Utahgyn - Women's Surgery Specialist

Endometriosis Foundation

2011-11-12T16:10:00.001-07:00

I just returned from the World Congress of the AAGL. Our keynote speaker was Padma Lakshmi. She is a co-founder of the Endometriosis Foundation of America. She is better known for her show on Bravo network, Top Chef. She shared her endometriosis story with us and her devotion to education of this debilitating disease.

She suffered with pelvic and abdominal pain for 26 years before she was finally diagnosed with endometriosis. After finding a surgeon skilled in surgical excision of endometriosis she began her road to recovery. Three surgeries later she is now pain free and has a beautiful daughter.

I echo her statement and the opinion of the Endometriosis Foundation of America, that surgical excision is the "gold standard" treatment for endometriosis. The current average years to diagnosis is around ten years. As we educate parents and young women about the signs and symptoms of endometriosis, hopefully we can begin to prevent the most severe forms of the disease that can affect so many aspects of women's lives.

Why Use Laparoscopy for Complex Surgery

2011-03-14T07:40:00.009-06:00

I am frequently asked about why a surgeon would use laparoscopy for complex pelvic and abdominal surgery when it could be performed through a laparotomy or open incision in less time. It is true that in most cases, a hysterectomy for a very large 16-22 week size uterus can be completed in less time open than laparoscopically. Also complex cases such as large, non-cancerous ovarian cysts, severe endometriosis, and large or multiple fibroids can be completed through either open surgery or laparoscopy.

It is usually true that surgery for a large uterus, fibroids, or large ovarian cysts takes less time with an open incision (this is not always the case). Surgery for adhesions or severe endometriosis is difficult and long no matter the surgical approach.

When I am asked why I would take 2-3 hours to perform a hysterectomy laparoscopically or with robotic assistance instead of performing a laparotomy for a uterus the size of a 16-24 week pregnancy, my answer is clear, "My patients and I like the trade off!"

With the assistance of laparoscopy either to complete the entire operation or to convert from a large vertical incision to a small 3-5 cm mini-laparotomy incision, patients trade time spent in the operating room for a quicker recovery. Rarely do surgeries for even the most complex pathology take longer than three hours to perform laparoscopically. Most open surgeries for the same conditions average 1.5-2 hours. Frequently a laparoscopic surgery can be completed in that amount of time. When it is longer, a laparoscopic approach may add up to an additional 1.5 hours depending on what is done.

In the case of hysterectomy for a very large uterus, the uterus must be cut into small pieces to remove it in a minimally invasive fashion. This aspect of surgery often is longer than the actual hysterectomy itself.

In the beginning of my private practice, I often wondered if the extra time was worth it after a difficult, long surgery. I got my answer the next morning while rounding on the patients. They were doing well with minimal pain medicine requirement. They were walking and ready to go home within 24 hours of the completion of the surgery. This was reiterated when I saw them at their postoperative visits. They were already back to work and feeling normal again.

Laparoscopy can also make a big difference in patients who have some complicating medical conditions. Patients with obesity can benefit by a lower risk of wound infections. Diabetics are frequently out of the hospital before their regimen is interrupted. Patients with a history of blood clots in their legs or lungs are up walking the same day of surgery.

Yes, there are increased risks and cost with longer operative times under anesthesia. In my five years of practice after fellowship, I have not seen an anesthesia related complication. The higher operative cost is more than offset by the decrease in hospital stay by 2-3 days. The cost benefit to the patient is further increased by allowing them to return to work faster after release from the hospital.

A recent patient summed it up best when she wrote, "I am grateful that I was made to switch doctors at the last moment. My inconvenience turned out to be a huge blessing!!! To think that I went from being told I would need an abdominal hysterectomy to what you were able to accomplish is amazing. Thank you for being concerned about my healing and taking the time with the longer procedure. Your success was my gain."

Minimally Invasive Centers of Excellence

2011-01-11T20:50:00.007-07:00

The Council on Gynecologic Endoscopy sponsored by the AAGL allows application and designation of hospital centers to be come centers of excellency in regards to minimally invasive surgery. This council recognizes hospitals and centers who are committed to promoting and providing minimally invasive options to patients.

Although there are currently no designated centers in Utah, I am working with and encouraging the local Ogden hospitals to move in this direction. I hope they will continue to encourage the local physicians to expand their practices and skills to involve minimally invasive procedures in gynecology, general surgery and other specialties. From a gynecologic aspect and my practice, it is enticing. By expanding other specialties such and general surgery and urology into laparoscopic and robotic options, it opens the door to expanded endometriosis treatments. A specialized team will be able to offer complete surgical management of invasive endometriosis involving the female organs, bowel, bladder and ureters.

An expanded awareness in the general public and medical community will continue to promote the benefits of less invasive surgical options.

Access to Less Invasive Surgery

2010-02-18T20:27:00.005-07:00

A few posts ago I discussed the excitement about having a robotic surgical system come to the Ogden area. The most exciting part of this is the increasing availability of minimally invasive options to patients in our area. The robotic system does not offer much to a surgeon already trained in advanced laparoscopic techniques but it does increase the number of doctors who can perform advanced laparoscopic procedures.

For some reason, Utah seems to be lagging behind much of the US in its knowledge and acceptance of laparoscopic surgical options for women. Many patients are unaware that there is an option for surgery that does not require them to stay multiple nights in the hospital and take 4-6 weeks off work. Although 90% of patients surveyed said they expected their doctors to discuss less invasive options. Patients should be aware of all surgical and non-surgical options and discuss them in detail, even if their doctor does not offer that option.

Currently in Utah, 60-65% of hysterectomies are performed with a large abdominal incision. Over the last 4.5 years I have been able to decrease my open surgery rate for hysterectomy to less than 4%. Half of that 4% was due to patient choice. How I wish that more physicians would embrace these options and have a significant impact on their patient's lives.

With the advent of robotic surgery availability in Ogden, the number of surgeons performing laparoscopic hysterectomy has more than doubled. Unfortunately, after proven safety and efficacy in multiple studies, there is still resistance to implementation of robotic surgery programs at one local hospital. As these challenges continue, there are numerous women who are forced to accept open surgery as the only option provided by their doctors.

Many people believe that laparoscopic and robotic surgery is more expensive than "open" surgery. This is certainly true for costs of the actual surgery. What they fail to realize is that a less invasive surgery decreases cost outside the operating room. There are fewer costs attributed to lab work, room and board, complications, infections and nursing. There is also a significant financial advantage to patients as they return home sooner and are back to work in 3 days to 2 weeks as opposed to 4-6 weeks.

