Advanced Procedure, Advanced Recovery
Women talk to each other, even about personal issues like their hysterectomy. Nearly one-third of all women will have a hysterectomy before they reach age 60 and nobody is looking forward to it.
“Most women tell me they dread the hysterectomy,” says Donald Chamberlain, M.D., the first Chattanooga surgeon to perform robotic hysterectomy. “Afterwards they tell me they should have done it years ago because they feel so much better and that the surgery was so easy.”
By Barbara Bowen
A hysterectomy to remove a woman’s uterus is the second most common surgery among women in the United States. More than 600,000 women will undergo this procedure in the U.S. this year, and at least two-thirds will be done abdominally.
“It is a shame that so many women have an abdominal hysterectomy that opens them up hip to hip and leaves them with a minimum six week recovery, clutching a pillow to their belly for every cough or sneeze when minimally invasive is readily available,” says Del Ashcraft Jr., M.D., an obstetric and gynecology specialist (OBGYN) with Chattanooga Women’s Specialists. “We are changing those statistics right here in Chattanooga due to the commitment of our hospitals and the availability of resources.”
Minimally invasive procedures include robot-assisted laparoscopic hysterectomy, along with vaginal hysterectomy, laparoscopic hysterectomy, and laparoscopic-assisted vaginal hysterectomy. Each offers faster recovery and fewer complications than open abdominal surgery, but the rising star is robot-assisted laparoscopic hysterectomy using the da Vinci® Surgical System.
Approved in 2002 by the Federal Drug Administration, there were nearly 1,400 da Vinci Surgical Systems worldwide in 2009, with 73 percent of those located in the United States. Chattanooga was at the forefront when Parkridge Health System led the way in 2002 with the first da Vinci robot in the area. Now Memorial, Erlanger and Hamilton Medical Center in Dalton, Ga., all offer this state-of-the-science technology.
Enlarged uterus, endometriosis and prolapsed or sagging uterus are among the top conditions that lead to hysterectomy. Chronic pelvic pain, abnormal vaginal bleeding and gynecological cancers are also on the list. Over 90 percent of hysterectomies are done for benign reasons.
A total hysterectomy means the uterus is removed along with the cervix. In a supracervical or partial hysterectomy, part of the uterus is removed but the cervix remains. When one or both of the ovaries is removed this is called an oophorectomy. Surgery to remove the fallopian tubes is called a salpingectomy. A radical hysterectomy includes additional tissue removal, typically for diagnosis and treatment of cancer.
The lesser invasive technique between an open and vaginal surgery is a vaginal surgery in which the uterus is removed through the vagina with no abdominal incisions. With laparoscopic hysterectomy the surgery is done through a series of small abdominal incisions. The uterus is removed in pieces through those openings. Laparoscopic-assisted vaginal hysterectomy uses laparoscopic surgical tools to remove the uterus through the vagina. The abdominal incisions allow the surgeon a view of the uterus and surrounding organs and tissues through a telescopic camera inserted into the abdominal cavity. Once the uterus is detached it is removed through the vagina.
The most advanced, minimally invasive and precise procedure is robotic surgery. With better magnification for identifying cancer cells, significantly less blood loss and shorter recovery time, the patient can get back to work more quickly or can proceed to other treatments, like chemotherapy, in less time. Robotic surgery has been one of the great advancements relating to gynecological cancers.
“Robotic surgery is accepted by leading cancer specialists for uterine, cervical and early ovarian cancers,” says Dr. Chamberlain. “Uterine cancer is the most common pelvic female malignancy. In a comparison between open abdominal and robotic laparoscopic, the open surgery will take three hours with hospital stay for three to five days and back to work in four to six weeks. Robotic is ninety minutes of surgery, an overnight hospital stay and back to work in two weeks.”
Robot-assisted laparoscopic hysterectomy is similar to a laparoscopic hysterectomy, but the surgeon controls a sophisticated robotic system of surgical tools from outside the body while seated at a control console. Using enhanced three-dimensional (3-D) visualization and advanced robotic technology, the surgeon manipulates jointed surgical tools using natural wrist movements while seeing a magnified image through the viewfinder.
