robotic hysterectomy

Conquering the Uterus – Trends in Hysterectomy

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Every 10 minutes, 12 American women lose their reproductive organs, every day of every year. Hysterectomy is second only to cesarean in common surgeries. Approximately 660 women die each year in the United States from complications related to hysterectomy. Thousands more suffer long term side effects associated with oophorectomy – removal of the ovaries. The most common reasons for hysterectomy include:  uterine fibroids or rather the menorrhagia, heavy bleeding associated with the fibroids and endometriosis, an incredibly painful condition where uterine tissue grows outside the uterus. Both conditions are hormonally modulated, plague millions of women and take years to develop.

One would think that with such extended period of disease progression, 5-10 years, researchers and clinicians would have ample opportunity to develop innovative treatment protocols, long before the surgical removal of the uterus was necessitated. One would be wrong. Despite the cost of long term care leading to, and as a result of the hysterectomy; despite the outcry from the hundreds of patient associations, some with high profile members; despite the billions of dollars spent annually on performing what should be last resort surgeries, there has been no innovation in diagnostic tools for these conditions and no new therapeutics for women’s reproductive health developed in over 50 years, unless you call the re-purposing of old meds innovation.

Instead, innovation in women’s healthcare, much like American healthcare in general only magnified exponentially, comes at the end of the disease progression – when no other choice but surgery exists. Let’s build a cool robotic tool to remove even more uteri. Sure it will cost significantly more and have a higher complication rate, but the technology is so impressive that does not matter. Forget about developing early diagnostics and less invasive, more effective therapeutics, just take it all out and look cool doing so. Who would not want to perform surgery remotely with a million dollar piece of medical technology? Women don’t need their uteri anyway – a win win for all involved.

Robotic Assisted Hysterectomy

The robotic, joystick controlled, remote surgical tool is an impressive piece of engineering. With a price tag of over a million dollars per, it provides the cutting edge stature that all top-notch hospitals strive for. An added bonus, it makes gynecology, the long derided medical profession, the cool kid on the block. But does it work?

Well, not really. Sure it removes a woman’s uterus more quickly and with less scarring; a single ½ inch belly button scare versus two or three ½ inch abdominal scars, but it costs more and doesn’t reduce complications – may even increase them a bit. Compared to the minimally invasive laparoscopic hysterectomy, the robotic assisted hysterectomy costs $2000 more per procedure. As of 2010, about a quarter of all hysterectomies were performed robotically. That’s about $300 million dollars per year more to perform a robotic hysterectomy with no added gain health.  When combined with the costs multiple hospital stays, ineffective therapeutics and possible other surgeries that often led up to the hysterectomy, it is clear why women’s healthcare is so expensive.

Perhaps we could use our health dollars a little more wisely. Maybe we should spend some of those many billions of dollars or even a fraction of the $300 million spent annually on robot surgery, on prevention, early diagnostics or more effective therapeutics.

Update

Since this article was originally published in 2013, additional reports of complication rates for robotic surgery have been published. In a study of 298 patients undergoing robotic hysterectomy published in 2015, the complication rate was 18%. In 2017, a study of complication rates of a single surgeon using the robot, was 5.5% suggesting that some surgeons are better with this tool than others. In comparison, a study looking at 4505 hysterectomies performed by the same team between 1990 and 2006 (3190 were performed by laparoscopy, 906 by the vaginal route and 409 by laparotomy) saw the complication rates below 1%, significantly lower than that of the robotic surgeries, but again demonstrating that the skill of the surgical team is paramount.

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This article was published originally on March 18, 2013.

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My Hysterectomy Horror

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It all began when I noticed a tiny pinkish spot on my underwear. Maybe a bit of dryness, or perhaps a slight infection. But a few days later it happened again. Doing some research, I was convinced it was due to vaginal dryness–nothing to worry about. But a week or so later, there was real, actual blood on the toilet paper. It was obvious that something was going on that was perhaps more serious. Couldn’t put it off any longer–a trip to a gynecologist was in order.

