Pain & Poops: Then & Now

Well, here we are in 2019 and I’m starting my blog off talking about poop…Why? Because I’m SUPER excited to share with you how different my bowels (and pain levels) have been since my recent bowel resection and Endometriosis excision surgery.

If you weren’t aware, I underwent a bowel resection to remove deep-infiltrating Endometriosis from my small intestine. I’m waiting on a final surgery report before I blog about the specifics, so please be patient. Hopefully in a few weeks.

Until then, embrace this discovery with me! Here’s my pain journal summary for November of 2018:

And here’s my pain journal summary for January of 2019:

I went one step further and compared my bowel movements and their pain levels for the first eight days of November and of January! The difference is…staggering!

Look how numbers have completely shifted!!! I was flabbergasted when I did the comparison! I mean, I’ve obviously noticed a huge difference in my quality-of-bathroom-life, but wasn’t expecting THIS!

If I ever needed any sort of reassurance that my bowel resection and Endometriosis excision surgeries were the right call, this is it. Not that I needed that validation. And am so grateful to Dr. Mel Kurtulus and Dr. Matthew Schultzel for their expertise, compassion, and friendship.

But I was SO excited about the difference that I wanted to share it with you…And bring in the New Year with…poop-talk.

Stay tuned. I’ll be blogging full-force once again now that I can sit at a computer for longer periods of time. And I cannot wait to share with you the details of my last surgery and the findings.

Be well. I’ve missed you Readers. And I’m so pleased to be back in the saddle, so to speak.

July 2018 Surgery Recovery

Lisa Howard - Resilience
Dr. Mel Kurtulus and I before heading in. Photo courtesy of Brandy Sebastian https://www.brandysebastian.com/

As you may know, I like to take extensive notes during my recovery from my Endo surgeries. This helps me better be prepared in case I have another one – just to get a sense of what was normal and what I can expect next time. And who knows – it may help you…or someone you know.

A good friend of mine, Brandie, typed up my chicken-scratch notes. (Thank you BRANDIE!) They can be read here. BUT, the “cliff notes” version is below:

DAY ONE (July 18, 2018, took 1 Percocet, 1 Zofran, 2 Gas-X): We got home from the hospital around 7:00 p.m. I don’t remember any of the ride home, which is probably good because it was freeway rush hour and probably wasn’t very pleasant. The first thing I did inside was pop a throat lozenge. My poor throat was sooore and tender. Then had a bowl of bone broth. My lower stomach pain was a 3 out of 10, and my belly button incision pain was a 5 out of 10.

At around 8pm, I tried to sit down for the first time. That tell-tale shoulder pain began to creep up with a vengeance (7 out of 10) and I only sat for 3 minutes. Well, that was a waste. I needed help getting up and down. I knew I’d have to sit again or lay down…but not yet. I popped a Percocet, a Zofran, and a Gas-X.

By 8:30, I had my first pee since I got home. It hurt soooooo much (9/10), but I figured that pain was likely because my bits were still tender from the catheter. By 9pm, I tried sitting on the couch again: no luck. Shoulder pain was a 9/10 and gave up and walked for the next 20 minutes. Then tried to lay down (propped up on pillows), but the shoulder pain flew back up to a 9 out of 10. Did a lot of walking and breathing. By this time, my incision pain was a 2/10 and my lower back pain was a 1/10. I just wanted to sleep, though…

By 9:35, we tried laying down again propped up by even more pillows. The discomfort was minimal. By 10:15pm, I was awake and had to walk around for an hour. I had to pee before going back to bed (again, urination pain 9/10), then I was overcome by nausea. Mom helped me on my hands and knees and I vomited (pain 2/10). I believe my Percocet pill from 2 hours earlier was still floating around in my stomach because my puke was a beautiful shade of blue. At 11:45pm, mom helped me back into bed, but I couldn’t fall asleep until 12:20-ish.

DAY TWO (Fiber; took 2 Gas-X):

Incision pain 2 – 6/10 (10/10 when struggled to get out of bed)

Shoulder/CO2 Gas pain 3 – 10/10

Lower abdominal pain 2 – 9/10

Lower rib pain 1 – 4/10

Lower back 1 – 4/10

Lower ab pain near right hip 2 – 8/10

Pain while urinating 1 – 6/10

Woke up nearly every hour still…poor Jim and Mom. And needed help getting on and off the toilet.

Was still passing some clots throughout the day.

Nothing to eat except bone broth and crackers.

Memorable Moments:

At 1:20am, I woke back up stiff and needing to walk. Dragged my husband out of bed to help me get out of bed and proceeded to walk around the house for an hour. Jim went back to bed. And Mom was in and out of sleep as I cruised around the living room using the walker. When I went to go back to bed, the shoulder pain came back a 10/10. Mom and Jim had to help me (panicked) out of bed and I had to calm down before we tried to reposition and go back to sleep. At 2:40am, we did just that. I slept off and on until 7:15am.

