washingtonpost.com
Minimally Invasive Hysterectomies

Dr. John George
Director of Gynecologic Endoscopy at Washington Hospital Center
Tuesday, October 2, 2007 2:00 PM

Why are only a quarter of all hysterectomies done with minimally invasive techniques, using smaller incisions and offering a quicker and easier recovery? Dr. John George was online Tuesday, Oct. 2 at 2 p.m. ET to explain the risks and benefits of a laparoscopic hysterectomy.

A transcript follows

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Chevy Chase, Md.: Is laporoscopic surgery effective for hysterectomy to address uterine prolapse?

Dr. John George: Laparoscopy is being used and at the Washington Hospital Center to treat some forms of prolapse

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Myersville, Md.: I'm currently at a 16-week-size fibroid stage and my ob/gyn has not recommended its removal yet. I have been getting bi-annual ultrasounds and am awaiting the results of an endometrial biopsy due to irregular (but not excessive) bleeding. Should I wait until my doctor recommends a hysterectomy or should I push for one now? I am very interested in laproscopic surgery at this point and would like it done before my fibroid increases in size. Is size alone a good reason to have a hysterectomy?

Dr. John George: the decision to have a hysterectomy is usually based upon symptoms of bleeding and pressure. Your uterus in terms of size may be removed by laparoscopy if the decision is made to operate

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Pittsburgh: I'm confused by what I read. Why did the reporter's gyn wait or allow for a fibroid, discovered "years ago" when it was small, to grow large enough for hysterectomy? What is it about fibroids that they can hang there for so long without less invasive treatment or medication to eliminate them, especially when first discovered? What professional liability does the doc hold for then recommending hysterectomy after watching the fibroid grow for years (i.e., why did they wait so long and how many years were 'years'?), and what should the patient have questioned, done or researched over the years before it reached the hysterectomy stage?

Lastly, what type of ongoing dialogue should a woman have with her gyn once a fibroid is found and she is told to "watch and see"?

Dr. John George: Since fibroids rarely become cancerous, they m,ay not require treatment until symptoms occur. Whats more they may regress after menopause. So surgery can be avoided nin 60% of cases.

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Chevy Chase, Md.: What forms of prolapse can be addressed with laproscopic surgery?

Dr. John George: Prolapse of the bowel, uterus, and bladder may all be amenable to laparoscopic repair.

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Arlington, Va.: I just had a 15-cm fibroid removed, along with the uterus/cervix and ovaries via the traditional abdominal incision. I had hoped to rely upon UAE (uterine abdominal embolization) to shrink the fibroid, but an early MRI revealed inconsistent density in the fibroid. The UAE specialist said that he wouldn't do the UAE due to concerns of cancerous cells in the fibroid, due to what the MRI films revealed. Would this laporascopic/strip uterus removal have been possible, given the concern over the fibroid's density?

I'm happy with the surgery and recovery, so no regrets.... just curious.... Thanks!

Dr. John George: This size fibroid can be removed by laparoscopy, however because of the concern for a malignancy such an approach is not recommended.

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New York, NY: My mother, who is 67, is going to be scheduled for a hysterectomy soon. They found precancerous cells and have determined that a hysterectomy is the best option. She is seeing her doctor on Thursday to schedule the surgery. What questions do you recommend she ask the doctor?

Dr. John George: She could ask her physician: Is laparoscopy an option based on the type of cancer she has?

Some forms of gynecologic cancers may be managed by laparoscopy, while others require the traditional abdominal approach.

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Anonymous: Do all LASH procedures require the "instant menopause" drug prescribed beforehand? What are the effects?

Dr. John George: Regarding the "instant menopause" drug: Lupron -

It may be administered prior to surgery to help shrink a uterus and decrease bleeding prior to surgery to improve the patient's blood count.

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Washington, D.C.: Why would a patient need to get a hysterectomy for a fibroid, versus something less invasive, like fibroid embolization? Does it have to do with the age of the patient? Or with where the fibroids are located?

Dr. John George: In many cases, the final decision is really one of the patient's choice. If she requires minimal or no surgery and is a good candidate for UAE (embolization), then that would be an appropriate choice. She must however, realize that a hysterectomy will be 100% successful in treating fibroids, particularly symptoms of bleeding. UAE will ameliorate symptoms in many cases, but fibroids may still pose problems later.