Being new to the area, I searched the Internet and found a Dr. C. His “Healthgrades” on the web were all glowing five star reviews. So off to him I went. I hadn’t seen one of these specialists in decades. There was no need to. Never any pain, no discharge and only the occasional UTI, which my family physician took care of. With no symptoms (until now) it seemed a waste of time and money. So I made an appointment with his office, a bit concerned but not overly so.

Dr. C was not intimidating, but there was something about him I did not like, although I could not put my finger on it. He greeted me kindly enough, talked about mundane matters and in general seemed a decent man. Then all of a sudden his demeanor changed, even before he had read through the history I had filled out in the waiting room. He started pointing out various things: my age, my early first menstrual period (at the age of 10) and my relatively late menopause (maybe 55? I cannot remember exactly). He then told me about the profile of women who were at high risk for endometrial cancer. Which of course I fit to a “T”.

The Big Sell Begins

Before he even examined me, the very next thing he did was to start talking about that wonderful new surgical instrument, the DaVinci robot. He explained that in most cases, women could avoid the large incision and blood loss because this method was an assisted laparoscopic procedure and patients were bouncing back to their former lives in a matter of weeks after having a total hysterectomy. Why was he discussing this now, before there was no exam, no diagnosis? My head was reeling.

After being lectured for not having annual mammograms, he wrote out a prescription and told me to get one post haste. Finally, the physical exam. After he looked around a bit, the speculum pinching and my nerves now totally frazzled, he took a Pap smear (the cotton tip was covered in blood). Then I was told to dress and come back into his office.

He told me that to rule out cancer he had to do a hysteroscopy–a procedure where the uterus is filled with saline solution, samples of the lining were removed for biopsy, and also pictures were taken of anything that looked amiss. But since his schedule was pretty tight, he advised me to get the mammogram first and then set up an appointment for the procedure sometime in the coming weeks.

Back in his office, he had me watch a video (everything already set up before I had even entered the room) about how all these women of various ages were giving glowing reports of their wonderful hysterectomies done by this latest advancement in surgical procedures. Back to work, back to exercising, back to everything in their former lives in six weeks! As I watched, my mind kept asking–why is he showing me this now, when not a single biopsy had been done and he had seen nothing amiss during his examination? After receiving the date of my hysteroscopy and pre-surgical testing, I left his office shaking, frightened, a bad headache coming on, and the thought that I just might be dying.

Phase 1 of the Hysterectomy Sales Job: Stoking the Fear of Cancer

I had the mammogram. The results were mailed to me, indicating that something was seen in my left breast and that I should come back for a more detailed look at this foreign mass that could not be felt by a physical exam. I went back to have a more in depth mammogram of my left breast. About a half hour later a radiologist spoke to me and said that it looked like I had a fibroadenoma, a type of benign lump. But the only way to be sure was to have it biopsied. I was given an appointment with yet another doctor; this time a general surgeon. After feeling around my left breast without success, he finally found it buried deep near the chest wall. He squeezed so hard I cried out in pain. His conclusion was to have it biopsied and then go from there.

I went to C— Medical Center, where an associate of the surgeon used a puncher to withdraw nine samples from the tumor, putting in a tiny metal clip to mark the spot. I was then subjected to still another mammogram against my vehement objections-I told them I thought I have been irradiated enough-to assure that the clip was in the right place. I left very angry, wondering how they dared to go against my rights as a patient to refuse any aspect of treatment. But their attempts to thoroughly frighten me about the “Big C” were very successful.

I returned to C— Medical Center for the hysteroscopy. Dr. C was almost one hour late, greatly increasing my sense of apprehension as well as giving me a pounding headache and trembling all over from nerves. Finally, I was wheeled into the operating room. It was a relatively short procedure and I woke up about 45 minutes later. As I was in recovery, Dr. C spoke to my husband in the waiting area, telling him that he had found some polyps but as far as he could tell there was no cancer present. While showing me the photos of the polyps, he mentioned that he would have to wait for the pathology report, but he was certain everything was benign as he had already done a microscopic examination of the growths. As I was dressing to leave, my husband came to help and informed me of what Dr. C had told him.

One of the nurses advised me to make a follow up appointment to see the doctor as he would be receiving the official pathology report as well as the results of my breast biopsies. However, I learned that he would be going away to Maine for a two week vacation and would see me when he returned.

