Endometriosis Surgery

[mustangsally65]

I didn't know whether this would be better off in the OB/GYN forum, but anyway, here goes.

I was wondering, when diagnostic laparoscopy is performed for endometriosis, is there usually a general surgeon brought in just in case there is involvement outside the expertise of the gyn?

For instance, if the patient has symptoms of bowel involvement, would a general surgeon be present at the time of surgery, or would this be a waste of his/her time if there is no endo found?

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[DrMom]

I had endo surgery with only an OB/Gyn & haven't personally heard of having a general surgeon in such a procedure as "backup." I suppose that if what was found was outside of the scope of an OB/Gyn's training, then they'd have a gen'l surgeon do a second surgery. Keep in mind that OB/Gyns are not limited only to surgery of the uterus and ovaries. My doc refers to himself as a pelvic surgeon (not professionally, but as a description of what he does) and does quite a bit of rectal reconstruction and such.

 

[Skylizard]

...when diagnostic laparoscopy is performed for endometriosis, is there usually a general surgeon brought in just in case there is involvement outside the expertise of the gyn?...

Generally, the answer is NO. Gynocology doctors do laparoscopy for those things they are "trained" in treating. Any good "surgeon" will complete a thorough work-up to ensure they are operating at the right time for the right disease. This of course is not perfect and that obscure <1% possibility on the differential diagnosis may come up. But, a gynecologist that routinely requires a general surgeon in the room is a gynecologist that shouldn't be in the room.

Having said that, there are occasions in which a gynecologist will obtain a pre-operative general surgery consult in anticipation of a disease process they are not trained to treat.

Finally, it also is not uncommon for a gynocologist to call franticly from the operating room for general surgical back-up either for an unexpected finding or a complication.

In any event and back to the original question, gynecologist performed exploratory laparoscopy for endometriosis is not routinely performed with a general surgeon in the OR as back-up.

 

[doc05]

when the gyn perf's the bowel, then the general surgeon is called in.

 

[mustangsally65]

when the gyn perf's the bowel, then the general surgeon is called in.

So there's a fine line between what a gyn can do and what a general surgeon can do? A gyn is qualified to remove endo from the outside of the bowel, but if a perforation is made then a general surgeon is required.

So what is beyond the scope of a general surgeon? If they are performing an appendectomy and find endo on the bowel, could they remove it at the time, or would they have to get a consult from a gyn?

Thanks for your replies!

 

[Idiopathic]

If it involves the bowel, GS should really be the only ones involved. End of story.

 

[dry dre]

In response to the original question,

I think the most common reason for a general surgeon to be brought into the room during a diagnostic lap would be to consult/show the surgeon what is found for a possible/likely follow-up general surgery procedure to clean things up.

To respond to the latter question,

Anytime any surgeon (general or gyn or ...) finds something wrong intraoperatively (that wasn't the indication for the procedure) that the surgeon is qualified/trained to fix, the fix it....you don't abort the procedure or go to the waiting room to ask the family what should be done. In the real world this means to take down adhesions or excise/biopsy a mass...it doesn't mean start lopping off moles etc.

 

[Skylizard]

So there's a fine line between what a gyn can do and what a general surgeon can do? A gyn is qualified to remove endo from the outside of the bowel, but if a perforation is made then a general surgeon is required...

So what is beyond the scope of a general surgeon? If they are performing an appendectomy and find endo on the bowel, could they remove it at the time, or would they have to get a consult from a gyn?...

This all goes into the "it depends" category. It depends on the scope of one's training in addition to the scope of ones actual practice.

There are Gynecologists that will repair or at least attempt to repair a bowel perforation and others who will call a general surgeon. There are gynecologists that while removing ovarian cancer will actually do bowel resection. In my experience, the gynecologists almost always exceeded their ability and performed poorly (i.e. a "bowel resection" but NOT a "cancer operation").

Second, in numerous communities, general surgeons will split call with the obstetrician and perform csections. This is not uncommon. A good many gynecologic surgeries are performed by general surgeons (i.e. TAH/BSO). The bottom line is you have to be up to date on the current standard of care, perform the right operation on the right disease.

A surgeon with extensive technical skill from a long and difficult general surgery training will be technically capable of doing these types of surgeries...they just need to keep up to date with the current recommended theraupies and keep their practice up to date. The same can not be said for a gynecologist. Their surgical training is limited during their residency and thus their overall technical and anatomical knowledge.

All things said and done, I would not discourage a woman from having a TAH/BSO by a Gsurgeon if the GSurgeon regularly performs that surgery anymore then I would refer someone to a GSurgeon for a whipple if the GSurgeon rarely performs this procedure.

I would strongly discourage a woman from having an appendectomy or inguinal hernia repair by a gynecologist.

 

[Celiac Plexus]

Anytime any surgeon (general or gyn or ...) finds something wrong intraoperatively (that wasn't the indication for the procedure) that the surgeon is qualified/trained to fix, the fix it....you don't abort the procedure or go to the waiting room to ask the family what should be done. In the real world this means to take down adhesions or excise/biopsy a mass...it doesn't mean start lopping off moles etc.

This is not completely true. For small incidental ovarian cysts, excision with preservation of the ovary is appropriate. However for large ovarian lesions, or lesions that are not amenable to simple excision, the patient should be closed, consent for defintive operation should be obtained, and the patient should then be taken back to the OR. A surgeon should never do a TAH/BSO without consent. Asking family members for consent for this while the patient is on the table is not acceptable.

 

[dry dre]

This is not completely true.

I meant to speak of general practices, not in absolutes. The absolutes more have to do with life over limb (or feet of colon), not relatively subjective procedures.

Are you saying that we should not do a TAHBSO if locally invasive CA is unexpectedly found in the organs duing the procedure?

 

[Celiac Plexus]

I meant to speak of general practices, not in absolutes. The absolutes more have to do with life over limb (or feet of colon), not relatively subjective procedures.

Are you saying that we should not do a TAHBSO if locally invasive CA is unexpectedly found in the organs duing the procedure?

Yes. That is what I am saying. Close the patient. Counsel the patient and get informed consent for the TAH/BSO, omentectomy etc... then take the patient back.

 

[Smoke This]

I opine that a gynecologic oncologist should be involved whenever you're going to be resecting what could possibly be a gyn cancer. A general surgeon and a gynecologist both could do a TAH/BSO for "benign" indications, but if invasive cancer is found I'm just not sure anyone but a gyn oncologist is prepared enough to stage that. Complex atypical hyperplasia of the endometrium, for example, is associated with occult invasive cancer more than 40% of the time.

 

[hans19]

when the gyn perf's the bowel, then the general surgeon is called in.

When the general surgeon nicks the ureter, then the urologist is called in.

 

[Celiac Plexus]

When the general surgeon nicks the ureter, then the urologist is called in.

when the urologist stabs the internal iliac, captain vascular gets the next call... that's gonna be one hell of an m&m....