Spokane-area physicians are ahead of the national curve in employing minimally invasive techniques rather than open abdominal surgery when performing hysterectomies, two surgeons here say.

About 55 percent of hysterectomies at the four major Spokane-area hospitals are performed via alternatives to open-abdominal surgeries, says Dr. R. Steven Brisbois, who heads the Center for Gynecology, Robotics & Minimally Invasive Surgery, at Providence Sacred Heart Medical Center & Children's Hospital. Brisbois also is medical director at the Women's Health Center, at Sacred Heart.

Nationwide, hysterectomies are the second most frequent major surgical procedure—following Caesarean-section births—conducted among reproductive-aged women. Only 40 percent of hysterectomies in the U.S. are performed employing alternatives to abdominal surgery, which is the most invasive conventional method for hysterectomies, Brisbois says.

Hysterectomies are most commonly performed to reduce or eliminate uterine growths, excessive bleeding, pelvic pain, uterine prolapse, and certain reproductive cancers.

The abdominal approach usually involves an incision six or more inches long. It requires a two- or three-night hospital stay, and a six- to eight-week recovery period before the patient can return to work and normal daily activities, Brisbois says.

"I do very few abdominal procedures," says Brisbois, who performs two to three hysterectomies a week.

The primary alternatives to abdominal surgery typically are a vaginal hysterectomy, a laparoscopic procedure, and robotically assisted surgery.

Dr. Nathan P. Meltzer, a physician at Valley Obstetrics and Gynecology PS, in Spokane Valley, says he conducts minimally invasive procedures almost exclusively at Valley Hospital & Medical Center, in Spokane Valley, and Deaconess Medical Center, in Spokane.

Meltzer says the vaginal procedure usually involves a single 1-inch incision at the apex of the vagina, through which the uterus is removed.

In a laparoscopic hysterectomy the uterus is removed using instruments inserted through tubes in four or five small abdominal incisions. One instrument is a tube with a tiny camera and light called an endoscope that the surgeon uses to visualize the operating area.

Following a vaginal or laparoscopic hysterectomy, the patient likely will be in the hospital for less than 24 hours, and she usually can return to work in a week or two, Brisbois says.

Brisbois also performs robotically assisted gynecological surgery at Sacred Heart, using the da Vinci Robotic Surgical System, which typically involves four or five lower abdominal incisions, each less than an inch in length. A lens for a binocular camera is inserted into one incision, and thin instruments attached to up to four robotic arms are inserted into the other incisions.

The surgeon controls the robotic arms via a console that provides 3-D views via the binocular camera, and a control system with foot pedals and joysticks translates the surgeons hand movements into the motion of the surgical instruments.

Brisbois says he recommends the robotic procedure if the operation can't be done with laparoscopic equipment and the only other option is open abdominal.

"What I call straight-stick laparoscopy is limited," Brisbois says. Laparoscopic surgical tools don't bend, and they can't reach around internal structures in tight spaces, he says.

Robotic instruments, however, are wristed, Brisbois says. They can work at right angles.

"You can do cases with a robot that you could never do with straight sticks," he says.

Still, he says, most of the hysterectomies he performs are laparoscopic procedures, and about 30 percent are robotically assisted. Brisbois says he performs some vaginal hysterectomies, particularly for patients who have prolapse problems. Uterine prolapse is the falling of a portion of the uterus into the vaginal canal.

Abdominal hysterectomies make the most sense for certain obese patients, patients with large uteruses, patients with scarring from previous abdominal surgery that obstructs less-invasive approaches, and patients with ovarian cancer, Brisbois says.

The majority of patients who have hysterectomies for reasons other than cancer retain their ovaries, Brisbois says.

"Patients commonly have a misconception that they will experience menopause immediately," he says. "If the patient is young, she probably will have her ovaries intact and won't go into menopause until it happens naturally."

About 600,000 hysterectomies were performed in the U.S. last year, a number that is slowly declining, Meltzer says.

Data provided by Providence Health Care show the number of hysterectomies at Sacred Heart and Providence Holy Family hospitals here have been on a slight downward trend in recent years, to a combined total of 1,045 procedures in 2010, from a peak of 1,167 in 2007.

Valley and Deaconess hospitals, which are owned by Franklin, Tenn.-based Community Health Systems Inc., decline to disclose comparable data. However, Julie Holland, a spokeswoman at Deaconess, says the volume of hysterectomies at both hospitals is on an upward trend consistent with growth in women's services at the facilities.

"We've been working hard to enhance women's services, including the addition of a da Vinci Robotic Surgical System (at Deaconess) in October 2009," Holland says.

Alternatives to hysterectomies include some newer medical-management techniques, such as certain hormone-releasing intrauterine devices that are proving effective for treating excessive menstrual bleeding in some cases and endometrial ablation, Meltzer says.

Endometrial ablation is an outpatient surgical procedure that destroys the uterine lining. Devices such as the Mirena IUD also can be inserted into the uterus in a physician's office.

A hysterectomy usually isn't the first treatment option, Meltzer says.

"A hysterectomy done through a minimally invasive surgical procedure still is a major medical intervention and carries definite risks that need to be balanced against the benefits the patient might receive," he says.

Some results of the operation are certain, though, Meltzer says.

"A hysterectomy is a definitive surgical intervention," he says. "If it's performed for dysfunctional uterine bleeding, there's no bleeding afterwards. If it's performed for fibrosis, no fibroids remain."

Uterine fibroids are noncancerous growths in the uterus that sometimes cause pain, bleeding, and fertility problems.

Most women are choosing subtotal hysterectomy, which leaves the cervix intact, because it's often not necessary to remove the cervix along with the rest of the uterus, Meltzer says.

"Women increasingly have done some research and have predetermined the procedure they might want," he says. "Laparoscopic subtotal hysterectomy is becoming increasingly popular for that reason."

The cervix is removed, however, in hysterectomies performed due to the presence of cervical or uterine cancers, he says.

The cost for laparoscopic hysterectomies is higher than comparable abdominal procedures, because of the specialized equipment involved, Brisbois says, adding the costs for complex robotic procedures are higher still.

"In my experience, there is much less risk and fewer complications in a robotically assisted procedure, and in complex cases, it turns out cheaper than an abdominal procedure," he says.

Meltzer says insurance companies usually defer to the surgeon's recommendation for which procedure to use as long as the operation is deemed necessary.

"Increased recovery time and other complications with the abdominal approach would increase overall costs even though the surgical cost would be lower up front," he says.