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.
Showing posts with label bandaid hysterectomy. Show all posts
Showing posts with label bandaid hysterectomy. Show all posts
Thursday, February 18, 2010
Laparoscopic Sacrocolpopexy (Vaginal Prolapse Surgery)
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.
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.
Saturday, January 23, 2010
Tuesday, May 12, 2009
Da Vinci Si Hysterectomy
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.
Tuesday, November 11, 2008
Painful periods and endometriosis
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.
Saturday, August 23, 2008
Press Release About Lack of Information for Minimally Invasive Procedures
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/
Friday, April 18, 2008
CBS Evening News Report about Laparoscopic Hysterectomy
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.
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.
Tuesday, January 15, 2008
Minimally Invasive Hysterectomy (video link to right)
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.
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.
Saturday, June 2, 2007
Laparoscopic Hysterectomy for Large, Fibroid Uterus
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.
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.
Sunday, March 25, 2007
Removal of Cervix after Supracervical Hysterectomy or LSH
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.
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.
Wednesday, January 10, 2007
Laparoscopic Hysterectomy (Bandaid Hysterectomy)
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.
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.
Saturday, December 2, 2006
Laparoscopy for Pelvic Prolapse
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.
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.
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