Single Site Hysterectomy

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Computerized robotic arms are turning this common surgery into a much easier process. (KFSN)

It used to be that hysterectomies involved a major incision and weeks of recovery. But that has changed in a big way. Now, computerized robotic arms are turning this common surgery into a much easier process. Martha O'Neil needed a full hysterectomy, but was back on her feet just days after the surgery thanks to a new procedure called single site hysterectomy.

Nancy Rector-Finney, MD, Four Seasons OB/GYN in San Antonio told Ivanhoe, "It's revolutionized hysterectomies."

"It" is a robot called da Vinci and it can assist a doctor performing a hysterectomy through a four centimeter incision in the belly button. The single site in the belly button is the entry port for the tiny robotic arms that do the intricate cuts and sutures doctors once did internally through a large incision across the abdomen.

"We separate all the structures that are holding it in place, and the blood supply, and then we cut it. This way we're able to do the whole hysterectomy through that two centimeter incision. It's pretty incredible," Dr. Rector-Finney explained. The procedure has many benefits, like less chance of infection and a much quicker recovery time. However, single site doesn't work for every woman.

Dr. Rector-Finney told Ivanhoe, "You have to have a uterus a certain size and you have to make sure there's not a lot of scar tissue from previous surgeries, because you're limited on how the instruments can be used in order to get the uterus out."

Another big benefit of single site is virtually no scarring. O'Neil explained, "It looks like an eyelash scar. You can barely even see the scar." A surgery that used to be so involved is now getting women back to their busy lives in no time at all.

Doctors say the average patient can usually go back to work in just a couple of weeks after the procedure, and the amount of pain medication needed is much less than previous methods required. It is considered an out-patient surgery.

Single Site Hysterectomy -- Research Summary

BACKGROUND: A hysterectomy is a surgical way to remove a woman's uterus. It is the most common type of surgery for women in the US with an estimated 600,000 performed every year. During a hysterectomy procedure, the entire uterus is removed, preventing any future pregnancies. Depending on the reason for the surgery, ovaries or fallopian tubes are also removed; however, most doctors are not able to tell if the reproductive system is abnormal until the surgery has begun. There are three types of ways a hysterectomy can be done: vaginally, abdominally, or laparoscopically. The reason for surgery usually determines the type of entry the doctor will take during the procedure. (Source: http://www.acog.org/Patients/FAQs/Hysterectomy, http://my.clevelandclinic.org/ccf/media/files/Florida/Gynecology/16-hysterectomy.pdf).

COMMON REASONS FOR SURGERY: Though some women choose to have elective hysterectomies, there are several medical reasons for a woman to undergo the procedure:
Uterine Fibroids: Also called leiomyomas, these growths are the most common reason for hysterectomy surgery. The tumors are benign but can cause bleeding and severe pain in the uterus.
Cancer: In some cases of cervical, uterine or ovarian cancer, a hysterectomy can assist radiation and chemotherapy in the treatment of the cancer. In addition, some women who are at risk for cancer elect to have the surgery to prevent cancer.

Endometriosis: This condition occurs when the lining that is normally found in the uterus is found on the outside, usually on the ovaries or fallopian tubes. It can be a very painful ailment for women, especially between periods. (Sources: http://my.clevelandclinic.org/health/treatments_and_procedures/hic_What_You_Need_to_Know_About_Hysterectomy, http://womenshealth.gov/publications/our-publications/fact-sheet/hysterectomy.html).

NEW TECHNOLOGY: In 2013, studies found that the least used entry method for hysterectomies was abdominally. Doctors found this approach to be too costly, invasive and it had the highest risk of complications after surgery. The laparoscopic approach is the most favored by doctors due to its less invasive approach, using robotic assistance. A high-tech machine called da Vinci has made it easier for doctors to perform hysterectomies. This machine, guided by a doctor, goes through a single site in the bellybutton which is the entry port for the robot to perform the hysterectomy. This incision is about two centimeters long and doctors are able to perform hysterectomies with less chance of infection, and patients can go home the same day. With many traditional hysterectomies there are three or four abdominal incisions and patients have a much longer recovery period.

(Sources: Nancy Rector-Finney, MD, http://www.acssurgerynews.com/home/article/advancements-in-robotic-hysterectomy/2d138bdf295a453b2d8f17b5c769097c.html)

FOR MORE INFORMATION ON THIS REPORT, PLEASE CONTACT:
Greg Wilson
210-827-9640
Greg.wilson@intusurg.com

Single Site Hysterectomy -- Doctor's In-depth Interview
Nancy Rector-Finney, M.D., F.A.C.O.G of Four Seasons OBGYN in San Antonio, Texas talks about the new single site hysterectomy.
Interview conducted by Ivanhoe Broadcast News in June 2015.


