Barbara Nesbitt

I write this with my daughter, Hunter, sleeping peacefully on my lap. As I look down on her, I am filled with a sense of awe, and of gratitude, for her journey to us was long. Here is her story......



hen I moved to Tahoe in May of 1994, I was looking to balance my career as an ob-gyn with the pursuit of the good life -- skiing, biking, boating, gourmet meals, travel. I was not thinking about having any children to disrupt my very comfortable lifestyle. In July I met a man with the sweetest smile and the bluest eyes who, on our second date, told me how he'd always dreamed of being a dad and how he hoped at age 39, it wasn't too late. In September, he asked me to marry him and I began to think that maybe a family wasn't such a bad idea after all. 

 Jeff and I were married on a snowy Saturday in January 1995. I added maternity coverage to my health insurance that Monday -- there was a 6 month waiting period for coverage to be effective and we wanted to start our family as soon as possible. I, the successful physician, had always accomplished what I had set out to do, and was sure I'd get pregnant as soon as we tried in September 1995; besides, I was an ob-gyn, so how difficult could it be for me to get pregnant?

 As it turned out, pretty darn difficult. After 6 months of not using contraception, I started doing ovulation predictor kits. Surprise, I wasn't ovulating! I had prescribed fertility drugs such as Clomid and I'd seen my patients turned into raving lunatics by these drugs, so I opted to try alternative approaches initially. I consulted an acupuncturist who stuck me full of needles and prescribed foul tasting herbal concoctions. We also shifted my cycle so I'd ovulate when the moon was in the same phase it was when I was born! Well, my cycles became more regular, but I still wasn't pregnant.

 Being an ob-gyn, I certainly knew how to get someone to ovulate, so I prescribed Clomid for myself (now, that's a real smart move -- taking care of yourself as a patient!). Not only did it not make me a lunatic, it mellowed me out so much that Jeff asked if I could take it all the time! I conceived right away, in August of 1996. We were ecstatic! We were going to be parents! I scheduled an ultrasound in my office for 10/19/96, my husband's birthday -- I thought seeing his child on the screen would be a wonderful present. Unfortunately, what we saw was an embryonic demise -- a fetal pole but no heartbeat. We were sad, but thought we'd do better next time.

 Next time took longer than we thought. I resumed the Clomid in December but didn't conceive until the 4th cycle, in March 1997, after an IUI. It was strange -- obviously I couldn't do the IUI myself (I had my partner do that), but I brought the sperm sample from home, prepped it myself and set the room up so Lauren could do the insemination. 14 days later I had a positive pregnancy test. This time, I knew from the start something wasn't right. I kept telling Jeff not to get too excited. We drew progesterone levels (excellent) and HCG levels. The HCG levels barely rose appropriately, and an ultrasound soon thereafter confirmed what I'd known all along --this was another blighted ovum. 

 At this point I took advantage of being a doctor and began the workup for repeated miscarriages. Jeff and I had chromosome analysis done (both normal) and I had an anti-phospholipid panel done; although the initial screening tests were normal, a more extensive panel revealed a very minor elevation in anticardiolipin, an elevation that should not have been clinically significant. At this point I decide it was crazy to continue treating myself, so I saw a reproductive endocrinologist. He felt that my lab tests were inconclusive, but he said a very wise thing to me when I asked if I should take the aspirin and heparin injections that are the treatment for anti-phospholipid syndrome; he said, "if you do the treatment and you have a miscarriage again, how will you feel?" -- my answer, "devastated, of course." Then he said, "and if you don't do the treatment and you miscarry?" and I answered, "devastated, and guilty, because I didn't do everything possible." 

