Credit: abc.go.com
Have you ever wanted to ask Dr. Harry Reich, EndoFound’s Honorary Medical Director Emeritus and Senior Medical Advisor, a pressing question? You can reach out to him via email at [email protected] or through EndoFound’s official social media channels on Instagram, Facebook, or Twitter. Just tag them and use #askharry to submit your question, and your answer might be featured!
As someone deeply involved in the field of endometriosis, I was intrigued when I learned that ABC’s primetime hospital drama, The Good Doctor, was featuring endometriosis in one of its storylines. I was prepared for an evening of entertainment, ready to see how a popular Tv Doctor show would handle this complex condition. However, my anticipation quickly turned to disappointment. What I witnessed was a highly inaccurate depiction of endometriosis surgery as it is actually performed. Frankly, I’m left wondering about the medical expertise behind this show – because when it comes to endometriosis, they seem to be completely off track!
The episode in question centered around a young woman experiencing pain and infertility. Crucially, her strong desire to become a mother was emphasized; she even had names picked out for her future children. She made this clear to her medical team, yet the possibility of a hysterectomy was never discussed with her, nor was her consent for such a procedure ever obtained prior to surgery.
RELATED: Top Ten Signs You Need a New Endometriosis Specialist
The surgical scene unfolded with the patient surrounded by a large team of surgeons in the operating room. (I couldn’t help but chuckle at this, as I’m accustomed to operating with just my assistant.) They commenced a laparoscopy using a multi-port umbilical system – essentially, all surgical instruments inserted through the navel – and successfully located endometriosis. So far, so good. But this was merely the prelude to a staggering 27-hour operation! (Seriously? Someone needs to alert Guinness World Records about this marathon endometriosis procedure.)
RELATED: Watch The Good Doctor Episode, “36 Hours”
The on-screen surgeons then discovered endometriosis lesions on the ovaries. The surgery then progressed to the dissection of each Fallopian tube, accompanied by extensive dialogue and questioning among the lead surgeon and numerous assistants. Eventually, the situation escalated as the patient began hemorrhaging, exhibiting low blood pressure and a rapidly rising pulse. This led to an emergency laparotomy, a large abdominal incision. Twelve hours into this already protracted procedure, they determined that the bladder needed to be removed and reconstructed using intestinal tissue. Following this, the decision was made to perform a hysterectomy due to a mass on the uterus compromising critical blood vessels. A significant amount of time was then spent attempting to obtain consent for the hysterectomy from the husband – who, legally, could not provide it. Let’s remember, the patient’s deepest wish was to be a mother, a point she had explicitly stated. Incredibly, the husband delegated this monumental decision to a junior resident. The episode culminates with the woman waking up to the devastating news that her uterus had been removed. At this point, I almost threw my popcorn at the screen!
Here’s where the tv doctors took a wrong turn, medically speaking. Performing an open laparotomy in this scenario was completely unnecessary. Even large endometriosis masses or nodules can be effectively excised using laparoscopic techniques. This often involves opening the bladder to excise the lesion, followed by meticulous bladder repair, all laparoscopically. Another significant misrepresentation was the surgeons’ description of her endometriosis as “invasive.” This is a fundamental misunderstanding of the condition. In medical terms, “invasive” typically refers to diseases like cancer, where cells aggressively invade surrounding tissues and spread. To label endometriosis as invasive is misleading and can cause undue alarm, wrongly associating it with cancer in patients’ minds. Deep Infiltrating Endometriosis (DIE) is more accurately described as Deep Fibrotic Endometriosis (DFE). What’s the distinction? When a surgeon operates on endometriosis, they are primarily dealing with fibrosis, or scar tissue, which encapsulates the endometriosis glands and stroma (connective tissue). Finally, laparoscopic hysterectomy for extensive endometriosis has been a well-established procedure for three decades. I have stated it before, and it bears repeating: the decision to undergo a hysterectomy for endometriosis should always be the patient’s. Patients should be empowered to find endometriosis specialists who are skilled in uterus-preserving techniques. Furthermore, while hysterectomy for extensive endometriosis can be complex and lengthy, typically ranging from three to eight hours, a 27-hour procedure is simply beyond the realm of realistic possibility.
Switching gears, I want to address feedback I received regarding my previous column, ‘IBS Is a ‘Wastebasket Diagnosis‘ from Jeffrey Roberts, the founder of IBSPatient.org.
“I have reviewed your credentials and acknowledge your expertise in your specialized field. However, I must respectfully disagree with your medical opinion regarding Irritable Bowel Syndrome (IBS). Your characterization of IBS as a ‘wastebasket diagnosis’ is not only hurtful but also potentially damaging to the 20% of the population suffering from this condition. IBS is not merely a collection of minor complaints, as your description implied. The impact of IBS on an individual’s quality of life is comparable to that of serious conditions like kidney disease, with sufferers often feeling as restricted by bathroom access as kidney patients are by dialysis. It is particularly concerning that IBS disproportionately affects women in Western medicine, and given your focus on women’s health, a more nuanced understanding of IBS would be expected. Gastroenterologists who specialize in IBS management use the Rome Criteria, a rigorous diagnostic framework based on patient history and symptoms, to diagnose IBS. This is far from a ‘wastebasket diagnosis,’ especially considering the extensive research dedicated to understanding its causes and developing effective treatments for millions of sufferers. The notion that IBS is simply caused by poor diet is a harmful oversimplification. If only it were that straightforward – we would all be cured by now. I am genuinely surprised and disappointed that an expert in your field would offer an opinion on IBS without, it seems, undertaking even basic research into current understandings of Irritable Bowel Syndrome. It is true that some women may present with symptoms that can be confused between IBS and endometriosis, and some may even undergo unnecessary surgeries when IBS is the underlying issue. I urge you to consider adopting a more empathetic perspective and to familiarize yourself with current research on Irritable Bowel Syndrome.“
Sincerely,
Jeffrey Roberts, MSEd, BSc
Thank you, Jeffrey, for your insightful and informative response. I find myself in agreement with the vast majority of your points. It’s important to remember that my column is intended to be an opinion piece, reflecting my clinical experiences and perspectives, rather than a rigorously researched summary of established medical literature. My practice has been primarily focused on patients with extensive endometriosis. In my clinical approach, a thorough pelvic examination was paramount. If a patient presented with symptoms suggestive of endometriosis, but the pelvic exam revealed no pain or tenderness, I would often question the initial diagnosis and recommend further evaluation elsewhere, unless the patient strongly desired a laparoscopy. In many of these cases, laparoscopy confirmed the absence of endometriosis. I concur that sometimes, visual confirmation of the absence of endometriosis can be as valuable as confirming its presence for patient reassurance and diagnostic clarity. My practice also included treating patients with severe adhesions, often resulting from multiple prior laparotomies, sometimes exceeding ten. These patients typically presented with chronic pain and symptoms of partial bowel obstruction, characterized by intense intestinal cramping. These symptoms could, indeed, be confused with IBS. However, my surgical decisions were guided by the patient’s symptom presentation and surgical history. These adhesion surgeries were often lengthy and complex, involving meticulous dissection to separate intestinal adhesions throughout the small intestine down to the rectum, often taking upwards of four hours. Most patients experienced significant symptom relief post-operatively. Interestingly, this specific surgical procedure still lacks dedicated billing codes, and regrettably, many surgeons may delay intervention until the patient develops complete bowel obstruction, a far more critical and potentially dangerous stage.
Editor’s note: The opinions, beliefs, and viewpoints expressed by Dr. Harry Reich in this column are solely his own and are based on his extensive professional experience.
For more Ask Harry columns, click here.
