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Roadmap For Hysterectomies

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BALTIMORE, Md. (Ivanhoe Newswire) - It's the second most common surgery performed on women in the U.S. and every surgeon has his or her own way of doing it. Now, one doctor is trying to change that.

When Mary Lou Olszewski was diagnosed with uterine cancer, these guys helped her through it.

"They took good care of mom. They were there for me," Mary Lou told Ivanhoe.

Mary Lou had a hysterectomy. Doctor Dwight Im used an approach he created and named the "IMSWAY." It's a step by step plan that guides surgeons like a map.

"It's almost like saying, well New York is northeast of Baltimore, I'll see you there. Well, how do I get there?" Dwight Im, M.D., a Gynecologic Oncologist at Mercy Medical Center, said.

Surgeons often have trouble locating the ureter which connects the kidney and bladder. They typically stay far away from it, which puts the patient at risk for bleeding. IMSWAY guides them closer to the ureter, so they can see it.

"You know you can see it. That's how you know you are not touching or injuring it," Dr. Im said.

The result: a shorter surgery, about 30 minutes instead of several hours and less bleeding. Doctor Im teaches the technique to surgeons all over the world and hopes it will become the standard.

"In the end, it's the patients who benefit," Dr. Im said.

"To me it was, this is not your mother's hysterectomy. I really feel that I got a lease on life," Mary Lou said.

Doctor Im has been using the IMSWAY technique for two and a half years and has performed more than 1,000 surgeries. The approach can be used for open, laparoscopic, or robotic hysterectomies.

RESEARCH SUMMARY

BACKGROUND: Hysterectomies are surgeries to remove a women's uterus or womb. Sometimes the whole uterus is removed and other times just a part of the uterus is taken out. Sometimes during hysterectomies, a woman's fallopian tubes and ovaries may also be removed. After having a hysterectomy, women will no longer have menstrual cycles and are not able to become pregnant. If the ovaries are removed they will enter menopause if they have not already done so. Hysterectomies are very common and are the second most common surgery among women in the United States, just after childbirth by cesarean section delivery.

TYPES: There are 3 different types of hysterectomy that can be performed:

  • Partial, subtotal, or supracervical hysterectomy – In these types of hysterectomies, only the upper part of the uterus is removed and the cervix is left in place.
  • Total hysterectomy – In a total hysterectomy, the entire uterus and cervix is surgically removed.
  • Radical hysterectomy – In a radical hysterectomy the whole uterus is removed as well as tissue on both sides of the cervix and the upper part of the vagina. This type of hysterectomy is typically only done when there is cancer present.

REASONS FOR: There are many reasons why a hysterectomy may be recommended for certain women. Below are some of the more common reasons for hysterectomies:

  • Fibroids – Non-cancerous, muscular tumors that grow in the wall of the uterus that can cause some women prolonged heaving bleeding or pain.
  • Cancer of the uterus, ovary, cervix, or endometrium
  • Prolapse of the uterus – This is when the uterus slips from its usual place down into vagina causing urinary or bowel problems and pelvic pressure.
  • Endometriosis – This occurs when the tissue that lines the uterus grows outside the uterus on your ovaries, fallopian tubes, or other pelvic or abdominal organs causing pain during menstrual periods and sex, bleeding between periods, and some other symptoms. (Source: www.womenshealth.gov)

"IMSWAY": IMSWAY is a robotic surgical alternative to the traditional surgical approaches, like hysterectomies, for addressing different types of serious gynecological conditions. The approach was pioneered by Dr. Dwight Im who uses the robot as a tool to enter the retroperitoneal space, identify vital organs, big blood vessels and veins, and then to remove the affected area without injuring the vital organs. (Source:www.mdmercy.com)

"What this technique allows you to do is stay calm, follow the steps, and be able to do a surgery that you are really happy about. In the end it's the patients who benefit," Dr. Dwight Im, Director for Gynecologic Oncology at Mercy Medical Center, told Ivanhoe.