 I was emotionally a wreck after the second miscarriage. I felt I was a double failure -- as a woman and as an ob-gyn (I mean, I helped women get pregnant and I delivered babies every week and I couldn't even do it myself???). I joined the multiple miscarriage e-mail support group. I told my story on the Women's Health Forum at obgyn.net. The support I got helped me through a very difficult time, as did the understanding that I wasn't alone in my suffering, that many other women out there had been through worse and many had gone on to have a child. Jeff was incredible; he held me when I cried and told me he would be behind me 100% whatever decisions I made about trying again or not. It took me 6 months to get up the courage to resume infertility treatments.

 This time, with the guidance of my RE, we did a combination of Clomid and Pergonal; again my partner did the IUI. No luck. We took a vacation, then came back and started a Pergonal cycle. I was giving myself Pergonal shots in my hips (ever the doctor, I gave myself the shots rather than having my husband do it -- besides he HATES needles!) and heparin injection in my abdomen twice a day; I was black and blue. This time we decided to have the RE do the insemination. For the first time I didn't prep the sperm and for the first time Jeff was actually I the room for the actual insemination. The karma must have been better, for this time worked. As we were driving back to Tahoe, I turned to Jeff and said, "we just conceived".

 I knew, just KNEW with all my being, that we were having a girl. I had thought the two miscarriages I had were boys. I had a brother who died when I was 4 and he was 3, and I had always thought that I should have a boy to take away some of the pain of my parent's loss; I had told Jeff early on in our relationship that if we ever had a son I would name him Timothy after my brother. I know now that you can't force a spirit to come to you, that any son I have will not be my brother and I cannot make up for his loss. I was told there was a little girl spirit hanging around me, and I just had to let go to allow her in (our dear Barbara Nesbitt was one person who told me long before I became pregnant with Hunter that I would have a daughter). Now I knew she was here, and I hoped, here to stay.

 Being an ob-gyn is not always an advantage -- too much knowledge leads to neurosis, and I was definitely neurotic throughout the entire pregnancy. First I worried about miscarriage, then about incompetent cervix, then about preterm labor, then, finally, about stillbirth. I was taking 81mg aspirin a day and injecting heparin twice a day from ovulation through 36 weeks. We did ultrasounds weekly until 12 weeks. I had CVS done at 11 weeks due to my age (38 at delivery), which confirmed what I already knew -- we were having a girl (BTW, Jeff lost a $50 bet on that one!) and, at least from a chromosomal standpoint, she was fine. We did weekly ultrasounds to check my cervix from 18 - 24 weeks (after I checked myself and thought my cervix was shortening -- I told you I made myself nuts!). After that, it was monthly ultrasounds to follow growth, then weekly again from 36 weeks to check amniotic fluid. This child had more pictures taken before birth than the average supermodel has in an entire career!

 I threw up every day for 6 weeks in the first trimester and thanked God every time; to me it was a sign of a healthy pregnancy and I was grateful for every reminder that she was okay. I felt her move for the first time at 19 weeks, and almost wrecked the car calling Jeff to tell him. I got varicose veins, but just got in the habit of putting on support hose every morning. I was constipated from the progesterone I took for the first 12 weeks, and from the pressure of the growing uterus for the next 27. I got up every 2 hours throughout the night to empty my bladder. Despite all that, I never felt better. I rejoiced in all the signs of pregnancy and I glowed. My husband told me every day how beautiful I was. I loved being pregnant. 

 By the middle of November, at 37 weeks, I really began to worry about stillbirth. Jeff did too. A friend of ours, and a patient of mine, had a history eerily similar to mine (same age, husband same age as Jeff, 2 miscarriages, mild anti-phospholipid syndrome), who had a stillbirth 8 days from her due date; I was in the first trimester at the time and was devastated. We were so afraid that same thing would happen to us. I was already doing twice weekly NSTs and weekly amniotic fluid volume checks. Jeff wanted me to deliver the baby -- now. My cervix was only 1cm at 38 weeks, but she was engaged. We decided if I hadn't gone into labor by 12/1, at 39 weeks, I'd be induced. We tried everything to get labor to start -- spicy dinners, taking Jeff's 10 year old beat up pickup with lousy shocks down bumpy roads, cutting down a Christmas tree, driving off the Hill (people in the mountains think the altitude change will start labor), sex, and even cross country skiing -- uphill! 