Two weeks! A long time to find out if there was cancer in either my breast, my uterus, or both. So I endured the wait, trying to keep my mind occupied with other things and also dealing with my entire uterus aching from the hysteroscopy. Regardless, I felt positive and when my follow up day arrived I walked into his office believing that all was fine, based on what my husband had been told.

During the follow-up visit, Dr. C told me that although the breast biopsy was benign, there was an encapsulated cancer in one of the endometrial polyps. The shock I felt cannot be described. Hadn’t he said everything looked good? I hardly heard his next words: that if he were to get cancer, “this is the type he would wish to have as it was very slow growing”.

Phase 2 of the Hysterectomy Sales Job: The Wonders of Robotic Surgery

He then began to tout the virtues of the DaVinci surgical system for hysterectomy, even remarking that he was thinking of becoming trained in the procedure and moving from private practice to becoming a specialist with the DaVinci. (He actually proceeded to do just that, and is now a practicing gynecological surgeon specializing in the DaVinci robotic surgery technique. That’s where the money is…but I digress.)

I was then forced to watch the same video TWICE about the wonders of robotic surgery-the same one I had seen at the time of my first visit. It did not reassure me. I had cancer growing inside me, and the happy, glowing faces of the women talking to me from the DVD player did nothing to reassure me that this was going to be easy and that everything would be rosy again.

While I was watching women jogging in a park and playing with their grandchildren on the video, Dr. C was on the phone to Dr. B, a gynecologic/oncologist who was “top of her field”. He spoke personally to Dr. B on the phone and was able to get me an appointment quickly. This couldn’t be happening; I walked into the office in such a positive mood and now my thoughts ran to how long I have to live. Despite his claims to the contrary, this would be major surgery and I would lose my (useless, as he put it) female organs.

I felt ill and told one of the nurses my head didn’t feel right. She took my blood pressure and it was around 204/107. The woman informed the doctor and he took me into another room and had me lie down as he would not let me drive home with such high numbers. And so there I was, lying on an exam table while he was telling me to imagine being on a tropical beach with the waves gently rolling to shore. How I did not have a stroke puzzles me to this day.

The drive home was one of the worst of my life. I told my husband the diagnosis, and he was as shocked as I was. I spent the greater part of the day crying, and even entertained suicidal thoughts thinking that just ending my existence quickly would be the easiest way to handle this. But truly all I could do was wait to see the oncologist, who would determine what course the rest of my life was going to take. My husband had suggested that I get a second opinion. At first this seemed reasonable to me, and I made an appointment with a second gynecologist to find out if such a drastic approach should be made. But I was so terrified of the “C” word, totally believing in the diagnosis and afraid that it would spread very quickly, that I decided to cancel and just go along with Dr. C. The fear they instilled in me was so intense I had lost my ability to think clearly.

Shortly after all the above had transpired, my husband and I sat in Dr. B’s office as she went through my records, which had been previously faxed over from Dr. C. Again the same words “If I had cancer, this is the type I would want to get”. (Much later, after perusing the internet, I found that these doctors seemed to be working from the same script, all using the exact same words to a large number of frightened women. To me this indicates they all received the same training and were told exactly how to present the “slow growing cancer” and the wonders of robotic surgery.) She then told us how she was going to perform a total hysterectomy/oophorectomy, probably using the DaVinci robot. Dr. B went into how there were risks including excessive bleeding, nerve damage and possibility of blood clots. It was then that I told her I had Reflex Sympathetic Dystrophy and felt that I was not a candidate for this type of surgery. The chances of the RSD spreading were high. She said she didn’t see where that would present any difficulty.

Hysterectomy and Robotic Surgery Side Effects Never Mentioned

Dr. B then went on to say that I would be put in a steep Trandelenburg position, with my head nearest the ground and my body near to a 45 degree angle. What she didn’t say was that this position would be maintained for about four hours. I was told that the abdomen would be pumped full of gas, but never mentioned the awful side effects that would occur post-op and that the gas would take a long time to dissipate. There was absolutely no discussion of what the ensuing lack of estrogen was to do to my body over time, the increased heart attack risk (which is very high in my family on both sides), osteoporosis etc., most stemming from the loss of my ovaries. Lastly, no mention was made of the weight gain of thirty pounds or more that the majority of women experience following a hysterectomy and how this weight would be almost impossible to lose. And the huge, huge breast size increase that would occur.

