When I proposed doing an article on surgical procedures that were less invasive than the traditional abdominal incision approach to hysterectomy, a colleague said, “Nobody gets abdominal hysterectomies anymore, do they?”

Well, yes, they do—far more often than is necessary. According to a recent position statement in The Journal of Minimally Invasive Gynecology, based on the latest available figures, more than two-thirds of hysterectomies in the US are performed through the “classic” five-to-seven-inch abdominal incision—even though the majority could be done using safer, less invasive procedures. The statement cited two such procedures, laparoscopic hysterectomy and vaginal hysterectomy. I’ll tell you more about these in a moment…

But first I want to let you know about a new hysterectomy procedure that not only appears safer but typically leaves no visible scar. With this technique, called laparoendoscopic single-site (LESS) hysterectomy (often referred to by the trademarked single-incision laparoscopic surgery, or SILS), the entire operation is done through a single three-quarter-inch incision hidden in the belly button…after which the uterus is eased out via the vagina. I asked R. Craig McClelland, MD, an attending physician at Piedmont Medical Center in Rock Hill, South Carolina, who performs and lectures on the LESS technique, to tell me about it.

He explained that with a conventional laparoscopic hysterectomy, the surgeon makes three to five separate incisions (one of which may be in the belly button) to allow insertion of a straight laparoscope (camera) and various surgical instruments. Because a straight laparoscope provides only a limited view, it generally must be moved to a different incision whenever the surgeon needs a different view—and each incision leaves a small visible scar.

Flexibility is the key difference with a LESS hysterectomy, Dr. McClelland said. A flexible spool-shaped device called a port, approved by the FDA in 2009, is placed in the single belly button incision. The port has three openings through which the surgeon inserts articulated (hinged) surgical instruments and a slim, flexible laparoscope that can see in all directions—so no other incisions are needed. Less cutting means significantly less pain…a lower risk for complications…and faster recovery. Bonus: The belly button generally hides the scar.

Another procedure that leaves no external scar is the vaginal hysterectomy, in which an incision is made inside the vagina and the uterus is removed via the vaginal canal. However, the required hospital stay and the recovery time typically are greater with a vaginal hysterectomy than with the LESS procedure, Dr. McClelland said.

Comparison of what is typically involved in various hysterectomy procedures…

Table_RecoveryHyst

Insurance generally covers LESS at the same rate as other types of hysterectomies. If your doctor is not experienced with the technique, ask for a referral to one who is. Before scheduling the procedure, ask about the doctor’s level of LESS experience. Dr. McClelland said, “If my wife were the patient, I would want her to use a board-certified surgeon who has performed at least 50 traditional laparoscopic hysterectomies and 20 LESS hysterectomies.”The LESS procedure is appropriate for most women who need a hysterectomy (for instance, because they have endometriosis, fibroids, abnormal bleeding, uterine prolapse, cancer or chronic pelvic pain that has not responded to less invasive treatments). Even extremely obese women and patients who have had multiple Cesarean sections, who often are told that the old-fashioned abdominal procedure is the only option, may be considered for LESS. Exception: The LESS hysterectomy may not be appropriate for a woman who has an extremely large uterus or extensive internal scarring.

R. Craig McClelland, MD, is an attending physician at Piedmont Medical Center in Rock Hill, South Carolina, and a pioneer in gynecological procedures using laparoendoscopic single-site surgery techniques. He has performed more than 125 LESS hysterectomies with minimal complications…has lectured on and taught the procedure to other surgeons nationally and internationally…and recently presented new data on the technique at the annual Global Congress of the American Association of Gynecologic Laparoscopists.