At 3:55pm, my first FART!

At 4:37pm, I can lift my leg higher than the bah tub rim!! I couldn’t do that earlier!

DAY THREE (Purelax; took 1 Gas-X; 1 Naproxen Sodium):

Incision pain 2 – 3/10

Lower abdominal pain 3 – 9/10

Lower back 1 – 8/10

Pain while urinating 1/10

Pain while farting 1/10

Was able to sleep for a few hours in a row before waking up throughout the night.

Ate soup and crackers. Snacked on a pickle. Small bowl of ice cream (I mean…like 2 small spoonfuls)

No shoulder/gas pain today!

Memorable moments:

7:20am, my first poop!!!!!

8:50am, although I still need help getting on and off the toilet, I was able to (carefully) pull up my panties by myself today!

12:58pm, was able to get off of the toilet by myself! But I still needed help getting down onto it.

1:01pm…oh dear god…the Enema Story. TEAM POOP! Rosie and Erin helped me. And let’s just say by sheer force of necessity, I was able to get myself onto and off of the toilet by myself…Needed the enema due to severe and constant lower ab cramping and figured it was poop. Yep…there was LOTS of poop. Throughout the day, continued to get on and off the toilet by myself! PROGRESS!

4:50pm, was able to slowly and gently walk down the stairs to check the mail with Rosie and Erin! One step at a time.

DAY FOUR (Purelax; 1 Naproxen Sodium):

Incision pain 1 – 6/10

Lower abdominal pain 2 – 6/10

Lower ab pain near left hip 7 – 9/10

Pain while urinating 1 – 2/10

Pain while farting 3/10

Still needed help getting in and out of bed.

Ate soup with crackers. Snacked on cracker. Nachos for dinner!

Memorable Moments:

10:10am, got into the shower by myself!!! FREEDOM!

4:00pm, getting better with the steps outside! Still one at a time, though.

10:00pm, FINALLY laid down flat to sleep. YES!! No pain. Although I did get myself out of bed alone…don’t do that again. Not yet.

DAY FIVE (Purelax):

Incision pain 2 – 6/10

Lower abdominal pain 2 – 5/10

Lower ab pain near right hip 2/10

Ate tomato soup with crackers. Snacked on watermelon, blueberries, dolma, and pickle. Chicken balti pie for dinner.

Memorable moments:

12:55am, got up out of bed alone to go pee! Kind of waddle around like a turtle on its back, but it works.

10:10am, got dressed in REAL clothes! Skirt, tank top, and brushed my hair!

6:50pm, Jim and I went for a walk around our mobile home park for a few blocks. It was marvelous to get out of the house. Slow going. Didn’t get far.

8:50pm, pooped again! No enema needed! And no pain!

DAY SIX (Started my period! Fiber; 2 Ibuprofen):

Incision pain 2 – 3/10

Lower abdominal pain 2 – 7/10

Lower back pain 3 – 5/10

Ate miso broth. Snacked on watermelon, popcorn, apple with peanut butter, pickles, tortillas. Dinner was a pork and (very little) cheese. Yep, my appetite is BACK!

Memorable Moments:

5:26am, woke up thinking I peed the bed. Nope, just started my Ninja Period.

6:20am, BIG poop with no pain! Yep, I’m back, baby!

9:00pm, another short walk around the park with my husband.

DAY SEVEN (Fiber):

Incision pain 2 – 6/10

Lower abdominal pain 3 – 6/10

Lower ab pain near right hip 3 – 6/10

Pain while urinating 1/10

Pain while farting

Pain while pooping 5/10

Ate broth and soup. Snacked on popcorn. Dinner was fettuccine alfredo with shrimp.

Memorable moments:

I can bend over!!!

Lower left window band-aid came off! Steri-strips still in place. Looks good!

7:00pm, rode in car to go to dinner. Speed bumps and potholes hurt my lower stomach and incisions (4/10). Had to walk around the restaurant while waiting for dinner since sitting too long hurt.

DAY EIGHT (Fiber; 2 Ibuprofen): – it’s been one week since surgery!

Incision pain 2 – 8/10

Lower abdominal pain 2 – 7/10

Lower ab pain near right hip 5 – 7/10

Ate miso broth and leftover pasta. Snacked on popcorn, dried apricots, tortillas.

Memorable Moments:

6:50am, Baku walked on my stomach. Damn cat. All incision pain 7/10.

2:15pm, I can get in and out of bed easier by myself.

11:30pm, right incision pain was an 8 out of 10 and kept me awake until 1:00 a.m.