Dr. B then asked if we had any questions, but we could not think of anything else at the time. She just so happened to have a cancellation, thus assigning next Tuesday as the date of my surgery. Since this was only a few days away, I then went to my primary physician, Dr. C’s wife, who filled out the necessary forms to clear the way for the operation.

Pre-Hysterectomy Fear Sets In

The night before my surgery was living hell. I could not sleep. I thought of the cancer. If this is what I truly had, then perhaps I should just commit suicide then and there rather than go through years of suffering. Yes, that is the horrendous state my mind was in that night. But my husband sat up with me and tried to reassure me that all would work out in the end.

The day dawned, and by 7 am my husband and I were waiting in the pre-surgical cubicle. Dr. B was running late due to complications from her first surgery that day. I happened to mention that the night before I was wondering if it wouldn’t be better just to bring all this to some kind of premature end. Immediately, I was surrounded by hospital personnel and had a young student nurse sit with me. I was put on suicide watch, my surgery canceled. They wheeled me (with a security guard following) into the isolation room, where for the entire day every move I made was watched. Why was I there? I only expressed my fears over the future and had no suicide plan. I felt like a criminal. My handbag was turned upside down and the contents roughly shaken out onto the table. When I had to use the bathroom, an aide came in to watch my every move. I will never forget the humiliation I felt. This lasted until a psychiatrist came in that evening. He asked me why did I have to take Ativan four times a day! This was totally incorrect. It was prescribed as a PRN medication and I rarely took more than one or two in a week. The hospital apparently had screwed up my entire medication list. At any rate, I was OK to be discharged the next morning and the suicide watch was canceled. To this day I don’t feel free to tell any health professional if I am feeling suicidal or even close to thinking about it for fear of being subjected again to the demeaning treatment of being “locked up” for the crime of feeling overwhelmed.

Hysterectomy Day and the Pain of Recovery from Robotic Surgery

My surgery was re-scheduled for October 2. Back at C Medical Center, I was anesthetized and woke up in recovery screaming. I was wheeled into some kind of maintenance area while they prepared a room for me-all this while my agony was extremely apparent. My entire rib cage felt like knives were being thrust through it. I thought I was having a heart attack and would die right then and there. The response was for someone to bring in a dinner plate of regular food as though I hadn’t just had over four hours of being under heavy anesthesia. Eventually the terrible pains ended, and I later learned that because of the head downward position during surgery, most of the gas pumped into my abdomen ended up in my rib cage around my heart and lungs. No one ever prepared me for this.

While in my room, I kept asking where my regular medications were and why I was not being given my hydrocodone. They informed me that the pharmacy did not have my dose on hand. I called my husband. He came rushing back to the hospital to give me my pain medication. This was against “the rules”, but by then he was furious with the lack of care. When I asked for my night time medications as they helped me sleep, I was instead offered a regular sleeping pill, which I refused. My medications for my RSD and psychiatric conditions were withheld from me for my entire stay.

Dr. B arrived the next morning and when I informed her I had been given no pain meds because they “didn’t carry my dose”, she appeared angry and said that I should have been given two of the dose they presumably carried. I felt well enough to walk around the hall and was then discharged with the usual post-op instructions. There had been some benign cysts removed from one of my ovaries. Abdominal lymph nodes were removed. Everything was biopsied and came back benign.

Botched Surgery or Normal Aftereffects of a Robotic Surgery?

I came home Wednesday, October 3. All seemed fine until Friday evening, three days later, when I looked down and saw two large spots of dark blood growing ever bigger on my white T-Shirt. Extremely alarmed, I called Dr. B’s number. Her assistant, Dr. H. (whom I later learned had been present during my surgery) told me this was “normal”. If it didn’t stop I was to go to the ER; otherwise, just keep my regular follow-up appointment on Wednesday.

