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.
Showing posts with label robotic hysterectomy. Show all posts
Showing posts with label robotic hysterectomy. Show all posts
Sunday, November 24, 2013
Wednesday, December 19, 2012
Robotic Surgery and Cost
Over the last few years there has been a significant increase in the number of hospitals starting up "robotic surgery" programs. In fact, robotic assisted surgery for prostate removal has become the "standard of care" for prostatectomy. Robotic surgery in gynecology has become more controversial.
I think all providers would agree that the benefits of laparoscopic approach to surgery are much greater than by traditional laparotomy or open surgery. In my view, robotic assisted surgery is merely a laparoscopic surgery that is helped by robotic or computer assistance.
Robotic systems have allowed many gynecologists the opportunity to offer a less invasive approach to surgery that would otherwise have been done by a large incision. These are gynecologists who were not trained to perform advanced laparoscopic procedures.
With the "buzz" around robotic surgery, hospitals have had a difficult time understanding the appropriate use of the robotic system. From which procedures to allow to appropriate training of the surgeons, hospital systems are wading through new waters to provide a better service while assuring that patient safety and economic sensibility is maintained.
Many published studies have shown that robotic hysterectomy is more expensive to the healthcare system than laparoscopic or open, abdominal, hysterectomy. These studies include the purchase price or depreciation of the robotic system for each surgery performed. In most cases, the additional amount applied to surgical cost is around $2500 per surgery.
The major flaw with this approach to calculating cost of robotic surgery is that any hospital that commits to a robotic prostate program has to purchase the system. The cost of the system and the annual maintenance are fixed costs that are required if only one type of procedure is done. Allowing hysterectomy to be performed robotically, does not increase the cost that hospitals have already committed to a robotics program.
In fact, at one of the hospitals I practice, we did an internal cost analysis of robotic hysterectomy compared to regular laparoscopic and abdominal hysterectomy. We were surprised to find out that the robotic approach was actually the least expensive for total hospital cost of the surgery. The cost of robotic hysterectomy is close to that of laparoscopic and is significantly less than that of abdominal or open.
As each day passes patients are becoming more aware that regular "open" surgery really is a thing of the past. Most abdominal surgeries can be done and should be done in a less invasive way. New surgeons are constantly being trained as they see their patients seek out providers who can offer a less invasive treatment.
Patients should understand that they have a right to find the least invasive option for treating their medical conditions. This may include robotic or laparoscopic surgery or, often, treatment with medicine that doesn't require surgery. If surgery is chosen, surgeon experience and outcomes are the two most important aspects to a safe surgery with expected outcomes.
There is a large myth that robotic surgery is too costly and dangerous to use for more routine surgeries. The overall cost to the healthcare system is not increased, at least in my practice. The safety of robotic surgery depends on those aspects that the safety of any surgery depends on: surgeon experience, proven techniques, experienced operative team, appropriate decision-making and educated patients.
Thursday, March 1, 2012
Uterine Fibroids
Over the past few months I have seen a higher number of patients with uterine fibroids. Over the course of my practice and fellowship, I have treated one fibroid that reached a patient's liver. I recently removed 4 fibroids from a patient who still desired the possibility of having children in the future. Fibroid surgeries can be difficult, but there are many benefits that laparoscopy and robotics offer.
Uterine Fibroids or "leiomyomas" are growths of uterine muscle that often form in a circular or ball shape. They can be small or very large. On patient may have a single fibroid or many within the uterus. Honestly, most patients with fibroids don't have any symptoms. They are often diagnosed during a yearly exam when the uterus seems larger than normal or has an irregular or "bumpy" shape to it.
When fibroids do cause symptoms, some of the common ones are heavy bleeding with periods, a fulness or pressure feeling, or feeling a hard mass or ball in the low belly. Fibroids that are located deep inside the uterus next to the internal lining or cavity are the most likely to cause abnormal bleeding. Some fibroids ban be in the middle of the uterine muscle and some can be on the outside of the uterus almost like they are "attached" to the uterus. These latter two types are ones that can cause the pressure or fulness feelings when they become large or if there are multiple fibroids. The symptoms are mostly due to the bulk or size of the uterus with the fibroids. Occasionally fibroids can become painful if they outgrow their hormone or blood supply. When this happens, the inner cells start to die and pain results. This is more common during pregnancy when fibroids tend to increase rapidly in size.
Fibroid tumors are generally benign or non-cancerous. There are rare types that are cancerous but these are usually present less than 0.1% of the time. Concerning features are very large fibroids or very rapid increase in size outside of pregnancy. Also menopausal patients with an enlarging fibroid should be evaluated for the cancerous type of fibroid.
There are many options for treatment. Often the most appropriate option is observation. As fibroids are generally benign, they do not need to be treated or removed just because they are there. If there are no symptoms, it is often appropriate to check them with a periodic ultrasound and examination. When fibroids need to be treated there are a few options.
Uterine artery embolization (EUA) is a radiology procedure where the blood vessels that feed the fibroids are closed off with small particles or gel. This causes the fibroids to die and shrink down. It does not make the fibroids go away, but can decrease their size and symptoms. Care must be taken with this approach in patients who are not done with child bearing as there have been reports of the ovarian blood supply being cut off as well.
