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SEPTEMBER 27, 2004
Women's Surgery: Less Of An Ordeal Laparoscopy can cut recovery times, but you may have to ask for it If you need your gallbladder removed, most likely it will be done laparoscopically -- through tiny incisions using a miniature video camera and special surgical instruments. Same is true for a gastric bypass if you want to lose weight, as well as other operations that once required slicing open the abdomen. Now, this minimally invasive technique is transforming women's surgery, as it moves from simple procedures such as tubal ligations to hysterectomies and removal of fibroid tumors. But, as is often the case in medicine, to benefit from this advance you often have to know enough to ask for it. Since many gynecologists are not trained to perform the more difficult laparoscopic operations, they are apt to recommend traditional open-abdominal surgeries, says Dr. Franklin Loffer, medical director at the American Association of Gynecologic Laparoscopists. Only about 10% of the approximately 650,000 hysterectomies performed each year are done laparoscopically. Perhaps 5% to 10% of all myomectomies to remove benign uterine fibroids are handled this way. On the other hand, 85% of all gallbladders are taken out laparoscopically, and, in women, laparoscopy is used in most surgeries to excise ovarian cysts or endometrial tissue that grows outside the uterus. Not all patients are good candidates for laparoscopic surgery. Anyone who can't tolerate general anesthesia may have to opt for open surgery, since doctors can use an epidural to numb just the lower body. Laparoscopy is generally performed while the patient is completely under. Ovarian cancer patients usually should have an open operation to let the surgeon evaluate the cancer and remove adjoining tissue. And many surgeons will turn away a woman with a large uterus or very big or numerous fibroids. SAVING MONEY For others, however, a laparoscopic hysterectomy can mean the difference between three or four half-inch or smaller incisions and a 6-to-12-inch gash in the belly. Recovery time is one to three weeks vs. up to six weeks for an abdominal hysterectomy. Many patients don't even need an overnight hospital stay. That can make the overall cost of a laparoscopic hysterectomy comparable to that of an open procedure, which typically runs around $6,000 and requires a two-to-three-night hospital stay. Also, several studies have shown that the less-invasive surgery is not so likely to result in internal adhesions that can bind organs and create painful bowel obstructions. Dr. Hallie Bell, a neurologist, was concerned about recovery time and adhesions when she needed a hysterectomy last year. Then living in Destin, Fla., she searched until she found an Atlanta surgeon willing to do it laparoscopically. He was Dr. Ceana Nezhat, one of three brothers who are leaders in the field. Using an experienced surgeon is important. A British study published earlier this year in the online edition of BMJ (formerly the British Medical Journal) reported more frequent complications such as hemmorhage and blood clots after laparoscopic surgery. Even proponents say such complications can be a problem in inexperienced hands and that if a novice is doing the procedure, the patient will probably spend more time on the operating table than the typical one to four hours. A patient should ask not just how many -- but what type -- of laparoscopic surgeries the doctor has performed, advises Dr. Elena Yanushpolsky, director of reproductive surgery at Brigham & Women's Hospital, the teaching hospital for Harvard Medical School. A study published this May in the Journal of the American Association of Gynecologic Laparoscopists reported a learning curve of about 80 surgeries for one type of laparoscopically assisted hysterectomy. Meanwhile, there are other options to avoid the knife. Fibroids can be killed by injecting polyvinyl particles to block their blood supply. The procedure, called uterine artery embolization (UAE), is not recommended for women who may want to become pregnant or whose fibroids hang by only a stalk. GENTLY, GENTLY A uterus can can be removed vaginally -- although laparoscopy is sometimes used to assist in such surgeries. On a recent morning, Nezhat performed a hysterectomy on a 49-year-old woman in an operating room at Atlanta's Northside Hospital. He made three small incisions and inserted laparoscopic tools to cut loose her uterus. He then took it out through her vagina. The laparoscopic part of the procedure allowed him to see what he was doing and to cut away adhesions and endometrial tissue. The important thing for patients is to study the alternatives, says Nezhat. "That way, you have less chance of regret." Bell is glad she did her homework. When her surgery was over, Nezhat told her he found five adhesions tying her intestines to her abdominal wall -- legacies from surgery for an old automobile accident, as well as a C-section. Had a surgeon performed an open hysterectomy, he might have cut through her bowel -- a serious complication that would have meant, at best, a lengthy hospital stay. Instead, a month later, she started a new job in Mississippi.  By Carol Marie Cropper
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