 I was admitted to the hospital on 12/1/98 at 6:15 AM. I was 1cm (still!) and 60% effaced. Patty, the nurse finishing her shift, placed Cytotec into my vagina to ripen my cervix. Normally, we admit patients in the evening for Cytotec, but I didn't want to keep my partner up by delivering in the middle of the night! After the mandatory bedrest and monitoring after the Cytotec was placed, I got up and played Minesweeper on the nursing station computer! I sent Jeff to work as I was feeling so good and knew it could be a long day and night. The contractions were every 3 minutes, but weren't bad at all. I received an additional dose of Cytotec at 11:00 and was 3 cm. I had had a positive strep culture during the pregnancy, so an i.v. was started shortly thereafter to administer antibiotics. I was still feeling great and even ate a veggie burger for lunch. By 2:00 I was getting uncomfortable and asked Jeff to come back; the contractions were every 1 - 2 minutes but I was still walking the halls and I still thought I could do labor without medication, but I needed my back rubbed. Jan, my labor nurse, checked me and I was 4-5 cm. Lauren came in after office hours, around 6:00, and I was barely 5 cm. She ruptured membranes -- lots of clear fluid --but I could see she was thinking I was making slow progress and might end up with a c-section. As an obstetrician, those same thoughts were in my head as well. 

 After the membranes were ruptured, the contractions really increased in intensity. I had also started retching -- no veggie burger reruns though! It was time for an epidural, the hell with unmedicated childbirth! Here's another example of it not always being an advantage to be an ob-gyn while one is pregnant: throughout my pregnancy, everyone -- from the RE I saw in order to conceive, to my partners, to the perinatologist who monitored growth, to my nurse -- always asked what I wanted to do and the anesthesiologist was no exception. When I asked her whether she wanted me sitting up or laying on my side to get the epidural, she asked me how I was more comfortable; well, the contractions were horrendous when I lay down, so I naturally opted for sitting. Despite the fact that I had gained only 18 pounds the entire pregnancy and my back was very easy to feel, she had a hard time getting the epidural in -- the interspinous spaces were just too tight. She tried for 45 minutes and I looked like a pincushion before she did what she would have done with any other patient from the start -- had me turn on my side. She popped the epidural in in no time flat and I was soon comfortable (and when it came time to take the epidural catheter out later, I had to be on my side -- it wouldn't come out with me sitting). I remember turning to Jan, my labor nurse, while I was trying to get on my side and telling her, "I'm in transition and I'm losing it!!" Jan was wonderful at helping me through that most difficult time (Jeff, quite wisely, had stepped out of the room for the epidural; remember he HATES needles). The epidural was the weirdest feeling -- I kept poking my legs and laughing because I couldn't feel them, although I could wiggle my toes.

 Shortly after the epidural was in place I began to feel pressure, but I didn't say anything because I was enjoying being comfortable. Lauren had left to say goodnight to her 2 kids and we all thought it would be a while longer. The pressure continued to build and I began to feel an urge to push; I asked Jan, who had stayed past her shift, to check me -- I was fully dilated and +1 station! Jan didn't want me to push until Lauren got back to the hospital, and I was still comfortable, so I was happy to oblige. Once I started pushing, it took about 45 minutes. Hunter began to have drops in her heart rate down to the 60s, so on went the oxygen mask. Lauren was about to use the vacuum when her heart rate went up and stayed up. I pushed a while longer, then Lauren asked if I cared whether she cut an episiotomy --the only thing I cared about was having a healthy baby! -- so she did. Two pushes later, at 9:41 PM on 12/1/98, Hunter Katherine Shanahan Turney, all 5 pounds 13 ounces and 19 inches of her, slipped into the world. Daddy Jeff was too excited to cut the cord, all he wanted to do was look at his beautiful daughter (besides, he doesn't like blood and all involved agreed it was pretty darn amazing that he was able to be there for the delivery)

 After a few whiffs of oxygen to perk her up, Hunter was placed on my chest, skin to skin. I put her to the breast and she latched on right away -- good thing one of us knew what she was doing! She was incredibly alert and just looked around. There was wisdom of the ages in her eyes. She was perfect. We were blessed.

