DualPortGYN

Groundbreaking Minimally Invasive GYN Surgery

DualPortGYN^® procedures use only two incisions and the powerful retroperitoneal dissection approach to include uterine artery ligation (UAL) to perform surgery. The Center for Innovative GYN Care^® (CIGC^®) surgeons can remove very large fibroid uteri with this approach and can manage complex cases of endometriosis and other conditions.

CIGC specialists developed the groundbreaking DualPortGYN procedure, which is among the safest and most effective minimally invasive GYN surgeries available worldwide. Our physicians are among the few surgeons nationally and internationally routinely using this approach for surgery. The DualPortGYN technique is faster, more affordable, safer, and more efficient than standard laparoscopy or robotic surgery, and can be used for hysterectomy, endometriosis surgery, removal of ovarian cysts, and other procedures.

History of DualPortGYN

At about the same time the LAAM^® technique was being developed by CIGC for fibroids, DualPortGYN was being used for hysterectomy and other GYN procedures. This technique, which only uses two incisions, is well matched to a retroperitoneal approach to ensure safety, minimal blood loss, and lower complication rates. Retroperitoneal means “behind the peritoneum,” which allows for complete visualization of the structures of the pelvis, such as the ureter, bladder, and uterine artery, to avoid complications and control blood loss. It is important to note that procedures performed by the OBGYN regardless of the technique — robotic, laparoscopic, or open — typically do not use retroperitoneal dissection, and are associated with increased complication rates, blood loss, longer recovery, and a higher conversion rate to open surgery. It is the surgeon and the technique that create safety and lower complications in surgery, not the device. CIGC surgeons are advanced laparoscopic specialists that focus entirely on surgery, not primarily obstetrics as do OBGYNs. As a result, CIGC surgeons have much lower complication rates, higher success rates, and very high patient satisfaction rates with these procedures as compared to OBGYNs.

What Is Retroperitoneal Dissection (RP Dissection)?

If you have ever used GPS when driving, you know how easy it can be to find your way. The DualPortGYN technique uses an advanced procedure that is similar to a GPS mapping system for the pelvis. Using a technique called RP dissection, the DualPortGYN procedure allows for complete identification of all the structures of the pelvis such as the bowel, bladder, ureters, and large vessels. “Mapping” the pelvis through the DualPortGYN technique avoids injury to these vital structures during surgery, and allows for safe, effective results with the best recovery possible.

Standard laparoscopic or robotic approaches to surgery performed by OBGYNs do not map the pelvis using the RP dissection approach. With standard laparoscopy, vital structures, such as the ureters, the lateral bladder, the vessels, and the uterine arteries, are often never fully visualized or seen at all during the procedure. If vital structures are not identified during surgery, there is a risk of injury leading to higher complication rates and longer recovery times. Uterine artery ligation (UAL) in the retroperitoneal space at the takeoff point from the internal iliac artery is also not performed with standard laparoscopy. UAL provides excellent blood loss control and increases the safety and effectiveness of the surgery.

How Many Incisions Are Used for DualPortGYN Procedures?

Along with mapping the pelvis through RP dissection, the DualPortGYN technique uses only two 5 mm incisions to create remarkable results. One incision is placed at the belly button and the other is at the C-section line. They are essentially invisible one to two months after a procedure. Since the incisions are in the mid-line, the risk of muscle injury and bleeding is almost completely eliminated. With these incisions, large fibroids and masses can be removed safely with vaginal access procedures to limit the incisions to only the two 5 mm placements.

What Is a Single Site Surgery?

Single site procedures used in robotics involve the use of one incision at the umbilicus. With these procedures, the umbilical incision is much larger, often 3 cm or more, and the capability of single site robotic procedures is significantly limited as compared to DualPortGYN. This means that DualPortGYN procedures can handle much more complex procedures — such as stage 4 endometriosis removal of very large fibroid uteri — faster and safely. All with overall smaller incision size and placed cosmetically. Further, larger incisions at the belly button have an overall higher incidence of herniation and postoperative pain.

