Surgical Risks: What's the Big Deal?
Revised since original publication in 1991 by Dr Robert B. Albee, Jr. and current as of 2025.
A primary goal of any surgical procedure is a safe outcome. In planning for surgery, all risk factors must be considered. Sometimes these factors can be so significant they make us reconsider the advisability of proceeding surgically at the current time. Some factors can be removed (such as smoking) and some can be controlled (such as diabetes). Among the most common risk factors we face when planning for LAPEX (Laparoscopic Excision of Endometriosis) are:
Pain Medications
Pain can make us feel imprisoned in our own bodies. At one time or another most of us have used narcotics (or other pain medication) to achieve relief from severe pain. Unfortunately, some have found medication to be the only way they can get relief from chronic, severe pain. Thus they use it regularly. A person facing surgery who has taken opiates regularly for longer than two weeks may encounter added surgical risks. Although the following list is incomplete, it gives some examples of the impact long-term use of these drugs can have.
Anesthesiologists note a consistent need for larger doses of medications for anesthesia and analgesia. This means the patient may receive doses closer to critical levels that can have side effects and consequences. Because critical levels can vary from one person to another without any indicators, the increase in the required dose elevates the relative risk.
Nurses in post-operative care report that larger doses of medication are needed to keep these patients comfortable. This can result in excessive drowsiness, disorientation, and misunderstanding.
Post-operative constipation is a much more frequent problem as well as a slowed return to bowel function (ileus). It is much more difficult for doctors to monitor for signs of surgical complications because of reduced communicating abilities.
It is much more difficult to evaluate the success of the surgery because pain evaluation can be complicated by a physiological and/or psychological, dependence on pain medication.
Smoking
The regular inhalation of smoke has an enormous number of different unhappy consequences for the patient undergoing surgery. The good news is that studies show patients who quit smoking as little as two weeks before surgery show remarkable improvement in the tolerance of anesthesia. Other risks for smokers include:
Chronic lung disease and emphysema increase anesthesia risks.
Smokers increase the methemoglobin in their blood stream, which reduces the ability of the red blood cells to deliver oxygen to the cells in the body. All organs can suffer.
Infection rates after surgery are significantly increased.
As a group, smokers tend to have altered abilities to absorb nutrients from their stomach and small intestine. They are commonly malnourished and frequently take oral medications without receiving the expected benefits.
High BMI/Obesity
We want to help as many individuals as possible. However, we must always consider patient safety and well-being above all else when evaluating surgical candidates. We understand this is a highly sensitive matter, and our safety guidelines have not been arrived at lightly and without much deliberation, as we always try to safely accommodate as many patient circumstances as we can. We recognize the vast struggles and significant difficulties this disease and chronic pain imposes on an individual, and we know very well that BMI does not account for a person's overall health whatsoever. Nonetheless, when it comes to Laparoscopic surgery for endometriosis - which differs from minimally invasive procedures like cholycystectomy, bariatric surgery and others - there are many high-risk factors that affect our ability to perform our procedures safely and successfully.
For example, individuals in high BMI ranges are at exponentially increased risks of cardiac and pulmonary issues from anesthesia, as well as risks of blood clots, infection(s) and aspiration(s). In addition to higher rates of complications including but not limited to those from anesthesia, there are also critical technical difficulties that would prevent us from performing satisfactory surgery. Patients in this category are also more difficult to intubate (where a breathing tube is inserted into the trachea), and because they need to be in steep Trendelenberg (a position where the patient’s head is angled down 30 degrees), it is inherently more difficult to ventilate the patient since their airway pressures are higher and this can subsequently cause trauma to their lungs if they exceed these pressures. Were we to compromise on the degree of Trendelenberg, this would allow the bowel to move into the pelvis and increase the risk of injury to the bowel - a potentially significant injury - as well as cause inadequate visualization of the anatomy and our ability to view and treat all the potential endometriosis and other gynepathologies which may be present.
It is due to these and other critical increased risks to a patient's well-being and possible intra- or post-operative complications that our surgical consideration limit is a BMI of equal to or less than 45, which allows to safely avoid barotrauma from high ventilation pressures and properly treat any pathologies which may be present.
We know this particular topic can be deeply upsetting and disappointing, and it is not a consideration we take lightly nor a judgment of any kind. For those candidates who do not meet the 45 or below criteria at present, we are always absolutely delighted to review their case and potentially plan surgery in the future, as we have done with many of our patients who underwent weight loss, bariatric surgery, etc. over the years. Although attempting a loss may seem significant and unachievable, particularly when feeling poorly as a result of the disease, a great number of our patients have embarked on successful journeys of even much higher losses until they were able to have surgery safely with a BMI of 45 or below. We are glad to wait and assist throughout the journey to the extent possible.
Diabetes
Diabetes is a common illness that can significantly raise the relative risks of surgery. Insulin dependent diabetics at the CEC are treated in concert with endocrinologists.
Surgery intrudes into the routine of diet and insulin use. Diabetes is best controlled when the blood sugar remains in a narrow range. Blood sugar must be monitored carefully to avoid extremes and insulin doses must be varied according to changes in diet, activity, IV fluids, and insulin dosage.
Diabetics require close observation because they are more at risk for infection.
Immune Deficiencies
Ideally, we would not choose any elective surgery in a patient with any significant form of immunologic deficiency as it may place them at increased risks. This includes patients on chemotherapy, steroids, and patients with AIDS. However, each case will be assessed on an individual basis.
Medications
Many commonly used medications (including over-the-counter drugs and herbs) can alter the surgical risks for a given patient. It is very important that you disclose any and all drugs you may be taking, whether they are legal or not.
Summary
We have listed many factors to be considered when planning a surgical procedure. Having one or more of these risk factors does not mean you will not be accepted as a patient at the CEC. However, it is important that you become aware of how your personal situation can impact the safety and efficiency of any procedure.