By Dawn Swann The room is hushed and dim but for the beeping of the heart-rate monitor and the murmurings of the surgeons. Tucked beneath layers of plastic and blue medical sheets, and oblivious to the equipment-filled world around her thanks to general anesthesia, a patient is about to have her uterus removed. “If you feel faint, sit down, and let someone know,” one of the three attending nurses tells me as the operating room door swings shut.
I drift over to the anesthesiologist, who is sitting near the patient’s head as he monitors her heart rate and IV drip. My eyes grow into silver dollars as they fasten onto one of the two video screens in the room. I am at Framingham’s Metrowest Medical Center, where I have been invited to watch a laparoscopic hysterectomy. The innovative surgery unfolds before me, magnified and in full color. “Good morning!” the doctors say cheerfully.
A hysterectomy is the second most common surgery performed on women, next only to a cesarean section. One in three women will undergo the surgery by age 60, according to the US Department of Health and Human Services. Under the traditional method, surgeons remove the uterus through a four-to-eight inch incision in the abdomen. The highly invasive procedure requires a three-to-four day hospital stay and what can be a painful four-to-eight-week recovery period.
However, laparoscopy has revolutionized the procedure. Surgeons insert the laparoscope—a tubelike device for peering inside the abdomen—into a small incision in the bellybutton. The scope transmits images to video monitors, allowing doctors to perform major surgery without having to open the abdominal cavity. For a hysterectomy, surgeons make two other small incisions— on the right and left sides of the pelvis—through which to operate.
Three surgeons are present for this morning’s operations: Edmun Jacobson, 52, of Framingham; Robert Gottlieb, 51, of Weston; and Henry Klapholz, 66, chairman of the Obstetrics and Gynecology Department. Klapholz, a Weston resident whose hobbies include the piano and photography, is snapping pictures for this article. His colleagues are just getting to work. As a team, Gottlieb and Jacobson have performed more than 350 laparoscopic hysterectomies since 2005. Klapholz says they do more each year than do surgeons at most other hospitals the size of Metrowest; their numbers even exceed those at some of Boston’s large teaching hospitals. Klapholz expects the procedure to become more common elsewhere, but that will take time as it requires extensive training.
Jacobson and Gottlieb have pared the operating time to 75 minutes. Gottlieb tells me that today’s surgery might take a little longer since they’re teaching me about it, but that’s not unusual as Metrowest is a teaching hospital. Before they were certified to perform the procedure, the pair were observers many times themselves. Klapholz, who says New England is a relative newcomer to laparoscopic hysterectomy, decided to bring it to Metrowest after seeing the procedure’s success in the South. He supervised Jacobson and Gottlieb as they went through a six-month schooling program, which began with training on inanimate objects and animals.
In addition to becoming adept with the instruments, the doctors learned how to identify and address potential complications of the procedure. An infection, like staph, is a possible, though uncommon, side effect. Another concern is accidentally nicking nearby organs, such as the bladder, bowels, or the ureter (a tube that connects the kidney and bladder). Gottlieb shows on the monitor just how close those organs are to the uterus. To give the surgeons more room to maneuver, the patient’s abdominal cavity is filled with carbon dioxide.
The patient, who is a nurse at Brigham and Women’s Hospital, is having her uterus removed because it causes her severe pelvic pain. Most hysterectomies are prompted by uterine fibroids. Typically non-cancerous, the tumors may be as small as an apple seed or as large as a grapefruit. They can cause excessive menstrual bleeding and pelvic pain. Other reasons for the surgery include endometriosis, prolapsed uterus, irregular periods, and cancer. Patients range from their mid-30s to about 50, when menopause sets in (postmenopausal women are less likely to suffer the conditions that require a hysterectomy). Cancer patients require traditional surgery to make sure all the malignant tissue is removed, but a laparoscopic hysterectomy can be used in most other cases, Klapholz says.