DAY NINE (Fiber; 2 Ibuprofen):

Incision pain 2 – 3/10

Lower ab pain near right hip 2 – 3/10

Pain under left rib 2/10

Ate soup & crackers, baked beans. Snacked on Hershey Kisses. Orange chicken for dinner.

Memorable Moments:

6:12pm, can still only sit upright for 10 minutes before incision pain is a 6 – 8 out of 10.

8:10pm, went for a 20 minute walk around the park with Jim. No pain!

DAY 10 (Fiber; 2 Ibuprofen):

Incision pain 2 – 7/10

Lower abdominal pain 1 – 4/10

Pain while urinating 1 – 2/10

Pain while farting 2/10

Pain while pooping 2/10

Ate scrambled eggs with cheese, soup, leftover orange chicken. Snacked on kettle corn.

Memorable Moments:

8:15am, Able to wash my calves for the first time in the shower! And I was able to blow-dry my hair! Lost left incision band-aid in the shower. Steri-strips are in place. And my belly is much less bloated!

9:00am, still can only sit upright for 10 minutes without pain.

7:00pm, walked around the grocery store for an hour with Jim. He did all the heavy lifting, but I’m exhausted.

DAY 11 (Fiber; 4 Ibuprofen):

Incision pain 2 – 6/10

Lower abdominal pain 2 – 6/10

Pain by right lower ab near hip 2 – 5/10

Pain while urinating 2/10

Pain while pooping 2/10

Ate eggs, corn beef hash, toast. Snacked on a plout and cherries. Snacked on kettle corn.

DAY 12:

Incision pain 2 – 6/10

Lower abdominal pain 2 – 5/10

Pain while urinating 8/10

Pain by right lower ab near hip 2/10

Ate rolled tacos.

Memorable moments:

Went thrift store shopping with Jim. Exhausted and napped for 2.5 hours afterward.

DAY 13 (2 Ibuprofen):

Lower abdominal pain 1 – 5/10

Pain by right lower ab near hip 5 – 9/10

Pain while pooping 1/10

Ate fried egg sandwich. Snacked on cherries, a pluot, watermelon, and cherry tomatoes. Dinner was cauliflower, beans, corn & cheese burrito with salsa.

Memorable Moments:

Spent 2.5 hours at the library. Too much sitting on hard chairs caused a lot of pain! And the Lyft ride was brutally bumpy.

DAY 14 (Fiber):

Incision pain 2/10

Pain by right lower ab near hip 1 – 3/10

Ate nachos (with very little cheese). Snacked on an apple with peanut butter. Dinner was yellow curry with chicken and rice, golden shrimp, and crab rangoons.

Memorable Moments:

Only woke up once during the night to go pee!

DAY 15:

Incision pain 2 – 7/10

Lower abdominal pain 3/10

Pain by right lower ab near hip 1 – 3/10

Lower back pain 1/10

Ate sushi.

DAY 16:

Incision pain 2/10

Pain by right lower ab near hip 1 – 3/10

Ate 2 eggs, french toast, and bacon. Lunch was a baked potato with sour cream and chives.

Memorable Moments:

Lost a few Steri-Strips today! Looks good.
Ran errands with brother in law: Trader Joe’s and Sprouts and Smart&Final. Minimal discomfort but exhausted. I didn’t do any heavy lifting.

Drank 3 glasses of pomegranate champagne. My first alcohol since 2 weeks before surgery!

Jim and I enjoyed a little bit of foreplay and “just the tip.” Didn’t penetrate too much and it was a lot of fun. No pain!!

DAY 17 (2 Ibuprofen):

Incision pain 1 – 4/10

Lower abdominal pain 3/10

Pain by right lower ab near hip 2 – 4/10

Pain while pooping 3/10

Lower back pain 1/10

Lower right rib pain 4/10

Ate leftover yellow curry. Snacked on a pluot. Dinner was a chicken breast sandwich.

Memorable Moments:

Vacuumed, did laundry, and changed the cat litter. It was exhausting, but I took it slow and easy and didn’t overdo anything. But…by looking at the cumulative pain scores above, I can tell I overdid it. Crap.

DAY 18 (2 Ibuprofen):

Incision pain 2/10

Lower abdominal pain 2/10

Ate two waffles with fake butter and real maple syrup.

Ate Indian food for dinner.

Memorable moments:

Enjoyed 3 glasses of white wine. And it looks like my body recovered well from yesterday’s chores.

DAY 19 (Took 2 Ibuprofen):

Incision pain 3/10

Lower abdominal pain 3 – 8/10

Pain by right lower ab near hip

Pain while pooping

Lower back pain 3/10

Ate 2 waffles, drank three glasses (small) sangria, 1 glass wine, lots of water. Bean guacamole chips, chicken sandwich, pickles, chocolate chip cookie, lentil salad.

Memorable Moments:

Today was our Endo Support Appreciation BBQ! It was WONDERFUL to see everyone, to meet their support, and enjoy their company. I’m tired, though!

