In this episode of PodMD, Obstetrician, Gynaecologist and Laparoscopic Surgeon Dr Basia Lowes will be discussing the topic of minimally invasive surgery in gynaecology, including how the minimally invasive surgery is undertaken, how to refer to the right surgeon, the benefits of minimally invasive surgery, the specific risks invovled in surgery, post-operative tips and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Basia Lowes
Dr Basia is an experienced Obstetrician & Gynaecologist based in Sydney, with additional training in Advanced Laparoscopic surgery accredited by the Australian Gynaecology & Endoscopy Surgery Society.
While achieving her Obstetrics & Gynaecology specialisation in 2020, Basia also completed her Masters in Women’s Health Medicine and a Master’s in Advanced Gynaecological Surgery in 2021.
Basia’s mission is to provide women-centred, holistic and integrated care for women’s health concerns at various stages of her patients life journey; focusing on empathy, education & empowerment for her patients throughout the decision-making process.
Today, we’ll be discussing the topic of minimally invasive surgery in gynaecology.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Basia, thanks for talking with us on PodMD today.
Basia: Thank you for having me.
The topic of today’s discussion is minimally invasive surgery in gynaecology. Basia, can you give us a brief overview about minimally invasive surgery in gynaecology?
Basia: Thank you so much for having me. I’m very excited to be here to talk about this topic as this is an area of specialist training that I’ve undertaken myself as a gynaecologist. So our minimally invasive gynaecological surgery is essentially the use of less invasive techniques such as laparoscopy, so keyhole surgery through the abdominal wall or hysteroscopy, so surgery through the cervix into the uterus to treat surgically any kind of benign gynaecological conditions that might be requiring treatment.
We know that these minimally invasive techniques require only a few incisions, and in some cases for example in Hysteroscopy no incisions to the abdomen rather than the traditional large incision or midline laparotomy that you may have seen in the generations past. Some of these procedures can also be done on an outpatient basis so the patient doesn’t actually need a general anaesthetic. Or most of them require very short hospital stay of one or two nights or even a same day discharge if everything goes well.
So we’ll cover some of the conditions in the next question, but really, it’s a really exciting space because actually it was gynaecologist to back in the 60s and 70s started to do laparoscopic surgery, in terms of [inaudible] ovarian cysts, and those techniques were actually then taken up by general surgeons, colorectal surgeons, urologists to develop laparoscopic surgery into basically the standard of care and the gold standard for operating in various domains, not just gynaecology.
So that’s why someone like myself who finished in general O&G training, had an interest in undertaking extra fellowships and a masters in developing more skills in these minimally invasive techniques and advanced techniques. Certainly there’s a lot of developments coming and robotics coming on board and I’ll touch a little bit on that in this podcast. But it’s a really exciting space and you’ll see lots of your patients who may have conditions that would benefit from minimally invasive gynaecological techniques, in particular you know women with endometriosis, it’s really revolutionised the way we can in detail resect endometriosis.
We now are able to do hysterectomies even of reasonably large uteruses with keyhole, half a centimetre cuts, which means a woman has a much better recovery we can treat fibroids and also various infertility conditions with these minimally invasive techniques, which is great because not only does it improve our women quality of life, but also potentially allows her to go on and start a family.
What gynaecological conditions are amenable to minimally invasive techniques and laparoscopic surgery and what type of patient should a GP refer?
Basia: So as a gynaecologist and laparoscopic surgeon I see a whole vast of benign gynaecological conditions that can be treated if needed with minimally invasive techniques, and I’m going to focus on benign conditions rather than malignant conditions because we do find that if there’s a suspicion of malignancy or confirm malignancy, some of these patients will be better off having an open procedure.
But in terms of healthy young women and we would see women with ovarian cysts with endometriosis, with any issues with their periods, for example, heavy painful periods. Women with pelvic pain fibroids or uterine polyps in women with more in the middle to later stages of their life, a gain, we would look at, managing fibroids, abnormal uterine bleeding, menorrhagia, polyps, issues with endometriosis and pelvic pain and in this age group we start to see women who come with issues regarding incontinence and pelvic organ prolapse and there’s are certainly fantastically skilled surgeons around who can perform minimally invasive pelvic prolapse procedures and also procedures to manage incontinence as well.