Taking into account the cost of the entire hospital stay, laparoscopic surgery is less expensive than open surgery and robotic surgery is less than, but almost equivalent to, open surgery.

Certainly I am biased in my discussion of surgical options, but the bias is proven by experience. I have had many grateful patients who have benefited from laparoscopic options. When I sit down and discuss options for a surgical need, all options are discussed including vaginal surgery, abdominal or open surgery, and laparoscopic surgery. In over four years I have had only 2 patients that have chosen to have an open procedure. Patients are grateful to have an option that will not "lay them up" for 6 weeks when vaginal surgery is not an option.

Change is difficult at times, but I am hopeful that those who are passionate about minimally invasive surgery will continue to share their knowledge and experience with others. As this happens, patients will truly be able to make an educated choice that is the best for their life and needs.

Laparoscopic Sacrocolpopexy (Vaginal Prolapse Surgery)

2010-02-18T20:10:00.005-07:00

After becoming more proficient over that last few years and with the availability of the Davinci Robotic System, I have now added laparoscopic sacrocolpopexy to the procedures I can offer to patients. Sacrocolpopexy is considered the "gold standard" surgery for severe vaginal prolapse. It is a surgery that uses a synthetic mesh to help the body develop a strong support of the upper vagina to repair prolapse. From inside the abdomen, the mesh is sewn to the front and back of the vaginal wall. A tail of mesh is then sewn to a ligament along the front part of the sacrum.

Again this is a surgery that has been done for years by the "open" technique. For many years now it has been performed laparoscopically and with robotic assistance. The same benefits from laparoscopy apply in this situation also. These include similar operative times, much shorter hospital stay, quicker recovery and faster return to work when desired.

Some complications may occur with this procedure whether it is performed laparoscopically or open. These include bleeding, bowel or bladder injury and occasionally mesh rejection or infection. Thankfully these complications are rare.

The advances in laparoscopic surgery are very exciting to me. Every week I see the benefit it has in women's lives as they are faced with a difficult decision for surgery. They are thrilled and grateful to know that there is an option that does not require weeks off of work and days away from home.

Benefits of Robotic and Minimally Invasive Surgery

2010-01-23T16:36:00.002-07:00

First Utah Robotic Myomectomy (fibroid removal)

2009-09-27T14:33:00.005-06:00

Myomectomy is the removal of fibroids from the uterus without hysterectomy. Over the last four plus years, I have been performing these laparoscopically. A couple of weeks ago, I was able to perform a myomectomy surgery on the DaVinci System. This was the first of it's kind in Utah.

Since the robotic service has started at Ogden Regional Medical Center, two gynecologists have begun offering minimally invasive, robotic surgeries to their patients. These are surgeons who did not offer minimally invasive options previously. Just an example of a movement toward understanding the benefits of laparoscopic and robotic approach to women's surgery.

It is great to see the movement toward less invasive surgical options for women!

Da Vinci Si Hysterectomy

2009-05-12T16:12:00.005-06:00

Well, today we completed the first surgery in the western United States using the latest Intuitive surgical robot, the Da Vinci Si. Ogden Regional Medical Center in Ogden, Utah purchased this machine a couple weeks ago. After much training and time spent working on the system, the first surgery went without a hitch.

Actual operative time with the robot assistance was similar to my average times with traditional laparoscopy, about 1 1/2 hours for the first case. The actual visualization during surgery was better than what I had experienced with the practice "toys" we used. The 3-D vision was really exceptional. The robotic instruments were very easy to use and the surgeon console is fantastic. The two aspects I like the best are the individual hand clutching of the instruments and the ability to use bipolar energy or monopolar energy with either the cut or coagulation mode. The cutting current is great for minimizing thermal damage to the vaginal cuff when removing the cervix.

The hospital is "all a buzz" and people seem to be excited to offer this advanced surgical tool at their hospital. It is too bad that it took an instrument such as this for people to get excited about minimally invasive gynecology when I and other surgeons have been offering laparoscopic hysterectomy for years. Outcomes should be the same.

With the robot technology, more women will be able to take advantage of the "outpatient" hysterectomy and avoid having their abdomen cut open as more surgeons learn the robotic approach.

DaVinci Si Robotic Assisted Surgery

2009-05-01T10:17:00.004-06:00

Good news for women in the intermountain area. Ogden Regional Medical Center has purchased a new DaVinci Si Surgical System. This new laparoscopic tool will allow more physicians to offer minimally invasive surgery to the women in the surrounding area. Ogden Regional will also be one of the few hospitals in Utah that have a robotic system to allow women with non-cancerous conditions to have their surgery done with robotic assistance.

New cost comparison studies have recently come out that look at the surgical and patient costs of the robotic system. These studies have shown that there is very little difference in hospital and patient cost to benefiting from robotics. The total cost difference is actually less with robotic or laparoscopic hysterectomy compared to "open" hysterectomy. This does not even take into account the financial benefit of being able to return to work between 2-4 weeks earlier after laparoscopic hysterectomy.

I am excited about the robotic option coming to women of the area for a few reasons. First, the articulation of the robotic instruments allows a more precise surgery. Second, I experience less fatigue and body strain which I believe could translate into safer surgery during a difficult or prolonged case. Third, and most importantly, more women will be able to benefit from minimally invasive surgery as more providers develop the skills to perform advanced laparoscopy through robotics.

Even though robotics allows a surgeon to complete a surgery through small incisions, I still feel it is important to choose a physician with training in and comfort with dealing with difficult pathology. Things such as severe endometriosis or adhesions could prompt a surgeon planning on robotic surgery to convert to open laparotomy if the surgery appears too difficult to perform robotically.

Painful periods and endometriosis

2008-11-11T14:06:00.003-07:00

I will have a patient come for help who has had a long history of painful cramping with her period. Occasionally these patients will have had a hysterectomy performed at an early age because none of the medical therapies have worked to control her pain. Painful periods can have many causes. I would like to discuss one of the most common - Endometriosis.

Endometriosis pain typically starts one to two days prior to bleeding. In the beginning stages, endometriosis is usually cyclical (it comes and goes with the menstrual cycle). At later stages if the endometriosis becomes invasive, there can be dense fibrosis or scarring that may give the pain a more constant character. Approximately 10% of endometriosis is invasive. This means that it grows deeper in the tissue to which it is attached. Common medical terms for this type of endometriosis are Deep Infiltrating Endometriosis or Deep Fibrotic Endometriosis.

