
Sulaiman H, Gabella G, Davis MSc C, Mutsaers SE, Boulos P, Laurent GJ, Herrick SE.Presence and distribution of sensory nerve fibers in human Peritoneal adhesions. Ann Surge 2001 Aug; 234(2):256-61

Department of Medicine, University College London, The Rayne Institute, London, UK.

RESULTS: Nerve fibers, identified histologically, ultrastructurally, and immunohistochemically, were present in all the peritoneal adhesions examined. The location of the adhesion, its size, and its estimated age did not influence the type of nerve fibers found. Further, fibers expressing the sensory neuronal markers calcitonin gene-related protein and substance P were present in all adhesions irrespective of reports of chronic abdominopelvic pain. The nerves comprised both myelinated and nonmyelinated axons and were often, but not invariably, associated with blood vessels.

CONCLUSIONS: This study provides the first direct evidence for the presence of sensory nerve fibers in human peritoneal adhesions, suggesting that these structures may be capable of conducting pain after appropriate stimulation.
"If the adhesions are extensive, and the patient has undergone previous adhesion surgery that failed, I have taken an unorthodox approach to such individuals. Because adhesions begin to form almost immediately, along with the healing process involving the raw anterior abdominal wall, I have in special situations recommended a repeat laparoscopy in one week. At this point, the "new" adhesions are flimsy, soft, do not contain a blood supply, and can be swept away with minimal tissue injury, compared to a conventional adhesiolysis (freeing the adhesions surgically) of old adhesions that are dense, very adherent, and bloody. This is performed in an outpatient setting, and usually takes but a few minutes, compared to the time involved dealing with extensive, dense old adhesions."
Adhesion Prevention Home Page:

Proven Adhesion Prevention:

Welcome to SPRAYGEL :: Adhesion Barrier: Meta-analysis of Interceed Barrier Safety/Efficacy:


Contemporary Adhesion Prevention:

GYNECARE INTERGEL® Adhesion Prevention Solution:

Seprafilm surgical intestinal adhesion prevention:

CO2 laser, Harmonic Scalpel, Electrosurgery, LAP Surgery:ADHESIOLYSIS:

ANTI-Adhesion treatment for Gynecologic surgery:

Gynecare Intergel:

Adhesions info on the pain & problems they can cause:,00.html

Recurring Endo:

Endometriosis Conquering The Silent Invader:

Recurring Endo at the Center For Endometriosis Care:

Endometriosis-Dr. Stanley West:

Endometriosis Treatment Program @ St. Charles Medical Center-Bend, OR-Dr. David Redwine:

Hysterectomy & Endometriosis Questionnaire:

Post-Op Ovarian Suppression:

Incisional Endometriosis:

Endometriosis Research Center:

Radical Endometriosis Surgery:

can I still have endometriosis after having my uterus and both ovaries removed?

Yes, but this can be one of the most difficult situations encountered with endometriosis. It can be difficult from the patient's standpoint, because, not uncommonly, she is dealing with a medical profession, family etc. who is really starting to question the legitimacy of her pain. From a physician's standpoint, this can be the most difficult type of surgery encountered by a gynecologist and thus the most likely not to be correctly or completely treated resulting in "treatment failure" with recurrence of symptoms.

There is no question that endometriosis can be present in a woman who has undergone a hysterectomy and removal of both ovaries (even more likely if the ovaries remain). Performing a hysterectomy does not in itself treat endometriosis. It may reduce the chance of future recurrence of endometriosis, reduce non-endometriosis related cramps, bleeding etc. The key point is that endometriosis, for the most part, does not grow on the uterus, it grows behind the uterus, on the bowel, in the rectovaginal septum, in the pararectal spaces, under the ovaries, around the ureters, on the bladder, etc. If a hysterectomy is part of the agreed upon treatment plan between you and your physician that is fine, but ONLY AFTER the endometriosis has been completely removed from all of the areas which will not be taken out with the uterus. If you have undergone a hysterectomy alone for the treatment of endometriosis (the endometriosis was not treated just prior to the hysterectomy) there is a good chance you will have persistent or recurrent symptoms. The most common symptoms include constant pain, pain with bowel movements, pain with intercourse (usually deep penetration, like he is hitting something inside) and occasionally mid back pain (secondary to ureteral involvement). You can also experience the emotional changes we have seen with endometriosis including moodiness, depression, etc.

