Laparoscopic hysterectomy: A surgeon makes the case (transcript)

This is the transcript of my recent podcast interview on minimally invasive hysterectomy.David E. Williams:            This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Dr. Bob Darrow.  He’s an OB/Gyn in Dallas, Texas.  He’s at Presbyterian Hospital and is on staff at the University of Texas Southwest Medical School.  Dr. Darrow, thanks for being with me today.Dr. Robert Darrow:             Thank you David.Williams:            I understand that about 80 percent of the 600,000 or so hysterectomies that are performed in the U.S. every year are done with open surgery but that something like 95 percent of those could be done with minimally invasive approaches.  Is that the case and if so, why are there so many open surgeries?Darrow:            That does seem to be the case these days.  I think the reason for so many open surgeries is lack of training.  Most people in their training as a resident only learned the open way or they learned how to do a vaginal hysterectomy. The vaginal hysterectomy becomes difficult for a lot of people who don’t do them often, especially if they have to retrieve or evaluate the ovaries on each side.  The abdominal approach seems to be the easiest approach for most surgeons to learn and to execute.Williams:            So it’s more about what the surgeons are comfortable with and what’s easiest for them as opposed to an overall assessment of what’s best for the patient or most effective economically?Darrow:            In my opinion that’s probably the case.Williams:            From a patient’s standpoint, what’s the difference?  Does it matter if they have an open surgery versus a different approach?Darrow:            An open surgery is often done when there a lot of difficult pathology is anticipated, meaning a lot of scarring inside or things are stuck together.  A vaginal approach is usually reserved for women who have had multiple births where their pelvic support system is not as adequate, so things are going to be more relaxed and fall out.The laparoscopic approach seems to be more successful and could be done even with these larger cases that I just described.  I think the doctors simply aren’t as familiar with them.Williams:            Is it better for the patient in terms of their recovery or their prognosis?Darrow:            In my opinion, the laparoscopic approach is usually the best because there’s less pain and a faster recovery.  With the vaginal procedure, there’s tugging and pulling on the vaginal support system which, in my opinion and that of others, creates a little bit more pain, but the recovery is almost as swift as the laparoscope.The abdominal or open approach is the most extensive as far as recovery, sometimes taking six to eight weeks. It requires a longer hospitalization, which makes it more expensive and also more painful.So in my opinion, the laparoscopic or the vaginal approach are much more comfortable for the patient. If the surgeon is skilled enough to do one of those, it’s preferable from the patient point of view in terms of getting back to work faster, saving money and having an easier recovery.Williams:            Are there multiple laparoscopic approaches or is it just one specific approach or technique?Darrow:            There are basically three laparoscopic approaches right now.  The first approach that became the popular earliest was a laparoscopic assisted vaginal hysterectomy in which they started dissecting the tissues down to the laparoscope, then ended up pulling everything out through the vagina --kind of like a modified vaginal hysterectomy.With time, going into the 1990s, the instruments were better and we started doing laparoscopic hysterectomies where we had basically three ports --three separate incisions-- one at the umbilicus and one in each lower quadrant. The right lower quadrant and left lower quadrant went through muscles, but were used for exposure and manipulation --like extended arms of the surgeon-- and the umbilicus had the eyes of the surgeon or the laparoscope.  This became more popular and the recovery was much less.We’ve now developed a single puncture hysterectomy where we can put all three arms or ports in through the umbilicus or belly button. Since we don’t have to go through the muscle, this is a lot less painful in my opinion. The recovery is faster and these patients are going home in two hours whereas a lot of people with the three puncture laparoscopy were staying overnight.The newest approach besides the single puncture is the robot, which is also through the laparoscope. But the robot has four or five puncture sites.Williams:            Is there any downside to this single puncture approach?Darrow:            The main downside right now is the inability to see the entire area that you need to see if the uterus is difficult.  In the really difficult cases it may not be the best approach.  When I say “difficult” I mean extensive pathology.  I always tell my patients that we start out with one puncture through the umbilicus and if we have to add one or two more we can do so.The single puncture hysterectomy seems to work best in uteruses that are not quite as big and not as stuck or scarred.Williams:            I imagine if you’ve got a surgery that takes less time to recover from, that’s probably less costly economically and the woman can get back to work sooner. But are there also any losers from an economic standpoint that might stand in the way of allowing this approach to go forward and become more prevalent?Darrow:            You would like to think that it would become more prevalent as more and more people know about it.  Everybody seems to like the idea of having surgery with less pain and a faster recovery. As the learning curve of the physicians improves with the new technology, I would like to think that more and more physicians would embrace this technology that comes with less pain, less cost, an less time away from work. It seems like a win-win-win situation.Williams:            My understanding is that various OB/Gyns such as you have come together from competing practices in Dallas to work on this issue of less invasive hysterectomy.  Can you tell me about what’s going on there and what the motivation is for that?Darrow:            In the three-prong laparoscopic approach you’re absolutely correct.  There’s a group of us from Dallas Presbyterian Hospital who have applied for and received a certificate of excellence through AIMIS, The American Institute of Minimally Invasive Surgery. AIMIS recognizes us as a leader in laparoscopic hysterectomies.  Of this group, I am the only one that does a single puncture and as far as I know, the only one in North Texas that is doing it since this is frankly new technology. But there are many of us that are skilled laparoscopists with the three-prong approach. And yes, we do talk among ourselves and try to share secrets. A friendly rivalry makes all of us better.Williams:            If someone were told they need a hysterectomy, what advice would you give them?  Let’s say they’re not in your neck of the woods.  What should somebody in another city be thinking about?  What questions should they be asking and what should they be looking for?  It sounds like not everyone is getting it in the most optimal fashion and different surgeons are trained different ways.Darrow:            Anytime a patient has to make a difficult decision they need to know what the options are from their physician. They need to know the risks and benefits of each option including: pain, potential complications of the surgery, recovery, healing, back to work.  The bottom line is some physicians just don’t have the skill sets that other physicians do. But if they have the trust of the patient, that may be more important to the patient.Williams:            I understand you’re working with a new technology.  Is there a body of research --either established or emerging-- that supports some of the experience that you’re having?Darrow:            Absolutely.  There’s a body of research otherwise I wouldn’t have started this way without the research to help support me.  Understand that the hysterectomy is a long and proven operation.  All we are doing with our technology is developing newer instruments that make our job easier, whether this has been from day one with the improvement of surgical instruments for open abdominal hysterectomies all the way through vaginal hysterectomies and laparoscopic hysterectomies.  We physicians are always made better by the research that we do and the observations of our complication rates versus success rates.  Certainly you don’t want to have a procedure that has a high complication rate.  Fortunately so far none of these did.Williams:            Are there other topics that we should cover today?Darrow:            I think we’ve done a good job of covering it.  I think patients have to always know what the risks are of surgery.  Also always try to resort to non-surgical remedies first in my opinion.  Surgery should be a last resort and you have to weigh the factors that affect your life.  Patients need to be aware of all the options available to them and why their physician chose one over the other.Williams:            I’ve been speaking today with Dr. Bob Darrow, an OB/Gyn in Dallas, Texas.  We’ve been talking about minimally invasive approaches to hysterectomy.  Dr. Darrow, thanks for your time.Darrow:            Thank you very much David.