INTERVIEW

Dr. Dwight Im, Director for Gynecologic Oncology at Mercy Medical Center, talks about the new technique for hysterectomies called ‘IMSWAY' and what it could mean for women requiring hysterectomies in the future.

Can you give me a quick overview of what is the IMSWAY technique?

Dr. IM: It's a mnemonic for a systematic reproducible way to perform what they call a retroperitoneal hysterectomy.

It's named after you, correct?

Dr. IM: I came up with the term, yes.

What does it actually stand for?

Dr. IM: It works like this: I stands for infundibulopelvic ligament which is the ligament that contains ovarian artery and vein which supplies the ovary. M stands for the medial leaf of the Of the broad ligament where the ureter is located. Then S stands for skeletonizing or dissecting out the ureter all away down to W, which is the term that we use for water under the bridge. This is the term used to describe the point where the ureter crosses under the uterine vesselsso you see the blood vessels on top and the ureter IMSWAY makes it possible to do any case with one surgical approach, hence the term water under the bridge. Then A stands for at, that's where you would ligate or coagulate the uterine vessels at its origin. Then finally Y stands for yes, I did it; it's wonderful I finally did it. That's the IMSWAY.

So what kind of problems can be fixed with this procedure?

Dr. Im: A traditional hysterectomy is performed where you would coagulate or ligate the uterine vessels right near the cervix, staying as close to the uterus as you possibly can. Now you run into a problem if there is a large mass, the ovary is much bigger than you thought, there are a lot of adhesions, scar tissues inside, and then you run into problems because you cannot just stay close to the uterus and perform the surgery because number one, it may not be an adequate surgery and number two, you may run in to a lot of bleeding. So what this technique allows you to do is open up what's called retroperitoneal space which is where all the big blood vessels and the nerves live. You can then dissect out all those vital organs and go up to the origin of all those vessels and deal with the issues right there and it makes the entire surgery much easier.

So you're maybe operating further away from the uterus?

Dr. Im: That would be correct. Normally our course would be, ‘okay I know the ureter is there I just don't want to get near it, I want to stay as far away as I can.' That doesn't always work right. You need to be close to the ureter to get it out of the way and if you can't see it, how do you know where it really is? You're kind of guessing. What my technique allows people to do is they can actually see the ureter, dissect it out, and follow it all the way down to the pelvis. You can physically see it and that's how you know you're not touching it or injuring it.

It's done robotically as well, correct?

Dr. Im: You can do it with open case, laparoscopically, or robotically, but what the robot allows you to do first of all is it's a minimally invasive approach. You have a three dimensional view so it gives you that additional tool to really dissect out the small vessels that you would not be able to see in that open case or even in a regular laparoscopic case.

Can you use this type of procedure for fibroids and endometriosis and ovarian remnant?

Dr. Im: It works for every case. IMSWAY makes it possible to do any case with one surgical approach but it works for every type of surgery whether it's traditional hysterectomy or big fibroids, parable cervical cancer cases, or even ovarian tumor debulking, it's the same approach. That's why it's so useful because once you master it you can do just about everything; any kind of pelvic surgery can be done with the same technique.

How long have you been doing this?

Dr. Im: I've been doing it for about two and a half years. I've done about a thousand cases.

So now you teach this technique as well?

Dr. Im: I do, people from all over the country and abroad come and watch it and they learn, but anybody can really master it if they put their effort into it because it's not that difficult to learn once you have the system down.

Who would be a candidate for this procedure?

Dr. Im: Any patient who is undergoing a hysterectomy is a candidate. In fact, we're publishing a paper. We are comparing the outcomes of patients who had hysterectomies performed using IMSWAY with the traditional approach to prove that it is both safe and effective because you know people would say, ‘why isn't it more complex surgery?' Well the patients do just as well in terms of the operating time and complication rate. It's all comparable to the traditional hysterectomy patients.

Is there any more benefit to the patient as far as recovery?

Dr. Im: It's comparable but if a patient can have a surgery performance of thirty minutes versus three hours because it was done the correct way and the right way, then it's a lot of benefit to her. The recovery time will be shorter, maybe she won't have to get a blood transfusion. So it makes more sense.