Lost another Steri-Strip!

And on DAY 20: August 6, 2018, I returned to work. It was my first time driving since surgery. And it was tough. I also had my post-op appointment that day. Dr. Kurtulus removed all of my Steri-strips and everything continues to heal well.

Today is August 27, 2018, and it still hurts to sit at the computer for too long. I have to get up and stretch/walk several times during the work day.

My advice if you’ve got a surgery recovery to look forward to? Take one day at a time. ASK FOR HELP! And listen to your body.

Endometriosis Excision Surgery 3.0

Lisa Howard - Resilience
Dr. Mel Kurtulus and I before heading in. Photo courtesy of Brandy Sebastian; used with her permission https://www.brandysebastian.com/

On July 18, 2018, I underwent my third robotic-assisted laparoscopic excision of Endometriosis by Dr. Mel Kurtulus ( of San Diego Womens Health).  As always, I love to share my experiences with you – not only to create awareness of this illness, but in the hopes that the process of my surgery (and later recovery) may help you, or others.

Before I go on, I just want to take a moment to express my joy in the above-photograph.  I am a detached head, floating beneath a fluffy warm-air blanket in the pre-op area, enjoying a wonderful moment with an incredible surgeon and man.  Thank you, Brandy, for capturing this.  And thank you, Dr. Kurtulus, for being so marvelous!

Okay, on with the nitty-gritty!

My mom, husband, and I were awake at 6am and in the hospital by 8am to check-in.  If you’ve never been to the Scripps Hospital La Jolla, it’s glorious.  Every attention to detail and the efforts of the staff are meant to soothe and calm: beautiful artwork, a live piano player in the lobby, and compassionate staff.  It’s wonderful.  We were joined by a wonderful friend and fellow EndoSister, Brandy, to document the experience (these photographs will be shared at a later date…I’m so excited about what she is doing!)  I was rolled back for pre-op somewhere around 11:30 and wheeled back to the OR by noon.  My surgery took approximately four hours.  And here I was worried he wouldn’t find any Endometriosis…(I should know better…)  We arrived home around 7:00pm.  A very, very long day for my friends and loved ones.

procedures

The plan was to open me up and peek under the hood, so to speak.  If any Endometriosis was discovered, Dr. Kurtulus would excise it; any adhesions would be freed; the ovarian cysts that were seen in ultrasounds would be removed; my ureters would be examined and freed of any adhesions; he’d look inside my bladder for any Endo or evidence of Interstitial Cystitis; and he would (with my willing and educated permission) remove both of my Fallopian tubes.

What did he find?  Following is a page of my op report, in case you enjoy reading all of the medical terminology (like I do).  I’ll also further explain what I understand and share photographs below!

op page

In a nutshell?  I had:

  • I was laid on a table, strapped in, and tilted somewhat upside-down.  Then a tiny hole was punched in my belly, 3 liters of CO2 gas was pumped in and I was inflated, and the doc took a peek around.  Three additional ports were added (tiny incisions) so tools and the robotic arms (tiny!) could be inserted.  On with the discovery:
  • A cyst on my right ovary;
  • A cyst on my left ovary;
  • Endometriosis on my cul de sac, small intestine, near my sigmoid colon, and on my left ovary and fallopian tube;
  • My fallopian tubes were hideous, “angry”, inflamed, swollen;
  • Adhesions on/near my sigmoid colon, my bladder, my fallopian tubes;
  • My sigmoid colon was stuck to the left side of my pelvis;
  • My bladder was pinned to my uterus;
  • My left ureter was surgically detached to allow safe access to Endometriosis lesions on my left ovary, then reattached once all-clear;
  • And (hooray!!!) NO evidence of Endometriosis was found on my liver or diaphragm (discovered there in prior surgeries).

During my post-op meeting, Dr. Kurtulus let me know that this time my Endometriosis lesions were all either clear or red.  He said they were almost grape-like.  I’m so pleased that he is so skilled and thorough during these procedures!!  And grateful he knows what to look for!

Ready for photos of my insides?  I don’t know if you can click on the photos and make them full-size, so if you ARE curious about the full-sized (and zoomable) versions of these photos, you can view them here.

The Fallopian Tubes

My Mum told me that when Dr. Kurtulus showed she and my husband the photographs after the procedure, he said my fallopian tubes were “angry” and swollen.  That description will stick with her for quite a while, especially when she saw the photographs.  I am so glad we had already discussed removing my fallopian tubes before my procedure; as he likely would have removed them due to their massive state.

I had a 3cm cyst on my right ovary, which he removed while saving my ovary.  Also,  a cyst and Endometriosis lesions on my left ovary, which he excised (still saving my left ovary).

