Understanding Bowel Endo & Pelvic Health with Dr. Vincent Obias

Hello everyone and welcome back to the vocal pelvic floor. I have a first, I think this is our first ⁓ colorectal surgeon on today and ⁓ I want to do like two fist pumps for this. Welcome Dr. Vincent Obias.

Dr. Vincent Obias, MD (00:17)

Thank you very much. Thank you, Dr. Garner, for allowing me to speak on your podcast.

Dr. Ginger Garner PT, DPT (00:21)

Oh my gosh, I’m so glad that you’re here and you guys are in for a treat today. I want to read a little bit of a bio in an intro before we get started. you know a little bit about Dr. Obias. He is a board certified colorectal surgeon, one of the nation’s few fellowship trained colorectal surgeons specializing in deep infiltrating endometriosis involving the bowel. He completed colorectal fellowship training at the Cleveland Clinic.

followed by advanced laparoscopic training at Case Western Reserve University. He’s a founding partner of Washington Endometriosis and Complex Surgery and has served as chief of colon and rectal surgery at GW, George Washington University, and later as chief of colorectal surgery for the National Capital Region at Johns Hopkins Medicine. He is a pioneer in colorectal surgery in terms of robotics. He performed the first robotic colorectal procedure in Washington, DC.

in 2009 and has helped launch robotic surgical programs internationally. He’s authored so many papers, y’all, over 40 peer-reviewed publications and delivered more than 250 national and international presentations on complex colorectal disease and minimally invasive excision techniques. He’s been consistently recognized as a Washingtonian top doctor, Castle Connolly top doctor, and U.S. News top doctor for more than a decade.

Dr. Vincent Obias, MD (01:28)

You

Dr. Ginger Garner PT, DPT (01:50)

That’s like so fantastic. It really speaks to the depth and level of what women need when they have pelvic pain and are told, ⁓ you just have IBS or anxiety or that painful BM that you’re having during your period. it’s just part of being a woman. But what happens when the pain is coming from endometriosis that has gotten into the bowel? What happens when ⁓

Sex hurts, not because of hormones, but because the rectum and vagina are maybe tethered together. We don’t know. Today, we’re going to talk about that. The intersection of bowel endo, a pelvic pain, which impacts mental health and what true surgical excellence actually looks like. So Dr. Obias, welcome to the vocal pelvic floor.

Dr. Vincent Obias, MD (02:43)

Thank you, Dr. Garner . I appreciate it. And thank you for allowing me to speak. ⁓ You know, as you pointed out, and we chatted even earlier before we started, ⁓ you know, I’ve had a lot of experience taking care of patients with cancer and Crohn’s and ulcerative colitis and diverticulitis. And one of the areas that I enjoyed taking care of was endometriosis. At GW, we started quite early on taking care of endometriosis, working with Dr. Vargas. I’ve worked with her for over a decade, actually over 12 years.

Dr. Ginger Garner PT, DPT (03:11)

Wow.

Dr. Vincent Obias, MD (03:12)

when she was at GW and seeing these patients who’ve come in, who’ve had multiple surgeries before finally coming to us to have excisional surgery. It really is amazing. So I’m excited. I’ve left my practices at Johns Hopkins to fully focus on endometriosis. We’ll probably do a little colorectal on the side, but truly my focus now is on endometriosis and taking care of these patients who really could use a specialist. Cause there’s a lot of

surgeons who take care of cancer and even diverticulitis. ⁓ But when it comes to endometriosis, that’s something that ⁓ sometimes it’s not ⁓ a center of focus on one type of surgeon or another. You can get some surgical oncologists and gynaec and colorectal surgeons and general surgeons. And so it’s nice to have someone kind of focus on just endometriosis and developing techniques that are minimally invasive and excise it all out without.

damaging other structures.

Dr. Ginger Garner PT, DPT (04:12)

Yeah, that’s essential. And I just want to say thank you for dedicating your practice to Endo because, and I’m sure we’ll get into this later, some of the cases and people, women that have come into my practice specifically with this problem, it has been life-changing to have access to skilled surgery like you do. But for listeners who’ve never even heard the term, ⁓

or think that endometriosis is a reproductive organ disease only, describe a little bit about, define for them what’s bowel endo and how common is it for women with pelvic pain?

Dr. Vincent Obias, MD (04:50)

Absolutely. So bowel endometriosis is a bit more common than people think. It’s actually the most common location of endometriosis outside the reproductive organs is the rectum and bowel. And it can end up on the rectum, it can end up on the sigmoid, it can even end up on the small intestine and the appendix. Those are all areas that can kind of go into the pelvis. And interestingly enough, the second most common area outside of…

the pelvis or the most common area outside the pelvis is the diaphragm. So whenever we do ⁓ endometriosis surgery, we look in the diaphragm as well as the entire abdomen and of course closely in the pelvis. ⁓ Bowel endometriosis can have a variety of symptoms. ⁓ I see patients, especially if the nodule is quite large, have almost sort of like a sharp tugging sensation where they can feel like…

I’m having a bowel movement and then I feel the sharpness. It’s not a sharpness around the anus, as much as a sharpness down lower in the pelvis. And this is obviously, or maybe not so obvious, but it is worse during a patient’s menses. They can see rectal bleeding at times. ⁓ Sometimes they have issues of straining and constipation or irregularity in diarrhea. ⁓ If the endometriosis is bad enough, they might even have sort of…

localizing pain in the pelvis or even the leg or the buttock region in the lower back. And it’s sort of very nonspecific. You know, we were talking about patients we knew who get other diagnosis and other workups and sometimes even other procedures because they’re trying to find the cause of this pain, which is very phantom. So, you know, when you have ⁓ a cut on the hand, that area is very localized and it’s sharp right there.

when the intestine gets cut or it’s damaged or injured, it’s a more diffuse sort of ⁓ like gassy and nauseous type pain rather than a sharp local pain. But if the endometriosis and inflammation is bad enough, it can have localized pain, but it’s again, since it’s in the pelvis, sort of manifests itself not necessarily exactly where you think it would go.