Now, assume for a minute that everyone understands your situation (your doctor, significant other, employer etc.) and your gynecologist surgeon is standing there ready to go after the endometriosis. What are the pitfalls? In my experience, by the time a patient has gotten to this point she has undergone so many surgical procedures that is impossible to tell what is and what is not endometriosis. The anatomy is distorted, fairly extensive scar tissue and fibrosis (tough leathery tissue) is present, and often endometriosis is buried out of sight in a patient who has had a hysterectomy performed. The endometriosis gets buried when the surgeon clamps, cuts and ties the tissue during the hysterectomy. The endometriosis that is present get wadded up and buried in this process. After this area heals following the surgery it can be impossible to see endometriosis without dissecting the areas in which endometriosis is known to grow. Another common area for residual endometriosis is the vaginal cuff. Unless all of the endometriosis is removed from the rectovaginal septum prior to the hysterectomy, it can be easily sewn into the vaginal cuff.

We have seen and treated more than 200 women with residual endometriosis after undergoing a hysterectomy. If you are experiencing this situation, you are not alone. In my experience there are several key factors in successfully treating this type of case. First, this is probably the most technically challenging surgery a gynecologist will face. It is important to seek out a surgeon who is technically good and has experience in dealing with this situation. Second, since it can be impossible to determine what is and what is not endometriosis, all abnormal tissue must be removed and the areas in the pelvis where endometriosis is know to grow must be dissected out. It is not uncommon for an area to look normal on the surface, but to have deep endometriosis when opened up. In my experience, all areas need to be dissected down to normal tissue (endometriosis until proven normal). Depending on the specific situation a small portion of the vaginal cuff may need to be resected.

In summary, you can have endometriosis and the associated symptoms and pain even if you have had a hysterectomy. Treatment of this condition is technically challenging and requires the ability, expertise, and equipment to dissect and laser all of the pelvic areas deep down to normal tissue. In my opinion, a surgeon can not get all of the endometriosis and scar tissue by just spot treating or selectively excising lesions. In my experience, once all of the pelvic area is explored and all the abnormal tissue is laser out, the patient feels better.

Is My Endometriosis_coming back?
After endometriosis surgery, a woman wants to believe she is better, but is afraid to hope too strongly for fear of being disappointed yet again.When such a woman has pain or any other symptom resembling the symptoms she had before surgery, she might draw (or be given) an erroneous conclusion that, "the endo is back".This article tries to explain what some of these symptoms might mean, when they are worrisome, and what you can do about them._General InformationEach case of endometriosis is unique, because of the locations of the implants and the depths to which the tissue was invaded. Therefore, it is a bad idea to try to compare your recovery to anyone else’s, or even to yourself at a previous operation.Even if the surgeries seem very similar, recovery varies due to a number of host (that’s you) factors including the following:
immune system status
nutritional status
percentage body fat
blood clotting factors
differences in anatomy
smoking status
chronic lung disease, or
inadequate oxygen delivery to the tissue
ambulatory activity
other disease processes
life stresses and pressures
compliance with post-op directions
number of prior surgeries
type of anesthesia
co-dependency factors (environmental, social, and personal factors that can cause certain responses to pain and stress). The first approach about any concern: Do the symptoms suggest a need for immediate attention to evaluate a new problem or a surgical complication? Consult the post-operative instructions you were given to check your doctor’s guidelines about what is normal and what is not. If you have reasonable doubt, always call for advice._The Healing ProcessHealing begins as soon as the surgery ends. First, injured blood vessels clot and the body speeds host defense mechanisms into the area. Each location injured by excision begins to have local edema with an infusion of serum. Multiple blood-borne factors and cells are rushed into place. The tissue swells and nerve endings are irritated and sensitive to these changes. Adhesions may form over the area in an attempt to wall it off. The body then begins to lay down new blood vessels and new peritoneum to cover the injuries. Soft tissues are amazingly reconstructed. This is your body’s natural response. The deeper the surgical dissection that was needed to remove all your endometriosis, the more injury there is to heal.For the completion of this process we estimate that 10-12 weeks need to pass. This time period can increase due with factors such as those listed above, or complications such as infection or bleeding.

Adhesion Formation:]
adhesions are your body’s natural defense mechanism for dealing with intra-abdominal injury. The adhesions form as your body tries to wall off the injured area.This is basically a very good process. However, it concerns us when it affects the function of the ovaries or tubes and interferes with fertility. It also becomes a problem when it causes active organs (such as the bladder, uterus, tubes, ovaries, and/or intestine) to become bound together. This can cause pain because tissue that was designed to float freely within the pelvic is now stuck together.Adhesions usually form in the immediate post-op period. We use every available technique to protect the active organs listed above from becoming involved with adhesions. Still, some adhesions may form. We certainly expect them more often in Stage III-IV patients due to the more extensive surgery needed to totally excise all their disease.Most of the time, adhesions can exist harmlessly in the abdomen without creating painful problems. However, the potential for pain or infertility is certainly increased in the endometriosis patient.Interestingly, we have observed in some women the recurrence of symptoms attributed to adhesions in the one to five year period post op. I believe that once adhesions have formed in the immediate post-op period, they will not continue to form unless there is a new insult to the tissues such as injury, infection, or more surgery.Later (1-5 years), some women report symptoms related to adhesions. The adhesions already present may undergo a very slow process of coalescing or shrinking. If this process begins to limit the mobility of organs that need to change size and/or position, painful symptoms can result