During my Wednesday appointment I told Dr. B what had happened. She did not seem concerned until she began taking the steri-strips from the incision above my naval. When she removed the one on the end a large amount of very dark red blood literally exploded out of the incision, so much so that her assistant had to jump back in order not to be sprayed by the blood. Then began a massive cleanup job as blood continued to come out with the removal of each steri-strip. Dr. B gave no explanation as to what had happened. She began packing the area with iodoform tape, shoving it into the incision (very roughly, I might add). She must have used over a yard of the tape. Dr. B then said that the incision had to be cleansed and packed twice daily for at least two weeks. Since my husband is an LPN, she instructed him how it should be done, and I was to come back the next week for a check up.

I then went through two weeks of hell, as the amount of packing needed was huge, the tape itself was scratchy and caused additional bleeding in and around the wound. I would have to stuff part of a pillow in my mouth to keep from screaming. The blood stained tape that was removed had to be pulled out of the wound each time, and the amount needed to pack the hole was, to me, unbelievable. Twice a day I had to endure this torture, while my husband tried to make the procedure as gentle as he could. But there is no way the scraping of the wound and the bleeding this caused could be anything but excruciating.

This went on for two weeks, and I told Dr. Brudie I could not stand it anymore. She then took about three large pieces of gauze and shoved it into the hole under and to the left of the original incision. Unfortunately, this proved to be not enough and it was back to the iodoform strip. Healing of this incision and area was long, painful and left me with a keloid scar that constantly feels as though someone is stabbing me in my belly. It only occurred to me later that a blood vessel must have been nicked during surgery.

The Pain Continues

Several months later I experienced pain in the keloid area and vomited up very light green fluid with small white pieces floating around. To this day I cannot eat more than a small amount of food at one time because of the pain it causes underneath the keloid.

Because my pain management doctor, Dr. G, had prescribed that I be given Ketamine during surgery to decrease possible complications from my RSD (and which the hospital VERY reluctantly used even though my pain management doctor had discussed this with Dr. B prior to surgery), it seemed my healing was proceeding normally. It was in November of that year that I suddenly experienced intense burning like fire from my groin area and down my legs. About one week later, large lipomas appeared on both thighs where the burning had been.

When I tried to discuss this with Dr. H (Dr. B had since moved back to Florida), the matter was dismissed. I believe these lipomas were the result of lymph node removal, but no one seemed to want to discuss this latest development. Occasionally I would experience a light reddish-pink discharge from my vagina. This was put down to vaginal dryness. I have since discovered that this would occur when I was severely constipated and the vaginal walls began rubbing against each other. This constipation is still an almost everyday affair.

Post Hysterectomy/Oophorectomy: Pain and Suffering

I had made up my mind that I was finished with all of this. Cancerhead was literally driving me crazy, as every ache and pain to my mind had to be cancer. My life has changed so much for the worse that I often feel that I died the day they took my female organs. I don’t understand why organs are first removed and then biopsied. I was given no physical therapy instructions, no offer of some kind of hormone replacement to stop the horrible symptoms that have developed since the surgery. Even though I was already menopausal, it has since come to my knowledge that our ovaries, uterus etc. still perform certain functions that help us get through our later years. We don’t even know today just what these organs continue to do after menopause and the totality of how they continue to influence our other bodily organs, including the thyroid gland.

Most of the following symptoms began about a year after my DaVinci hysterectomy and oophorectomy and include:

  • Varicose veins
  • Constant constipation
  • UTIs
  • Pain throughout my torso that is elicited by just a light touch
  • Extreme dryness
  • Extreme mood swings
  • Suicidal thoughts
  • Cognitive difficulties
  • Serious depression
  • Unexplained weight gain unresponsive to diet/exercise
  • Huge growth of breasts
  • Constant backache from the “apron”-a horizontal lump of flesh and drop of the abdominal structures from the cutting of suspensory ligaments and muscles
  • Vision problems with extreme dry eyes
  • Panic attacks
  • Occasional loss of balance
  • Sexual difficulties
  • Nerve tingling and pain
  • Severe pain in both lower legs from calves to ankles with no obvious source
  • Joint Pain
  • Painful lipomas on upper thighs
  • Movement of section of lower colon down to the pelvic floor. This sometimes necessitates manually pushing it back into place in order to complete a bowel movement.

