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Surgical Picture Pages – laparoscopic myomectomy via DaVinci October 11, 2012

Posted by therealtinlizzy in Uncategorized.
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So – onto the Picture Pages summary of (my interpretation of) laparoscopic myomectomy (i.e. removal of uterine fibroids) by the DaVinci method.

Let’s consider the uterus, in this case a happy not-presently-hassled-by-any-undue-hardship uterus:

Now let’s consider a sad-panda uterus that’s been beset with uterine fibroids:

I know – bummer right? Uterine fibroids are a sort of benign tumor of the smooth muscle of the uterus. While they’re benign and nothing to generally worry about cancer-wise, they can become a damn hassle, leading to “gynecologic hemorrhage, heavy or painful periods, abdominal discomfort or bloating, painful defecation, back ache, urinary frequency or retention, and in some cases, infertility” (thanks Wikipedia!).

There are a few ways to treat fibroids, one of which is to slice them off-of/out-of the uterus.

Back in the day, the only way of accessing a patient’s abdominal bits was by slicing the patient’s belly wide open:

Laparoscopy is instead a means for accomplishing abdominal or pelvic surgical procedures without going in through a large incision. This is the only real photo I’m going to show (that’s actually a lie, there will be one or two other non-Simonesque illustrations) – and nothing that will upset any delicate sensibilities, it’s just so you can see the jist of the laparoscopy setup that I really can’t capture with my mad art skillz:

So comprehend – in a laparoscopic procedure, the entire surgery, whether a hysterectomy*, cyst/ovary/fibroid removal or other procedure, takes place entirely within a (mostly) closed abdomen, where there are only four or five small incisions (less than in inch by my reckoning), though which narrow tubes (called “ports”) are inserted. Through each port then a different slim instrument is inserted – including a camera of fantastic resolution (which displays to multiple screens in the room the inside of the abdominal cavity), cauterizing/slicing/dicing tools, suction tool, needle drivers, and the mentioned-in-previous-post reverse garbage disposal through which ostrich-egg sized fibroids can be sausagified in order to exit the abdomen. If the procedure is a hysteruterectomy, the uterus comes out by a different method. We’ll save that for another Surgical Picture Pages day.

Here’s the jist of the camera-eye view that you see on the screen – where the top of the screen is the “ceiling” of the abdomen, which has been inflated with air in order to give the surgeons room to work in there:

No – that’s not a badly-colored Polaroid of the start of a Thanksgiving dinner.

Here’s my impression of what it looked like part way through the removal of the fibroids, after cutting the largest fibroid out from what was the (relatively) posterior portion of the uterus:

I know – that wasn’t so bad/gory was it? See – viewing a procedure in Surgical Picture Pages can make it possible to “see” something that those with a more squeamish nature might otherwise avoid! It can look rather fantastically gory in there, but here – it’s just some colored squiggles, giving you the idea, without the hurling.

Anyway – main upside to laparoscopy is that recovery post-laparoscopy is super fast relative to open abdominal surg. Still – there are scenarios under which you can’t have laparoscopy done for conducting your uterine/ovarian business. An example of no-laparoscopy-for-you is having a metric fuckton of scar tissue (say if you’ve had numerous abdominal procedures already). Scar tissue is different than not-previously-sliced/healed-tissue; scar tissue, particularly lots of it, can make the tissue (and the surrounding tissue) sort of stick stubbornly together. My observation is that maneuvering around/through loads of abdominal scar tissue is not entirely unlike hacking one’s way through the Fire Swamp (ROUS’s notwithstanding),

thus maneuvering through layers and layers of scar tissue via narrow abdominal ports can become entirely futile. This was the case in what started out as a laparoscopic ovary-removal I observed back in May: the patient had previously experienced numerous open-abdominal uterine procedures, which made the tissue connecting everything not exactly impenetrable, but more like this:

Everything was stuck to everything else, where usually teasing the uterus/ovaries away from the viscera (all the other bits) is like butter. No really – as slippery and slidy as things coated in melted butter. Yum. Anyway – that procedure turned into an open oophorectomy (that’s the big-kids’ term for ovary removal), as the surgeons needed way more elbow room, which I mean nearly literally.

Anyway – back to ROBOTS! The Davinci method of laparoscopy is the same procedure I explained above, just that the instruments (camera, snippers, etc) going through the trans-abdominal ports, are held in place by a “robot”:

Granted the real DaVinci apparatus is somewhat less freakish and hulking than my vaguely anime tentacle rendition above (c’mon – an artist is only as good as her complete lack of skill): the arms are more compact/maneuverable, and the whole thing is a little less, well hulking arachnoid. Oh – and note the tilt of the patient: that’s not on account of my inability to draw a horizontal line, but rather part of the procedure – since the uterus is at the lowest part of the pelvis, tilting the patient allows the rest of the organs to slide down, leaving the uterus et al nicely exposed/accessible than would otherwise be the case.

See? Totally not terrifying scary stabby spider robot of doom, just a helpful friendly mulit-armed Wall-E.

The instruments themselves (held in place from above by DaVinci) are then manipulated remotely by the surgeon from a console entirely separate from where the patient is laying:

I don’t even need to include a real photo – because my Picture Pages version gets it pretty dead on. I’ll repeat my blurb about it from my previous post: “the surgeon…is doing the equivalent of playing a virtual reality video game, complete with 3-D visual display, hand/finger/foot controls,” and with assistance from the intern/resident in swapping out instruments as needed. Swear to god. And actually, it’s just sort of happenstance that the console is in the room at all – hell, it could be in another country for all it matters. Except for the fact that the final bits of procedure (like extraction of the snipped off bits) and occasionally complications require the surgeon reverting to hands-on laparoscopy.

From what I understand, the DaVinci method was developed originally with the idea that surgeons could operate remotely (e.g. injured soldiers on a battlefield) by such means. I don’t know if/that such application of DaVinci has come about, or if those have simply been bypassed in favor of the non-combat applications that seem to be working out quite lucratively for the DaVinci folks.

My only complaint is that I’m not sure why this beautiful bit of tech was dubbed DaVinci rather than Skynet.

*which Dr. Terrell and I and anyone not completely given over to nitwittery would agree should by this point be called a uterectomy. Hey look there’s a Care2 petition out there for that – happy face! Sadly it only has 11 signatures – sad trombone.

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Comments»

1. Stefanie - October 11, 2012

Once again, great explanation and great art! I must admit though, cool as DaVinci is, it totally creeps me out and the idea of it looming over me while I was out is kinda scary and makes me think of all kinds of really bad scifi scenarios.

snipy (@snipy) - October 11, 2012

Is totally how I had my surgery done. tinlizzy watched a video of it (not of mine, another one) while i did it, thing was awesome. i went home the next day.

therealtinlizzy - October 13, 2012

It really is awesomely (scarily) sci-fi isn’t it? 🙂


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