FT and ovaries copy
The yellow circles are showing Endometriosis on my fallopian tubes

My husband and I don’t want children at our age, but it doesn’t make the medical sterility any easier to bear.  I have grieved and mourned and cried and sobbed.  I am feeling much better now (although sometimes it still hits hard) after talking about it with friends and family and I wanted to share some incredible words from a few friends that they shared to comfort me:

“You may no longer have fallopian tubes, but you got one of the biggest pair of brass balls I’ve seen.” ~Barbara Carrera

“It’s a good thing to have the diseased bits out of the way.  And now you don’t have to worry about condoms.  And it’s fun to imagine your ovaries as crazy, free-floating googley-eyes!  They’ve been unleashed!!  Fly my pretties!  Fly!!”  ~Sarah Mew

Thank you, ladies.  I needed those laughs. ❤

The cul de sac (aka Pouch of Douglas)

This is my third surgery and during both of my prior surgeries, I had Endometriosis in my cul de sac.  To quote both of my first two op reports, my cul de sac was “obliterated.” What the heck is a cul de sac?  It’s the little empty space between the back of the uterus and the rectum.  It’s usually very common for Endometriosis patients to have lesions in this area.  This time, most of my Endo was on the left side, rather than everywhere in that little pouch.  And, Dr. Kurtulus excised all that he saw.

PofD Before and After

I’m flabbergasted at the difference!!! But, here are more photos of what my cul de sac looked like before I was all tidied up:

PofD Additional copy
Again, circles indicate Endometriosis lesions that I’m aware of

The Small Bowel

Two lesions were discovered on my bowel.  Dr. Kurtulus brought in a colo-rectal surgeon to look at the lesions to determine if they could be removed superficially or if something greater would be required.  The colo-rectal surgeon confirmed the spots looked like Endometriosis, but I would require a resection of that bit of small intestine.  It’s close to my appendix, on the right side.  So, it’s still in there, but I did already have a consult with that colo-rectal surgeon on August 8th.  My surgery date for the resection is pending and may take place by the end of this year!

Bowel Pics

The Bladder and Uterus

When I saw the photographs of my bladder being pinned to my uterus and held in place by a literal web of adhesions, I was amazed!  AMAZED!  I’d been having pain often when I peed and wonder if it was related to anything-Endo.  So Dr. Kurtulus freed my bladder (he’s my hero!).  He also looked extensively at the inside and outside of my bladder and found no evidence of Endometriosis or Interstitial Cystitis (aka IC).

bladder uterus copy

The Cost of it All!

As usual, I LOVE to share what this type of surgery costs.  And, to date, this was the most expensive for my insurance company!  I paid a $500 co-pay to the hospital and my insurance covered a whopping $121,669.50!  Holy moly!!!  I’m still waiting to see if the colo-rectal surgeon will submit a separate bill for his time, as it wasn’t itemized on my Estimate of Benefits form.  Other than that, there shouldn’t be any sneak attack bills…I hope.  If you’re curious what my first and second surgeries cost, check this out!

Future Plans

I had my post-op appointment with Dr. Kurtulus on August 6th.  He spent some time with me going through the details, labeling the photographs, and talking about our future plans.  Did we pick curtains or china patterns? No.  We covered prospective treatments!  I’ll see him again for an 8-week follow-up in mid-September.

He brought up birth control and remembered I don’t want to take it as I feel it truly makes me a different person.  Then he mentioned Lupron Depot and Orilissa, but acknowledged (before I could say anything), that he knew I didn’t want to take those.  So, he wonderfully respected my opinions and desires; didn’t push anything.  Didn’t make me feel like I was a “hostile patient” or making poor choices.  And he supports my desire to strive toward an anti-inflammatory diet, keep a positive attitude, and pursue the bowel resection surgery as soon as I am able.

The Recovery Process

I fully intend to fully blog about my 2-week recovery and share my notes soon.  But I wanted to also mention it briefly here.  It wasn’t easy at times, but mostly it wasn’t hard.

My pre-op Endometriosis pain is 99% gone!  Just a little bit of “ugh” near the lower-right edge of my abdomen…and I may either just be healing or it’s the last bit of Endo clinging to my bowel waving at me.  I was even on my period! And it was so pain-free that it was a Sneak Attack period and caught me by surprise (the poor bed sheets).

The first week was a whole lot of paying attention to my body, small little walks, a mostly-liquid diet, lots of lounging on the couch-bed and watching Netflix.  There was the expected post-op pain the first day, a vomit on Day One (whoever wants to do that so soon after abdominal surgery?), sleepless nights, and difficulties getting comfortable.  And those first few days of hardly any sleep wasn’t easy on my husband or mother, who had to help me get in and out of bed multiple times throughout the night.

The second week I felt far more capable, although I didn’t do much of anything other rest and be lazy.  And I returned to work on August 6th.

