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Dr Huh (Host): Hey, everyone. It's Dr. Warner Huh again. I'm the chair of OB/GYN here at the University of Alabama at Birmingham. And I'd like to welcome you to this month's episode of Women's Health with Dr. Huh.

So today, I'm very excited to invite one of our experts on GYN surgery and we're going to talk about minimally invasive surgery and gynecology. This is a topic that I'm particularly interested in as a fellow gynecologist. And with me is Dr. Todd Jenkins, who's a professor in the Division of Women's Reproductive Health in the Department of Obstetrics and Gynecology here at UAB. He also serves as the Senior Vice Chair for Clinical Affairs in the department. So Dr. Jenkins, welcome to this month's podcast.

Dr Todd Jenkins: Thank you for having me. It's an honor to be here.

Dr Huh (Host): So I think we both can agree that how we approach surgeries for gynecologic disorders has changed quite a bit over the last 20 years with more and more of these surgeries being done via what we call a minimally invasive surgical approach. I think our listeners would be very interested in understanding what that exactly means, minimally invasive, and why is this important for women to consider.

Dr Todd Jenkins: Yeah, minimally invasive just encompasses surgeries that work to limit the size of the incisions needed. So historically, we would've made what's known as a laparotomy, which is a large incision on the woman's abdomen. But over the course of our careers, we've been able to do a growing number of cases through very small or sometimes no visible incisions.

For us in gynecology, minimally invasive essentially includes vaginal surgery, laparoscopic, and then robotic laparoscopic procedures. And I think these are important for our listeners to look for and know, because what we've also learned is the majority of the pain from the surgical procedures that we as gynecologists have done is from the incision. And so by reducing the incision, we reduce the postoperative pain, which allows the patient to get back to life and normal activities faster, get out of the hospital faster and, in some cases, have an improved cosmetic result. So all of those are very important to our patients.

One thing that's important to me as a surgeon about our minimally invasive techniques is that the majority of them take advantage of advances in fiberoptic cameras. And so, I feel like we have a better visualization of the surgical field than we used to have with traditional open surgery. And that allows us to be more precise and, in many cases, have a little bit lower blood loss, again which allow our patients to get back to their normal activities faster than they have done previously.

Dr Huh (Host): I totally agree with all those things. And just for clarity for our listeners, Dr. Jenkins, our college, the American College of Obstetricians and Gynecologists, I think at this point, strongly recommends that particularly for women that are undergoing a hysterectomy, many of which we do minimally invasive, that should be always the initial preferred route. So if you just can comment on that briefly.

Dr Todd Jenkins: As we work with our patients, we first make the decision, does this patient need and would benefit from a hysterectomy? That's choice one. Then, the second choice is how are we going to do it? And at least here at UAB, our first option is, can we do this vaginally? And then, if we cannot do it vaginally, we move to can we do it laparoscopically? And then, in that arena becomes whether robotics are necessary or whether we can do it with traditional laparoscopy. And then, only if you are not a candidate for those vaginal or laparoscopic techniques will we consider an open or abdominal hysterectomy.

Dr Huh (Host): Yeah. And you actually touched upon this already in your response, but I'm going to ask you sort of a more specific question. I think there's a lot of confusion in the community about what really robotic surgery is, and I think some people have this vision that you put 25 cents in the machine and the machine is operating on you and there's no surgeon in there. Can you describe really what robotic surgery is and, more importantly, why this is an important consideration for women?

Dr Todd Jenkins: Yeah. The thing I always like to impress upon people is that robotic surgery is still laparoscopy. It is a tool that enhances either the skills and ability of the surgeon or the number of patients that we can offer laparoscopic surgery to. In robotics, we use the same trocars or small holes that we put in your abdomen as we would for laparoscopy. However, the surgical robot has mechanical arms that attach to instruments that we use within the body. The surgeon actually sits at a console adjacent to the patient and manipulates those instruments using the robotic surgical console.

The irony of the name robotics is this instrument isn't actually a robot. It does nothing on its own. Everything that it does is controlled and managed by the surgeon. Now, the robot does do some valuable things for the surgeon. If there's any fine tremor in your hand, it actually eliminates that. It actually works with wristed instruments that allow you to do things that you can't do with a straight laparoscopic instrument. But it is still laparoscopic surgery. It is still managed by the surgeon. But it is a great tool to enhance either the things that the surgeon can do for you as a patient or enhance the number of patients that can benefit from laparoscopic surgery.

