Deborah Wilson. M.D. Gynecology
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Laparoscopic Hysterectomy

Click on the images below to hear Dr. Wilson answer questions about laparoscopic hysterectomies, along with Kelly Perry, one of our hysterectomy patients, give a testimonial about her experience as a hysterectomy patient.

www.HerHealth.org

March 2012: Dear Dr. Wilson, It has been 5 weeks since my laparoscopic hysterectomy and I am feeling better than ever! I have had significant improvement with my urinary and digestive issues too! I just wanted to thank you again for taking my case and thoroughly explaining everything to me. I can't express enough gratitude to you and your team for making everything go so smoothly. My recovery was speedy, pleasant, and easy and I know that it is because of your skill and expertise! ~Sue


April 2012: On January 3, 2012, I had a total hysterectomy that was performed by Deborah D. Wilson, MD, who in my opinion, is a miracle worker. I have heard a number of horror stories from women who have had hysterectomies. With that thought in mind, I tell just about every woman I meet (no lie) that “I had a hysterectomy performed by Dr. Wilson, who is absolutely amazing, and if you need a hysterectomy or know someone who does, I would highly recommend”. After a thorough search, I had confidence in knowing that I had chosen the right doctor and only doctor that would make me feel completely confident. I was happy with my decision but still petrified to have the surgery.

Your staff was wonderful and caring! The receptionist at the front desk was very kind along with the person who input my information in your system. Next step was to the surgical unit to get my intravenous line and wait to be wheeled into surgery. Nurse Mary in pm op was wonderful, compassionate, kind, understanding, and reassuring! She shared her surgical experience with me and really made me feel at ease. Mary made me feel like a friend she was trying to console rather than a stranger who was a patient and just another facet of her job! The nurses who attended to me once the surgery was over were absolutely wonderful. Whenever someone came into the room to take vitals or for meds, I was offered a hot compress (which was very much appreciated) along with hot tea, and something light to eat. I told my husband and friends that I felt like a “rock star” at the Virginia G. Piper Center.

The following morning when I was released, I walked with my husband to our mail box, the second day I went out to lunch, and the third day I was off to a craft show. I did not drive, lift anything or overdo but tried to keep active enough to avoid clots. I never took one pain pill of any kind at the surgical center or at home. I credit my rapid recovery to having a phenomenal physician and being surrounded by exceptionally caring and positive people...your staff is outstanding! ~C


First, let's discuss terminology. A hysterectomy is a surgical procedure in which the uterus is removed. A total hysterectomy means that the uterus and cervix (the piece of the uterus that stabilizes the uterus by attaching to large ligaments in the pelvis and extends into the vagina) are removed. A hysterectomy does not include removing the ovaries and fallopian tubes-that is called a salpingo-oophorectomy and frequently is performed along with a hysterectomy.

Historically, hysterectomies have been performed either by making an incision in the abdomen (either a "bikini" incision or a vertical incision between the belly button and the pubic bone) or, if the uterus is not too large, an incision in the top of the vagina-a vaginal hysterectomy. When an incision is made in the abdomen, not only the skin but many other layers need to be cut and to heal. This produces a significant amount of post-operative pain and recovery time. It is actually the healing of the skin and other layers beneath it that accounts for most of the pain women experience after a hysterectomy, not the actual removal of the uterus. A vaginal hysterectomy reduces the pain of recovery, but can only be performed on women who have a relatively small uterus and have no other diseases or prior surgery that may have caused adhesions. Also, the cervix must be removed in a vaginal hysterectomy.

A laparoscopic assisted vaginal hysterectomy is a relatively new procedure that allows some women with adhesions to be candidates for a vaginal hysterectomy but does not solve the problem of a too-large uterus and still requires that the cervix be removed.

A laparoscopic total hysterectomy can also be performed in women who need to have their cervix removed.

A Laparoscopic Total Hysterectomy involves removing the uterus and cervix. If the uterus is not greatly enlarged, the uterus (and possibly the tubes and ovaries) are removed vaginally, and the top of the vagina is sewn closed with sutures placed through the laparoscope. The apex, or top, of the vagina, is then supported by incorporating the uterosacral ligaments into the vaginal apex.

Why leave the cervix? Why remove the cervix? The answers to these questions are very controversial. Historically, the cervix has always been removed along with the uterus when a hysterectomy was performed. In the late 1990's, it became popular to leave the cervix after a few studies indicated that sexual function after supracervical hysterectomies was better than after a total hysterectomy. There was also the thought that the cervix served a supportive function in the base of the pelvis.

