08 Nov Superior Techniques, Proven Results and Publications
This is the last and probably most important article in this series, and sheds light on how you, the patient, can make the correct decision on the technique used for your surgery. The BEST results in surgery depend on the Techniques the surgeon is using. Proof of the best techniques available are through Publications showing superior outcomes, low complications, and fast recovery.
Number 3 in this series “OB’s, GYNOs, and True Specialists” provides a great review of the qualifications of surgeons. However, techniques used for surgery really determine outcomes. As an example, a GYN surgeon that has only been in practice for a year, but using exceptional techniques can have much better outcomes than a surgeon practicing for 30 years who has done thousands of cases using inferior techniques. Likewise, Number 2 in this series discusses Tools and Techniques with a reference to robotics. A robot will NOT provide a better outcome just because it is used. A robot directed by a surgeon with poor techniques will create a poor result.
Techniques used are by far the MOST IMPORTANT FACTOR in successful surgical outcomes with faster surgical time, smaller incisions, the lowest complications, and faster recovery with less pain. Dr. MacKoul uses a specific powerful technique that is only truly learned through training with a GYN Oncologist, called Retroperitoneal Dissection, or RPD for short. This article reviews RPD, what it is, and compares RPD to other techniques through the publications provided.
The RPD Concept
RPD is an amazing and powerful way to perform surgery. Thinking of it in more simple terms, imagine if you were driving and became lost without a GPS or even those old school road maps that people used to use. You would not know where to go or what to do, and you can easily become “lost.” RPD IS that GPS or road map for the pelvis – it allows the surgeon to follow landmarks that guide the surgeon from getting lost. A “lost” surgeon can have very dire consequences for patients, such as higher blood loss and complications (like “knicking” bowel, bladder or other structures) resulting in a “crash” with serious injury as the result.
What is RPD?
The Retroperitoneal Dissection concept is simple: a method that actually exposes all the structures in the pelvis so the surgeon can “see” everything. By going behind (Retro) the peritoneal lining that covers all these structures (Peritoneal), and dissecting out these structures as necessary (Dissection), Retro Peritoneal Dissection “uncovers” or identifies all these structures so that they will not be injured during surgery.
Procedures Performed with RPD: Endometriosis, Myomectomy (fibroid removal surgery), Hysterectomy
One of the most important procedures performed in RPD is Uterine Artery Ligation, or UAL, which means the uterine artery is blocked to control bleeding. This is a vital procedure that controls blood loss BEFORE the surgery, and when used during RPD hysterectomy almost completely eliminates conversion from minimally invasive to open surgery. Open surgery has a recovery of months, compared to RPD hysterectomy with a recovery of one week. Conversion from laparoscopic to open surgery is not uncommon due to blood loss with non RPD techniques.
Dissection of the Ureter – Ureterolysis – is equally as important. The ureter transports urine from the kidney to the bladder and is right in the way with more complicated surgery such as endometriosis, hysterectomy, and myomectomy, and can be easily injured. Going behind the peritoneum with RPD identifies the ureter and can safely “dissect” it away during surgery to prevent injury.
Lateral Bladder Dissection is an invaluable RPD technique. It allows the surgeon to use the retroperitoneal spaces to dissect under the bladder, free it from adhesions, and prevent serious bladder injury. Bladder adhesions can be severe with prior C-Sections, with endometriosis, for patients requiring hysterectomy and myomectomy for a larger uterus, and for those patients with many prior GYN surgeries.
Proven Results: Publications
Dr. MacKoul, along with his CIGC colleague Dr. Danilyants, have published data supporting the use of RPD. In these publications – the largest of their kind in the world – laparoscopic procedures such as hysterectomy, myomectomy, and endometriosis using RPD resulted in the lowest complications and lowest cost in the world’s published data. Robotics are not used.
Publications are “proof” of the techniques used and the expertise of the surgeons using those techniques. A brief review of some of the more important articles are as below, with links to the articles for your reference.
Endometriosis: Retroperitoneal Excision with Superior Outcomes
RPD is an excellent match for removal of endometriosis. Endometriosis is a “peritoneal” disease, which means that the “implants” of endometriosis, or areas where the endometriosis grows, are always on the peritoneal lining. Retroperitoneal dissection goes behind the peritoneal lining, isolates out the endometriosis, and excises – or removes – all of it without damaging structures beneath such as bowel, bladder, and ureters.
