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Minimally Invasive Surgery for Reproductive Medicine and Gynecology

At JCRM, our mission is to help patients resolve their surgical problems in the least invasive method possible, thus allowing prompt return to work or normal activity.  Our goal is to offer the most advanced, cutting edge technical expertise, surgical judgement, and experience in gynecologic and reproductive surgery available in the United States.  We offer a friendly, compassionate, and caring environment where patients can undergo comprehensive diagnosis and treatment.  A large majority of our surgeries occur at Southpoint Surgery Center where patients can undergo the highest quality surgical service in a friendly, non-assuming atmosphere.  When indicated, we work in all the area hospital operating rooms.  In all these settings,  excellent success rates have been achieved with extremely low complication rates for our patients compared to the national average.

Minimally invasive surgery is any surgical procedure that avoids the large traditional incision (laparotomy) that allows the patient to return home the day of surgery (outpatient).  In Gynecology and Reproductive Surgery, Laparoscopy is the minimally invasive method utilized whereby small 5 mm incisions in the abdomen are made through which the camera and instruments are placed to perform the procedure.  Our practice offers all aspects of minimally invasive surgery from traditional laparoscopy to the DaVinci Robotic System.  Robotics is proposed to offer distinct surgical advantage in some complicated cases, yet simply represents another instrument or tool for surgeons to utilize in caring for patients via the laparoscopic method.  Minimally invasive surgery or laparoscopy requires a great deal more surgical expertise and technical ability than traditional open laparotomy.  The vast majority of Gynecologic surgeons lack training and experience in complicated laparoscopy and either proceed with open surgery, use easier less effective laparoscopic techniques, or refer patients to more experienced surgeons. Today, in general, most cases that are labeled complicated, or associated with a large uterus such as with fibroids, are performed via open laparotomy or are converted to laparotomy after starting with laparoscopy.

Each member of our staff plays an integral role in caring for and educating our patients. As a whole, our practice is involved in surgical research and participates in national surgical societies, advancing and participating in the latest surgical changes.  Dr. Fox, now a 20 year surgical veteran, has developed many innovative minimally invasive surgical techniques.  Some of these techniques and treatments are not available elsewhere.  Drs. Lipari and Paschall are equally well versed in all surgical techniques offered by JCRM.    In years past, approximately 40% of Gyno and Reproductive surgeries were performed as open procedures requiring large incisions, hospital stay, and long recovery times.  Through progressive innovation over time, JCRM, now performs more than 98% of cases utilizing minimally invasive techniques (laparoscopy).  Aside from surgical innovation, our extensive innovation in the area of anesthesia has allowed our patients to experience much less operative discomfort and return to normal activity sooner.  In addition to the surgical treatment, we believe it is important to treat the entire patient and address the medical, hormonal, and psychological issues that often coexist with surgical problems. That is why our patients’ care is closely coordinated with their referring physicians. 

Pelvic Pain and Endometriosis are some of the most confusing and poorly managed areas in medicine.  It is frustrating that the majority of gynecologists don’t understand the nuances of this disease continuum and its management (by virtue of gynecological training).  Laparascopic laser vs cautery “spot treatment,” or medical therapy with lupron, are used by 99% of the gynecology world to treat endometriosis.  Surgery is the only effective treatment, but to cure the disease it must be completely excised laparoscopically to achieve the desired outcome.  There are fewer than 20 practices in the US that offer comprehensive excisional surgery for all stages of endometriosis.  In a patient without prior disease, there is no consistent way to predict the severity of the disease before surgery because symptoms and the amount or nature of disease are poorly correlated.  For example, most infertility patients with endometriosis have very little, if any, pain.  At JCRM, all causes of pelvic pain are considered and often at surgery we are addressing 3 or more different sources of pain.  Without such a comprehensive approach, patients are left with residual endometriosis and often continue with pain since other common causes of pain are not addressed.  Read more on our Pain and endometriosis pages. 

