How is Advanced Laparoscopic Surgery from Standard Laparoscopic Surgery?
Advanced Laparoscopic Surgery is a new development in the field of minimally invasive surgery for women. Now, almost every patient with a gynecologic problem, including cancer, can avoid open surgery.
Under the direction of a surgeon who has received extensive training in advanced laparoscopic techniques, open surgery can be avoided completely. Advanced Laparoscopic Surgery can be effective for women with complex conditions or who have been denied access to minimally invasive solutions in the past.
Unlike standard laparoscopic or robot-assisted surgery, Advanced Laparoscopic Surgery can be used for:
• Very large fibroids or masses
• Extremely overweight patients
• Patients with multiple prior surgeries, including C-sections or prior gynecologic treatments
• Patients who have possible malignancies
This medical breakthrough in treatment technology means that women with almost any gynecologic condition don’t have to suffer any longer. In the past, many women have chosen to put up with constant discomfort, painful and/or heavy periods, or embarrassing incontinence just to avoid open surgery, and who can blame them? Having to miss several weeks of work or find someone to care for your children was an enormous obstacle.
Laparoscopic Retroperitoneal Hysterectomy compared to Standard Laparoscopic Hysterectomy
| Laparoscopic Retroperitoneal Hysterectomy - WSC | Laparoscopic Standard Hysterectomy – OB/GYN | |
|---|---|---|
| Discharge Home | 80% same day | 20% or less same day |
| Recovery Time | 2 weeks or less | 2 to 4 weeks |
| Incision size – small to moderate size uterus | 3 – ¼ inch | 3 to 4 incisions, range from ¼ to ¾ inch |
| Incision size – large uterus | 4 – ¼ inch | 3 to 4 incisions, range from ¼ to ¾ inch or conversion to open with standard open incision. Success of procedure dependent on surgeon skill level. |
| Incision size - massive | 3– ¼ inch, 1 – 1 – 2 inch | Conversion to open with standard open incision |
| Pain Tolerance | Excellent to good, with mild to mod pain first 2 days. Pain dependent on incision size | Excellent to fair, with pain dependent on incision size. Larger incisions = more pain |
| Fibroid Size | Unlimited | Limited – success rates decrease dramatically with increasing uterine size |
| Blood Control | Very good to excellent – all sizes | Very good to poor with increasing blood loss with increasing uterine size |
| Complications | Extremely low to include bladder, ureter, blood loss | Increasing complications with increasing uterine size and limited surgeon skill. Ureteral and bladder injury can be significant, blood loss increasing with increasing uterine size and limited surgeon skill. |
| Procedure Time | 30 minutes to 1.5 hours | 1 to 4 hours, depending on uterine size and surgeon skill level |
So why don’t all patients undergo advanced laparoscopic surgery instead of open procedures?
Very few gynecologic surgeons have received the proper training and exposure to perform advanced laparoscopic surgery successfully. The key to advanced laparoscopy is application of a technique called “retroperitoneal dissection,” or RP for short. RP is refers to evaluation of the retroperitoneal space – the space underneath the lining of the body – which contains the blood vessels, lymph nodes, and ureter. Dissection of this space allows the surgeon to identify these structures and clamp specific arteries and veins as needed so the surgery can be performed successfully and with minimal blood loss. RP also allows isolation of the ureter – the tube that connects the kidney to the bladder for the flow of urine. The ureter is very close to the vessels, the ovaries, and the uterus, and is often involved with endometriosis, large fibroids and masses, and with malignancy. The ability to identify and isolate the ureter allows many procedures that could only be performed open to now be done safely with laparoscopy. Lymph node dissections can also be performed with dissection of the RP space, thereby allowing patients with cancer to be treated with laparoscopy. Since advanced training in pelvic surgery or gynecologic oncology is usually needed to enter the retroperitoneal space safely, very few gynecologists have mastered this technique. Even fewer have applied these techniques laparoscopically. This is the reason advanced laparoscopic surgery is not offered as an alternative to patients.
By far, surgeon preference for open procedures is the main reason advanced laparoscopy is not more widely practiced. Open procedures take less time and are easier to perform. Advanced laparoscopic techniques are much more difficult to learn, and are not practiced by most gynecologists during their training programs. As a result, most GYN surgeons have very little exposure to dissection of the retroperitoneal space, and are not comfortable applying these techniques in surgery. Realize that surgeons are like everyone else – they are not comfortable doing something they are unfamiliar with – and many have a bias against laparoscopic procedures for this reason. As a patient, you need to ensure that your physician discusses with you all the options available, including laparoscopic surgery and the potential need for retroperitoneal dissection. If you feel you have not obtained all the facts from your physician, always consider a second opinion. Seek the advice of a well trained laparoscopic surgeon, such as a GYN Oncologist trained in laparoscopic techniques. It is also important to understand that a large number of procedures scheduled as laparoscopy are not completed that way, with the surgeon performing the procedure open after an “attempt” was made laparoscopically. As important as the surgeon’s experience is his or her success rate at completion of the procedure laparoscopically. Conversion of a laparoscopic procedure to an open one requires more time and leaves the patient with all the disadvantages of open surgery, including increased pain, hospital stay, blood loss, and far greater recovery time.