Adhesions are the method the body uses to isolate injury, infection, and certain types of irritants to the peritoneal surfaces, such as blood or cancer cells.The ovary may be the source of the problem, or it may be an innocent bystander. Pelvic infection may come from the tubes and involve the ovaries, or be secondary to a different type of pelvic surgery, such as for a_ tubal pregnancy. The ovary itself can spill contents that create adhesions, such as blood, fat (from a dermoid), or chocolate from an endometrioma.If an ovary is stuck to another organ, we can often tell the source of the problem, especially with active endometriosis. Certain patterns and types of adhesions also suggest certain causes. Pelvic Inflammatory Disease (PID) is almost always bilateral and generalized, as opposed to unilateral and focal. Sometimes we can match a patient's known history of infection or previous surgeries with her adhesions. This can help eliminate some possible causes for the scarring.
The survey found that 40% of women who suffer from chronic pelvic pain due to endometriosis or the formation of postsurgical scar tissue have been told they exaggerate their pain. More than half (52%) were told this by their ob/gyn and 43% by a friend or family member. Nearly 60% of these women have been told that their pain is normal. Of these, 56% were told this by their ob/gyn and 29% by family or friends.

"The results of this survey are concerning given the impact pelvic pain can have on a woman's life," said Mary Lou Ballweg, president and executive director of the Endometriosis Association, who announced the data. "On a regular basis, we see women completely alter their lives because of the debilitating effects of pelvic pain. The frustrating part is that it often takes years for women to receive a diagnosis, and by then, many are unable to work or fully participate in normal activities."

In fact, 43% of women surveyed describe their pain as constant. More than half describe the intensity of pain as severe to unbearable (26% say it's severe, 18% say very severe, and 9% say unbearable). At this level of pain, it's not surprising that more than 80% say they have been unable to work at times due to pelvic pain, and 45% say they have been debilitated for 2-3 days or longer each month.

"Chronic pelvic pain accounts for 12% of hysterectomies and 40% of laparoscopic surgeries. The total costs of treating chronic pelvic pain are more than $2 billion each year," said Dr. Charles Miller, reproductive endocrinologist, gynecological surgeon and medical director of Specialists in Reproductive Health in Arlington Heights and Naperville, Illinois. "As I've seen with many patients and with this survey, chronic pelvic pain also exacts a significant emotional toll, which makes it even more important that women speak to a doctor at the first signs of pelvic pain."

The survey of 968 women ages 15 through 59 with endometriosis and/or postsurgical scar tissue was designed to uncover specific information about women's experiences with chronic pelvic pain. The survey, conducted by The Endometriosis Association, was cosponsored through a restricted educational grant by Gynecare, the women's health division of Ethicon, a Johnson & Johnson company, and Purdue Pharma L.P.

Two of the leading causes of chronic pelvic pain are Endometriosis and the formation of post surgical scar tissue
also called adhesions. Of the women surveyed, 89% had endometriosis, and nearly 40% had been diagnosed with adhesions.

Endometriosis is an immune and hormonal disease that affects 5 million women and girls in the U.S. It occurs when tissue similar to the lining of the uterus (called the endometrium) is found outside the uterus, usually in the abdomen, on the ovaries, or on fallopian tubes.

Postsurgical adhesions are abnormal bands of scar tissue that form inside the pelvis after gynecologic surgery. Endometriosis can also cause adhesions.

As many as 90% of the 3 million women who undergo gynecological surgery each year to treat common female health problems such as ovarian cysts, fibroids and endometriosis, will develop adhesions.

Ironically, women who undergo pelvic surgery to correct endometriosis or to remove adhesions (a procedure called adhesiolysis) are at risk for developing pelvic pain from new formations of pelvic adhesions.

However, new treatments are available to help stop the recurring cycle of pelvic pain. A variety of treatments can help treat pain due to endometriosis, and doctors now have tools to help reduce the risk of adhesion development after surgery to treat endometriosis or remove adhesions. Women should proactively talk with their physicians about chronic pelvic pain, its underlying causes and how it can be treated, or even prevented, in some cases.
Conscious Pain Mapping:

What You Don’t Know Can Hurt You: Knowledge Is Power In A Doctor/Patient Relationship:

Resection of Endometriosis*video*-warning graphic:

The Price of Pain on the Economy:

Disorders More Common in Women:

Endometriosis Angels:

eMedicine - Endometriosis : Article by Manuel Hernandez, MD

Jenny's Endo page:

Endo Association family program:

Theories of origin:

New and Emerging Treatments for Endo:

Danazol Vaginal:

This appears to be a new and very promising method of suppressing pelvic endometriosis. The treatment plan I use is based on data from studies by a Japanese research group lead by Dr Masao Igarashi.

