MINIMALLY
INVASIVE SURGERY
OVERVIEW – APPROACHES TO SURGERY AND THEIR EVOLUTION
WHAT IS HAPPENING IN OTHER AREAS
OF MEDICINE
MIS is a rapidly advancing concept of surgery
in general. The principal is to approach the same basic concepts of standard
surgical procedures through less invasive ways, especially through endoscopy.
While the laparoscope was first used in gynecology to see what was present
in the deep pelvis and give access to the fallopian tubes for tubal ligation,
this type of endoscopy was greatly expanded by other surgeons. It has
become the standard for dealing with gall bladder disease since 1988.
It is now being used to approach disease of the prostate and kidney in
urology. Diseases of the adrenal gland, spleen, stomach, and bowel can
be considered. If the surgery can be done safely and successfully through
this manner, the degree of trauma can be reduced making it easier for
the body to heal. The magnification of the instrument also is a distinct
advantage since the operating surgeon is "closer" to his/her
work and can be more precise. <
top
LAPAROSCOPIC SUPRACERVICAL HYSTERECTOMY
This approach to hysterectomy began in the early 90s. Supracervical hystectomy,
removing the body of the uterus, but leaving the cervix in place at the
back of the vagina, is an old concept revisited. Up until 1950, this is
the way the majority of hysterectomies were done. Once blood and antibiotics
came in to use, the entire uterus was removed, a total abdominal hysterectomy.
At that time cervical cancer was much more common so it was felt to be
safer removing the cervix. In time their were more vault prolapses seen
following both total abdominal and vaginal hysterectomies. Presently,
there is a greater awareness of the importance of the cervical ring with
its uterosacral and cardinal ligaments that support the apex (top) of
the vagina. Laparoscopic supracervical hysterectomy permits the uterus
to be removed through a morcellator, a tubular cutting device, that removes
the uterus in smaller strips. Her vaginal vault and cervix can be supported
in their natural location. The end result is that the woman does not have
major incisions to heal, but puncture wounds that cause less post operative
pain. Her overall healing time is reduced; she can resume her normal routines
sooner, including going to work, having sex, and driving. Laparoscopic
total hysterectomy can also be performed in this way if it is necessary
to remove the cervix.
Two additional websites to explore for further information on this laparoscopic hysterectomy procedure are www.womenssurgerygroup.com and http://www.drwilsonobgyn.com. < top
LAPAROSCOPIC BLADDER SUSPENSION
The Burch colposuspension is a procedure to suspend the bladder and urethra
to correct stress urinary incontinence. This same prodedure can be done
by a laparoscopic method. It is a procedure that has a significant learning
curve, so has not been done by the majority of gynecological laparoscopist.
It is often done along with a PARAVAGINAL REPAIR, where the sides of the
vagina have become disconnected from the pelvic side wall and need to
be reattached to better support the bladder. <
top
LAPAROSCOPIC VAGINAL VAULT SUSPENSION
The support of the apex of the vagina can be resecured through the laparoscopic
approach. The principals of the surgery are the same as in the open, abdominal
approach. The break in the support from the uterosacral ligaments are
reconnected to the anterior and posterior vagina. Often an enterocele,
a type of peritoneal hernia sack, exists between the separated leaves
of the vagina and can be removed. <
top
LAPAROSCOPIC FIBROID REMOVAL
Removing fibroids through the laparoscope in selected circumstances is
very satisfying to the woman and her pelvic surgeon. Principally, her
recovery is shorter and she experiences less pain. However, if she plans
on further pregnancy, this choice might not be the best approach. It has
been more difficult to obtain a secure closure of the fibroid bed laparoscopically.
With increased experience and newer suturing techniques, this may change.
<
top
LAPAROSCOPIC STERILIZATION
The laparoscopic approach to tubal closure has been well established over
the past thirty years. For a long time it was one of its main indications.
Before that it was difficult to access the woman’s tubes surgically
except right after giving birth. Bipolar cauterization of the tube via
the laparoscope has long been used. A newer clip device has evolved out
of the experience of the Canadians and the French. <
top
HYSTEROSCOPIC FIBROID REMOVAL
Removing fibroids that grow to the inside of the uterine cavity can be
accomplished with an operative hysteroscope with a electrical loop device
to cut through the fibroid and remove it in smaller pieces. This same
method is used to remove endometrial polyps. <
top
HYSTEROSCOPIC ENDOMETRIAL ABLATION
A cautery device can be attached to the hysteroscope so that the lining
of the uterus can be heated destroying the surface cells that generate
the monthly lining of the uterus. This technique is used to treat some
forms of excessive uterine bleeding. Some women do not have periods after
this treatment, but the majority do. There are several newer, second generation
techniques used to accomplish this destruction of the lining of the uterus
that have just recently become available. <
top
TVT BLADDER SUSPENSION
The placement of a tension-free tape (TVT) under the mid-urethra in an
outpatient surgical setting is revolutionizing incontinence surgery. While
there are reservations about its long term results because of its limited
history, the procedure seems sound. It has been compared to the laparoscopic
Burch urethral suspension at the Cleveland Clinic by Dr. Mark Walters,
a leading Urogynecologist. Their data show comparable outcomes. <
top
OFFICE CERVICAL LEEP PROCEDURE
For years woman with significantly abnormal Pap smears had to be taken
to the operating to have a "cold knife" cervical cone biopsy
under anesthesia. For the past ten years, that procedure is infrequently
necessary. An office LEEP procedure can be performed under local anesthesia
in virtually seconds. This loop electrical excision procedure (LEEP) has
greatly simplified a common need. <
top
OFFICE ENDOMETRIAL ABLATION and OFFICE STERILIZATION
These are two newer procedures that have the potential
to migrate safely from the day surgery operating room to the office. There
are several new, second generation forms of endometrial ablation (see
above) that will lend themselves to office practice. The new form of tubal
ligation, which is a plug device (Essure), inserted with a hysteroscope
into the opening of each tube via the uterine cavity has just been approved
by the FDA (http://www.fda.gov/cdrh/pdf/p010013.html).
< top