Endometriosis can be treated in a number of ways. There are many medical options such as birth control pills and shots, intrauterine devices and injections such as GnRH agonists that put the body into a menopausal state. These therapies only make the endometriosis dormant and does not "cure" it. The stronger therapies such as GnRH agonist injections are limited in their duration of safe use. Some newer evidence shows promising results using aromatase inhibitors to decrease the estrogen stimulation to the endometriosis. It is important to realize that none of these therapies get rid of the disease. They are useful, however in patients whose pain is controlled on the medicines and allows some patients to avoid surgery.

The only therapy ever shown to "cure" endometriosis is surgery. That being said, it provides a "cure" in only 50-60% of patients. Surgery combined with post operative medical therapy tends to give patients the longest pain free interval after treatment.

It can be difficult for a physician to adequately know the extent of the disease prior to surgery. Symptoms and physical exam in the office are very important. In Europe and South America, some institutions are using vaginal ultrasound to locate implants in and around the rectum. Skilled ultrasonographers can deterime the location, size and depth of endometriotic nodules. I am beginning to impliment this technique into my practice. Hopefully, this will allow me to better predict the extent of the diseae prior to surgery.

Surgery for endometriosis can be very complex. The endometriosis is often located around areas that are of concern the the gynecologic surgeon. These include the bowel, bladder, vagina and ureters. I feel it is important in planning your surgery for endometriosis to choose a surgeon who has experience in working around these areas and are trained in dealing with the complications or injuries that may occur.

One common practice is to perform a hysterectomy in patients with painful periods. Sometimes a hysterectomy is performed without knowing if endometriosis is present. If the uterus is removed without removing the surrounding endometriosis, patients may have continued pain or future complications. I have come across a few patients who have had a hysterectomy performed, either vaginally or through an abdominal incision, who had endometriosis left behind. In these cases, I have discovered endometriosis growing into the wall of the rectum, the bladder and the vagina, and completely encasing the ureters.

In many patients with painful periods and endometriosis, it is not necessary to have a hysterectomy performed. If the endometriosis does not involve the uterus, it is often adequate to remove the endometriotic implants and nodules throughout the pelvis and abdomen, thus preserving fertility. This is especially important in young patients.

Press Release About Lack of Information for Minimally Invasive Procedures

2008-08-23T21:36:00.005-06:00

This is a link to a press release by the President of the American Association of Gynecologic Laparoscopy. It has some data to suggest that patients are not made aware of minimally invasive options to treat common gynecologic disorders. http://www.prnewswire.com/mnr/aagl/33994/

Hysterectomy for the Very Large Uterus

2008-07-22T22:47:00.003-06:00

As time has gone by I have gained greater experience with laparoscopic hsyterectomy. I am now thankfully entering my fourth year of practice after my fellowship. I have had some very interesting hysterectomy surgeries lately involving uteruses the size of 16 to 20 week pregnancies. That is near or at the belly button in size.

As techniques are perfected the management of these surgical cases becomes smoother and safer. I am now having more patients choose to go home the same day of surgery instead of staying overnight if their pain is sufficiently controlled. This can be for patients receiving supracervical hysterectomy or "LSH", or total hysterectomy as long as the surgery is in the morning and the patient is stable for 6-8 hours after surgery.

This is even possible for a motivated patient with a very large uterus. That is where my satisfaction is gained in offering these procedures. It allows women to be treated and return to their normal activities and lives much quicker with typically less blood loss.

CBS Evening News Report about Laparoscopic Hysterectomy

2008-04-18T20:53:00.005-06:00

While browsing through the American Association of Gynecologic Laparoscopy (AAGL) website, I ran into an article regarding a report on the CBS Evening News. The link to the report and website is on this page below to the right.

It is interesting that over 600,000 hysterectomies are performed in the U.S. each year. Of these, 75% are performed through a large incision in the abdomen. This significantly increases the hospital stay, post operative pain, and recovery time. Only 15% of hysterectomies are performed laparoscopically.

In other posts on this blog, I have deliniated many of the benefits of laparoscopy over traditional "open" surgery. I strongly believe that there are very few instances that would require an "open" surgery. I have even had patients with a uterus up to the belly button, dense pelvic and abdominal adhesions, and severe invasive endometriosis who have had the benefit of a purely laparoscopic surgery. In three years after fellowship I have only performed traditional surgery on 3 patients, two for medical implications and one at patient request.

The relative scarcity of gynecologists offering laparoscopic hysterectomy is due to many things. I believe that the most prominent of these is the lack of advanced training in laparoscopy and the lack of motivation for gynecologists to learn these skills. As pointed out in the article, transitioning from traditional hysterectomy to laparoscopic hysterectomy will likely be patient driven. The laparoscopic option is often not offered to many patients whose doctor does not perform advanced laparoscopic surgery.

Patients must take an active role in inquiring about the benefits of a laparoscopic approach to surgery. As this happens, physicians will see a want and a need to learn these skills and offer them to patients.

Robotic Surgery

2008-02-15T13:50:00.004-07:00

There has been much talk in Utah recently about the new DaVinci Robot for performing laparoscopic or minimally invasive surgery. It offers many advantages including a minimally invasive approach to surgery, less blood loss, fewer infections, better surgical visualization, and increased dexterity of performing complex laparoscopic procedures, not to mention a more ergonomic and comfortable operating experience for the surgeon.

There are a few hospitals in Salt Lake City which have these laparoscopic robots. They are allowing physicians in the Salt Lake area the ability to offer their patients advanced laparoscopic procedures instead of surgery performed through larger, traditional incisions.

I have trialed one of these robots at a conference, and it is truly a neat device. It allows a simplicity in performing advanced dissection techniques, and laparoscopic suturing. Access to a laparoscopic robot would provide many more surgeons the opportunity to learn advanced procedures without the time and effort of a fellowship or extended training.

Although there is an increase in cost to performing robot assisted surgery, the overall cost is still lower than a traditional "open" surgery.

To surgeons who are already trained and skilled in advanced laparoscopic surgery, the robot does not at this time offer too many advantages except in difficult cases. Gynecologic surgeries performed by laparoscopy include surgery for: hysterectomy, extensive endometriosis, uterine fibroids, adhesion, pelvic prolapse and bladder drop surgery.

