Robotic Myomectomy—the State of the Art


Meet with Ulas Bozdogan, MD, FACOG

Endometriosis & Fibroids Specialist located in Hackensack, NJ and New York City, NY

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Uterine fibroids (“leiomyomata”; singular, “leiomyoma”) are benign growths that compete with the normal tissue of your uterus (womb). Functionally—or dysfunctionally—they occupy space that makes it difficult for the muscular portions of your uterus to compress against veins during a period, making your period’s bleeding heavier and more painful. In this way, fibroids disrupt a protective mechanism that otherwise keeps your usual cycle’s blood loss manageable and balanced.

Fibroids also add weight to your uterus, which is typically balanced in position by its own ligaments and tissue connections; added weight upsets this balance and can tilt or prolapse your uterus, causing

* pelvic pain,
* painful walking or activity,
* painful intercourse,
* feelings of heaviness and
* fatigue.

Worse, they can press on your bladder and/or rectum, giving the sensation of urinary urgency or “false alarms” for needing to have a bowel movement. Because of bleeding, cramping, painful intercourse, aching along the ligaments, and bladder and rectal issues, fibroids are troublemakers in a part of your body important for reproduction, which is yet another indication for removal.

How does one remove fibroids—and only fibroids—without sacrificing the normal tissue of your uterus?

Removal of fibroids (“myomectomy”) presents a challenge: in the past, the only way to do this was with a hysterectomy. Thankfully, today’s procedures prevent this “overkill.” After all, the uterus is important, especially in women who may want children.

The answer is robotic myomectomy, like the technique performed by Dr. Bozdogan of NYC Endometriosis.

Cosmetic vs. dexterity. Is it really either/or?

Surgery—be it myomectomy or any other surgery—has a natural enemy: scarring.

Scars are what a patient sees long after the reasons for having surgery are forgotten. Because of this, minimally invasive surgery was developed—making the incisions into the body as small and as inconspicuous as possible. In the 1980s, this movement gained momentum with the technique of laparoscopy, which involved small incisions and a camera (the laparoscope) that allowed the surgeon to operate—for lack of a better description—with special, long “poles.” There were poles with little scissors on one end, poles that transmitted electricity to cauterize bleeding, and even poles with little deployable bags to snatch whatever it was that was being removed.

It has been said that the hands of a surgeon are his or her most important parts, but this is a cliché, because the surgeon’s brain—education, training, and decision-making skills—are just as crucial. Nevertheless, when laparoscopy was being developed, it sidestepped the importance of the hands—ten-finger dexterity. Simply put, working at the ends of poles can be nothing like a surgeon using his or her hands and fingers; that is, laparoscopy showed its limitations by missing out on the dexterity that defines excellent surgical technique. And removing fibroids while simultaneously saving the uterus requires such excellence.

Using the hands, unfortunately, requires big enough incisions for them to fit in an operative site. This was the driving force behind the Da Vinci robot—to marry the best of minimally invasive, cosmetic surgery to the manual dexterity of which “open” procedures boasted. But unless you were in a dream world of “Honey, I Shrunk the Surgeon,” the separation between cosmetic sensibility and manual dexterity forced a choice in the therapeutic process—each with pros and cons.

Uterine fibroids: why is this a condition that brings out the best that robotic surgery offers?

Imagine being able to bypass large incisions to “get one’s hands” into the meticulous surgery required to remove fibroids while protecting the rest of the uterus. This is what the robotic instrument—the Da Vinci—does. Using the same small incisions typical of laparoscopy, stereoscopic cameras are used to put the surgeon into a virtual reality of the inside of your body. Wearing stereoscopic goggles, not only does the surgeon get an accurate 3-D perspective that the 2-D images of laparoscopy fail to give, but there is the capability to manipulate the image—magnify, rotate, invert, etc. Thus, it is possible for the surgeon to actually get “under” the uterus to remove a hidden fibroid that any other type of surgery would miss.

Even better, today’s computer technology allows the surgeon to grasp left and right-handed controls that manipulate special Da Vinci instruments. No longer just “poles,” these are jointed and multifunctional devices that when magnified allow the unprecedented detail and meticulous tissue manipulation that myomectomy requires. The smoothly controlled movements of these manipulators, matched to the real-time movements of the surgeon’s hands and fingers and operated with the immersive 3-D views the surgeon enjoys, are like having the pair of operating hands doing the job and a view not from outside of your body, but from inside of it. And at the end, the incisions are no more noticeable than with the minimally invasive laparoscopy of yesteryear.

The “new” robotic way to do surgery. Is it really new?

Believe it or not, robotic surgery has been around now for almost 20 years, so it is hardly “new.” Yet, for a surgeon to become skilled in this approach it requires considerable extra training. This is why it isn’t done all the time and everywhere.

Or by just anyone.

The reality is that—like any medical procedure—the surgeon must be specially trained to use the Da Vinci robot, be knowledgeable of the cosmetic concerns of the patient, and be aware of and anticipate the possible complications unique to this type of surgery. The Da Vinci approach, when done by a surgeon so trained, makes much less likely all of those dreadful things mentioned in the consent you sign before surgery. Safety, meticulousness, minimal risk to other tissue and less (if any) substantial blood loss are the bragging points of a skilled robotic surgeon.

Who should do your Da Vinci robotic myomectomy?

Dr. Ulas Bozdogan of NYC Endometriosis has this special training. In fact, he gives this special training as a teacher for other surgeons learning to use the Da Vinci. When Dr. Bozdogan does a robotic myomectomy, it is as much a leap in excellence as the Da Vinci is a leap in excellence compared to the procedures of the past. Myomectomy is an important surgery, so you will want the best technique and the best surgeon using the best technique. This means Dr. Bozdogan + the Da Vinci.

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