Urogynecology Pelvic Surgery

Approximately fifty percent of women who have experienced childbirth have varying degrees of pelvic organ prolapse that affect the vagina. Some of these conditions can include:

• Vaginal Prolapse. Where the top of the vagina loses its support and drops, this condition occurs most often with women who have had a hysterectomy. Vaginal Prolapse can cause include difficulty urinating, bowel function, painful intercourse, vaginal pain loss of bladder control and a feeling of heaviness in the vaginal area.
• Small Bowel Prolapse (Enterocele). A condition when the small bowel presses against and moves the upper wall of the vagina causing a bulge or hernia to form.
• Anterior Vaginal Prolapse (Cystocele). A bulge or cystocele forms on the front wall of the vagina and causes a loss of support to the bladder that rests on that area of the vagina. Symptoms can include incontinence, a feeling of pelvic heaviness or back pain.
• Posterior Vaginal Prolapse (Rectocele). A condition when the rectum bulges into or out of the vagina. May cause difficulty with bowel movements.

Proper diagnosis is essential in treating pelvic support conditions. Being open about symptoms with your physician is important in finding the exact cause. Depending upon your symptoms and the type or vaginal prolapse you are diagnosed as having, treatments can include special exercises, lifestyle changes, the use of pessaries, changes in diet and lifestyle, reconstructive surgery and obliterative procedures to narrow and shorten the vagina.

Vaginal Prolapse Treatment

In treating or repairing vaginal prolapsed” apical” suspensions are used to restore the support of the top of the vagina (vaginal vault). Procedures used include:

• Abdominal Sacral Colopexy (ASC) – performed through an incision in the abdomen either laparoscopically or robotically, ASC involves the use of graft material to reinforce the walls of the vagina by forming straps that, when attached to the ligaments overlying the sacrum, support and suspend the vagina over the pelvic muscles and backbone.
• Uteroscral or Sacropinous Ligament Fixation – this procedure involves suspending the vagina to a patient’s own uterosacral ligament or sacrospinous ligaments. Graft material can also be added to improve the durability of the repair.

Small Bowel Prolapse (Enterocele) Treatment

The surgical procedure to correct this condition is called a sacral colpopexy. The surgical procedure uses polypropylene or biologic grafts so as to close over the apex of the vagina and correct the bulge or herniation of the small bowel into the vagina. The procedure approaches the vagina intra-abdominally. It is a complicated procedure in which a Y shaped mesh is positioned over the apex of the vagina and re-suspended to the sacrum.

Anterior Vaginal Prolapse (Cystocele) Treatment

A cystocele repair elevates the anterior vaginal wall back into the body to support the bladder. This can be done either vaginally or through an abdominal approach at the time of a sacral colpopexy. In an anterior colporrhaphy, an incision is made in the front wall of the vagina. The vaginal skin is separated from the bladder wall behind it.  The weak or frayed edges of the deep vaginal wall are found and the strong tissue next to edges are sutured to each other lifting the bladder and recreating the strong ”wall” underneath it. 

Since this part of the pelvic floor is subjected to significant pressure with each cough or when picking up heavy items,  up to one third of women will develop recurrent anterior prolapse after an anterior colporrhaphay.  To reduce this recurrence, a surgeon may use graft material over the repair to reinforce it.

Posterior Vaginal Prolapse (Rectocele) Treatment

If muscles at the vaginal opening are stretched or separated at childbirth, this condition can be corrected by a perineorrhaphy. It may also be corrected abdominally during a sacral colpopexy. To correct the vaginal bulge, a surgical procedure called an anterior colporrhaphy is performed to raise the back wall of the vagina back into the body to support the bladder.

A posterior coloporrhaphy is a procedure used to repair the rectal bulge that protrudes through the back wall of the vagina. In this procedure, an incision is made in the back wall of the vagina. The vaginal skin is separated from the rectal wall underneath.  Once the weak or frayed edges of the deep vaginal wall tissue are identified, the strong tissue next to edges is sutured to each other to recreate the wall between the rectum and the vagina. Occasionally, a surgeon will use graft material to provide additional strength to the repair.

Gynecologic Oncology Pelvic Surgery

Hysterectomy Options

Physicians perform hysterectomy - the surgical removal of the uterus - to treat a wide variety of uterine conditions. Each year in the U.S., doctors perform approximately 600,000 hysterectomies, making it the second most common surgical procedure for women. ¹

Types of Hysterectomy

There are various types of hysterectomy that are performed depending on the patient's diagnosis. All hysterectomies involve removal of the uterus. What can vary are which additional reproductive organs and other tissues that may be removed. Types of hysterectomy include:

• Partial or subtotal hysterectomy: This procedure, also known as a supracervical hysterectomy, involves removing the uterus, but leaves the cervix intact. This decision is often based upon patient preference. Some women feel that leaving the cervix intact will preserve sexual function following surgery. ²
• Total hysterectomy: This procedure involves removing the uterus and the cervix. The vagina remains entirely intact. This is the most common type of hysterectomy performed.
• Removal of lymph nodes: For hysterectomies performed for malignant conditions - such as uterine, cervical, or ovarian cancer - the surgeon will also remove certain lymph nodes. This procedure is often referred to as a lymph node dissection or lymphadenectomy. Lymph nodes will be removed in certain areas, depending upon the location and extent of the disease. Lymph node removal also helps your surgeon determine the extent or stage of your cancer, and can guide further adjuvant treatment, such as radiation therapy or chemotherapy.
• Removal of the fallopian tubes and ovaries: These organs may or may not be removed during your hysterectomy procedure. This will depend upon your condition, age, and other factors. Often, the ovaries and fallopian tubes are left intact. 3 Removal of the ovaries is called an oophorectomy. Removal of fallopian tubes and ovaries is called a salpingo-oophorectomy.
• Radical hysterectomy: This procedure is most often performed for cervical cancer, and involves removal of the uterus, tissues next to the uterus, the upper part (about 1 inch) of the vagina and pelvic lymph nodes. The fallopian tubes and ovaries may also be removed

Approaches to Hysterectomy

Surgeons perform the majority of hysterectomies using an "open" approach, which is through a large abdominal incision. An open approach to a hysterectomy requires a 6-12 inch incision.

A second approach is vaginal hysterectomy, which involves the removal of the uterus through the vagina, without any external incision or subsequent scarring. Surgeons most often use this minimally invasive approach if the patient's condition is benign, when the uterus is a normal size and the condition is limited to the uterus.

In laparoscopic hysterectomies, the uterus is removed using instruments inserted through small tubes into the abdomen, resulting in 3-5 small incisions in the abdomen. One of these instruments is an endoscope - a small miniaturized camera - which allows the surgeon to see the target anatomy on a standard 2D video monitor. A laparoscopic approach offers surgeons better visualization of affected structures than either vaginal or abdominal hysterectomy.

You may encounter shorthand abbreviations describing different approaches to hysterectomy. Some of these are as follows:

• Total Laparoscopic Hysterectomy (TLH): The uterus and cervix are removed using laparoscopic instrumentation through 3-5 small incisions made in the abdomen.
• Laparoscopic Supracervical Hysterectomy (LSH): The uterus is removed, but the cervix is left in tact, using laparoscopic instrumentation through 3-5 small incisions made in the abdomen. The uterus is removed through one of the small incisions using an instrument called a morcellator.
• Total Vaginal Hysterectomy (TVH): The uterus and cervix are removed through an incision deep inside the vagina. This is often the surgical approach to treat uterine prolapse.
• Total Abdominal Hysterectomy (TAH): The uterus and cervix are removed through a large abdominal incision. The incision size can vary from 6-12 inches, depending upon the patient's condition.

While minimally invasive vaginal and laparoscopic hysterectomies offer important potential advantages to patients over open abdominal hysterectomy - including reduced risk for complications, a shorter hospitalization and faster recovery - there are inherent drawbacks. With vaginal hysterectomy, surgeons are challenged by a small working space and lack of view to the pelvic organs. Additional conditions can make the vaginal approach difficult, including when the patient has:

• A narrow pubic arch (an area between the hip bones where they come together) ⁴
• Thick adhesions due to prior pelvic surgery, such as C-section ⁵
• Severe endometriosis ⁶
• Non-localized cancer (cancer outside the uterus) requiring more extensive tissue removal, including lymph nodes

With laparoscopic hysterectomies, surgeons may be limited in their dexterity (since the instruments are straight and rigid) and by 2D visualization, both of which can potentially reduce the surgeon's precision and control when compared with traditional abdominal surgery.

da Vinci^® Hysterectomy

One in three women in the U.S. will have a hysterectomy before she turns 60.1 While no woman wants to face surgery, today the vast majority of gynecologic conditions - from endometriosis to uterine fibroids, heavy menstrual bleeding to cancer - can now be treated effectively without a big incision. With da Vinci^® Surgery, a hysterectomy requires only a few small incisions, so you can get back to life faster - within days rather than the usual weeks required with traditional surgery.

da Vinci Surgery enables gynecologists to perform the most precise, minimally invasive hysterectomy available today. For most women, da Vinci Hysterectomy offers numerous potential benefits over traditional open surgery, including:

• Significantly less pain ⁴
• Minimal blood loss and need for transfusion ^{5, 6}
• Fewer complications ^{6, 7}
• Shorter hospital stay ^{6, 7}
• Quicker recovery and return to normal activities ^{3, 4}
• Small incisions for minimal scarring
• Better outcomes and patient satisfaction, in many cases ⁵

Surpassing the limits of conventional laparoscopic surgery, da Vinci^® is revolutionizing gynecologic surgery for women. No wonder more and more women are choosing da Vinci^® Surgery for their hysterectomy.

If you have been putting off surgery to resolve a gynecologic problem, it may be time to ask your doctor about da Vinci^® Surgery.

1. http://womenshealth.gov/faq/hysterectomy.cfm
2. http://medical-dictionary.thefreedictionary.com/partial