Robot assisted laparoscopy is an upcoming addition to women's surgery. There are thousands of "robotic" surgeries performed each year. For years, traditional laparoscopic surgeons have been struggling to find a route to decreasing the number of open surgeries performed. Robotic surgery will dramatically increase the number of physicians able to perform minimally invasive surgery. Hopefully we will finally see a change in the type of surgery done for the majority of women that will allow them to get back home, go back to work, and get back to life quicker with less pain.

Minimally Invasive Hysterectomy (video link to right)

2008-01-15T17:48:00.001-07:00

Laparoscopic Hysterectomy, or "Band-Aid Hysterectomy", is a wonderful option for many women who need a hysterectomy. Overall, laparoscopic hysterectomy is indicated as an alternative to open or abdominal hysterectomy. In this discussion I will talk about the indications, the benefits and risks and different methods of laparoscopic hysterectomy.

The indications for laparoscopic hysterectomy are similar to those for abdominal hysterectomy. Any patient who has previous abdominal surgery such as cesarean section or surgery for ovarian cysts may not be a candidate for a vaginal hysterectomy. This is due to the risk of adhesions of the bladder or other organs with in the abdomen. Also in patients with limited uterine descent, the uterine support is still very good. Patients with a concern for other intra-abdominal problems such as infection or endometriosis. Also women with a very large uterus that is too big to be removed vaginally.

It has been shown that vaginal hysterectomy is the safest method when possible. However; when there are contraindications to vaginal hysterectomy, laparoscopy offers some significant benefits over abdominal hysterectomy. The biggest benefit is the recovery time and hospital time. A patient who has had an abdominal hysterectomy usually stays in the hospital for 3-4 days because of the invasiveness of the procedure. A bikini type incision is made on the low abdomen and the abdominal muscles are separated. Pain is more significant because of the larger incision. Laparoscopy offers a similar hysterectomy through smaller “keyhole” incisions. In performing a total hysterectomy through the laparoscope I typically place 4 incisions, the largest being approximately 1.5 cm in the belly-button. Laparoscopy usually allows a patient to go home within 24 hours of surgery and is considered an “outpatient” surgery. Patients usually are able to perform normal activities sooner. The normal course for my patients after total laparoscopic hysterectomy has them feeling close to normal in 10-14 days.

Another benefit is the increased ability to see small disease. If there is endometriosis or other problems, the laparoscope magnifies the view inside the abdomen and allows me to see better. I can then remove any disease that I see. I can look all around the abdomen also, including visualization of the liver, gallbladder, stomach and spleen. Adhesions, or organs sticking to each other, are more common after abdominal or open procedures. Laparoscopy decreases the likelihood of forming adhesions due to smaller incisions and increased ability to control very small bleeding.

Some of the risks of laparoscopic hysterectomy include injury to major blood vessels during entry, injury to bowel, bladder or ureters. Early studies have shown laparoscopy to be more risky than vaginal surgery. But again, laparoscopy is not an alternative for vaginal hysterectomy. I feel that laparoscopic suturing is a very important skill for anyone performing laparoscopic hysterectomy. This allows management of most complications without having to convert to laparotomy.

Laparoscopic hysterectomy can be divided into three categories. The first is laparoscopic assisted vaginal hysterectomy. This is performed in women with good uterine descent who have other abdominal concerns that need to be addressed. Some of these concerns may be an ovarian cyst, endometriosis, or adhesions. Most gynecologists can perform some portion of the surgery through the laparoscope. The next one is laparoscopic supracervical hysterectomy or “LSH”. This is performed fully laparoscopically by removing only the upper portion or “fundus” of the uterus. The cervix is left in place. The only benefits to this are quicker recovery, limited post operative restrictions, quicker return to intercourse, and not interrupting the uterine support that is already in place. Many patients believe and are told that sexual response is better with leaving the cervix; however, many studies have shown no benefit in this regard. This type is also less risky because the uterus is “amputated” at a level above the ureters and bladder. The next type is total laparoscopic hysterectomy, or “TLH”. This procedure performs the hysterectomy in a similar fashion to abdominal hysterectomy. The full hysterectomy removes both the fundus of the uterus and the cervix. The top of the vagina is then closed and support is re-established to supporting ligaments. This is a very good alternative for a woman who needs a hysterectomy who also needs or wants to have her cervix removed. Concerning surgical management of gynecologic and uterine problems, a physician who can perform laparoscopic hysterectomy can offer a full line of options to each patient.

Treating Endometriosis

2008-01-09T12:58:00.000-07:00

As my surgical practice continues to evolve, I am seeing many more patients referred from other physicians and from patients for surgical management of endometriosis. Due to the nature of my fellowship with the AAGL and Dr. Liu, I have become a fan of excising endometriosis as opposed to just coagulation/vaporization with electrical energy or laser. This is especially true in the cases of extensive endometriosis.

Endometriosis can be treated in many different ways. Initially it is prudent to control symptoms of endometriosis with medical therapy in patients who may not want surgery. Common medical therapies for endometriosis include medications such as ibuprofen, birth control pills, depoprovera injection, levonorgestrel IUD, danazol and depo-lupron. The goal of any of these medical therapies is to control the symptoms of endometriosis. They do not cure the disease. Symptoms usually recur when therapy is stopped and some of the medications can only be used for a limited time.

Although surgical excision is not the perfect treatment for endometriosis (the perfect treatment is not available) it does provide the highest cure rate of any therapy. Surgery combined with post operative medical therapy has been shown to give the longest pain free period for patients with endometriosis.

Surgical excision of endometriosis requires very advanced laparoscopic skills. These are by far the most difficult surgeries I have encountered. Endometriosis tends to cause a great deal of internal scarring. Also approximately 10% of endometriosis is of an invasive nature. It does not stay on the superficial lining tissue of the pelvis treated with coagulation or vaporization.

To make it more difficult, invasive endometriosis may involve structures such as the bowel or rectum, the bladder, the ureters, the cervix and uterus and the vagina. Except in the cases of endometriosis of the vagina, cervix and rectum, it can be very difficult to know the extent of endometriosis prior to surgery. I have assisted many surgeons in residency and practice, who have looked inside and ended the surgery because the disease was too extensive and beyond their skills to treat surgically. This is appropriate. Many of these patients are pushed to the realm of Lupron. Although Lupron can treat symptoms in some patients, I have found through experience that it does not control symptoms of invasive endometriosis where tissue damage has already occurred.