The following article published in the the American Journal of Obstetrics and Gynecology details results seen with RPD on 350 patients. After 7 years, the reoperation rate on these patients was very low, mainly because RPD allows for removal of all disease.
A retroperitoneal approach to endometriosis excision: Surgical outcomes & 7-year follow-up N. Danilyants, P. MacKoul, L. van der Does, M. MacKoul, N. Kazi The Center for Innovative GYN Care, Rockville, MD AJOG 2021
Myomectomy: Quality and Cost of Care
CIGC comparison trials for CIGC LAAM myomectomy showed the lowest complications and lowest cost for myomectomy with superior outcomes compared to robotics, laparoscopic, and open surgery.
Number of Patients Studied: 1,313 (largest study of its kind in the published data)
Comparison trial: LAAM myomectomy (CIGC), robotics, standard laparoscopy, and open myomectomy. This is a Holy Cross Hospital based review in Maryland
LAAM JMIG 2018. Mackoul et al. Laparoscopic Assisted Myomectomy with Bilateral Uterine Artery Occlusion/Ligation, Feb 2018. (link to article here)
LAAM Myomectomy: A Procedure for ALL Patients
The LAAM procedure is a safe procedure performed by CIGC in surgery centers which can be performed for almost all patients, including those who are overweight. Myomectomy is a procedure that removes fibroids and keeps the uterus and is often required for those patients who want to become pregnant who have fibroids. The safety of LAAM has been proven in surgery center settings by CIGC since the techniques used include RPD and others, and cell savers are available when required. A cell saver prevents the need for blood transfusion since it can recycle blood lost during surgery back to the patient, eliminating transfusion in many cases. Surgery centers increase patient satisfaction, decrease complications, and lower costs.
Myomectomy is one of the most challenging of all minimally invasive GYN procedures. In this published study, all patients underwent successful LAAM procedures in the free-standing surgery center setting, with no statistically significant intraoperative or postoperative complications across all BMI (weight) categories ranging from 33 to 70 (more than 300 pounds).
LAAM GS 2020. MacKoul et al. Laparoscopic Assisted Myomectomy with uterine artery occlusion at a freestanding ambulatory surgery center: a case series. 969 patients
Hysterectomy: Quality and Cost of Care
CIGC comparison trials for hysterectomy showed the lowest complications and lowest cost for CIGC LRH (Laparoscopic RETROPERITONEAL Hysterectomy) with superior outcomes compared to robotic, laparoscopic, open or vaginal approaches.
Number of Patients Studied: 2,689 (largest study of its kind in the published data)
Comparison Trial: LRH Hysterectomy (CIGC), robotics, standard laparoscopy, vaginal hysterectomy. This is a Holy Cross Hospital based review in Maryland.
LRH GS 2019. Danilyants et al. A Value Based evaluation of minimally invasive hysterectomy approaches. Gynecologic Surgery, 2019. (link to article here)
LRH JOGR 2019. Danilyants et al. Value Based assessment of hysterectomy approaches. Journal of Obstet Gynaecol Research, Feb 2019. (link to article here)
Hospital vs Surgery Center Comparison: Holy Cross Hospital compared to Innovations Surgery Center (ISC) for CIGC LRH Hysterectomy and CIGC LAAM Myomectomy
Data showed no difference in outcomes when the site of service “shift” occurred from the HOPD/Hospital to the free-standing surgery center setting for both hysterectomy and myomectomy.
Patient demographics and clinicals at ISC were identical to the hospital. Costs were significantly lower than the hospital due to this ASC shift at up to 60%, further decreasing the overall cost of ISC procedures. This decrease in cost is passed on to the patient as well as to the healthcare system.
Currently, CIGC does NOT perform any major GYN surgical procedures in the hospital setting. All major GYN procedures are performed in the Non HOPD, free standing surgery center setting.
LRH JSLS 2019. MacKoul et al. Laparoscopic Hysterectomy Outcomes: Hospital vs Ambulatory Surgery Center. 2019.. 2,031 patients (link to article here)
LAAM JOGR 2020. Danilyants et al. Laparoscopic Assisted Myomectomy: Surgery center versus outpatient hospital. 2020. 816 patients. (link to article here)