⁓ Sometimes ⁓ diaphragm endometriosis will cause shoulder pain, even though the diaphragm is lower. And sometimes when you have endometriosis pain, or sorry, endometriosis eating into the bowel, you’ll have sort of almost like a lower back pain or a buttock pain. But the most common symptoms that we’re seeing is sort of a ⁓ sharp tugging type pain, especially when they have a nodule. ⁓ So when you think about the physiology of the rectum, which many people do not,

think about the physiology of the rectum and having a bowel movement. The rectum needs to descend down. Like when you’re on the toilet and you’re trying to have a bowel movement, it descends down and you’re supposed to relax your pelvic floor and you have a bowel movement, right? And so the thing is, is that if you have an endometrioma that’s stuck there, the rectum can’t descend down and it’s kind of pulling on it. So you feel like this tugging sensation that’s kind of sharp. you know,

That’s something honestly that I picked up from working with my endometriosis partners, Dr. Vicky Vargas and Dr. Melissa McHale, educating me on these symptoms. And what I’ve noticed as well talking to these patients that are, I think, very unique. ⁓ Whenever someone says they have rectal pain and rectal bleeding, it can be a variety of things. And that’s why it is important to have a colorectal surgeon involved in these because

It could be anal fissures. It could be hemorrhoids. It could be internal or external hemorrhoids. It could be ⁓ slow transit constipation. It could be idiopathic. It could be something else that isn’t necessarily endometriosis. But the difference is that most colorectal surgeons are necessarily trained for a deep understanding of endometriosis. So when you throw that in there, ⁓ you know, that…

and take care of it, a lot of these pelvic symptoms and anal symptoms can go away. But yes, it’s distinct and different, sort of that tugging sensation, sharp sensation, especially when they’re trying to have a bowel movement. And I can see why. The nodule is sort of holding it in place and not allowing the normal descent and sort of like kind of pulling on the rectum a little bit. And I’ve had patients, when we’ve taken it out, that symptom goes away.

Dr. Ginger Garner PT, DPT (09:19)

Yeah, yeah. I just had a ⁓ patient send me a message in the portal today. She just had excision surgery last week and she had texted me on the day of and I’m also surprised and like, should you not be sleeping right now in recovery? But ⁓ she said that sensation that you just described, that, you know, anal sensation, she’s like, I woke up, it was gone. She had deep, you know, deep infiltrating, know, stage four, you know, endo and it was in the bowel.

Dr. Vincent Obias, MD (09:35)

Yeah.

Wow.

Dr. Ginger Garner PT, DPT (09:49)

She said, I woke up, it was gone. And that’s just ⁓ incredible and immediate pain relief for women who will go into the ER, and we’ll talk about this in a minute, and have no positive diagnostic tests, nothing be sent home with pain meds and told to relax, that kind of thing. Or mistakenly diagnosed as every…

Dr. Vincent Obias, MD (10:09)

Yeah.

Dr. Ginger Garner PT, DPT (10:16)

patient that comes into my office, it gets saddled with just it’s IBS. So you touched on this a little bit already about what symptoms make you suspect that it could be endo versus a functional gastrointestinal problem. So can you just go over one more time? It’s worth repeating, like what are some of those symptoms that are yellow and red flags to you?

Dr. Vincent Obias, MD (10:39)

So ⁓ symptoms and the rectal discomfort and pain in the anal region and pelvic region that worsens during your menses. Those are obviously times during the menses, the endometrioma is probably the largest and most active. And then at that time, you’re going to have the most intense symptoms on the bowel itself. And those are, if it’s cyclical like that, that to me is a red flag. ⁓

you know, most endometriosis, believe it or not, is not full thickness eroding through the wall into the lumen. So rectal bleeding actually is probably, I would say it’s noted, but only in the most severe diseases do we see rectal bleeding. But if the patients are like, I noticed rectal bleeding for sure during my menses, that also would be a red flag to me about it. ⁓ But yeah, I mean, that’s sort of like, ⁓ like, like,

almost like you’re sitting on a rock kind of sensation or something deep in the pelvis pulling. ⁓ I’ve had many patients. I’ve had a patient, her endometriosis was so severe and it was extremely low in the pelvis. ⁓ And when we took it out, she had less pain when she woke up than when she went to sleep. And it’s amazing. It’s amazing. ⁓ And ⁓ this surgery is extremely complicated. Sometimes,

Dr. Ginger Garner PT, DPT (11:55)

Yeah.

Dr. Vincent Obias, MD (12:03)

You know, actually most of the time patients have fairly straightforward disease in the bowel and there are different ways of taking it out and be happy to talk about those. Sometimes they’re extremely complicated. And, you know, it’s not necessarily something that, you know, a general surgeon who gets called in into the middle of a case should just, you know, go after these things. No, you have to be, you know, a very comfortable pelvic, you know, surgeon. I have done a thousand robotic procedures.

doing these kind of procedures are more comfortable with, but if the surgeon doesn’t have lot of experience in it, actually the best thing is not to touch these things because it can cause some major issues.

Dr. Ginger Garner PT, DPT (12:40)

Yeah, and I definitely want to circle back to that ⁓ in a second because I’ve had so many patients as many of us in the pelvic health realm end up referring all the time for endo that how often would you say women get misdiagnosed before they end up getting to you?

Dr. Vincent Obias, MD (13:06)

Yeah, mean, there’s statistics out there. There’s even a wonderful movie that just won a BAFTA award called Endometriosis that actually talked about a patient’s journey. And these women can have years, up to 10 years, in terms of getting misdiagnosed and quite honestly, gaslit and kind of told that it’s this or that or whatnot until finding the true cause of it. ⁓

Dr. Ginger Garner PT, DPT (13:15)

Yeah.

Dr. Vincent Obias, MD (13:35)

You know, rarely do we see patients, especially in our field where we’re sort of like the end specialists within a specialty group. ⁓ You know, we feel lucky if we’re the first, you know, gynecologist and endometriosis group that’s seen a patient, because if they’ve seen a large variety of patients that end up having all these procedures, at the very least, their, you know, minimally invasive surgeries that didn’t do much but didn’t cause a lot of trauma.

and at the very worst cause, make it harder to get it out. ⁓ So, you know, it is very common, sadly, for it to take many years. People just are not thinking about it. I mean, things are getting better. Every year I’ve been involved with endometriosis, I feel like it’s become more and more of ⁓ an area where people are becoming more aware of. And I think that’s wonderful. And movies like that are great. ⁓ But it’s never…

You know, it’s not even close. We’re, you know, there’s literally, you know, there are more new diagnosis of endometriosis than there are of cancer, colon cancer. And yet we know the focus on colorectal cancer, it’s huge. And yet the focus of endometriosis is minimal. And especially when it comes to research dollars, mean, NIH is spending millions and millions on various types of cancers, but benign disease, it’s very hard ⁓ to get a lot of funding for treatment of it. So we are hoping.

Dr. Ginger Garner PT, DPT (14:51)

Yes.

Dr. Vincent Obias, MD (15:02)

to do research on this field sometime in the future. ⁓ right now we’re just focusing on building this practice and taking care of as many patients as possible. But there’s so many areas of growth that need to be done and research. And excited to be part of any of that.

Dr. Ginger Garner PT, DPT (15:17)

Absolutely, and I definitely want to get to that ⁓ in just a few minutes. One of the things that I wanted to kind of describe as we move into talking about surgery a little bit, let’s get technical, because it’s such an enormous skill set that takes you years to develop. There’s such precision in it, and there’s a lot of fear. ⁓ Anytime you talk about bowel surgery, immediately, there’s a lot of fear surrounding what’s going to happen. Am I going to have to wear a…

Dr. Vincent Obias, MD (15:30)

Mm-hmm.

