Update on Gynecologic Surgery

Abstract

Christ Hospital of Cincinnati (OH, USA) sponsored the 13th annual Pelvic Anatomy and Gynecologic Surgery Symposium held on 9–11 December 2010 in Las Vegas (NV, USA). Course directors were Mickey M Karram and Michael S Baggish. Invited faculty included Tommaso Falcone and Mark Walters, both from the Cleveland Clinic Foundation in Cleveland (OH, USA). In addition, John Gebhart from the Mayo Clinic in Rochester (MN, USA) and Javier F Magrina from the Mayo Clinic Scottsdale (AZ, USA) rounded out the speakers' list. The symposium gathered renowned experts in open, vaginal, laparoscopic and robotic pelvic surgeries to discuss issues and controversies surrounding minimally invasive gynecologic surgery.

Key presentations

Mickey Karram opened the symposium with a detailed review of female pelvic anatomy. State-of-the-art surgical video was used to expertly describe the anatomy of the retroperitoneal and retropubic spaces. Surgical techniques for entry into these spaces and maneuvers to circumvent anatomic pitfalls unique to each region were demonstrated. Great emphasis was placed on reviewing the course of the ureter through the retroperitoneum as well as common sites and types of ureteral injury. Ureteral injury is still one of the most common injuries in gynecologic surgery. Injuries typically occur at the pelvic brim and the area where the uterine artery crosses over the ureter. Discussion was aided by multiple laparoscopic and robotic video clips.

Karram continued his review in a second lecture, ‘Pelvic Floor Anatomy: What Every Gynecologist Should Know’. Pelvic bony landmarks, and anatomy of the anterior and posterior vaginal walls, retropubic space and transobturator region were reviewed via surgical video and videos of detailed cadaveric dissection. It was noted that the practicing gynecologist is less familiar with the retropubic space, since Burch procedures (retropubic cystopexy) are uncommonly performed in the era of simplified anti-incontinence procedures such as midurethral slings.

John Gebhart, Director of the Female Pelvic Medicine and Reconstructive Surgery Fellowship at the Mayo Clinic in Rochester (MN, USA), then addressed complex abdominal surgeries. Basic surgical principles were reviewed and their importance emphasized. Intraoperative principles intended to minimize tissue necrosis, thrombosis, fistula formation, nerve dysfunction and infection were highlighted. Special emphasis was placed on hemostatic techniques in complex abdominal surgery.

Gebhart and Mark Walters, Vice Chairman of Gynecology at the Cleveland Clinic (OH, USA), then discussed pelvic floor dysfunction. Evaluation and management of urinary incontinence, overactive bladder and defacatory dysfunction were detailed. Surgical approaches for stress urinary incontinence and prolapse were compared and contrasted. Special attention was paid to the controversy of surgical meshes in the management of prolapse, as well as to the efficacy of open versus laparoscopic surgical approaches.

There are major advantages of the slings for stress urinary incontinence compared with open or laparoscopic procedures, such as shorter operating time and outpatient procedure, and decreased incidence of postoperative voiding dysfunction. The transvaginal approach can be performed with an ‘upward’ or ‘downward’ pass. The transobturator (TOT) needle pass is the most recent approach to the use of a sling. Data suggest similar rates of continence of TOT with traditional slings but with less postoperative voiding dysfunction and urgency. A TOT approach may have fewer bladder perforations. Prolapse surgery requires advanced skills but has not substantially changed. The main areas covered were the use of robotic sacrocolpopexy for apical prolapse, which is quite promising, and the controversy on the use of mesh. For example, although an anterior or posterior repair with nonabsorbable mesh may have better objective outcomes, the erosion rate is quite high.

Tommaso Falcone, Chair at the Department of Obstetrics and Gynecology at the Cleveland Clinic, overviewed clinical indications and myomectomy-open, laparoscopic and robotic surgical approaches. Myoma surgery is still commonly performed for women with symptomatic myomas that wish to retain their fertility potential. Perioperative and reproductive outcomes as well as fibroid recurrence rates were similar between laparoscopic and laparotomy approaches. However, the minimally invasive approach is associated with faster recovery time. Rates of conversion to laparotomy were attributed to preoperative use of gonadotropin-releasing hormone agonists. Robotic surgery may facilitate the extensive suturing required for a proper closure of the myometrium. Laparoscopic suturing requires advanced skills that the robot may facilitate.

Day 2 of this packed 3-day conference began a robust discussion regarding route of hysterectomy in gynecologic surgery. Hysterectomy is still one of the most frequently performed gynecologic surgeries. Walters addressed transvaginal hysterectomy and Falcone discussed the laparoscopic approach. Javier Magrina from the Mayo Clinic Scottsdale (AZ, USA) focused on robotic hysterectomy.