 And are blessed. Hunter is almost 6 weeks old now and is the most wonderful, beautiful, smart and talented baby on earth. She has a cry that can shatter windows and a smile to rival the sun. Her skin is like cashmere and her eyes are the color of the sky. She has the hands of a concert pianist and her feet -- well, lets just say she'll be in no danger of tipping over once she starts walking!! She is an angel and the embodiment of all that is right and beautiful and precious in this world. She is our little girl, and we love her more than mere words can express.

Articles

I write this with my daughter, Hunter, sleeping peacefully on my lap. As I look down on her, I am filled with a sense of awe, and of gratitude, for her journey to us was long. Here is her story......

An Obstetrician Becomes a Mommy: The Story of Hunter's Birth



 We compared laparoscopic-assisted vaginal hysterectomy (LAVH) with total abdominal hysterectomy (TAH) in a case control study that evaluated length of operation, blood loss, length of hospital stay, drug requirements for pain, and postoperative pain and activity levels. Of 81 women who underwent nonradical hysterectomy for a primary diagnosis of pelvic pain between June 1 and December 31, 1992, 19 who underwent each procedure were chosen for inclusion in the study. Patients were matched in a case control manner for age, weight, diagnosis, and uterine weight. All 38 hysterectomies were completed without incident. When indicated, unilateral or bilateral oophorectomies were performed. The average surgery time for LA VH was 144 minutes and for TAH 98 minutes, a significant difference (p <0.005). There were no significant differences between estimated blood loss and change in hemoglobin from preoperative levels to postoperative day 1 levels between the groups. Women having TAH reported significantly more pain after their release from the hospital. There was no significant difference in pain during hospitalization apparently because patients who had TAH self-medicated to maintain acceptable levels. That group in fact used an average of 436-mg meperidine during their hospital stay, significantly more than the 197mg used by the LAVH group (p <0.005). The length of stay was 2.125 days for LAVH and 3.542 days for TAH (p <0.00 1). On a scale of 1 to 10 (10 being complete normal activity) the activity level of women undergoing LAVH was 9.2 by day 14 compared with 6.4 for those having TAH (p <0.005). By the sixth postoperative week, the latter group reported an activity level of only 8.5, indicating that the ability to function is much more severely limited after TAH than LAVH.

 Dr. Carter is Assistant Clinical Professor, Department of Obstetrics and Gynecology. University of California College of Medicine, Irvine, California. Dr. Ryoo is Chairman of the Department of Obstetrics and Gynecology, and Ms. Katz is a member of the nursing staff of Kaiser Permanente Hospital, Panorama City, California.

 The Endo GIA was used successfully for laparoscopic hysterectomy in a 42-year-old woman for the treatment of pelvic pain and endometriosis in 1990. The first seven women to undergo laparoscopic-assisted vaginal hysterectomy (LAVH) in Italy experienced rapid recuperation, and the authors concluded that the procedure was a reasonable alternative to total abdominal hysterectomy (TAH). 2 We evaluated the two procedures on a case control basis for length of - operation, blood loss as estimated by the surgeon drop in hemoglobin in the 24 hours after surgery, drug use to control postoperative pain, length of hospital stay, and pain and activity levels in the immediate postoperative period to week 6.