Danazol was one of the first drugs used to suppress endometriosis. Although it provided good suppression, its side effects: weight gain, acne, hot flushes, increased hair growth and decrease in breast size caused us to abandon it in favor of GnRH agonists. Vaginal Danazol suppresses endometriosis without causing any of the above-mentioned side effects. It gets absorbed directly to the pelvic tissues through the wall of the vagina. The only side effects experienced by my patients using Vaginal Danazol include some vaginal irritation and occasional constipation and those effects are easily corrected. I use Vaginal Danazol after removal of endometriomas and laparoscopic resection of fibrotic endometriosis to suppress any residual and microscopic endometriosis. I am also evaluating the use of vaginal Danazol prior to operative laparoscopy, especially in women with endometriosis involving their bowels. The hope is that pretreatment will decrease size of the fibrotic lesions, making less extensive surgery possible.

Progestagen Releasing Intrauterine Device:

European centers are evaluating intrauterine device containing a slowly released progesterone like, drug. Patients using these devices seemed to have less painful periods and less menstrual flow.

Antiprogesterone Drugs:

GnRH Antagonists:

These drugs are used in Europe to treat endometriosis. They are comparable in their effectiveness to GnRH Agonists.

Vessel Growth Factor Agents:

Agents that affect the growth of new vessels in our body are being tested in cancer therapy. I am not presently aware of the results of any studies in US in patients suffering from endometriosis.

There may be no significant symptoms of implants on the surface of your ovary unless there is the formation of adhesions. You may, however, experience pain on the side of the pelvis where the implants are present. The pain might be a continuous ache or burning, usually worse during menstruation. Additionally, you may feel pain deep in the pelvis or inside the vagina during sexual intercourse, this pain also will intensify during menstruation. During pelvic examination, your physician can likely reproduce some of the pain when he or she palpatesand move the affected ovary.
Treatment: Laparoscopic CO2 laser vaporization or harmonic scalpel destruction of the implants is the optimal surgical treatment for you because neither of these causes significant damage to the ovary itself.If you do have adhesions between the ovaries and the surrounding organs, they should be resected by use of CO2 laser, harmonic scalpel, or laparoscopic scissors with only minimal use of electrocautery. In some cases Lupron Depot suppression for six to nine months may be effective, but you should be aware that it will not affect already formed adhesions. As an additional option you may want to consider suppression using Danazol vaginal suppositories.

Endometriosis inside the ovary:
Description: Endometriosis inside your ovary is usually transformed into the cystic structure within your ovary called endometrioma (chocolate cyst).The endometriotic implant within your ovary or the surface implants burrowing into your ovary are surrounded by ovarian tissue. A small amount of fluid and blood produced by the implant during each menstrual cycle cannot escape that enclosure and it will accumulate within your ovary, forming a cyst (fluid filled space) called endometrioma.The inside of the cyst provides the surface for the endometriosis to spread and grow. This in turn makes the volume of fluid produced with each menstrual cycle greater and makes the cyst grow larger.There are occasional breaches of the wall of the cyst, which allows some of the bloody fluid to escape into your abdomen and pelvis. This in turn causes an inflammatory reaction (irritation) within your abdomen and the formation of scar tissue around the leak as your body tries to prevent wider spread of this irritating material.
You should note that endometriosis of the ovary is almost always a benign condition, and only very small number of endometriomas will show malignant changes.

Symptoms: Pain in your lower abdomen is a common symptom of endometrioma. It is usually chronic and more pronounced on the side of the cyst, sometimes it will radiate to your lower back. You will find that the pain is usually worse around the time of menstruation and on occasion it will become quite severe.There also may be deep pain during sexual intercourse.If you have this condition pelvic examination will usually reveal an enlarged ovary, which may be quite tender and often times is immobile.

Diagnosis: While the combination of your symptoms and a pelvic examination, are often enough to make a diagnosis, you should likely also get an ultrasound in order to identify the cyst within the ovary.Vaginal ultrasound usually provides significant detail as to the appearance of the cyst and aids toward fuller diagnosis of endometrioma. Ultimately, only Laparoscopy and surgical removal of the cyst wall provide a definite diagnosis as to the kind of cyst. Note that CT scan and MRI scan can usually identify cystic masses in your pelvis but they are not as helpful as ultrasound in providing details of its internal appearance.

Treatment: Aspiration of the bloody or chocolate fluid from the cyst is not an effective treatment because the entire lining of the cyst, including all of its endometrial implants, is left behind and ready to form a new cyst.