Dr. Ginger Garner PT, DPT (15:47)

a bag or something like that. when patients describe, you know, sharp pain with bowel movements during their period, and the other thing that I wanted to ask too is, you know, in the perimenopausal, menopausal realm, things also shift hormonally. And I also see women coming in in that period timeframe where they somehow made it through.

to perimenopause, menopause, and maybe that’s a result of gaslighting, medical gaslighting, self gaslighting. They’re like, it’s not that bad, it’s not that bad. ⁓ But can you talk a little bit about what’s happening anatomically when they’re having that sharp pain, that sharp pain with bowel movements? Because that’s probably the most common thing that I hear patients say.

Dr. Vincent Obias, MD (16:31)

Yeah, yeah. you know, going back to what you mentioned earlier about the ER. So, ⁓ you know, most commonly when you go into the emergency room, ⁓ if you have bad enough pain, they’ll get ⁓ a CT scan. The CT scan is great for solid organ issues like the liver. ⁓ If there’s any kind of pararyctal abscess or something on the spleen, it’s not great for hollow structures, you know, like the rectum or bowel.

⁓ And it’s very nonspecific for endometriosis. Unless there is a massive endometrioma someplace, it’s usually missed. ⁓ The more common ⁓ diagnostic study is the MRI of the pelvis, but there are different protocols, right? If you just get an MRI of the abdomen, they may not even look at the pelvis. And most of these are never done in the emergency room. ⁓

They’re harder to get, the waiting lines are longer. many times women will just get a bunch of CT scans. The other one would be an ultrasound, right? An abdominal ultrasound will see nothing in the pelvis. ⁓ And transvaginal ultrasounds are very dependent on ⁓ the operator doing them. So if you have my partners doing the transvaginal ultrasound, you’re going to get the best assessment for endometriosis in the pelvis and on the bowel.

If you have it done by somebody in the ER, they might be able to find the ovary and the uterus and maybe that’s about it, which I’m not even sure if they do transvaginal ultrasounds in the ER, unless they get like a gynecology consult. So at the end of the day, even in the ER is going to be hard to get a proper workout. Now, if women come in with these symptoms and sort of this, that tugging sensation and, and pain and dysparenia and pain during your menses. ⁓ and, and you mentioned it, ⁓

tugging and sharp and discomfort ⁓ and they’re concerning for endometriosis, ⁓ many times my partners will just do the ultrasound. ⁓ They’ve had extra training in it. You can see endometriosis on the rectum. You can see it on the uter, actually the ureter. You can see it on the ovary and the fallopian tubes. Very accurate and very good.

If there’s any concern, sometimes you can also get an MRI of the pelvis with the endometriosis protocols, making sure you have contrast in the vagina and rectum at times, as well as ⁓ focusing in specifically in the pelvis. ⁓ And then based on that, we’ll be able to have a ⁓ better idea roadmap of what needs to be done. Early on, I used to do a lot of colonoscopies on these patients. ⁓

But when you think about the population, it’s fairly young. If they don’t have a family history of colon cancer, it’s only pain during the menses, and you can see something on workup, I’m not necessarily so excited on seeing every single one of these women have needs of colonoscopy. I’ve done many colonoscopies, and I’ve not found a secondary cancer by accident. I have found polyps, which say, okay, you might need a repeat colonoscopy in five years, but I’ve never found something that generally…

that made me like, oh wow, I missed something. Colonoscopy is helpful if there’s a sharp angulation or a full thickness erosion, but the ultrasound will also tell you the nodule too. Plus if somebody needs to have an endoscopic exam, we can do it at the time of the operation. So I’ve been a little bit less aggressive with a colonoscopy unless the symptoms are really concerning for, or have a high family history of colon cancer.

There are other ways of also assessing the bowel, including something like cologuard, which doesn’t necessarily require a colonoscopy. ⁓ Now, you know, once we do the full workup and we know there’s say something on the bowel, my partners can usually say if it’s one centimeter, half a centimeter, two centimeters, three centimeters, and that does help us in terms of staging. You know, if it’s relatively small, like say half a centimeter, ⁓

Dr. Ginger Garner PT, DPT (20:36)

Mm-hmm.

Dr. Vincent Obias, MD (20:42)

we can maybe shave it off. Or if they say we can’t find anything, but we find it incidentally in a small lesion, we can just shave it off and put a couple of absorbable sutures robotically. Generally, the complication rates are very low and post-op the patients don’t have a lot of change in their bowel habits because you really haven’t cut the bowel. If there’s a larger nodule, say about anywhere from a half to a centimeter up to about two two and a half centimeters,

You can actually have what we call a disc excision. use a stapler trans-anally to invaginate the nodule into the stapler, fire it, do a full thickness excision, but only a part of the wall. We don’t take the blood vessels or the nerves around the rectum at all, and we over-sew it. And honestly, we’ve looked at those numbers ⁓ internally over last two or three years, and the leak rate’s less than 1%. But I tell patients 1 to 2%, just because there are data out there that

that because it’s a full thickness, ⁓ some of the other papers have worse leak rates. But in our hands, it’s very benign. Now, the lesions larger, say above three centimeters, we definitely talk about taking a resection called low anterior resection. But remember, most of these ⁓ nodules are about anywhere from eight, six, seven, eight centimeters and more proximal.

doing a resection and you’re very close to the anus, say like one or two centimeters from the anus, the leak rates are higher. And that’s when you think about giving a temporary bag. But if it’s more proximal, you can still resect and put them back together without needing a temporary bag. The leak rates are higher, but again, about four, three, 4%, 5%, but these are healthy women. They’ve not had radiation. They’re not taking chemotherapy.

Dr. Ginger Garner PT, DPT (22:15)

Boom.

Dr. Vincent Obias, MD (22:38)

and they’re younger, they’re not the older population. The data that looks at leak rates are in a different population than young, healthy women. And so I think that the leak rates are lower and we tend not to give bags or stomas. And so when we have all that information, the ultrasound, the MRIs, ⁓ our experience doing these complex surgery, we tend not to give bags unless the truly difficult patients and then…

Dr. Ginger Garner PT, DPT (22:45)

Mm, true.

Dr. Vincent Obias, MD (23:06)

you we would give a temporary stoma. I’ve probably done close to a hundred of these now, and we’ve done it like one or two patients. And these are the patients. And of course, before I joined this group, I saw the worst of the worst. So, you know, it’s not that common. We try to avoid it, but, you complications occur. We have to talk about that. And we want to make sure that everyone’s educated because…

Dr. Ginger Garner PT, DPT (23:15)

Okay.