Do DualPortGYN Procedures Use Electronic Morcellation for Removal of the Uterus?

CIGC never uses electronic morcellation techniques with any of its procedures, including the DualPortGYN technique for hysterectomy as well as for removal of fibroids during myomectomy.

Why Should Patients Consider DualPortGYN Procedures Versus Robotic or Standard Laparoscopy?

The most important part of the performance of any surgery has to do with the surgeon performing it, and the techniques used.

The Surgeon.

CIGC surgeons are fellowship trained advanced laparoscopic surgical specialists performing high volumes of surgical GYN procedures. CIGC surgeons are completely immersed in surgery. This means that they dedicate themselves to surgery 100 percent of the time, and are FULL-TIME SURGEONS. OBGYNs in comparison are focused mostly on obstetrics rather than surgery, with obstetrics encompassing 60 to 70 percent of their practice. As part-time surgeons, OBGYNs do not have the time, expertise, additional training, and surgical volume to learn or perform procedures using techniques such as DualPortGYN. As a patient, the surgical expertise, training, and exposure to new and better ways of doing surgery are paramount to decreasing complication rates and enhancing surgical success.

The Technique.

Surgical technique is the most important part of any surgical procedure. Superior techniques lead to superior results. Retroperitoneal approaches to GYN surgery are quickly being recognized by major societies as a better and safer way to perform GYN procedures. So why does the OBGYN not do complete retroperitoneal dissection for their patients? OBGYNs are typically not trained in RP dissection approaches. The focus on obstetrics limits the OBGYN’s ability to learn new approaches to surgery, and their surgical volume is so limited that most only perform one to two major cases a month. The lack of training and low surgical volume do not lend themselves to learning and adopting new and better techniques and approaches to surgery.

The Robot.

Robotic surgery is only as good as the surgeon sitting behind the console and performing the procedure. Since the robot takes instructions from the surgeon, the robot is only as good as the surgeon directing it. In general, robotics are needed for the OBGYN to perform a type of laparoscopic surgery that has a greater number of incisions, larger incision size, longer surgical times, and higher complication rates than even standard laparoscopy. The robot does not enhance the quality of the surgery, and in actuality may decrease it. There is no substitute for a well-trained surgeon, and the robot is not that substitute.

DualPortGYN Compared to Other Surgical Techniques

¹ Danilyants N, MacKoul P, Baxi R, van der Does LQ, Haworth LR. Value-based assessment of hysterectomy approaches. JOGR. 2018.

² Pasic et al. Comparing Robot-Assisted with Conventional Laparoscopic Hysterectomy: Impact on Cost and Clinical Outcomes. JMIG. 2010 17 (6): 730-738

³ Landeen LB, Bell MC, Hubert HB, Bennis LY, Knutsen-Larson SS, Seshadri-Kreaden U. Clinical and cost comparisons for hysterectomy via abdominal, standard laparoscopic, vaginal and robot-assisted approaches. South Dakota Medicine 2011; 64(6): 197-199

⁴ Drahonovsky J., Haakova L., Otcenasek M., Krofta L., Kucera E., and Feyereisl J.: A prospective randomized comparison of vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy, and total laparoscopic hysterectomy in women with benign uterine disease. EJOGRB 2010; 148: pp. 172-176

⁵ Einarsson, J. I., & Suzuki, Y. (2009). Total laparoscopic hysterectomy: 10 steps toward a successful procedure. Reviews in obstetrics & gynecology, 2(1), 57-64.

⁶ Paraiso MF, Ridgeway B, Park AJ, et al. A randomized trial comparing conventional and robotically assisted total laparoscopic hysterectomy. AJOG. 2013;208(5):368.e361–367.

⁷ Wright KN, Jonsdottir GM, Jorgensen S, Shah N, Einarsson JI. Costs and outcomes of abdominal, vaginal, laparoscopic and robotic hysterectomies. JSLS. 2012;16(4):519-24.

