Technique Advanced GYN Techniques
Advanced GYN Techniques at CIGC
Advanced GYN techniques at The Center for Innovative GYN Care include enterolysis, pelvic node dissection, and laparoscopic bowel and bladder repair.
Enterolysis refers to the removal of adhesions to the bowel. 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. An example is a cut on the skin with a knife. The cut heals and forms a scar, which is a type of adhesion.
In pelvic and abdominal surgery, scarring 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 thirty 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 in the pelvis or abdomen. This is a surgical emergency that, if not corrected immediately, can lead to a severe infection and death.
Enterolysis requires a great deal of experience and refined laparoscopic skills. If performed properly, enterolysis will prevent a surgeon from performing open surgery. Consider the following examples that are very common with less experienced GYN laparoscopic surgeons or OB/GYNs. In the cases described, the surgeon is attempting laparoscopic procedures on patients with prior infections or surgery.
LAPAROSCOPIC SURGERY PERFORMED BY AN OB/GYN RESULTED IN CONVERSION TO MORE INVASIVE OPEN PROCEDURE
Patient M had a prior severe infection to the right ovary. The patient was treated with antibiotics in the hospital, and went home after one week. Two months later, she has developed severe pain on her right side. An ultrasound shows a large pelvic mass, which is thought to be an old abscess. The ultrasound will not show adhesions, since they cannot be detected by any imaging study – ultrasound, CT scan, or MRI.
The patient wants the ovary removed, and sees her OB/GYN who schedules a laparoscopic surgery for removal. At the time of the laparoscopy, the appendix and colon are severely adhesed, or scarred, to the right ovary. After an hour of attempts to free the colon from the ovary laparoscopically, the OB/GYN decides she needs to open Patient M. A large 10 inch incision is made. The colon is freed from the ovary, and the ovary removed. The patient stays in the hospital for 3 days, and has a longer recovery of 6 to 8 weeks, rather than the 5 days she was told would be required with the laparoscopic procedure.
Unfortunately, in this situation, it was safer for the OB/GYN to open the patient and free the bowel off the ovary. This decision avoided a perforation to the bowel, and possible infection.
THE CIGC ADVANTAGE: ENTEROLYSIS
CIGC surgeons encounter these types of situations routinely, and in greater than 99% of the cases, the bowel can be freed from the ovary using advanced enterolysis techniques.
Procedures that would be considered “complex” or even “impossible” by the OB/GYN in cases such as these are routinely and successfully performed by CIGC surgeons. They have the training, skill, and experience to perform what would normally be open surgeries laparoscopically using enterolysis safely and effectively.
Patient N has enlarging fibroids, and had decided to have a hysterectomy. She has had several myomectomies – open surgical procedures to remove fibroids from the uterus – in the past. Her OB/GYN performed all her procedures, and has taken care of her through her deliveries and GYN office care. Pt N meets with her OB/GYN who agrees that hysterectomy is necessary, and offers a robotic procedure. Pt N agrees.
At the time of the robotic hysterectomy, there are dense adhesions between the bowel and the abdominal scar used several times to remove the fibroids. During the course of the robotic dissection, the OB/GYN moves the scissors on the robotic arm improperly, and an incision is made in the bowel. She cannot repair the bowel defect since she does not have privileges to do so. A general surgeon is called in, makes an incision, and repairs the bowel. A longer hospital stay and recovery is required.
In this situation, a bowel injury occurred using robotics, and a general surgeon was needed to fix the defect using an open incision. Remember that robotics are directed by the surgeon – they do not operate on their own. OB/GYN’s do not have privileges to repair bowel, so the appropriate surgeon was called in to affect the repair.
THE CIGC ADVANTAGE: ENTEROLYSIS
CIGC surgeons perform enterolysis routinely. Should a bowel injury occur, in the vast majority of cases a laparoscopic approach can fix the problem with no increased recovery or larger incisions. CIGC surgeons have been trained to repair injuries to bowel, bladder, ureters, and other structures safely and effectively with laparoscopic techniques, and often have more experience with laparoscopy than general surgeons or urologists. CIGC surgeons do not require robotics for their procedures. The robot requires more and larger incisions, requires more time, and is much more expensive.
Pelvic Node Dissection
Laparoscopic 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 used by CIGC surgeons safely and effectively for all patients with cancer and 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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