Dr. Vincent Obias, MD (23:31)

know, lots you want to do as a patient wakes up and they see something and they’re like, what happened? And they’ve never, they were never educated on it. So, you know, I definitely strive to educate my patients as much as possible. So everyone’s happy when they go home the next day after surgery with no problem.

Dr. Ginger Garner PT, DPT (23:46)

Yeah, but you

just totally read my mind about that next question actually, because I wanted to talk about the parameters, you know, when there would be shaving versus that dis-droid, you know, excision versus a full resection. And then if you have to do a resection, when does someone actually need to have a stoma in a bag? I guess, you and you totally answered all of those already. But the one question that I had, because I have had patients come in who do need to have that.

Dr. Vincent Obias, MD (24:10)

You

Dr. Ginger Garner PT, DPT (24:16)

you know, maybe it’s stage four, you know, it’s deep infiltrating. In this particular case, I’m thinking about, and this is why, this is why, listen, dear listener, you need to go to Washington Endometriosis. You need to go to practices like this who exclusively specialize in endometriosis excision.

Dr. Vincent Obias, MD (24:17)

Mm-hmm.

Yeah. Yeah.

Dr. Ginger Garner PT, DPT (24:39)

because a patient came to me and ⁓ unfortunately this isn’t unusual, but as time goes by, hopefully this will become a rarity. Where she sat down and said, well, I had excision from someone who said they did excision and they opened me up and said it was all over the bowel and they really couldn’t do anything, but it was good enough and they just, and they closed me up.

So when she went to actually have real excision done, she needed a resection. was, as you alluded to, as you mentioned, if someone goes in that doesn’t really know what they’re doing and they’re not prepared to handle it, it can leave more of a mess behind, more problems behind. So I would love to hear your input on that because I do hear a lot of… ⁓

Dr. Vincent Obias, MD (25:19)

Yeah. ⁓

Dr. Ginger Garner PT, DPT (25:26)

Stories where they’re like, well, it was convenient. They were close. They said they could do it. They, know, et cetera. I’ll just see what they find first. Right. Versus going straight to the expert. So in this case, she did have a resection. She did have a stoma. She did have a bag and they reversed that. And I’m wondering ⁓ how much time goes by before that reversal. And then what would be your messaging to someone who’s thinking, well, I’ll just go and see what they can do.

Dr. Vincent Obias, MD (25:35)

Yeah.

Yeah.

Dr. Ginger Garner PT, DPT (25:55)

even if they’re not an endo specialist.

Dr. Vincent Obias, MD (25:56)

Right.

Well, so whenever we give somebody a temporary ostomy, ⁓ you know, we call it a protective ostomy. ⁓ It doesn’t necessarily reduce the risk of a leak, but if a leak occurs, ⁓ it’s not as devastating because the rectum and bowel is relatively empty. So only mucus leaks out versus stool. So, ⁓ and you know, the majority of those patients are able to reverse quite easily in about eight weeks. And it’s a simple procedure again.

it’s not an in and out procedure. You stay in the hospital for a day or two afterwards. ⁓ In terms of ⁓ having endometriosis and saying, you know, I’ll just choose a surgeon. would really ask the surgeon, you know, how much of this did he do? know, if they’re a general gynecologist ⁓ who do plenty of, you know, laparoscopy and looking through things that, you know,

You know, how much endometriosis do they do? This is, this is not the same as just, you know, fibroids. This is, this is a bit different. There’s peritoneal stripping, there is nerve preservation, and of course, you know, nodules on the bowel. What do you, how do you deal with that? And so, you know, those are, and those are things that really you don’t necessarily find unless you’re getting the right studies, you know, MRIs are fine, but ultrasounds are sort of

the gold standard in my mind of finding these rectal nodules. So, ⁓ and I would ask that. would ask, know, how much have you done? You know, what happens if you see it on the bowel? Is there going to be a ⁓ colorectal or a general surgeon involved and who are they and how much experience do they have? Or are you just going to get somebody on call? Should I get more studies? You know, I think that what

An MRI of the pelvis that would specifically look at endo, it’s probably as good as what most patients can get around where they are. I would say getting a specialized ultrasound like my partners do, which I think is a gold standard, that’s tough. mean, there’s only two that I know of who does it, do it at a high level in my area. And I live in Washington, DC. And, but you know, an MRI is somewhat standardized and we certainly, and it certainly can find items, especially if it’s big. And that’s, that’s probably what

most of the gynecologist would be worried about taking care of. And honestly, I would be worried about, know, excising any bowel, any endometriosis in the bowel unless they’re a bowel surgeon, because that’s, you know, as you point out, most women, you know, they would like to have their disease taken care of, but they worry about having a bag or a septic complication or, you know, these terrible complications.

That’s the biggest worry. And that’s honestly, you know, why my partners approach me to join them is because they understand that it’s the most common location for endo outside of reproductive organs. And, ⁓ you know, they want to be a one-stop shop. They want to be a multidisciplinary shop. And they understand that this is what your patients are looking for. ⁓ But I would have, you know, a patient ask ⁓ their…

operating surgeon who’s recommending surgery is like, how much have you done? What happens if we find it here? Do we need more studies to be done? mean, to just do a laparoscopy with symptoms of endometriosis without understanding what’s happening internally, I’m not sure that’s a proper workup for somebody who needs surgery. mean, ⁓ most surgeons don’t do surgery just based on symptoms.

if they can avoid it. ⁓ If somebody comes in really sick in the emergency room and needs emergency surgery, okay, you just gotta do what you gotta do. But these are patients who’ve had symptoms for months to years, they can get a good workup and get a better idea of what’s gonna happen. And then, that I think is really important that they get a good workup before jumping in there.

Dr. Ginger Garner PT, DPT (29:45)

You

Yeah. Well, and then the other very important aspect of this is with the work that you’ve done in robotic surgery between now, you know, and when, you know, that the advent of that, that’s massively changed the landscape of what you do and outcomes. ⁓ Can you talk a little bit about that? Because that’s just another layer to add on that ⁓ I’m not sure that people who suspect they have endo or know they have endo know that this is such ⁓

know, an in-depth specialty that really, you know, a general OB-GYN doing surgery is not necessarily equipped to handle.

