Selected Podcast
Minimally Invasive Gynecologic Surgery
James Robinson, MD, discusses new advances in minimally invasive, non-invasive and robotic-assisted gynecologic surgeries. These new approaches address issues such as endometriosis, uterine fibroids, chronic pelvic pain, and abnormal bleeding. Benefits include shorter hospital stays, less pain, a more rapid return to work and daily activities, preserved fertility, and a reduced risk of post-operative infection or other complications.
Featured Speaker:
Learn more about James K. Robinson, MD
James Kane Robinson, MD
James K. Robinson, MD, FACOG, is board certified in obstetrics and gynecology and fellowship trained in minimally invasive gynecologic surgery (MIGS).Learn more about James K. Robinson, MD
Transcription:
Minimally Invasive Gynecologic Surgery
Melanie Cole (Host): The landscape of gynecologic surgery has evolved rapidly in the past few years. New surgical and non-surgical options are emerging for a variety of gynecologic conditions with a major emphasis on minimally invasive and noninvasive options. My guest today is Dr. Jim Robinson. He’s a board-certified Obstetrician and Gynecologist and Fellowship-trained in Minimally Invasive Gynecologic Surgery at MedStar Washington Hospital Center. Welcome to the show. Dr. Robinson, what has typically been done for women in the department of gynecologic surgery?
Dr. Jim Robinson (Guest): Well thank you, for having me. In general, women historically -- with gynecologic problems including things like uterine fibroids, and chronic pelvic pain, endometriosis -- have required invasive abdominal surgeries that require prolonged hospital stays and often times have led to the loss of fertility.
Melanie: And what are we seeing now in terms of endometriosis or uterine bleeding, fibroids and the like.
Dr. Robinson: Advancements in minimally invasive surgery have allowed us to do almost every surgery that we historically did through open incisions, through small keyhole incisions called laparoscopy. In terms of uterine fibroids, historically women with large, symptomatic uterine fibroids would require a hysterectomy. And while this is still an option for some women, women who desire future fertility often require uterine preservation and, therefore we’re looking at removing the fibroids and repairing the uterus in a procedure called myomectomy. We’re now doing almost all of our myomectomies in minimally invasive ways using laparoscopic, hysteroscopic, and sometimes robotic-assisted laparoscopic ways to remove these fibroids.
Melanie: And in terms of fibroid procedures, let’s start with those. What are some of the benefits to the patient? What’s that procedure like if you’re using robotics or minimally invasive?
Dr. Robinson: In general, most people recognize the benefits of minimally invasive surgery as being shorter hospital stays, less pain, quicker return to work and better return to activities of normal living. But other benefits also exist and those benefits include the potential for decreased bleeding, the potential for decreased risk of postoperative infections like deep venous thrombosis, which is a blood clot in your leg that occurs from immobility that can travel to your lungs in a pulmonary embolism. Those postoperative risks are lower after laparoscopy since those patients are up and moving around faster. In fact, our patients are generally up the day of surgery. We make sure they get up and are going to the bathroom the day of surgery. Many of our patients are able to go home on the day of surgery and instead of spending two to three days in the hospital are typically out the day of surgery or maybe spending one observational day in the hospital and then going home and beginning their recovery and returning to normal activity.
Melanie: In terms of endometriosis, Dr. Robinson, what are you doing for women that also helps to preserve their fertility?
Dr. Robinson: Again with endometriosis, endometriosis is a condition that has the potential to wreak havoc on a woman’s reproductive organs. Endometrial tissue, which typically grows within the uterine cavity, or the womb, is growing outside of the uterus, proliferating, and shedding on a monthly basis. This can lead to both chronic pelvic pain, which typically worsens and progress and also can lead to a lot of pelvic scarring. That scarring can both affect fertility because it can block fallopian tubes and cause the pelvic organs to become matted together. But it can also affect those surrounding organs, like the bladder, the rectum, and the ureter. We often see endometriosis that is affecting all of the pelvic structures, and sometimes structures outside of the pelvis. When we do surgery for endometriosis in women who desire preservation of fertility it is imperative that we restore anatomy back to normal and we actually remove, or excise, all of the endometriosis that exists. That procedure sometimes requires a high level of expertise because the endometriosis can be on the bowel or the bladder, and it can require a more advanced level of surgery so that you can repair those structures. That’s something that we can do now laparoscopically and sometimes with the assistance of robotics.
