January 16, 2012

New Approaches to Hysterectomy
By Carolyn Gutierrez
For The Record
Vol. 24 No. 1 P. 24

Minimally invasive techniques create more options for patients and surgeons.

With almost 600,000 procedures performed annually, hysterectomy, or the removal of the uterus, is the second most common surgery for US women, trailing only cesarean sections. Although traditional abdominal hysterectomy, in which the uterus is removed through a large incision, continues to be the most common form of the procedure, less invasive approaches such as vaginal hysterectomy and laparoscopic and robotic hysterectomies are becoming more popular due to swift recovery rates, general safety, and cost-effectiveness.

Types of Hysterectomies
Supracervical (or partial) hysterectomy is when only the body of the uterus is removed, and the cervix is left in place. When the cervix is removed as well, the procedure is known as a total hysterectomy. A total hysterectomy can be accompanied by a unilateral or bilateral salpingo-oophorectomy in which the fallopian tubes and ovaries are removed. A radical hysterectomy describes a procedure in which the uterus, cervix, ovaries, and lymph nodes are excised, generally due to cancer. Because ovaries produce protective hormones over a woman’s lifetime, studies have shown that it is safer in the long term to leave them intact during most benign hysterectomies.

Different Routes
According to Stacey Jill Wallach, MD, an associate professor in the department of obstetrics and gynecology at UC Davis Health System, “It used to be that if you were doing a hysterectomy, you either did it through a belly approach or through a vaginal approach. Conceptually, that’s still the same. We can go in through an incision in the belly and take out the uterus or we can go in vaginally and take the uterus out, and the difference is really almost a top-down or bottom-up approach.”

What has changed in the last 20 years is that there are now a variety of less invasive routes for removing a uterus. “With a vaginal hysterectomy in the past,” notes Wallach, “some of the factors that would limit our ability to do it would potentially be the size of the uterus, the risk of injury to structures nearby, or blood loss.”

Surgeons can now make very small incisions—typically ranging from 10 to 12 mm—to enable laparoscopic or robotic equipment to remove the uterus through a patient’s abdomen. On occasion, the laparoscopic or robotic approach can be combined with the vaginal route.

Reasons to Consider a Hysterectomy
Common benign conditions that may warrant a hysterectomy include uterine fibroids causing pressure, pain, and abnormal bleeding; endometriosis (the growth of endometrial tissue outside the uterus); pelvic pain; uterine prolapse; and a symptomatic enlarged uterus (usually due to fibroids). Along with other treatments, hysterectomy may be the best option for patients with cancers of the uterus, cervix, ovaries, or endometrium.

“Bleeding is one of the top reasons for hysterectomy,” notes Wallach, “but we also have newer therapies to potentially control heavy menstrual flows or irregular menstrual bleeding. The first thing we do is evaluate the cause of the bleeding and make sure there isn’t cancer or another underlying cause.”

If fibroids or polyps are causing the bleeding, they can be removed through a hysteroscopic resection, leaving the uterus intact. The hysteroscope, a thin telescopelike device inserted into the cervix to image the inside of the uterus, can be used to remove fibroids without making an incision.

Minimally invasive specialists known as interventional radiologists can perform uterine artery embolization to treat fibroids. Using an arteriogram to visualize selected uterine arteries, the radiologist inserts a catheter through a small incision in the groin into the uterine arteries to inject minute particles of polyvinyl alcohol that block the flow of blood to the fibroids. Once the blood supply has been cut off, the fibroids die and the uterus shrinks.

In the case of a severely enlarged uterus, gynecological surgeons, in the past, generally had no choice but to operate abdominally. Today, there are medications that can put patients in a temporary menopause to shrink the uterus, allowing them to pursue an alternative route to a less invasive hysterectomy.

 Another procedure to control excessive bleeding is endometrial ablation. Not recommended for postmenopausal women or women looking to get pregnant, the procedure obliterates the endometrium through freezing, heating, or even microwave energy/radio frequencies. In most women, endometrial ablation either stops the menstrual flow entirely or reduces it to a normal or lighter flow.

Depending on the cause of the bleeding, some patients can benefit from the insertion of an intrauterine device that releases progesterone. This procedure that can be performed in a gynecologist’s office.

“A hysterectomy is not our first-line treatment,” says Wallach. “Usually, we try other treatments before proceeding with a hysterectomy. There are lots and lots of things in our armamentarium that we would do before taking the uterus out. But if these treatments don’t work—if we can’t embolize or if we can’t control the bleeding with ablation or we can’t alleviate whatever the patient’s symptoms are—that’s when we would bring them to a hysterectomy.”

Traditional Abdominal Hysterectomy
According to Scott W. Biest, MD, an assistant professor in the department of obstetrics and gynecology and director of the division of minimally invasive gynecology at the Washington University School of Medicine in St Louis, approximately 65% of the hysterectomies performed in the United States are traditional abdominal hysterectomies.

The incision on the abdomen required for this surgery can range from 6 to 12 inches. Open abdominal surgeries have the advantage of giving the surgeon a more complete view of the abdominal cavity, and the customary belief has been that the abdominal route is advantageous for procedures involving the removal of the ovaries due to this increased visibility. “For patients that have, for example, a large ovarian mass, and we don’t know whether it’s benign or whether it’s malignant, in general, these are going to have to be removed through a larger incision,” Biest says.

The disadvantages to traditional abdominal hysterectomy are that the incision is painful, the hospital stay can be lengthy (ranging between three to five days), and recovery time is long (an average of four to eight weeks). There are also the typical risks that accompany any surgical procedure, including concerns about blood loss, infection, possible reactions to anesthesia, and injury to surrounding tissues.