So really the whole array of patients that are GP might see in different life stages with these gynaecological complaints could benefit from seeing a gynaecologist who has experience in minimally invasive procedures. Some of these procedures would need a laparoscopy, so keyhole surgery through the abdomen to manage but other conditions for example, issues around your own fibroids, polyps, or heavy bleeding could be managed just through hysteroscopy techniques so through the uterus without any incisions to the abdomen.
And they might include resection or ablation of the endometrium to help treat the bleeding. Obviously, if at any stage at of the surgery process we identified that there might be suggestion of a malignancy, benign gynaecological surgeons would then refer to GYN oncologist, and communicate that to the GP, and I would just also add that you know, in the generation of IVF and lots of women looking at some help with managing fertility issues and conception, minimally invasive techniques have also really come to the floor and are often a part of the management process for infertility.
We can use laparoscopy and hysteroscopy to diagnose any structural or anatomical problems that might be contributing to infertility, but we can also use these techniques to manage these problems. So for example, dividing adhesions, resecting endometriosis, respecting fibroids laparoscopically or hysteroscopically or managing any issues with polyps or abnormalities of the uterus that could cause problems with implantation, and definitely a fertility specialist and minimally invasive gynaecologists such as myself do have that extra training inn helping these women along their journey and improving outcomes and it’s really amazing after a surgery when they get pregnant and carry a baby and being part of that journey is really wonderful.
How is minimally invasive surgery undertaken?
Basia: Yeah, so great question. There are essentially two types of memory, invasive procedures in gynaecology. One is hysteroscopy and one is laparoscopy. So Hysteroscopy is essentially a procedure whereby a very thin camera is introduced into the cervix of the uterus while the patient is under general anaesthetic so they don’t feel any pain. It allows us to look at the cavity and to see if there’s any causes, for example for bleeding such as fibroids or polyps, also lets us actively treat any of these conditions weather by resection or ablation and also manage certain findings that might contribute to infertility.
Some hospitals or services actually do hysteroscopy in an outpatient setting with the patient being awake so that minimises any risk of general anaesthetic. But I find that most patients do prefer to be asleep for the procedure. Laparoscopy, something you’re probably familiar with, because a lot of other surgeons use it as well. But it is a minimally invasive procedure whereby a little port is introduced via the usually the belly button and gases inflated into the abdomen to allow us to see all the structures. We then insert smaller ports via about 5 millimetre incisions to allow us to place instruments down to perform the procedure that is required and the at the end of the procedure of gases deflated and the little incisions are closed with just dissolvable stitches.
Usually the patient stays overnight but can also potentially go home the next day and in addition to this and I’ll talk a little bit later in the podcast we’ve now started to develop more advanced techniques utilising robotics to aid laparoscopic minimally invasive surgery, which is really exciting and I’ll cover that a little bit later in the podcast.
How would a GP know how to refer to the right surgeon or specialist in Minimally invasive gynaecological surgery?
Basia: That’s a really great question because it’s a question I get asked often by a lot of medical colleagues. Essentially, in the last, in the last decade or so minimally invasive gynaecological surgery, the surgery has started to become really a kind of subspecialty in its own rights, given that it requires a commitment to training and getting really comfortable with a lot of the new developments and advanced techniques and advanced technology that’s coming out.
So a lot of O&G’s who have come through the training programme in the last few decades haven’t necessarily had that higher level exposure to the advances that have happened, sort of in the last decade, and so they’ll be able to certainly manage basic entry level conditions such as ovarian cysts, bleeding, fibroids, but may not have the necessary advanced training, for example, for higher end in endometriosis resection and laparoscopic myomectomy or performing keyhole hysterectomy or laparoscopic hysterectomy.
So I think it’s really important when you’re thinking about referring a patient to a surgeon because they think they’ll need a minimally invasive procedure is to do some research around the surgeons training and some of that might be available on their website. So in particularly we’re looking for surgeons who’ve done a committed laparoscopic or advanced gynaecological fellowship, which is usually two years of extra training so for example myself I’ve undertaken 2 extra years of training in the unit that does high volume, minimally invasive surgery in addition to my general O&G training and this sort of fellowship is accredited by the Australian Gynaecological and Endoscopy Surgery, Society or AGESS for short and there’s stringent requirements that have to be met in terms of assessment and examination and meeting the skills that are required.