I live with constant fear of cancer on a daily basis. It has made my life miserable, increased my depression tremendously and has resulted in a number of suicidal ideations which I don’t tell anyone about because I don’t want to be put (again) in any kind of mental institution or subjected to the criminal like treatment I received while on suicide watch at the medical center. Never.

Absolutely NONE of the above effects were ever mentioned as possible outcomes from the hysterectomy/oophorectomy surgery. My life has been drastically changed for the worst. I refuse to go back to any gynecologist and/or oncologist because the very thought causes me extreme anxiety. From the lack of empathy, post-op care and refusal to give me my proper medication in the hospital, the rupture of blood and ensuing pain from treatment of the hemorrhage, I cannot bring myself to let a doctor touch me again.

I Was Railroaded

I feel as though I was railroaded from that first visit to Dr. C’s office. The da Vinci robot was marketed to me as though it were some type of miracle device. I was never told about some of the problems that have since been associated with this type of robotic surgery, and that I was used as part of a money making scheme despite the fact that the rest of my life would be changed forever.

Regardless of my objections, I believe their insistence in having a mammogram after the biopsy procedure violated my right to refuse any and all treatments. I am concerned that all the radiation I received between the mammograms and the biopsy will have deleterious effects on the rest of my life.

The fact that heart disease is widespread throughout my immediate family and my diagnosis of Reflex Sympathetic Dystrophy should have been sufficient to warrant serious consideration regarding this procedure and whether or not I was truly a candidate for it. Being thrown into isolation for just expressing my fears and being treated like a hard core felon was unnecessary and resulted in extreme mental stress and anxiety. I feel I was a victim of a system which saw a means to make money without any regard for other approaches to treatment or the quality of life that would be lost forever. All courtesy of an uncaring and greedy medical establishment that believes that our life producing organs are of little to no consequence while there is money, lots of it, to be made through the use of scare tactics and the “it’s always been done this way” approach when certain types of (potential) cancer is found. In other words, we are dispensable when it comes to increasing the bank accounts of all involved except, of course, the victimized patient.

© October 2015 Sharon A. Hutchinson

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Hysterectomy in America

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Women suffer in childbearing, many women suffer during their periods, and many more women suffer from various methods of birth control. They also suffer from fibroids, leiomyoma, uterine prolapse, immobilizing pain, bleeding, migraines, endometriosis, uterine cancer, and are immobilized, squirming in bed, and crying out for mercy before they die or  sadly seek suicide as what they see as the only definitive option. After seeing doctor after doctor, after immeasurable doctor, hysterectomy is offered as an escape for each and every of these problems. After Cesarean Section, hysterectomy is the second-most popular surgery in American women, providing 600,000 procedures per year, and 20 million procedures to date (Keshavarz, 2012), with 55% having both ovaries removed.

Given that an astounding 40% of American women have had a hysterectomy by age 45, and about one-half have had both normal ovaries removed, if you are a woman, and you have had menstrual problems, it is likely that you have talked to your doctor about hysterectomy. You may even have considered scheduling it, particularly if the pain persists as so often it does.

Gynecologists and Hysterectomy

For many women, the gynecologist drives conservation. He thinks you’re ready for the hysterectomy now. It’s the only solution to your problems. There’s an ever-so-subtle pressure for you to pick a date for your hysterectomy already.  And so, you pick the date, and he practically stumbles out of the room to go get it on the Schedule.

As he’s leaving and just before the heavy door closes, he says his nurse will give you the details. Not knowing any better, you sit in your blue, stiff paper garb, freezing cold and still bleeding from your fibroids. You feel like he just told you that all your problems will melt away, and your life will start over again.

Did I Consent to this?

You are just too busy smelling the roses to stop and ask yourself, “Wait. What does this mean?” But really, it nags at you. You further contemplate: what’s wrong with this picture? Several huge and glaring things suddenly hit you like a smack in the face. It’s like you just heard the buzzing of a bee in the middle of the rose you are about to sniff.

No Informed Consent was given, and you don’t even know the risk: benefit ratio (Aranda, 2013).