I had very little shoulder pain related to the CO2 gas and I blame that on my surgical team’s skill in deflating me as much as possible and getting out as much gas as they could!  For anyone who doesn’t know that absolute agony of post-laparoscopy gas pain, please, read this! I did have a few episodes of that pain, but nothing in comparison to my first surgery.

It took three days to poop.  The discomfort was so great that I opted for an enema.  That is a tale in and of itself; one you shall never read about!!

My body is still healing: sitting too long causes discomfort; stairs are from the Devil; and  I don’t allow myself to squeeze out a poo – if I have to do more than just a gentle push, it’s not time yet.  No straining.  No lifting.  No pushing. No pulling.  BUT I have been cleared to go swimming in a pool (no lakes or oceans)…and we can have sex! We were recently brave enough to give it a go and I’m happy to report there was no pain or discomfort!

The last of my steri-strips were removed at my August 6, 2018, post-op appointment and they’re healing well.

 

BEFORE I GO…

I want to thank Dr. Kurtulus and his staff for their excellent care, the incredible nurses and other surgical team members at Scripps Hospital La Jolla, Brandy for her amazing photographs and the project she is working on, my Mum for driving out (yet again) to be with me for surgery and during a hardest days of my recovery, my husband for all that he’s endured with me, Erin for taking care of me for a few days, Rosie for spending time with me during my recovery, Laura & Chris & Carrie for their wonderful company to celebrate my health, Zeiddy for constantly checking in on me, my employers and co-workers for the beautiful flowers, and all of my EndoSisters, friends, and family who also threw me well-wishes and love.

This has been an amazing experience.

Be well. All of you.

~ Again, I am a layman. I do not hold any college degrees, nor mastery of knowledge. Please take what I say with a grain of salt. If curious, do your own research 😉 Validate my writings. Or challenge them. And ALWAYS feel free to consult with your physician. Always. Yours ~ Lisa

Endometriosis: Excision vs Ablation

endo-graphic-soward-2017
Detail,”The Endo-Graphic” by Sarah Soward. http://sarahsoward.com/projects/endometriosis.php

So, you may be reading this because you have a surgery pending, or you’ve had surgery and want to know if it was the “right” one.  Well, when it comes to Endometriosis, there are typically two ways of dealing with the lesions that I’ve read of. If there’s more, share with me, please!  Whichever way your surgeon opens you up : laparotomy or laparoscopy, robotic-assisted or not – your surgeon will still need to decide how best to handle the lesions he or she finds within your body.

  1.  Excision – removing the entire lesion by cutting a margin of healthy flesh around the lesion – see the graphic above, scooping the healthy soil around the flower to get the roots, and then some.
  2. Ablation – destroying the lesion by burning the surface away.  Like freezing off a mole or wart, but burning away the Endo.  The graphic above with the flamethrower may leave the roots of the lesion, and unhealthy Endometriosis tissue, behind…

Is one better than the other?  That’s purely a matter of opinion, but the popular opinion is, “yes!”  There are countless studies that agree.  But why?

Ablation only affects the surface of the lesion by destroying the tissue.  It may leave unseen portions of the disease beneath the surface, which may allow for speedy recurrence of Endometriosis growth and symptoms.  Ablation may also cause further scar tissue to develop – you are literally burning or melting the lesion away.  Other names for ablation may include cauterization, vaporization, and fulgeration.  Terms for some of the tools that may be used during ablation can be electrosurgical devices, thermocoagulation devices, lasers, a harmonic scalpel, helium or argon plasma therapy, and the cavitron ultrasonic surgical aspirator (CUSA).

Excision (sometimes called resection) removes the entire lesion, as well as a healthy bit of flesh around the lesion.  The surgeon hopes to remove all traces of that particular lesion, in the attempt to make recurrence more difficult.  The more lesions that can be excised, the better chances you may have at a longer symptom-free life.  Tools can be cold, hard cutting tools such as scissors or even lasers (but…but…heat energy – burning!?!) – nope, lasers are often used for excision surgeries to cut around the lesions and harvest it out whole.

You may be interested to go back, grab a copy of your operation report, and compare these tools and techniques.  What exactly DID your surgeon do?  Or you can use this information to better ask questions of your doctor prior to a pending surgery.

F7AYUAJG5FR5GA7.LARGE

Imagine an avocado (mmmmm avocadoooo) – you slice that bad boy open, remove the pit, and discover a bit of browning on the surface.  Nasty bruises and icky…But, there’s plenty of good avocado still to be enjoyed.  If you only scraped off the surface of that brown spot, you’d likely still have MORE brown spot beneath it – that rotten little bruise extends deeper into the avocado flesh (delicious green flesh).  You’d want to take a spoon and scoop out the brown spot in it’s entirety, and enjoy the fresh avocado that you have remaining.