Gynecologists often treat fibroids by removing them. This is called myomectomy. Fibroids that are in the muscle portion of the uterus or toward the outside can be removed by making a cut in the uterus over the fibroid then removing the fibroid and sewing the uterus closed. This is a surgery that very often can be done without a large incision on the abdomen, just like most of the procedures I have discussed on this blog. Laparoscopy and robotic assisted laparoscopy can be a great way to manage symptomatic fibroids. This allows all the benefits of laparoscopy and often patients will be able to go home the same day. This is one of the most challenging laparoscopic procedures and care must be taken to not damage the uterus too much and to use appropriate care and skill when stitching the uterine incisions after removing the fibroids.
Many fibroids are treated by hysterectomy. In patients with symptomatic fibroids who are done having children, this probably a more logical option. Hysterectomy is less risky than myomectomy and has lower complications and blood loss. Again, most hysterectomies can be completed without a large incision on the abdomen. This can be done with laparoscopy or robotics or at times with a small 3-5 cm incision on the low belly when fibroids are very, very large.
GNRH Agonists such as Lupron can be used to shrink the fibroids prior to surgery. In my experience this makes a laparoscopic or robotic approach more difficult. GNRH agonists cause fibroids to shrink but also makes them mushy and hard to grasp during laparoscopy.
A less common approach is to isolate the uterine arteries laparoscopically and tie them off. The uterus itself continues to get blood supply from extra flow through their connection with the ovaries, but the decrease in blood supply to the fibroids causes fibroid cells to die and the fibroid to shrink down.
Uterine Fibroids or "leiomyomas" are growths of uterine muscle that often form in a circular or ball shape. They can be small or very large. On patient may have a single fibroid or many within the uterus. Honestly, most patients with fibroids don't have any symptoms. They are often diagnosed during a yearly exam when the uterus seems larger than normal or has an irregular or "bumpy" shape to it.
When fibroids do cause symptoms, some of the common ones are heavy bleeding with periods, a fulness or pressure feeling, or feeling a hard mass or ball in the low belly. Fibroids that are located deep inside the uterus next to the internal lining or cavity are the most likely to cause abnormal bleeding. Some fibroids ban be in the middle of the uterine muscle and some can be on the outside of the uterus almost like they are "attached" to the uterus. These latter two types are ones that can cause the pressure or fulness feelings when they become large or if there are multiple fibroids. The symptoms are mostly due to the bulk or size of the uterus with the fibroids. Occasionally fibroids can become painful if they outgrow their hormone or blood supply. When this happens, the inner cells start to die and pain results. This is more common during pregnancy when fibroids tend to increase rapidly in size.
Fibroid tumors are generally benign or non-cancerous. There are rare types that are cancerous but these are usually present less than 0.1% of the time. Concerning features are very large fibroids or very rapid increase in size outside of pregnancy. Also menopausal patients with an enlarging fibroid should be evaluated for the cancerous type of fibroid.
There are many options for treatment. Often the most appropriate option is observation. As fibroids are generally benign, they do not need to be treated or removed just because they are there. If there are no symptoms, it is often appropriate to check them with a periodic ultrasound and examination. When fibroids need to be treated there are a few options.
Uterine artery embolization (EUA) is a radiology procedure where the blood vessels that feed the fibroids are closed off with small particles or gel. This causes the fibroids to die and shrink down. It does not make the fibroids go away, but can decrease their size and symptoms. Care must be taken with this approach in patients who are not done with child bearing as there have been reports of the ovarian blood supply being cut off as well.
Gynecologists often treat fibroids by removing them. This is called myomectomy. Fibroids that are in the muscle portion of the uterus or toward the outside can be removed by making a cut in the uterus over the fibroid then removing the fibroid and sewing the uterus closed. This is a surgery that very often can be done without a large incision on the abdomen, just like most of the procedures I have discussed on this blog. Laparoscopy and robotic assisted laparoscopy can be a great way to manage symptomatic fibroids. This allows all the benefits of laparoscopy and often patients will be able to go home the same day. This is one of the most challenging laparoscopic procedures and care must be taken to not damage the uterus too much and to use appropriate care and skill when stitching the uterine incisions after removing the fibroids.
Many fibroids are treated by hysterectomy. In patients with symptomatic fibroids who are done having children, this probably a more logical option. Hysterectomy is less risky than myomectomy and has lower complications and blood loss. Again, most hysterectomies can be completed without a large incision on the abdomen. This can be done with laparoscopy or robotics or at times with a small 3-5 cm incision on the low belly when fibroids are very, very large.
GNRH Agonists such as Lupron can be used to shrink the fibroids prior to surgery. In my experience this makes a laparoscopic or robotic approach more difficult. GNRH agonists cause fibroids to shrink but also makes them mushy and hard to grasp during laparoscopy.
A less common approach is to isolate the uterine arteries laparoscopically and tie them off. The uterus itself continues to get blood supply from extra flow through their connection with the ovaries, but the decrease in blood supply to the fibroids causes fibroid cells to die and the fibroid to shrink down.
Saturday, November 12, 2011
Endometriosis Foundation
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.
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.
Monday, March 14, 2011
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."
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."
Tuesday, January 11, 2011
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.
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.
Thursday, February 18, 2010
Access to Less Invasive Surgery
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.
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.
Friday, May 1, 2009
DaVinci Si Robotic Assisted Surgery
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.
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, February 15, 2008
Robotic Surgery
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.
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.
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