Dr Huh (Host): Just to kind of reiterate that, Dr. Jenkins, for our listeners. You said at the very end of the point that I think is really important to highlight. You know, I think what robotic surgery has allowed, particularly for many gynecologists, not just here locally in Birmingham, in the state of Alabama, but nationally, is increasing the option set for minimally invasive surgical approaches for women. And I think that has been a game changer for a lot of women. Whereas 10 years ago, those women would have an incision, now they have basically smaller incisions and many of those patients are going home the same day.

Dr Todd Jenkins: I think nowhere else than your world, with the world of endometrial cancer, has it had more of a benefit in the sense that those patients all had large midline incisions. They all were in the hospital for two or three days, had high complication rates due to some of their other medical conditions, and now they're afforded a minimally invasive technique and are home the same day, and their recoveries are so much faster. So it definitely has changed what we do.

Dr Huh (Host): So you also touched upon this very briefly earlier, but are there circumstances in which you might never or want to consider minimally invasive surgery when doing a gynecologic procedure?

Dr Todd Jenkins: Of course. What we teach our residents and what we try to practice is that the patient's safety is our number one priority. So if you don't feel like either for a patient factor or a surgical factor that a minimally invasive technique is appropriate, then we encourage everyone here at UAB to do the safest surgery possible.

Some patient factors that we have to think about are if you have a contraindication to general anesthesia. Often this is you have a heart condition or some type of lung condition that prevents you from having general anesthesia. Our patients that we do any type of minimally invasive surgery are in what we refer to as Trendelenburg position, which just means you're a little bit head down and that puts a little more stress on the heart and the lungs. And so we always want to make sure our patients can tolerate general anesthesia.

The second patient factor that comes to mind is if you've had multiple surgeries. Now, that's not an absolute, but we take a pause before rushing right in in a minimally invasive fashion in a patient who's had multiple procedures. There are also some surgical factors that we have to take into account. If you have a very large tumor. In my condition as a benign gynecologist, that usually represents a uterine fibroid, which are benign tumors of the uterus. They can be very large. And sometimes, it doesn't make a great deal of sense to do an elegant surgery and then have to make an incision to get the large tumor out when we could have done the procedure open in the same fashion.

Also, from the GYN-oncology sphere, many of our ovarian masses we need to remove intact, so that in the chance that they're a cancer, we don't spread that across the patient's abdomen. And then, as I said earlier, there are some cases where there are significant pelvic adhesive disease, either from previous surgeries or from a benign condition known as endometriosis that make the pelvis not a great place for laparoscopic surgery.

So those are some of the conditions that come to mind. But again, your safety as a patient has to be our first priority, not how we do the procedure.

Dr Huh (Host): You know, I couldn't agree more. And just from my own personal experience, I mean, I think sometimes it's a gray zone in terms of do I approach this with a minimally invasive surgical technique? Do I just start off with a larger incision? And oftentimes, I'll start the surgery through a minimally invasive approach. And as the surgery goes along, I sometimes determine, "I don't think I can do this safely," and underscoring the word safely, as you mentioned, Dr. Jenkins, and then convert to an open procedure.

But, you know, I think our listeners just have to recognize that not everything could be done in a minimally invasive approach. And the tenet here and the important thing is that we want the surgery to go well and safely for the patient irrespective of approach. And sometimes, you need to use the right tool for the right situation.

So let me ask you, since you're a true expert in the area of minimally invasive surgery and gynecology, are there any other novel surgical approaches that you would want to share with our listeners that you think are currently benefiting women?

Dr Todd Jenkins: Yeah, and I actually want to start out with something that's not technically surgical, but has really revolutionized what we do here and at many institutions across the country, and that's our enhanced recovery protocols. Traditionally, we've taken a very passive approach. We operate on you, we manage your pain, and then we let you go home. However, as a part of the enhanced recovery protocol, we take an active aggressive approach all the way from ensuring you're properly hydrated prior to surgery, to using what we refer to as multimodal or multiple types of pain management options to aggressive use of local and regional blocks by our anesthesia colleagues all the way to early ambulation and early feeding. And it has really revolutionized how our patients recover and it has probably most importantly lowered our patient's opioid or narcotic pain management need significantly.

The second thing is same-day surgery. We are now able to do many more surgeries same-day than we have previously. We have very strict milestones that our patients have to meet to go home same-day. But we found that following these milestones in benign cases, roughly 85% to 90% of patients are able to go home and safely recover in their own home without any challenges. And that has really changed what we do as well.

