Minimally Invasive Surgery

As the name suggests, minimally invasive surgery is a new generation of procedures that allow the surgeon to access the internal anatomy with minimal trauma to the body. Through our use of minimally invasive approaches to treat a variety of urogynecological conditions, we are able to offer patients the best results with the added benefits of a decreased length of hospitalization, easier postoperative recovery and less postoperative pain.

The field of minimally invasive surgery is expanding, and we constantly strive to make sure our patients have access to cutting-edge technology that is safe and effective. For example, we are the largest provider of robotic reconstructive pelvic surgery in the Washington D.C./Baltimore region.

Some examples of the minimally invasive surgeries we frequently perform include:

Mid-urethral slings for stress incontinence

A sling is a strap of graft material that is placed under the urethra or neck of the bladder to provide support during activities that increase abdominal pressure such as coughing, sneezing or lifting. The support helps to prevent loss of urine during these activities.

The sling is inserted through a small incision (half inch) in the front wall of the vagina under the urethra, and two tiny incisions above the pubic bone or in the groin region. The slings are made out of a permanent graft material called polypropylene mesh. Common names for these slings include Tension-free Vaginal Tape sling(TVT) , Transobturator sling (TOT) and Mini-sling (Secur) . The sling is generally placed as an outpatient procedure under minimal anesthesia unless other procedures are done at the same time. Continence rates are equal to or better than traditional, more invasive surgeries such as a Burch.

Vaginal mesh procedures for prolapse

Straps of graft material are placed between the vagina and bladder and/or rectum, to provide additional support for a cystocele or rectocele repair. These straps are also attached to ligaments or muscles to provide support to the top of the vagina. The graft material can be biologic, but most are now made out of a permanent material called polypropylene mesh. The mesh is usually placed through 1-2 inch incisions along the front and back walls of the vagina. Additional tiny incisions may be required near the groin and buttocks to anchor the graft.

Newer minimally invasive “mesh kits” have been developed to decrease operating time, postoperative pain and recovery time with a typical one day hospital stay. Some of the more commonly used “mesh kits” include Prolift , Apogee/Perigee , Avaulta and Pinnacle . We do not yet know whether these procedures provide better, long-lasting support compared to prolapse surgeries that rely on the patient's own tissue. For this reason, we are conducting a study comparing vaginal surgery with and without mesh.

Vaginal surgery without mesh for prolapse

Traditional prolapse surgery performed vaginally uses a patient's own tissue to restore normal support.

• A cystocele repair or anterior colporrhaphy repairs breaks or tears in the good strong tissue that separates the bladder and vagina, by tightening or reapproximating this tissue with sutures.

• A rectocele repair or posterior colporrhaphy repairs breaks or tears in the good strong tissue that separates the rectum and vagina, by tightening or reapproximating this tissue with sutures.

• A perineorrhaphy or perineoplasty can also be performed to restore support to the tissue and muscles between the vagina and rectum at the vaginal opening.  These muscles are reattached with sutures.

• A vaginal colpopexy or vaginal vault suspension reestablishes support to the top of the vagina, using ligaments or muscles of the pelvis. Permanent sutures are placed through the strong tissue known as the uterosacral ligaments, sacrospinous ligaments, or iliococcygeus muscles and fascia. The uterosacral ligament suspension can also be done through the abdominal or laparoscopic incisions.

All of the procedures detailed above maintain vaginal function. There are still other surgeries that restore support, by closing the vaginal lumen with sutures (LeFort (partial) colpocleisis or total colpocleisis). These procedures are highly effective and minimally invasive, but are only useful for those women who no longer are interested in maintaining the ability to have sexual intercourse.

Most of these procedures involve a short hospital stay of one day. Vaginal surgery usually involves less pain and an easier recovery compared to abdominal surgery.

da Vinci ® S™ robotic surgery for prolapse, incontinence and fibroids

Surgeon’s console and patient cart

Our surgeons are using advanced robotic technology, the da Vinci ® S™ Surgical Robotic System, to perform minimally invasive surgeries for a variety of pelvic disorders, including sacral colpopexy, uterosacral ligament suspension, Burch urethropexy (bladder suspension for stress incontinence), paravaginal repair (cystocele repair), fistula repair, suture rectopexy, supracervical hysterectomy (remove uterus, leave cervix), total robotic hysterectomy (remove uterus and cervix), myomectomy (remove fibroid(s)), oophorectomy (remove ovary) and removal of adnexal mass.

In robotic surgery, surgical instruments at the end of robotic arms are inserted in the patient's abdomen through 3-4 small incisions (less than a half inch). The surgeon sits at a console and controls the robot's arms, permitting improved visualization, more complete range of motion and ease of suturing compared to normal laparoscopic techniques.

Laparoscopic sacral colpopexy

This surgery restores support to the upper vagina using straps of graft material. This is the most durable repair for uterine and vaginal vault prolapse that leaves the vagina open and functional. The most common graft material is a permanent material called polypropylene mesh.

The procedure is performed through 3-4 small abdominal incisions (less than a half inch). A small telescope (camera) and instruments are inserted into the abdomen to perform the procedure. Because these incisions are small, there is usually less pain after surgery than with a large open abdominal surgery and requires a hospital stay of usually one day.