Not Her Mother's Hysterectomy

Incentive Lacking

What's going on here? First of all, fellow feminists, put down your copies of "Our Bodies, Ourselves." It's not sexism. I spoke with five experienced gynecologic surgeons from across the country, and here's what I found.

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Removing large parts through small holes isn't easy. John George, director of gynecologic endoscopy at Washington Hospital Center, did my three-hour laparoscopic hysterectomy. He's been doing the procedure since 1991 and explained it to me.

Simply speaking, George starts by inserting a telescope through the belly button or, in the case of large uteri like mine, just above it. A camera attached to the telescope projects the image of the internal organs onto a TV monitor.

George inserts other tools (the ones that cut, burn and shred) through two or three other tiny holes. Gas is blown into the body cavity to expand the area and allow the surgeon some room to maneuver.

Seeing what the camera sees on a monitor, George cuts the uterus away from its blood supply and its tethers until it's just floating in there, connected to nothing. Then he inserts a cylindrical morcellator -- something like a miniature circular saw with a very sharp, rotating blade at the tip. The blade cuts the uterus into long strips. Then George uses a pincer to pull them out.

The challenges of any hysterectomy are to avoid nicking the bladder or bowel, to minimize bleeding and to do the surgery quickly to minimize the time the patient is under anesthesia. Doing it laparoscopically means doing it with no hands inside the patient and no eye directly on the ball, so to speak.

George is low-key, even humble -- rare for a surgeon, I know -- but when pushed, he acknowledged that the procedure "takes a tremendous amount of skill and experience and confidence."

Too often, explained Stephen Young, president of the Society of Gynecologic Surgeons, "residents don't have enough time or cases to learn how to be comfortable doing advanced laparoscopic surgery."

Once out of school, most OB-GYNs, Young said, deliver babies, treat infections and handle a few hysterectomies a month or a year. To get comfortable with laparoscopic techniques, they would need to work with more-experienced surgeons who can mentor them, then do more procedures themselves.

In addition, most insurance companies pay doctors the same fee for any hysterectomy, regardless of the type of incision, so there's little economic incentive to invest the time in learning a new and difficult technique.

The Toyota dealer isn't going to tell you about the Kia, and doctors may not tell you about minimally invasive hysterectomies if they don't do them. I made a real pest of myself, calling my gynecologist several times, asking repeatedly for more options.

"I saw a study that says size of uterus isn't necessarily a reason to avoid a laparoscopic procedure," I said.