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How to Choose a Surgeon

How does one go about choosing a Minimally Invasive Surgeon, a most daunting but critically important task?  

1.  Be Careful of Internet “Claims,” there’s more to the story

2.  Evaluate surgical Experience, Judgement and Skill

3.  Look for practices that have been innovative and are striving to make the patient experience better.  

4.  Outcomes and low complication rates are very important as well as total surgical procedure numbers

5.  Seek practices offering all aspects of surgical treatments for particular diagnoses

The Minimally Invasive Surgical Technique in Gynecology and Reproductive Endocrinology is Laparoscopy.  Simply defined, small incisions are used to gain access to the abdominal cavity where procedures can be performed as an outpatient with rapid recovery time.  This is in contrast to traditional open or laparotomy approach where a large incision is utilized, the patient hospitalized for a few days, and recovery is relatively slow causing more time out of work or life.  For reference, Robotics = Laparoscopy (see below). 

For most practicing physicians, especially earlier in the training or experience process, require significantly longer time in the operating room to perform complicated Minimally Invasive Surgery than traditional surgery without any added reimbursement. This negative  incentive causes most to avoid this approach for what are perceived as difficult cases.  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 surgical 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 important, our outcomes are excellent, with patients finding relief of pain and other symptoms and achieving pregnancy in the vast majority of cases.  Equally important, 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 read below as we further discuss these issues.  

The internet has created an enormous marketing platform where any claims can be made and patients can be given very misleading information.  Comparing physician abilities is extremely difficult, even for physicians and medical personnel in the field.    In this discussion, we hope to offer some constructive information to help you make an informed decision about your care since surgery care is much more involved than an annual exam for example and can be critical for your quality of life potentially for many years.  Most women love their OB/GYN physician who may have a great bedside manner and typically stay with them for any surgical needs.  This may be adequate in many settings, but a surgical decision is much more complicated in many situations and may require advanced care.  It is hard for any physician, if asked, to say someone else may be more qualified to do something they were ostensibly trained to do.  If you have such a physician, then you have a true advocate for your healthcare.  Patient care should always come before ego.   

Three primary qualities are most important in choosing a surgeon: Experience, Judgement and Skill.  

In any educational setting, there are people who make “A’s” and excel and those who make “C’s” and just pass.  Medical education and surgical education is no different.  This performance information is not available to the public, just that someone is “board certified or fellowship trained” – pass or fail.  A great example are hairdressers.  They all have a “license,” but as we know there is a great variation in skill level and outcome.  Aside from acquisition of knowledge, the difference in surgery is the element of technical skill.  Is a person good with their hands?  Most training physicians don’t really know their manual dexterity capabilities until they are already in their residency programs and, even if they are not so good, tend to press on anyway.  This inherent skill is the starting point from which surgical education begins.  Surgical technicians in the OR who watch surgeons’  daily work are the best people to ask about technical skill, yet that information is also not available to the public.  This ability or inability can significantly affect surgical times, which has an impact on the amount of anesthesia a patient experiences, blood loss, etc.  A good example is cardiac surgery where patients go on bypass.  If the surgeon is fast and efficient, the risk of bypass associated complications is minimized. The same goes for blood loss and operative time in Gynecologic surgery.  Inherent coordination and fine motor skill is something one either has or doesn’t have, and can not be trained to a large degree.  These variables are impossible to determine by patients.  

In laparoscopy, since we are working from a video camera feed to a TV monitor, the hand eye coordination needed is magnified dramatically over open surgery.  It’s like a video game.  In fact, Dr. Fox purchased a ninetendo video game for the resident lounge at Shands to help the residents improve this hand to TV skill.  It’s almost like using very long chopsticks: one in each hand to do very fine manipulation while watching on TV; it clearly is not for everybody.  Some surgeons are very good at “open” surgery but don’t make the quantum leap to laparoscopy.  

It is hard for the public to understand, but training in surgery in residency programs varies dramatically from residency (or fellowship) to residency and from doctor to doctor in each residency.  The resident experience in surgery has been declining dramatically over the last 15 years, especially in laparoscopy.  Most residency programs depend on community physicians to provide much of the surgical experience for residents and now, with decreasing volumes and extreme fear of law suits, this experience has dramatically decreased over time.  Fellowship, representing subspecialty training such as Reproductive Endocrinology (RE), builds on the this residency experience.  After training, when a physician is in practice, 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 now need surgery have much more complicated cases that, due to the average surgical ability, will likely be performed as an open case with a large traditional incision and a two day hospital stay. Alternatively, this could be performed using minimally invasive techniques as an outpatient by a much smaller subset of more skilled surgeons.  Some surgeons may start many cases using 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.  