Hysterectomy Second Opinion

You haven’t had a Second Opinion from another surgeon (eHow, 2014; Cornforth, 2014). Big Boo-Boos, because maybe you don’t need the surgery at all. “C’mon me. Get a hold of ourself.”  “I have to know that getting a hysterectomy isn’t like getting my tooth pulled out.” It is this author’s personal opinion is that surgery should be used as a ‘last’ resort, not a ‘first’ resort. Additionally, alternatives should be sought and tried before resorting to any surgery that requires general anesthesia. I was an anesthesiologist. My opinion. Take the time to get a second opinion and maybe even a third before finalizing the hysterectomy.

In my case, my second opinion Ob/Gyn was female, had two children of her own, the last one by C-section. She knew the drill, and gave a detailed analysis of the algorithm she would use; it led to my decision to have an open hysterectomy. I agreed, and scheduled it with her, later cancelling with the first doctor.

She told me that the risks of surgery are about 10% for complications related to infection, inability to see structures and a need to operate with an “open” (large) incision, bleeding, transfusion(s), adverse drug reactions, death, etc. Informed consent includes (a) the general risks of the procedure, and (b) the specific risks for me. If the doctor does not discuss the risks of the surgery specific to you run, don’t walk, out the door and find another doctor. For more information on what an informed consent should include: Informed Consent is the Law: Stop, Talk and Show Should be the Standard.

I should note that this conversation has to be between patient and the surgeon, not the patient and a nurse, not the patient and a doctor-in-training.

In my case, I happen to be both a patient and an anesthesiologist. I know the general and the specific risks of anesthesia; most women do not. We’re talking general anesthesia, a breathing tube down the windpipe, anesthetic gases breathed in from a ventilator, a high chance of vomiting afterwards; the whole shebang.

I knew that I would be bloated and blown up like a 7 month old pregnancy for a matter of days. Or could it be it weeks? Or…could it be months?  Most women do not know this and sadly many surgeons do not discuss this with the patients either.  She reminds me to bring gym pants with an elastic waist.

About the Hysterectomy: In the Operating Room

The doctor will fill her belly up with CO2 gas, and will leave it blown up for the duration of the surgery. She will be in ‘extreme’ lithotomy and ‘extreme’ Trendelenburg position. Legs wide open, head down, feet to the sky. The anesthesiologist will have to add positive airway pressure (PEEP) to push her lungs opened to fill with oxygen, and sometime the surgeon argues saying, “Hey, anesthesia, I can’t see anything.” Then a classic argument ensues: lungs for the patient vs. visibility for the surgeon. So they both work together, sometimes screaming, to get it done for the patient. Anesthesia always wins. No one wants a pneumothorax, a popped lung on the O.R. table. Then it will become a blame game and both of them are responsible. Sometimes the poor patient needs a chest tube and an ICU stay instead of going home.

Some people get shoulder blade pain that hurts like the dickens, and she already knew that if your shoulder blade hurts afterwards, it is ‘referred’ pain coming from your belly. Most of my patients had not been told that information by their surgeon, but if they are lucky, a good anesthesiologist will give her the down low.

Who will be Performing the Hysterectomy and How?

The types of hysterectomy procedures themselves aren’t always explained to the patient (Aranda, 2012). Admit it. You were so eager and desperate to have your uterus out, that you didn’t really even care how it came out; as long as it was gone by the time you woke up. You didn’t care if a medical student, resident, intern, Fellow, or Attending did it with or without a morcellator. Oh. A morcellator. What’s that (Fulton, 2014) ? Or the daVinci robotic hysterectomy robotic machine ~ Are they using that on me? Uhm. Each of these technologies carries with it discrete risks. You should know those risks to make the decision most appropriate for your health.

The Morcellator Problem

It wasn’t generally known until recently, but in order to get the ball of the uterus out of the large straw of the laparoscopic instrument, Ob/Gyn surgeons have been using, for the last 20 years, what is called a power morcellator once you are good and asleep. It pretty much goes into the laparoscopic scope and into the uterus to churn and blend it up like a garbage disposer, so it can be sucked up the tube.

