Podcast Transcript: Clinical Pearls: Managing Endometriosis Post-Hysterectomy

[Dr. Emad Mikhail]
Yes, I start high, I start at the brim. It is almost the same thing if there is adnexa still there, the adnexa get dissected and it moves out of the way. If I dissect the ureters in all those cases, because the ureter is probably stuck either to the lesion or to the bowel or to the residual adnexa. Freeing off the ovary and freeing off the ureter, this is the start. It's a bowel disease, so I free the bowel. If it's a bladder disease, I free the bladder. You think about it, I use manipulation in all the organs. What is the meaning of that?
I have a vaginal cuff manipulator. It's a post hysterectomy case. You cannot use a uterine manipulator. There is no cervix. You use a vaginal cuff manipulator specifically made for this. You use a rectal probe in all cases. You have to use a rectal probe. Most commonly and easily available is to use an incisor as a rectal probe. For the bladder, in all these cases, I backfill the bladder to see the contour of the bladder. Sometimes I use a fully catheter guide. A guide inside the fully catheter metals, a guide. Then I push it so I can see the borders of the bladder. For the ureters, I'm becoming a big fan of ICG. Now, in all repeat endo, retrograde ICG, it takes three minutes and you see the ureters so amazingly.
The beauty about this is that, do we need to do ureterolysis in every single case? Probably not. If we don't see the ureter, we have to do ureterolysis because you're going to injure it. If you have ICG and the ureter is very far from the lesion, you don't have to fully strip the ureter and risk its vascularity just because. No, we can actually see the ureter very well. If you don't need to come close to it, don't come close to it. Think about this. In redo surgery, I technically manipulate all organs of somehow. You know whatI mean? Of some sort.

[Dr. Mark Hoffman]
You're not using stents. ICG for the ureters is enough for you to see what you need to see.

[Dr. Emad Mikhail]
I used to use lighted stents, which is an indwelling, stays in the whole time during the surgery. It is six French, so it is thicker. Then everybody gets hematuria at least for the first day. Then when I started doing way more robotics, I found the idea about the Firefly and the retrograde ICG. There's no indwelling stent, the ureter just has the ICG injected inside, and the polycatheter.

[Dr. Mark Hoffman]
How do you get the ICG into the ureter? Just through ureteroscopy or--

[Dr. Emad Mikhail]
I use a polycatheter, no cystoscopy, and I put the polyc inside the ureters for very brief moment. I inject and I remove it away, and it stays. Sometimes I have done cases that lasted for eight hours and still you can see the ICG until the last minute. You use a polycatheter inside the ureter, but you just push the dye, remove the catheter, the ureter does not becomes bulky because of the stent inside. It's practice-changing for me.

[Dr. Mark Hoffman]
Wow. There's so many different things that we can do. It just shows the value of doing tons of endometriosis surgery. I've operated a lot in the last 12 years, but there's always somebody doing more. There's always somebody who's thought of things you haven't thought of. That's the beauty of, not just the show, but meetings and keeping in touch with our colleagues who do this, because there's always a way to do it better than we're doing it. You have to be open to the idea that there's-- Even if you're doing great work, there's always that opportunity to think, oh, man, let me think about how I can try something new or better. Not that we all have to change everything all at once, but every one of us has hard cases. When you get into a situation where it's challenging, oh, that idea you had would be really helpful right here.
That's something I haven't done. I've never used retrograde ICGs, so that's really interesting. The idea of using a probe every time, the vaginal cuff manipulator, and the bladder, refilling every single time, really is those extra steps that you think, ah, should I do it? Should I not? If you're doing it every single time, you get used to it, you recognize those visual cues. It really allows you to be a little bit more certain in those areas where there isn't a lot of certainty if you're not really using something to identify those organs.

[Dr. Emad Mikhail]
Yes. After hysterectomy, and think about hysterectomy itself induces scar formation. Endometriosis itself is a scar-forming disease. Dissection that was done, especially if you have done a lot of dissection, all these factors makes the surgery way harder. Actually, you are 100% right, this is the value of discussing with your colleagues. For example, I'm going to tell you something interesting. For abdominal wall endo, for me, that's a really straightforward case. It's a subcutaneous case. You cut on it, you excise it on block. If you cut the fascia, you repair the fascia. If you have a very big fascial defect, you have your hernia friend, he will help you. Done. It's not a big deal. Actually, I just have seen videos lately of people doing laparoscopic removal of the abdominal wall endometriosis.
Actually, we did a course at AGL, and Dr. Ted Lee was one of my co-faculty, and he was showing that you always think about the abdominal wall endometriosis as it is a subcutaneous superficial fascial lesion. There is some cases that it is a subperitoneal nodule, like you can get access to it from within easier than from without. He's showing that, how he did it laparoscopically and put the mesh laparoscopically. Again, this is the same concept that you mentioned. It is the value of we learn from each other all the time.