Melanie: Dr. Robinson, many women experience abnormal bleeding whether they’re in perimenopause, or just prior to that. What do you tell them about abnormal bleeding or ultra-heavy bleeding? What do you tell them about procedures for that?
Dr. Robinson: The first thing we always have to do when somebody comes in with abnormal bleeding is we have to try to figure out what’s causing the abnormal bleeding. There are two classic types of abnormal bleeding, bleeding that happens cyclically, during the cycle, so it’s really no change in the hormonal status of the patient, but now when they have a period, their periods are much heavier, they’re lasting longer, potentially they’re more painful and the patient’s becoming anemic and symptomatic. The problems that cause that type of heavy menstrual bleeding -- or abnormal bleeding -- typically are from things like fibroids that enter the endometrial cavity, or a condition called adenomyosis, which is similar to endometriosis in that it’s endometrial tissue that is now growing within the muscle of the uterus. In those patients, we want to address the disease.
In women who come in with abnormal uterine bleeding that’s not cyclic -- that happens randomly -- that is typically of hormonal origin and in those cases, we want to really identify what’s going on. Is there something in their endocrine system – their thyroid, their prolactin -- or from perimenopause, that’s causing them not to ovulate regularly, giving them the abnormal bleeding? It’s important for us first to diagnose what’s going on so we can tailor our treatment to the patient.
With respect to treatment, many of our treatments -- once we diagnosis the patient -- can be performed either in an office setting or in a very strict outpatient surgical setting where we actually operate hysteroscopically up within the cavity of the uterus. Our procedures range from hormonal management with either birth control pills or intrauterine devices, all the way through minimally invasive hysteroscopic surgeries where we either remove the fibroids that are entering the cavity -- or the polyps that are entering the cavity -- or we can even, in women that do not desire to preserve fertility, do things like endometrial ablation, where we destroy the endometrial cavity so that no further bleeding occurs. That’s something that we can do in patients that don’t want to get pregnant in the future but would like to avoid a bigger surgery that’s going to cause them to miss more work, or that’s going to cause them to be in a little bit more pain postoperatively.
Melanie: Dr. Robinson, when women hear about hysterectomies, we’ve been hearing about them for many, many years and then you hear somebody say, “Oh, they’re not doing those very often anymore.” Tell us about hysterectomies. What’s going on in the world today?
Dr. Robinson: Well, I like to tell my patients that it’s not your mother’s hysterectomy. We’ve really come a long way with respect to hysterectomies. While some women want to preserve their uterus either for fertility or not, many women who are past childbearing would benefit from a hysterectomy, so the disease that’s causing their problem is definitively treated. The beauty of the current era is that we can do close to 100% of hysterectomies in a minimally invasive way at this point. It should be very uncommon for a woman to have to undergo an abdominal hysterectomy even with very large, symptomatic fibroids, or a uterus that is large and is involved with adhesions and other problems. You can almost always remove even those larger uterusus in a minimally invasive way, generally as an outpatient.
The other thing that’s really important is that we’ve learned that the benefits ovaries and woman’s hormonal status lasts well past menopause. Even after women have stopped ovulating and making the estrogen that they typically make, they’re still making testosterone. Their ovaries are still functioning and the benefits of the ovaries extend to sexual function, heart health, bone health, skin health, memory, and probably even years of life. We’ve become much more ovarian conservationists in the modern era and even women who are menopausal and postmenopausal are often discussing ovarian preservation at the time of hysterectomy.
