2016, Responses from: Dr Guy Gudex, Mr Simon Edmonds, Mr Michael East and Prof Neil Johnson
“I am considering paying for my second laparoscopy myself. I want to know whether it is worth seeking out the best laparoscopic surgeon? Does the skill of the surgeon make a difference to the recurrence of endometriosis?”
Dr Guy Gudex: “The experience and skill of a surgeon can make a difference with respect to the chance of recurrence of endometriosis, particularly depending on the site of the endometriosis.
If the endometriosis is involving the bowel or the space between the vagina and rectum (recto-vaginal septum) then the extent to which that is treated may vary from surgeon to surgeon based on the age of the patient, symptoms, whether fertility is an issue or not and the experience and training of the surgeon.
Endometriosis in the ovary (endometrioma) can recur up to 10% of the time no matter which method is used to treat them surgically and again surgical management can vary depending on the particular circumstances of the patient.
If you are concerned you should ask about the relevant experience of the surgeon you have been allocated in the public system. Most District Health Boards have gynaecologists with a special interest in laparoscopic surgery.”
Mr Simon Edmonds: “All gynaecologists in New Zealand are trained to a basic level of laparoscopic surgery as per the RANZCOG training programme. This should include making the diagnosis of endometriosis and performing diathermy and minor excision of disease.
Some gynaecologists have specialized further either by having an interest and experience in managing endometriosis, or by undertaking a fellowship training programme. For the last 10 years, the AGES (Australasian Gynaecological Endoscopic Surgery Society) has endorsed a 2-year structured training Fellowship programme in Australia and New Zealand. There are a number of other good quality informal laparoscopic fellowships for trainees across the country.
Many public hospitals across NZ will have a lead consultant in this type of surgery and you should ask if unsure.
For more advanced endometriosis, particularly involving the rectum (rectovaginal endometriosis), or for women with refractory pain, a multidisciplinary approach is required, with involvement of other specialties such as colorectal surgery, urology, pain teams, health psychologists, dietitians and physiotherapists.
If you wish to see someone in the private sector using insurance or self pay, then the advice as above should still apply. You can ask your GP and past patients who they would recommend or check out the ESIG page on the Endometriosis NZ website. Many surgeons will have information on a website. This may help you to find the most appropriate clinician.”
Mr Michael East: “The persistence of symptoms and the persistence of disease may not be one and the same thing. Skill level is important especially when one is dealing with stage 3 and 4 disease. However once any kind of treatment surgery has been performed, a very careful appraisal is required before subjecting oneself to further surgery. Remember, surgery itself is a trauma and the law of diminishing returns, definitely exists with regard to repeated surgeries. The strategy for improving your quality of life needs to be multifaceted regarding investigations and treatments. The most important thing you can do now is to read widely and then seek a management opinion from a well respected clinician who is known to work in a multidisciplinary centre that at least includes physiotherapists and dietitians etc.”
Prof Neil Johnson: “The WES consensus statement – into which there was considerable consumer input, reinforces some of the points already made and makes other points that at least have a level of consensus concerning surgery and secondary surgery. Here’s the link to an overview of the Consensus Statement. A link to the full publication:
Best practice, gold standard surgery is excision or resection to remove the endometriosis. The skill of the gynaecologist does matter! The first surgery should be the best surgery. Multiple surgeries are now ill advised and can cause further pelvic trauma.
We are fortunate to have several gynaecologists who are also advanced laparoscopic surgeons in New Zealand, some of whom also work in the DHBs. Follow the advice of Dr’s Guy Gudex, Simon Edmonds, Neil Johnson and Michael East (all of whom are advanced laparoscopic surgeons and excise the endometriosis) and ASK your gynaecologist about their relevant surgical experience.