Vaginal Hysterectomy
Biest notes that the American Congress of Obstetricians and Gynecologists deems vaginal hysterectomy to be the gold standard because it is considered to be a safer, minimally invasive, and cost-effective approach compared with the traditional abdominal route. In this procedure, the surgeon makes a small incision inside the vagina. The connecting tissues are cut, and the uterus is removed through the vagina.

The advantages of vaginal hysterectomy include less pain, no scarring, a shorter hospital stay, and a quicker recovery time. A disadvantage is that surgeons have less visibility of the uterus and the surrounding tissues, a drawback that has been rectified in recent years by combining vaginal hysterectomy with a laparoscopic approach, allowing surgeons to view the uterus on a monitor or screen while removing it vaginally.

Laparoscopic Hysterectomy
According to Biest, the first laparoscopic hysterectomy was performed in the mid- to late 1980s. As the benefits of other types of laparoscopic surgeries, such as those involving the gall bladder, became apparent, laparoscopic hysterectomies have become more popular over the last 10 to 15 years.

In a typical laparoscopic hysterectomy, small incisions are made on the patient’s abdomen in which miniscule ports are fitted, enabling surgeons to insert a laparoscope, a lighted tubelike instrument with a tiny camera attached. While viewing the inside of the abdomen, the surgeon can either take out the uterus in small pieces (through the ports) or remove it whole through the vagina.

“A lot of times what we can do is take down the structures that would be difficult to reach from a strictly vaginal approach, so we can take them down with the laparoscope,” Wallach says.

There are many variations possible in performing a laparoscopic hysterectomy. One of the newest is known as single-incision laparoscopic surgery in which one incision is made in the patient’s naval. The incision is slightly larger than other laparoscopic incision sites because the instruments have a slight curve, allowing the procedure to be performed without the instruments coming into contact with each other.

“The advantage of the laparoscopic approach is that the patients may recover faster because they don’t have a big incision on the abdomen—the healing is quite painful in an abdominal hysterectomy,” says Wallach. “With laparoscopic, you don’t have the same risk of incisional hardness because it’s a very small scar.”

“Women who are overweight experience less complications [with laparoscopic surgery],” says Biest. “With an incision that’s 1 cm vs. 20 cm, there are night-and-day differences as far as potential problems that can occur with the wound and follow-up and so on.”

Robotic Hysterectomy
Introduced in 1999, the da Vinci robotic surgical system has proven to be a valuable tool during cardiovascular, urologic, and gynecologic procedures. Using refined robotic hand controls attached to laparoscopic ports, a surgeon is able to manipulate the instruments from a console in the same room, lessening the chance of surgical fatigue or tremors.

“The advantage of the robot,” says Wallach, “is that it’s ergonomically much easier for the physician because it has a ‘wrist.’ It’s easier to do surgical procedures with—it’s easier to learn how to throw a suture and tie knots, the normal procedures that we would do. It’s also a 3-D visualization that we’re getting, and it’s anatomically correct, meaning if you move your hand to the right, it moves to the right, and if you move your hand to the left, it moves to the left. When operating laparoscopically without the robot, our hand movements are somewhat opposite, and the instruments that we’re using primarily are what we call ‘straight stick,’ so they don’t have that wrist.”

Minimally Invasive Approaches
When applied to hysterectomies, the term “minimally invasive” means all procedures that do not result in a large abdominal incision. “When I talk about minimally invasive,” says Wallach, “I’m talking about a laparoscopic or robotic hysterectomy. But other minimally invasive procedures would be the hysteroscopy where we go in and resect the fibroid and the uterus stays in place. Anything that is a shorter surgery is potentially safer.”

Despite these safer options, including the vaginal approach alone or combined with laparoscopic surgery, the traditional abdominal route remains the most common. To Biest, this can best be explained by patients’ deep-rooted allegiance to their gynecologists.

“They’ve had a long-standing relationship with their gynecologist and whatever their gynecologist says is best for them,” he says. “They trust them—they’ve delivered Johnny and Sally and Susie, and they’ve taken care of them, in some cases, since they were 18 years old. They’re now 45 years old and have bleeding fibroids, and when their gynecologist says that they need to have an abdominal incision, they don’t even question it. Compare this to if they have a gallbladder attack, they want the best specialist to do the surgery. If they need heart surgery, they want the best heart surgeon. But they don’t ever question their gynecologist because they trust them.”

Another reason for the prevalence of the abdominal approach is a lack of physician training in laparoscopic procedures, says Biest. “The reason why minimally invasive hysterectomy is not performed as often,” he explains, “is that technology has been changing quickly, and many of the physicians that are currently in practice are not comfortable performing the surgery laparoscopically. Most hysterectomies done for benign reasons can be done minimally invasive—rarely would they need to be performed abdominally—and it’s a matter of convincing physicians and also training them and making them feel comfortable in performing the surgeries laparoscopically. Certainly, the outcome of the surgery is identical—we’re removing the uterus—however, it’s a totally different skill that you have to develop by doing it laparoscopically.”

As more insurance companies recognize the cost-effectiveness of minimally invasive gynecologic procedures, there has been a movement toward developing centers of excellence throughout the country, with the idea of promoting medical centers that have refined laparoscopic surgery to a high level.

“The advent of these technologies is allowing us to do things that we never dreamed we would be able to do in a minimally invasive fashion,” says Biest.

— Carolyn Gutierrez is a freelance writer based in New York City.