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.

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.

Rectovaginal Endometriosis

I recently had a patient who was referred to me for treatment of pelvic pain and pain with intercourse. She had multiple prior surgeries for “endometriosis”. During one of her prior surgeries she was noted to have “adhesions of her rectum to the uterus.

On her office exam, there was a nodule behind the uterus that I could feel. It appeared to be pulling her rectum into the back side of the uterus. This is the third patient I have seen with this similar presentation and history.

During surgery, she was noted to have a nodule of endometriosis that pulled the rectum forward and blocked her normal “pelvic cul-de-sac” (the area between the uterus and the rectum. During dissection, this nodule was dissected off the uterus and the rectum and freed up. After identifying the rectum, ureters and uterine blood vessels, the nodule was removed.

When treating endometriosis surgically, it is important to use the physical examination to know what to expect at the time of surgery. It is also important for the surgeon to feel comfortable removing endometriosis in difficult areas such as over the ureters or bowel. There are many times endometriosis surgeries are performed and the surgeon takes a look and then stops the surgery because the endometriosis is too bad or in locations “too risky” to remove.

This patient is an ideal example of the necessity to know how to identify and adequately excise the endometriosis encountered during surgery.

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.

Urinary Incontinence Surgery

Stress Incontinence occurs when the pressure on the bladder overcomes the mechanisms in place to keep urine from leaking. To begin with, stress incontinence must be differentiated from urge incontinence or detrussor instability. Urge incontinence occurs when the bladder muscle begins to contract in an attempt to empty the bladder. The most common occurrence with this type of incontinence is feeling the urge to go and not being able to make it to the restroom in time. This type of incontinence is treated with medicines as opposed to surgery.

Stress incontinence can be divided into two categories: 1. Urethral hypermobility and , 2. Instrinsic sphincter deficiency. Urethral hypermobility occurs usually in conjunction with other anatomic pelvic prolapse. Normally the bladder and bladder neck is supported within the realm of the abdominal and pelvic cavity. As the pressure within the abdomen increases, the rise in pressure also surrounds the bladder neck helping to close off the area where urine leaves the bladder and enters the urethra. If this area has lost its support, the increased pressure can no longer be used to assist in controlling the urine. The entire increase in pressure is transmitted to the dome or “balloon” part of the bladder. This in effect causes a greater force of urine on the bladder neck. The muscles surrounding the urethra are often not strong enough to hold the urine in.

Intrinsic sphincter deficiency occurs when the bladder and bladder neck are held in a normal position, but the closing pressure of the muscle surrounding the bladder neck is insufficient to prevent urine from leaking.

It is not uncommon for patients to have “mixed incontinence.” This includes a combination of stress and urge incontinence. In difficult cases or in patients with medical complications affecting the bladder innervation, special urodynamic testing can be performed to evaluate the pressures of the bladder and the muscle activity.

Common procedures for “stress incontinence” include: Burch urethropexy, suburethral sling procedures, and injection procedures. For many years the Burch procedure was and is considered the “gold standard.” This is performed with through and open “c-section” type incision or can be performed laparoscopically. The area behind the pubic bone is entered and the tissue on either side of the urethra is grasped with permanent suture and attached to a ligament on the pubic bone. This provides support to the urethra and bladder neck to prevent leaking.

Suburethral slings have been a remarkable addition to the surgical treatment of stress incontinence. Data regarding slings is very promising and studies have shown the efficacy to rival or exceed that of the Burch. A small incision (1-2 cm) is made in the vaginal mucosa underneath the urethra and the area is dissected with a scissor tip to the space behind the pubic bone. Two 1 cm incisions are then made just above the pubic bone. A permanent mesh is then passed underneath the urethra, behind the pubic bone, and through the incisions on the abdomen. This procedure is much less invasive than the Burch procedure and patients go home the same day after a voiding trial.

Some physicians can also perform bulking or injection procedures to assist in closing off the urethra. These injections are good procedures for patients who are not good candidates for longer more complex surgeries.

I perform suburethral sling procedures as well as laparoscopic Burch procedures for patients with stress incontinence.

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.

Dermoid Ovarian Cyst

Recently I had a patient that presented with a 4-5 centimeter ovarian cyst. Her initial complaint with this cyst was severe, intermittent pelvic pain. On ultrasound examination, she had a complex, solid and cystic, mass on her ovary. There was a high suspicion of what is called a "Dermoid Cyst".

Dermoid cysts are very interesting in that they can have many cell types within them. They have been known to grow an oily, sebaceous material, hair, teeth and other strange and interesting things to find in an ovary. They are very rarely of a malignant type which include nerve type tissue.

This patient elected to have her entire ovary removed although it would have been feasible to remove only the cyst itself. Either of these surgeries can be performed easily with a laparoscopic surgery.

As always if you have questions, please feel free to send me an email. You can find it under my profile link.

Large ovarian and tubal cysts

This last Tuesday I performed a surgery on a patient in her late twenties who had a large, cystic mass involving her left ovary. On ultrasound it measured approximately 8 centimeters. Her ovarian tumor markers were normal. The decision was made to remove the ovary and tube on the left. With all complex ovarian masses there is a concern for malignancy. For this reason, traditionally these surgeries are performed with a large, “open” incision.

With careful laparoscopic technique these masses and ovarian large ovarian cysts can be managed laparoscopically. With careful attention to keeping the cyst from rupturing and with careful removal techniques, patients can be treated with same day surgery with a much easier recovery.

AT the time of surgery this patient was noted to have an 8 cm cyst on her fallopian tube and a 6 cm cyst in her left ovary. The surface of both tube and ovary were otherwise normal appearing. The tube and ovary were removed separately to facilitate removal from the abdomen. Both cysts were unruptured throughout the surgery.

Once the tube and ovary were removed, a sterile bag was placed into the abdomen through the small incision at the belly button. The bag was then opened and the tube with was placed inside the bag. A laparoscopic needle was then used to aspirate the cyst fluid. Any spilled fluid remained in the bag. The cyst and tube were then removed through the belly button incision.

Because there is often more concern for malignancy with ovarian cysts, the ovary was placed in the bag. The belly button incision was then extended to approximately 3 cm. The opening of the bag was brought through the incision and the ovarian cyst was incised and drained into the bag. The ovary and its contents were then easily removed through this small incision.

The patient went home that same day and was doing very well at a follow up call two days later. Both cysts were benign. She incidentally had a small amount of endometriosis around her left ovary that was removed at the time of surgery.