Removal of the ovary containing endometrioma is quite a radical approach and you should consider this if you are not contemplatingfuture pregnancy, if you have massive adhesions around the ovaries that failed previous attempts of conservative surgical treatment or if there is a possibility of ovarian malignancy.

Endometriosis of the pelvic sidewall:
Description:Your pelvic sidewall is covered by a peritoneal layer and faces the front and sides of your ovaries. It contains large blood vessels, nerves and your ureter.This is one of the most common locations for endometrial implants and adhesions.

Symptoms: Pain (burning and aching) in the right or left lower quadrant of your abdomen and on the right or left side of your pelvis is a common symptom.The pain usually worsens before and during menstruation. The pain may also increase with walking or physical activity, especially if there are lateral pelvic wall adhesions between the enlarged endometriotic ovary and peritoneum of your pelvic sidewall.
Treatment: Reestablishment of your normal pelvic anatomy and removal of all endometrial implants is the goal of the treatment.If adhesions are present between your ovary and your pelvic sidewall, the adhesions will need to be divided before your entire pelvic sidewall can be evaluated for the presence and extent ofendometriosis.Your physician may use one of many methods to divide the adhesions between your ovary and pelvic sidewall, including dissection with scissors, CO2 laser dissection and harmonic scalpel dissection.

With your ovary freed up, your peritoneum is exposed such that the extent of endometriotic lesions can be assessed.The most effective method of treatment in this area is to resect endometriotic lesions together with the area of your peritoneum through which they are growing.The key to successful treatment is for your surgeon to identify the course of your ureter (the tube that carries urine from each kidney to the bladder) that traverses just below the peritoneum of your pelvic sidewall. The other important structures that your surgeon needs to identifiy include large blood vessels and nerves that are located in your pelvic sidewall.

Once these structures are identified, your surgeon will inject normal saline solution below your peritoneal layer, which elevates your peritoneum and endometrial lesions away from these vital structures. This produces a safe buffer zone where the laser, harmonic scalpel, or scissors dissection can be carried out.In dissection I try to avoid using unipolar electrocauthery which, although it provides for bloodless resection, it uses high-density electrical current. The surge of electricity can theoretically damage sub-peritoneal mesothelial cells, which are essential for reconstruction of a normal peritoneum within seven to ten days after surgery.To control bleeding points, your surgeon may use CO2 laser, harmonic scalpel, or bipolar electrocauthery.Note that resection of the lesions of the pelvic sidewall is greatly preferred over their destruction by laser, harmonic scalpel, or electrocauthery, due to the fact that destruction is often incomplete (it does notdestroy the lesion deeply enough).

Additional postoperative therapy with GnRH agonists (Lupron Depot, Synarel, etc) or Danazol may improve the effectiveness of the surgical treatment. As an additional option, you may want to consider using Danazol vaginal suppositories.

Endometriosis of the posterior cul-de-sac :

Description:The posterior cul-de-sacis the space behind your uterus. It is surrounded by your uterus in the front, pelvic sidewall and ovaries on the side, and your sigmoid colon in the back. The floor of your cul-de-sac contains your uterosacral ligaments, your rectum and the upper portion of your vagina.The posterior cul-de-sac is one of the most common locations of endometriosis in the pelvis.Most of the time, the implants are quite superficial, but in a number of women they will invade deeper into the tissues. They may form nodules within your uterosacral ligaments, they may cause attachment of your sigmoid colon and rectum onto the posterior wall of your uterus. This causes the most extreme form of the involvement, cul-de-sac obliteration.

Symptoms: Constant pelvic pain/ache is the most common symptom.The pain is usually more severe during menstruation and is usually located in your lower abdomen and lower back. Pain may extend to your upper thighs and your rectum and there may be deep pain in your vagina during sexual intercourse, many times preventing normal sexual relations.There also may be pain with bowel movements.

Endometriosis of the bowel:
Description:Your sigmoid colon (lower portion of the large bowel) and your rectum are pelvic organs which are anatomically associated with areas that are common sites of endometriosis.In some patients, especially those with severe endometriosis, there is extensive involvement of the bowel wall.Most commonly, the endometriotic bowel implants will be restricted to the surface of you bowel and adhesions around your bowel. In more severe cases, the implants may involve the entire thickness of your bowel wall.Your appendix is part of your bowel and on occasion it will become a pelvic organ. The appendix is involved in approximately one percent of patients with endometriosis.