Then, as far as surgical techniques, I want to highlight three things that we're doing that are really changing over the course of my career, how we manage things. And that is, number one, we have increased the size of uterine fibroids that we are able to manage in a minimally invasive fashion. Previously, it was pretty much relatively normal-sized uteri were managed laparoscopically. And now through techniques to shrink the fibroids preoperatively and surgical techniques to reduce the size of the fibroid mass at surgery, we're able to do larger and larger fibroids in a minimally invasive fashion. So that has been one exciting thing.

The second thing specific to uterine fibroids that I will mention is a new technique called radiofrequency ablation of uterine fibroids. In this procedure, the patient gets two incisions, one for a camera, it is a five-millimeter, or I tell patients roughly the size of your pinky incision that's somewhere near their belly button. And then, a second incision right above your pubic bone, sort of at the top of the hairline. And we are able to view the fibroid through one incision, and then we use a laparoscopic ultrasound device through the other incision.

Finally, we bring a needle tip into the abdomen under visualization. So again, safety is our first priority. And we insert it into the actual fibroid. And using radiofrequency energy, we heat the fibroid, which denatures it. And the best way to describe that is fibroids are usually hard and to be very similar to almost like a baseball or softball, depending on their size.

After radiofrequency ablation, we turn that fibroid into almost like a marshmallow or Nerf ball, so it's much lighter, much softer and, in most cases, causes fewer symptoms. That's a new technique that we've been doing that we're excited to bring to our patients.

The other thing that we have been able to change here at UAB is a procedure that is done for a pregnancy complication known as cervical insufficiency or inability of the uterine cervix, which is sort of the mouth of the uterus or the mouth of the womb, as some people say, that it can't hold a pregnancy. And unfortunately, women who have this condition often suffer pregnancy loss at 16 to 18 weeks of pregnancy.

Historically, the only way to correct this issue has been an open procedure with a large, vertical midline or up and down incision, that of course requires a large amount of time in the hospital and recovery. We're now able to do that procedure laparoscopically with similar results and have afforded women up to an 85% to 90% rate of taking babies home when previously they've been unable to carry a pregnancy past 18 weeks.

So those are some of the new techniques. Of course, as we train newer and newer surgeons, they are continuing to expand the field for us. So I'm excited about the future.

Dr Huh (Host): Now, that's a great response. And going way back to the earlier part of your question about enhanced recovery pathways, I think what some of our listeners would be interested to know that I think what we learned over the many, many years, was that we were overprescribing narcotics and opioids to patients after their surgery because, when they're on this enhanced recovery pathway, it's not surprising at all for a patient to use none or next to no narcotics for pain control. So I think it's been truly revolutionary. And again, I concur with you, Dr. Jenkins. I think that the future is really, really bright in this field and you and I have been practicing a little bit over 20 years together, but it's amazing to me the changes that we've seen just during that time span and it's quite remarkable. I don't know if you have any other closing thoughts or comments for the audience.

Dr Todd Jenkins: I think the future's bright. Dr. Huh just said we've both been practicing over 20 years, but I think it's safe to say we both were trained and learned as open surgeries, and laparoscopy or minimally invasive surgery was the outlier. The residents we are training today, laparoscopy is the main technique that we use, and open surgery is the outlier. And so I'm excited with where this generation is going to move this field when laparoscopy is their baseline. Whereas for us, we were not only learning laparoscopy but then trying to advance the field.

Secondly, as I said earlier, new fiberoptic technology, new surgical technology, I think can only enhance what we can do. So I'm excited about the future for minimally invasive surgery. And because of that, I'm excited for the opportunities for care that we will have for women in the future.

Dr Huh (Host): That was great. I really couldn't agree more with you, Dr. Jenkins. So again, I'd like to thank Dr. Jenkins for coming by to discuss some novel and minimally invasive surgical approaches in gynecology.

And as always, please rate this podcast and we welcome any comments, particularly on topics that you guys are interested in. And for more information on our gynecology services and expertise and really any clinical service that UAB provides, please check out uabmedicine.org. And again, I'm really proud to announce on behalf of this department of OB/GYN, is that we were ranked number five by US Newsroom Report, which really speaks to the excellent care that this department provides, including the expertise that Dr. Jenkins has shared today. So until next time, thank you. We'll see you next month. Take care. Peace out. Bye-bye.