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.
Showing posts with label laparoscopic supracervical hysterectomy. Show all posts
Showing posts with label laparoscopic supracervical hysterectomy. Show all posts
Friday, April 18, 2008
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.
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.
Wednesday, December 6, 2006
Ovarian Remnant
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.
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.
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