Beyond the Operating Room: Dr. Mona Orady’s Endometriosis Revolution and Mini Laparoscopy Mastery

Speaker 1:
0:03

Welcome to Indobattery, where I share about my endometriosis and adenomyosis story and continue learning along the way. This podcast is not a substitute for professional medical advice or diagnosis, but a place to equip you with information and a sense of community, ensuring you never have to face this journey alone. Join me as I navigate the ups and downs and share stories of strength, resilience and hope. While navigating the world of endometriosis and adenomyosis, from personal experience to expert insights, I'm your host, elana, and this is Indobattery charging our lives when endometriosis drains us. Welcome back to Indobattery. Today. I am joined by none other Excision specialist, dr Mona Arati from the Arati Women's Clinic, and I am so excited to have you here. I was telling you not long ago that I am thrilled just to sit down with you and talk about anything and everything endometriosis, so thank you for joining me today.

Speaker 2:
1:04

Well, thank you for inviting me and I'm really happy to be here. And, yes, we could probably talk forever with you about endometriosis and everything related.

Speaker 1:
1:13

I think we could. Dr Arati, could you tell us a little bit about what you are doing and where you're at, because you just recently opened up your clinic? So if you can enlighten us as to what you're doing in your clinic and give us just a little bit of your backstory, I think that it is powerful to understand who these doctors are that are giving everything they have to us within endometriosis.

Speaker 2:
1:40

Yeah well, my backstory is long and complicated, but the short cliff notes version is I decided I was going to be a gynecologist when I was nine years old, when I was sitting in a woman's professionals meeting with my mom, who is a woman professional she has a PhD in engineering and she was kind of like the woman leader for women in that community and the women started talking about GYN problems, their periods, pain with sex, all sorts of stuff, and all of them, universally, were complaining about how no one listened to them, how they would go to their doctor and they would feel blown off or like they would even feel embarrassed to bring it up, because they all felt that, oh, it was just part of being a woman that they had to suffer. And this really hit home with me as a nine year old, because a week later I got my period. I got my first menstrual period and I was literally curled up on the floor in agony, thinking I was dying. I was in 10 out of 10 pain. My mom, unfortunately, was on a business trip, she wasn't home. My father was kind of just blew it off and I literally cried myself to sleep that whole night long, thinking I was going to die. And after that my mom came explained to me. But then it was a long journey of ER visits and all sorts of stuff and people just saying, oh, you should just have constipation. I'm like, well, how come I just get constipation every time I get a period? It honestly, it remained like that until I was a gut, became a gynecologist and I like accelerated. People don't know this about me, a lot of people do, but some people don't.

Speaker 2:
3:18

I went to college when I was 12. Wow, I went to med school at 17, at 21. I was a full blown MD studying gynecology, and by that point I started realizing that women menstrual disorders was just not taught, wasn't treated, wasn't addressed. And this was early 2000 by this point, because I finished medical school in 2001. And I literally graduated by residency and I started traveling the world. I went to Brazil, I went to Italy, I went to France. I started going to every conference there was about minimally invasive surgery and gynecology and just learned as much as I could. Because I felt that all women were ever offered were birth control pills or a hysterectomy for these types of problems. And I'm an engine my, both my parents are engineering, so I couldn't make sense to me that what were we treating? No-transcript, why birth control pills are distracting me, why can't we just fix the problem, like, why can't we find what the problem is and fix it? And that's how I became, like long story short, and menstrual disorders expert.

Speaker 2:
4:24

I worked at Henry Ford, I worked at Cleveland Clinic, I taught fellows and then my family brought me over to California where I did create a women's center and a center for mentally invasive surgery at Dignity Health. But because of the way I was being restricted in the way that I could treat my patients by Dignity Health and I couldn't really treat women in the way I wanted to, I decided to try to work as a private doctor to create a center for women's health and I wanted to create something that was holistic and took care of the whole woman. So it wasn't just a surgery place where people women would come and have surgery for endometriosis, but it would be a place that we could treat them as a whole, take care of their women's health needs, take care of their surgery, do surgery for endometriosis, but also treat all the other issues that go along their mental health, their physical therapy that they need, sexual health, their bladder issues, their bowel issues, every aspect of them. And that's what I'm trying to create with the Iorati women's clinic. And I named it after my father, who passed away a couple of years ago a legacy after his name, because his family in Egypt, which is where I'm from, were literally the people that took care of everybody, anybody that needed anything. I think they had like 10 orphans in their house Like anybody that needed anything. The Iorati family would be the ones that people would go to to take care of them. And I felt like that's how I want, like I even want to create like a subset of the clinic that's charity care that can help women in all aspects. And that's been like my philosophy to create this kind of holistic center where we could treat women's health comprehensively, but also with the focus on menstrual disorder, so the PCOS, the hormonal dysfunction, sexual dysfunction, endometriosis, fibroids, fertility where a woman could come and feel like she's finally being heard. Yeah, so basically I want a place where women can not only feel heard but be taken care of in every way and we think about the woman as a whole, her mental health, her fertility, her sexual health, her pain in different aspects, because, as we know, excision surgery works and you can help people's endometriosis pain and endometriosis symptoms and their fertility.