A recent article in Ob.Gyn. News stated that failure of medicines to control pain does not suggest that endometriosis is not the cause. In fact some of the most advanced cases of endometriosis I have encountered are in patients in their mid to late twenties who have never had a surgical diagnosis or treatment.

Because of the uncertain nature of endometriosis, having a surgeon skilled in advanced laparoscopy is essential. On his website, www.endometriosissurgeon.com, Dr. David Redwine lists questions that you should ask your physician prior to endometriosis surgery. These questions will assure the most appropriate surgical management of your disease.

Rectovaginal Endometriosis

Rectovaginal Endometriosis

2007-09-25T09:04:00.000-06:00

I recently had a patient who was referred to me for treatment of pelvic pain and pain with intercourse. She had multiple prior surgeries for “endometriosis”. During one of her prior surgeries she was noted to have “adhesions of her rectum to the uterus.

On her office exam, there was a nodule behind the uterus that I could feel. It appeared to be pulling her rectum into the back side of the uterus. This is the third patient I have seen with this similar presentation and history.

During surgery, she was noted to have a nodule of endometriosis that pulled the rectum forward and blocked her normal “pelvic cul-de-sac” (the area between the uterus and the rectum. During dissection, this nodule was dissected off the uterus and the rectum and freed up. After identifying the rectum, ureters and uterine blood vessels, the nodule was removed.

When treating endometriosis surgically, it is important to use the physical examination to know what to expect at the time of surgery. It is also important for the surgeon to feel comfortable removing endometriosis in difficult areas such as over the ureters or bowel. There are many times endometriosis surgeries are performed and the surgeon takes a look and then stops the surgery because the endometriosis is too bad or in locations “too risky” to remove.

This patient is an ideal example of the necessity to know how to identify and adequately excise the endometriosis encountered during surgery.

Large Ovarian Cyst

2007-06-14T11:27:00.000-06:00

I had a very interesting surgery a little while ago. I had a elderly woman who was referred with a large, complex, cystic mass on her ovary. After my discussion with her, she chose to have an evaluation through the laparoscope with possible removal of the ovary.

At the time of surgery, her ovary was noted to be free, without adhesions, and with a smooth surface. She did have multiple cysts on the ovary. The largest cyst was about 15 centimeters in size. Because there were no adhesions, no abnormal fluid within her abdomen, and no concerning features on the surface of the ovary, I elected to drain the cyst and removed the ovary laparoscopically.

A 5 millimeter incision was made just above the pubic bone. A small tube was inserted through this incision and into the cyst. A suture was placed around the cyst and tube and the cyst was then drained. As the cyst collapsed, the suture was tightened around the cyst to prevent spilling.

After the largest cyst was drained, I was able to remove the ovary and place it inside a sterile, plastic bag. Once contained within the plastic bag, the opening of the bag was brought through the 2 centimeter incision in her belly button. The cyst was then removed through that small incision.

The patient went home the same day and two days later was feeling well and off of pain medication.

In appropriate patients, laparoscopy can be safely used to treat cysts and masses of the ovaries and fallopian tubes. Even large masses such as described above can be managed with the benefits of minimally invasive, laparoscopic surgery.

Laparoscopic Hysterectomy for Large, Fibroid Uterus

2007-06-02T18:41:00.000-06:00

Laparoscopic Hysterectomy

I have already written a post regarding laparoscopic hysterectomy. However, I recently had a patient who presented a difficult challenge. Her uterus was approximately the same size as the uterus of a 16-18 week pregnancy, just below her belly button. For most gynecologic surgeons this large of a uterus would be removed through a c-section type or a vertical incision. I was able to complete the hysterectomy through the laparoscope with only an additional small bikini type incision which was used to remove the uterus.

This particular case was challenging due to the size and shape of the uterus. The uterus was filled with numerous and large myomas, or fibroids. The position of the fibroids made access to the blood vessels supplying the uterus difficult. I had to use a knowledge of the anatomy of the pelvis to dissect out the uterine artery and vein at their origins. This is accomplished by opening the lining of the pelvis and identifying the ureter, blood vessels, and nerves in the area. Once all structures were identified, the uterine artery and vein were clipped with a laparoscopic clip device. This allowed control of the blood vessels supplying the uterus.

Typically with a large fibroid uterus, the veins can be quite distended. Traditional devices used to close the vessels and cut them may be insufficient. In this case I placed a suture into the abdomen and through laparoscopic suturing ligated or tied off the blood vessels prior to cutting them.

With the blood supply to the uterus controlled, I was then able to safely cut the uterus into smaller pieces that would allow it to be removed through the smaller incisions used in minimally invasive surgery. In the case of a supracervical hysterectomy this can be done either with a morcellator or through a mini bikini type incision. For a total hysterectomy the uterus can be removed through the vaginal opening.

Although laparoscopy for a very large uterus may take significantly more time in the operating room, the recovery is much quicker than with open surgery. Patients still usually go home in less than 24 hours as opposed to 3-4 days.

Urinary Incontinence Surgery

2007-05-15T19:42:00.000-06:00

Stress Incontinence occurs when the pressure on the bladder overcomes the mechanisms in place to keep urine from leaking. To begin with, stress incontinence must be differentiated from urge incontinence or detrussor instability. Urge incontinence occurs when the bladder muscle begins to contract in an attempt to empty the bladder. The most common occurrence with this type of incontinence is feeling the urge to go and not being able to make it to the restroom in time. This type of incontinence is treated with medicines as opposed to surgery.

Stress incontinence can be divided into two categories: 1. Urethral hypermobility and , 2. Instrinsic sphincter deficiency. Urethral hypermobility occurs usually in conjunction with other anatomic pelvic prolapse. Normally the bladder and bladder neck is supported within the realm of the abdominal and pelvic cavity. As the pressure within the abdomen increases, the rise in pressure also surrounds the bladder neck helping to close off the area where urine leaves the bladder and enters the urethra. If this area has lost its support, the increased pressure can no longer be used to assist in controlling the urine. The entire increase in pressure is transmitted to the dome or “balloon” part of the bladder. This in effect causes a greater force of urine on the bladder neck. The muscles surrounding the urethra are often not strong enough to hold the urine in.

