by Tina D. Fries
Abnormal bleeding. Uterine Fibroids. Pelvic pain disorder. Endometriosis. These are some of the most common reasons more than 600,000 total abdominal hysterectomies are performed on women each year in the United States, making hysterectomy one of the most commonly performed surgical procedures.
By age 60, one in three women will have undergone the procedure, with 65% of them having both uterus and cervix removed, with or without ovaries or fallopian tubes, in the most invasive way: through a 4-8 inch abdominal incision requiring an extended hospital stay and a 4-6 week recovery time.
But there are alternatives to total abdominal hysterectomy. Vaginal hysterectomy — with or without the assistance of a laparoscope — is performed by removing the uterus through an incision in the vagina, requiring a 2-day hospital stay and 4-week recovery period.
Since 2001, Surgeons Jon L. Crockford, M.D., and C. Dwight Groves, M.D. of The Group For Women, a Division of Mid-Atlantic Women’s Care, PLC, have been teaming up to bring a third, minimally invasive alternative called laparoscopic supracervical hysterectomy (LSH) to women in Hampton Roads. Laparoscopic supracervical hysterectomy is performed by making three half-inch long incisions in the patient’s abdomen through which the upper two thirds of the uterus is removed. The bottom third of the uterus — the cervix — is left in place and therefore no incision is made in the vagina.
While not an appropriate option for women with malignancies, LSH offers a number of benefits for the patient with benign disease including a short, one night or less hospital stay, significantly shorter recovery time of 7-14 days, less scarring, less risk of injury to surrounding organs, fewer post-surgicalncomplications such as infection, better long-term support of the top of the vagina and maintenance of sexual health, including earlier resumption of sexual activity. “With this procedure, we’re not seeing the GI complications or the infection complications,” said Dr. Groves. “We don’t have the wound problems we had before. For obese patients this may actually be better than the other options.”
Equipment Advances Increase Safety
LSH uses specialized equipment including a laparoscope, a thin lighted endoscope connected to a camera that allows the surgeon to see the patient’s organs on a monitor, a harmonic scalpel for cutting and a uterine morcellator with a thin rotating barrel that removes the organs in tiny pieces through a long, cylindrical tube.
“Given recent advancements in technology and new instruments on the market we are able to accomplish a large operation inside the body through small, minimal incisions,” said Dr. Crockford. “We now have the technology to do this procedure safely and quickly.”
Both physicians affirm that wasn’t always the case, given the equipment of yesteryear. “It was dangerous when they first started doing laparoscopy in the 1950s,” said Dr. Groves. “Getting the initial point of entry used to be the most dangerous part of the surgery and they used monopolar electricity which resulted in burns.”
But with advances in equipment and technique, incandescent lights gave way to fiberoptics, blades for entry were set aside in favor of blunt, clear-tipped trocars, and air pumps were replaced with computerized equipment to monitor the precise amount of air being injected.
“We used to put our eye to the eyepiece and now we have a camera and digital images so it’s actually better than the naked eye,” said Dr. Crockford.
Unique Learning Curve
Dr. Crockford and Dr. Groves trained in LSH at Florida Hospital Celebration Health in Orlando under the medical direction of Steven McCarus, M.D., nationally recognized for laparoscopic surgical expertise.
“The learning curve with this procedure is a little different,” explained Dr. Groves, who earned his medical degree from Marshall University in Huntington, West Virginia and completed both internship and residency with Eastern Virginia Medical School. He practiced with The Group for Women early in his career and returned in 2000 to log a total of 12 years there.
“Normally with surgery things are very tactile, but this is a very visual thing, very remote,” he said, zeroing in on one of the major challenges physicians face in using robotic techniques. “We’re outside of the body so we have to work with visual cues without the benefit of the sense of touch.”
Dr. Crockford earned his medical degree from the University of Virginia and completed both internship and residency in obstetrics and gynecology at Barnes Hospital, Washington University School of Medicine in St. Louis, Missouri. He has been practicing with The Group for Women for 26 years.
