Minimally invasive hysterectomies often a good choice for women
July 8, 2009 8:00 AM
Dr. James Garver watches a monitor as he places the endoscope inside the abdomen of a patient to prepare for a hysterectomy using the da Vinci surgical robot at Allegheny General Hospital.
Dr. Garver operates da Vinci tools from a console, looking at a 3-D image of the operation site.
By Pohla Smith Pittsburgh Post-Gazette
Allegheny General Hospital personnel rolled Tinisha Nelson into a surgical suite for her robot-assisted laparoscopic hysterectomy about 2 p.m. on June 11. By 4 p.m., the procedure surgeon James Garver did with the aid of the big, two-piece robotic device was over.
The North Side mother of three went home the following evening. She was sore and still unable to feel when she needed to use the bathroom, and she was forbidden to take stairs for a few days, but she was home nevertheless.
If Mrs. Nelson, 28, had had the hysterectomy, or removal of her uterus, by conventional means, she could have been hospitalized for as long as four days. That's because the most common type of hysterectomy is via an abdominal incision of 5 to 7 inches that also is known as a laparotomy. The da Vinci Surgical System-assisted laparoscopic surgery requires just four, dime-sized incisions that readily heal up like dimples.
Time of total recovery from an abdominal hysterectomy probably also would have been longer than that facing Mrs. Nelson.
According to medlineplus.gov, an online encyclopedia run by the U.S. National Library of Medicine and the National Institutes of Health, recovery from the big-incision surgery averages four to six weeks after leaving the hospital.
Dr. Garver said some of his patients who have had da Vinci-assisted laparoscopic hysterectomies feel well enough after two weeks' rest to return to desk jobs. Intuitive Surgical Inc., the Sunnyvale, Calif.-based maker of the da Vinci, says patients sometimes even can resume normal activity in less than a week.
And the robot-assisted laparoscopy is just one of several methods of hysterectomy that fall into the category officially labeled "minimally invasive surgery," or operations done for the same purpose but with smaller incisions than open surgery.
The most common minimally invasive procedure, sometimes counted as a category by itself, is a vaginal hysterectomy, in which the uterus is removed through an incision in the vagina.
Then there are the laparoscopic-assisted vaginal hysterectomy; surgery by use of laparoscopes only; and the da Vinci. In the da Vinci, the surgeon sits at a console and, while using both hand and foot controls and viewing a highly magnified three-dimensional image of the surgical area, operates two or three instrument arms and a camera/light called an endoscope.
The newest minimally invasive procedure is the single incision laparoscopy, better known as bellybutton surgery because the 11/2-inch incision is done through the navel.
The many options are all designed to reduce recovery time and, in most cases, pain, while providing less noticeable scarring.
Yet only 35 percent of the approximately 600,000 hysterectomies the Centers for Disease Control and Prevention says are performed each year were done laparoscopically or vaginally in 2006, according to statistics gathered by the American College of Obstetrics and Gynecology. Twelve percent of those 600,000 were laparoscopically assisted vaginal surgeries and 4 percent were laparoscopic alone.
ACOG didn't have statistics for da Vinci laparoscopic procedures for 2006, but Intuitive Surgical said there were approximately 34,000 da Vinci hysterectomies performed in 2008.
There are gynecologists who believe the percentages of minimally invasive procedures should be higher.
"I am a firm believer that virtually all of benign [non-cancerous] gynecologic surgical conditions can be treated in a minimally invasive fashion," Dr. Ted Lee, director of minimally invasive gynecologic surgery at Magee-Womens Hospital of the University of Pittsburgh Medical Center, wrote in a letter to area gynecologists.
"I live and breathe that approach," Dr. Lee said in a subsequent interview. He noted that he does more traditional laparoscopic procedures because those are the most frequent referrals he gets. To do a da Vinci surgery now, he must go to UPMC Shadyside; Magee is set to get its own machine soon.
There also is a da Vinci at Western Pennsylvania Hospital and at the Veterans Administration Hospital.
Another big fan of laparoscopic surgeries is Dr. Vladimir Nikiforouk, of Ohio Valley Hospital, who recently began offering the bellybutton surgery.
"My goal is to educate women on the availability of laparoscopic surgery that can put them back to work in three to seven days," Dr. Nikiforouk said. "What has happened in the United States over the last couple years with the advance of instruments is we are able to perform procedures much, much faster with way less complications and provide women with definitive treatment. ...
"My goal is to educate women and to try to persuade an older generation of gynecologists to be open to the laparoscopic approach. It's a problem we encounter, doctors who drag and drag and drag and women who suffer and suffer and suffer [as] they undergo D and C [dilation and curettage] after D and C. ..."
But both Dr. Lee and Dr. Nikiforouk said they believe minimally invasive procedures are becoming more accepted and prescribed in the Pittsburgh area. "A lot who did not train [for laparoscopic procedures] are starting to do it. The tendency toward it is more and more popular the last 12 months," Dr. Nikiforouk said.
"When I first came to Pittsburgh [in 2001], abdominal surgeries were done 70 percent; vaginal were 20 percent and 10 percent were laparoscopic," Dr. Lee said. "Over the last 10 years, the change has been very, very slow" but noticeable nevertheless.
"At Magee, abdominal surgery is about 60 percent of all surgeries and vaginal approach is always stable, 20-25 percent," he added. "Laparoscopies have risen to about 20 percent [but] part of that is because of our [practice] group."
A cost-effectiveness comparison done in November 2007 for National Women's Health Resource Center on treatments for pelvic health disorders came down firmly on the side of minimally invasive hysterectomies.
"Less invasive types of hysterectomy -- vaginal and minimally invasive/laparoscopic -- are generally recommended by medical authorities over TAH [total abdominal hysterectomy]," said the report submitted by The Lewin Group Inc. "This is because they achieve similar outcomes to TAH, with generally lower complication rates, shorter hospital stays, less pain and quicker return to major activities by patients."
In the meantime, the Cleveland Clinic is doing a study comparing conventional laparoscopy to robotic-assisted lapascopic hysterectomies.
Whatever the results of such studies, it seems unlikely that minimally invasive surgical techniques ever will replace abdominal surgery completely, for there are pluses and minuses for each, depending upon the case history of the patient.
Dr. John D. Brungo, a medical director for Highmark Blue Cross Blue Shield, talked about both.
"The laparotomy is a more complicated procedure. It's an open surgery. It requires a heavier anesthetic, a longer stay in the hospital and also a longer recuperation period," he said.
On the other hand, a woman's specific condition, the size of her uterus or anatomy in that area, "may provide greater risk to do it in a more minimally invasive way," Dr. Brungo added.
"If you have a uterus laden with fibroids and it has a 12-week gestational size, that's going to be more difficult to do vaginally, let alone laparoscopically. In addition, if previous infection or pathology led to adhesions ... it's going to create significant risk to be able to do the hysterectomy [minimally]. ...
"You have to understand operating in a limited field, you can't see as much, you can't feel as much and there are a lot of issues surgeons could come across that could change the nature of the procedure he's doing.
"The biggest thing they like [about minimally invasive techniques] is the smaller incision ... Aesthetically it's better, but you have to balance that against safety. That's where clinical judgment comes into play: Which is the least risk to the patient? What are the alternatives?"