⁸ Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677.

⁹ Schmitt, J. J., Carranza Leon, D. A., Occhino, J. A., Weaver, A. L., Dowdy, S. C., Bakkum-Gamez, J. N., Pasupathy, K. S., Gebhart, J. B. (2017). Determining Optimal Route of Hysterectomy for Benign Indications: Clinical Decision Tree Algorithm. Obstetrics and gynecology, 129(1), 130-138.

¹⁰ Mayo Clinic

¹¹ Paraiso MF, Ridgeway B, Park AJ, et al. A randomized trial comparing conventional and robotically assisted total laparoscopic hysterectomy. AJOG. 2013;208(5):368.e361–367.

¹² Yeung P, Bolden C et al. Patient Preferences of Cosmesis for Abdominal Incisions in Gynecologic Surgery. JMIG. 2013; 20(1): 79-84

¹³ Jones, H. W., III, & Rock, J. A. (2015). Te Linde’s operative gynecology (Eleventh edition). Philadelphia: Wolters Kluwer.

¹⁴ Royal College of Obstetricians & Gynaecologists, London, UK.

Publications

CIGC surgeons continuously publish their data on DualPortGYN and other approaches to surgery. A recent publication in 2018 compared robotic, standard, and open hysterectomy procedures to DualPortGYN. The result was clear — DualPortGYN hysterectomy had the lowest complication rates, fastest recovery, lowest blood loss, and lowest cost. Additional abstracts and publications highlight the importance of this surgical technique with enhanced results.

What Is the Capability of DualPortGYN and What Type of Conditions Can It Treat?

DualPortGYN can be used for hysterectomy procedures in uteri of all sizes, endometriosis including stage 4 disease, large ovarian masses, and reconstructive procedures. For very complex cases, an additional third 5 mm port is sometimes needed to complete the procedure safely. The capability to successfully complete the surgical procedure requires the use of many of the components of RP dissection.

Uterine Artery Ligation (UAL).

This is a very powerful approach to control blood supply during pelvic surgery. The UAL technique ligates, or permanently blocks, the uterine artery at its origin from the internal iliac artery in the RP space. The artery is more accessible at this location, which is up to 5 cm away from the uterine sidewall, and UAL very effectively controls bleeding during any procedure involving removal of the uterus. Uterine artery ligation has been shown in studies conducted by CIGC to prevent the conversion to open procedures 100 percent of the time, and is one of the most important components of a successful RP approach to surgery. Standard OBGYN approaches to uterine artery ligation are at the side of the uterus, which can lead to increased bleeding, ureteral injury, and bladder injury in more complex cases.

Ureterolysis.

Ureterolysis refers to the removal of adhesions from the ureters. The ureters lie within the retroperitoneal space, and are responsible for transport of urine from the kidney to the bladder. The ureters are often involved with scarring in the RP space, called retroperitoneal fibrosis, and removal of these adhesions is required in more advanced cases of fibroid removal, endometriosis, pelvic masses, and for patients with prior pelvic surgery. Effective ureterolysis can prevent the conversion of a laparoscopic procedure to an open one.

Lateral Bladder Dissection.

For patients with multiple cesarean section, myomectomy, or other procedures performed prior, the bladder may be involved with extensive adhesive disease. Lateral bladder dissection in the retroperitoneal space allows for the bladder to be safely removed from the uterus to complete the procedure.

The use of these three main components of RP dissection greatly enhances the safety and success rates of DualPortGYN procedures. Using all three is sometimes needed in more complicated procedures and when necessary to allow for laparoscopic procedures to be performed safely and with low complication rates, with a close to zero percent chance for conversion to open surgery. Conversion to open surgery is common with standard laparoscopic or robotic procedures and is a failure for the patient, who has entered the surgery expecting a minimally invasive approach.

The DualPortGYN technique can be applied to treatment of complex GYN conditions:

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