Transcription:
Minimally Invasive Gynecologic Surgery

Melanie Cole (Host): Having surgery is never a first choice for any woman, however, when medicine, lifestyle changes and other noninvasive treatments cannot ease gynecological symptoms; it may be time to recommend surgery. My guest today is Dr. Michael Karram, he’s the Executive Medical Director for Women’s Health Service Lines at The Christ Hospital Health Network. Welcome to the show, Dr. Karram. What are some of the most common conditions that women suffer from that might require a surgical intervention that you see at The Christ Hospital Health Network?

Dr. Michael Karram, MD (Guest): Well, thanks for having me Melanie and the answer to that question is more complex than you would think, because there are multiple surgeries, but at our hospital, where we have a dedicated OR, operating room designed specifically for women’s types of surgery, the main surgeries that we would perform would be hysterectomies, oophorectomies, or removal of the ovaries, myomectomies for women who have fibroids, pelvic organ prolapse surgeries for women who have pelvic organ prolapse problems such as prolapsed bladders, prolapsed uteri, prolapsed rectums, stress urinary incontinence, and those types of things. So, there is a large number of surgeries that we perform at The Christ Hospital, but those categories are probably the most common.

Melanie: And what are some of most valuable prognostic tools that you look to, to aid in early diagnosis of some of these conditions?

Dr. Karram: Well, the diagnosis really isn’t that complex. We use clinical exam, we use ultrasound, we use x-rays, MRIs, CT scans etc. But really, it’s more designed towards trying to tailor the appropriate surgical procedure for the condition and every woman is a little different.

Melanie: So, speak about that then for a minute about patient selection and certain criteria. How do you discuss with a woman what the procedure would be like for her and what the outcome is going to be?

Dr. Karram: That’s a great question. And that’s probably where we spend most of our time. Historically, in gynecology, there used to be basically two ways we could do procedures. One would be a vaginal procedure and the most common example of that would be a vaginal hysterectomy and then the other one would be an abdominal procedure where you have an incision, very similar to a cesarean section incision and you do the procedure through the abdominal incision. Well, the vaginal hysterectomy then and now, is the most minimally invasive type of hysterectomy that you can do because you basically have no external incisions. Everything is done through the vagina. And some people even label that a cosmetic hysterectomy because there are no external incisions. So, as we have learned more about the different disease processes that take place and the surgical procedures, more minimally invasive surgery procedures have come to the forefront in our armamentarium to deal with these conditions.

Still vaginal hysterectomy is very, very important and as I mentioned, is the most minimally invasive surgery. Then you have a laparoscopic hysterectomy which is done using the laparoscope and then you have a robotic assisted laparoscopic hysterectomy where it’s a laparoscopic hysterectomy but using the robot to assist you in that procedure. And so those are the types of procedures that we do, and everybody has to be tailored to the type of condition that they have as to what would be the best procedure for them.

Melanie: So, you mentioned robotic assisted surgeries, so speak about that and what are you using? Are you using da Vinci there and what do you use the robot for?

Dr. Karram: Right, yes, the da Vinci robotic system is the system that we use, and it is the most common and the most studied system so far that has been used in the United States. And what’s nice about the da Vinci system is it aids you in the procedure by giving you an easier access to the appropriate techniques and instrumentation that you need to perform the procedure. And you really can do it almost on your own versus if you are doing a laparoscopically you need two or three or sometimes four assistants. But the key with any type of minimally invasive surgery, is you want to try and decrease the – allow the patient to recover quicker, allow her to return to her normal activities quicker, if she’s in the workforce, return to the workforce quicker. So, not only do you give her a better care, hopefully a better outcome and a quicker recovery at a more cost-effective means of doing it. But not everybody is a robotic candidate. And a lot of it has to do with their conditions and the type of problems that they have.

Melanie: Well speaking of the types of problems, if somebody has comorbidities, they are obese, or they have got some other condition; does that then change the way that you are going to be able to do the procedures?

Dr. Karram: Actually, it does. And sometimes with comorbidities a robotic procedure is a better procedure, sometimes with a large obese patient, a vaginal hysterectomy is a better procedure because you never have to do any – perform any abdominal incisions or even a small laparoscopic incision still has some risks and complications related to that procedure when you are putting that trocar into the abdomen. You can injure a blood vessel, you can injure the bowel, you can injure the bladder whereas, the safest and again, I keep mentioning the most minimally invasive is the vaginal hysterectomy because that avoids all of that. So, really if you can get a patient who needs a hysterectomy done vaginally, they could weigh 400 pounds and it would still be the best procedure for them. And the safest. And the quickest recovery.