Speaker 2:
6:43

But it doesn't stop there. No, right, you don't just have surgery and then you're miraculously better, right. I mean far in some ways, but it's a process, right, and you have to feel really taken care of. Like even my logo, I made it like a heart with a hug. Like I told my marketing person, I want people to feel hugged, to be cared for, warm. You know I want that. You have the surgery but you still feel like you're being held. Yes, you're being supported, you're being cared for After the surgery ends, when you go home. We have telehealth. We help you find people that can help you in other aspects and to truly take care of that person. It's not just surgery, it's taking care of them and that's a big meaning for me.

Speaker 1:
7:24

Yeah, that's a big step. When someone walks in your clinic, you approach it differently because you approach it from the whole person, not just from the surgical standpoint. In opening your clinic you've had your PA with you for a long time, You've had your support staff with you for a long time and your manager. Can you tell us kind of what your intake looks like and what people can expect when you do an intake?

Speaker 2:
7:53

Yeah, I mean my intake. Really, my office manager and my PA are a very large portion of it, because they've been with me forever and they've taken care of thousands and thousands of patients. They basically know everything there is to know about what I do and how I do it. My physician assistant takes care of my patients before and after surgery in consultation with me. She does the surgery with me. She's literally my assistant in surgery too, so she knows every aspect of what we do and what we found and what our plans for going on is. So I find it a lot easier if patients see my PA first, because she can do all the nitty gritty look at all the thousands of pages of records, look at all the prior surgeries, get records if we need it, get labs, get an MRI, get a GI consult, get a colonoscopy, get a urology consult or whatever else she needs, again in consultation with me, because we talk about every single patient that she's seen. At the end of the day, Right.

Speaker 2:
8:55

So she does the front work so that by the time the patient is seeing me we have everything ready.

Speaker 2:
9:01

I have all the information. I have the MRI images, I have the consults, I have the colonoscopy, I have the prior records, I have a summary of what's going on so that I can truly focus on really coming up with a really good plan for that patient. If I see them initially, I can do all that, but it's kind of hard because my time is a little bit more rushed. I don't have two hours to spend with a patient, especially a new patient, where my PA does.

Speaker 1:
9:27

Right.

Speaker 2:
9:29

So I ultimately usually just end up sending them to my PA to do that work and then come back to me and then my office manager, she's the coordinator of care, so she's the one that will help you get your MRI, help you get the colonoscopy referral, the GI referral, the general surgery referral if I need a general surgeon, if you have rectal endometriosis to get the urology referral if you have ureter, bowel or bladder endometriosis, to kind of help coordinate everything.

Speaker 2:
9:52

And then after surgery, she's the one that helps to refer to physical therapy or refer to integrative medicine, refer for acupuncture and all the things that we do after surgery to help people with the healing process. She does all of that as well, and again in coordination with my PA. So we really work together as a team, Right, and we basically do the same thing and I think the flow is my PA and office manager usually want to see the initial people, the people coming in, so that by the time again they're seeing me, that I have all the information I need to come up with a management plan.

Speaker 1:
10:28

Right.

Speaker 2:
10:28

And then my PA and my office manager will help execute that plan, yeah, and then I'll schedule the surgery and all that, and then I will see the patients again before surgery, after surgery, but again kind of back and forth between me and my physician assistant so that we can maximize the amount of care that they're getting.

Speaker 1:
10:46

And the reason why this is important is because efficiency is key and when there are so many endometriosis patients coming in and needing care and assistance, your time is so precious and valuable.

Speaker 1:
11:00

If you're having a surgery, like if I were walking into your office and wanted a surgery with you, I would want you to be able to give the time I needed in that surgery and the best care, and if there are multiple eyes on that, that's so important to giving someone the best care, and I think a lot of us have had maybe the misconception that if we're not talking to the doctor directly first time, then we're not getting the best care, and in your case that is.

Speaker 1:
11:28

That is not the case, because you have trained these people and the reason why your passion has driven you to where you are with opening your own clinic is that you trust these people so much with your patients, and your patients are like your babies. You take so much pride in helping your patients and walking with them through this journey, and I think it's important to highlight that. This is step one, the intake. So knowing who your doctor is, knowing their support staff, knowing that they're going to give you their absolute best, and that means by with their staff and everything else. It's important to recognize that.

Speaker 2:
12:02

And that's actually. You know. It's interesting when I decided I was going to open up the already women's clinic and we've only been open for about two and a half months now. So, I literally went to grace my physician assistant Angelita, who's my key office manager and she basically does everything, and I told them, like I cannot do this without you.