Intrinsic sphincter deficiency occurs when the bladder and bladder neck are held in a normal position, but the closing pressure of the muscle surrounding the bladder neck is insufficient to prevent urine from leaking.

It is not uncommon for patients to have “mixed incontinence.” This includes a combination of stress and urge incontinence. In difficult cases or in patients with medical complications affecting the bladder innervation, special urodynamic testing can be performed to evaluate the pressures of the bladder and the muscle activity.

Common procedures for “stress incontinence” include: Burch urethropexy, suburethral sling procedures, and injection procedures. For many years the Burch procedure was and is considered the “gold standard.” This is performed with through and open “c-section” type incision or can be performed laparoscopically. The area behind the pubic bone is entered and the tissue on either side of the urethra is grasped with permanent suture and attached to a ligament on the pubic bone. This provides support to the urethra and bladder neck to prevent leaking.

Suburethral slings have been a remarkable addition to the surgical treatment of stress incontinence. Data regarding slings is very promising and studies have shown the efficacy to rival or exceed that of the Burch. A small incision (1-2 cm) is made in the vaginal mucosa underneath the urethra and the area is dissected with a scissor tip to the space behind the pubic bone. Two 1 cm incisions are then made just above the pubic bone. A permanent mesh is then passed underneath the urethra, behind the pubic bone, and through the incisions on the abdomen. This procedure is much less invasive than the Burch procedure and patients go home the same day after a voiding trial.

Some physicians can also perform bulking or injection procedures to assist in closing off the urethra. These injections are good procedures for patients who are not good candidates for longer more complex surgeries.

I perform suburethral sling procedures as well as laparoscopic Burch procedures for patients with stress incontinence.

Bladder Drop and Incontinence

2007-04-06T12:31:00.000-06:00

Many women have problems with what doctors refer to as prolapse. One specific area of prolapse is with the bladder. Most prolapse is considered some form of a hernia. Similar to hernias of the groin or "belly button," pelvic hernias and prolapse are caused by a break in the tough tissue or fascia that acts as a supportive layer. When the fascia is broken or separated, other organs or areas can bulge through.

One of the most common areas of prolapse is the bladder. The bladder sits right in front of the anterior vagina. If the support of the bladder is disrupted, such as in childbirth or just over time, the bladder can bulge into the vagina or even out through the vaginal opening.

Some forms of urinary incontinence can be caused by or complicated by bladder drop. Frequently, patients who leak urine with coughing, sneezing, or with exercise, have a defect in the bladder support that contributes to the leaking.

Dr. Cullen Richardson studied the defects involved with bladder support problems and found three different support areas that can break and cause a bladder hernia. The first and most common site is where the bladder fascia attaches to the pelvic bones. This is referred to as a lateral defect or paravaginal defect cystocele. As the lateral support is broken, the bladder is allowed to drop down out of position. This is similar to spring support on a trampoline that attaches to the frame.

The other two types of hernia defects are transverse and midline defects. These two are less common and are likened to a tear in the trampoline fabric itself.

Common treatments for bladder prolapse include exercises to strengthen the pelvic muscles, pessary treatment, and surgery. Bladder prolapse is not a dangerous condition and many women live without any treatment. Pessaries are similar to contraceptive diaphragms which are placed in the vagina and act as a supporting "shelf" to hold the bladder in place and keep it from protruding out the vaginal opening.

Common surgeries for bladder prolapse include an "anterior repair." This is a god procedure for transverse and midline defects. Essentially the vaginal mucosa is opened exposing the supporting bladder fascia. This fascia is then sewn with stitches closing the defect.

Lateral or paravaginal defects are repaired either vaginally, laparoscopically or abdominally. Each surgeon has his/her preferred method of operating. The goal of the surgery is to re-attach the fascia to the lateral pelvic bones. I perform these surgeries laparoscopically. This allows a similar procedure to the abdominal method, but uses only small one centimeter incisions. Laparoscopy magnifies the view and the defects are identified. Permanent sutures are then placed to hold the support back into its normal position.

Incontinence surgery can be performed at the same time. There are minimally invasive procedures used to treat stress incontinence. These will be addressed in an upcoming post.

Removal of Cervix after Supracervical Hysterectomy or LSH

2007-03-25T15:42:00.000-06:00

I have had a few patients who have presented to me for problems after a supracervical hysterectomy or LSH. This type of hysterectomy is typically performed laparoscopically. The uterus is divided into two portions; the top or fundus, and the bottom or cervix. As described in a previous post in January of 2007, the supracervical hysterectomy can be a good procedure for patients desiring a fast recovery. There is also some benefit by not disrupting the existing supportive ligaments that attach at or near the level of the cervix.

However, up to 30% of patients may need to have the cervix removed at a later date due to continued bleeding, continued pain, or other problems. Most of the patients I have encountered request removal of the cervix due to continued pelvic pain or pain with intercourse after having a supracervical hysterectomy.

Removal of the cervix can be completed by three different methods. It can be removed by vaginal surgery. The risk with this method is the possibility of adhesions to the amputated cervix. Another method is through a laparotomy or large incision. The third method is with the laparoscope. Much in the same way a hysterectomy is performed, the laparoscope allows evaluation of the abdominal cavity for adhesions and also allows completion of all or part of the removal of the cervix.

As with hysterectomy patients are chosen for method of removal based upon their risk of adhesions, continued pain, and amount of cervical descent. Offering laparoscopy allows the physician and patient to choose between all available methods for surgery.

Endometriosis

2007-03-08T15:17:00.000-07:00

I recently had a patient present with pain during periods and deep pain during intercourse. On her physical exam I felt a nodule or mass at the top of the vagina. This can be very common in patients with endometriosis. At the time of her surgery she had a thick endometriosis nodule behind her uterus that corresponded to the findings on physical exam. This is a very common place to find endometriosis. One of the difficulties with endometrisosis in this area, is that it can grow in close proximity to the ureter. That is a tube that carries urine from the kidney down to the bladder. A surgeon must be careful in dissecting this area to avoid injury to the ureter. I usually just use my scissors without any electricity or very minimal. If there is extensive endometriosis in the ureteral area, it may be necessary to close the uterine vessels on the same side to avoid significant bleeding durring removal of the endometriosis.

Some patients may also have endometriosis cysts on the ovary. These are referred to as endometriosis cysts or "chocolate cysts." The fluid and old blood inside the cyst often as a liquid chocolate appearance when opened. These are best treated by actually opening the cyst and removing the wall of the cyst. Any minor bleeding can be controlled with cautery or with large cysts, the cyst bed can be sewn closed.