So when a GP is looking for a surgeon, they should really look at their website and see if this surgeon is accredited or trained via societies such as AGESS or has done a similar type of fellowship. If that information is not available, it might be useful giving the secretary of call and particularly asking around the skill set or the interest of that surgeon because again, certain surgeons might have a core skill set more in endometriosis, some more in hysterectomy others more in managing pelvic organ prolapse via minimally invasive ways. So doing a little bit of research beforehand, or asking medical colleagues are asking other O&Gs is really important.
I would just add that now hospitals and also our college and also AGESS are becoming certainly a lot more strict in terms of how they create credentials surgeons who practise in minimally invasive skills and surgery for gynaecology. So we rank the procedures that we do based on levels from one to six, and certainly those advanced surgeons who have that extra training are accredited to perform those higher end, more difficult level 5 and six procedures, whereas people coming out of a general programme are more accredited to a Level 3 and four.
So if you can have that knowledge before referring the patient, or at least some idea about the interest in the skill set of the surgeon, you’re thinking of referring to, it really means that the patient goes and sees the right person at the get go and doesn’t need to then seek out referral to other surgical colleagues who might be required to help with more difficult operations.
What are the benefits of minimally invasive surgery in gynaecology?
Basia: Yeah, excellent question and one that we know a lot about because there’s certainly been a lot of data published in the last couple of decades regarding the benefits of minimally invasive laparoscopic surgical techniques. We know that there is certainly evidence of degree decreased blood loss at surgery, less need for blood transfusions, generally, patients who have minimally invasive techniques require much less opiate post operatively and they have decreased post operative pain scores come because the cuts are smaller and they don’t have that one big large cut that can generate a lot pain.
We know that there’s also a shorter hospitalisation rates and the patient can go home much more quickly. Many patients after laparoscopy will even go home on the same day and there are actually some units who are now doing laparoscopic hysterectomies with same day discharge because the patients do so well. Overall, the patient will recover faster to their baseline daily activities following a minimally invasive procedure then they will after laparotomy or an open procedure. And data does show that there’s generally less post operative and perioperative complications.
So women undergoing minimally invasive procedures are have less issues with wound infections, with wound dehiscence, there’s a lower rate of developing postoperative clots and again all the kind of complications associated with long term heavy pain relief use, which is often the case if you’ve had an open procedure. So definitely minimally invasive gynaecological surgery is now the standard of care for a lot of benign conditions and so it should be, because the benefits are clear.
So one thing I just wanted to add from the perspective of a surgeon doing this type of surgery, we really see the benefits in terms of the high magnification that we can get, getting really close up to the pathology which we don’t get with an open procedure and it just means that for cases for example, within endometriosis, we know this is the gold standard now because with the really close up camera work and the fine instruments we can get really good resection of the disease completely because often in endometriosis the deposits are only a couple of millimetres or less in size.
Adding to this with complex surgery, so a patient, for example, who has had lots of other procedures, and there’s a lot of adhesions in the abdomen, I find laparoscopic surgery to be superior to open techniques because it really allows us to get right up close to divide those adhesions really carefully, and see all the structures up close and some of the new advanced instruments that we use are excellent at helping achieve this.
So in my mind, this type of surgery compared to traditional open surgery means that where we’re hopefully safer in in our dissection, in in situations where the patient is quite complex and we’re achieving much better outcomes in terms of treating the condition and restoring the anatomy.
What are the specific risks to laparoscopic surgery that gynaecology patients need to be aware or?
Basia: Yes, so important question because obviously patients will come and see their family doctor, to possibly go through these once they’ve seen a surgeon. So, just to recap that laparoscopy is the process of keyhole surgery through the abdominal wall, using small incisions and gas to look into the abdomen at the same time. So the risks of surgery are all well known to us, we counsel patients about the general risk of infection and bleeding gum, the risk of thromboembolism and also the risk of damage to other organs that are potentially around where we are operating.
Really, when we look at the datam, the complications with laparoscopic surgery are really quite rare between 3-6 in 1000 cases and the really serious ones are even rarer than that. But we do tend to cancel our patients to be wary that there is a very small risk of damage to other organs such as perforation of the bowel, perforation of the bladder and potential damage to the ureters that carry the urine from the kidneys to the bladder. And a lot of these can be recognised and fixed at the time, but I just need to reinforce that you know, in the hands of a skilled surgeon, those complications are really, really quite rare, and there is a very remote risk obviously of bleeding or damage to vessels, weather in the abdominal wall or or other parts of the pelvis.