Melanie: Another common problem that women encounter would be fibroids and also chronic pelvic pain. So, how do you and what do you want other physicians to know when a woman is complaining to their gynecologist about chronic pelvic pain and when to refer or what should they be looking for?

Dr. Karram: Well anybody, chronic pelvic pain is something that is a very difficult diagnosis to treat because there are so, so many causes of chronic pelvic pain. So, in your workup, you want to look for the most common causes which would be for example ovarian cysts, which would be pelvic inflammatory disease, women who have had recurrent infections in their pelvis, endometriosis is a common cause of chronic pelvic pain, previous surgeries that predispose women to have adhesions in the pelvis, those are common. So, once you work patients up and that can be again, clinical exam, history, ultrasound, CT scans, MRIs and even a diagnostic laparoscopy to look and see because sometimes your workup will be negative but yet the patient is incapacitated because of her pain and when you do a laparoscope you can see things because you are looking with your naked eye that you can’t see on ultrasound or x-ray or MRI or CT scan. So, really, once you have done the workup and or they haven’t responded to what we would consider common treatments for chronic pelvic pain; then that would be somebody that would be referred or somebody who has recurrent pelvic pain where they have been treated and now it has come back.

Melanie: What sets The Christ Hospital Health Network apart from other hospitals in your technology and in your team approach?

Dr. Karram: Well, that’s a very, very good question. And I really think that’s very important because at The Christ Hospital as I mentioned earlier in the discussion, we have an operating room or an operating suite with six ORs, operating rooms that are designated specifically for women’s health and women’s types of surgery. So, on our eighth floor OR, that’s all we do is women’s surgery. That’s number one. Number two we have board certified and highly credentialed both Nationally and Internationally renowned surgeons that work at The Christ Hospital. And I say that based on two things. Number one based on our credentials because we are all board certified in obstetrics and gynecology, female pelvic medicine, reconstructive surgery, GYN oncology for our oncologists, reproductive endocrinology and infertility for our reproductive doctors. So, we are highly qualified, highly trained and highly credentialed.

Because of that, we have two training programs where we train fellows to become board certified in these different specialties. So, we have a training fellowship in female pelvic medicine and reconstructive surgery and we also have a training fellowship in minimally invasive surgery in gynecology. And so, we basically work with these younger physicians who have finished their residency in obstetrics and gynecology to become board certified in these two specialties. So, in reality, when we are teaching the younger generation, our credentials, our referral system, we get referrals from all over the country as well as the world on very complex cases; it really separates us apart from any other institution in this area and puts us very close to any other institution in the Ohio region or the United States.

Melanie: And what does current research indicate for future developments and treatments. Give us a little blueprint for where you see the world of gynecologic surgery going from here?

Dr. Karram: I think it really will develop into more minimally invasive surgeries. It will also give us better alternatives to treat very common conditions for example stress urinary incontinence, fibroids, endometriosis, I see all these areas developing as we understand more of the pathophysiology which means how do these things develop, why do they develop, why do some patients have symptoms, others don’t and what are the best treatments with the best outcomes. I think this is the future in gynecology, in women’s health as well as in gynecologic surgery and minimally invasive surgery.

Melanie: What a wonderful answer. So, in summary, Dr. Karram, tell other physicians what you would like them to know about minimally invasive surgery for gynecologic issues, when to refer and also what a referring physician can expect from your team?

Dr. Karram: I would just say, if you have any patient that you would consider to have any gynecologic issues that they don’t feel comfortable taking care of or they may not have the technical skills to take care of; refer them to The Christ Hospital, they can be guaranteed that they will get the highest level of care, the best care, the most cost efficient care as well as the most recognized care that they could get anywhere in the country or the world. And rest assured that once the care was given and delivered; that they would be sent back to them for their future care and they could take care of the patient and if they have problems again, they could obviously send them back. But they would not lose the patient, they would send them to us, we would take care of them and then we would send them back to them.

Melanie: Wow. Thank you so much. What a great segment and such great information. You’re listening to Expert Insights Physician Views and News with The Christ Hospital Health Network. More information on Dr. Karram and all of The Christ Hospital physicians is available at www.tchpconnect.org that’s www.tchpconnect.org . This is Melanie Cole. Thanks so much for listening.