First ever two incision robotic hysterectomy

I have posted a link to a new video showing the first ever two incision robotic hysterectomy. Two Incision Robotic Hysterectomy.  This hysterectomy is done through only two small incisions, one in the belly button for the camera and one just above the pubic bone for the instruments.  Both would be completely un-noticeable with swim wear.  With the help of my OR staff, we managed to work out the logistics of the robotic arms to allow this.

Single incision techniques have been developed that allow the surgery to be done all through the belly button, but the incision is much larger, between 2.5-3 cm in size.  These incisions are 1-1.2 cm and theoretically would have a lower risk of herniation.

There are limitations with this.  It likely is only possible with hysterectomy and possibly removal of ovaries. Any endometriosis would be difficult to treat this way with excisional approach.

With this technique it is possible to also perform laparoscopic supracervical hysterectomy and total laparoscopic hysterectomy with removal of tubes and ovaries.

I am so excited about this procedure that we can now offer with or without robotic assistance.

Why Use Laparoscopy for Complex Surgery

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

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.