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Also, think of an iceberg.  The tip is only visible above the surface of the water, but the iceberg can extend for quite a long while beneath the waves.  Endometriosis lesions do the same.  Who knows what’s lurking beneath the surface.  And if the entire iceberg – um, Endometriosis lesion – isn’t removed, it may resurface.

Studies have shown that women who undergo excision surgery of Endometriosis lesions have less painful periods, less painful bowel movements, and chronic pelvic pain than women who underwent ablation.  Studies also indicate that painful sex levels remain about the same for both excision and ablation surgeries.

Women who undergo ablation surgery for Endometriosis have a 40-60% chance of recurrence, sometimes within months of surgery.  In contrast, 75-85% of women who undergo excision surgery claim long-term relief.    I personally have undergone two excision surgeries, within two years of each other.  Some of my Endometriosis was in similar areas of my body as my first surgery, but some was found in new locations…My surgeon opted instead of excising (or even ablating) a lesion on my diaphragm, to leave it there for safety’s sake – nobody wants a perforated diaphragm! Excision surgery may not be ideal in every situation – and a skilled surgeon will be able to know when, and when not, to cut.   Even then, it may not work and you still may be slated for a future surgery.  The only guarantee with this illness: there is no guarantee.

In the end, it’s not all about the type of surgery or the tools used – it boils down to the skill level of the surgeon and their method of dealing with Endometriosis.  How competent are they? Do they do excision or ablation?  How often do they perform excision surgeries?  What’s their recurrence rate among patients?  Ask questions! Get answers!  Be comfortable and confident with your surgeon’s skills.

And, as always – there is no cure for Endometriosis.  We may get relief from medication, supplements, lifestyle changes, or even surgeries, but there is always, always, the chance for recurrence.  Listen to your body.  And don’t be afraid to head back in for another consultation…

I’d like to extend a special Thank You to Sarah Soward, a local artist and EndoSister who granted me permission to use a detail of her Endo-Graphic as our cover photo for today.  To view the entire image and all of the information contained there, please visit her site.   You can also view and purchase her other artwork here.

Resources:

Center for Endometriosis Care

Diamond Women’s Center

Endometriosis Australia

Endometriosis Foundation of America

EndoSupport.com

Eric Daiter, M.D.

Nezhat.org

Sarah Soward

The Journal of Minimally Invasive Gynecology – (Unedited Manuscript; April 2017) Laparoscopic Excision Versus Ablation for Endometriosis-Associated Pain – Updated Systematic Review and Meta-Analysis

Vital Health Institute

~ Again, I am a layman.  I do not hold any college degrees, nor mastery of knowledge.  Please take what I say with a grain of salt.  If curious, do your own research 😉 Validate my writings.  Or challenge them.  And ALWAYS feel free to consult with your physician. Always.  Yours ~ Lisa

Meet Dr. Sonia Rebeles

Sonia Rebeles, MD-094

I’ve recently learned of an Endometriosis workshop taking place next Wednesday, February 24, 2016, in Beverly Hills.  I reached out to Dr. Sonia Rebeles, who will be conducting the workshop and she graciously agreed to answer some of our questions.

If you’re in the Beverly Hills area and available that evening to attend, I highly suggest you sit in.  For more information on that upcoming workshop, please click here for their Facebook page.  Don’t have Facebook? Don’t worry – more information can be found here.  And, if you’re like me and can’t attend, Dr. Rebeles may be able to upload a Youtube video afterward.

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Please begin by telling myself and the readers a little bit about yourself.  

I’m 39 years old, originally from El Paso, Texas.  Professionally speaking, I recently relocated to Los Angeles to start a new private practice in Beverly Hills. I did my undergraduate training at Stanford University and fell in love with California.  Along multiple points throughout my career I’ve tried to venture back to the sunny state, but the timing was always off.  Finally, early last year when I was contemplating a career move and revisiting my career goals, I was recruited by and offered a truly once in a lifetime opportunity to showcase my talent by the phenomenal people at K and B Surgical Center in Beverly Hills.  I couldn’t pass up the opportunity to work alongside such a respectable group of physicians in such a prestigious region of the country.

Personally speaking, I love staying physically active and fit.  I am a Crossfit fiend, but I also enjoy cycling (road and mountain) and running on occasion, especially with my dog Bella.  My passion for photography is almost as great as my love of surgery and healing patients.  In both realms, I feel completely in my element.

Let’s see, what else…my birthday is April 1st.  No joke. 🙂

Do you have Endometriosis? 

Not as far as I know.  I suffer from the usual common female maladies like annoying periods and menstrual cramps and bloating, but I think that’s more PMS-related. I’m lucky that my symptoms have never been severe and on the rare occasion that they are, a couple of Advil do the trick.

What got you interested in treating Endometriosis?