Dr. Vincent Obias, MD (30:46)

Right, right. So, ⁓ you know, nowadays they do have fellowships in robotic surgery, but when I started off, the best we could do was laparoscopic surgery. And laparoscopic surgery is fine. It’s sort of, I kind of call it chopstick surgery because you’re just kind of using two sticks and you’re dissecting things off. robotics is sort of, it follows the contours of your hands and fingers and it’s, it’s wristed and very accurate. ⁓

And so when you’re trying to dissect and peel off the peritoneum down in the pelvis where the endo is, and you can do a finer ⁓ movements with the three dimensional view on the robot, you can do a very fine dissection, avoiding the pelvic nerves down there. Also, when it’s on the bowel, you can, when you cut it off, over-sew it and suturing it. Laparoscopically, that’s kind of hard to do. ⁓ And so many of the, I mean, I would say younger, but I’m not young, but

Many younger surgeons are do a lot of robotics and, this actually, think is, ⁓ you know, robotics is perfect for endometriosis because you’re doing fine dissection. You’re suturing. ⁓ if there’s a endometrioma on the ovary, you’re removing that you’re suturing the endometrioma on the ovary you’re doing. And these are things you can do laparoscopically. I’m not saying you can’t, are excellent laparoscopic surgeons. but I sort of say like robotics and laparoscopy. So.

Robotics is sort of like ⁓ when you’re driving a car. There are sports cars that are stick shift and they’re manly to drive and people love driving them. But the truth is, is that an automatic is faster than a stick shift. brings everyone makes everyone drive the car faster. Most modern supercars are not stick shift. So same thing with robotics. It brings everyone skill level up to tackle this complex surgery.

And if your surgeon happens to do a lot of robotics, like my partners and I, we really, I think we can do things that we do, we can do things in a minimally invasive fashion that many people, other people can’t. I just, obviously I built my entire career on it. Many of the papers I wrote are on robotics and some, and not on endometriosis, but it has changed rapidly and it’s great. I mean, I love it when I see patients.

Dr. Ginger Garner PT, DPT (33:02)

Yeah.

Dr. Vincent Obias, MD (33:07)

even if they’ve had previous surgery, at least it’s still minimally invasive. So I know I can do a minimally invasive surgery for them. Yes, I’ve been trained in open surgery at the Cleveland Clinic, but that’s the last thing I want to do for these women if we can avoid it. We will if we need to, but most of the time we pull off a minimally invasive procedure.

Dr. Ginger Garner PT, DPT (33:26)

So one of the things that ⁓ I hear a lot in the ⁓ pelvic ⁓ health realm and the pelvic PT realm is ⁓ dyspareunia. Of course, that’s a red flag for ⁓ more involvement, more complicated involvement.

So, and our season is dedicated to sexual health as an aspect of mental health for women with pelvic pain and endometriosis. So it’s a very specific topic this season. But how can you describe a little bit about the anatomy and physiology? Because there’s not a lot of space in there, right? So if we think about the proximity and how close things are and functioning in terms of anatomy and physiology.

Can you describe a little bit about from the bowel endo perspective, how that can contribute to pelvic pain, to dysparenia? And of course, if you’re listening, you’re like, what the heck is dysparenia? That’s ⁓ pain with intercourse or penetrative intercourse.

Dr. Vincent Obias, MD (34:33)

Yes, absolutely. ⁓ So when you take a look at the endometrioma, the area that we see it most commonly is in the anterorectum and the rectovaginal space there. And it tethers the vagina and the rectum together. So when you’re having ⁓ sexual intercourse, ⁓ obviously it will put tension on that nodule. It will actually, yes, it will.

Dr. Ginger Garner PT, DPT (35:01)

Okay, for those of you

who are not watching, you can go to YouTube and watch and here’s the anatomy.

Dr. Vincent Obias, MD (35:03)

you

Yes, it will actually, so when it goes in there and it pulls on it, it’ll actually tug on the right thumb, it’ll tug on the vagina and they’ll have pain. They’ll have pain actually associated with, ⁓ especially on intercourse and also in deep penetrating intercourse. That’s a dead giveaway patients who have deep pain on deep penetrating intercourse. And actually my partners will ask that question and it’ll be part of the questionnaire.

as part of it and again, it’s all consistent. So when the patients come to our office with the symptoms of dyspareunia, especially on deep penetration, that to ours is like, there’s probably something like a nodule down there. And then they can use an ultrasound and pinpoint identify exactly is the nodule over here next to the ovary or is the nodule actually in the rectal wall and the rectovaginal septum.

They can even what they’ll do with the ultrasound is sort of see if there’s any sliding between the vagina and rectum. If there’s no sliding between the vagina and rectum, that means it’s fixed in place by that nodule, right? But if it’s sliding back and forth, that’s a good sign that there’s no endometriosis between in that rectovaginal septum. But if it’s fixed and what they call a fixed, and again, that’s all done by the operator and using the ultrasound probe and watching the three-dimensional

or the 2D view at the same time, they can see if things are moving. that is not something that, unless you’ve been trained to do that and have done it a bunch, you’re not necessarily, ⁓ you’re not getting the full workup on that. But yes, ⁓ an endometrioma down in the pelvis attached to other things, it’s going to hurt. And we do see some absolutely benefits from this. We do say, especially if we excise endometrial on the vaginal side, they do wait.

few months or so before any kind of intercourse, but eventually they’re able to have it with a little, pain, hopefully.

Dr. Ginger Garner PT, DPT (37:12)

Yeah, yeah. Well, that’s where pelvic PT comes in because, you know, from the anatomical perspective, if we just look at the bottom of the pelvic floor, course, I took the superficial pelvic floor off here, but we take the superficial pelvic floor off and we see the deep pelvic floor. when, me take the ladder out, the other model here, we see that there’s not, you know, a lot of that space. And so we want to normalize, here, I’ll just show everybody who is watching.

Dr. Vincent Obias, MD (37:15)

Yes.

Mm-hmm.

Dr. Ginger Garner PT, DPT (37:42)

So, if the bladder was here, it be right here. But since there isn’t a lot of space, yeah, often six to eight weeks is the time to wait for everything to heal. And then from a therapy perspective, we go in and try to normalize that glide and movement and strength and all of the things that you need to get back again. Yeah. So gosh, that sexual health and pelvic health.

Dr. Vincent Obias, MD (38:01)

Absolutely. Yeah.

Dr. Ginger Garner PT, DPT (38:08)

because it can cause not just bowel, problems, sexual health problems, pelvic health problems. ⁓ Before we pressed record, we were talking about that patient who had ⁓ a bunch of hip arthroscopies done thinking it was a hip labral tear and it wasn’t. They had a lot of hip pain. I’ve had people with SI joint pain, back pain come in. And all of that is a burden on mental health. A heavy, heavy burden on mental health. ⁓

Dr. Vincent Obias, MD (38:26)

well.

Yeah, yeah, absolutely. Yeah.

Dr. Ginger Garner PT, DPT (38:36)

The psychological toll of a delayed diagnosis, mean, that’s a whole other like podcast, you know? So when you get to interact, you know, with these patients, maybe sit down with the patient’s family or the patient before or after surgery, ⁓ what are some of the things that you want women to know, you know, that you have relayed to patients who’ve been told for years that nothing’s wrong and then you go in and you find those things, you find what’s wrong?

