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1. Hysterectomy

Robotic Hysterectomy Q & A

by David Ahdoot, MD, FACOG

What Is a Robotic Hysterectomy?

A robotic hysterectomy is also known as a “laparoscopic hysterectomy.” Robotic hysterectomy is a surgical technique in which the surgeon controls a robotic arm during the procedure. The robotic approach allows the surgeon to essentially have extra “hands” that are able to make extremely precise movements. Robotic hysterectomy can be performed through a small incision thanks to the high degree of control this method offers.

How Is a Robotic Hysterectomy Different From an Open Hysterectomy?

A robotic hysterectomy is less invasive than an open hysterectomy, and it has a much smaller incision. Since the robotic method is so much less invasive, most patients spend less time in the hospital and experience reduced blood loss, fewer complications and less pain than with an open hysterectomy. Ultimately, the great majority of women who opt for a robotic hysterectomy have an easier and faster recovery than they would with an open hysterectomy.

What Can Patients Expect on the Day of the Surgery?

On the day of the surgery, patients undergo a prep period of about one hour. The surgery is typically done under general anesthesia so that patients will be sleeping peacefully during the entire procedure. Patients may be given antibiotics prior to the surgery to help guard against infection. During the procedure, the doctor will make a couple of very small incisions in the abdomen. The robotic instruments are then put into place. The doctor can perform the surgery with the robotic arms precisely handling each surgical instrument. The surgery is viewed on a high-definition screen that renders the reproductive system in 3-D. This allows for very up-close views that far exceed what would be possible with an open hysterectomy. Once the surgery is complete, patients will be taken into recovery, where they will come out of anesthesia. After that, the recovery process begins, first at the hospital and then at home.

2. Oophorectomy

An oophorectomy (oh-of-uh-REK-tuh-me) is a surgical procedure to remove one or both of your ovaries. Your ovaries are almond-shaped organs that sit on each side of the uterus in your pelvis. Your ovaries contain eggs and produce hormones that control your menstrual cycle.

When an oophorectomy involves removing both ovaries, it’s called bilateral oophorectomy. When the surgery involves removing only one ovary, it’s called unilateral oophorectomy.

Why It’s Done

An oophorectomy may be performed for:

  • A tubo-ovarian abscess — a pus-filled pocket involving a fallopian tube and an ovary
  • Ovarian cancer
  • Endometriosis
  • Noncancerous (benign) ovarian tumors or cysts
  • Reducing the risk of ovarian cancer or breast cancer in those at increased risk
  • Ovarian torsion — the twisting of an ovary

Oophorectomy combined with other procedures

An oophorectomy can be done alone, but it is often done as part of a more-complete surgery to remove the uterus (hysterectomy) in women who have undergone menopause.

In those with an increased risk of ovarian cancer, an oophorectomy is commonly combined with surgery to remove the nearby fallopian tubes (salpingectomy) since they share a common blood supply with the ovaries. When combined, the procedure is called a salpingo-oophorectomy.

Risks of premature menopause

If you haven’t undergone menopause, you will experience premature menopause if both ovaries are removed. This deprives the body of the hormones, such as estrogen and progesterone, produced in the ovaries, leading to complications such as:

  • Menopause signs and symptoms, such as hot flashes and vaginal dryness
  • Depression or anxiety
  • Heart disease
  • Memory problems
  • Decreased sex drive
  • Osteoporosis
  • Premature death

Taking low doses of hormone replacement drugs after surgery and until about age 50 may reduce the risk of these complications. But hormone replacement therapy has risks of its own. Discuss your options with your doctor.

3. Salpingectomy

Salpingectomy is the surgical removal of a fallopian tube. Salpingectomy is different from salpingostomy (also called neosalpingostomy). Salpingostomy is the creation of an opening into the fallopian tube, but the tube itself is not removed in this procedure.

The term fimbrioplasty is often used instead of salpingostomy (ie, simply opening the fallopian tube) because salpingostomy does not address the important role of the fimbriae. Reconstruction that preserves the delicate fimbriae is important for fertility outcomes. The purpose of fimbrioplasty is to open the obstructed fallopian tube and salvage enough function of the fimbriae to allow successful entrapment and transportation of the oocyte.

Indications

In vitro fertilization (IVF) is often used to treat infertility caused by tubal disease. IVF is the only treatment available for severely damaged, inoperable fallopian tubes and for situations in which tubal disease is concurrent with another fertility factor. However, reconstructive tubal surgery, such as salpingostomy and salpingectomy, should be considered in select individuals.

Distal tubal obstruction is found to be the culprit of tubal disease in the majority of cases. Various techniques of treating or bypassing tubal disease include either open or laparoscopic surgery, namely salpingectomy or salpingostomy, or assisted reproductive techniques. Fimbrioplasty is performed for patients who have patent fallopian tubes, whereas salpingostomy is performed with occluded tubes. Many times, patients have pelvic adhesions and phimosis of the fimbriated end of the fallopian tube.

Surgical treatment should be considered for all women with hydrosalpinges prior to IVF treatment. In cases of sonographically apparent hydrosalpinges, a salpingectomy, rather than a salpingostomy, is the preferred route of treatment. Some couples, however, may prefer a salpingostomy, which offers some potential of a spontaneous pregnancy. 

For many infertile couples, a several-month postoperative trial at spontaneously conceiving is undesirable and unwise. Therefore, patient selection for surgical treatment of infertility must be individualized and carefully considered.

