With Smaller, More Precise Instruments, Private Practice Physicians Develop Faster, Safer, Gynecologic Procedures

Thanks to quicker, less-invasive procedures, many hysterectomies that would have been required a decade ago can be avoided today. And when the uterus does need to be removed, new techniques are making it possible for women to resume their normal routines in days and weeks instead of months.

While research centers and clinics are often considered the major sources of medical breakthroughs, many advances in endoscopic procedures are being driven by gynecologists in private practice who are associated with Cedars-Sinai Medical Center but are not full-time faculty members.

Lawrence D. Platt, M.D., chairman of Obstetrics and Gynecology at the medical center and chairman and director of the department’s residency program, said specialists in obstetrics and gynecology who are in private practice often develop innovations and direct clinical research projects that result in less-invasive procedures and greater patient comfort.

According to Philip G. Brooks, M.D., who established his private practice in Los Angeles in 1964, the ever-increasing sophistication and miniaturization of telescopes and instruments enables gynecologists to perform more and more procedures in less and less invasive ways. “I think the greatest change in the last 50 years in operative gynecology and in all of surgery, has been the development of telescopic surgery,” he said. “The minimalization of approach using modern telescopes and optics really has enabled us to do things and look into places that heretofore we could not.”

Although the concept of using a scope to peer into the body has existed for centuries, the approach became practical only within the past few decades with technological breakthroughs that provided improved optical systems, miniaturized instruments, and the ability to thoroughly illuminate the surgical site with “cold light” delivered from a source outside the body.

With these developments, surgeons could use a laparascope to see and operate inside the abdomen using small puncture holes instead of a large incision. And with each passing year, they are able to perform more sophisticated procedures. Recently, for example, Dr. Brooks used a laparoscopic technique to remove a large tumor that was resting atop a patient’s uterus. In a painstaking procedure, he shaved off pieces of the tumor and suctioned them out through a tiny incision. The patient was discharged from the hospital the same day, uterus intact, and was able to resume her normal activities within a few days.

The miniaturization of the hysteroscope, inserted into the vagina and through the small opening of the cervical canal, allowed gynecologists to see and operate within the uterus itself.

“Hysteroscopy with large-bore telescopes had been around for over 100 years. It was cumbersome, painful and difficult, and we didn’t have the ability to get a bright light in through the cervical canal,” said Dr. Brooks, who previously served as chief of gynecology at Cedars-Sinai and is clinical professor in obstetrics and gynecology at the University of California Los Angeles School of Medicine.

According to Dr. Brooks, today’s “diagnostic” hysteroscopes measure only about three millimeters in diameter. Even “operative” hysteroscopes, which are thicker because they contain a channel that allows instruments to be positioned beside the scope, can easily be placed into the uterus through a cervical canal dilated to eight or 10 millimeters.

“We can look into the uterus with wonderful optics,” said Dr. Brooks. “With a three-millimeter scope, we have the rest of that 10-millimeter space to use operating instruments.”

One application of this capability is the removal of tumors and other structural anomalies inside the uterus. For three years in the late 1980s, Dr. Brooks conducted a study that provided the data leading to the Food and Drug Administration’s approval of an instrument called the resectoscope for gynecologic procedures. This instrument, which has a wire loop at the end, had been used by urologists to shave the prostates of men whose glands were enlarged.

Now, using the resectoscope, doctors are able to shave an intrauterine tumor into small pieces that can be removed through the cervical canal, avoiding the trauma, long recovery period and potential complications of major surgery. Among their recent endeavors, specialists in gynecology are pursuing a variety of methods to provide relief for women who suffer from excessive menstrual bleeding.

Because severe bleeding can result from a variety of disorders – including hormonal imbalances, benign fibroid tumors, polyps, and even cancer – doctors first diagnose the cause then attempt to remedy it employing the least invasive method available.

In decades past, open surgery to completely remove the uterus was often the only treatment. In many cases today, however, endoscopic procedures offer a quick, relatively painless, effective alternative.

“We can remove such problems as a uterine fibroid or a giant polyp using the resectoscope to shave it out. But there are many women who have excessive bleeding without these kinds of structural changes. About 200,000 of these women have hysterectomies each year. We’re developing new ways to avoid a radical procedure like a hysterectomy for women who choose to keep their organs that are reasonably healthy,” said Dr. Brooks a founding member and past president of the American Association of Gynecologic Laparoscopists.

In a normal menstrual cycle, the endometrium, or inner lining of the uterus, grows thicker until it is shed during menstruation, after which the process begins again. For women who experience excessive bleeding, or menorrhagia, the monthly period becomes more than a mild inconvenience.

They may need more than 10 pads or tampons a day, find their periods extending beyond seven days, and have their everyday routines seriously interrupted. If they do not find relief through hormone therapy or other conservative approaches, destruction of the endometrium may provide a safe, effective, permanent solution.

The FDA has approved several methods of hysteroscopic endometrial ablation, such as the insertion of a balloon filled with extremely hot water, or the use of an electric rollerball, which may be the most common technique in use today. The rollerball is inserted through the cervical canal and moved along the surface of the uterus, burning the tissue and sealing the blood vessels. With the permanent removal of the endometrium, menstrual bleeding is stopped or controlled.

Physicians and medical equipment manufacturers are constantly seeking better ways to accomplish endometrial ablation. Dr. Brooks recently served as principal investigator on a method that used a balloon with electric plates to burn the uterine lining. His office is currently one of eight in the country conducting an FDA study of a heated saline device that may offer several advantages over its predecessors.

The heated saline approach can be performed in the physician’s office rather than in a hospital or outpatient setting, and because the liquid completely fills the uterus, it can “get into all of the nooks and crannies and corners inside the uterus and even around irregular edges,” said Dr. Brooks, who has performed the operation on about 20 women participating in the study.

In preparation for this procedure, an insulated telescope and straw-like device are placed through the cervical canal, which is sealed to prevent liquid from leaking out. To ensure safety, the uterus is first filled with a body-temperature liquid. A computerized monitoring device is attached to detect any leakage and disable the equipment.

The patient is given a local or spinal anesthetic and medication to help her relax before the saline solution, heated to 180 degrees Fahrenheit, is administered through the tube, filling the uterus, destroying the lining and sealing the blood vessels. According to Dr. Brooks, women are able to go home shortly after the procedure. They experience cramping for several hours that day but their symptoms typically resolve by bedtime.

Not only are gynecologists seeking better ways to help women avoid having hysterectomies, they’re developing better ways to perform hysterectomies that are necessary. Some of the area’s leading gynecologists now use the laparoscope and miniaturized instruments to detach the uterus the uterus from surround support tissue. The uterus is then removed through the vagina rather than through the large abdominal incisions previously required. Patients heal more quickly, have tiny puncture wounds instead of a long scar, go home within days and fully recover within weeks instead of months.

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