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."
Showing posts with label laparoscopic surgery. Show all posts
Showing posts with label laparoscopic surgery. Show all posts
Monday, March 14, 2011
Thursday, June 14, 2007
Large Ovarian Cyst
I had a very interesting surgery a little while ago. I had a elderly woman who was referred with a large, complex, cystic mass on her ovary. After my discussion with her, she chose to have an evaluation through the laparoscope with possible removal of the ovary.
At the time of surgery, her ovary was noted to be free, without adhesions, and with a smooth surface. She did have multiple cysts on the ovary. The largest cyst was about 15 centimeters in size. Because there were no adhesions, no abnormal fluid within her abdomen, and no concerning features on the surface of the ovary, I elected to drain the cyst and removed the ovary laparoscopically.
A 5 millimeter incision was made just above the pubic bone. A small tube was inserted through this incision and into the cyst. A suture was placed around the cyst and tube and the cyst was then drained. As the cyst collapsed, the suture was tightened around the cyst to prevent spilling.
After the largest cyst was drained, I was able to remove the ovary and place it inside a sterile, plastic bag. Once contained within the plastic bag, the opening of the bag was brought through the 2 centimeter incision in her belly button. The cyst was then removed through that small incision.
The patient went home the same day and two days later was feeling well and off of pain medication.
In appropriate patients, laparoscopy can be safely used to treat cysts and masses of the ovaries and fallopian tubes. Even large masses such as described above can be managed with the benefits of minimally invasive, laparoscopic surgery.
At the time of surgery, her ovary was noted to be free, without adhesions, and with a smooth surface. She did have multiple cysts on the ovary. The largest cyst was about 15 centimeters in size. Because there were no adhesions, no abnormal fluid within her abdomen, and no concerning features on the surface of the ovary, I elected to drain the cyst and removed the ovary laparoscopically.
A 5 millimeter incision was made just above the pubic bone. A small tube was inserted through this incision and into the cyst. A suture was placed around the cyst and tube and the cyst was then drained. As the cyst collapsed, the suture was tightened around the cyst to prevent spilling.
After the largest cyst was drained, I was able to remove the ovary and place it inside a sterile, plastic bag. Once contained within the plastic bag, the opening of the bag was brought through the 2 centimeter incision in her belly button. The cyst was then removed through that small incision.
The patient went home the same day and two days later was feeling well and off of pain medication.
In appropriate patients, laparoscopy can be safely used to treat cysts and masses of the ovaries and fallopian tubes. Even large masses such as described above can be managed with the benefits of minimally invasive, laparoscopic surgery.
Friday, April 6, 2007
Bladder Drop and Incontinence
Many women have problems with what doctors refer to as prolapse. One specific area of prolapse is with the bladder. Most prolapse is considered some form of a hernia. Similar to hernias of the groin or "belly button," pelvic hernias and prolapse are caused by a break in the tough tissue or fascia that acts as a supportive layer. When the fascia is broken or separated, other organs or areas can bulge through.
One of the most common areas of prolapse is the bladder. The bladder sits right in front of the anterior vagina. If the support of the bladder is disrupted, such as in childbirth or just over time, the bladder can bulge into the vagina or even out through the vaginal opening.
Some forms of urinary incontinence can be caused by or complicated by bladder drop. Frequently, patients who leak urine with coughing, sneezing, or with exercise, have a defect in the bladder support that contributes to the leaking.
Dr. Cullen Richardson studied the defects involved with bladder support problems and found three different support areas that can break and cause a bladder hernia. The first and most common site is where the bladder fascia attaches to the pelvic bones. This is referred to as a lateral defect or paravaginal defect cystocele. As the lateral support is broken, the bladder is allowed to drop down out of position. This is similar to spring support on a trampoline that attaches to the frame.
The other two types of hernia defects are transverse and midline defects. These two are less common and are likened to a tear in the trampoline fabric itself.
Common treatments for bladder prolapse include exercises to strengthen the pelvic muscles, pessary treatment, and surgery. Bladder prolapse is not a dangerous condition and many women live without any treatment. Pessaries are similar to contraceptive diaphragms which are placed in the vagina and act as a supporting "shelf" to hold the bladder in place and keep it from protruding out the vaginal opening.
Common surgeries for bladder prolapse include an "anterior repair." This is a god procedure for transverse and midline defects. Essentially the vaginal mucosa is opened exposing the supporting bladder fascia. This fascia is then sewn with stitches closing the defect.
Lateral or paravaginal defects are repaired either vaginally, laparoscopically or abdominally. Each surgeon has his/her preferred method of operating. The goal of the surgery is to re-attach the fascia to the lateral pelvic bones. I perform these surgeries laparoscopically. This allows a similar procedure to the abdominal method, but uses only small one centimeter incisions. Laparoscopy magnifies the view and the defects are identified. Permanent sutures are then placed to hold the support back into its normal position.
Incontinence surgery can be performed at the same time. There are minimally invasive procedures used to treat stress incontinence. These will be addressed in an upcoming post.
One of the most common areas of prolapse is the bladder. The bladder sits right in front of the anterior vagina. If the support of the bladder is disrupted, such as in childbirth or just over time, the bladder can bulge into the vagina or even out through the vaginal opening.
Some forms of urinary incontinence can be caused by or complicated by bladder drop. Frequently, patients who leak urine with coughing, sneezing, or with exercise, have a defect in the bladder support that contributes to the leaking.
Dr. Cullen Richardson studied the defects involved with bladder support problems and found three different support areas that can break and cause a bladder hernia. The first and most common site is where the bladder fascia attaches to the pelvic bones. This is referred to as a lateral defect or paravaginal defect cystocele. As the lateral support is broken, the bladder is allowed to drop down out of position. This is similar to spring support on a trampoline that attaches to the frame.
The other two types of hernia defects are transverse and midline defects. These two are less common and are likened to a tear in the trampoline fabric itself.
Common treatments for bladder prolapse include exercises to strengthen the pelvic muscles, pessary treatment, and surgery. Bladder prolapse is not a dangerous condition and many women live without any treatment. Pessaries are similar to contraceptive diaphragms which are placed in the vagina and act as a supporting "shelf" to hold the bladder in place and keep it from protruding out the vaginal opening.
Common surgeries for bladder prolapse include an "anterior repair." This is a god procedure for transverse and midline defects. Essentially the vaginal mucosa is opened exposing the supporting bladder fascia. This fascia is then sewn with stitches closing the defect.
Lateral or paravaginal defects are repaired either vaginally, laparoscopically or abdominally. Each surgeon has his/her preferred method of operating. The goal of the surgery is to re-attach the fascia to the lateral pelvic bones. I perform these surgeries laparoscopically. This allows a similar procedure to the abdominal method, but uses only small one centimeter incisions. Laparoscopy magnifies the view and the defects are identified. Permanent sutures are then placed to hold the support back into its normal position.
Incontinence surgery can be performed at the same time. There are minimally invasive procedures used to treat stress incontinence. These will be addressed in an upcoming post.
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.
Subscribe to:
Posts (Atom)