Robotic Excision of Endometriosis? Just What Are You Getting Into?

Endometriosis. Surgery is the only way to diagnosis it. Surgery is the best way to get rid of it. Yes, that’s unsettling, but today’s surgery for endometriosis is not the ordeal it used to be. Still, any surgery is a bit of an heavy concept to accept, so you are best prepared knowing exactly what you’re getting into when you decide to get rid of your pain and improve your ability to become pregnant.

Today’s Endometriosis Surgery

Endometriosis poses daunting challenges to a GYN surgeon. First of all, it is often in multiple locations in the pelvis and abdomen. This means operating in different areas, requiring flexible exposure opportunities for the surgeon. Next, endometriosis can infiltrate over, under, or even within other tissues (e.g., ovary, tube, bowel, or bladder). This means meticulous technique is needed to remove only the endometriosis and not any tissue of the organ with which it’s involved. Finally, endometriosis distorts normal anatomy, and restoring it to its pristine glory is as much a challenge as the endometriosis surgery itself. Certainly fertility depends on your anatomy being normal, requiring restoration when it isn’t. All in all, endometriosis surgery is an important, intricate, tedious, and difficult surgery.

…which begs the questions:

  •  What type of surgeon should you entrust to these difficult conditions?                      
  • What type of surgery should you have for it?

Your Surgeon: Choose Wisely

Given the list of challenges above, you’re going to want a surgeon who has already dealt surgically with endometriosis thousands of times—performed surgery for it in all of its myriad presentations and difficulty levels. Having a surgeon like Dr. Ulas Bozdogan at NYCEndometriosis will relieve you of that worry, for he meets these criteria easily while getting how important your body is to you and your plans for the future.

Your Surgery: Robotic Excision, Of Course

Robotic removal of your endometriosis also satisfies the conditions cited above. It allows unprecedented exposure—stereoscopic 3D views on pivoting lenses that can look at any part of your pelvis or abdomen from any angle with excellent depth of field. (The simpler laparoscopic approach, while sharing the quick recovery and reduced postoperative pain of robotic surgery, simply cannot match the da Vinci® robot for manipulation and visualization.)

So You’ve Decided to Schedule Robotic Excision of Your Endometriosis… Now What?

Before Surgery

Often these surgeries, especially in the experienced hands of someone like Dr. Bozdogan, will be outpatient surgeries, so you’ll need someone who can dedicate his or her whole day around you and your outpatient procedure. You won’t be able to drive home—hospital policy—because of any sedation lingering. Besides acting as chauffer, your responsible person will be able to listen to your surgeon’s explanations and the nursing staff’s postop directions with a clear head, while you may still be decluttering your own.

You will be instructed to not eat or drink anything after midnight the night before your surgery. (Sips of water to take daily medication is O.K.) This is so that your stomach will essentially be empty and not threaten the aspiration of food contents into your lungs during anesthesia.

Speaking of daily medications, you may or may not be taking them the morning of surgery, based on your surgeon’s recommendations. For example, if you take something that may affect your ability to clot, you’ll be off of that for up to a week before surgery.

Most hospital protocols recommend you bathe or shower with an antimicrobial soap the night before. Whether this actually helps or not hasn’t been proven conclusively, but certainly it can do no harm. After all, surgery exposes your insides to the outside world, and your insides are sterile while the outside world—including your skin—isn’t. However, you’ll be pleased to know that the incisions in robotic surgery are tiny and are basically “plugged” with the operating instruments used, limiting any real communication (bacteria-wise) between your inside body and the rest of the universe.