Within Reproductive Endocrinology, Reproductive (fertility) Surgery has been downplayed now for many years, with most fellowship programs offering very little training.  Peritoneal excision for endometriosis, for example, is not taught primarily to any fellows in Reproductive Endocrinology.  Most practicing Reproductive Endocrinologists, including those who train fellows, perform very little surgery.  Our specialty has evolved into an In Vitro Fertilization (IVF) weighted specialty characterized by practices offering and recommending IVF as a first treatment for infertility to the majority of patients presenting for therapy.  This allows streamlining of practices and is much more  convenient and beneficial for the physicians.  For the most part, surgery has been minimized and relegated to getting patients ready for IVF.  In contrast to the widespread IVF oriented approach, careful meticulous surgeries to open or repair tubes, and/or rid women of endometriosis are very successful in many cases.  Successful tubal surgery allows patients to achieve pregnancy without IVF.   For patients with a prior tubal ligation, tubal reversal surgery is extremely effective, yet the vast majority of practices push these patients directly into IVF and fail to offer this highly effective surgery.  It is our clear impression from years of practice that patients want to become pregnant utilizing the least technical means possible. At JCRM, we are committed to providing you with surgical approaches that allow for spontaneous pregnancy and are proud of our extensive success utilizing long established conservative fertility treatments including surgery. Likewise, our IVF program has been extremely successful for patients that eventually need this more advanced therapy. We will work diligently as a team to provide you with the most appropriate cost effective treatments in your particular situation.  

Surgery, and getting the correct surgery, is a big deal – you only want one surgery:  one that will tackle all of your problems completely.  It is amazing the wide range of surgical abilities and approaches, a fact only known by those of us in the sub-specialty world by reading thousands of operative reports through the years.   It is difficult for patients to choose a reproductive or gynecologic surgeon. Many just stay with their general OB/GYN doctor who they have seen for their pap smears and annual exams.  While this may be fine, it is very difficult to know the surgical skill of a particular surgeon despite their wonderful bedside manner.  It is difficult for the OB/GYNs that refer to us to truly know our surgical skill, unless they have operated with us which is not a common occurrence.  In our current system it is common with endometriosis, to have a general OB/GYN perform laparoscopy and partially treat endometriosis or just note the severity and send the patient on to a more skilled surgeon who can completely treat the disease, vs in many cases, not referring and just treating with birth control pills or Lupron.  In general, a better approach is to start surgery with a surgeon who, for example, in the case of endometriosis, can treat any stage of a disease and if other problems are discovered such as tubal occlusion or fibroids where a fine micro-surgical tubal repair or myomectomy, could be performed at the same time removing the need for a second surgery.  

Three primary qualities are important in choosing a surgeon: Experience, Judgement, and Skill.  It is hard for the public to understand, but training in surgery in residency programs varies dramatically from residency to residency and from doctor to doctor in each residency.  The resident experience in surgery has been declining dramatically over the last 15 years.  After training, because of the emergence of numerous conservative alternatives to surgery, the surgical volume for each practitioner has diminished as well.  In the 1980’s for example an average gynecologist would perform 20-25 hysterectomies per month and now that number is 2-5.  Because of this trend, patients who need surgery have much more complicated cases that depending on the skill of the surgeon, might be performed as an open case with a large traditional incision by one surgeon, or as minimally invasive and outpatient by another.  Some surgeons may start many cases with minimally invasive techniques and then “convert” mid  case to open or more traditional surgery in a moderate or high percentage of cases.  This makes a huge difference to the patient but it’s hard to know these nuances from the patients’ perspective.  For most, to perform complicated minimally invasive surgery takes longer than traditional surgery without any more reimbursement to the doctor, an incentive to avoid this approach.  Most physicians don’t have the patience to stick with this approach long enough or don’t have the surgical volume to gain the necessary experience in the technique.  This has resulted in a system with very few excellent minimally invasive surgeons in our medical environment.  At JCRM, we have the skill, the judgement derived from thousands of cases, and 30 plus years of experience to plan the correct surgery and to be able to accomplish all the necessary tasks for each patient in a minimally invasive way.  This allows for rapid return to work and normal activity and avoids subsequent surgeries as we see in so many patient histories.  

Most importantly, our outcomes are excellent with patients finding relief of pain and other symptoms and achieving pregnancy in the vast majority of cases.  Our complication rate is extremely low, less than all the published benchmarks in gynecologic and reproductive surgery.  These great outcomes occur despite having a large volume of the most complicated cases referred by other local surgeons where complication rates would be expected to be higher.  Please review more detailed information and view some of our videos in our subsection on our surgery website.  Also feel free to read some of our patient success stories.  

Please call our office for a consultation regarding  your particular situation.