 Of the 81 women (32 TAH, 49 LAVH) who underwent nonradical hysterectomy for a primary diagnosis of pelvic pain between June 1 and December 31, 1992, at the two study sites (Kaiser Foundation Hospital, Panorama City, CA; Mission Hospital Regional Medical Center, Mission Viejo, CA), 38 were selected for inclusion in this study, 19 undergoing each operation. Inclusion criteria were that patients be matched in a case control manner for age, weight, diagnosis, and uterine weight, and that they be candidates for TAH.

 All 19 LAVHs were performed by one surgeon to ensure uniformity and familiarity with the procedure. Abdominal hysterectomies were performed in the standard manner using similar techniques.

 Patients with fibroid uterus in the LAVH group underwent therapy with a gonadotropin-releasing hormone analog (depot leuprolide; TAP Pharmaceuticals. Deerfield, IL), resulting in a 40% to 60% reduction in uterine volume from initiation of therapy to surgery. The LAVH was performed by placing one 10-mm cannula infraumbilically and two 12-mm cannulas in the lower quadrant approximately 6 cm above the pubic rami, lateral to the inferior epigastric arteries. A 5-mm cannula was placed 4 cm above the pubis in the midline. A ZUMI catheter (Zinnanti Surgical Instruments, Chatsworth, CA) was placed in the uterus for uterine manipulation.

 In each case, the round ligaments were treated with bipolar coagulation  and transected with the contact-tip neodymium:yttrium-aluminum-gEtrnet (Nd:YAG ) laser (Surgical Laser Technology, Oak Ridge, PA) with a GRP6  sapphire-tip scalpel. The anterior leaf of the broad ligament was similarly transected. The bladder flap was  then developed by placing 4 x 8-cm gauze on a ring forceps into the vagina and elevating the vaginal apex so that  the bladder could be taken down over the apex by sharp and blunt dissection. The bladder pillars were coagulated  with bipolar electrocoagulation and transected with a GRP6 probe. The perivesicle and perivaginal spaces were then  developed. Windows were created using a right-angle dissector. The Endo-GIA linear stapler was used to transect the  infundibulopelvic or utero-ovarian ligaments according to an earlier decision to remove or preserve the ovaries.

 Using contralateral placement of the linear stapler, a very close approximation of the uterine body and cervix and vagina was obtained, and the ascending branch of the uterine artery was transected. The anterior and posterior colpotomy incisions were opened with the laser. The cardinal ligaments were cross-clamped, divided, and suture ligated from below, with the final vaginal cuff closure also being accomplished from below. Once the vaginal cuff was closed, the peritoneal cavity was insufflated, inspected laparoscopically for hemostasis, and irrigated with warm lactated Ringer's solution. Throughout the procedure and at the final look, bleeders were coagulated with the argon beam coagulator (Birtcher Medical Systems, Irvine, CA). The bladder was drained with a Foley catheter, and no vaginal packing was used postoperatively.

 In the TAH group, 25 procedures were performed: 14 women had bilateral and 1 unilateral salpingo-oophorectomies. 1 had an appendectomy. 2 had lysis of pelvic adhesions, and 7 were treated for endometriosis. In the LAVH group. 24 procedures were performed: 7 patients had bilateral and 5 unilateral salpingo- oophorectomies. 7 had lysis of adhesions, 1 had a repair of bilateral hernia, and 4 were treated for endometriosis.

 After a brief stay in the recovery room, the patients were transferred to the wards. They were discharged when they were able to void, pass flatus and tolerate oral agents to control pain. Discharge criteria were the same for both groups.

 Operating time, blood loss as estimated by the surgeon, and intraoperative complications were recorded. Hemoglobin levels in blood drawn the morning after the procedure were compared with preoperative levels. Pain control was assessed by aggregate intramuscular narcotic use on all hospital days.

