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Technology makes more options possible for those considering hysterectomies

March 15, 2013|By MARIE GILBERT | marieg@herald-mail.com

For more than six months, Nancy McClain thought her abdominal cramps and low back pain were the result of a bladder infection.

But when the discomfort wouldn't disappear, she headed to her gynecologist, who performed a pelvic ultrasound, revealing a large benign uterine tumor.

McClain, who was 50 at the time, began considering a hysterectomy.

The Hagerstown woman eventually elected to have the surgery, but her decision didn't come easily, she said.

"In fact, I was a bit apprehensive. I remembered my grandmother having a hysterectomy —the big, ugly scar, the months of recuperation — and I wasn't sure I wanted the same experience," McClain said.

But she quickly learned this wasn't her grandmother's hysterectomy.

Instead of a long stay in the hospital, McClain underwent same-day surgery.

Instead of being off work for several months, she was back on the job within a few weeks.

And that scar?

Thanks to medical advances, her incision was so small, it's hardly noticeable, she said.

According to the Centers for Diseace Control, each year, more than 600,000 hysterectomies are performed in the United States, making it the second most common surgery among women, topped only by cesarean section childbirth.

Reasons for having a hysterectomy range from uterine fibroids and endometriosis to cervical or uterine cancer and prolapse, where the uterus, cervix or bladder might be falling through lack of support.

In many cases, a number of conservative alternatives is tried before progressing to the more invasive procedure, said Dr. Jay Greenberg, an OB-GYN with the Mid-Atlantic Women's Health Center in Hagerstown. This might include a dilations and curettage, often referred to as a D&C, endometrial ablation or some type of hormone therapy.

"It is usually after these patients fail at these treatments that they then opt to proceed with surgery," he said.

"Hysterectomy is not an automatic procedure," noted Dr. Christine Molloy with Summit Women's Group in Chambersburg, Pa., an affiliate of Summit Health. "Usually, it is considered the last option after other, less invasive options are offered."

According to Greenberg, hysterectomies can be confusing to some patients.

"Many of them think that we mean removing all female organs," he said. "But the word 'hyster' just refers to the uterus, so hysterectomy means just removing the uterus. One has to specify if they are taking out the tubes and the ovaries, which would be termed a 'salpingo-oophorectomy.'"

In the past, Greenberg said, hysterectomies required open abdominal surgery — a six-inch incision through layers of skin and muscle resulting in a six-week post-operative recovery.

Now, women have alternatives to this procedure.

"More and more (hysterectomies) are done, instead of through large midline incisions, what we call a pfannenstiel incision or what the average person thinks of as a bikini incision," he explained. "This is less painful and provides a stronger repair following surgery."

Even less painful, he added, is laparoscopic hysterectomy, which is done through a series of small incisions with a telescope after inflating the abdomen with carbon dioxide.

"This enables the patient to avoid a large incision and go home sooner with a shorter hospital stay," Greenberg said. "Patients have less pain and recuperate quicker so they go back to work sooner."

Laparoscopic surgery works well for benign procedures like fibroids, endometriosis, a prolapsed uterus and heavy bleeding, he noted. Patients with extensive cancer and large masses might require open surgery.

The latest variation of this is a robotic hysterectomy, he said, where the operation is done laparoscopically but using a robot so that the surgeon doesn't have to stand at the bedside but sits at a remote console controlling the robot.

At Chambersburg Hospital, surgeons can perform robot-assisted hysterectomies with the da Vinci robotic surgical system, said Karlee Brown, Summit Health spokeswoman.

"This surgical advancement enhances the surgeon's skills by providing a higher-definition, 3-D view of tissue and a greater range of motion for more precision and control," she explained.

Surgical advances have resulted in faster and easier recoveries and a reduction in complications, both Greenberg and Molloy said.

"Typically, patients are able to go home after an overnight's stay," Molloy noted. "Usually, they require minimal pain medication because there is much less pain involved in the recovery of a minimally invasive hysterectomy."

Molloy said all surgery has risks, including infection, bleeding and injury in surrounding organs. There also are risks with anesthesia.

"However, in general, today's hysterectomies are safer with faster recoveries," she said.

"In terms of recovery time, we have made great strides," Greenberg said. "When I was a resident 30 years ago, patients generally stayed in the hospital five to seven days. They would have a rather large midline or bikini incision and they would be out of work six to eight weeks. Now, many of my colleagues do this surgery laparoscopically and patients, in many areas, go home the same day. In fact, I recently was watching a friend of mine perform a robotic hysterectomy and by the time we had finished in the afternoon, the first patient of the day had already gone home. This enables the patients to go home so they can be with their families, to have less pain and to get back to work quicker. This all has been dramatically accomplished during the past five to 10 years."

When it comes to complications, Greenberg believes there are fewer problems because of the better training of OB-GYNs in their residencies that includes exposure to newer technologies.

"All of these advanced laparoscopic procedures require more advanced training and there are plenty of places to obtain this throughout the world," he said.

"The views and pictures we get using high-definition monitors for our advanced laparoscopic surgeries enable us to get extremely close-up and detailed views of all structures we are dealing with and that we have to be careful of when we are operating," he said. "This has improved surgical outcome."

Greenberg recommends that women should schedule annual visits to their gynecologist and discuss any problems being experienced, as well the options that are available.

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