Dermoid Ovarian Cyst

2007-02-21T15:37:00.000-07:00

Recently I had a patient that presented with a 4-5 centimeter ovarian cyst. Her initial complaint with this cyst was severe, intermittent pelvic pain. On ultrasound examination, she had a complex, solid and cystic, mass on her ovary. There was a high suspicion of what is called a "Dermoid Cyst".

Dermoid cysts are very interesting in that they can have many cell types within them. They have been known to grow an oily, sebaceous material, hair, teeth and other strange and interesting things to find in an ovary. They are very rarely of a malignant type which include nerve type tissue.

This patient elected to have her entire ovary removed although it would have been feasible to remove only the cyst itself. Either of these surgeries can be performed easily with a laparoscopic surgery.

As always if you have questions, please feel free to send me an email. You can find it under my profile link.

Essure Tubal Sterilization

2007-02-14T11:51:00.000-07:00

I have now begun performing female tubal sterilization procedures in my office. There is a new technique available that offers great results with minimal risk. There is even a lower risk of serious injury than laparoscopic tubal ligation and the recovery is much, much faster. Patients usually only experience cramping similar to menstrual cramps. No painful incisions!!!

The Essure procedure allows women who are absolutely finished with childbearing the opportunity to permanently prevent future pregnancy without taking hormonal birth control.

The nice thing about Essure hysteroscopic sterilization is that it can be performed in my office without anesthesia or sedation if desired. A small camera is inserted through the cervix into the uterine cavity. While directly visualizing the tubal openings, a small coil is diercted into the tube. After placing the coil, the body begins to scar the tubal opening, thus closing it off.

A special x-ray test must be done 3 months after the Essure procedure to confirm that the tubes are blocked.

A link to the Essure website is available in the link list to the right.

Laparoscopic Hysterectomy (Bandaid Hysterectomy)

2007-01-10T13:53:00.000-07:00

Laparoscopic Hysterectomy, or "Band-Aid Hysterectomy", is a wonderful option for many women who need a hysterectomy. Overall, laparoscopic hysterectomy is indicated as an alternative to open or abdominal hysterectomy. In this discussion I will talk about the indications, the benefits and risks and different methods of laparoscopic hysterectomy.

The indications for laparoscopic hysterectomy are similar to those for abdominal hysterectomy. Any patient who has previous abdominal surgery such as cesarean section or surgery for ovarian cysts may not be a candidate for a vaginal hysterectomy. This is due to the risk of adhesions of the bladder or other organs with in the abdomen. Also in patients with limited uterine descent, the uterine support is still very good. Patients with a concern for other intra-abdominal problems such as infection or endometriosis. Also women with a very large uterus that is too big to be removed vaginally.

It has been shown that vaginal hysterectomy is the safest method when possible. However; when there are contraindications to vaginal hysterectomy, laparoscopy offers some significant benefits over abdominal hysterectomy. The biggest benefit is the recovery time and hospital time. A patient who has had an abdominal hysterectomy usually stays in the hospital for 3-4 days because of the invasiveness of the procedure. A bikini type incision is made on the low abdomen and the abdominal muscles are separated. Pain is more significant because of the larger incision. Laparoscopy offers a similar hysterectomy through smaller “keyhole” incisions. In performing a total hysterectomy through the laparoscope I typically place 5 incisions, the largest being approximately 1.5 cm in the belly-button.

Laparoscopy usually allows a patient to go home within 24 hours of surgery and is considered an “outpatient” surgery. Patients usually are able to perform normal activities sooner. The normal course for my patients after total laparoscopic hysterectomy has them feeling close to normal in 10-14 days.

Another benefit is the increased ability to see small disease. If there is endometriosis or other problems, the laparoscope magnifies the view inside the abdomen and allows me to see better. I can then remove any disease that I see. I can look all around the abdomen also, including visualization of the liver, gallbladder, stomach and spleen.

Adhesions, or organs sticking to each other, are more common after abdominal or open procedures. Laparoscopy decreases the likelihood of forming adhesions due to smaller incisions and increased ability to control very small bleeding.

Some of the risks of laparoscopic hysterectomy include injury to major blood vessels during entry, injury to bowel, bladder or ureters. Early studies have shown laparoscopy to be more risky than vaginal surgery. But again, laparoscopy is not an alternative for vaginal hysterectomy. I feel that laparoscopic suturing is a very important skill for anyone performing laparoscopic hysterectomy. This allows management of most complications without having to convert to laparotomy.

Laparoscopic hysterectomy can be divided into three categories. The first is laparoscopic assisted vaginal hysterectomy. This is performed in women with good uterine descent who have other abdominal concerns that need to be addressed. Some of these concerns may be an ovarian cyst, endometriosis, or adhesions. Most gynecologists can perform some portion of the surgery through the laparoscope.

The next one is laparoscopic supracervical hysterectomy or “LSH”. This is performed fully laparoscopically by removing only the upper portion or “fundus” of the uterus. The cervix is left in place. The only benefits to this are quicker recovery, limited post operative restrictions, quicker return to intercourse, and not interrupting the uterine support that is already in place. Many patients believe and are told that sexual response is better with leaving the cervix; however, many studies have shown no benefit in this regard. This type is also less risky because the uterus is “amputated” at a level above the ureters and bladder.

The next type is total laparoscopic hysterectomy, or “TLH”. This procedure performs the hysterectomy in a similar fashion to abdominal hysterectomy. The full hysterectomy removes both the fundus of the uterus and the cervix. The top of the vagina is then closed and support is re-established to supporting ligaments. This is a very good alternative for a woman who needs a hysterectomy who also needs or wants to have her cervix removed.

Concerning surgical management of gynecologic and uterine problems, a physician who can perform laparoscopic hysterectomy can offer a full line of options to each patient.

Large ovarian and tubal cysts

2006-12-10T10:03:00.000-07:00

This last Tuesday I performed a surgery on a patient in her late twenties who had a large, cystic mass involving her left ovary. On ultrasound it measured approximately 8 centimeters. Her ovarian tumor markers were normal. The decision was made to remove the ovary and tube on the left. With all complex ovarian masses there is a concern for malignancy. For this reason, traditionally these surgeries are performed with a large, “open” incision.