One of the other things that we’ve started doing is we’ve started to routinely remove the fallopian tubes when we do a hysterectomy, even when we leave the ovaries. And we’re doing this because we now know that approximately 20% of ovarian cancers probably start in the fallopian tube. By removing the fallopian tube, it can actually decrease a woman’s lifetime risk of ovarian cancer by about 20%. The last thing that laparoscopic, vaginal approach to a hysterectomy offer women is we don’t shorten the vagina at all. Because we’re not shortening the vagina, we’re not affecting sexual function, which historically were the problems. We’re also not severing the supportive ligaments of the uterus, so we’re not increasing a women’s risk of prolapse, or urinary incontinence.
Melanie: That’s absolutely fascinating, Dr. Robinson. Wrap it up for us with your best advice. If a woman is sitting across from you at your desk and asking you about the future of minimally invasive surgeries and gynecologic surgeries, and what they can expect, what do you tell them every day?
Dr. Robinson: I have this con—[laughs] I’m glad you asked. I have this conversation every day with a patient and unfortunately, we still live in an era where many people are using older techniques. They’re still using these open approaches. They’re still removing ovaries as a matter of routine. I think it’s important for women to research what they’re having done. I think it’s very interesting that many women will spend a lot of time researching their plastic surgeons, about maybe a cosmetic procedure, or something else that they were considering having, but they trust their OB/GYN because their OB/GYN is the person that delivered their baby. That person may or may not be skilled in the less invasive approaches to care for them as they’re getting older or having more problems.
I think it’s imperative for women to take control of their healthcare and to research the options that exist. I think it’s important for all of us as physicians to really lay out the options because surgery is not the only option. I spend a lot of time talking people out of surgery who I don’t think need it. I certainly don’t want to be taking somebody to the operating room when we can expect the same benefit in a less invasive way. When surgery is an option, I want my patients to know that with very few exceptions, we can approach their problem in a much less invasive way than they’re probably aware of and maybe even a less invasive approach than their regular OB/GYN is aware of.
Part of the education that we need to do is we need to educate not only our patients and our Primary Care physicians so that they know what kind of options are available for them. I think it’s an exciting time for women and I think that as we train more people in minimally invasive gynecologic surgical techniques, we’re going to see the landscape of surgery for women’s healthcare continue to change rapidly.
Melanie: Thank you, so much, for being with us today, Dr. Robinson. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to MedStarWashington.org, that’s MedStarWashington.org. This is Melanie Cole. Thanks, so much, for listening.
Minimally Invasive Gynecologic Surgery
Melanie Cole (Host): The landscape of gynecologic surgery has evolved rapidly in the past few years. New surgical and non-surgical options are emerging for a variety of gynecologic conditions with a major emphasis on minimally invasive and noninvasive options. My guest today is Dr. Jim Robinson. He’s a board-certified Obstetrician and Gynecologist and Fellowship-trained in Minimally Invasive Gynecologic Surgery at MedStar Washington Hospital Center. Welcome to the show. Dr. Robinson, what has typically been done for women in the department of gynecologic surgery?
Dr. Jim Robinson (Guest): Well thank you, for having me. In general, women historically -- with gynecologic problems including things like uterine fibroids, and chronic pelvic pain, endometriosis -- have required invasive abdominal surgeries that require prolonged hospital stays and often times have led to the loss of fertility.
Melanie: And what are we seeing now in terms of endometriosis or uterine bleeding, fibroids and the like.
Dr. Robinson: Advancements in minimally invasive surgery have allowed us to do almost every surgery that we historically did through open incisions, through small keyhole incisions called laparoscopy. In terms of uterine fibroids, historically women with large, symptomatic uterine fibroids would require a hysterectomy. And while this is still an option for some women, women who desire future fertility often require uterine preservation and, therefore we’re looking at removing the fibroids and repairing the uterus in a procedure called myomectomy. We’re now doing almost all of our myomectomies in minimally invasive ways using laparoscopic, hysteroscopic, and sometimes robotic-assisted laparoscopic ways to remove these fibroids.
