Get the Facts on Minimally Invasive Gynecologic Surgery

Doc Talk With Roa Alammari, M.D. of Mansfield Ob/Gyn Associates, a Women’s Health CT practice, to learn about minimally invasive surgery.

You hear the term a lot, but what exactly is minimally invasive gynecologic surgery?
Minimally invasive gynecologic surgery involves performing gynecologic surgical procedures using small skin incisions (laparoscopy) or no skin incisions at all (vaginal surgery, endoscopy). During laparoscopy, a small camera is inserted into the abdomen through a small incision in the umbilicus to visualize the target organ on a screen. Additional 2-4 small incisions are made to allow the insertion of thin long instruments to perform the surgery. In vaginal and endoscopic surgery, a natural opening is used to gain access to the target organ.

What types of conditions might this type of surgery be for?
Minimally invasive surgery is utilized in many surgical disciplines. In Gynecologic surgery, it can be used for a variety of indications such as removal of ovarian cysts, treatment for ectopic pregnancy, tubal sterilization, excision of endometriosis, excision of uterine fibroids or removal of the uterus, ovaries or fallopian tubes. Hysteroscopy, a type on endoscopic surgery during which a camera is inserted into the uterus through the cervical opening, can be used for removing growths from inside the uterus.

Why is it beneficial to patients?
Minimally invasive surgery is associated with less pain in comparison with open surgery performed with a large incision. Many patients will require no narcotic pain medications after minimally invasive surgery, even after major surgery such as hysterectomy. Furthermore, research shows faster recovery and less complications such as bleeding and wound infections with the use of minimally invasive surgery. In addition, laparoscopy and endoscopy enable the surgeon to visualize the tissue under magnification which improves surgical precision. Given these clear benefits, minimally invasive surgery is the standard of care for many surgical procedures.

What are the disadvantages of minimally invasive surgery?
Minimally invasive surgery is associated with longer operative time than open surgery. However, high-volume surgeons become more efficient with increasing expertise. Another disadvantage of laparoscopy is that it requires positioning the patient at a tilt with the feet above the level of the head (Trendelenburg position) which can be challenging for some patients with heart and lung disease or extreme obesity. Laparoscopy also has been criticized for increased operating room cost due to the need for specialized instruments and increased operative time, but this increased cost is offset by the shorter hospital stay and reduction in complications and loss of productivity.

How are large specimens removed from the body through small incisions?
Large specimens can be removed using a procedure called morcellation. It involves cutting the specimen into smaller fragments after it is placed inside a bag to isolate it from other organs. The fragments can be then removed through a small incision.

Is Robotic surgery a type of minimally invasive surgery?
Yes, robotic surgery is a type of minimally invasive surgery where the laparoscopic instruments are attached to a machine (the robot). This machine is controlled by a computer in the surgeon’s console. This allows better dexterity and superior optics and ergonomics. When used appropriately, it can offer a minimally invasive option for patients who otherwise may have required and open surgery. This includes patients with extreme obesity or with particularly large uterine fibroids.

Do all gynecologists offer minimally invasive surgery?
Most gynecologists are trained in minimally invasive surgery as part of residency training. However, surgical exposure in obstetrics and gynecology residency is varied and does not consistently meet the expertise needed to attempt or complete complex pelvic surgery using a minimally invasive approach. Moreover, the learning curve for laparoscopic surgery is steep and surgeons must perform minimally invasive surgery routinely after residency to maintain their skills. Therefore, many gynecologists choose to undergo additional training in minimally invasive gynecologic surgery after residency.

The American Association of Gynecologic Laparoscopists (AAGL) is the leading association promoting minimally invasive gynecologic surgery. AAGL offers a 2-year comprehensive surgical fellowship in minimally invasive gynecologic surgery to address the concern that many graduating residents in obstetrics and gynecology are not fully trained in minimally invasive gynecologic surgery. Fellows receive focused training in pelvic surgical anatomy, endoscopic and laparoscopic technologies, management of surgical complications and treatment of endometriosis, uterine fibroids and pelvic pain among other benign gynecologic conditions. Data suggest that surgeons who have completed post-residency training have improved surgical outcomes.

What’s the best way to find a physician who specializes in minimally invasive surgery?
Be aware of your minimally invasive surgical options. Find a high-volume minimally invasive surgeon because surgeon volume affects surgical outcomes. Most providers are forthcoming with their level of surgical expertise and comfort with performing certain procedures. This level of comfort can be procedure-based. While most gynecologists are comfortable performing a salpingectomy (removal of the fallopian tube) laparoscopically, they may not be comfortable performing a complex hysterectomy or advanced endometriosis surgery using a minimally invasive approach. AAGL developed a dedicated web site called MISforWomen.com with information on a wide range of gynecologic conditions and related minimally invasive surgical procedures. In addition, MISforWomen.com provides patients with access to AAGL’s Physician Finder which is an easy-to-use physician search engine with a comprehensive database of more than 7,500 AAGL members.