Nathan Mordel, M.D. »Janet Lefkowitz, D.O. »

Robotic and/or laparoscopic surgery advantages for Jehovah Witness patients​

Hysterectomy (removal of uterus) and, especially myomectomy (removal of fibroids) may be associated with significant blood loss. Since Jehovah Witness patients decline blood transfusion, a blood loss may limit the scope of surgery or pose a risk to their life. Elimination, or at least reduction of blood loss is always desired, but it’s of paramount importance in Jehovah Witness patients.

During laparoscopic surgery, intentionally, CO2 gas is insufflated into and maintained at certain pressure within the abdominal cavity (inside the belly). This is aimed to sustain a distended abdominal cavity to create a safe space for the surgeon to perform the operation. One of the additional desired results of such constant CO2 insufflation is partial compression of smaller blood vessels, especially veins, which reduces the inherent blood loss. In contrary, during laparotomic (open belly incision) surgery, blood vessels are not subjected to increased pressure resulting in higher blood loss.

Robotic surgery is based upon laparoscopic surgery but adds significant advantages to it. Two of these virtues – the three dimensional visualization and higher precision allow better control of blood vessels, thus reducing or eliminating blood loss.

Jehovah Witness patients in need of gynecologic surgery, including hysterectony, myomectomy, and excision of endometriosis benefit greatly from robotically assisted laparoscopic gynecologic surgery.

Most important factor that determines surgeon’s ability to perform any operation

Correct recognition of surgical anatomy is the most important factor that determines surgeon’s ability to perform any safe and effective operation.

Surgeon’s dexterity and availability of assistants, proper instruments and devices are also important but have only a secondary role in achieving a desired outcome.

The more surgical anatomy is complex and significantly altered by disease process, the more challenging it becomes to identify the correct tissue landmarks.

When surgical anatomy is not properly identified, complications such as unintentional organ injury may occur, blood loss may be higher, operation may take longer, infection may develop, blood clots may be formed, reoperation may be required, hospital stay may be prolonged, home recovery extended and return to normal activities delayed.

Surgeon learns correct recognition of surgical anatomy during medical school, residency and fellowship. Surgeon’s dedication and length and quality of the training programs are important in achieving such an intricate skill.

Unequivocal knowledge of three dimensional appearance of different organs, tissues, cavities, blood vessels is the quintessential prerequisite for a surgeon to execute a successful operation.

Ovarian Dermoid Tumor

Ovarian dermoid cyst (cystic teratoma) is a certain type of germ cell tumor. The vast majority (98%) of these tumors are benign (mature) and only 2% are malignant (immature). Dermoids derive from certain cells within the ovary that have the ability to generate different tissues such as hair, skin, bone, cartilage and sebaceous (greasy) fluid.

These tumors can expand and create large masses within the ovary. Due to its significant size, such ovary may undergo torsion (twisting) causing blockage of ovarian blood supply (ischemia) which results in severe pain and possibly loss of the ovary. Spontaneous leakage from or rupture of the dermoid may also happen generating severe inflammation inside the abdomen. Often, these complications necessitate emergency surgery.

Timely diagnosis of ovarian dermoid/s can preclude complications and prevent emergency surgery. Proper bimanual pelvic exam and pelvic sonogram usually are the most efficient means to detect ovarian dermoids. Sometimes CT scan needs to be done as well.

Elective (non-emergent) surgery is best suited to remove the dermoid without compromising the ovary and avoiding spillage of it’s contents inside the abdomen. Minimally invasive surgery, such as laparoscopy or robotically assisted laparoscopy further reduce these risks. Careful and precise extraction of the dermoid while preserving healthy ovarian tissue and avoiding abdominal spillage is paramount. If properly performed, such an operation is outpatient with a relatively short recovery of one to two weeks. Correct completion of such surgery should preserve future fertility.

Minimally invasive removal of Essure avoiding hysterectomy

One of the options for permanent sterilization is hysteroscopic intra-fallopian tube placement of two flexible coils made of a mixture of polyester fibers, nickel, titanium, platinum, silver-tin and stainless steel. Intentionally, after three months, these coils become embedded into lumen of corner of the uterus and lumen of the fallopian tubes. It is called Essure and is an effective permanent birth control device. Unfortunately, some patients develop persistent pain, and suspected allergic or hypersensitivity reactions which can be exhausting.

Removal of Essure coils is the only way to eliminate these quality of life disrupting side effects. Due to permanent embedding of these coils, both fallopian tubes and both lumens of uterine corners need to be removed. Given the complexity of the task, some of these patients, unfortunately, undergo unnecessary hysterectomies.

Robotically assisted laparoscopic removal of Essure coils containing fallopian tubes and lumen of uterine corners is bloodless, spares the uterus and is done in an outpatient setting without the need for overnight stay. Patients can return to normal activities in one week.