Problem is…no one can possibly know if you have uterine cancer or not, until after the whole uterus is out. It is simply undetectable until then. Some women, like Amy Reed, M.D., an anesthesiologist and internist at Harvard, got her uterus, along with undiagnosed uterine cancer, splatted all over the abdomen at the same time (Reed, 2014). Now that was a big Oops.

As it turns out, they’ve been doing it to our mothers, aunts, and sisters for decades, and even invented the daVinci robot to do the hysterectomy instead of a surgeon. What do you think the Ob/Gyn Associations have let their surgeons do? No one knows if it’s 1:1000, or 1:500, or 1:400, or 1:315 women that actually does have uterine cancer, but splat!splat!splat! There it all goes! All over the woman’s abdomen, it is upstaged from a Stage I to a Stage IV cancer because the doctor has now iatrogenically done the bad deed. Never should have happened. Never should have been allowed. Ethics Committee should have been involved. One woman in the same hospital as Dr. Reed had also been upstaged to uterine Stage IV cancer, one year before. “Hush! Hush!” There was no need for Dr. Reed to be placed in this position. But “Hush! Hush!” She was. An “n” of 1 is too much. We don’t want one woman to ever suffer this known fate.

No one knew this was really happening until Dr. Amy Reed’s husband, Dr. Hooman Noorchasm, and his love for his wife and family of six children, that he took this to Change.org, then the Senate, then to the FDA.

The July 10-11, 2014 FDA Hearing where Dr. Noorchasm spoke, resulted in these conclusions by the FDA:

  1. Little to no evidence that morcellation can be performed without spreading cancer to other parts of the body;
  2. Informed consent, including the risk of spreading an unknown cancer, should be included from now on;
  3. There is no evidence that the bags…prevent the outcome we are trying to prevent.”
  4. “There is at present no safe way to offer morcellation as part of gynecological surgery.”

Watch the video of Dr. Noorchasm’s testimony to the FDA.  Now, he has accomplished the seemingly impossible for all women: he has all but put a ban on most uses of the morcellator. ROCK ON, Dr.Hooman Noorchasm! There’s always more work to be done, but once the people have a heart, a Movement has started.

What about the Ovaries?

Are they planning to keep your ovaries in? And the Fallopian tubes? If they take the ovaries out, you will not only have your uterus out when you wake up, but you will be in surgical menopause.  Surgical menopause sounds benign enough, but really it isn’t. The rapid depletion of hormones can cause serious mental health issues, along with a compilation of physical health issues that will be with you for the rest of your life. And although hormone replacement is available, hormone management is never as easy as popping pill or pasting a patch on your abdomen.

If the ovaries are removed with the hysterectomy, women enter surgical menopause overnight, leaving them with huge fluctuations in the estrogens, progesterone and the androgens. There’s no ‘gradual’ menopause for them over the course of 1-10 years, as other women naturally have. They hit the menopause wall POOF! When they wake up and oh! Eeeh! Was surgical menopause part of the Informed Consent? These ladies are ready to throw in the towel by now, as they are living in “hell”.

Symptoms range from precipitous drops in hormones if the ovaries were taken out: hot flashes, night sweats, they can’t sleep with their husbands any more, thinning hair, pain on intercourse, insomnia, disturbance in day/night cycles, depression, irritability, and with the uterus gone. Hormones need to be tested and hormone replacement is used on an individual basis, in light of lab results, contraindications to hormones, family history, and other risk factors.

It is important to note that surgical menopause also means faster aging, increased risk of heart attack, cognitive dysfunction, osteopenia, osteoporosis, a fractured hip from a fall.  Ask any woman who has had her ovaries removed about the complications and health issues she has faced. It might just change your mind.

Making the Hysterectomy Decision

Weigh the pros and cons and above all realize that your health matters. Whatever you do, speak up! Ask questions. You are expected to ask questions, like ordering food at a restaurant. So ask them.

Your body belongs to you. It is your temple, meant to be treated with respect and care. Ask if the if the daVinci robotic and morcellator will be used. Make sure you understand. The choice is yours, and no one can take it away from you.

Hysterectomy Research

Hormones Matter is conducting research on hysterectomy outcomes. If you have had a hysterectomy, please take a few minutes to complete The Hysterectomy Survey.

References

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