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Dr.
Hugo Verhoeven: “My
name is Hugo Verhoeven from the Center for Reproductive Medicine in
Dusseldorf, Germany. I am on the Editorial Board of the OBGYN.net,
and I’m reporting from the 9th International meeting of the
Society of Laparoendoscopic Surgeons in Orlando, Florida. It is a real pleasure for me to have the chance to talk this
afternoon with Dr. John Morrison from Fayette in Alabama who is one of the
leading experts in the United States in the field of laparoscopic
hysterectomy. John, thank you
very much for giving me this pleasure to talk to you.
One of the biggest disadvantages of hysterectomy, independent whether you perform the procedure by laparotomy or by
laparoscopy is the destruction of the pelvic floor support. There are some alternatives. I think you are one of the
leaders in performing a technique of hysterectomy without destruction of
the pelvic floor support. Please inform us about this technique.” Dr.
John Morrison:
“Hugo, the options for maintaining the pelvic floor support
whether done laparoscopically or open, are to either do a supracervical
hysterectomy which leaves the cervix, the support of the vagina and pelvic
floor intact, and particularly the uterosacral ligaments and cardinal
ligaments, or to take that procedure one step further and perform a CISH
hysterectomy which has the same advantages of a supracervical hysterectomy
regarding pelvic floor support but reduces or completely eliminates the
possibility of cancer in the cervix because the transition zone and
endocervical canal are also removed at the time of surgery." Dr. Hugo Verhoeven: “What does the abbreviation CISH stand for?” Dr.
John Morrison:
“CISH stands for classic intrafascial supracervical hysterectomy.
Professor Kurt Semm in Kiel developed the procedure initially in
1991. I’ve been performing
the procedure myself since October of 1992 and continue to perform the
procedure to this day." Dr.
Hugo Verhoeven: “It is my understanding that you are working in a very
small village with only one big hospital but that you have patients from
all over the United States. This
technique must have quite a lot of advantages for the patient.
Indeed, patients are going there where they expect advantages.
So what is the advantage of the technique for the patients?” Dr.
John Morrison:
“Of course, the advantages are what we talked about initially
with leaving the pelvic floor intact but you’re right, I do have
patients that seek out my services from other states throughout the United
States. Mainly what the
patients are looking for when they come to see me is that they are very
interested in having the procedure done laparoscopically so they can
return to work much sooner, get back to their normal activities much
sooner, they’re out of the hospital sooner, and they have less pain
which goes along with most laparoscopic procedures.
Plus, we can obtain an adequate surgical procedure for the
patient’s problem with, again, leaving the pelvic floor intact and doing
this with very little risk to the patient and, again, them returning to
their normal activities much, much sooner - that’s what the patients are
looking for.” Dr.
Hugo Verhoeven: “Describe very briefly the technique so that the patients
know about what you’re doing.” Dr.
John Morrison:
“When I describe the technique to the patients I start off
initially by telling them that most of the procedure regarding mobilizing
or releasing the uterus from its upper support is basically the same as it
is with either a normal open hysterectomy or a laparoscopic assisted
vaginal hysterectomy, etc. Once we get down to the main vascular supply to the uterus
including the uterosacral ligaments and cardinal ligaments of pelvic
support, that’s when the procedure varies from a standard open or
vaginal hysterectomy. I
describe to the patients then that we in essence core out the center of
the uterus like you would remove the core of an apple or a pear, which
leaves a circular rim of muscle behind with all of the attachments to that
circular rim of muscle. Then
the uterine body is removed, and I don’t get into the details with the
patients of how that’s removed but I stress to them that with leaving
the pelvic floor intact there is no incision at all in the vagina.
This seems to be something the patients recognize is a good concept
and they’re very willing to proceed with the procedure. They accept that
some little part of tissue is left behind.
I describe to them that it is usually not anything of much
consequence because we do take out the transition zone and cervical canal
to reduce their chances of cancer.” Dr.
Hugo Verhoeven: “Can you perform this technique in all patients or are
there some limitations?” Dr.
John Morrison:
“The only limitations that I have in my practice are either the
presence of cancer, and this is not a technique to be used in the presence
of cancer, or in patients that weigh over 200 kg.
I’ve attempted it; it’s very, very difficult.
The instruments are not long enough but I have several patients in
the range of 100-150 kg that I’ve successfully performed the procedure
on. A previous surgery does
not restrict the use of this technique and the presence of significant
endometriosis does not restrict the use of this technique,
so I only use the presence of cancer or weight greater than 200 kg
as a restriction.” Dr.
Hugo Verhoeven: “How do you exclude the chance of cancer?
Are you doing a D&C or hysteroscopy before you start the
procedure? What are you
doing?” Dr.
John Morrison:
“My standard approach is any patient who is forty years old or
older has a D&C if they’ve not had it within the preceding six
months. Also, routine Pap
smears have to be done within the preceding six months to a year to make
certain that there is no sign of any cancer prior to doing the CISH
hysterectomy.” Dr.
Hugo Verhoeven: “One
of my concerns is : is there a chance for post-operative bleeding?
You are cutting away 90% of the uterus and leaving maybe 5% in
place. How are you managing
that there is no bleeding in this remaining 5%?” Dr.