Dr. Vincent Obias, MD (38:44)

Yeah.

Yeah, mean, one of the things, and this just happened this week, know, a patient was coming out of anesthesia and the first thing they ask is, did you see something? Did you find something? And when we tell them, yes, we found it, they’re so happy. They’re so relieved, you know? When I, you know, when I took care of my cancer patients, they all knew they had cancer. So their question is, did you get all of it? Is it anywhere else?

And these women, the questions were just so basic, were like, was it there? Because they’re just getting told all these different diagnosis. And like you said, it’s nothing to worry about. Don’t worry. Take more pain medicine. Take more NSAIDs. Take more Advil. Take more Tylenol. It’s just your menses. Everyone has pain during their menses. And yet the truth is that when you’re not able to work because your menses is so severe, that’s not normal. That’s a sign that this is more severe.

At the very least, you should get a workup. And so when these women are waking up, they’re not even asking, like, has it spread anywhere? Is it on my diaphragm? It’s like, was it there? And then when they were told it was there and then we got it out there, they’re literally just, they’re literally crying because they are just so happy that something was found. That, you know, that maybe their journey is over for finding it and the workup. And, you know, they see a light on the end of the tunnel.

And of course, before coming onto this practice, I would only see the worst of the worst. But it was amazing when we would, like said, I had this one patient and her endometrioma was eating through the levators in the pelvic floor, that low, right? And she was told by a local colorectal surgeon, you would need a permanent bag, permanent colostrum, because it was so low. So I was able to go in robotically and excise it, but

Dr. Ginger Garner PT, DPT (40:43)

my goodness. Wow.

Dr. Vincent Obias, MD (40:57)

because it was benign disease, I was able to excise it, but keep the rectum in place because ironically, the endometrioma was on the levators, but it wasn’t in the bowel. was just so weird. So I excised this large endometrioma. She woke up with less pain. She was able to walk around. We even say that like the next day, we’re like, hey, you need to walk around. She goes,

Dr. Ginger Garner PT, DPT (41:07)

Wow.

Dr. Vincent Obias, MD (41:20)

doc this is the first time I’ve been able to lie flat in years. I just want to rest on this bed because I can actually rest on this bed. And it was amazing. And no bag, didn’t touch her bowel, didn’t need to, able to dissect it out. And that’s not a case that somebody can just jump in and do it. You need a lot of years of experience dissecting down low in the pelvis like that, you know, and it’s…

Dr. Ginger Garner PT, DPT (41:28)

No.

Dr. Vincent Obias, MD (41:45)

I mean, that’s why even local colorectal surgeons are like, yeah, you’re going to need your uterus out and you need the colon out and rectum out and you need a permanent bag. Cause that to them was how you do it. Cause that’s how you treat cancer, right? If there was a cancer on levators, that’s what you do, but it’s not cancer. You don’t need to be that radical. The patient knew there was risks for all this and she turned out fine. She needed some heavy physical therapy afterwards. ⁓ But you know, she was very, like I said, she didn’t want to move because she was just able to lie flat.

once for the first time. it’s some amazing stories, some amazing stories.

Dr. Ginger Garner PT, DPT (42:19)

That is an amazing story. ⁓

And for those of you watching again, I’ll just pull out my anatomy model. So right here, if you’re watching as little levators, think about your sit bone. And then if you reached on the inside of your sit bone and you went up into here, there’s levators right here. There’s the obturator internus, which is a hip muscle, which is why you can have hip pain with endo.

Dr. Vincent Obias, MD (42:26)

you

Dr. Ginger Garner PT, DPT (42:41)

But the pelvic floor is like right here, the levator group is right here. So very, very close to what you’re talking about with the aneuromotile area. So that’s incredible that, and there’s not a lot of space there. I know we’ve said that a lot, but it is true. So the fact that you could go in robotically and do that and preserve all those structures is exactly why more women need to know about the work you’re doing.

Dr. Vincent Obias, MD (42:52)

Yeah.

Yes. Yeah.

Yeah,

I tell you, that was one of the procedures that got me really excited about taking care of these patients because it’s as complex as it gets as like all these other cancer patients. But ⁓ you’re providing a service that not a lot of people are specialized in. So I was very excited doing that and I look forward to doing more. We’ve got a couple coming down the line that’s going to definitely challenge us. ⁓

The toughest surgeries I did last year were endometriosis, even though I was still doing cancers. The toughest surgeries I was doing was endometriosis. ⁓ Yeah, and they were only a handful, but I remembered them quite vividly. Lots of cancers, a lot of diverticulitis, and those patients did well, but just the endometriosis, ⁓ when they come to my hands and they need me, they can be challenging. So they’re very fulfilling taking care of these patients. But the majority of patients don’t have that, so we take care of everyone. ⁓

Dr. Ginger Garner PT, DPT (43:41)

says a lot.

Yeah.

Dr. Vincent Obias, MD (44:03)

Yeah, but you want to make sure if you have that disease, you’ve got the full workout before someone jumps in because, you know, if someone had taken out her anus and rectum , and gave her a permanent colostomy, I couldn’t do anything. couldn’t put her back together. So fortunately she got a second opinion from me and we were like, don’t need to. And we got it out and she was very happy to say the least.

Dr. Ginger Garner PT, DPT (44:23)

That’s an

incredibly powerful story. ⁓ And I know that just based on the way you described it, that that’s an incredible amount of relief to come after that. I can’t imagine the broad range of symptoms that she actually had. I don’t know if you recall all of the symptoms that she did have.

Dr. Vincent Obias, MD (44:42)

I mean,

yeah, she had, she couldn’t sit, she couldn’t lie flat. She always had to lie on her side. She had a hard, she would walk with a limp. She had pain radiating down her leg and to her buttock and hip. it was, it was, it, like you said, she’s got multiple procedures and multiple workups until they found someone finally did a more thorough workup and found some really complex stuff. They thought it might’ve been cancer. They thought it might’ve been a pre-sacral mass, you know. But if you have a good MRI and a good radiologist, can tell the difference between endometriosis and.

⁓ teratoma or any other type of presacral mass, and even if it’s a cancer. ⁓ And it’s not easy. The endometriosis, ⁓ like a presacral mass is kind of easier. It’s well encapsulated. Meanwhile, the endometriosis sort of like causes a scarring and star effect because it kind of crunches everything together from the inflammation. And those are pretty daunting. I mean, I can see why other surgeons would be like, you can’t get that done unless you remove everything. And I’m like, no, you can’t.

You can’t remove everything. You need to preserve as much as you can. ⁓

Dr. Ginger Garner PT, DPT (45:46)

That’s an important point to make too, because we may end up showing the model of pelvis again and the proximity of everything, is that really, when you’re talking about someone who would go in and say, oh, we just took everything out, we can’t get to it, is that really because things kind of look frozen and all stuck together?

