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Atlanta Woman

July 2005

Less Pain, More Gain

Several Atlanta physicians are leading the way making surgical procedures less invasive.

by Java Solis

Surgery without a scalpel? Atlanta area healthcare centers have the technology and the staff to make surgery with fewer or no incisions and less scarring a reality. Minimally-invasive surgeries promise patients shorter recovery times, fewer complications and improved quality of life. Such procedures are available for a wide range of health problems including brain tumors, heart and venous diseases, as well as uterine fibroids, hysterectomy and breast reconstruction. Technological advances in robotics, radiation, lasers and surgical techniques are revolutionizing treatment options for both patients and physicians.

Brain Surgery - No Knife, No Incision, No Scar

In October 2002 Catherine Burroughs took her dog for a walk, sent her husband an email and passed out in the kitchen. "I had a severe headache, and that's all I remember," she says. At the hospital, Burroughs was diagnosed with three arteriovenous malformations (AVMs), nests of abnormal blood vessels in the brain.

Although most people with AVMs do not experience symptoms, Burroughs was one of the few who face life-threatening complications, including brain hemorrhage. Burroughs' AVMs were inoperable, and she was instead treated at Piedmont Hospital with the Leksell Gamma Knife from Atlanta-based Elekta Instruments. The gamma knife, developed more than 35 years ago in Sweden, allows physicians to treat patients with both cancerous and noncancerous brain abnormalities without ever opening the skull. Focused radiation rays pass harmlessly through healthy tissue, reaching a targeted lesion. "The Gamma Knife allows us to pinpoint and specifically treat tumors in the brain," says Linda Wobeck, M.D., a radiation oncologist at Piedmont Hospital. "We don't have to treat the entire brain as with traditional procedures."

Patients receiving gamma knife surgery are first fitted with a head frame, which acts as a mechanical guiding device. The frame is screwed to the skull; however, most patients require only local anesthesia and a mild sedative during placement. The patient's head then is placed within a large helmet-like device with small openings known as collimator ports. Radiation beams are adjusted through these ports to direct the appropriate amount of energy at the target tissue. "I was awake during the procedure," says Burroughs. "I was in a drowsy state. I wasn't scared."

The technique is simple, quick and painless, with no scarring or disfigurement. Patients return home within 24 hours and are able to resume normal activities within a few days, avoiding the hospital stay and recovery time associated with more invasive brain surgery.

Specific risks and benefits of this procedure depend on the patient and the location and size of the target." In general, there is a short recovery after the head frame is removed, and patients are home the same afternoon.

Two years later, Burroughs calls her experience with the gamma knife "absolutely fabulous." Once a teacher of gifted children, Burroughs' neurological functioning was affected by her condition, leaving her unable to teach. Despite the lasting effects from her condition, Burroughs reports no negative experiences related to the procedure. "I would recommend it to others," she says. "It saved my life."

Hysterectomy Recovery in Days, Not Months

Approximately one in three women in the United States will undergo a hysterectomy by age 60. Traditional surgeries include a vertical or horizontal incision across the lower abdomen and are associated with recovery periods lasting nearly eight weeks. Minimally invasive procedures now offer women options that promise less scarring and shorter recovery times.

Colette Jones-Watts had experienced pain during intercourse and ovulation for more than 20 years. Multiple medications, as well as treatment for endometriosis and gall bladder disease had failed to control her pain and monthly breakthrough bleeding.

In 2004, when Jones-Watts was told she needed a hysterectomy, she was terrified. "Six years prior, my sister-in-law had a hysterectomy and on the fifth day, the day she was supposed to leave the hospital, she passed away," says Jones-Watts. She was also concerned about an extended absence from her job as a school and hospital speech pathologist.

Kevin Windom, M.D., a women's health specialist in the Atlanta area, calmed Jones-Watts' fears when he explained the minimally invasive procedure. Three incisions the size of a fingernail would be made in Jones-Watts' abdomen. A laparoscope, a small fiber optic instrument, would then allow Windom to guide the surgical procedure and remove her uterus vaginally.

Patients receiving minimally invasive hysterectomies experience quicker recoveries, fewer complications, less pain and less scarring. "I had my surgery on a Friday, I was walking around at home Saturday, and by Monday I felt great. I didn't need any pain pills and asked my doctor if I could go back to work," says Jones-Watts. "I don't have a scar and I don't have pain, It's important that women know there is another type of surgery option."

Shrinking Uterine Fibroids

Between 20% to 40% of all women over the age of 35 have uterine fibroids. Fibroids are more common in African American women than in women of any other racial group. These non-cancerous tumors may cause a range of symptoms including pelvic pain, increased menstrual cramping, irregular menstrual bleeding, backache, lower abdominal pressure, the need to urinate more frequently, constipation, abdominal bloating and infertility.

Traditional treatment of uterine fibroids may involve hormone therapy (see "The Raging Debate Over Your Hormones" on page 50 ) or invasive surgery, including the removal of individual fibroids (myomectomy) or the removal of the uterus (hysterectomy). Several Atlanta-area healthcare centers now offer uterine fibroid embolization (UFE), a noninvasive procedure to treat fibroids without the physical and emotional impact associated with hysterectomy and myomectomy. Sirini Tummala, M.D., of Vascular & Cosmetic Specialists asserts that UFE "offers women a treatment for symptomatic uterine fibroids that does not require major surgery, general anesthesia or a long recovery period."