John Morrison:
“There are several different ways to manage the cervical stump
which is left behind. Some
people coagulate the stump, some use laser, and some surgeons inject the
tissue with hemostatic agents. I
personally prefer to suture the stump closed.
Occasionally, patients will have some spotting or minor bleeding
after the procedure but this seems to be very limited and it has been only
a very, very small percentage of the patients that I’ve had to actually
either cauterize a bleeder or bring them back as an outpatient to resuture
the cervical stump. It is a
very rare occurrence, and I think it is a small price to pay in this
procedure for the advantages of the procedure and the patients agree.” Dr.
Hugo Verhoeven: “Postoperatively,
there’s no chance of developing cancer as you are resecting the complete
endometrium and the transition zone of the cervical canal.
How can you be sure that you do not miss a minimal part of the
transition zone or the endometrium ?” Dr.
John Morrison: “Prior to doing the surgery or initiating the abdominal
part of the procedure, instead of doing the classic technique that
Professor Semm described, I initially will perform a large conization to
make certain I remove the entire transition zone but to answer your
question, no, I tell patients I cannot guarantee them that they cannot
develop any dysplasia or carcinoma in the remaining cervical stump.
But I encourage all my patients whether they have the CISH
hysterectomy or they have a standard abdominal or vaginal hysterectomy to
have follow-up Pap smears on somewhat of a routine basis because there are
diseases, particularly HPV infections, which can be detected by a Pap
smear. I encourage them to do that but we’ve not done this long
enough to give a good evaluation of the patient’s risk but I encourage
all of them to still have follow-ups because, yes, that is still a
possibility. I think that
removing the transition zone and intracervical
canal greatly reduces the chance but I’m not going to go so far as to
say it completely eliminates the possibility of malignancy but I think it
greatly reduces it.” Dr.
Hugo Verhoeven: “I
guess the duration of the CISH procedure is not longer than the duration
of a traditional laparoscopic hysterectomy, so the price is probably the
same. Is that correct?” Dr.
John Morrison:
“Yes, the time that it takes to do the procedure excluding large
uteruses - 900-1600 gm - for a standard CISH hysterectomy is about one
hour from beginning to end. By the way, since I am the only surgeon in my town I do all
of the procedure myself, I do not have an assistant surgeon helping me do
the procedures so it’s all done by myself with nurse assistance holding
the camera, etc. The operative time is certainly increased in cases of
endometriosis or after multiple previous surgeries, but this is not
different from open procedures. But even if the operating time is two
hours or more, patients are routinely discharged from the hospital in less
than twenty-four hours.” Dr.
Hugo Verhoeven: “As you are conserving the pelvic floor support, I guess
the patients will have no problems with incontinence postoperatively?” Dr. John Morrison: “What’s been interesting is : as part of the procedure I usually suture the round ligament stump down to the cervical stump and that gives a little bit of extra support to the patients. Now I’ve had some patients that had mild incontinence preoperatively that this corrected, and I understand that there is some controversy about whether round ligaments do really support the vagina pelvic floor or not but this has been my experience. Now in patients that have significant uterine prolapse or significant incontinence, I will add other procedures, particularly vaginal sacral suspension or Burch procedure as needed, but just doing the CISH hysterectomy with suturing the round ligament down to the stump does add a little bit of extra support to the vagina and pelvic floor. I’ve had the fortune of re-operating on some of these patients for other conditions and it’s amazing to look at the pelvic floor and see the comparison to a standard hysterectomy where there’s a lot of weakness in the pelvic floor, and the support after the CISH seems to be very close to what it is immediately after surgery.” Dr.
Hugo Verhoeven: “The
technique is perfect but I think you still have wishes for the future and
you are trying to make the technique even better.
So what are your expectations for the near future with this
technique?” Dr.
John Morrison:
“Initially for the future, I would like to encourage other
gynecologic surgeons to consider the technique and to try to adapt the
technique to their patients because this is an excellent, excellent
operation for benign uterine conditions.
Initially it is technically challenging, I will admit that, and it
does have a learning curve particularly involved with some of the
morcellators that are used to remove the specimen but the procedure as I
do it right now, I cannot see any real major changes that I would like to
see in the future because I’ve had so few problems with this procedure
that it is a very, very well suited operation for what it’s used for.” Dr.
Hugo Verhoeven: “How
many patients did you do surgery upon and what is your follow-up time?” Dr.
John Morrison:
“We started doing the CISH in October of 1992, up to this point,
I have close to 450 CISH hysterectomies that I’ve performed
successfully. I’ve had 3 in
that time that I’ve had to convert to open procedures and so our
follow-up is anywhere from less than a month to eight years. There have been an occasional mucocoele which is formed at
the cervical stump, which was easily drained as an outpatient procedure
but otherwise the re-operative rate or particularly the infection rate has
been very impressive to me. I’ve
had no cervical stump infections or intraabdominal infections at all, and
I think that is a testimony to the operation and to leaving the vascular
integrity of the pelvic floor intact so that you have good healthy viable
tissue that can fight off any kind of infectious process.” Dr.
Hugo Verhoeven: “John,
thank you very much for this information.” Dr. John Morrison: “Thank you.” |
