Advanced Laparoscopic Techniques Improve Patient Safety
DualPortGYN® and LAAM-BUAO® are the powerful laparoscopic GYN techniques developed by the minimally invasive GYN specialists at The Center for Innovative GYN Care® (CIGC®). Our specialists use these surgical techniques to give women suffering from complex gynecological conditions a better surgical outcome, with less risk and recovery time. The advanced laparoscopic techniques that are the foundation of DualPortGYN and LAAM® include retroperitoneal (RP) dissection and uterine artery ligation (UAL) or uterine artery occlusion (UAO). RP dissection and UAL/UAO should only be performed by skilled and experienced laparoscopic GYN specialists.
Retroperitoneal Dissection & Uterine Artery Ligation/Occlusion
Improving visibility and controlling blood loss makes it possible for the CIGC advanced laparoscopic GYN specialists to perform minimally invasive outpatient surgery for complex GYN conditions. Many GYN procedures like hysterectomy or myomectomy — that may normally be performed as invasive open surgery by non-laparoscopic surgeons or as less thorough standard or robotic laparoscopic procedures — can be performed as advanced laparoscopic surgery with DualPortGYN or LAAM at CIGC.
The RP dissection technique allows the CIGC surgeon to go behind the peritoneum, a filmy layer that covers the pelvic cavity. This technique makes it possible to have clear visibility of the entire pelvic cavity. The surgeon can effectively map the delicate structures of the pelvis including the bowel, bladder, ureters, and large blood vessels to protect them and prevent injury during surgery. The result is a safe, effective procedure with fast recovery and less pain.
Unlike DualPortGYN and LAAM, standard laparoscopic or robotic approaches to surgery do not “map” the pelvis using the RP dissection approach. If vital structures are not identified during surgery, there is a risk of serious injury leading to higher complication rates, potential for additional surgery, and longer recovery times.
Uterine artery ligation/occlusion: UAL or UAO both refer to blocking the blood flow to the uterus. Bilateral uterine artery ligation/occlusion (BUAL or BUAO) are the same as UAL or UAO. Bilateral just means the uterine artery ligation/occlusion is performed on both sides of the uterus. Ligation means, in general, a permanent blockage of the uterine artery(ies). Occlusion means a temporary blockage using a removal «tourniquet» so that blood supply is restored to the uterus. Occlusion is generally used during myomectomy procedures, whereas ligation is used during hysteretomy procedures. There are some patients with very large fibroid uteri that may benefit from permanent ligation to control bleeding during the procedure as well as after, thereby avoiding hysterectomy.
This is an important skill that is essential to performing CIGC procedures. Many women with complex GYN conditions often have uncontrolled bleeding at the neck of the uterus. Without using these techniques, non-CIGC surgeons often have to convert to open surgery, which increases risks, recovery time, and pain to the patient. More concerning is the potential for injury to other structures near the uterine artery, such as the ureter and bladder, which can lead to complications and additional surgery.
The UAL technique permanently blocks the main source of blood flow to the uterus. When the uterine artery is blocked at its source, it eliminates the problems of excessive bleeding and helps prevent injury to the surrounding structures that can occur during surgery. The UAL technique must be performed by a skilled retroperitoneal laparoscopic surgeon.
This technique makes laparoscopic removal of almost any size uterus possible. The UAL technique is also extremely effective for patients requiring myomectomy (removal of uterine fibroids). Using UAL/UAO during a myomectomy can help prevent the surgeon from having to convert to a hysterectomy. It can also help control heavy bleeding during and after a myomectomy. Occlusion, or temporary blockage, uses the application of removable clips or a tourniquet. The clips or tourniquet are removed after the surgery, allowing for full restoration of blood flow to the uterus for fertility.
The Benefit of Small Incisions Strategically Placed
The small incisions used for DualPortGYN and LAAM surgeries are placed in the midline, away from the abdominal muscles. One incision is placed at the belly button and the other just above the pubic bone. The size and placement of these incisions allow patients to feel better faster.
For DualPortGYN, large fibroids and masses can be removed safely with vaginal access procedures to limit the incisions to only two 5 mm placements. Vaginal access procedures that do not use DualPortGYN techniques are performed blind, and can lead to complications.
LAAM uses one 5 mm incision at the belly button and one 1.5 cm incision just above the pubic bone. LAAM fibroid removal is possible through the lower 1.5 cm incision, morcellating by hand at the surface to avoid the risk of spreading undetected cancers.
CIGC never uses electronic morcellation techniques with any of its procedures, including the DualPortGYN technique for hysterectomy or the LAAM myomectomy for fertility.
Advanced GYN techniques at The Center for Innovative GYN Care include enterolysis, pelvic node dissection, and laparoscopic bowel and bladder repair.
Additional Advanced Surgical Techniques Performed at CIGC
Enterolysis: Removal of Adhesions to the Bowel
Enterolysis requires a great deal of experience and refined laparoscopic skills. If performed properly, enterolysis prevents a surgeon from performing open surgery. Adhesions, or scar tissue, are dense or filmy bands of tissue that connect themselves to structures due to injury. An injury can occur from prior surgery, from infection, or any episode that requires the body to heal itself. Internal adhesions form similarly to external cuts on the skin: as the cut heals, it becomes inflamed and forms a scar.
In pelvic and abdominal surgery, scars or adhesions form between structures in the pelvis subjected to surgery. Open surgery causes significant adhesions in many patients, as does a pelvic infection or ruptured bowel. Since the pelvic and abdominal cavities are occupied for the most part by the small and large bowel, adhesions form to bowel loops. In some cases, the adhesions are extensive, covering almost every foot of the 30 feet of small and large bowel in the pelvis and abdomen. Other cases are less severe.
Pelvic surgery often requires removal of pelvic adhesions. When extensive enterolysis is required, the surgery can be very difficult to perform. CIGC surgeons consider extensive enterolysis to be the most challenging of all the procedures they perform. The reason is that perforation — a “nick” or hole in the bowel — can lead to leakage of fecal material into the pelvis or abdomen. This is a surgical emergency that, if not corrected immediately, can lead to severe infection and death.
Laparoscopic Pelvic Node Dissection
Pelvic node dissection is a routine procedure in GYN oncology for uterine, cervical, and ovarian cancer. The laparoscopic approach, although more difficult to learn, is easier, more effective, and safer than open node dissection. Bleeding is decreased, node yields are increased, and recovery is very fast. This is the preferred approach safely and effectively used by CIGC surgeons for all patients with cancer requiring node dissection. The use of this approach completely eliminates the need for open surgical procedures for almost all uterine, cervical, and early stage ovarian cancer patients.
Laparoscopic Bowel and Bladder Repair
In very complicated conditions, patients with extensive adhesive disease, injury to the bladder and bowel can occur. In these circumstances, CIGC surgeons are trained to repair defects using proven and safe laparoscopic techniques. The ability to repair these complications laparoscopically avoids the need for open surgery, which is associated with increased pain, higher complication rates, and longer recovery times.
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