Melanie: And in terms of fibroid procedures, let’s start with those. What are some of the benefits to the patient? What’s that procedure like if you’re using robotics or minimally invasive?
Dr. Robinson: In general, most people recognize the benefits of minimally invasive surgery as being shorter hospital stays, less pain, quicker return to work and better return to activities of normal living. But other benefits also exist and those benefits include the potential for decreased bleeding, the potential for decreased risk of postoperative infections like deep venous thrombosis, which is a blood clot in your leg that occurs from immobility that can travel to your lungs in a pulmonary embolism. Those postoperative risks are lower after laparoscopy since those patients are up and moving around faster. In fact, our patients are generally up the day of surgery. We make sure they get up and are going to the bathroom the day of surgery. Many of our patients are able to go home on the day of surgery and instead of spending two to three days in the hospital are typically out the day of surgery or maybe spending one observational day in the hospital and then going home and beginning their recovery and returning to normal activity.
Melanie: In terms of endometriosis, Dr. Robinson, what are you doing for women that also helps to preserve their fertility?
Dr. Robinson: Again with endometriosis, endometriosis is a condition that has the potential to wreak havoc on a woman’s reproductive organs. Endometrial tissue, which typically grows within the uterine cavity, or the womb, is growing outside of the uterus, proliferating, and shedding on a monthly basis. This can lead to both chronic pelvic pain, which typically worsens and progress and also can lead to a lot of pelvic scarring. That scarring can both affect fertility because it can block fallopian tubes and cause the pelvic organs to become matted together. But it can also affect those surrounding organs, like the bladder, the rectum, and the ureter. We often see endometriosis that is affecting all of the pelvic structures, and sometimes structures outside of the pelvis. When we do surgery for endometriosis in women who desire preservation of fertility it is imperative that we restore anatomy back to normal and we actually remove, or excise, all of the endometriosis that exists. That procedure sometimes requires a high level of expertise because the endometriosis can be on the bowel or the bladder, and it can require a more advanced level of surgery so that you can repair those structures. That’s something that we can do now laparoscopically and sometimes with the assistance of robotics.
Melanie: Dr. Robinson, many women experience abnormal bleeding whether they’re in perimenopause, or just prior to that. What do you tell them about abnormal bleeding or ultra-heavy bleeding? What do you tell them about procedures for that?
Dr. Robinson: The first thing we always have to do when somebody comes in with abnormal bleeding is we have to try to figure out what’s causing the abnormal bleeding. There are two classic types of abnormal bleeding, bleeding that happens cyclically, during the cycle, so it’s really no change in the hormonal status of the patient, but now when they have a period, their periods are much heavier, they’re lasting longer, potentially they’re more painful and the patient’s becoming anemic and symptomatic. The problems that cause that type of heavy menstrual bleeding -- or abnormal bleeding -- typically are from things like fibroids that enter the endometrial cavity, or a condition called adenomyosis, which is similar to endometriosis in that it’s endometrial tissue that is now growing within the muscle of the uterus. In those patients, we want to address the disease.
In women who come in with abnormal uterine bleeding that’s not cyclic -- that happens randomly -- that is typically of hormonal origin and in those cases, we want to really identify what’s going on. Is there something in their endocrine system – their thyroid, their prolactin -- or from perimenopause, that’s causing them not to ovulate regularly, giving them the abnormal bleeding? It’s important for us first to diagnose what’s going on so we can tailor our treatment to the patient.
With respect to treatment, many of our treatments -- once we diagnosis the patient -- can be performed either in an office setting or in a very strict outpatient surgical setting where we actually operate hysteroscopically up within the cavity of the uterus. Our procedures range from hormonal management with either birth control pills or intrauterine devices, all the way through minimally invasive hysteroscopic surgeries where we either remove the fibroids that are entering the cavity -- or the polyps that are entering the cavity -- or we can even, in women that do not desire to preserve fertility, do things like endometrial ablation, where we destroy the endometrial cavity so that no further bleeding occurs. That’s something that we can do in patients that don’t want to get pregnant in the future but would like to avoid a bigger surgery that’s going to cause them to miss more work, or that’s going to cause them to be in a little bit more pain postoperatively.
