One inch. Now that’s all it takes to perform a hysterectomy.
Thanks to recent improvements in robotic surgery technology, it is now possible that an entire hysterectomy—surgical removal of the uterus— can be completed through a one-inch incision hidden in the belly button. This new technique, referred to as “single-site” hysterectomy because only the single incision is needed, will truly provide “scarless” surgery for many patients.
Hysterectomy is the most common gynecologic surgery in the United States; by age 60, more than one third of all women will have undergone the procedure. This is due to the fact that hysterectomy is often the recommended treatment for numerous reproductive issues when more conservative treatments, such as medications, have been unsuccessful. Hysterectomy may be necessary for conditions including uterine or cervical cancer, uterine fibroids, menstrual disorders or severe endometriosis, a painful condition which occurs when uterine tissue grows outside of the uterus.
In the U.S., approximately 600,000 women have a hysterectomy each year. In the past, a hysterectomy traditionally required open surgery with a large incision in the lower abdominal area, a minimum of several days in the hospital, and an extended recovery period that included several weeks of rest. Pain could be significant and, as with any open surgery, there were greater risks of complications such as bleeding and infection.
In many cases, traditional open surgery has been replaced by laparoscopic (and robotic) surgery that requires several small incisions placed in the abdomen instead of a large incision. Several thin instruments, along with a video camera attached to a telescope, are inserted through the incisions. The camera transmits an image of the internal organs onto a television monitor, and the surgeon uses the image as a guide. This type of minimally invasive surgery has fewer risks than open surgery and provides additional benefits such as reduced length of surgery, less pain, less blood loss, a shorter hospital stay and recovery time, and lower cost. However, it does result in several small scars. Single-site robotic hysterectomy provides all of the benefits of minimally invasive surgery, but in most cases will leave no visible scar at all.
Robotic surgery provides several other advantages over traditional laparoscopic surgery as well. These include a true 3-D view of the surgical field and more precise replication of the surgeon’s hand motions. Single-site robotic technology uses curved tubes which allow surgeons to operate from several angles using just one insertion site. In traditional laparoscopic surgery, this approach would cause the surgeon to have “crossed hands”; the surgeon’s left hand would operate the instrument viewed on the right side of the surgical field and vice versa. This is very difficult to do and is the main reason single-site surgery has not been more widely used until now.
The robotic computer system can “flip” right-hand and left-hand instrument control, so that during surgery, the instrument viewed on the right can now be controlled by the right hand and the instrument on the left can be controlled by the left hand. When the surgeon is operating at the robotic console, it is truly like having tiny hands in the operating field. This allows more precise and safer tissue dissection, and is one key to allowing the surgery to proceed smoothly.
As the technology continues to improve and more surgeons are trained in robotic surgery, single-site hysterectomy should become more widely available, but it is not yet an option for every patient. For example, patients who have significant scarring, adhesions or large fibroids may require several small incisions instead of just one. However, as this technology matures, more surgeons and more patients will be able to take advantage of this procedure.Bruce Kahn, M.D., is an OB/GYN with Scripps and director of the Scripps Fellowship in Minimally Invasive Gynecologic Surgery.