Again because we’re using gas are very rare risks associated with gas embolus or anaesthetic and overall I find the post operative recovery is good and actually the most common sort of issues that arise are around that recovery and things like managing Constipation, managing post-op nausea and vomiting, and managing pain. And if those are done well and the patient mobilises early starts on a good diet and has good postoperative pain relief, they can really genuinely bounce back and have a really good recovery with coming back to their baseline activities really quickly.
Have there been any recent developments in the are of gynaecological laparoscopic surgery or are there any key trials or developments happening now?
Basia: Oh so many and I certainly would love time to go through them in great detail. As you can see, it’s a topic that I’m really interested in, but I guess the main thing to touch on that in the last decade there’s been great advances in terms of some of the devices and techniques that we use. So a lot of the basic electrical surgical devices that have been around for decades have been upgraded because companies have done a lot of product development and now we have amazing devices that conceal vessels and cut at the same time that are really useful for dissection of adhesions. And really they make the procedure a lot quicker and a lot safer for the patient, which again means a shorter anaesthetic and a quicker recovery time.
There’s also been a lot of research and talk done around extracting the specimen so in particular with fibroids and the minor risk of malignancy and some fibroids, extracting them safely in a minimally invasive way so morcellating them in a bag so that there’s no spread of any cells around the abdomen, and that allows us to really extract large fibroids, 12 to 13 centimetres through these very small incisions that are only a couple of centimetres in length and that means a really great cosmetic and pain management result for the patient.
The other one thing I wanted to touch on is that there’s great advances in surgical approaches in minimally invasive surgery as well, which I think will only skyrocket in the next couple of decades, in particular around robotics. You may have patients coming to see you now saying the doctor recommended a robotic procedure or robotic hysterectomy, and certainly in gynaecology, we’re seeing more and more uptake by surgeons using robot. It basically means that the surgeon is operating from a console next to the patient, whereas the robotic instruments adopt in the same way as laparoscopic instruments adopt.
It does allow for a complete 3D view. The visualisation of the pathology is amazing and also the instruments atually allow us to move like we would in real life with our hands so 360 articulation in all directions and again that makes really difficult surgery, so for example, in the context of stage 4 endometriosis or very large fibroids or very large uteruses, far more ergonomic and conducive to having a better outcome in it and a quicker operation than with standard laparoscopic instruments.
So although the data is not showing a clear benefit between robotics and stand laparoscopy and gynaecology at the moment, from my experience, certainly with the more difficult cases, and we are seeing more of them as people have more surgeries in their lifetime, particularly around endometriosis surgery, robotics is a really great modality to make difficult cases far more manageable and I’ll just touch on the fact that there are some surgeons in Australia now doing single porch laparoscopic surgery.
So essentially operating through one port via the umbilicus, where all the instruments can be inserted in, and again, that’s a great cosmetic result for the patient, because there’s only one incision at the umbilicus, and there’s also a new technique that’s coming out of Europe that’s been taking up here called VENOFs, that stands for vaginal natural orifice surgery and it essentially is a combination of laparoscopic surgery and vaginal surgery for hysterectomy that’s done through the vaginal canal and it means that we’re using laparoscopic instruments, but we’re doing it through the vagina term of the uterus, and so the patient doesn’t have to have any incisions on their abdomen for the surgery which is amazing and so I would say watch this space as you may be seeing more patients coming back to GPs after that type of operation.
How can I GP help prepare patient for such surgery and are there any specific pre- operative preparations they should be aware of?
Basia: A fantastic question we really rely on our GP colleagues to help collaborate in, you know pre and post op care for our gynaecology patients. So making sure that after the initial review, if the patient comes to you with any questions or concerns, potentially you flag them back to the surgeon if something hasn’t been sort of covered or explained very well preoperatively, optimising any of their medical conditions is obviously very important as this will help their recovery particularly around blood pressure management, diabetes management, because that affects wound healing.
And also looking at a plan for any anticoagulation that they might use because we need to look at potentially seizing this, so making sure that the surgeon has good information from the cardiologist or the haematologist to look at preoperative anticoagulation planning. So the GP is really part of that information sharing for the team. We tend to not require any specific pre-op diets, but some patients may come to you with questions and a request from the surgeon for bowel prep and in more difficult surgeries, particularly stage four endometriosis where there might be bowel lesions or in need for a bowel resection or a colonoscopy. It’s really important that the bowel is well prepped and the patient understands the importance of that.
