ABDOMINAL, VAGINAL AND LAPARASCOPIC HYSTERECTOMY

I believe in technology; it has miraculously changed my life over the last twenty years. I think that most of these changes have been for the better. There are still some great challenges ahead in the health care field that I hope and pray our know-how and inventiveness can overcome.

There is a major area in my field that has recently been re-addressed and that has had some exciting improvements made. This is in the area of the hysterectomy. I wrote a newsletter back in the 90s describing the differences between a vaginal hysterectomy (VH) and abdominal hysterectomy (AH); much of that has now changed.

From the patient's point of view, the differences between the two types of hysterectomy revolve around the incision on the abdomen. With an AH, whether the incision is made up and down, or crosswise as a "bikini cut," this incision is the major source of discomfort and is directly related to recovery time. The VH avoids this large painful abdominal scar.

I had a patient recently return to work the day after she left the hospital, that is just five days after having a VH! Now, this was a surprise to me, and was not what I had recommended, but it does illustrate how rapidly one can recover from vaginal surgery, if done well.

There have been studies that describe a return to normal activity in about three weeks on the average after a VH, as opposed to the four to six weeks after an abdominal surgery. If you consider the time lost from work nation wide due to this surgery, this is very significant. The other cost consideration is the length of hospital stay; a patient can leave the hospital one to two days earlier after a VH than after an AH.

Well, after hearing this, why aren't all hysterectomies done without this infamous abdominal incision? It is because of the technical difficulties of doing a hysterectomy in a small space (i.e., the vagina) as opposed to a wide open abdominal incision, with as much room as you need. This additional room to operate may be needed: 1) for inspection of the internal structures and to look for reasons for abdominal pain 2) to destroy areas of endometriosis, if any are present 3) to closely examine or take a biopsy of a cyst on an ovary that may be cancerous 4) to deal with scar tissue from previous surgery or prior infections 5) to be able to assure a patient her ovaries will be removed (the ovaries are frequently too high up inside the pelvis to be reached from the vaginal approach) 6) doing surgery on a woman who's vaginal anatomy is too small or her uterine anatomy is too big, such as with fibroids 7) there are also some doctors practicing that have not been trained to do vaginal surgery and can only do an abdomimal hysterectomy.

So, what is so new? What has changed? "Belly-button" hysterectomies! To prevent my being accused of making any false claims, the surgery isn't done just through the belly button. There are a total of four half inch incisions on the abdomen and those are the only scars anyone will see. Using a laparoscope, 60-70% of women needing a hysterectomy can benefit from vaginal surgery! For those of you that don't know what a laparoscope is, it is a fiber optic device similar to the peep-hole you may have in your front door, but the laparoscope is longer and about the diameter of a soda straw. It directs light into the abdomen so the pelvic organs can be seen. It is placed into the abdomen through a tiny cut under the belly button. This has been used for years to look inside the abdomen for abnormalities. We now have the technology to do surgery through it.

You have probably heard of someone having their gall bladder removed with the laparoscope. We gynecologists were using this modality long before the general surgeons. A Dr. James F. Daniel has pioneered the use of operative laparoscopy: I've had the opportunity to operate with him. I have done vaginal hysterectomies that I would have been forced to do through the abdomen, if I had not used the laparoscope first.

Now, without a large abdominal incision, reasons for abdominal pain can be looked for with the laparoscope. I can use a laser through the "scope" to destroy endometriosis. An ovarian cyst can be examined and biopsied. I can break up scar tissue with the laser or with tiny scissors that can also let into the abdomen through a tiny cut. The ovaries can now also be removed with almost certainty. A new device called the Endo GIA-30 can be put into the abdomen through a half inch incision, can be placed on the support structures of the ovary, and when it is applied, it places six rows of microscopic titanium staples to seal off any bleeding! This device also allows us to cut off the blood supply to the uterus "from above" as we say (Who says we doctors sometimes think we are God?) and this allows surgery to be done with removal out of the vagina in women with a large uterus.

Now, this type of surgery isn't always possible, but if you end up having to open the abdomen because the surgery can't be done vaginally, you know at least you tried. The disadvantages of this surgery are that it does take longer, it is technically more difficult and not all gynecologists are familiar with the techniques needed to do it.

If you want more information on this new development, call my office. No one wants to have a hysterectomy, but if you really need this surgery to be done; less pain, less time in the hospital and faster recovery would certainly seem to be the way to go!

 

FRED CREUTZMANN, M.D. CARROLLTON

972-394-7277 or www.DrCmd.com