“The vast majority of hysterectomies that I perform are done robotically. Robotic-assisted surgery provides a greater degree of freedom and range of motion for surgeons to work in locations that are difficult to reach using traditional laparoscopic surgery,” says Gary Brunvoll, D.O., who performed the first robotic GYN surgery in Tennessee. Dr. Ashcraft adds. “With robotic surgery you can bend the instrument in every direction that you can bend your wrist.”
Robot Eyes and Arms
Robotic-assisted laparoscopic hysterectomy combines common sense with technology. After the patient is stable and secure on the operating table, she is tilted so the head is lower than the feet. This causes the internal organs to shift away from the pelvic region, leaving a larger space and clearer path for the surgeon’s work.
“Carbon dioxide gas is pumped into the abdominal cavity to create a dome of free space in which to work,” says OBGYN Michael Sprague, M.D., of UT Erlanger Women’s Health Specialists.
Three or four surgical tools about the width of a pencil are inserted into the abdomen through small incisions and these become the eyes and hands of the surgeon. One is the camera, providing the high-definition 3D vision through two lenses, the other three are equipped with surgical instruments for manipulating tissue and vessels, snipping organs free, and tying sutures.
“When the surgeon sits at the control console he is looking into the viewfinder, like padded goggles,” Dr. Sprague describes. “The right eye sees images from one camera lens and left eye sees images from the second lens. The optical images combine for the 3D effect.”
With foot pedals almost like a pipe organ, the surgeon can control the camera angle and focus to zoom in and turn corners for a careful look around. After evaluating the structures, the surgeon cauterizes the blood vessels leading to the organs to be removed. “This seals the blood vessels, and it is here that the surgeon can cut with virtually no blood loss,” says Anthony Harbin, M.D., an OBGYN with North Georgia Women’s Center. “For the total operation only a few tablespoons of blood are lost.”
Precise hand-eye coordination allows the surgeon to free the appropriate organs, using morcellation for removal in smaller pieces. The robot eliminates equipment tremors and filters out involuntary human hand movements.
“You have no tactile sensation at the end of the robotic arms,” Dr. Harbin says. “Yet when you use the robotic instruments to touch an organ you can almost feel that pressure as if it is your own hand in there. The mind merges with the technology.”
Robotic surgery has a unique advantage not offered by any other type of surgery. Being seated in a relaxed position at the console allows the surgeon to focus all his or her attention on the details of the operation with minimal fatigue factors, improving the chances for a better outcome.
“Robotics won’t make a bad surgeon a good surgeon,” Dr. Harbin says, “but if you are a good surgeon it can make you better.”
Faster is Better
“The benefit to the patient is directly related to how long they are in surgery,” says Dr. Chamberlain. “When we can shorten the surgery time, the patients do better.”
Dr. Harbin agrees, “The goal is to do the surgery as quickly and safely as possible.”
Robotic hysterectomy patients usually go home within 24 hours. Recovery is faster because there has been less trauma to the body, and healing progresses rapidly. After several days of moving slowly, managing abdominal soreness with minor pain killers and daily naps, patients are encouraged to return to normal activities. Two weeks after surgery, most are ready to go back to work.
Dr. Brunvoll reflects, “The Chattanooga medical community has really embraced robotic surgery as part of its overall health care. It was among the first cities in the U.S. to offer robotic hysterectomies.”
Robotic surgery is overcoming complex medical problems for women. The full impact of robotic surgery is something we can only imagine, as medical experts are already using robotic technology for cardiac, ear/nose/throat, colorectal and hard to discover cancers. Today, a growing cadre of women are able to describe their hysterectomy as “a piece of cake,” and that in itself is amazing.
Barbara Bowen is a Chattanooga resident with a mass communications degree from Middle Tennessee State University. She serves on the PTSA board for Chattanooga School for the Arts and Sciences, and is a member of the Chattanooga Women’s Leadership Institute. Barbara and her husband have four children and four grandchildren.