Themost common symptom associated with endometriosis of the bowel is cramping and diarrhea during menstruation (many patients will be incorrectly diagnosed as having irritable bowel syndrome).Minimal and superficial endometriosis of your bowel does not have any specific symptoms different from those of the endometriosis of the cul-de-sac.But severe endometriosis infiltrating deep into your bowel wall is usually associated with chronic pelvic and back pain and painful bowel movements, generally worse before and during menstruation. In endometriosis that has penetrated your bowel wall completely, you may note rectal bleeding or some blood covering the stool during menstruation. In such case, you will likely suffer from extreme pain during bowel movement.
I'm sorry this is soo long but there is soo much controversy on how to treat Endo & Adhesions...Unfortunately, even w/the use og the prevention products, the amount of Adhesion that will reform is high. IMO, I would look into alternative treatments for Adhesions. Pls discuss indepth your concerns with your is a few ??'s to ask that have been helpful to many:[list=1][*]How successful have you been at removing Endo & Adhesions in previous patients?[*]Are there certain techniques you use in preventing Adhesion reformattion?[*]Since I had surgery to take care of this previously, & it was unsuccessful, how do I know this one will be?[/list=1]

Here is some good info to take with you to discuss w/your Dr to see what his thots on these techniques are:

Reduction of Post Surgical Adhesions:
The prevention of adhesion (scar) formation should be a primary goal of all fertility surgery. Efforts can (and should) be undertaken to reduce postoperative adhesion formation partially by using principles collectively referred to as "microsurgical techniques." When the infertility surgeon recreates a pelvic organ, opens a previously blocked fallopian tube, removes abnormal structures from within the uterine cavity, ablates endometriosis, or lyses existing pelvic adhesions the restoration of normal anatomy and function often depends on minimizing scar tissue secondary to the surgery.

The microsurgical techniques that should be employed include:
  • very gentle tissue handling (pulling, rubbing and poking the delicate reproductive tissues can result in trauma and adhesion formation),
    meticulous control of bleeding = hemostasis (whole blood within the pelvis is highly irritating to the peritoneal lining and the inflammation that results can lead to adhesion formation),
    use of magnification if necessary (for establishing proper tissue planes during dissection and for determining the degree of reapproximation accomplished when tissues are placed together)
    careful avoidance of infection (administration of antibiotics to prevent reactivation of a dormant infection within say the fallopian tubes, sterile technique in handling the operating instruments)
    maintaining tissue moisture (irrigation is generally better than sponging, preventing desiccation or drying is important since either leads to adhesion formation)
    minimal effective coagulation of bleeding sites (over cauterizing results in ischemia and this may enhance adhesion formation)
    reducing foreign material that is placed intraoperatively (use of small caliber suture material reduces overall bulk, rinsing sterile gloves or similar objects placed intraabdominally removes talc)
    reducing lateral thermal damage of tissue (lasers, especially ultrapulse and superpulse CO2 lasers, allow application of very high power densities to tissues to accomplish ablation by vaporization with little lateral thermal damage. This is theoretically of great significance)

In theory (although not proven in the existing literature) laparoscopy has an advantage over laparotomy in terms of adhesion formation. With laparoscopy, small abdominal incisions are made and ports maintain access while occluding the holes when no instruments are actively being used. When compared to laparotomy, this should result in less infection (since the sites are not open for the duration of the case), less tissue drying (especially for longer duration cases when drying can be tremendous for open laparotomies), and less tissue trauma secondary to rubbing or moving intraabdominal structures with surgical gloves. Additionally, the laparoscope is able to be placed immediately adjacent to the operative site to enhance visualization of structures that are buried in the pelvis and the laparoscope can magnify tissues slightly. The magnification achieved with the laparoscope is proportional to the distance of the lens from the tissue viewed, such that at a distance of 1 cm from tissue the laparoscope typically magnifies the tissue about 6 fold, at 2 cm about 4 fold, at 3 cm about 2 fold, at 4 cm there is no magnification and at distances greater than 4 cm there is a reduction in size of the viewed tissue.

Adjuvants are materials that can be used to help prevent adhesion formation. The two primary classes of adjuvants include mechanical barriers and surgical adjuvants.

Mechanical barriers include Gore-Tex surgical membranes (that must be sewn into position), Interceed TC-7 (a material placed over raw surfaces), and 32% Dextran 70 (a highly concentrated sugar like solution made up of high molecular weight glucose polymers that draws in water to act as a mechanical barrier between structures).

Of these barriers, Interceed seems to be the most commonly used. Literature from several clinical reports support a role for Interceed in adhesion prevention.

32% Dextran 70 (Hyskon) has been popular in the past and is still in use in some centers. Mechanical separation of raw surfaces is associated with the water drawn into the concentrated solution (hydroflotation) and a siliconizing effect (the solution is slick). When 200 cc of 32% Dextran is placed intraperitioneally there is usually some ascites for up to a week, and patients occasionally complain of fluid leaking from the incision sites, labial swelling, bloating and weight gain.

Surgical adjuvants include antiinflammatory drugs, anticoagulants, prophylactic antibiotics, calcium channel blockers and plasminogen activators.