Mark Walters spoke of changing trends in gynecologic surgery with decreasing percentages of vaginal hysterectomies and increasing numbers of laparoscopic and robotic procedures being performed. Walters postulates that if and when a vaginal hysterectomy can be performed, it should. Nulliparity and previous cesarean section are not absolute contraindications to total vaginal hysterectomy, and techniques of morcellation, coring, wedge resection and myomectomy can even make the larger uterus amenable to a transvaginal approach. Walters offered a solid rationale for total vaginal hysterectomy as the route of choice for hysterectomy, including decreased complication rates, rapidity of patient recovery and lower overall cost when compared with other approaches.

There are numerous debates on whether the cervix should be removed and at what age the ovaries should be taken out. Randomized clinical trials have shown no advantage of leaving the cervix. The trend is to not remove ovaries in premenopausal women that are undergoing hysterectomy. Removal of the ovaries can be accomplished at the time of vaginal hysterectomy in most patients. Laparoscopic surgical access was discussed. Falcone agreed with Walters in that a vaginal surgical approach may be the procedure of choice for hysterectomy. However, he cited several specific situations where a laparoscopic approach may prove superior to either vaginal one. Cases with larger uteri, significant adnexal pathology or endometriosis, for example, may be better served by laparoscopy. Falcone reviewed intraoperative complications common to the laparoscopic approach such as injury to blood vessels of the abdominal wall. The most common injury is still with the pneumoperitoneum needle. Alternatives to the umbilical route should be used for patients with previous surgeries that involved a midline incision. Options include a left upper quadrant entry or an open technique. Although vaginal and conventional laparoscopy are the most commonly used approaches, single-port technology is rapidly being introduced. This involves using a single umbilical site with three to four ports that may be part of an access platform. Outcomes are promising with potentially faster recovery.

Javier Magrina gave an elegant overview of a robotic hysterectomy. Again, tenets for patient selection were reviewed. In addition, the procedure, from patient positioning and preparation to postoperative care, was reviewed. The most common limitation of robotic surgery is usually anesthesia, as these procedures are long and require steep Trendelburg. Special attention was paid to the issue of vaginal cuff dehiscence in robotic surgery as well as surgical principles to prevent this occurrence. It is unclear why there was an increased frequency of cuff dehiscence, but suture placement in necrotic tissue may play a role.

Magrina argued that robotics represent the future of gynecologic surgery. He likened this innovation to that of laparoscopy over 20 years ago. Initially, universal acceptance seems fraught with concerns, such as limited availability, providers trained in procedure and cost. However, benefits to surgeons and patients, as well as patient demand, will necessitate continued expansion of this modality. Magrina contends that every hospital in the country will have a robot by the year 2020. A lively question and answer session followed the aforementioned presentations.

Magrina returned to discuss ‘Laparoscopic and Robotic Management of the Adnexal Mass’. Characteristics of benign versus malignant masses were reviewed, and the issue of ovarian cysts in pregnancy was addressed. Special attention was paid to the issue of cyst rupture at time of laparoscopy and its impact, if malignant, on prognosis and therapy. Robotic access does not have the versatility of conventional laparoscopy for management of large adnexal masses.

All faculty engaged in a panel discussion: ‘Criteria for the Incorporation of a New Procedure, Material or Device into Your Surgical Armamentarium’. Experts discussed their hospitals’ policies and protocol for introducing new technology to physicians. Each shared opinions as to how physicians should be trained and certified to use new devices. While opinions varied on small details, all agreed that hopitals/eduation programs should have some formal process in place to inspect/review new technology and to incorporate this technology into the clinical realm.

The final conference day included a thorough discussion of ‘Lateral Pelvic Wall Anatomy and Dissection’ by Magrina. Special attention was paid to the anatomy of the hypogastric artery and its branches. Magrina emphasized that the branching of the hypogastric artery can prove quite variable. As such, patient dissection and following these branches for a distance is required to avoid complication.

Gebhart ended the formal lectures with a talk on ‘Avoiding and Managing Lower Urinary Tract Injury’. With the aid of surgical video, common mechanisms of ureteral, bladder and urethral injuries were outlined. The most important concepts were prevention and intraoperative identification. Liberal use of cystoscopy is recommended with intravenous contrast such as indigo carmine. Cost analysis shows that cystoscopy is cost effective with certain procedures such a laparoscopic hysterectomy.

Conclusion

The 2010 Pelvic Anatomy and Gynecologic Surgery Symposium assembled experts in vaginal, laparoscopic and robotic surgery to discuss controversies and dilemma in minimally invasive gynecologic surgery. Attention to basic anatomic and surgical principles was emphasized with assistance from a rich library of surgical video. Vigorous discussions of new and established technology as well as surgical choices for patients were reviewed.