Speaker 2:
12:21

Is this your passion, is this what you want to do? And they said absolutely. Dr Adi, you know we want to come with you, we want to do this with you. They're just as passionate about it as I am.

Speaker 1:
12:31

Yeah, it makes a big difference in the overall care that you will receive from your doctor is if the people that are in their clinic are just as passionate as they are.

Speaker 2:
12:42

Yeah, exactly, and the thing is that I mean I think patients are surprised when I do see them and I literally know everything that's happened, everything they know. I mean I don't think people know this, but I read every single email that comes in through the website, every single one. I read every single voicemail that's left, every single one. Maybe I might respond personally sometimes I do, but my staff knows what I want and I make sure that it's done. I know every single patient that my PA has seen. I know every single consultation that's been put in. I know every single MRI we've ordered. I literally do know everything that's going on.

Speaker 2:
13:18

I just don't do it personally. I'm more just kind of supervising so that I can focus on making sure that we have a good management plan for every patient, that we can get surgeries done efficiently. I try to get patients, you know, scheduled within six weeks, which is really difficult. If fertility patients, I try to get them in. I mean, my goal is to get them into the office within two weeks and to have surgery within six weeks, which again is really difficult as a single human being. Yeah, so it does take longer when we need other surgeons, like a general surgeon or urologist, but I literally do bend over backwards to try to make sure patients are taken care of as best as I can, and my staff are the same, Like they are. On top of it, they all work after hours.

Speaker 2:
14:04

Like it's not a nine to five job to us, you know I mean I joke. Like some people say, oh, why are you responding to the portal messages at 3am? I'm like, well, I'm breastfeeding my baby at 3am and I'm reading the emails and the messages and I'm responding at 3am. Yeah, so this is my life and these are my babies. So, just like I breastfeed my baby at 3am, I'll respond to your email.

Speaker 2:
14:29

Now, I may not sometimes I don't respond right away when I do get really busy but I will get you know, get back to you, and definitely by the weekends I usually will get back to people. But it's something that I think is really important to know that this is not just it's not just a job for me. This is my passion. It's the legacy from my family name. You know I was telling you my father. He comes from a family called the Oradi family in Egypt and that family was the family that would take care of everybody, like my father had. He doesn't even know who his real brothers and sisters are, because there were so many orphans living in the house with him and I when I was a kid and I'd go and he'd be like this is your uncle, this is your uncle. This is your uncle.

Speaker 2:
15:09

I'd be like how many uncles do I have, and it was just because that was they were. They were in a very poor area of Egypt and the Delta and the villages and everything belonged to everybody and that's how I feel. Like anything I can give it's for everybody and that's why I also told you I'm still trying to like I'm literally contracted with every insurance that I can you know, I'm trying to provide care to anybody who can and I'm trying to do it to the best of my ability.

Speaker 2:
15:38

But that's kind of the flow is. Patients will come in. We try to get them to see the PA first, to make sure everything is cup of static, and then I see them, we come up with a management plan and then we will coordinate a management plan and surgery if needed, or referrals if needed, et cetera.

Speaker 1:
15:54

Right, when the patients come in and they've seen your PA and you're going through that process. What does the diagnosis to surgery process look like? Because a lot of patients coming in are coming in because they think they have endometriosis or they're just in pain and they're finally seeing someone that might actually listen to them. What is that process? And I know that each doctor does this a little bit differently, but I do think that there is value in understanding that there is a process from diagnosis to surgery. Like not everyone's going to rush into surgery or can rush into surgery. So understanding from diagnosis how severe something is in order to know when surgery is appropriate.

Speaker 2:
16:35

So the process is really it depends on where the patient is. But some people come in already with a diagnosis or a prior surgery or you know they have infertility and they think it's endometriosis. They've already had a receptiva test as positive. Those patients are easy because they come in almost ready for surgery and what we do is my PA will order labs, records and imaging that what we'll need, and then they'll usually schedule them with an exam and ultrasound with me and pretty much on physical exam and ultrasound and looking at labs and imaging, I can tell how severe someone's endometriosis is and whether it's involving the diaphragm, the rectum, the bowel, the bladder, the ureter. I can usually tell just during my exam what severity of endometriosis we're talking about and then, dependent on the severity, I will direct them to what we need.