The antiinflammatory drugs include corticosteroids (intended to decrease vascular permeability and enhance lysosomal stabilization, each of which should limit adhesion formation), antihistamines (intended to decrease vascular permeability and decrease fibroblast proliferation, each of which should limit adhesion formation), and nonsteroidal antiinflammatory agents like motrin (reduces prostaglandin formation to limit adhesion formation). None of these agents has been shown to be beneficial in terms of adhesion formation in large clinical trials but they are often used by physicians whose personal experience with the medications has been favorable. I do not use these agents at this time.

Anticoagulants include low dose heparin (about 1-5 units/mL) within irrigation solutions. High doses of heparin should not be used because there is an increased chance of hemorrhagic surgical complications. Low dose heparin has not been shown to be of benefit in terms of adhesion formation in clinical trials.

Antibiotics may reduce the incidence of infection when given prophylactically. The goal is to achieve adequate doses at the tissue sites during the surgery. Vibramycin is often used for tubal surgery since it effectively treats Chlamydia. Many of the higher generation cephalosporins also work well for gynecological pelvic surgery. I typically use cefotetan or mefoxin (depending on availability).

Calcium channel blockers have been used in hamsters with good results, but human studies are lacking. In theory, these agents decrease tissue ischemia, limit prostaglandins, reduce platelet aggregation, and limit vasoconstriction. The use of these agents is awaiting appropriate human trials.

Plasminogen activators accelerate fibrinolysis to reduce the bulk of fibrin clots. Use of these agents is also awaiting appropriate human clinical trials.
Pelvic manipulation:

Good Luck...pls keep us posted...(((hugs)))
Unread 04-13-2003, 10:19 AM
Help! More surgery?

I can tell you that I know just how you feel! I can also tell you that with my experience with Lupron, I think it is normal for you to experience worsening symptoms in the first couple weeks. That's exactly what happened to me and that's what I have read happens alot. It got really, really bad the first couple weeks and then I was pain free after that.........until I went on add-back therapy to help with the side effects, then my pain came back again. Hang in there. Keep us posted
Unread 04-13-2003, 01:32 PM
Thank you so much!

Wow! I posted my troubles just yesterday and this morning I had 24 pages of medical information and sympathy to print up - and that's before I visit all the links! I am so grateful I can't even express it. The information gives me confidence in making my decisions, and the sympathy and stories let me know I'm not alone. Thank you sooooo much. I hope I can help someone else as much as you helped me.
Unread 04-13-2003, 09:53 PM
Help! More surgery?

Hi and welcome.....

I see Sheri gave some great information to read. She is the info QUEEN!!

I even go back through the threads sometines and retreive info she has listed..

I am also a victum of either adhesions or recurring endo. I am having another lap the 30th. I know the pain oh to well and hate to see sisters going through recurring pain, what ever it is caused from!!

I did not have any experience with Lupron as I have EVERYTHING removed.

I just wanted to send you a HUGE and wish you happy reading!!

We are all here to help you through this!!
Unread 04-14-2003, 03:46 AM
Re:Lupron Info~

Lupron Endometriosis Home Page:

Women Talk About Lupron Depot®

Hysterectomy, HRT and Endo Resources:

A Woman Guide to Endometriosis:

Myths & Misinformation:

Lupron a cure for Endometriosis?_ Believe that one, and I've got a bridge to sell you.

Let's first address the fact that not only are GnRHs like Lupron not a cure, but there is currently no definitive cure for Endometriosis._ Given the current research underway, there certainly may be one on the horizon, but the best we can hope to attain at this time is long-term remission...which, thankfully, is completely possible when working in partnership with an Endometriosis specialist.__ We owe a debt of gratitude to the men and women, lay persons and professionals alike, who do treat the disease seriously and who have dedicated their lives to understanding it better._ It is these people who will lead the way to early detection and definitive treatment for the Endometriosis daughters of the future.__
Unfortunately, however, the longer certain members of the medical establishment continue to prescribe stop-gap measures without addressing the significant need for a cure, the longer we will be without one. What can we do to help speed the process along?_ Get educated._ Get involved._ With awareness comes recognition of needs: the need for more funding for disease research, the need for better support of patients with Endometriosis, the need for more doctors to better understand the disease, the need for more effective treatments, and ultimately, the need for a cure._ Women with Endometriosis do not deserve to have to travel thousands of miles, often at their own expense, for effective treatment with an Endometriosis specialist because they are few and far between._ Women should not have to resort to ER visits on a monthly basis because they are crippled with unresolved pain._ Women should not be misled as to the efficacy of their treatment options and blamed for the subsequent - yet inevitable - return of symptoms at the treatment end._ Most of all, women with Endometriosis do not deserve to feel alone with their disease.