Surgical/procedural alternatives to hysterectomy

Hysterectomy, which means removal of the uterus (womb), should always be the last resort in surgical armamentarium. Some of the indications for hysterectomy include menorrhagia (prolonged and heavy menstrual flow) and symptomatic leiomyomata (fibroids). Though the vast majority of hysterectomies can and should be done in a minimally invasive way without overnight stay, it still constitutes a major surgical intervention. Non-hysterectomy interventions need to be considered and exhausted before deciding to remove the uterus.

Endometrial ablation, which means destruction of the uterine cavity lining, can be used to treat menorrhagia (prolonged and heavy menstrual flow). This procedure entails no incisions and no removal of uterus and takes less than 10 minutes to perform. Patients can go back to normal activities in 2-3 days. It is effective in about 75% of cases. The remaining 25% may need a hysterectomy later on.

Myomectomy, which means removal of fibroids, is done to treat symptomatic leiomyomata (fibroids). The vast majority of myomectomies can and should be done in a minimally invasive way without overnight stay. Preservation of the uterus is achieved. If they wish so, patients may get pregnant 3 months after myomectomy.

Uterine fibroid embolization (UFE) is done to treat symptomatic leiomyomata (fibroids). UFE is done in a minimally invasive way with only a small incision in the groin. Fibroids are not eliminated but their volume and activity are decreased. Uterus is preserved. UFE is effective in about 80% of cases. The remaining 20% may need a hysterectomy later on.

Who is a candidate for Robotically assisted Laparoscopic Hysterectomy, Myomectomy, Excision of Endometriosis and Sacrocolpopexy?

Scores of women suffer from huge aching uteri, enormous painful fibroids, debilitating endometriosis and incapacitating pelvic organ prolapse. Many times they had prior abdominal surgeries and/or are obese.

In US each year hundreds of thousands of women undergo hysterectomies (removal of uteri), myomectomies (removal of fibroids), excision of severe (frozen pelvis) endometriosis and sacrocolpopexies (suspension of vagina). The majority are performed by laparotomy which is making a several inch incision through the abdominal wall in order to access the pelvic cavity. Such an incision cuts through skin, fascia and muscle. It requires a several day hospital stay and six to eight week recovery at home. It is also associated with more pain, higher risk of infection, creation of adhesions and scar tissue, weakening of the abdominal wall and hernia formation.

Fortunately, the vast majority of hysterectomies, myomectomies, excision of endometriosis and sacrocolpopexies can be performed using advanced robotically assisted laparoscopic surgery. Laparoscopy eliminates the need for the several inch long abdominal incision, thus significantly reducing the above mentioned unpleasant results and complications.

Every patient suffering from huge aching uteri, enormous painful fibroids, debilitating endometriosis and incapacitating pelvic organ prolapse is a proper candidate for such a minimally invasive surgery, regardless of the size of uterus, number/dimensions of fibroids, severity of endometriosis, extent of pelvic organ prolapse, history of prior abdominal surgeries or obesity.

These conditions present significant challenges for the common OB/GYN to perform such advanced robotically assisted laparoscopic surgery. Therefore, unfortunately, many patients are advised by their doctors, that they are not a candidate for the minimally invasive surgery. Many patients don’t seek a second opinion and end up undergoing the much more invasive surgery, laparotomy.

These patients should not be misguided from undergoing a minimally invasive surgery. Robotically assisted Laparoscopic surgery requires only four to five quarter of an inch to half an inch incisions, no hospital stay and 2-3 week recovery at home.

Benefits of outpatient surgery for hysterectomy, myomectomy and sacrocolpopexy

Traditionally, patients have recovered in the hospital for several days after a major gynecological surgery such as hysterectomy, myomectomy and sacrocolpopexy, Customary justifications for the inpatient stay included better pain control and immediate recognition and care of postoperative complications. However, the following benefits of minimally invasive surgery (MIS) virtually eliminate the need for open abdominal surgery (laparotomy):

Replacement of laparotomy by MIS results in significant pain reduction. Incisions are smaller and disruption of internal tissues is minimized. Pain medications may be reduced versus open surgery.

Early (same day) postoperative ambulation improves total body blood circulation and lung ventilation, greatly decreasing the incidence of clot formation (DVT) and pneumonia. Because outpatient surgery is “less involved” than inpatient surgery, patients released home just hours after surgery feel good enough to move around a bit. They sleep in their own bed, eat in their own kitchen, and use their own bathroom (instead of a bed pan). Obviously, they have no IV’s or catheters, which also helps with ambulation.

Patients are not exposed to hospital borne infections.  