 Pain levels were assessed by patient interviews 1, 3, 7, 14, and 21 days, and 6 weeks postoperatively. The women rated their pain on a 10-point scale from 1 -no pain to 10 unbearable pain. Their activity levels were assessed by interviews 1, 3, 7, 14, 21 days, and 6 weeks postoperatively, with 1 extremely limited activity and 10 no limits on activity. The data on pain and activity were analyzed by Wilcoxon's signed rank test. The rest of the data were analyzed by two-tailed Student's t test.






 All patients were operated on for a primary diagnosis of severe, disabling pelvic pain. As shown in Table 1, demographics and pathologic diagnoses in the two groups were closely matched.

TABLE 1. Patient Demographics and Pathologic Diagnoses

a Two-tailed Student t test.
 b The primary diagnosis for all patients was pelvic pain
 NS = not significant at p <0.1

Surgeries were successfully completed in the proposed manner in all patients. The mean operating time for LAVH was 46 minutes longer than for TAH, a significant difference (p <0.005). The estimated blood loss for those who underwent LAVH was not significantly different than that for women having TAH.

The drug requirement to control pain during hospitalization after TAH was almost double that after LAVH (p <0.001). The mean length of hospital stay was significantly shorter after LAVH (2.135 days) than after TAH (3.54 days) (p <0.005) (Table 2).

Table 2. Length of Time in Surgery, Blood Loss, Hemoglobin Drop, Meperidine Use, 
 and Length of Stay.

a Two-tailed Student's t test.
 b As estimated by the surgeon.
 S= significant at p < 0.005; NS = not significant at p< 0.1


Postoperative complications in the TAH group were one woman with mild fever and atelectasis, three with hemoglobin below 10g/dl, and two with urinary tract infections. In the LAVH group. one woman had mild fever with atelectasis and two had anemia with hemoglobin below 10g/dl; no patients were affected by urinary tract infections. No patients required transfusions of nonautologous blood.

Pain levels are shown in Table 3 and Figure 1. Patients undergoing LAVH reported a significantly lower level of pain than those having TAH on days 7,14, and 21 (p <0.05). The difference in postoperative activity level achieved statistical significance on day 7. This difference became more pronounced at day 14, when it was 9.2 for LAVH and only 6.4 for TAH (p <0.005) (Table 4, Figure 2). By day 21 women in the LAVH group reported an activity level of 9.6, where-as those in the TAH group reported only 7.9 (p <0.005). At 6 weeks, the levels were 9.95 and 8.5, respectively (p <0.005). Another way of comparing this is to note that the former women felt more fully recovered at 2 weeks than the latter did at 6 weeks.

a Wilcoxon's signed rank test.
 Ten-point activity scale: 1 = no pain, 10 = unbearable pain.
 S = significant at p < 0.005; NS = not significant at p <0.01

a Wilcoxon's signed rank test.
 Ten-point activity scale: 1 = extremely limited activity, 10 = no limits on activity
 S = significant at p < 0.005; NS = not significant at p <0.01

Figures 1 & 2 match data points in Tables 3 & 4



In 1992, a minimum complication rate, less postoperative analgesia, faster recovery, and shorter hospital stay were reported for the first 75 consecutive cases of LAVH than for abdominal or vaginal hysterectomy.

A very short hospitalization was reported for 72 patients in 1992,~ and 215 subsequent laparoscopic hysterectomies required an average operating time of 114 minutes and a mean hospital stay of 1.21 days.

At 1 week after surgery the majority of these women were permitted to drive and resume normal, non-strenuous physical activity.

In a comparison of LAVH with standard vaginal hysterectomy in a prospective study of 56 patients,

the LAVH group had a longer operating time (120 vs 65 mm). The clinical outcomes were similar for both groups, including a 12-hour hospital stay. The mean hospital charge for LAVH was $3000 more than for vaginal hysterectomy.

Perioperative and postoperative courses of hysterectomy with or without bilateral salpingo-oophorectomies were compared in 10 women undergoing LAVH and 10 undergoing TAH.