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Upper Marlboro, MD: Why not minimally invasive hysterectomies for 99% of women who need them? I had a vaginal hysterectomy (one cut through the bellybutton) in May, to remove a tilted uterus that was about the size of a 4 month pregnancy. I have always had fibroid problems, even before I had three children, and the 3rd may have died because of the fibroids. And I still had a laprosco...tiny little incision.

Dr. John George: When a patient requires a hysterectomy the vaginal route is the first consideration. This may not be feasible if the uterus is larger than a 12 week pregnancy. Under those conditions an abdominal hysterectomy would be considered. If the surgeon has the skill to do that same hysterectomy laparoscopically then it is an appropriate option. I set the limit for hysterectomy by laparoscopy at 20-24 weeks size.

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Virginia: I'm planning a hysterectomy, and I've found that most of the information out there (especially related to post-surgery issues) is geared toward older women. Any good resources for us in our 30s? Thanks!

Dr. John George: The article by Stephanie Weiss in today's Washington Post gives several sources where information may be derived.

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Alexandria, Va.: I had a hysterectomy the traditional way years ago for a grapefruit-sized fibroid. I had never had any signs of endometriosis. When the surgery was done, they found endometriosis everywhere, wrapped around one ovary and my liver, all stuck together. They had to call in another surgeon to ensure no damage was done, and the surgery was longer than usual. So, my question is, I assume I would not have been a good candidate for laproscopic surgery. Would you have known this in advance? What would you do if you did a laproscopic cut and found this mess?

Dr. John George:50% of my patients with fibroids have endometriosis. When pain is present more than 90% have endometriosis. Pain in the presence of fibroids in the gynecologic patient is the single most important symptom that may indicate endometriosis. The diagnosis is confirmed either by laparoscopy or when the abdomen is open. Unfortunately many cases are not typical and are not diagnosed prior to surgery.

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Arlington, Va.: But, aren't most hysterectomies done unnecessarily? I've seen news stories that say hysterectomy is totally overused. I DO think that's a product of doctors marginalizing the importance of women's body parts.

Dr. John George: At the Washington Hospital Center and particularly in the Fibroid Center we counsel patients regarding all options not just hysterectomy. Such options may include lifestyle changes, medical therapy, embolization, laparoscopic conservative surgery as well as hysterectomy.

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Bridgehampton, N.Y.: I also have a melon sized fibroid, and had ruled out surgery because my doc said that traditional hysterectomy was the only option. How can we locate a highly experienced laproscopic surgeon in our local area?

Dr. John George: The Post article lists several websites including the AAGL (Association of Gynecologic Laparoscopists) that would be helpful.

www.aagl.org

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Chevy Chase, Md.: How many laporoscopic hysterectomies have you performed?

What is the risk of operative infections with this kind of surgery?

Dr. John George: I have performed approximately 900 laparoscopic hysterectomies since 1991. I routinely administer antibiotics at the time of surgery. The infection rate is much less than 1%.

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Annapolis, Md.: Dr. George,

I am 46 and have fibroids which interfere with my quality of life. They are not large but there are more than one. I have been told by my doctor that a laparoscopic hysterectomy is not possible for me because I have never given birth (nor been pregnant). I believe he was indicating that the birth canal would not be large enough to do the procedure. In your experience is this true?

Dr. John George: The limiting factors for a laparoscopic hysterectomy include the size of the uterus, associated pathology, patient's weight, and physician skill. The size of the birth canal has little relevance to the safe performance of a laparoscopic hysterectomy, but may be important for a vaginal hysterectomy.

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Washington, D.C.: What are the most common risks of the surgery?

Dr. John George: The four main categories of risk of a laparoscopic hysterectomy include: bleeding, infection, accidental organ injury, and anesthesia complications.

When performed by a skilled laparoscopist major complications are uncommon. Complications unique to laparoscopy may include injury with the specialized instruments used for laparoscopy. Again these are uncommon.

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Dr. John George: It has been a pleasure answering questions on hysterectomy. At the Washington Hospital Center we perform all categories of minimally invasive surgery on the uterus, fallopian tubes, ovaries, and pelvic support structures. For information regarding our capabilities and physicians you may call 202-877-DOCS or visit the washington hospital center website.

Thanks

Dr George

Many thanks to our host.

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