Let's begin the education process by debunking some 100+ yr. old myths about Endometriosis which, unbelievably, are still circulating today._ The more we know, the more we can take charge of our own healthcare._ The more we take charge, the more empowered over Endometriosis we become.

Fallacy Number One:_ Endometriosis is a career woman's disease.
Most likely, these "career women" were the ones that sought medical care most often, and therefore obtained the most diagnoses._ We know now, of course, that Endometriosis knows no barriers whatsoever and is found in every socio-economic and ethnic class world-wide._ For more background information on Endometriosis, read "Endometriosis 101: the Basics."

Myth Number Two: Endometriosis only affects women in their reproductive years.
While certainly most_ prevalent in reproductive-aged women, especially those in their 20s and 30s, Endometriosis has been found in the autopsies of infants, in 7 year old girls, in women well into their 80s, in post-hysterectomy and menopausal women; and even in a few men who were treated with estrogen for certain cancers.

Sadly Mistaken Idea Number Three: Pregnancy and/or hysterectomy will cure Endometriosis.
It is frightening to know that students just out of med school, when asked for treatment alternatives, responded by saying that pregnancy would cure the disease, as would a hysterectomy. Women all over the world are still being offered the same treatments that were initially given when the disease was first mentioned in 1870: "prescribed" pregnancies and hysterectomies._ Neither is a definitive cure.

Misleading Myth Number Four:_
Medications can cure Endometriosis.
There are many non-surgical alternatives to treating the disease, the most common of which are medical therapies like GnRH agonists, oral contraceptives and medroxyprogesterone acetate._ Some women are led to believe that such therapies will cure them - they won't._ They certainly have their purpose in Endometriosis treatment and can be very useful, even provide long term relief for some._ But there has never been any medical evidence to support the notion that they will cure the disease._ Women need to be fully informed about the drug they will be taking: what the possible side effects are, what the expected outcome might be, what the realistic expectations of the treatment are...all the pros and cons._ They should not be misled to believe that popping a pill or getting an injection will solve all their problems - Endometriosis tends to be a sleeping giant which awakes angrily at the end of the treatment. On a side note:
GnRHs are still, as of this writing, only FDA-approved for 6 months in a lifetime._ While there are trials going on and other research being done into long-term usage, re-treatment beyond a 6 month period is not recommended._ Request that your physician perform a bone density scan prior to undergoing GnRH therapy to establish a baseline, and another at the end of treatment to determine if there has been significant loss of trabecular bone density._ And always, always establish that you are not pregnant prior to beginning treatment and use caution throughout the treatment period._ Although difficult, it is not impossible - and is ill-advised - to become pregnant while undergoing GnRH therapy. Lupron, like all GnRHs, is a hormonal agent [GnRHs=gonadotrophin releasing hormones]._ It was initially used in the treatment of prostate cancer and has since extended into other areas, such as reproductive disorders and precocious puberty._ There seems to be a widespread misconception that "Lupron has chemotherapy in it."_ Chemotherapy is not a substance, it's a concept - it simply means "treatment of disease through chemical therapy."

Should GnRHs be taken prior to surgery?_ That is a decision best left to the woman and her Endometriosis specialist._ Sometimes, GnRH therapy is needed to debulk the disease._ However, it can also shrink lesions enough to be missed by a lesser-trained surgeon.

Misinformed Notion Number Five: Only higher stages of Endometriosis cause pain and infertility.
Stage of disease does not indicate pain or fertility status; it is simply a method by which the disease is scored._ While it is true that higher stages (3 and 4) are more likely to be involved in infertility, this is not always the strict case._ A woman with stage 1 disease may be debilitated and infertile, while a woman with stage 4 has no symptoms - and vice versa._ Staging has been defined by the American Society for Reproductive Medicine (formerly the American Fertility Society), with criteria based on the location of the disease, amount, depth and size. These factors are all graded on a point system and classification is thus determined. The first classification scheme was developed in 1973, but since then it has been revised and refined 3 times for a more precise method of documentation. As of 1985, the stages are classified as 1 though 4; 1-minimal, 2-mild, 3-moderate and 4-severe. There are many other myths circulating today which continue to hinder the diagnosis and treatment of some women with Endometriosis; these are just a few of the more common ones._ In summary, the facts as supported by medical literature:_ any woman of any age can have Endometriosis, no matter how many children she may have had [or not had, as the case may be]._ Currently, the best bet for long term remission is the meticulous excision of disease and care by an Endometriosis specialist. Luckily, most patients know that these are just myths and will not stand for a physician who subscribes to them._ But what of the doctors who don't keep up on current research and the newly diagnosed patients who are not being properly informed?_ Let's help make a difference - working together, the Endometriosis community will get the answers we seek, doctor and patient alike._
Get educated.
Get involved._
Do your part to help shatter the myths surrounding this disease.

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