Surgery time was 160 versus 102 minutes, length of hospital stay 2.4 versus 4.4 days, and recovery time 3 versus 5 weeks, respectively. The laparoscopic Doderlein hysterectomy compared favorably with standard abdominal hysterectomy in 167 procedures.

Postoperative recovery times and pain levels were assessed in 37 patients with a primary complaint of pelvic pain and diagnoses of fibroid uterus, adenomyosis, and severe endometriosis who underwent LAVH.

Women reported an activity level of 8.7 on a scale of 1 to 10 (10 no limits on activity) by postoperative day 14. In another study those undergoing abdominal hysterectomy had a mean uterine weight of 418 g compared with 150 g for those undergoing LAVH.

The hospital stay after abdominal hysterectomy was 4.5 days and after LAVH 2.5 days. Hospital costs were $10,511 and $12,814, respectively, a difference of $2303.

Women who underwent vaginal hysterectomy experienced significantly fewer complications than those who had undergone TAH in one study.

The major finding was that the overall complication rate after TAH was 70% higher than that after vaginal hysterectomy, although the morbidity associated with both procedures was appreciable.

Women in our study who underwent LAVH had a shorter hospitalization but longer operating room time than those having TAH. They also experienced a much more rapid recuperation and much quicker return to normal activities. The primary advantage of TAH is clearly the shorter operating time; the primary advantages of LAVH are shorter hospitalization, reduced requirement for drugs to control postoperative pain, and faster return to normal activities.

An important public policy issue now confronts us. As it is currently performed, LAVH is more expensive than TAH. The issue is whether the benefits of shorter convalescence and faster return to the work force, shorter hospitalization, and less need for narcotics for postoperative pain outweigh the disadvantage of the higher cost. If total health care system costs are evaluated, the short-term disability costs of 2 weeks of recovery after laparoscopic hysterectomy should be compared with disability costs of 6 to 8 weeks of recovery after abdominal hysterectomy. The woman who returns to work 4 to 6 weeks earlier is producing.

For LAVH to be, economically viable compared with TAH, savings in disability costs and the increased contribution to the gross domestic product must offset the increased health care costs. In the current system, insurance companies and hospitals do not share in these benefits, only the costs. The economic impact of laparoscopic surgery must take into account both the cost to the hospital and insurance payors and these productivity and social issues. Insurance is based on a risk pool whereby the cost of a premium is based on the cost of treatment, not the ability of the subscriber to return to work. An economic and social cost-benefit analysis must be performed before decisions are made to modify or judge a procedure that provides substantial benefits to the patient.

Laparoscopic versus open cholecystectomy was discussed in 1991 by the medical director of Blue Cross/Blue Shield of South Carolina.

He stated that hospital charges for the former were 14% higher, surgeon fees were 25% higher, and the anesthesia professional charges were 34% higher than for the latter, resulting in a 25% average higher cost for laparoscopy despite a 63% reduction in hospital days. These matters must be addressed, together with the development of methods to improve efficiency, to shorten the length of surgery time by using partial vaginal approaches, and to reduce the cost of instruments required for the procedure. Without a resolution to these problems, LAVH may not be a viable option for the health care consumer of the future.

In this case control study LAVH resulted in a significantly shorter hospital stay, with a much more rapid return to normal activities, than TAH. The drug requirement to control pain and the level of pain patients experienced were also significantly less. Blood loss was not different for the two procedures.

Although LAVH took on average 46 minutes longer to perform, women in that group were able to leave the hospital in an average of 2.1 days and return to normal activity by 2 weeks, thus demonstrating significant advantages over TAH for both patients and the health care system. If 80% of patients scheduled for abdominal hysterectomy undergo LAVH, the average reduction of hospital stay of 1.5 days would save more than half a million hospital days over 1 year.

The impact on the workforce is equally important. Allowing women to return to employment in 2 weeks rather than 8 weeks will result in more than 16 million more days spent in productive work. This translates into equally important savings in disability insurance.