Universal implementation of MIS (vaginal and/or laparoscopic and/or robotically assisted laparoscopic methods) instead of laparotomy can eliminate inpatient hospital stays for patients undergoing major gynecological surgeries, such as hysterectomies, myomectomies and sacrocolpopexies. The combination of less pain, quicker ambulation, fewer infections and the convenience and comfort of recovering at home result is a speedier emotional and physical recovery.

Eliminating open abdominal surgeries in major gynecological operations – hysterectomy, myomectomy and sacrocolpopexy

Unfortunately many women will undergo one (or more) major gynecological surgeries including hysterectomy (removal of the uterus), myomectomy (removal of fibroid tumors in the uterus), and sacrocolpopexy (repair of “fallen” pelvic organs). Most women assume that such surgery is done through an open abdominal incision but in fact, the vast majority of these surgeries could be accomplished using minimally invasive techniques.

Open surgery entails a multi-inch incision cutting through all six layers of the abdominal wall – skin, fat, two layers of fascia (natural “mesh”), muscle, and peritoneum (inner lining). It commonly also involves usage of a self retaining retractor which exerts additional strain on already cut abdominal wall layers, including its blood vessels and nerves. Additionally, the bowel is packed with moist sterile cloths during surgery, slowing down bowel function recovery after surgery. Even months or years after an open surgery, the incision may develop a hernia.

Minimally invasive surgery (MIS), which includes vaginal, laparoscopic and/or robotically assisted laparoscopic methods mostly avoids these problems. A well-trained gynecological surgeon can safely perform a hysterectomy, myomectomy or sacrocolpopexy using MIS regardless of uterine or fibroid size, adhesions and scar tissue, or obesity. Recovery time, pain severity and complication rates after MIS are half and sometimes a third of that of open surgery and cosmetic appearance is preserved as well.  

If you have been told you need a hysterectomy, fibroid surgery, or correction of pelvic prolapse, please contact us to learn if MIS is the best choice for you.


Minimally Invasive Surgery for Fibroids

Minimally invasive gynecologic (MIG) techniques have generated significant improvement in surgical outcomes. The advent of laparoscopic and robotically assisted laparoscopic (L/RAL) method (surgery through 0.25-0.5 inch “holes”) made the greatest contribution in that positive trend. Employing MIG techniques, patients undergoing major surgeries, such as hysterectomies and myomectomies, are able to go home the same day and return to normal activities in only 2-3 weeks. Major complications, such as clot formation (DVT), infection, scar formation, bowel obstruction and incisional hernias are reduced remarkably as well. Unfortunately, the majority of patients are still undergoing the traditional laparotomy (open abdominal incision). This makes them to stay 2-3 days in the hospital, postpones their return to normal activities by 6-8 weeks and increases the rate of major complications.

Thousands of patients afflicted with large fibroids needing a hysterectomy or myomectomy can benefit from L/RAL. Large fibroids are being extracted through small (0.5-0.8 inch) “holes” using special devices called morcellators. These tools are able to cut fibroids into smaller fragments enabling their removal through these small incisions.

Recently (4/17/2014) and surprisingly, the FDA issued a safety communication stating “FDA discourages the use of laparoscopic power morcellation during hysterectomy or myomectomy for the treatment of women with uterine fibroids”. It’s important to note that the FDA didn’t ban morcellation. The FDA continues it’s investigation and will issue final recommendations later this year. The concern expressed by the FDA stems from a possible risk of spreading sarcomatous (certain cancerous) tissue that could be inside these morcellated fibroids throughout the abdomen. The FDA stated that risk of sarcoma in fibroids is 0.3%. The Society of Gynecologic Oncologists (SGO) reported that the risk to be 0.1%. This means that out of every 1000 patients with fibroids, 1-3 will have sarcoma within a fibroid. There is no reliable way to diagnose sarcoma prior to surgery.

Sarcoma is known to spread through blood vessels and, unfortunately, at the time of diagnosis, the distant dissemination has already occurred. Therefore, if sarcoma is unknowingly morcellated, the possible detrimental impact of intraabdominal spread is at best, questionable. On the other hand, banning morcellation from 99.7-99.9% of patients who have benign fibroids, will cause them to undergo traditional laparotomy surgery (instead of L/RAL) and subject them to significantly longer hospital stays, longer recovery at home and higher risk of complications. These complications could be deadly as well. Patients afflicted with obesity, diabetes, risk for clotting or desiring to preserve fertility could suffer especially.

Any surgery is not without risk. Therefore, all conservative measures need to be exhausted before deciding to undergo an operation. Once a decision to proceed with surgery is made, careful risk/benefit analysis needs to be done. If the benefit outweighs the risk, then the least potentially harmful operation has to be chosen. MIG in general and L/RAL in particular can minimize complications. The 0.1-0.3% risk of sarcoma in fibroids with questionable morcellation harm needs to be weighed against well proven complication reduction in 99.7-99.9% of patients with benign fibroids.

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