It's really benefiting the surgeon and preventing anything bad from happening?

Dr. Im: Absolutely. By using this systematic approach, it should allow one to perform complex cases in a reasonable amount of time. This should improve patient safety and outcomes You should be able to learn this technique and get everything done within just a short period of time, whether it's thirty minutes or an hour.

So how many doctors do you think are doing this now?

Dr. Im: Well the people that have come and that have been trained by me are beginning to do it more and more, but again the technique, and I need to make this clear, is not something new. People have done so called retroperitoneal hysterectomy for many years, but there has not been a single sort of standardized way of doing it from the beginning. It's the same approach every single time and to me that's the beauty of it. It's sort of drawing a map for these people and directions; this is where you start, this is how you need to go, you make a right turn here, a left turn there, and that's how you can follow just using a map.

The procedure is not new, it's the way they're doing the procedure; it's like an instruction manual?

Dr. Im: Exactly, and I use the analogy where you are about to jump off a ten meter diving board that's pretty high and you might be able to do it once, but to do it again you're going to be like, ‘I'm scared.' What I'm trying to do is teach these people to dive off a ten meter diving board but maybe you would start at half a meter and go up and up so they can be more comfortable because to find the ureter and the blood vessels in the beginning, even though it's only five centimeters deep, that is a no-man's land. You don't want to go there because one small mishap and you are running in to major hemorrhage; once you bleed, then that's it. So you're starting from very high and shallow and going down step by step, and how to get to that area where you can see everything is almost like finding an oasis in the middle of the dessert. That's how I see it. My job is to get them there using this technique.

How common is that bleeding?

Dr. Im: It is more common than you think.

Is there any way to put it in a percentage of cases?

Dr. Im: Again, it depends on the surgeon who is doing it and how experienced the surgeons are. We all know that minimally invasive surgery results in less blood loss than an open case, and for me the robot allows you to see the vessels that you would not be able to see during an open case and sometimes even during a conventional laparoscopic case.

Why are you passionate about this?

Dr. Im: Because in the end I think it will be of benefit to patients. They don't know, they put all their trust in their doctors and I want their doctors to be really well trained. This technique allows the surgeon to comfortably dissect out the important structures in the pelvis so any complex surgery can be safely performed with good visualization of the patient's pelvic anatomy.You may think that it's going to be a routine case and you go in and there's so many adhesions, horrible endometriosis, and things are so stuck, and then what do you? Start panicking because you can't do the things that you would normally be able to do? What this technique allows you to do is stay calm, follow the steps, and be able to do a surgery that you are really happy about. In the end it's the patients who benefit.

Can you tell the difference between the IMSWAY versus what other surgeons maybe do routinely?

Dr. Im: I think what this does is it allows an average surgeon to learn how to do it. It's an, I wouldn't say easy, but surely teachable technique and they can learn through a series of cases. Once they become comfortable I think it's doing the same thing over and over again. There have been techniques reported but nothing is really systematic. It's like, ‘okay well you develop a certain space.' ‘Well how do you do that?' ‘Well it's very easy, you kind of take your hand and there it is.' That's not very useful to an average surgeon; you need to know how do I develop that space and how do I get there. So it's almost like saying, ‘well you know New York is northeast of Baltimore, I'll see you there.' ‘Well how do I get there?' ‘You've got to get on 95, get on the turnpike and so on.' That's what I'm trying to do; this is how you have to go to New York if you're going to drive.

We talked to Mary your patient and she was really impressed, so as a doctor how rewarding is it to help your patients this way?

Dr. Im: It really is. Like in her case it's a high cloudy mass index and to have it done laparoscopically would have been a challenge because the instruments are not long enough. But the robot allows you to do the surgeries comfortably without a lot of complications. It's really very rewarding for the doctor as well. As you can see, I'm very passionate; it's like a religion for me so it's the preacher in me coming out.

FOR MORE INFORMATION, PLEASE CONTACT:

Dan Collins, Senior Director
Media Relations
Mercy Medical Center
(410) 332-9714
dcollins@mdmercy.com

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