Klapholz advises removing an organ only after less extreme measures have failed or been ruled out. Hormone therapy, for example, could be the first option to address excessive menstrual bleeding. Another noninvasive treatment is ablation, a procedure that destroys the lining of the uterus with heat from electricity, radiofrequency, or a balloon filled with hot water. In the case of fibroids, a radiologist in effect can starve a fibroid to death. Using a catheter, the doctor injects a pellet into the fibroid that blocks its blood supply, causing it to wither away. “We have lots of tricks now that we never used to have,” Klapholz says.
Jacobson and Gottlieb are working from opposite sides of their patient. Gottlieb says that the instruments become an extension of their arms. Jacobson is maneuvering the laparoscope with one hand while using the other to control an instrument that cauterizes the blood vessels attached to the uterus. This is the first step in the operation and the most difficult. The job must be complete; otherwise bleeding will occur. The surgeons speak softly and gently. At times, they pass each other instruments without saying a word. They can read each other’s cues.
After the uterus is disconnected, the doctors take five—seconds, that is. They pause to see if the uterus will blanch from pink to bluish white, proof that that the blood supply is sealed off. During this break, Gottlieb and Jacobson give me a tour, pointing out the bowels, the bladder, the cervix, the arteries, and the ureter. I’d been nervous that my layperson’s stomach might turn squeamish, but instead I’m amazed.
Jacobson next cuts the uterus from the cervix. To me, this looks as easy as slicing off a pat of warm butter, but Gottlieb tells me that Jacobson’s incredibly straight line takes great skill and is not nearly as easy as it looks. After the organ is completely disconnected, the doctors check again for bleeding and then insert a tubelike device into the incision on the left side of the bellybutton. Called a morcellator, it contains sharp rotating razors. The doctors guide the uterus into the morcellator, a little at a time using artery clamps. One clamp feeds the morcellator, the other pulls the shredded uterus up and out, with the assistance of suction. If the uterus is small, it comes out in a single strip.
While the doctors are removing the organ, I ask a nurse about the inflated bag that surrounds the patient’s head and Monitor displays the surgical area in the abdomen. shoulders. She explains that warm air is pumped into the bag to promote healing. Meanwhile, the patient’s legs are being manipulated by what looks like big blood pressure cuffs in order to prevent blood clots, and her arms are protected by gel padding.
If all goes well (as it did), the nurse will be home tonight. She can be back to work in as little as a week and fully recovered within two weeks. Compared with a traditional hysterectomy, laparoscopic surgery is less painful and results in less blood loss, reducing the need for a transfusion. Klapholz says his surgeons—who perform two to three hysterectomies a week—have not yet had to do a transfusion during the laparoscopic procedure.
Gottlieb shakes Jacobson’s hand when the hysterectomy is done. He’s got a busy day ahead and must leave. They banter about babies they expect to deliver later in the day. I overhear Jacobson say how happy he is that the patient will wake up and feel so much better. In the course of the day, the surgeons see women who are at the start of their childbearing years and those at the end. Jacobson sets to work stitching up his patient, Gottlieb steps out the door, and I head up to the third floor to Klapholz’s office to look at the photos he took today.
Klapholz, who came to Metrowest Hospital in 2001 after 20 years at Beth Israel in Boston, has the manner of a friendly neighbor or kind uncle. Jacobson, too, shows that personal touch. He says that over the years his patients feel like family to him. When they struggle and hurt, so does he. As for Gottlieb, Jacobson calls him the funny guy. From what I’ve seen, Gottlieb is also upbeat, energetic, and just as approachable as the other two. It takes a remarkable man to dedicate his life to women’s medicine, one who has the empathy to understand a body so different from his own. His hands both save lives and usher in new life. Not many jobs come with rewards like that.
Dr. Henry Klapholz, who hosts a local cable television show “Doctors on Call,” plans a May program on laparoscopic hysterectomy. Videos can be downloaded from mwmclearningportal.com (click on video library).
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