Mary Madrinan had already had two Caesareans when her gynecologist suggested a hysterectomy to remove fibroids and a large ovarian cyst that was causing her back pain.
After two major abdominal incisions from the C-sections, she was worried about further scarring and a lengthy healing process.
"I'm 36, so it was difficult to decide if I wanted a hysterectomy," says Mrs. Madrinan, who lives in Hampstead.
She decided to have the operation, but chose a new type of hysterectomy, which allows removal of the uterus with no major surgical incisions and preserves the outer wall of the cervix.
Her gynecologist, Dr. Paul F. Vietz, and his colleague, Dr. T. Samuel Ahn, of Westminster, first performed this procedure in December 1991 -- the first doctors in the country to do so. In the past 2 1/2 years, the doctors have performed 150 such operations at Carroll County General Hospital.
"I had the surgery on Sunday and went home on Tuesday," says Mrs. Madrinan, a registered nurse who underwent the surgery in December. "Within a week, Dr. Vietz had taken away any restrictions, and I was driving and taking care of the children.
"I was really, really fine within a week," she says, "and I've taken care of people who need six to eight weeks for total recovery [from traditional hysterectomy]."
Drs. Ahn and Vietz published the results of their pioneering work in the February issue of the American Journal of Obstetrics and Gynecology.
The article details their surgical procedure, which was originally developed by Dr. Kurt Semm in Germany. It removes the uterus without the abdominal or vaginal incision characteristic of traditional hysterectomies. The technique also preserves the outer wall of the cervix and its surrounding tissue.
"In our judgment, this is the gentlest hysterectomy we can provide," says Dr. Vietz. "It's minimally invasive surgery and organ-preserving surgery."
Their American Journal of Obstetrics and Gynecology article was based on the results of the first 62 hysterectomies the doctors performed, from December 1991 to December 1992. The surgeons learned the technique from Dr. Semm, a pioneer in laparoscopic surgery.
A thin, hollow tube, the laparoscope's camera lets a surgeon peer into the abdomen through a small hole. A TV monitor shows the picture to the surgeon.
Using the laparoscope and special instruments, doctors are able to remove the uterus without making large surgical incisions. This technique also preserves a part of the cervix that is removed in traditional hysterectomy procedures.
Dr. Vietz says that in the past 50 years, studies and interviews with women who have had hysterectomies indicate the cervix plays a role in normal sexual functioning, but other gynecologists say that not enough data exist to make such a conclusion.
The new hysterectomy offers several benefits over the conventional operation, according to Drs. Ahn and Vietz. No surgical incisions mean almost no scarring and a quicker recovery. A conventional hysterectomy requires a four- to five-day hospital stay and six to eight weeks for complete recovery, Dr. Ahn says. The new technique reduces time in the hospital to two or three days, with a recovery of three weeks, he says.
Because the surgery preserves a portion of the cervix, the surrounding ligaments and muscles -- which support the pelvic floor -- are left untouched. These muscles play a role in preventing bladder problems.
"If the woman has a healthy cervix, I have no reason to touch it or remove healthy tissues," Dr. Vietz says.
According to the journal article, about 600,000 conventional hysterectomies are performed in the United States each year. The most common reasons for the procedure include abnormal bleeding, fibroids and pelvic inflammatory disease.
Although some gynecologists have been performing hysterectomies using the laparoscope since 1989, Dr. Ahn says their technique still requires a vaginal incision.
Dr. Vietz predicts that the new laparoscope technique described in the journal eventually will replace the traditional hysterectomy.
But some gynecologists and surgeons doubt the new technique will ever be widely used in this country.
"It's a very exciting option, and for the right patient it's clearly an excellent option," says Dr. Gay Guzinski, chief of benign gynecology at the University of Maryland Medical Center in Baltimore. "But to say this will replace abdominal or vaginal hysterectomies may be a bit premature."
Dr. Jordan Phillips of Santa Fe Springs, Calif., an expert in laparoscopic gynecology, says the surgical procedure is quite difficult to master.
"It requires an extraordinary amount of manual dexterity, and not every doctor has that," says Dr. Phillips, chairman of the board of the Association of Gynecologic Laparoscopists. Surgical complications may include hemorrhaging, he says.
Drs. Ahn and Vietz say that if surgeons follow the technique carefully, complications are minimal.
"If some doctors don't learn properly, they're going to make a lot of mistakes," says Dr. Ahn. "That applies to all kinds of endoscopic [laparoscopic] surgery."
Through workshops at Carroll County General, Dr. Vietz says he and Dr. Ahn have trained about 12 doctors to perform the surgery.
The procedure begins with three small incisions at the navel and pubic hair line. The surgeon inserts the laparoscope through one cut and will insert special instruments designed by Dr. Semm in Germany through the others to perform the surgery.
After cutting the uterus free of surrounding tissues, the doctor inserts an instrument through the vagina to "core" out the center of the cervix -- the part most susceptible to cancer. Then a sharp-edged instrument is inserted through one of the incisions to cut the uterus into small pieces and suction it out through a tube.
TTC Some gynecologists question the wisdom of preserving a portion of the cervix. Dr. William Saye, medical director of the Advanced Laparoscopic Training Center in Marietta, Ga., says it's not clear that the cervix plays a role in sexual function and that it's easier to repair ligaments that provide pelvic support if the cervix is completely removed.
"It has just not been the standard of care in America to leave the cervix," Dr. Saye says.
The mincing of the uterus causes some concern for Dr. George Morley, a professor of gynecology at the University of Michigan Medical Center in Ann Arbor.
"I think it's dangerous to piecemeal the uterus," says Dr. Morley. "What if there was a malignancy there that had not been previously detected?"
Cutting up a cancerous uterus increases the chances of spreading the diseased cells, Dr. Morley says.
Drs. Ahn and Vietz say their surgery is not appropriate for patients who have cancer.
Although some experts question certain aspects of Drs. Ahn and Vietz's procedure, they agree the operation provides a new option for women facing a hysterectomy.
"We're seeing a great deal more attention to whether a hysterectomy is needed and a great deal more attention to sexual functioning and more use of newer technologies in innovative ways," says Dr. Guzinski. "Any information that expands on the current capabilities is worth considering."