[Dr. Mark Hoffman]
I'm lucky to have such talented and smart friends who are so generous with their time. So many people have- for our patients, have spent time with me, have done these courses like you've done, like our colleagues have done. It is a great circle where you give to someone, they give to someone else, it always comes back around. You mentioned that hysterectomy and endometriosis from prior surgery, all those things lead to scar tissue. Something I've found to be really challenging is to know what should we be taking out? What is the lesion? What is normal scarring? Because there's plenty of folks that have scarring that don't have endometriosis. Vaginal cleft is a scar. What do we take out and how far to go? A lot of opinions, oh, this is fibrotic, it all has to come. No, here's just the one nodule here, are we really going to go through and take out all the scar tissue that in a few weeks will again be a scar tissue? How do you know what's what?

[Dr. Emad Mikhail]
Again, you're asking very hard questions, but this is actually what I did for myself. When I excise a lesion, I name it in a way that gives me a clue when I review the pathology. For example, let's say peritoneal disease. When I'm sure it is endometriosis, I call it, I have my OR nurse, they call the lesion peritoneal endometriosis of the specific location that it was. When I'm taking an a peritoneal area, which I am not sure what it is, I don't call it endometriosis. I call it peritoneal biopsy suspected endometriosis. So that when I review,-

[Dr. Mark Hoffman]
That's smart.

[Dr. Emad Mikhail]
I review my pathology reports and I compare my judgment every single time. How many times I was correct? How many times I was not correct? When I thought this is only scar tissue and actually came back endometriosis, when I called it endo and it was not endo. By time, you revise yourself and you keep learning, when you over call it, when you under call it. Then after a while, because you are revising yourself every single time and you are making yourself to go back and look at the images, and then you get better. For the deep endo, when I first started doing deep endo, I didn't know how it looked. It looked funny. This is not normal. I didn't know what is this. Then again, same philosophy, that everything I excise, you have to name it in a way that makes sense to you to be able to judge if you over call or you're under call compared to the pathology, because the pathology is the gold standard.

[Dr. Mark Hoffman]
It takes a lot of repetition and doing and doing and doing, but also there's additional steps you're taking of naming it in a certain way. It's such an ingenious way. Did you come up with that or is that something that someone else was doing? You thought about, because to me, that's- it's such a simple,-

[Dr. Emad Mikhail]
It's very simple.

[Dr. Mark Hoffman]
Easy thing to do. When you're doing all these biopsies and some are endo, I don't remember which was which, and going back and taking pictures. By giving yourself that little clue, it's such a brilliant- it's a brilliant, simple little way to help yourself get better at identifying endometriosis. I love that. I think that'll be the thing that I take away the most from this is, it's a little thing that you do that's like, oh my God, it's so genius.

[Dr. Emad Mikhail]
No, and it's very simple, as you mentioned. One other thing that I really found very important is that you try to fight your ego. Because if you are the endometriosis person in the department, everybody will say, oh, I'm going to send it to Mark, he will just do it. But every single one of us will have a case that they should not do. For example, it is very hard for me to say, I'm going to stop or I'm not going to start a dissection where I don't see the end clear. You start when the end in your mind. I had patients where there is lesions invading the internal iliac vein. I say, I'm going to stop. This is something that, I don't know, some people have a hard time taking that call.

[Dr. Mark Hoffman]
No, it takes being self-aware. It takes being humble. I got some good advice. I think I told Arnie, every time I see him, but on the show too. That he told me when I was coming to Kentucky, listen, you're the first mixed person down there. Certainly we all get good training and fellowship, but you're a new surgeon, you're not seasoned yet. Don't be a cowboy, because if you do these things out beyond your scope, people will never send you patients again. It's not good patient care. Live with that. Your way of saying it is a little different than mine, but in my mind, I have algorithms for the case, right? If I see this, then this, if I see this-- If there's a question mark here, in any one of these steps, don't go down that path, right? If you don't have an answer for what you're going to do in this situation, don't start, because you can't go backwards in surgery.
I tell patients all the time, when you're talking about hysterectomy or some other IUD or pills that you can stop, or, hey, I can take your IUD out. I cannot put your uterus back. Just thinking about, how you get to these points and decisions for surgery, we're really good at taking stuff out. We're really bad at putting it back. Being able to have the self-awareness, take a step back, big picture, okay, what are we actually trying to accomplish here? What's the end goal? Will we still accomplish our goal? If the goal ultimately is patient safety and good outcomes, we have to weigh all of that. Yes, it does take some humility. It does take some ego. You don't want to be scared either, right? You don't want to take patients at OR and just dabble around, and they've gotten a surgery they didn't need. Knowing your skill level and knowing the surgeries you want to do and committing to it, because I think one of the challenges we have in our profession is folks that operate a little bit. When you're operating a little bit, just like if you did a little bit of OB, it's not fun when you're dabbling in something and get into really challenging things.
Having that self-awareness, that support structure, knowing what your practice looks like, who your partners are, what your support looks like, and that's different for every practice, but knowing where you fit in the scheme of things. You are not the center of the universe in that situation. I think that's a great point. I think that you have to be very thoughtful about that, but yes, just understanding what's the goal here? Why are we here? That's the biggest question we surgeons can ask ourselves, I think.