Dr. Marshall Smith: "Good morning, I'm Marshall Smith with OBGYN.net. Today we're honored to have Dr. Charles Koh with us, one of the pioneers in doing a lot of advanced laparoscopic surgery, the advanced hysterectomies, myomectomies, and things like that. At the session yesterday at the ASRM, he performed a lab surgery on a laparoscopic myomectomy. What I'd like to do Charles, if it's okay with you, is ask you just a couple things about the evolution of the laparoscopic myomectomy and where you see the status of that procedure today."
Dr. Charles Koh: "Yes, certainly. As we know, in the era of assisted reproduction, almost anything that can be performed by in vitro fertilization has replaced surgery. Fortunately or otherwise, the fibroid is still a serious factor in reproduction in that it can cause heavy bleeding or miscarriages. So myomectomy is still an essential operation, and the laparoscopic route with it's minimal access is appealing because of the fact that recovery is very rapid. For example, in this demonstration surgery, the woman had a 10-cm fibroid and was able to go home the following day. Over time with laparoscopic evolution, I think earlier on it can be criticized from the standpoint that doctors were enamored of the laparoscopic approach and did not bother to do as complete an operation as they would do by laparotomy."
Dr. Marshall Smith: "I agree."
Dr. Charles Koh: "And in the early days, we saw reports of uterine rupture at twenty-four weeks, thirty weeks fistulas and so on, and I think that's unacceptable. So I think we've gradually evolved to knowing which are the appropriate cases and which are not. Additionally, I think the gynecologists who perform laparoscopy have taken the trouble to learn how to suture appropriately and make sure the repair is adequate. Today the data is that increasingly, it can be safe to perform intramural myomectomy laparoscopically with a good case selection and with adequate skills by the laparoscopist."
Dr. Marshall Smith: "This was a 10-cm fibroid yesterday that you had?"
Dr. Charles Koh: "That's right. This was an interesting fibroid in that it wasn't only 10-cm but we did as we always do a preoperative ultrasound. We did a hysterosonography because I sometimes find when you get in, you don't know whether the fibroid is interior or posterior to the uterus."
Dr. Marshall Smith: "That's correct."
Dr. Charles Koh: "So if you do a hysterosonography and do both abdominal and transvaginal ultrasound, you can characterize the fibroid. In this case, the fibroid was abutting against the posterior endometrium as well as being totally intramural. So during the surgery it was very interesting, we were able to peel the endometrium from the fibroid laparoscopically, and it is so easy to get in and in fact, remove the whole endometrial cavity without realizing it, that one has to be very alert for that. So it went well in that respect, and afterwards because of the enormous gap, I used a three-layer closure, first interrupted and then continuous and continuous before closing the several muscular areas with 4-0. So this was a bit involved and is not something everybody should tackle instantly. I have found with regard to selection of fibroids, that it is actually advantageous to do a single large or maybe two or three medium-sized fibroids laparoscopically. I find that if you have a lot of fibroids even though they're small, it is too tedious laparoscopically, and I think this woman should have a standard laparotomy."
Dr. Marshall Smith: "Two comments come to mind, one is that Dr. Koh is being very humble, most people would not approach that, he's very, very good at it for those of you that have seen him operate before. And second of all, I just had a question about perhaps posterior fibroids versus anterior fibroids. I would think a beginner would certainly approach the anterior ones first - would you agree with that?"
Dr. Charles Koh: "First of all, a beginner should not choose a intramural fibroid. A good one would be subserous with a broad stalk or otherwise so you have your skills for morcellation and so on in that. And interior may be a little easier than posterior, certainly, I think that's a good point especially from a repair standpoint and future adhesions and so on."
Dr. Marshall Smith: "So what do you see new on the future with microscopic myomectomy? Do you think more and more people will develop the skills whereby they can safely approach some of these?"
Dr. Charles Koh: "Yes I think so. I think first of all the triage and selection is important, and ultrasound is getting better and better, everybody does hysterosonography, the resolution gets better so you can plan. In fact, I find that if on ultrasonography you can't quite make out how many fibroids there are - that might not be a good case for laparoscopy, you'll get lost. Secondly, I see encouragingly increased suturing skills evident, and one of the things that used to be a problem which is removal of the fibroid in strips, with the advent of the electric morcellators, that has certainly cut down that sort of time…"
Dr. Marshall Smith: "Time frame."
Dr. Charles Koh: "So I think it is a very acceptable operation, and we do know the advantage of laparoscopy versus laparotomy with regard to de novo adhesions and so on, it's certainly absent in laparoscopy."
Dr. Marshall Smith: "Yes, Dr. Koh, I want to thank you very much for joining us today. Those of you that have seen him operate know what an elegant surgeon he is. Thank you very much, and we'll be seeing more of you here on the site I hope."
Dr. Charles Koh: "Thank you, Mark."
MIMIS, The Milwaukee Institute of Minimally Invasive Surgery at Columbia St. Mary's is the Midwest's first multi-specialty minimally invasive surgical center of excellence. Established in 1992 by a group of highly respected leaders in the field of minimally invasive surgery,
the Institute grew out of a strong desire to provide the most innovative surgical care and treatment for patients. In addition to providing excellent patient care, physicians of the Milwaukee Institute of Minimally Invasive Surgery have published books and articles, reported
their results in medical literature, and taught and lectured worldwide. [http://www.mimis.us/]