A Dramatic Alternative
to Abdominal Hysterectomy
Sherry Figueredo, despite
experiencing debilitating pain and heavy bleeding from fibroids and
endometriosis each month during her period, had avoided having a
hysterectomy for several years because of the nightmare of a six to eight
week recuperation and concern over the potential for sexual problems
post-operatively. The mother of three at the time was manager of national
accounts for Delta Air Lines' Meeting Network, and had to be "on" at all
times during trade shows and group presentations to customers.
"I envisioned being unable to
carry on--with no one to help me, since the kids are grown and out of the
house," she said. "Despite having to deal with the pain using occasional
medication, heating pads and hot baths, for years I could not bring myself
to schedule this debilitating operation."
Like many women, Ms. Figueredo
was unaware that there are alternatives to total abdominal hysterectomy.
"No previous gynecologists or surgeons had suggested laparoscopic surgery,
even though this was a long-term problem. All they talked about was
surgery performed the old way, with scalpels," she said.
New Procedure Aids
Resumption of Sexual Activity, Documented by 30-Year Finnish Study
As the originator of a new laser
procedure which leaves the woman's cervix intact, called supracervical
laparoscopic hysterectomy, I feel that less is more in surgery. The cervix
is a supportive structure to the female anatomy, something of a
'keystone,' so I feel that there are many more positives to this approach
than even the laparoscopically assisted vaginal hysterectomy. The woman
experiences significantly less discomfort and an even quicker
recovery--she's leaving outpatient surgery after 18 hours. She can resume
normal activity within two days and sexual intercourse within two weeks,
compared to a six to eight week resumption with abdominal hysterectomy.
Within the first week after
surgery Sherry Figueredo walked a mile. She was back at work two weeks to
the day after the surgery was performed, and back at the athletic club
doing Nautilus, Stairmaster and playing tennis within a month.
My philosophy is to perform the
procedure only when absolutely necessary, and to make it as minimally
invasive as possible. A study conducted in Finland by Pentti Kilkku, M.D.,
and other physicians between 1950 and 1980 determined that the reduction
in orgasm and problems with sexual function after total abdominal
hysterectomy as compared to supracervical hysterectomy appears to result
from the greater radicality of the former.
With total abdominal
hysterectomy, the vagina and cervix are damaged more than in supracervical
hysterectomy, and scar tissue often forms in the vagina. It is probable
that these physical changes and subconscious psychological reactions due
to total removal of the uterus explain why supracervical hysterectomy
yields more satisfactory sexual response than total abdominal
hysterectomy. In the study, preoperatively 76% of the patients were
orgasmic, and six months after surgery 78% were orgasmic.
As another patient Venita Dobbs
said, "If I didn't know that my uterus had been removed, I wouldn't know
the difference. It's like a modern day miracle to me."
Hysterectomy, surgical removal
of the uterus, is one of the most commonly performed procedures in the
United States--some say too common. Each year, some 650,000 women
nationwide undergo hysterectomy for abnormal uterine bleeding, fibroids
(benign uterine tumors), chronic pelvic inflammatory disease,
endometriosis and uterine or ovarian cancer. Abdominal hysterectomy
typically requires women to spend four to six days in the hospital and and
four to six weeks recuperating at home. Supracervical laparoscopic
hysterectomy is performed as an outpatient surgery, which means most
patients can go home the same day. Until about four years ago, 75 per cent
of all hysterectomies were performed through an incision in the abdomen.
In the remaining cases, the uterus was removed through an incision in the
vagina, a procedure that also carried a two-to-three day hospital stay and
Both procedures have drawbacks,
according to gynecologic surgeons. The abdominal approach requires a
four-to-six inch incision and results in considerable postoperative pain,
a lengthy recuperation and a visible scar. Vaginal hysterectomy is not
possible if the patient's ovaries must be removed, if the patient has had
previous pelvic surgery or if the surgeon must treat related disorders
near the uterus.
The new procedure was developed
in response to the problems we saw surgeons experience while learning
laparoscopically assisted vaginal hysterectomy. I looked for a procedure
that would cause less trauma to the patient, and adapted supracervical
hysterectomy to the laparoscopic approach. With the pelvic floor still
intact, support mechanisms are in place as a further deterrent to urinary
stress incontinence later on.
The surgery takes place under
general anesthesia, so the patient is unconscious throughout the
procedure. Using a trocar (a narrow, tube-like instrument), the surgeon
gains access to the abdomen through the navel. A laparoscope (tiny
telescope) connected to a camera is inserted through the trocar, allowing
the surgeon to view a magnified image of the patient's internal organs on
a video monitor. This enables the surgeon to perform the hysterectomy as
well as to diagnose and treat related conditions at the same time. The
laparoscope allows the surgeon to see small areas of endometriosis (a
painful disease in which tissue of the uterine lining occurs outside the
uterus) as well as check the gallbladder and liver for possible disease.
Two or three additional trocars
are inserted to accomodate special instruments, including lasers and other
minimally invasive devices which detach the uterus. After the uterus is
detached, it is removed through the navel. Tubes and ovaries can also be
removed with the laser, if necessary. Because the laser cauterizes during
the surgery, blood loss is generally 50 cubic centimeters or less. Even a
patient with a large uterus may be a good candidate for the procedure.
Laparoscopy was pioneered by
gynecologists in the early 1960s, and has been widely used in a range of
procedures, including tubal ligation, the removal of ovaries and fibroids
and the treatment of tubal pregnancies. Laparoscopy is also used for
gallbladder removal, appendectomy, hernia repair and lung and bowel
surgery. In one of the newest applications, also developed by our group,
it is being used to repair the bladder to treat urinary stress
hysterectomy requires more skill than abdominal hysterectomy because
you're operating through a camera. Technically, it is a more difficult
Patients should choose a surgeon
who is experienced in working with lasers and laparoscopy, and should be
presented all of the available medical options for relief of their pain
and/or bleeding, in addition to surgical alternatives.
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