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These are videos of endometriosis excision from around pelvic nerves, performed by Marc Possover in Switzerland. What these videos demonstrate to me is that while excision surgery as a category is better than ablational techniques, not all excision is the same.
The field of neuropelveology (in endometriosis) is all about using a patient's history and exam to directly understand the exact location of endometriotic lesions that may affect pelvic nerves, and then to execute the surgical technique required to remove them.
The vast majority of "endometriosis experts" or "excision surgeons" in the United States could not replicate any one of these procedures. I myself feel like I am just at the precipice of being able to do this sort of work. I have spent a great deal of time trying to absorb the cognitive part of Neuropelveology, and now am starting to really work on the physical part.
Doing these procedures takes a lot of courage on behalf of the surgeon. Working around deep nerves means one misstep could leave a patient unable to walk or permanently without sensation in an area of their body. One also is operating around large blood vessels which if violated would likely cause life threatening bleeding that would be difficult to control. Most surgeons have no taste for that. That said, given enough study of anatomy and technique, these risks should be quite minimal. What I know, is that I used to be afraid of many of the things I routinely now, and over time no doubt will feel the same about deep nerve dissection.
One of the things I have really learned from Possover's work is that if patient has a history and physical exam that says that they have a specific area of nerve involvement, then they really have it. Furthermore, presence of gnarly endomeriosis in the pelvis is not required for there to be a very deep lesion that is causing symptoms. In the past I thought that if I scoped someone and saw a "negative" pelvis, there is no way that there is some big lesion on the sciatic or femoral nerve, and therefore absolutely no reason to be digging through what appears to be healthy tissue to remove some thing I don't even know exists. What I know now is that if the physical exam and history says the lesion exists, then it does, and yes it is worth it to dig through normal tissue to get there.
This winter I will be spending severals days in Germany digging through cadavers with Dr Possover, and am really looking forward to that experience. I hope to spend that time absorbing as much as I can, and to bring that expertise home to the US and to my patients.
When I see endometriosis patients, I realize that some patients just don't seem to get better from traditional (non-neuropelveologic) excision surgery.
It is my hope that with these skills at least some of those patients are in fact curable, and that we can march forward towards a goal of helping all women with endometriosis.
Nicholas Fogelson, MD