Studies comparing laparoscopic supracervical hysterectomy (leaving the cervix in place) and laparoscopic total hysterectomy (removing the cervix along with the uterus) have been recently published. It appears that there is really no difference in sexual function between the two procedures. Women generally report that sexual function is better after any type of hysterectomy, probably related to the fact that these women are no longer bleeding, cramping, and hurting.

In this practice, a woman has a choice. She can elect to leave the cervix or she can elect to have it removed. If a woman has had abnormal pap smears or has cervical prolapse as a result of childbirth, we will advise her to have her cervix removed. If a woman absolutely does not want to bleed any longer, we should remove the cervix because despite our best efforts, some women who retain the cervix still have periods.

If a woman has no problems with pelvic relaxation and has a history of normal pap smears, she can opt to leave the cervix. The potential negative consequences of leaving the cervix include the possibility of monthly periods, the chance that the cervix may eventually prolapse (fall) as she ages, or the potential for an abnormal pap smear or even cervical or uterine cancer.

If a supracervical hysterectomy is performed and problems develop with the cervix later, a laparoscopic trachelectomy (removal of the cervix) can be performed. This, however, is not an optimal situation and we would rather anticipate problems and make the correct procedure choice the first time.

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Disease Terminology

Fibroids occur in 40% of women at some point in their lives. Fibroids run in families, so if your mother and sister had fibroids, you have a good chance of developing them, too. They are almost always benign, but can cause very heavy menstrual bleeding, bleeding between periods, or simply pain and pressure due to the space they take up. A woman can have just one fibroid or many. Sometimes just one fibroid can grow quite large. The most common reason for having a hysterectomy is fibroids. If the fibroid uterus is large, a vaginal hysterectomy can be difficult. A laparoscopic hysterectomy is generally possible in these cases unless the uterus is enormous. Even if the uterus is very large, drugs such as Lupron can be used for a few months before the procedure to shrink the uterus and make a laparoscopic hysterectomy possible.

You might ask: -Why not just use Lupron to shrink my fibroid and not do surgery? Lupron will only temporarily shrink a fibroid uterus. As soon as the Lupron is stopped, the uterus will go back to its previous size. Lupron is not a drug that can be used over a long period of time due to its side effects. It creates a temporary state of menopause which causes hot flushes, night sweats, mood swings and bone loss. For a short period of time, Lupron is tolerable and safe, but not for more than a few months.

Women with fibroids are the largest group of women who undergo laparoscopic hysterectomies. Since fibroids rarely occur in the cervix, a woman with fibroids may choose between a laparoscopic supracervical hysterectomy and a laparoscopic total hysterectomy. Either way, most fibroid uteri can be removed laparoscopically, and the recovery is much shorter than a hysterectomy that involves a large incision.

Adenomyosis is a disease in which the glands that normally line the muscle of the uterus, and bleed off monthly, grow backwards into the muscle. Adenomyosis is a benign condition but can cause cramping and bleeding that can become quite severe and debilitating. A uterus affected by adenomyosis can be only slightly enlarged or can get to be very large. Again, laparoscopic hysterectomy is a good solution for this problem.

Endometrial polyps are growths of uterine lining tissue that do not shed off with the monthly period and can cause abnormal bleeding. They can be removed during a D&C, but tend to grow back. A laparoscopic hysterectomy removes the uterus so that this cannot happen again.

Hyperplasia is overgrowth of the uterine lining. Hyperplasia can cause heavy bleeding and bleeding between periods. If hyperplasia is left untreated, it can develop into cancer. Simple hyperplasia is an early benign form of the disease. As the disease progresses, hyperplasia can develop into complex hyperplasia, complex hyperplasia with atypia, and finally cancer of the uterus. A woman with simple hyperplasia is a candidate for a laparoscopic hysterectomy. It is generally recommended that a laparoscopic total hysterectomy be performed in this case, since this procedure avoids morcellization. Morcellization is the process of cutting the uterus into strips, which is necessary to remove the uterus in a supracervical hysterectomy. If any cancer cells do exist inside the uterus, these would be spread throughout the abdominal cavity during the morcellization process. This is obviously undesirable. If the hyperplasia is complex or involves atypia, a laparoscopic total hysterectomy can be performed. The reason for not doing a supracervical hysterectomy on a woman with complex or atypical hyperplasia is that we would not want to spread disease throughout the pelvis by cutting the uterus into strips. A laparoscopic total hysterectomy avoids this step; the uterus is removed in one piece along with the cervix.

