Surgical Approaches

In this post I want to talk a little more about surgical approaches available in gynecologic surgery. The three primary approaches to surgery are laparoscopy, laparotomy, and robotic assisted.

LAPAROTOMY, LAPAROSCOPY, ROBOTIC (1)

Laparotomy is how abdominal surgeries had been performed for centuries. This method has become far less common in the last 20 years. During a laparotomy a large incisions is made spanning the abdomen. Retractors are placed to pull skin, fat, and muscle tissue out of the surgeons way. This gives the surgeon compete access to the inside of the abdomen enabling him to complete procedures using just his hands and surgical instruments. This method is the most invasive, has the longest recover, and leads to the most operative and postoperative complications.

Some complications that are more common in laparotomies then laparoscopic or robotic operations include postoperative scar tissue formation, greater intraoperative blood loss,1 more common occurrence of intraoperative bowel proliferations, greater anesthetic requirement, incision site complications2, post-operative hernia, and infection. All that being said laparotomy is still the fastest surgical approach boasting much shorter operation time then other modalities. Also it allows for greater manipulation of internal organs. Due to these two factors laparotomy is often still the best approach in critical emergency surgeries when time is of the essence or in extremely complex cases where laparoscopic and robotic approaches do not allow enough manipulation of the tissues.

Laparoscopy is a procedure performed by puncturing a small hole through the abdominal wall then inflating the abdominal cavity with gas. Once inflated two to three more holes are puntered and ports are places. The surgeon then slides his instruments through the ports. Typically there is a combination of tools used including, fiber optic cameras, a tool used to cut and cauterize such as bipolar scissors or lasers, and a tool to grab and manipulate tissue. Tools are manipulated seeing the inside of the abdomen to on a screen while moving the instruments with a series of small levers and dials locate outside of the body. As stated above this approach reduces blood loss, adhesions, post-operative pain, incision site complications, intraoperative trauma, etc. when compared to laparotomies. Robotic assisted surgery is similar to laparoscopic. As the name implies, the only difference is that a robot moves the instruments that are inside the body while the surgeon dictates the movements in a controller area.

When it comes to robotic versus laparoscopic surgeries the research seems to show comparable outcomes. Robotic surgery tends to have slightly less intraoperative bleeding then laparoscopic surgery. Laparoscopic surgery tends to take less time then robotic. Neither of these “issues” are extreme enough to cause a marked difference in surgical outcome. According to the research I read the biggest difference is base on the surgeon’s experience with each modality. A surgeon who has completed hundreds of procedures laparoscopically and another surgeon who has completed the same amount of robotic surgeries will have similar rates of success. Laparoscopic and robotic surgery scars are similar in size though number and location can vary depending on multiple factors. Below are some picture of each approach along with post-op scars from a robotic surgery and a laparotomy.

Warning!! Graphic depictions of surgery!

 

 

 

 

 

 

A special thanks to Nina whom I connected with on instagram for allowing me to use the picture of her laparotomy scar. Scars are testimonies to our bravery, keeping fighting powerful warriors.

Stay tuned. My next post will be on ablation vs excision followed by a post on question to ask when trying to find the right surgeon for your operation.

References
1

Laparoscopic-Assisted Vaginal versus Abdominal Surgery in Patients with Endometrial Cancer—A Prospective Randomized Trial Malur, Sabine et al. Gynecologic Oncology , Volume 80 , Issue 2 , 239 - 244

2Yuen, P.m., et al. “A Randomized Prospective Study of Laparoscopy and Laparotomy in the Management of Benign Ovarian Masses.” American Journal of Obstetrics and Gynecology, vol. 177, no. 1, 1997, pp. 109–114., doi:10.1016/s0002-9378(97)70447-2.

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