With careful laparoscopic technique these masses and ovarian large ovarian cysts can be managed laparoscopically. With careful attention to keeping the cyst from rupturing and with careful removal techniques, patients can be treated with same day surgery with a much easier recovery.

AT the time of surgery this patient was noted to have an 8 cm cyst on her fallopian tube and a 6 cm cyst in her left ovary. The surface of both tube and ovary were otherwise normal appearing. The tube and ovary were removed separately to facilitate removal from the abdomen. Both cysts were unruptured throughout the surgery.

Once the tube and ovary were removed, a sterile bag was placed into the abdomen through the small incision at the belly button. The bag was then opened and the tube with was placed inside the bag. A laparoscopic needle was then used to aspirate the cyst fluid. Any spilled fluid remained in the bag. The cyst and tube were then removed through the belly button incision.

Because there is often more concern for malignancy with ovarian cysts, the ovary was placed in the bag. The belly button incision was then extended to approximately 3 cm. The opening of the bag was brought through the incision and the ovarian cyst was incised and drained into the bag. The ovary and its contents were then easily removed through this small incision.

The patient went home that same day and was doing very well at a follow up call two days later. Both cysts were benign. She incidentally had a small amount of endometriosis around her left ovary that was removed at the time of surgery.

Ovarian Remnant

2006-12-06T17:15:00.000-07:00

I recently saw a patient who has struggled with pelvic pain for years. She has undergone numerous surgeries and treatments. She most recently had a laparoscopic supracervical hysterectomy (LSH) with removal of her tubes and ovaries. She was noted to have endometriosis at that time.

She presented to me with concerns over continued, worsening pain. She was being seen by a pain specialist and enrolled in a pain management program. Her pain affected many areas of her life. She struggled to work, be a mother, and a wife.

Her symptoms consisted of general pelvic pain which was sharp and debilitating. She also had pain with intercourse or dyspareunia.

During her surgery she was found to have her sigmoid colon attached to the side of her pelvis. This is called adhesions. The bowel was densely adhered to the pelvic sidewall and continuing down to and involving half of the area of her cervical stump.

As I began dissecting out the adhesions it became evident that a small portion of her ovary had been left behind with her previous surgery. This is known as “Ovarian Remnant Syndrome.” When a small piece of ovary is left behind due to difficult adhesions or other reasons, the ovary begins to grow in an invasive nature. It seeks out a new blood supply and in doing so invades into surrounding structures.

This patient had her ovary growing into the pelvic sidewall, completely encasing her ureter. It was also growing into the bowel wall.

During her surgery the ureter was identified high in the pelvis and carefully dissected along its course. As I approached the area of the ovary it became evident that it was “stuck” to the underlying structures. Using careful laparoscopic dissecting techniques, the ureter was unroofed and the adhesions were cleared off. The residual ovary was then dissected deeply and removed. A portion in the bowel wall was also removed.

At the end of the surgery, cystoscopy was performed to check the integrity of the bladder and ureter. I also perform a bowel integrity test any time there is concern for possible bowel injury.

I have hopes that removing the residual ovary will allow her more ability to do the things she likes to do and be the mother she wants to be.

Laparoscopy for Pelvic Prolapse

2006-12-02T08:30:00.000-07:00

The latest addition to this blog is regarding pelvic prolapse. More common terms heard at your doctor’s office are: cystocele, rectocele, and uterine or uterovaginal prolapse. This occurs when the thick tissue, or fascia, which supports the female structures, becomes weakened over time. This is most likely due to injury sustained with labor during childbirth or with previous pelvic surgery such as hysterectomy. Anything that interrupts by tearing or disrupting nerve input to the supporting muscles can contribute to the problem of prolapse.

The most common symptoms of prolapse are pelvic pressure, a bulge either felt or seen at the vaginal opening. Many patients have problems with bowel movements even requiring “splinting” or use of a finger in the vagina to help express stool. With cystocele, patients can have either urinary retention (the inability to void), and or leaking urine with coughing, sneezing, etc. This is known as stress incontinence.

I would like to mention that a cystocele can be of three different natures. The support of the bladder runs underneath the bladder, runs to the side and attaches to the connective tissue of the side of the pelvis. This attaching tissue may have breaks at the lateral attachment, in the midline, or at the top of the bladder where the bladder sits on the anterior part of the lower uterus. The most common defect seen is the lateral attachment defect in greater than 90% of patients. These breaks in the fascia are considered to be hernias as they allow abdominal and pelvic contents to bulge through the fascia.

The most recent surgery performed was in a woman in her 60’s. She had problems with bowel movements, stress incontinence, and pelvic pressure. On her examination, she had a rectocele (bulging of the rectum into the vagina), cystocele (bulging of the bladder into the vagina), stress incontinence and prolapse of the uterus. She desired to preserve her uterus. This is appropriate as the uterus itself is not involved in support of the pelvic organs.

This patient underwent a laparoscopic surgery which, through laparoscopic suturing, re-established support of the upper vagina and uterus to the uterosacral ligaments. This is a relatively simple surgery for uterine prolapse that has an 80% success rate. The benefit of this is uterine preservation.

The second portion of the surgery was to correct cystocele. As this patient had a lateral defect, her repair consisted of re-attaching the supporting tissue to the side at the area it originally detached. If there is a large separation, a modification can be made that may increase the likelihood of a successful repair. This surgery, paravaginal repair, can be done vaginally, abdominally, or laparoscopically. Laparoscopic surgery allows much easier visualization of the area of concern with precise placement of sutures to correct the torn supporting tissue.

After this, a mesh “sling” was place underneath the urethra to correct the stress incontinence. This was done with a small one centimeter incision in the vagina with two small incisions on the lower abdominal wall. There are many ways to treat stress incontinence. The two “gold standard” treatments are Burch Urethropexy and suburethral slings.

The final part of the procedure was a traditional posterior repair correcting the defect in the supporting tissue between the rectum and vagina.

The surgery went well without any complications. The patient had a normal recovery and went home on the third day after surgery. She was urinating on her own and was holding urine with coughing. She had a quick return to normal diet and her pain was controlled with pain pills. Infact, this patient had adequate pain control with only Tylenol on day number three after surgery.

Laparoscopic correction of pelvic organ prolapse allows wonderful visualization of the specific defects causing prolapse. It also allows preservation of the uterus if desired. The traditional advantages of laparoscopy apply in these cases. These benefits include smaller incisions, quicker recovery, and shorter hospital stay.