Winner of the Golden Laparoscopy Award - Larry Demco, MD

Dr. Paul Indman: “I’m Paul Indman, and we are broadcasting live from the AAGL meeting in Las Vegas, Nevada. I would like to introduce Dr. Larry Demco from Calgary, who has just won a very prestigious Golden Laparoscopy Award for doing pelvic pain mapping with a microlaparoscope. Larry, can you tell us a little bit about the procedure?”

Dr. Larry Demco: “This involves keeping the patient awake during the entire laparoscopy procedure. Before when we used to operate, we would put the patient asleep but this would eliminate our ability to ask the patient exactly where the pain starts, where it ends, and exactly how to fix her problem. This was always an enigma. Keeping the patient awake suddenly gave us the opportunity to ask her questions and to confirm with her exactly what’s causing the pain and how we can actually go about relieving her symptomatology.”

Dr. Paul Indman: “Now when you say awake, are you using some sedation to start out with?”

Dr. Larry Demco: “When we’re initially doing this we are using just IV sedation along with a local anesthetic. But recently with the development of the heated and humidified YAG, we are now able to do the entire procedure just under straight local anesthetic.”

Dr. Paul Indman: “That’s incredible. What do you find is the normal response of touching pelvic structures such as the tube infundibulopelvic ligament, the cul-de-sac, and other structures?”

Dr. Larry Demco: “What we were taught in medical school and we had a belief in was that when we had to touch something on the left side of the body - the pain or sensation produced would be normally be produced from that same side. With the patient being awake, we can usually touch almost any structure in the abdomen and it doesn’t usually cause any discomfort other then they know that they feel something. It is the pain limit, which is actually a pathological condition. The patient can dramatically tell us exactly where the pain starts and where it ends. But what we’ve done and what won the award was that we’re finding that a lot of the pain does not follow the right and left side of the body. Thirty-five percent of all pain in the abdomen is now referred to a different site. That means that the patient may say that the pain is on the right but the lesion causing it may actually be on the left side of the pelvis or in the bottom of the pelvis at the top of the vagina. We’ve also noticed that approximately 15%-18% of patients are actually reversed. If you touch something on the right, she’ll tell you that it’s on the left, and say you touch a left ovary, she’ll tell you it’s on the right.”

Dr. Paul Indman: “Now one of the crucial questions in my mind would be in terms of managing someone with pelvic pain - are you able to see pathology before touching that area? In other words, you see an implant of endometriosis, you touch it, and the patient says it hurts - that’s not a surprise. Are you finding things you’d otherwise miss on conventional laparoscopy?”

Dr. Larry Demco: “Yes, two things - first of all we can all see a lesion but we don’t all realize - we have no ability to determine - whether that lesion is actually causing the pain, and this is one of the things that we can confirm. We can also determine that the microscopic disease can extend beyond the lesion to what looks like normal peritoneum. Through pain mapping, we’re able to locate the actual outer edge of the pain, signifying the end of the microscopic disease.”

Dr. Paul Indman: “What’s the maximum, let’s say, radius that you’ve seen outside of the normal looking, or outside of the lesion when IV pain mapping?”

Dr. Larry Demco: “Eight millimeters under direction.”

Dr. Paul Indman: “Is that pretty common or is that…?”

Dr. Larry Demco: “There’s a certain percentage that do end right at the lesion, but this is only about 20%. The majority of them are around approximately 15-20 mm and that’s a good guideline to go on but the maximum has been up to 28 mm.”

Dr. Paul Indman: “Again, if you touch normal peritoneum, that wouldn’t be painful to most women?”

Dr. Larry Demco: “Not painful to touch.”

Dr. Paul Indman: “When you do these, are you prepared to do definitive treatment at that time, put them to sleep, and let’s say, remove those areas?”

Dr. Larry Demco: “That would be a great and ideal situation when you have unlimited time, and that would be the best. We are forced to actually videotape it with the patient in a twin video system so she’s in the picture in a picture so that we can refer to this and actually treat them at a later date when we can book appropriate operating time, and we can discuss with the patient our findings and our potential complications.”

Dr. Paul Indman: “So you’re finding that this may turn out to be office evaluation in an ideal setting, putting economics aside?”

Dr. Larry Demco: “Yes.”

Dr. Paul Indman: “In an ideal setting, you might do this in an office, see if you find something, and then go take them and treat them at a later date.”

Dr. Larry Demco: “Yes, in a ideal setting, unfortunately most of this is done in a surgery center. And from where I live in Canada, that’s dictated by the political opponents here rather than by practicality.”

Dr. Paul Indman: “It’s unfortunate that we get into politics once more managing medicine. This seems like a promising technique, and I’m looking forward to hearing more about it. Thank you very much.”

Dr. Larry Demco: “Thank you.”