Since completing their training in LSH, Dr. Crockford and Dr. Groves have performed 270 of these procedures with consistently positive outcomes and an estimated one percent conversion rate to abdominal hysterectomy. They perform an average of 2-5 per week, the vast majority of them at Sentara Leigh Hospital. While national averages indicate that 65% of women continue to have traditional abdominal hysterectomy, the frequency and demand for LSH at Sentara Leigh Hospital during 2003 actually reduced this figure to 45%.
To aid physicians like Dr. Crockford and Dr. Groves in their work, Sentara Leigh Hospital is in the process of developing a state-of-the-art operating room equipped for advanced laparoscopic procedures with voice-activated robotics.
Do No Harm
Leaving the cervix unharmed has many benefits for the patient. The cervix provides key support to the upper vagina. The uterosacral ligaments attach the vagina to the spine via the cervix and with LSH these supports are left intact. “What we’re doing with this surgery is we are saving the cervix,” said Dr. Groves. “The first rule of medicine is ‘do no harm’ and I think that applies very nicely here. With the availability of regular pap smears to screen for cervical cancer, there’s no reason to remove a healthy cervix. If it’s diseased, by all means take it out. But why increase infection rate, bleeding and the possibility of complications unnecessarily?”
One of the primary complications following total abdominal hysterectomy is posthysterectomy vaginal vault prolapse which results from not maintaining support to the top of the vagina.
“LSH preserves the pelvic floor so we’ll see fewer complications and less need for corrective surgery down the road by maintaining the cervix than we would by taking it out,” said Dr. Crockford.
Benefits for the Patient
By minimizing pain and trauma to the body, LSH provides significant benefits for the patient. The procedure reduces pain, minimizes scarring and significantly shortens recovery time. The patient can be home within 24 hours and back to their normal activities in just 1-2 weeks.
Kathryn Hall, 46, a patient of Dr. Crockford’s, elected to have the procedure in 2002 for severe uterine fibroids when she learned the recovery time with regular hysterectomy would require 4-6 weeks of missed work.
A regional manager with Landmark Property Services, Hall said, “I’m a work-aholic. The number one reason I chose the surgery was they told me I could be back to work in a week. My employer didn’t believe me at first.”
“The next day after surgery our patients are up and dressed, eating their breakfast and waiting on us,” said Dr. Crockford. “This procedure has fewer complications and patients are back living their lives sooner and they’re loving it.” “It was the most amazing thing,” said Hall. “I was stunned at how well I did and how easy the surgery was. I stayed in the hospital one night and when I came home I took Ibuprofen one time. You’re sore and you have a little bit of a problem getting up and down, but you don’t feel pain.”
The Bottom Line
Hall said in conducting Internet research prior to surgery she learned that LSH is somewhat more costly to perform than traditional hysterectomy because of the technology and equipment investment.
“It is more expensive,” said Dr. Crockford. “But we have to look at the long run and gross national product. These women are back to work 4-5 weeks sooner and that’s got to have a tremendous economic impact. Not to mention, how do you put a dollar figure on the overall impact of recovery time on their families?” Hall expressed concern that many women, despite being better educated health care consumers via the Internet, don’t seem to know about LSH.
“I know someone who had a regular hysterectomy and I was telling her about laparascopic and she had no idea what I was talking about,” said Hall. “She had never heard of it. This is an option for women and I believe physicians should learn about it and offer it to their patients.”
Physician Awareness and Training
Research presented in the Journal of Obstetrics and Gynecology last year suggests that few OB/GYN physicians in our region of the country discuss laparoscopic alternatives to total abdominal hysterectomy with their patients. In an effort to change that, Dr. Crockford and Dr. Groves serve as consultants for Ethicon, Inc. and GYNECARE, subsidiaries of Johnson and Johnson Company who manufacture minimally invasive equipment used in the procedure.
They offer half-day to full-day training sessions for physicians every 2-3 months at Sentara Leigh Hospital. The sessions involve viewing a live surgery with twoway audio-visual feed so they can discuss techniques with their colleagues during surgery.
“We’re happy to share. We’re trying to get people trained,” said Dr. Groves. “Gynecologists are slowly coming on board. I never thought we’d have a professional relationship with a surgical equipment company, “ he added. “But we really feel passionate about this.”