Dr. Vincent Obias, MD (46:05)

You know, it’s funny because I have done surgery on many patients where the other doctor said it was frozen and that is just, that is a misnomer. I’ve not, if you give a patient enough time, let’s say they have really bad inflammation back there or they’ve had surgery, right? And then someone tries to do surgery too soon, like a few weeks later, the adhesions are so intense, they think, I can’t dissect it without causing more damage, i.e. it’s frozen. You just give them time.

Dr. Ginger Garner PT, DPT (46:11)

Mm-hmm.

Dr. Vincent Obias, MD (46:35)

You give them four to six months, you can go back in there and do it robotically and do it. I’ve taken care of many patients who’ve had a quote unquote frozen pelvis and you just give them time. The other thing is that what’s frozen to one surgeon who doesn’t do a lot of robotics and laparoscopy and complex pelvic surgery is not necessarily frozen to others. So we have that diagnosis all the time and it’s what they’re basically saying and is that everything is stuck together so much that they were too scared to mess with anything.

And that also is fine. If the surgeon understands their limitations and they’re like, look, if I do something, I cause a hole in the bowel, this person’s going to get really sick. They’re going to end up with a bag, you know, in my hands, this is unoperable. Okay, fine. Moving on to the expert, we’ll take care of that patient, be able to do that and correct the anatomy and it’s much safer. So, you know, it’s frustrating, but it’s more frustrating if they try to do something partially and cause a problem.

Dr. Ginger Garner PT, DPT (47:23)

Yeah.

Dr. Vincent Obias, MD (47:32)

and then it’s become a catastrophe and these patients do much worse. but yeah, so frozen is a sort of a gradation and where it’s coming from. I’ve had, when I was at the Cleveland Clinic, we’ve had Crohn’s patients who’ve had like dozens of surgeries and can’t have minimally invasive, only open surgery and the bowel and scar tissue were so fused, you had to actually inject saline to help.

Dr. Ginger Garner PT, DPT (47:35)

video.

Dr. Vincent Obias, MD (48:01)

cause a space that you can dissect. And that truly was a frozen abdomen that we still did surgery on. ⁓ So, you know, again, time heals all wounds. And if you have someone with good experience and a good plan for surgery, most frozen abdomens can ⁓ have surgery done.

Dr. Ginger Garner PT, DPT (48:22)

That’s so hopeful. Yeah. I’m glad that we got to include that exploration in that, because that’s really important. So if a woman suspects bowel endo, really, what is the first step she should take? Obviously, we’ve gone over kind of the yellow, red flags, the signs, the pain that might be there, but what’s the first step she should take?

Dr. Vincent Obias, MD (48:28)

Mm-hmm.

Well, I think the first step she should take, so let’s just say this. So the symptoms are pelvic pain, rectal pain, right? Sometimes rectal bleeding, discomfort. If it’s definitely coming cyclically during her menses, ⁓ seeing a specialist endometriosis is helpful. ⁓ Or going to their general gynecologist or general doctor and saying, ⁓ could this be it? ⁓

an MRI of the pelvis specifically looking for endometriosis is helpful. The other thing is it doesn’t hurt to see a colorectal surgeon ⁓ or even because let’s say the patient has, I have pain with bowel movements, right? Well, the workup for pain with bowel movements could be endometriosis, but pain with bowel movements could also be anal fissures. It could be constipation. It could be a hemorrhoid depending, and there’s different types of hemorrhoids, internal and external.

So seeing a colorectal specialist can at least rule those other things out. They can do an anorectal exam and say, don’t have a fissure. I talked to you about your bowel habits. It doesn’t sound like you’re constipated or straining. ⁓ There’s your anorectal exam shows normal hemorrhoids. I don’t see a thrombus external hemorrhoids, which causes constant pain. ⁓ You know, these are things that you can do to help rule it out. And then you can be like, yeah, it’s not all any of these things.

I can’t explain why you’re having sort of this pelvic pain and then that should push, I hope, most people to look at other diagnosis, including endometriosis of the bowel. So I wouldn’t necessarily say if I have rectal pain, I need to rule out endometriosis of the bowel. But if you have pain during your menses, that’s very specific to what we discussed, I would have a bit higher suspicion, but also just a normal inner rectal workup for pain.

rectal pain by a colorectal surgeon is also helpful. Most of the time, if they see something, they can treat it. It usually doesn’t require major surgery. And at the same time, you can also get, if they think on it, you might want to just rule out the endometriosis with MRI. Most of the time for endorectal pathology, you don’t need an MRI. You can just do a physical exam. You can take a look and can see if it’s an abscess, a fissure, a fistula, any of those things.

but if they’re all ruled out, then you have to look at other things. Sometimes you can have sort of vague symptoms of anal pain, then you can’t see anything. And in men, it could be something else. It could be pelvic floor issues and proctology if you go, and other things. But certainly in women, they pain in the menses, they should definitely get an endometriosis workup.

Dr. Ginger Garner PT, DPT (51:35)

You know, the other thing that you had mentioned too, which I thought was ⁓ a really critical piece to point out is that you’re talking about where you get patient referrals from. And I think this speaks a little bit to the education piece that you guys get maybe an unusual or higher amount of referrals from pelvic PTs.

Dr. Vincent Obias, MD (51:41)

Thanks.

Yes, so we were just chatting about that. you know, I remember one of our, ⁓ actually our first referral dinner that we had, we had a happy hour, invited a bunch of physical therapists, as well as gynecologists. And I was talking to my partner, was like, wow, there’s a lot of physical therapists. And they’re like, yeah, a lot of our referrals come from physical therapists because they’re actually the ones who on workup of pelvic, ⁓ for people with pelvic pain, you know, that’s one of the differential. And honestly,

That’s not a huge differential for, let’s say, even colorectal surgeon. I’ve been doing this for 20 plus years, trained at a Cleveland Clinic. ⁓ I know I would just went over the entire anorectal workup for anal pain, right? ⁓ You know, but once that’s negative, you gotta start thinking outside the box and in a little bit of other disease processes. ⁓ But a physical therapist like yourself, probably see, you know, you probably see patients who’ve already been worked up.

Like you’re not seeing a patient with a chronic anal fistula with Crohn’s disease, right? You’re like, okay, you need to see a doctor and get treated for this, but you’re probably seeing patients that have been ruled out for obvious pathology. And now, and those patients are selected. And now those are patients who are like have chronic pelvic pain of unknown etiology that can’t be, can’t be given a diagnosis, like at least a colorectal side.

And then, and a lot of those patients could have endometriosis, like you were telling me, a good percentage of your patients. yeah, we are seeing a lot of patients from ⁓ physical therapists.

