Minimally Invasive Gynecologic Surgery

Leigh Matlaga, MD

Department of Obstetrics and Gynecology

The best surgery is an indicated surgery

• Trial of medical management for fibroids, endometriosis, painful or heavy periods

• Complete evaluation• NSAIDs• Birth control pills, patch, ring• Depo-provera• Mirena IUD, nexplanon• Lysteda• Endometrial ablation• Uterine artery embolization

Minimally Invasive Surgery

• For hysterectomy

• For myomectomy

• Vaginal surgery

• Laparoscopic and robotic surgery afford less bleeding, pain, better cosmetic outcomes

• Same day surgery with same day discharge

Morcellation Controversy

• In patients with fibroids and hysterectomy risk of sarcoma – 1/300– 2.5/1000

• Rare but important to consider• Favors surgery, but removal of specimen needs

to be considered– Power morcellation– Vaginal removal– Minilaparotomy– Open incision

Preoperative Evaluation

• Pap smear• Ultrasound• MRI• Endometrial biopsy• CBC, iron studies• Treatment of anemia• Bloodless Medicine department consultation

• Cell saver system

Postoperative Management

• IV iron

• Supportive therapy

• Embolization

Journal of Minimally Invasive Surgery

2/2014 Lehigh Valley Health Network

• Recent study (February 2014) regarding blood loss from four different methods of hysterectomy

Method Average EBL Readmission Days

Robotic 108.2 mL 1% (6)

Laparoscopic 315.0 mL 2.58% (11)

Open 318.0 mL 3.52% (42)

Vaginal 340.0 mL 2.41% (8)

Mean Length of Stay: Less time, less

readmission cost

Method Minutes Readmission Cost

Robotic 1570.0 $32,946

Laparoscopic 3038.5 $50,290

Open 3440.5 $328,230

Vaginal 3789.2 $51,264

da Vinci® Si™ Surgical System

19992000200120022003

da Vinci ® Surgical System U.S. Installed Base

1999 – 2010

2004

Alaska

2005

Hawaii

2006200720082009

Puerto Rico

2010

Value = Efficacy ÷ Invasiveness2

•

•da Vinci •Open

Surgery

Alternative

Therapies

Open Surgery da VinciIncision Hysterectomy

Incisions*

Hysterectomy

• 600,000 per year

• 90% benign indications

• Women in the US: 1 in 3 in their lifetime• Women in the UK: 1 in 5 in their lifetime• Indications

– Bleeding: fibroids– Pain: endometriosis– Cancerous and precancerous conditions of

the uterus, cervix, ovaries

Myomectomy

Ovarian Cystectomy

Fibroids

Adhesions

In Conclusion

• Minimally invasive surgery offers less blood loss and better cosmesis.

• 3D visualization, improved haptics, precise instruments with natural movement.

• Offers opportunity for improved recovery time and minimal or absent overnight hospitalization.

• Available in gynecology, general surgery, bariatrics, urology, and thoracic surgery at MedStar Franklin Square Medical Center.

THANK YOU