Pelvic adhesions can make a vaginal hysterectomy difficult or impossible. Adhesions can result from prior surgery, endometriosis, or infection. If the adhesions are not severe, a laparoscopic supracervical hysterectomy is possible. If the cervix needs to be removed, a laparoscopic total hysterectomy or a laparoscopic assisted vaginal hysterectomy can be done.

Abnormal bleeding is a condition that describes either heavy menstrual bleeding and/or bleeding between periods. It can be due to fibroid tumors (benign muscle tumors of the uterus), adenomyosis (a process in which glands normally lining the uterus grow into the muscle of the uterus), or abnormalities of the uterine lining such as hyperplasia (overgrowth of the uterine lining) or polyps (clusters of uterine lining tissue that grow inside the uterus).

The patient is then taken to the recovery room to wake up from anesthesia. She will stay one night in the recovery center or the hospital, depending on her insurance. Patients almost always feel well enough to go home the next day and can count on feeling back to normal within a week. Many patients don't even need pain medication! Generally, patients report that the incisions feel a little sore and the residual gas in the belly hurts a bit. This gas often collects under the right diaphragm and causes the sensation of right shoulder pain. Some patients say that they feel tired for a few weeks and need a nap in the afternoon. Some go back to work full-time after a week and some go back part-time or wait 2 weeks.

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Description of a Laparoscopic Total Hysterectomy

The laparoscopic total hysterectomy removes the uterus and cervix intact, without morcellating unless the uterus is very large. It is similar to the supracervical hysterectomy except that instead of morcellating the uterus and removing it through the umbilical incision, the uterus and cervix are removed through the vagina. This leaves the vagina open to the abdominal cavity, and it is closed by suturing the apex of the vagina with a series of "figure of 8" sutures placed with laparoscopic instruments. Permanent sutures are then placed in the uterosacral ligaments to support the vaginal apex so that it will not fall, or prolapse, at a later date.

Sometimes the uterus is too large to remove through the vagina, and it is then morcellated using the same technique we use in the supracervical hysterectomy.

The recovery from a laparoscopic supracervical hysterectomy is very similar to the recovery from a laparoscopic total hysterectomy. After a laparoscopic total hysterectomy, unless the procedure was being performed for cervical disease, pap smears are no longer necessary.

Dr. Wilson and Kurt Sanders, RN First Assist, produced the following video as a teaching tool for gynecologists who want to learn laparoscopic hysterectomy. In conjunction with Gyrus/ACMI, Dr. Wilson and Kurt Sanders teach a course on total laparoscopic hysterectomy to physicians nationally. At least 20 physicians fly to Scottsdale from all over the country for the monthly course, which is held at Greenbaum Outpatient Surgery Center. The gynecologists are instructed in suturing and knot tying, instrument techniques, and avoidance of complications. These courses have been very popular and are booked months in advance. You are welcome to view the video (but it is graphic) by logging on to http://www.obgyn.net/hysterectomy-resource-center/display.asp?page=procedures.

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What are the Risks?

Whenever a patient has surgery, she must accept that there is a risk of injury from the instruments inserted into the abdomen. Injuries that have been reported in association with this procedure include puncture injuries of the bowel and bladder, burn injuries of the bowel and bladder, injuries to the ureters (the tube that runs from the kidney to the bladder), and blood vessel injuries. Generally speaking, as long as these injuries are recognized right away, they can be fixed at the time of surgery, but may require another specialist to operate and may require a larger incision. However, if an injury is not recognized, the consequences can be more severe, and may result in permanent injury and even death. We are very careful to warn our post-operative patients to contact us if there is fever, severe pain, severe bleeding or any other symptoms that seem unusual. As long as these symptoms are evaluated, negative consequences should be avoided.

The physicians in this office have performed a combined total of over 3,500 laparoscopic hysterectomies. The complication rate is less than 1%. Approximately 2% of patients develop minor infections, which can be successfully treated with antibiotics. The complication rate of surgeons at this office is extremely low compared to national laparoscopic hysterectomy statistics.

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What Patients Say

LadiesOur patients are thrilled with the procedure and are glad to be rid of the problems that led them to decide to have the surgery. Most of them say that it was much easier than they thought it would be. Many of them never require pain pills or only require ibuprofen. They feel fortunate to have been given this option and not to have to suffer through a large abdominal incision. Many of them have friends and family who have had to recover from an abdominal hysterectomy. They can see that the difference is remarkable.

Quotes from Patients

"My mother had a hysterectomy for fibroids a few years ago. She spent 4 days in the hospital and it took her 6 weeks to feel like herself. When I found out that I had fibroids and needed surgery, I was terrified. I had a laparoscopic supracervical hysterectomy, felt fine the next morning when I went home, and I was back to my normal routine in a week. I never needed the pain pills that Dr. Wilson gave me — I just took Advil. Now I feel like nothing ever happened, except that I no longer bleed."