If you have a severe case of “deeply infiltrating endometriosis” in which your bowel is involved, it is reassuring to know that Dr. Bozdogan uses a team approach to your surgery. He will have a colon and rectal surgeon and a urology surgeon on standby in case some worst-case scenario occurs and they are actually needed. (Again, the value of experience!) Of course, you won’t be able to tell this type of melodrama from less complicated cases, because not only will you be asleep, but the recovery using robotic surgery is about the same no matter how complicated or how simple it is. That being said, if there is any chance bowel will be involved in any dissection, you will probably have to have what is called a “bowel prep.” For robotic excision of deep infiltrating endometriosis involving the bowel, whose inside contents are not sterile, a bowel prep will involve taking antibiotics preventatively along with clearing out the bowels themselves with medications the day before. Your surgeon will also be using antibiotics in the IV before and during the surgery. After the surgery (knowing what how things played out), antibiotics may or may not be used for you at home.

The Surgery

You will be admitted to the facility and clerical issues will be addressed, and then you will be placed in a holding area where an IV will be started and where you will see your surgeon for a chance to ask any remaining questions. You will also meet any other doctors or healthcare professionals involved in your case (anesthesiologist, nurse anesthetist, and nurse staff). You will be given sedation through your IV there and then moved to the OR suite.

Once you move (under your own power) to the OR table, sterile instruments will be counted, because the same number must be there after the surgery as before! The anesthesiologist and nurse anesthetist will have you drift off to sleep at this point and will remain committed to continuous—uninterrupted—monitoring during the surgery and after, until you go home.

A lot of the time spent will not actually be the surgery itself, but setting up for it. The da Vinci® robot is a complicated piece of technology with specialists used to set it up, check it out, and help administer it before, during, and after surgery. After setup, both your surgeon and the robotic staff will make the tiny incisions through which the robotic instruments will be inserted. Of course, you will feel or remember none of this. Your surgeon will then withdraw to a part of the room housing a small isolated area from which to don the stereoscopic goggles and use both hands to manipulate the ambidextrous controls; these controls will cause matching mirror movements of small devices within your body. This is the closest thing you can have to having your surgeon actually shrink down small enough to work around inside your body!

From the surgeon’s vantage off to the side (inside the same room), work can be done diligently with the best of all worlds—visibility, dexterity, meticulousness, and safety. These things are important when your pelvis, reproductive organs, bladder, and bowel are involved.

When the surgery is completed, your small incision will be closed using glue and/or steri-strips—the only thing you will see after 1-2 hours of state-of-the-art—and complicated—surgery.

After the Surgery

You will be rolled into the recovery area, called PACU (“post-anesthesia care unit”). Your anesthesiologist considers the PACU a continuation of the OR, monitoring you and managing any medications until you are completely awake and ready to go home. Once awake and alert (“recovered”), your responsible person—the chauffer, remember?—will be allowed in to visit and help you get dressed.

You will be sent home with some pain medication and possibly a follow-up prescription of antibiotics. You will be given an appointment to see your surgeon, which Dr. Bozdogan usually prefers to be within a week. You will be instructed to notify your surgeon for any of the following:

  • Increasing pain. (Pain, while there at first, should improve by 50% every day, not get worse. You probably won’t need the big-gun painkillers for more than a couple of days).
  • Unusual vaginal discharge.
  • Abdominal swelling. (Don’t worry if you don’t have a bowel movement soon after—remember, you were starved and cleaned out before surgery. If you’re passing gas, all is well.)
  • Burning with urination. (You will have had a urinary catheter placed while you were asleep during the surgery with a chance of introducing bacteria, but that is unlikely given the amount of antibiotics you’ve been given.)
  • Vaginal bleeding. (Not likely, and then only you’ve had an actual robotic hysterectomy, which is not the same procedure at all.)
  • Difficulty breathing or leg tenderness.

Way After the Surgery

You should be at normal—light—household activity within a couple of days and back to work (or all household and other activity if you don’t work) in a couple of weeks. If fertility was part of the reason for the endometriosis surgery, you’ll be advised on your next steps in attempting your pregnancy.

Robotic excision of endometriosis allows you to literally stick your head in the sand and come back up for the fresh air of a healthy pelvis and resumption of fertility. The right surgeon and the right surgery make this possible and are a powerful argument for no longer endangering yourself any longer with endometriosis.