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Every patient should know about the type of surgery, the advantages and
disadvantages of every surgical procedure, the possible risks of the procedure
and reasonable alternatives. I will obtain an informed consent from every patient
prior to any type of surgery.
Links to information about:
Surgery for cervical cancer
Surgery for endometrial cancer
Surgery for ovarian cancer
Surgery for vulval cancer
Type of surgery
Laparoscopy is commonly called keyhole surgery because the abdomen is
entered through three to four tiny incisions of 0.5 cm to 1 cm instead of a
large abdominal incision (see images below). A thin telescope is inserted
beneath the umbilicus into the abdomen. This telescope takes video pictures,
which are transferred to a TV-screen. The operating instruments are controlled
by the surgeon and the assistant on the screen throughout the entire operation.
The operation is carried out while the patient is under general anaesthesia. I
consider the laparoscopic approach in patients with endometrial and early
cervical cancer as well as for pelvic masses.
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Laparotomy means the opening of the abdomen through an incision in the
midline of the abdomen or through a crosswise incision in the lower abdomen.
Laparotomy is the method of choice in patients with ovarian cancer. The main
advantage of a midline incision is the excellent exposure of the organs in the
upper abdomen. The downside is the longer recovery and more pain.
Hysterectomy
What is a hysterectomy?
A hysterectomy means removal of the uterus. The fallopian tubes and ovaries can be removed at the same time when necessary. A hysterectomy is the most commonly performed gynaecological major operation. Approximately 35,000 women in Australia have a hysterectomy every year.
Types of hysterectomies:
The uterus can be removed in one of four ways. The options for the type of hysterectomy are:
1. Splitting the abdominal wall (Laparotomy)
2. From vaginally
3. A combination of vaginal hysterectomy and a laparoscopic operation
4. Total Laparoscopic (key hole surgery) (preferred).
A laparotomy (option 1) is the most commonly used approach to remove the uterus world-wide. While it is a very safe technique overall, its disadvantages include longer hospital stay (usually 4 to 6 days), longer recovery an longer time to return to work (usually 6 weeks), need for more pain medication and a relatively high rate of wound complications (especially in obese and cancer patients).
A vaginal hysterectomy or a combination of a laparoscopic operation with a vaginal hysterectomy (options 2 and 3) carries an increased risk of intraoperative complications, such as injury to bladder and ureter. Its hospital stay and recovery time is shorter and less pain medication is required than with a laparotomy. This technique is often not feasible for patients who are very obese or who have not had vaginal childbirths, patients with caesarean sections only or patients who had no children.
A total laparoscopic hysterectomy (TLH) is the preferred option. Patients usually stay in hospital for two days, they are back to work between one and three weeks, its overall complication rate is one third when compared to a laparotomy, and the need for pain killers is reduced by 90% when compared to laparotomy and 50% when compared to vaginal hysterectomy. This technique is often not feasible for patients with a very large uterus (larger than 10 weeks size). In 1 to 2% of patients where a TLH is planned, it needs to be converted to a laparotomy. Reasons for unplanned laparotomy are intraoperative complications (rare) or extremely difficult surgery where the continuation of a laparoscopic technique would increase the risk of complications.
While the latter technique (TLH) is the preferred option, some training in this particular technique is required. A minimum of 20 successful operations should be done under supervision until a gynaecological surgeon is accredited to offer TLH to patients.
TLH should only be performed in hospitals with adequate equipment and specially trained nurses. While the surgeon is a key factor for the success of surgery, advanced laparoscopic surgery is always a team effort based on effective interaction between doctors, nurses and technical staff.
For publications on TLH for endometrial and cervical cancer follow this link
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