Since its introduction in 1989, continued improvement of techniques will likely progress rapidly so that LAVH will be performed on an outpatient basis for many women, and will result in shorter recovery time.

Thus the increased operating room time of approximately 46 minutes is significantly outweighed by the benefits available with widespread application of this procedure.

1. Nezhat C, Nezhat F, Silfen SL: Laparoscopic hysterectomy and bilateral salpingo-oophorectomy using Multifire GIA surgical stapler. J Gynecol Surg 6:287-288, 1990

2. Minelli L, Angiolillo M, Caione C, et al: Laparoscopically assisted vaginal hysterectomy. Endoscopy 23:64-66, 1991

3. Padial JG, Sotolongo J, Casey MJ, et al: Laparoscopy assisted vaginal hysterectomy: Report of 75 consecutive cases. J Gynecol Surg 8:81-85, 1992

4. Liu CY: Laparoscopic hysterectomy: A review of 72 cases. J Reprod Med 37(4):351-354, 1992

5. Liu CY: Laparoscopic hysterectomy: Report of 215 cases. Gynaecol Endosc 1:73-77, 1992

We compared laparoscopic-assisted vaginal hysterectomy (LAVH) with total abdominal hysterectomy (TAH) in a case control study that evaluated length of operation, blood loss, length of hospital stay, drug requirements for pain, and postoperative pain and activity levels.

Laparoscopic-Assisted Vaginal Hysterectomy

Barbara Nesbitt, Executive Editor of MediSpecialty.com with 

, otohns.net                 Facial Plastics and Reconstructive Surgery                 Advisory Board Member


                 *requires RealPlayer - 

   "Hi, I'm Barbara Nesbitt, and I'm here in Washington, D.C. at the  Academy Conference with Dr. Miller who is in private practice in New  York and also Assistant Professor."
         
         

  "That's right, at the New York University School of Medicine."
         
         

  "In  talking to him a few minutes ago, one of the things that I also found  out was he is among a group of physicians that are involved in the         Face to Face program, that's the program for women that have  been severely damaged."
         
         

  "From domestic violence."
         
         

  "Tell me about it, how you got involved, and what do you do?"
         
         

  "The  American Academy of Facial Plastic and Reconstructive Surgery has an         affiliation with the National Coalition Against Domestic  Violence whereby individuals who are victims of domestic violence, once  they've proceeded through a full program regiment of the rehabilitation,  are eligible for receiving pro-bono facial plastic surgery work for  some of the physical scars that they have acquired while in the abusive  relationship."
         
         

  "You said pro-bono, everybody knows pro-bono means that these physicians are doing it for free."
         
         

  "And  something that I found really good was we're talking about the leading,  top notch - yourself obviously included - facial plastic surgeons that  are doing this."
         
         

  "That's  absolutely right.  Patients have to have been screened by a social  worker and demonstrated a variety of criteria, for example, making sure  that they are out of the abusive relationship for
         quite some time, and when a woman has finally been able to  remove herself from that abusive relationship and she's back on her feet  and actively seeking care because, unfortunately, one of the reasons  why women remain in the abusive relationship is that they financially  cannot survive without the abuser so once they're secure financially..."
         
         

  "So  somebody tells them they'll get some training, they're going to get a  job, they'll get an apartment, and they get a new identity. If a woman  watches this on OBGYN.net or otohns.net and they know of somebody maybe  in their family, in their neighborhood, or even perhaps themselves,  where is the first place that they should contact to get involved in  having this help?"
         
         

  "They  should call the 800 number, and the 800 number is 842-4546.  They'll  then be contacted by either the National Coalition Against Domestic  Violence or a representatives of the         

 American Academy of Facial Plastic and Reconstructive         Surgery

  "Thank you very, very much. "
         
         

  "My pleasure, thank you."
         
         

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