In all honesty, I didn’t enjoy treating patients with endometriosis when I went through my residency training.  Most of my senior attendings and colleagues taught me to treat endometriosis medically first and rule out all the other types of pathology that could cause pelvic pain, like irritable bowel syndrome or pelvic inflammatory disease, or bladder infections, etc., all of which tend to be more rare entities as a cause of pelvic pain than endometriosis itself!  Surgery was always considered as a last resort, and it was always met with a sense of dread by physicians not comfortable dealing with it surgically.

When I went through my minimally invasive gynecologic surgical fellowship in 2008-2009, my mentors were master surgeons in laparoscopy and robotics who taught me the satisfaction gained with a challenging case or in surgically tackling the difficult endometriosis case, which was typically a patient who had been sent from doctor to doctor without relief either because surgery was avoided or inadequately performed initially.  For the first time in my career, I saw patients actually get better because they were treated with surgery correctly.

I know that there are several surgical techniques to excise Endometriosis, and it appears you specialize in robotic surgery (yay!).  Which method of excision do you prefer (fully removing the lesion and some healthy tissue around it; ablation; cauterization)?

For me, I prefer excision, fully removing the lesion with either sharp dissection (small scissors used with the assistance of the robot), or electrocautery.  Very rarely I will ablate lesions if they are in a particularly challenging area where dissection might incur damage to adjacent tissues.  If I suspect involvement of bowel or bladder or other non-gynecologic organ, I will solicit the help of that particular surgeon.

I prefer the robotic approach because of the enhanced visualization, 3-dimensional view and magnified vision.  Identifying the many appearances of endometriosis is essential.

Recovering from surgery can be a painful and scary experience.  Do you offer and tips or tricks to your patients for their recovery?  Not case-specific, but as a general rule of thumb?

In general, patients should take about 1-2 weeks away from their usual activity and refrain from strenuous lifting or driving while taking pain medications.  A general rule of thumb is if it still hurts, scale back.  The challenge with endometriosis patients is that more times than not, the post-surgical pain is more bearable than their endometriosis-related pain, so much so that they feel amazing even immediately postoperatively.  So, the tendency is for these patients to want to do more rather than allow their bodies to heal.

There are so many theories regarding the cause of Endometriosis.  Which theory(ies) do you believe may be the cause, if any? 

There are at least four predominant theories and evidence to support each.  I believe it can be multifactorial.  I’ll get into more detail on this during my seminar if this is of interest.

Do you feel that Endometriosis symptoms can be controlled by diet and supplements? 

 Sure.  In my opinion, the adoption of healthy living and eating habits will enhance overall wellness and promote healing, no matter the illness.

How do you feel about hysterectomies as a cure for Endometriosis? 

Removal of endometriosis is the treatment for endometriosis.  Hysterectomy (removal of the uterus) does not cure endometriosis. It may result in less pain when painful periods are the main symptom, but it does not cure endometriosis.

Where do you see medical care and treatment headed for Endometriosis over the next 10-20 years? 

Hopefully treatment will head towards more aggressive surgical management as a first step, preferably by highly skilled surgeons with expertise in minimally invasive approaches to treatment.  Promoting awareness of the utility of surgical management amongst fellow physicians will hopefully minimize or eliminate the circuitous path too many patients with endometriosis are sent on.

Any words of advice for Endometriosis sufferers who may be reading this? 

Your symptoms are real, your pain is real.  You deserve to be heard and most importantly to feel better, so, do your research. If you have pain that you no longer want to live with physically or mentally, or pain that is disrupting your quality of life and your doctor hasn’t at least considered endometriosis or hasn’t referred you to a surgeon who treats it, then find another doctor. Also, find a highly skilled, board certified surgeon when you are ready to go the surgical route.

What can we do to help you and the medical community?

Exactly what you are already doing – spread awareness.  Follow and promote members of the medical community who give good, quality, evidence-based information and have the training and expertise to deal with complex issues like these.

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If you would like to contact Dr. Rebeles for a consultation or to ask your own questions about her experience treating Endometriosis, please feel free to do so:

Sonia Rebeles, MD
Minimally Invasive Women’s Surgery
9033 Wilshire Blvd. Suite 200, Beverly Hills, CA 90211
www.SoniaRebelesMD.com
Phone: (424) 285-8535
Fax: (424) 285-8534
Email: drrebeles@soniarebelesmd.com

Dr. Rebeles currently accepts all PPO insurances, cash pay.  (She is in the process of becoming an in-network provider with some PPOs and eventually Medicare, but this takes time).

I would like to extend a personal thank you to Dr. Rebeles, not only for taking the time to respond to these questions, but for doing so with such fervor!  It’s refreshing to find physicians and surgeons who understand so much about Endometriosis, and how best to treat it.

And, as always, together we can do great things!

Yours,

Lisa