By Dr. Stepp, CMC Women’s Institute
I love my job as a gynecologic surgeon. It is gratifying to be in a position to offer women some of the latest advances in healthcare. But I also know, that far too many women never realize they have a choice when faced with something that affects over 500,000 women a year in the United States. Incredibly, even in 2010, approximately two thirds of all hysterectomies are still done through a large abdominal incision – the way it was initially described in the 1920’s!
If you are unlucky enough to need a hysterectomy, I have two bits of advice. First, familiarize yourself with the three general techniques for performing a hysterectomy: Abdominal hysterectomy, vaginal hysterectomy, and laparoscopic hysterectomy. And second, don’t be afraid to ask your questions or seek a second opinion if necessary. You have that right. By all means, insist on the least invasive method you are a candidate for! Except in truly rare circumstances, almost every woman who needs a hysterectomy should have it done minimally invasively – either through the vagina or laparoscopically. Even women with prior cesarean sections or adhesions are still candidates. And virtually all other types of pelvic surgeries can be done minimally invasively by a skilled laparoscopic surgeon too: ovarian cysts, severe endometriosis, fibroid surgery, etc.
If you need a hysterectomy, vaginal hysterectomy is a great option. But in patients that have concerns about other conditions inside the pelvis (like ovarian cysts or endometriosis), it is hard to get a good view with the vaginal approach.
Laparoscopic surgery is performed by putting a small telescope into abdomen through the belly button. There are three types of laparoscopy: conventional laparoscopy, robotic assisted laparoscopy, and single incision laparoscopic surgery or single port laparoscopy. Conventional laparoscopy is good but requires 3-4 small holes (smaller than a pencil) through the abdominal wall to place additional instruments. Sometimes this is called “keyhole” surgery. Current technology allows the surgeon to then insert a high definition camera directly inside to get a very clear picture of all the structures.
The latest advance and least invasive laparoscopic approach is single incision laparoscopy. This approach enables specially trained surgeons to complete the entire surgery through the single small incision in the belly button. We don’t have to make any extra punctures in the abdominal wall. It is not necessary to cut any muscles if only one small incision is created in the belly button. That may mean less pain and the fastest return to normal activity. For an added benefit, the incision can be hidden inside the belly button leaving very little if any sign of the surgery at all.
We started out by offering single incision laparoscopy for simple cases, then further developed the technique for hysterectomies in 2008. Now, a few centers offer single incision laparoscopy for some of the most complicated reconstructive procedures gynecologists perform.
One might ask if single incision laparoscopy is the same as robotic hysterectomy. It is not. There may be instances where using robotic assistance provides an added benefit to the patient. However, until new instrumentation is available specifically for robotic surgery, robotic hysterectomies still use 3-5 abdominal incisions.
Women should feel empowered to ask a few key questions:
1. Am I a candidate for a less invasive approach?
2. How many times have you performed minimally invasive surgery in the last month/year?
3. What percentage of your patients are done using minimally invasive techniques?
4. How often do you have to convert to an abdominal approach (change from laparoscopic to an abdominal incision)?
Speaking as a surgeon, I’m never offended when a patient is proactive and asks me these questions. And you shouldn’t be afraid to ask. It’s too important. Some doctors say why should we do laparoscopic surgery through one small incision when the other incisions are so small anyway. But I think as we look to the future, if we can do the same surgery without increasing the risks, then the question shouldn’t be why should we do this… but why not.
Dr. Stepp is the Head of Urogynecology and Minimally Invasive Gynecologic Surgery at CMC Women’s Institute and has trained over 300 surgeons from 23 countries in single incision laparoscopy. CMC Women’s Institute is dedicated to improving health care for women of all ages. For more information, please call 704-355-3149.