Contraindications

The role of reconstructive tubal surgery in a woman of advanced maternal age is limited. Given the low monthly chance of pregnancy following surgery in the setting of an already reduced fecundability in a woman of advanced maternal age, IVF is the better treatment option. In contrast, reconstructive surgery for a young woman with minimal tubal disease is a reasonable option.

In general, patients who fail to conceive after primary tubal reconstructive surgery have severely limited success with repeat surgical procedures. In these cases, assisted reproductive techniques are strongly indicated.

5. Resection of Peritoneal Malignancy

Summary

Peritoneal neoplasia can originate de novo from the peritoneal tissues (primary) or invade or metastasize into the peritoneum from adjacent or remote organs (secondary). Primary peritoneal cancers, some of which have been implicated in many cases of carcinomas of unknown primary origin, include ovarian cancer arising in women several years after bilateral oophorectomy. Other described primary peritoneal cancers and tumors include malignant mesothelioma, benign papillary mesothelioma, desmoplastic small round cell tumors, peritoneal angiosarcoma, leiomyomatosis peritonealis disseminata (LPD), and peritoneal hemangiomatosis.

Signs and symptoms

Primary peritoneal carcinoma usually manifests with abdominal distention and diffuse nonspecific abdominal pain secondary to ascites. This tumor is described almost exclusively in women.

Patients with malignant peritoneal mesothelioma usually manifest with symptoms and signs of advanced disease, including the following:

  • Abdominal pain
  • Ascites
  • Weight loss
  • An abdominal mass

Diagnosis

The workup of peritoneal lesions includes peritoneal lavage cytology, as follows:

  • Peritoneal lavage can be performed using a percutaneous closed technique or at the time of laparoscopy or laparotomy
  • The sensitivity of the test results depends on the ability to completely lavage all regions of the peritoneal cavity and the ability to detect cancer cells being shed into the peritoneal cavity by the tumor

Laparoscopy or laparotomy

  • Direct visualization of the peritoneal surfaces along with palpation of the abdominal contents is by far the most sensitive modality for detecting peritoneal cancer
  • Laparoscopy is minimally invasive and allows for safe, directed peritoneal lavage
  • Open abdominal exploration and palpation are extremely sensitive for 1- to 2-mm peritoneal nodules

Studies for malignant peritoneal mesothelioma include the following:

  • Cytologic examination of ascites can suggest the diagnosis
  • Percutaneous biopsy of the omentum can help verify the diagnosis

Standard imaging tests, including ultrasonography and helical CT scans, are notably insensitive for the detection of peritoneal tumors. Ultrasonography findings that may suggest the presence of peritoneal lesions include the following:

  • Ascites
  • Fixing together of bowel loops
  • Thickening of mesentery
  • Omental matting

CT scan findings that suggest primary papillary serous carcinoma of the peritoneum include the following:

  • Ascites
  • Omental caking
  • Diffuse enhancement with nodular thickening of the parietal peritoneum of the pelvis
  • Normal-sized ovaries, with or without a fine enhancing surface nodularity of the ovary

CT findings in patients with malignant peritoneal mesotheliomas range from peritoneum-based masses (a so-called “dry” appearance) to ascites, irregular or nodular peritoneal thickening, and an omental mass (a so-called “wet” appearance). Scalloping of the peritoneum or direct invasion of adjacent abdominal organs may also be seen.

Radionuclide scan studies can help confirm the diagnosis of peritoneal hemangiomas; the isotope concentrates in the area where platelets are being sequestered. A CT scan and ultrasound also may detect larger hemangiomas. Angiographic evaluation is a more precise, although invasive, procedure that may be considered when radionuclide scans, CT scans, and ultrasound findings are negative.

Management

Multimodality therapy is currently the most commonly accepted therapeutic approach for peritoneal mesothelioma. This includes using the combination of the following:

  • Surgical cytoreduction
  • Intraperitoneal perioperative chemotherapy
  • Hyperthermia

Heated chemotherapeutic drugs used intraoperatively include the following:

  • Cisplatin
  • Mitomycin
  • Doxorubicin

For patients with unresectable or recurrent malignant mesothelioma, palliative systemic chemotherapy should be considered. Palliative regimens may include the following:

  • Cisplatin plus pemetrexed
  • Cisplatin plus paclitaxel or mitomycin, doxorubicin, and irinotecan
  • Intraperitoneal instillation of radioactive colloidal gold (Au-198)

Primary peritoneal carcinoma is treated with tumor debulking followed by chemotherapy with 5-fluorouracil, doxorubicin, or cisplatin. Newer approaches include the following:

    Taxanes, topoisomerase I inhibitors, gemcitabine, and vinorelbine, alone or in combinations

    Adjunctive antiangiogenic drugs such as bevacizumab and erlotinib

Surgical care

  • Treatment of primary peritoneal carcinoma consists of total abdominal hysterectomy and bilateral salpingo-oophorectomy as needed, with debulking of tumor and follow-up chemotherapy
  • Treatment of malignant peritoneal mesothelioma consists primarily of surgical palliation; complete surgical resection is rarely, if ever, feasible
  • Benign cystic mesothelioma tends to recur even with aggressive surgical removal; however, among recorded cases, no deaths have been attributable to this disorder
  • In patients with desmoplastic small cell tumors, the combination of aggressive surgical debulking and systemic chemotherapy with cyclophosphamide, doxorubicin, and vincristine interspersed with ifosfamide, etoposide, and mesna (P6 protocol) appears to lead to an improved outcome
  • Treatment of peritoneal and GI hemangiomas has involved surgical removal

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