I’m obviously looking at any preoperative weight loss. Some surgeons will delay surgery until patients with a high BMI have been optimised a little bit more because those patients that are generally at higher risk of complications from laparoscopy and also talking to them about general things such as smoking, optimising any lung issues prior to the general anaesthetic is really important from the perspective of an anaesthetist.
We may also ask the GP to help coordinate some preoperative imaging. For example, MRIs or deep infiltrating endometriosis scans and we are certainly using those modalities more and more in our preoperative planning for difficult gynaecological operations. So, knowing that those are important tests to do prior to the surgery is good for the GP to know.
Do you have any tips for post-operative care of such patients and any warning signs to look out for?
Basia: Yes, so obviously the patients having minimally invasive gynaecological procedures are often discharged over the same day or within a couple of days of surgery, and they will generally go home with simple analgesia such as Pandol or Nurofen, because their pain is generally of a good level.
They would generally return to their GP for follow up before their surgical follow up at about six weeks after surgery, so some of the things that they might require advice on and help with are wound care andchecking the incisions to make sure that they’re healing nicely that the stitches are dissolving nicely, and there’s no evidence of infection. So starting antibiotics early if you think that there are any concerns for infection, I find that one of the most common issues is really post operative gas retention and constipation.
Despite trying to get all the gas out at the end of the operation, there’s always some gas left in the tummy and until the bowels reabsorbed that gas and the patient starts passing wind, they tend to be a little bit tight and uncomfortable, and it’s really important to encourage them to mobilise state, active and also maintain good bowel health.
With fibre and stool softeners, because it’s often the constipation that’s the big component of any worsening pain post laparoscopic surgery. Making sure that the pathology from any of the surgery is followed up by the surgeon and the patients receive that information is also important because sometimes further investigation or further procedures would need to be undertaken. In terms of warning signs, it’s really usually in the first few days to a week that if there’s something serious going on, it will start to manifest. So if your patients coming to you with new onset of fevers, new onset of blood in the urine, not passing wind or stool at all, increasing abdominal pain and suggestions of an acute abdomen, peritonitis.
Or in the context of non-hysterectomy surgery, if there’s sort of sudden onset new fresh bleeding with any changes in the odour, to the discharge. We really need to be seeing those patients quickly, either through the emergency or direct referral back to the gynaecological surgeon, because they may need further investigation to rule out any complications.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on minimally invasive surgery in gynecology?
Basia: Yes, so thank you again for having me here today to talk about a topic that I’m really passionate about and I’ve sought to certainly enhance my skill set in. The three take home messages really are to understand that minimally invasive surgery is here to stay, ot’s really the standard care for many benign gynaecological procedures. So patients who come and see you may have lots of questions about that, and also questions about some of the new options that are that are starting to come out, including robotic surgery, VENOFs surgery and single site surgery so I would certainly encourage patients to be referred to doctors who practise minimally invasive techniques because the data does show that the post operative outcomes and the recovery and the cosmetic results are far better than open procedure.
On that note, the second take home point are that we you know the GP needs to understand that there are ways that we prepare our patients for the procedures before we decide that laparoscopic surgery is the right option for them, including maybe asking for imaging with a deep infiltrating endometriosis scan to rule out stage four endometriosis or MRI scans in particular in the context of endometriosis, adenomyosis and large fibroids. Because there are some patients who minimally invasive techniques will not be suitable for and that might include really large complex pathology and also in cases where there’s a suspicion of malignancy, an open procedure might be better for that patient.
And I guess the Third Point that I touched on is finding the right surgeon for the operation is really the key here for optimising your patients chance at having the right procedure done once, and an optimal outcome and good post op recovery, it also means that you’re minimising multiple referrals if the initial surgeon that you referred the patient to come is perhaps not highly skilled in this area or doesn’t have an interest in minimally invasive techniques, so taking some time to research the surgeon, look at their website.
Perhaps go onto the Australian gynaecological endoscopy, surgery or AGESS website to get some more information about surgeons in your area and asking your colleagues for surgeons that they would recommend and really look for the surgeons that have committed to that extra fellowship in advanced gynaecological surgery such as myself. Because we are really up to speed with not only the current evidence-based outcomes but also the new procedures that are coming out and have a high volume of operating, which means that as surgeons, we’re keeping our skill set really current to provide the best outcomes for our patients.
Thanks for your time and the insights you’ve provided.