Residency training in gynecology is significantly lacking in laparoscopic (minimally invasive) training, whereby, nearly all residents are lacking the ability to perform advanced laparoscopy at the conclusion of the residency.  There are no residency programs that teach peritoneal excision or laparoscopic surgery for advanced stage III and stage IV Endometriosis.  We now are just starting to see some laparoscopic fellowships starting around the US in response to this need.  Even in those programs however, the instructors teach only what they know and most fail to teach advanced Endometriosis surgery, focusing primarily on hysterectomy and myomectomy.  

Reproductive Endocrinology as a specialty has migrated far from surgery toward an IVF-only style of practice with minimal surgery and thus, the surgical experience in RE training programs is dramatically lacking with most fellows only doing a few surgeries during their fellowship.  Most surgeons have a basic foundation when training is over but need the first years of practice to significantly build their experience to achieve their maximum ability.   At the end of residency or fellowship, you can either slowly learn alone in practice or be paired with a more senior mentor practicing at a high experience level who can dramatically accelerate the learning and maturation process. Dr.’s Lipari and Paschall, both of whom have excellent skilled hands,  have worked with Dr. Fox over their first years in practice.  He has vast experience in all aspects of fertility and advanced gynecologic surgery, with more than 5000 cases performed to date.  This opportunity allowed for them to rapidly rise to the highest level of surgical expertise in minimally invasive surgery, drawing from his years of experience and many thousands of cases.  This valuable guidance can not be replaced by residency or fellowship training where surgery is only a small part of what goes on.  In addition, there are no RE fellowship programs that teach peritoneal excision for Endometriosis, which in our experience represents 70+% of what we do in our reproductive surgical practice.  So be careful of claims of “fellowship trained surgeon.”  Reproductive Endocrine fellowships don’t aim to train surgeons.   

 So when one goes to choose a surgeon, would one want a surgeon who performs fewer cases and is in the earlier point in their experience curve?  Most would want the surgeon who finds even the toughest cases routine that can be accomplished with confidence.  

Endometriosis as it relates to choosing a surgeon:  with Endometriosis involved in well over 70% of our cases in RE and likely 40% of a general gynecologists practice, why is there no good training in this area?  The answer is complicated.  Resection verses other techniques for surgical treatment of Endometriosis is covered elsewhere on the website but suffice it to say that excision cures the disease and cautery and laser destruction is not curative.  So why is it that the vast majority (<99%) of gyn surgeons don't do excision?  Primarily because it hasn't been a focus area of research and training, and most surgeons don't see the volume of patients and surgeries to learn about outcomes with various modalities.  The majority simply accept the fact that "Endometriosis recurs and patients need surgery every couple of years."  The DaVinci Robotics company identified JCRM, using outside validated data sources, as the number one practice nationally for endometriosis surgery in terms of cases and complexity.  

Because there are no good diagnostic modalities for endometriosis, as the surgeon, we have no idea what the stage of disease will be found at surgery (except in rare instances).  Why would a patient want to embark on surgery with a surgeon that utilizes laser or cautery destructive techniques that won’t scratch the surface of stage III/IV disease and is not capable of excising this deep and very problematic disease? In gynecologic oncology, the surgery for ovarian and cervical cancer represents a similar situation, yet the general gyn physician refers all suspected cancers to the sub specialist surgeon.  In the case of Endometriosis, because there is such misunderstanding about the disease and its treatment, thousands of women each day undergo laparoscopy across the country in settings that are not going to cure their disease.  Many will be told about their diagnosis post op and will either be treated with birth control pills, lupron, or much less often, referred to someone who can do excisional therapy.  Some are not even treated with cautery or laser at surgery; they are just treated with medicine post op, a therapy long known to not significantly impact the disease.  There are very few surgeons nationwide who have experience in severe stage III/IV Endometriosis surgery; likely numbering less than 20.  At JCRM, we have performed hundreds of stage III/IV cases, dramatically changing patients’ lives and future.  

A word on Robotics.  The robot is for all intensive purposes just another laparoscopic instrument.  We learn and use new laparoscopic instruments all the time.  The hardest task in laparoscopic surgery and the one that has prevented the vast majority of gyn surgeons from performing advanced cases is the ability to sew with suture in the field.  Myomectomy, hysterectomy and other surgeries require this skill.  So for most gyn surgeons, when it comes to these procedures, they must be performed open to be able to sew up structures to complete the case.  The robot is basically an instrument that allows people without that skill to complete these cases laparoscopically.  It also has 3D visualization which does improve visualization, but the new 2D HD systems are nearly comparable when used correctly.  In essence, the robot’s function in the gyn world is (should be) to bring average to above average surgeons from laparotomy (open incision) to laparoscopy or minimally invasive techniques (link).  It is, however, not magic and doesn’t do or provide anything over an above traditional laparoscopy and claims that it produces less pain are not true when compared to traditional laparoscopy.