"I was so afraid of having a hysterectomy that I suffered with bleeding and pain for 5 years, hoping that it would just get better. Finally, I was missing so much work that I had to have surgery. I had a laparoscopic supracervical hysterectomy and felt perfect within a few days. I went back to work in 10 days and felt better than I'd felt in years. I told Dr. Wilson at my 2 week post-operative visit that I wished she had forced me to do it 5 years earlier!"

"I had fibroids and heavy bleeding for a long time, and the doctor I was seeing recommended an abdominal hysterectomy. A friend of mine had gone to Dr. Wilson to have the laparoscopic supracervical hysterectomy so I went to see her. My fibroids were so large that I had to have Lupron to shrink them. I did not feel great when I was on the Lupron, but moodiness and a few hot flushes were the worst symptoms. The fibroids shrunk enough for me to have the laparoscopic surgery, and I breezed through it. I am so glad that this option is available to women now."

"I had polyps that would go away when I had a D&C, but would always come back and cause bleeding again. After 3 D&C's, I wanted to have a hysterectomy and I heard about the laparoscopic hysterectomy on television. I had no problems with the procedure, and I am happy that I don't have to worry about the bleeding anymore."

"I had a laparoscopic supracervical hysterectomy because I had adenomyosis. I never bled all that much, but I cramped with my periods so badly that I needed narcotic pain pills every month. I was worried that I would feel different, especially sexually. I am happy to report that I feel great, and it has not altered my sex life at all, except to make it better."

"Dr. Wilson told me that I could play golf a week after the procedure and I didn't believe her. I had the surgery on a Tuesday and played golf the following Monday and felt fine. My friends were amazed."

"I had fibroids that had grown so large that I could not find any doctor who would even consider anything but an open hysterectomy. I was told that they were so large that I would need a midline incision. I found Dr. Wilson's website and called her in Scottsdale to see if she would do the surgery. I sent her the ultrasound reports, and she recommended that I use Lupron to shrink the fibroids for 3 months. She said that she would give it a try. I flew into Phoenix a few days before the procedure, met Dr. Wilson, and had the surgery (through the laparoscope) on Tuesday. I flew home on Sunday and went back to work a week later. If I had not researched and found out what my options were, I would have had a much longer recovery time, not to mention a big ugly scar."

"I had abnormal pap smears, so I was told by my doctor that I was not a candidate for a supracervical hysterectomy. I never had children, so I was also not a candidate for a vaginal hysterectomy. I was left with one option — an abdominal hysterectomy. I was very concerned about the recovery time and the incision. Dr. Wilson said that I could have a total hysterectomy through small laparoscopic incisions and I was so relieved. I had a laparoscopic total hysterectomy and felt great within 10 days."

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labial reduction

Many women feel that the inner lips of the vulva are too large. Some women may be dissatisfied with the appearance, and others, especially athletes, experience discomfort when they run, bike, etc. There is a great variation in the size and shape of labia, and frequently, one side is significantly larger than the other.

Labial reduction surgery is, although not discussed much, a common procedure. It is performed in the hospital under general anesthesia. A labial reduction involves trimming excess tissue from the labia and suturing the edges with fast-dissolving suture. We can remove as much or as little as you like, and if the problem is asymmetry, we can even the labia out.

Recovery is approximately one week. You should plan to take it easy for the first few days with very few responsibilities. It is best during this time to wear very loose clothing and you will need a pad. Most of the swelling is gone after a few days, but you will still be uncomfortable for a week. The sutures dissolve in ten days, and at two weeks post-op, you will be almost back to normal.

Many women have felt uncomfortable with the size or appearance of their labia for years, but were unaware that anything could be done. Feel free to discuss this matter with your practitioner if you are interested in labial reduction surgery.

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pelvic reconstruction

The process of childbirth, especially if a woman has many children and they are over 8 lbs., causes weakness in the pelvic area. Many women will not notice any difference immediately, but over the years, under the influence of gravity and aging, problems develop.

The most common problem is uterine prolapse. The uterus actually slips from its supports and begins to move down in the vagina, until it actually protrudes out through the vulva. The protrusion will be worse after she is on her feet for a long period of time. Some women can relieve the symptoms temporarily by pushing it back up. Most women will notice the prolapse before the uterus actually comes out. They experience a pressure and heaviness in the pelvic area and they "feel something" when they put a finger in the vagina.