Dr. Ginger Garner PT, DPT (53:37)

I think it’s the other important thing too is, know, prior to, you know, like Gen X and prior, really, none of those women were properly screened. And if they did find out they had endo, it could just be, you know, accidental. And the quote treatment, which we know is not a treatment, was they were just given a hysterectomy and sent home. And so they didn’t really get the care that they needed and they weren’t even looking, you know, at the bowel. And it wasn’t obviously as complex and sophisticated, you know, back then. So,

I think that that’s probably one thing. That’s what I was going to ask to kind of shore up was kind of a rapid fire question of, it’s one thing that you wish every healthcare provider knew about, know, Indo, OBGYN, colorectal, because we’re already thinking in public PT world, if they’re in the door, Indo is just one of the differential diagnoses that’s there. because most of the

people that come in and sit down, no one has ever even asked them if Endo was in their family. Of course, that’s a loaded question because again, prior generations maybe didn’t get the surgery they need. Maybe they just had a general total hysterectomy and that was thought to be the end of it. So they didn’t really get a proper diagnosis. if you could, you’ve got a megaphone. What do you want colorectal and OBGYN, the surgeons, general surgeons to know about bowel endometriosis?

Dr. Vincent Obias, MD (55:00)

So, and I feel pretty passionate about this and this is what’s something that, you know, ⁓ we helped develop at GW with Vicky Vargas is that, you know, bowel endometriosis and deep infiltrating endometriosis is a multidisciplinary ⁓ process. ⁓ It’s important to have a bowel surgeon involved as well as a gynecologist. ⁓ Obviously,

the leaders of the team are the gynecologists who are endometriosis specialists, but colorectal surgeons and bowel specialists like myself are important part of that team. And I think that when it comes to really complex endometriosis and nodules on the bowel, I would state there should be some close communication between the specialists. And then you have these even more complex patients with endometriosis on the… ⁓

ureters or on the bladder or on the diaphragm. And, ⁓ you know, it’s important to be part of ⁓ a group that has a lot of connections with a lot of these doctors who have done these kinds of procedures and can do these procedures. So, you know, I would say, you know, deep infiltrating endometriosis and bowel endometriosis ⁓ is a multidisciplinary. I have gotten direct referrals ⁓ from gynecologists who send me the dodual ⁓

afterwards saying, I’ve done the endometriosis surgery, but I couldn’t get it on the valve. Here’s the valve. I tell the patient, we’re doing this still with my partners because I want to make sure when we go in and take care of this nodule, there’s no other endometriosis there. And some patients are like, well, I’ve already had, I’ve already had, I don’t need another gynecologist. And I’m like, no, you know, even from my side, it’s multidisciplinary. We know that the nodule is there, but I want to make sure that, you know, your next surgery, we take care of everything.

So multidisciplinary. ⁓ Just like the other thing I want to mention is that endometriosis is common. 10 % of women have it, 10 % of women have deep infiltrating endometriosis on top of that. There are literally hundreds of thousands of women with endometriosis. ⁓ It’s more common than colorectal cancer. ⁓ It is ⁓ as common as something like diverticulitis. And honestly, are many specialists who take care of those patients.

Dr. Ginger Garner PT, DPT (57:19)

diabetes.

Dr. Vincent Obias, MD (57:25)

And yet, you know, I truly feel like there are not enough endometriosis specialists that take and handle, you know, endometriosis, especially deep infiltrating endometriosis in bowel nodules. So, you know, it’s a multidisciplinary and it’s a common disease that we should definitely be more aggressive. Honestly, I think a lot of patients are being told like, you only need medical treatment or it’ll get better or wait till you go through menopause or something like that.

Dr. Ginger Garner PT, DPT (57:53)

All right,

Dr. Vincent Obias, MD (57:54)

You know, and it’s, yeah, and it’s a lot

of, it’s just something that can be taken care of in a timely fashion so that, you know, you have less pain.

Dr. Ginger Garner PT, DPT (58:04)

Yeah, absolutely. I mean, I’ve had so many patients who went in and I would say, you know, maybe 30 % are young, like early intervention teenagers. And then we’ve got, you know, the more young 20, 30 something year old. But then I have a whole contingent, maybe 30 % are perimenopausal, menopausal, postmenopausal, and they didn’t get their diagnosis until then. But…

Then the surgeon goes in and says, the bowel is actually kinked on itself. It was stuck to the pelvic sidewall. There were lesions there. There was so much going on that was debilitating to them that they weren’t able to go to work. They weren’t able to walk their dog. Significant things that across the lifespan really impaired ⁓ them so much.

Dr. Vincent Obias, MD (58:37)

Yeah.

Yeah.

Yeah, no,

it’s such a shame. I’m excited. I’m hopeful that we can reach more women and take care of a lot of patients because I think that it will make a difference. And ⁓ we’re just starting, but we’re getting busier, getting busier.

Dr. Ginger Garner PT, DPT (59:08)

Well, ⁓ I am so glad that you all are here in Washington, D.C., East Coast. We needed another amazing practice ⁓ in specialization in excision surgery. And you guys are like, you’re like an amazing team, like a trifecta. And you have more, have your, ⁓ think Jen is a part, Landoff of your team as well. Did I get her whole name right? I want to make sure I her name right.

Dr. Vincent Obias, MD (59:25)

Thank you. I appreciate it. Yes. Right. Yep. Jennifer Lendoff

Yep.

Dr. Ginger Garner PT, DPT (59:38)

Yes,

⁓ she’s on the team as well. Amazing. I read her bio. She’s going to be on the show ⁓ this season as well. So if you are even in the nearby vicinity, and I want to let people know it does not mean, Dr. Obias, you’re so right. There’s not enough providers. There aren’t enough providers of this level of care ⁓ really worldwide. But we’re talking about the United States here. So don’t think that just because you live, you know,

Dr. Vincent Obias, MD (59:43)

Mm-hmm. Yes.

Dr. Ginger Garner PT, DPT (1:00:08)

⁓ in North Carolina that you’re going to ⁓ just have someone in your state, you are going to have to more often than not travel to do that. So Washington Endometriosis and Complex Surgery, thank you so much for existing, for creating this ⁓ center. And thank you so much, Dr. Vincent Obias for joining me today.

Dr. Vincent Obias, MD (1:00:08)

Threat.

Yes.

Thank you, Dr. Garner, and we’d to take care of your patients and any other patients who come to see us. Appreciate the opportunity.

Dr. Ginger Garner PT, DPT (1:00:37)

Yeah, well, and you guys already are. And thank you very much because I’m already working on some of their post-op rehab. And they’re doing amazing with the same story of I woke up immediately, I felt better.

Dr. Vincent Obias, MD (1:00:40)

Good.

Great.

Wonderful, thank you so much.

Dr. Ginger Garner PT, DPT (1:00:54)

Yeah.