Speaker 2:
17:22

If they have rectal endometriosis or suspicion for appendix endometriosis, I will get a general surgeon and I work with two different general surgeons almost every Friday. I alternate. So Fridays are my like rectal, bowel endometriosis day, and then Mondays and Wednesdays are kind of my lighter days where I don't do bowel or rectal, although Mondays I tend to do the urology cases, the ones with ureter or bladder so, and Wednesdays I tend to do what I call the more minor, lower grade endometriosis, fertility patients. And for those patients that have a lesser degree of endometriosis, I will sometimes offer them mini or microlaparoscopy because they will heal so much faster. So if I do their surgery on Wednesday with a mini microlaparoscopy and they have stage one or two endometriosis which I can treat with mini laparoscopy, by Monday they're back at work. Interesting, so literally the five day recovery for them, which is why I tend to do those on Wednesdays, so by Monday.

Speaker 1:
18:16

What is that though? What is a mini microlaparoscopy.

Speaker 2:
18:21

So mini microlaparoscopy is you've heard of laparoscopic surgery right when you have a camera in the bully button and then you have instruments that are usually five or 10 millimeters that go through little ports that go in the external abdomen into the abdomen to do the surgery. Mini microlaparoscopy uses a three millimeter camera, so it's like this big.

Speaker 1:
18:41

So it's like a pencil tip. Smaller than a pencil, it's a pencil tip.

Speaker 2:
18:46

They call it needleoscopy. So it's just like a fat 14 gauge needle and all the ports and the instruments are that size too. So I can do endometriosis excision with almost basically no incision because these are like they're like the size of a fat needle that goes through the abdomen. So there is very little recovery time and there's very little downtime. There's no concerns about hernia formation or not running, not lifting. You can go back to normal physical activities almost immediately and there's no need for pain medicine and the healing is just so much faster. You still have like that post-op bloating and the anesthesia effect and like gas pain and that you get after a laparoscopy, but the recovery is so much faster. It's literally cuts recovery time it has.

Speaker 2:
19:32

And there's, the incisions are invisible, like you. Literally I see these patients a year or two later. I can't even find the incision. I don't know where they are, I don't know where I put them. I know approximately where I put them because I usually use the same locations for everybody, but they are. It's invisible surgery. And so for patients who are teens, you know, really young. For people who are athletes who, like they, can't stop running or exercising, for females who are infertility patients where, like they don't need to go through a major surgery. They just need to know do I have endo and how bad is it and can I treat it? And for patients that I think have mild disease, it's a really ideal solution for them because they won't have the downtime of surgery or the scars from surgery. It's almost like they didn't have surgery but they did and we can excise their endometriosis.

Speaker 1:
20:22

So this isn't like for severe cases or even for those who have a repeated surgery, necessarily. This is more like, or can it be used for, like a repeated kind of look around, so to speak, to see okay, or a repeated look around, it's okay.

Speaker 2:
20:38

But if I'm, if I'm going to be doing very like deep dissection around the rectum that's kind of what determines whether I use a robot or not. If I go in and there's disease around the rectum or the ureter where I have to like really dissect out those very deep spaces in the pelvis, it's not ideal to use micro. Have I done it? I have. I was surprised it was deep, I did it. But it's not the best way because it'll take a lot longer to do it using micro laparoscopy, because you're doing a very big dissection using two millimeter scissors.

Speaker 2:
21:08

So it's like it takes so much longer than having a robot where I can do the dissection in, you know, half the time. So it is ideal for people, as I said young girls, teens, early stage endo fertility diagnostic and then I use the robot for deep like stage three endo. If I'm having to peel off an endomastroma and reconstruct an ovary, if I think they have rectal disease or disease that's deep into the pelvis where I'm going to have to do a deeper dissection, then I tend to prefer a robot.

Speaker 1:
21:39

Okay, I mean I think that's such a valuable tool that isn't talked about enough, because I know for myself, having young girls, I'm always looking at how can I have the least amount of trauma to them early on. Because the other part of this is the adhesion part of this the more major the surgery I mean this is, I'm not the doctor, I'm going to let you talk about that but the more major the surgery. Typically you can get more adhesions from that than if you were to do something less invasive, even than minimally invasive, because we all know that minimally invasive is really not minimally invasive in the sense of like it still takes a toll on your body. It's full surgery, yeah.

Speaker 2:
22:21

It's major, full on surgery and yes, and in terms of the adhesion piece of it, that's a whole another piece I want to talk about and I actually just created an entire session at our Society of Laptoroscopic Surgeons conference that I just organized just on adhesion prevention, and I'm giving a session in Europe next week. Actually, I'm flying to Vienna. I'm giving an entire session on adhesion prevention, especially in fertile women, because a lot of people don't talk about this. But adhesions can have a huge effect on people, women who are still wanting childbearing. It can affect their fallopian tubes and block their tubes. It can cause pain, it can cause shifting of the uterus and a lot of them already have some adhesions from the endometriosis. And the question is how do we minimize reformation?

Speaker 1:
23:05

This conversation just keeps getting better and better, so to make sure that you join us, next week is Dr Arati talks about adhesions, teen endometriosis and shares in all the other passionate areas of adhesions. And until then, continue advocating for you.