Melanie: Dr. Robinson, when women hear about hysterectomies, we’ve been hearing about them for many, many years and then you hear somebody say, “Oh, they’re not doing those very often anymore.” Tell us about hysterectomies. What’s going on in the world today?
Dr. Robinson: Well, I like to tell my patients that it’s not your mother’s hysterectomy. We’ve really come a long way with respect to hysterectomies. While some women want to preserve their uterus either for fertility or not, many women who are past childbearing would benefit from a hysterectomy, so the disease that’s causing their problem is definitively treated. The beauty of the current era is that we can do close to 100% of hysterectomies in a minimally invasive way at this point. It should be very uncommon for a woman to have to undergo an abdominal hysterectomy even with very large, symptomatic fibroids, or a uterus that is large and is involved with adhesions and other problems. You can almost always remove even those larger uterusus in a minimally invasive way, generally as an outpatient.
The other thing that’s really important is that we’ve learned that the benefits ovaries and woman’s hormonal status lasts well past menopause. Even after women have stopped ovulating and making the estrogen that they typically make, they’re still making testosterone. Their ovaries are still functioning and the benefits of the ovaries extend to sexual function, heart health, bone health, skin health, memory, and probably even years of life. We’ve become much more ovarian conservationists in the modern era and even women who are menopausal and postmenopausal are often discussing ovarian preservation at the time of hysterectomy.
One of the other things that we’ve started doing is we’ve started to routinely remove the fallopian tubes when we do a hysterectomy, even when we leave the ovaries. And we’re doing this because we now know that approximately 20% of ovarian cancers probably start in the fallopian tube. By removing the fallopian tube, it can actually decrease a woman’s lifetime risk of ovarian cancer by about 20%. The last thing that laparoscopic, vaginal approach to a hysterectomy offer women is we don’t shorten the vagina at all. Because we’re not shortening the vagina, we’re not affecting sexual function, which historically were the problems. We’re also not severing the supportive ligaments of the uterus, so we’re not increasing a women’s risk of prolapse, or urinary incontinence.
Melanie: That’s absolutely fascinating, Dr. Robinson. Wrap it up for us with your best advice. If a woman is sitting across from you at your desk and asking you about the future of minimally invasive surgeries and gynecologic surgeries, and what they can expect, what do you tell them every day?
Dr. Robinson: I have this con—[laughs] I’m glad you asked. I have this conversation every day with a patient and unfortunately, we still live in an era where many people are using older techniques. They’re still using these open approaches. They’re still removing ovaries as a matter of routine. I think it’s important for women to research what they’re having done. I think it’s very interesting that many women will spend a lot of time researching their plastic surgeons, about maybe a cosmetic procedure, or something else that they were considering having, but they trust their OB/GYN because their OB/GYN is the person that delivered their baby. That person may or may not be skilled in the less invasive approaches to care for them as they’re getting older or having more problems.
I think it’s imperative for women to take control of their healthcare and to research the options that exist. I think it’s important for all of us as physicians to really lay out the options because surgery is not the only option. I spend a lot of time talking people out of surgery who I don’t think need it. I certainly don’t want to be taking somebody to the operating room when we can expect the same benefit in a less invasive way. When surgery is an option, I want my patients to know that with very few exceptions, we can approach their problem in a much less invasive way than they’re probably aware of and maybe even a less invasive approach than their regular OB/GYN is aware of.
Part of the education that we need to do is we need to educate not only our patients and our Primary Care physicians so that they know what kind of options are available for them. I think it’s an exciting time for women and I think that as we train more people in minimally invasive gynecologic surgical techniques, we’re going to see the landscape of surgery for women’s healthcare continue to change rapidly.
Melanie: Thank you, so much, for being with us today, Dr. Robinson. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to MedStarWashington.org, that’s MedStarWashington.org. This is Melanie Cole. Thanks, so much, for listening.