The second most common problem is vaginal cystocele or rectocele. During childbirth, as the baby moves through the vagina, the strong tissue surrounding the vagina is stretched and even split. The most common areas damaged are the wall between the vagina and the bladder and the wall between the vagina and the rectum. The "splits" in the strong tissue, or fascia, are actual hernias, and can begin to bulge just like a hernia. A woman who has a cystocele (defect in the wall between the bladder and the vagina) will feel a bulge in the top of the vagina when she inserts a finger in the vagina. Again, if the problem is not addressed, the bulge can actually protrude through the vulva. Along with the discomfort of a cystocele, women frequently lose urine when they cough or sneeze.

A rectocele is a hernia between the rectum and the vagina. Again, a woman will feel a bulge, this time in the back of the vagina. Sometimes the bulge actually protrudes to the outside. Another common symptom associated with a rectocele is obstipation (like constipation). The symptoms of obstipation are inability to move stool out of the rectum unless a finger is inserted into the vagina and the stool is actually pushed out. The stool is being caught in this pocket formed by the hernia.

Along with the above issues, women who have had vaginal deliveries actually feel "loose" or "open" in the vaginal area. They often complain that intercourse is not as satisfying to either partner.

Even women who have had hysterectomies can develop prolapse, known as vaginal vault prolapse, years after the hysterectomy. Again, these women feel pelvic pressure and heaviness and often feel something extruding from the vulva. Women who have had vaginal hysterectomies are especially susceptible to vaginal vault prolapse.

All of these problems can be remedied. If a woman has pelvic prolapse and wants to avoid surgery, we may fit her with a "pessary," a device that stays in the vagina and provides support to the organs. A pessary needs to be removed and cleaned regularly. Some women are able to use the pessary for years, but for most it serves as a temporary measure.

Surgery is available for any of the above problems. Moderate uterine prolapse is treated by removing the uterus laparoscopically and using the uterosacral ligaments to support the vaginal cuff. This is a very successful procedure and recovery is swift. It the uterine prolapse is severe, a small bikini incision is made in the abdomen and prolene mesh is sutured to the vaginal cuff after the uterus is removed. The other end of the prolene strip is sutured to the bone of the sacrum. The recovery is longer than the recovery for a laparoscopic procedure, but this is an effective procedure and is a permanent solution to a severe problem.

In the case of vaginal vault prolapse after hysterectomy, the above 2 procedures are very successful. Again, if the prolapse is moderate, a laparoscopic procedure is performed, but if the prolapse is complete, a larger incision is necessary.

Rectocele repair is a vaginal procedure in which an incision is made in the posterior vagina, the vaginal mucosa is separated from the underlying tissue, and a piece of cadaveric dermis is sutured in place. This corrects the hernia and allows the body to grow fibroblasts through the dermis, ultimately replacing the dermis and forming a strong wall between the rectum and the vagina. The dermis graft is a relatively new technique, and we have been impressed by how well women heal after this procedure. Post-operative pain is minimal, and the problem seems to be corrected permanently.

At the conclusion of a rectocele repair, we will "tighten" the vaginal opening if so desired. This reduces the feeling of looseness and openness in the vulvar area and usually increases sexual satisfaction.

Cystocele repair is generally done by a urologist and is similar to a rectocele repair. Surgery to correct stress urinary incontinence is also performed by a urologist. At the present time, there are a few different procedures available, and the surgery will be tailored to your problem. We will refer you to an excellent urologist if it is determined that these procedures are necessary. If a urologic procedure is necessary in addition to a gynecologic procedure, we will arrange to have both procedures accomplished under the same anesthetic.

Many women have been suffering for years with symptoms related to prolapse, cystocele, and/or rectocele. They are often embarrassed to talk about it, and the problem goes untreated. Please feel free to discuss any of these symptoms with us. We can't help you if we don't know about it.

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www.HerHealth.org

HerHealth.orgHerhealth.org is a brand new Web site with lots and lots of valuable information regarding laparoscopic hysterectomy and myomectomy (removal of fibroids).

The Web site is very well done and will answer any questions a potential hysterectomy or myomectomy patient might have regarding surgery.

Go to "Videos" for animated descriptions of each surgical procedure.

Go to "Testimonials" to hear Dr. Wilson and other surgeons answer questions about laparoscopic hysterectomies. Kelly Perry, one of our hysterectomy patients, gives a testimonial about her experience as a hysterectomy patient.

Go to "Symptoms", "Treatment and Recovery", and "FAQ" for more valuable information about issues women face, the decision to have surgery, and what can be expected after surgery.

We recommend this Web site to any woman who is facing gynecologic issues that may lead her to consider surgery
.

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