The single site hysterectomy, this is a huge change.
Dr. Rector-Finney: It's huge, it's revolutionized hysterectomies. When I trained we started out doing abdominal hysterectomies and vaginal hysterectomies, that's what I learned. When I got out in practice I realized that a lot of hysterectomies were being done laparoscopically. We transitioned to laparoscopic assisted vaginal hysterectomies which were great except, we had to stop at the cervix because we didn't have good suturing capabilities. We couldn't take out the cervix. We couldn't take out the whole uterus because we couldn't suture up the top of the vagina. Once the robot came about, it made a huge difference because we had so much articulation with our hands. We could start to suture the top of the vagina and take everything out which was wonderful. Patients who had problems with dysplasia, precancerous cells of the cervix, pain or the uteruses were really large - we could then take them out through the vagina. We didn't have to open the abdomen. The recovery time was a lot better.

I bet it is a big deal for recovery time. Many years ago my mother had a hysterectomy.
Dr. Rector-Finney: If you talk to patient's mothers, that's how they had their hysterectomy done. They remember being out of work six to eight weeks. Now, with the laparoscopic and robot assisted hysterectomies patients are out of work two weeks. They go home the same day. They're on pain medication that they can take by mouth which was unheard of with their mothers. They had to use a PCA pump for four or five days before they could go home.

Explain how the single site works.

Dr. Rector-Finney: Once the robot came about and we were able to do the hysterectomy using the robot. We made three to four incisions, tiny little incisions in the patient's abdomen, which was a great way to do it. I still do a lot of my hysterectomies that way if the uterus isn't really large. The problem is cosmesis. Everyone is worried about what it looks like. Luckily we were able to shrink down the area that we need to operate to a small hole. We make a small incision in the abdomen, in the belly button, about two centimeters large. We put a port right in that incision and put all of our instruments right in that little hole. We're able to do a whole hysterectomy through that two centimeter incision. It's pretty incredible.
How are you seeing it?
Dr. Rector-Finney: We're seeing it the same way. We have our instruments that we use to take out the uterus, and the camera, all in that one little hole. It's incredible because we can get the whole uterus out through that little hole. The patient has this tiny little incision in her belly button that she will have as a lasting remembrance of her hysterectomy.
Which is not something you want to see anyway.
Dr. Rector-Finney: No.
Having a smaller incision lessens the chance of infection, doesn't it?

Dr. Rector-Finney: That's exactly right. If you only have one site we can make sure that it's closed properly so we can reduce the risk of hernias and problems with infection. The recovery time is so much quicker than if they had a normal robotic hysterectomy.

How many of your patients opt for this?

Dr. Rector-Finney: This is pretty new so I think the more patients that we can offer it the more they'll go, "That's sounds pretty good". The majority of my patients that I can do the single site on opt for it because how wonderful to just have one incision to heal from. But it's not for everybody. You have to have a uterus that's a certain size. You have to make sure that there's not a lot of scar tissue from previous surgeries because you're limited on how the instruments can be used in order to get the uterus out. You have to be selective as to which patients can do it this way.

Who's the prime candidate then?

Dr. Rector-Finney: The prime candidates are women who would be concerned about the cosmetic look. Your thin patients, the patients that have fairly small uteruses, or uteri, are much better candidates than someone who's really large, has a pendulous stomach or has lots of previous surgeries. Those are all candidates that would make it difficult to get it out through a single site. You really do need the added areas of extra trocar sites in the belly button to do a robotic hysterectomy, the regular, the multiport way.

So you're going to go in through this one port, you're going to cut each of the fallopian tubes and then you're going to cut at the bottom of the uterus at the top of the vaginal canal?

Dr. Rector-Finney: That's right. With all of the robotic hysterectomies we take out the uterus, separate all of the structures that are holding it in place and the blood supply. Then we cut the uterus out above the level of the cervix. We take it all out through the vagina. It's like having a vaginal hysterectomy but the nice thing about it is you have much better support of the vaginal cuff, or the top of the vagina, than you would have if we had to do a traditional vaginal hysterectomy.

Because of the sutures?

Dr. Rector-Finney: Because of the sutures, right. Plus we take so little of the vagina off. We give the patient as long a vagina as possible because of how we take the uterus off. It makes it nice.

And do the fallopian tubes just stay in the body?

Dr. Rector-Finney: I like to take all the fallopian tubes because there's been new studies that have shown ovarian cancer starts in the fallopian tubes. There's no need to have the fallopian tubes after you have the hysterectomy. They're only going to cause you problems. They may get filled with fluid or they may get infected, lots of different things. I'll take the fallopian tubes with the uterus and leave the ovaries. The ovaries are fine with it - They don't care, they still work.

Is there anything else that we didn't mention?

Dr. Rector-Finney: It's really a great surgery because patients are going back to work a lot faster. They have very little requirement of pain medication which is really nice. I think the only problem we have with it is patients feel so good after they have their hysterectomy that they start doing things too much and too fast. They will start working with their kids and doing all the things that they normally do as moms and go back to work really fast. Then they go, "Oh my gosh, I'm tired". It's because they have to recover from the anesthesia. They have to recover from that fact that they've just had a major organ removed. I think that's the only problem, they feel too good too fast.

And that's not a bad problem.

Dr. Rector-Finney: That's not a bad problem but I have to tell them listen, just because you feel good doesn't mean you can't take a few days off to let your body realize what just happened.
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