Repeated Miscarriage

Laparoscopic Pelvic Surgery for Prolapse

A New Surgical Innovation - The Surgery of the Future Today!
What is Prolapse?
Prolapse refers to the extrusion of a mass through the vagina. This creates discomfort in walking, as well as, causing a feeling of pressure. On occasion, this prolapsed mass can ulcerate and cause bleeding. The medical terms for prolapse include: Cystocele, Rectocele, Enterocele, Procidentia and/or Uterine Prolapse. In the early stages of prolapse, it is seen at the end of the day after exertion, but reduces itself in the evening upon lying down. In the later stages, it remains out all the time. It also interferes with the ability to completely empty the bladder, or have a bowel movement without pushing the prolapse out of the way. Sometimes prolapse happens many years after an abdominal or vaginal hysterectomy. In such cases the uterus has already been removed, but insufficient support of the vagina causes eversion, very much like extruding one's pockets.

What is the Cause?
Prolapse is usually associated with weakening of the muscles during pushing at childbirth. Around the time of menopause estrogen production by the body is reduced, leading to further weakening of the vaginal muscles and prolapse is most commonly seen around that time.

Associated Stress Incontinence
Prolapse may also be associated with urinary stress incontinence, where during coughing or other physical activity urine leaks. The cause is similar due to weakening of the urethral support.

What is Laparoscopy?
During laparoscopy, a laparoscope -- the surgical instrument -- is inserted through the belly button. The laparoscope is a telescopic camera which provides visualization of the abdomen. Surgery performed using a laparoscope usually requires three to four small, quarter-inch incisions for insertion of additional surgical instruments. Traditional surgery requires one large incision several inches in length.

Traditional Treatment - Non-Surgical
In the past, various forms of pessaries (a device worn in the vagina) were used to prevent the extrusion of prolapse and these pessaries then had to be changed every month. Today, this form of therapy is unacceptable to most women, except those who are infirm and unable to ambulate. For the rest who lead active lives, surgery presents a much better alternative.

Surgical Treatment
Prolapse surgery has traditionally been performed by the vaginal route and has variously been termed Anterior Repair, Posterior Repair, Repair of Enterocele, and/or Vaginal Vault Suspension. However, when vaginal surgery results in recurrence of prolapse, an abdominal operation has to be resorted to, where synthetic mesh is attached to the vagina and to the sacral bone. This has traditionally been done through a large abdominal incision.

Laparoscopic Reconstructive Surgery
Today, in specialized centers, all forms of prolapse can be treated laparoscopically with much better suspension of the vagina. This is because the suturing of the vagina can be attached much higher up in the abdominal cavity, then is possible when working from below in the vaginal area. Hysterectomy can also be performed laparoscopically, if needed, and combined with the prolapse operation. The contemporary approach includes cystocele and paravaginal repair performed laparoscopically; culdoplasty for enterocele with shortening of the uterosacral ligaments; and in the case of post-hysterectomy prolapse, sacral culpopexy is performed where a synthetic prolene mesh is sewn to the top of the vagina and then sewed or tacked onto the sacral bone, pulling the vagina upwards and backwards in its normal position. This results in repair of the prolapse with little risk of recurrence. Recently, we have begun to employ this as a primary procedure after laparoscopic hysterectomy, in women whose uteri have prolapsed out of the vagina. Pelvic reconstructive surgery by laparoscopy is a new discipline and the doctors at the Milwaukee Institute of Minimally Invasive Surgery (MIMIS) are involved in teaching the art to other doctors. There are only about 10-15 centers nationwide where this is being practiced. Total Laparoscopic HysterectomyIn this operation, removal of the uterus and closure of the vagina is done laparoscopically. At the same time, other procedures may be performed to support the vagina to the uterosacral ligament (High McCall) or sacral culpopexy in order to prevent future chances of prolapse.


Micro and Mini Laparoscopy

While laparoscopy (key-hole surgery) has been an enormous advance from open laparotomy (big incisions) recent development in microfibres and lenses have seen the creation of even tinier laparoscopes measuring two to four millimeters which are known as micro and mini laparoscopes, respectively. At the same time, small ball laparoscopic instruments have been produced (KOH Ultramicro instruments) and others so that the total laparoscopic procedure can be performed with incisions of two to four millimeters. Conventional laparoscopy uses a 10 mm umbilical incision for the laparoscope and 5 mm to 10 mm incisions elsewhere. Because of the small diameter of the micro and mini laparoscopes, under suitable circumstances surgeries may be performed without general anesthesia.


Radical Endometriosis Surgery

In 1921, Dr. Sampson from John Hopkins Hospital theorized that endometriosis was due to the back flow of menstrual blood and that this blood containing uterine lining material began to grow and embed on the pelvic peritoneum and structures thus forming endometriosis. The corollary of this theory is that if the uterus is removed, then no further back flow can occur, therefore endometriosis would be cured. Furthermore, it was believed that the endometriosis implants in the pelvis responded to hormones in the same way as the uterine lining and that the estrogen from the ovaries stimulated their growth. Therefore, it was routine for the ovaries to be removed along with the uterus even in very young women in an effort to cure the pain of endometriosis. Surprisingly, there were and remains still a large number of women who still continue to have pain despite having undergone hysterectomy and removal of tubes and ovaries.


Stress Incontinence

Laparoscopic Burtch Procedure
An Effective New Treatment for Urinary Stress Incontinence - The Surgery of the Future Today!
Urinary Stress Incontinence is defined as the escape of small amounts of urine during "stress" activity, such as laughing, coughing, sports, and the like. Escape of urine during ‘stress' is due to weakness of pelvic support. This weakness is often, but not always, associated with childbirth. A feeling of "something falling out" or prolapse, may also be associated with leaking urine. Urinary continence depends on strong bladder and pelvic support.


Update on Laparoscopic Hysterectomy

 Hysterectomy today and home three hours later sounds incredible, but that is exactly what one patient did after undergoing total laparoscopic hysterectomy at the Milwaukee Institute of Minimally Invasive Surgery. A new technique for performing this operation has been patented, including appropriate instrumentation, called the 'Koh Technique' and 'Koh Colpotomizer for Total Laparoscopic Hysterectomy'.

 Dr. Koh has presented this method for the last year and a half at various meetings in and out of the country and the product had finally been approved by the FDA in 1996. The technique simplifies and makes the performance of laparoscopic hysterectomy safer without the use of stents in the ureter and the operative time has been cut down to 60 minutes in simple hysterectomies. Thus far more than 50 cases have been performed and 20 percent of the patients are discharged the same day, with 40 percent being discharged by the following day. About 10 percent are discharged by the second day. Occasionally, the TLH for cases of severe endometriosis is combined with laparoscopic colon resection, bladder resection or uteric treatment, necessitating a slightly longer stay. Because of the increased efficiency of the Koh Hysterectomy Technique, the total hospital costs have begun to come down, allowing the Minimally Invasive Specialists, LLC (a group of surgeons from the Milwaukee Institute of Minimally Invasive Surgery) to start the process of negotiating fixed price treatment, (including hospital, anesthesiology, radiology, lab and professional charges) with various self-insured groups. The satisfaction ratio from laparoscopic hysterectomy has been extremely high, as evidenced by postoperative follow-up questionnaires conducted by Lisa Jaeger, RN, Specialty Coordinator with the Milwaukee Institute of Minimally Invasive Surgery. Most women can resume some activity within three or four days and return to work between one and three weeks. One patient completed Al's Run (a Milwaukee 5K event) four weeks after her laparoscopic hysterectomy.