The confusion in robotic claims relates to the underlying premise of statements and claims regarding the robot.  The benefits of robotics refer to the difference in open surgery vs laparoscopy (including robotics) but not robotics verses traditional laparoscopy, where in many cases laparoscopy provides the advantage.  Clearly changing the case from a big open incision to a laparoscopic case is a huge benefit to the patient.  

To illustrate this subtle difference in logic:  one area robotic surgeon advertises for the robot, “incision size of one 10mm and three  8mm incisions is so much better for patient recovery.”  This is true for when compared to open laparotomy but not when compared to our laparoscopic techniques. We are often doing the same case with four 5mm incisions and now with microlaparoscopy, two 5mm and two 3mm incisions.  A 3mm incision is barely bigger than a needle that blood is drawn from your arm with.  The difference between the 10mm and 5mm incision in the belly button means the need for a stitch to close the larger opening which results in a significant increase in post op pain and the chance of infection.  

Another such example is Tubal Reversal.  The same claims of outpatient benefit with the robot to avoid a large incision are made – true.  Traditional laparoscopy however, offers multiple advantages with smaller incisions, such as the ability to be performed in a more comfortable outpatient setting and at a much lower cost.  Our experience locally with tubal anastamosis also involves differences in suture utilized for the closure.  The smaller the better.  In traditional open surgery 8-0 // 9-0 non absorbable (smaller the number: larger the suture)  suture smaller than human hair was utilized which provides by far the best outcomes.  When we migrated to microlaparoscopy 5 years ago, we did so only when we felt the instruments would allow us to continue to use this suture so the outcomes would be the same.  Other pre-robotic laparoscopists had long since been compromising and using 4-0 to 6-0 suture with poorer results for pregnancy.  Now as we read op notes from area robotic surgeons, these larger suture choices are being made, compromising the outcome and we are seeing patients with non-patent tubes (blocked) after this surgery.  The JCRM patency rate is nearly 100%.  So not only did the surgery not work, but the abdominal incisions are larger and more visible.  Again, these nuances are extremely difficult for patients to ferret out on the internet or anywhere else.  Our commitment is to you the patient and to the outcomes you desire.  

So while Robotics does bring many cases to the laproscopy realm which has been a extremely positive, in some ways it moves laparoscopy backwards in technique by requiring larger incisions similar to what we used in the 1990’s and for the young women who represent the majority of our patients, these larger incisions are closer to the middle of the abdomen making the scars that much more visible.  Microlaparoscopy is just one of the many innovative transitions that JCRM has made in laparoscopic surgery to the betterment of surgical care for our patients.  

History is important in all walks of life.  Historically, surgery was performed open with big incisions, hospital stays and long recovery times.  In the 1970’s, laparoscopy came online slowly and over 10 – 15 years.  Techniques and instrumentation developed to allow advanced surgery to be performed via the laparoscope with small 5mm incisions, outpatient and quick recovery times.  Those who performed laparoscopy had to learn the same procedure via laparotomy first because if there was a complication or the equipment malfunctioned, an incision was made to continue and complete the surgery.  No one who performs laparoscopy lacks knowledge or hospital privileges for an open surgery.  As the robot has emerged on the scene, most surgeons are skipping over the laparoscopic training step  and simply learning the procedures on the robot.  If the robot malfunctions and the surgeon is incapable of performing the procedure laparosopically, a large incision or laparotomy will be required, or the patient has to come back for a second surgery.  In contrast, for surgeons using the robot such as ourselves, fully capable of performing cases laparoscopically, when the robot malfunctions, the  case can simply be converted to traditional laparoscopy and completed.  This may sound far fetched but this exact scenario has happened twice to Dr. Fox in the first 100 robotics cases.  Equipment malfunctions in the OR all the time and it’s no different for the robot, surgeons simply must have the experience to work with all methods in order to provide the best patient care.  

 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.  We continually search for new, better, and more minimal ways to perform surgical tasks.  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, such as repair of inguinal fascial defects for endometriosis associated pain, ovarian suspension for adhesion prevention and presacral neurectomy to treat menstrual pain.  In years past, approximately 80% of Gyn and Reproductive surgeries were performed as open procedures requiring large incisions, hospital stays and long recovery times.  Through progressive innovation over time, JCRM now performs more than 98% of cases utilizing minimally invasive techniques (laparoscopy both robotic and traditional).  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. 

Thank you for your time.