UFE requires only light sedation and a quarter-inch groin incision. A catheter is inserted into an artery in the leg and tiny particles the size of grains of sand are released. The particles block the blood flow to the fibroids, causing them to shrink, while sparing healthy tissue.

"Patients can expect a greater than 90% improvement in their symptoms as well as about 66% reduction in the size of the fibroids within three to six months," says Tummala. In addition, the recurrence of treated fibroids is rare. Most patients are home the day after therapy and return to normal activities within three to five days. However, the procedure's long-term outcomes and its effect on future pregnancies and early menopause have not been determined by longterm studies. Thus, UFE is not blanketly recommended for all women with uterine fibroids.

Reducing Breast Surgery Scars

Breast surgery has long been associated with scarring, poor wound healing and unnatural breast shape. The SPAIR, the acronym for short-scar periareolar inferior pedicle reduction procedure, is a recently-developed technique that combines the favorable elements of well-established breast operations to limit scars and improve cosmetic results. SPAIR is used for breast reduction, breast lifts, breast lifts with augmentation and breast reconstruction after removal of the breast due to breast cancer (mastectomy). (See sidebar page 28)

Amy Ortega MD., of Aesthetic Specialists of Atlanta is one of only five surgeons in the United States trained by SPAIR-originator, Dennis Hammond, M.D. "After learning about the SPAIR approach, patients typically feel excited and empowered with new knowledge and expect better than average results, which they usually get," says Ortega.

With SPAIR, two short incisions are made around the colored part of the nipple (areola) and along the underside of the breast. Volume is removed from the upper portion of the breast and the remaining tissue is sculpted with internal sutures. The risks associated with SPAIR are similar to those associated with other breast surgeries and may include bleeding, infection, changes in sensation and scarring. SPAIR is applicable to breasts of all sizes and offers an aesthetic advantage with increased safety and consistent, long-lasting results. Complications that require surgical revision are rare.

Laser Treatment of Varicose Veins

Venous disease, which includes spider and varicose veins, affects approximately 80 million Americans. While spider and varicose veins cause cosmetic concerns for many women, they may also result in symptoms such as fatigue, leg pain, skin changes and ulcerations. In 2002, the U.S. Food and Drug Administration approved endovenous laser therapy for the treatment of varicose veins.

The most common underlying cause of varicose veins is a malfunction in a vein valve near the hip. Traditional treatments, including the injection of medications (sclerotherapy) and surgery, only address secondary causes. Endovenous laser therapy treats the underlying cause while helping patients avoid some of the risks associated with surgery, including general anesthesia, scarring and lengthy recovery.

Tummala is one of only a few Atlanta-area physicians offering endovenous laser therapy. "When I see clients with spider or varicose veins," says Tummala, "I test them with ultrasound to see if an abnormal one-way valve near the hip is the culprit, which is common. If it is, then I treat that first using laser as an outpatient with only local anesthesia."

During the 45-minute procedure, ultrasound allows the physician to guide laser components through a needle stick-sized hole in the skin, usually in the knee area. Laser pulses are used to collapse and seal the damaged vein. Patients are generally able to walk within 30 minutes of the treatment and can resume most normal activities immediately. Dr. Tummala estimates that 30% of his clients see improvement after the initial treatment.

Dr. Tummala has treated hundreds of patients with endovenous laser therapy and notes that risks are minimal and may include mild bruising and a temporary tingling along the inner thigh. "The outcomes, including length of procedure, risks, costs and appearance post therapy are all better than surgery," he states. "There is now a procedure that patients can afford and that is associated with less risk, no scarring and minimal recovery time."

Closed-chest Heart Surgery

In 2002, Saint Joseph's Hospital became the first healthcare center in Georgia to perform robotic-assisted, closed-chest heart surgery. This innovative da Vinci Surgical System, produced by Intuitive Surgical, Inc., Mountain View, Calif., involves less invasive treatments that reduce hospital stays, limit the risk of infection, enhance cosmetic results and improve overall patient satisfaction.

Saint Joseph's is the Southeast's exclusive da Vinci training center for the robotic system. "We have done more than 250 procedures with the da Vinci system with six cardiac surgeons trained for it," says Douglas Murphy, MD., a cardio-thoracic surgeon.

The robotic system allows traditional open-chest surgery to be accomplished without any incisions involving the ribs or breastbone. The surgeon accesses the heart through small puncture holes about the size of a pencil in the patient's chest. The surgeon guides robot arms, which hold surgical tools positioned inside the patient. "Outcomes have actually improved because we can see the heart so well," says Dr. Murphy. "The robotic instruments allow very precise work in tight, hard–to–get–to places." (For more details, see Atlanta Woman March 2005 "Secrets of a Woman's Heart" sidebar.)

This robotic system, first introduced in Europe in 1997, is considered as safe as traditional procedures. Patients receive fewer incisions and recover in days rather than weeks compared with traditional open-chest procedures.

The SPAIR Approach to Breast Reconstructive Surgery

Patients with breast cancer undergoing removal of the breast (mastectomy) and reconstruction can greatly benefit from the SPAIR approach, says Amy Ortega, M.D. To avoid the long scars associated with mastectomy, the plastic surgeon marks the patient for the general surgeon, who then removes the breast according to the SPAIR pattern. The plastic surgeon then reconstructs the breast by approaching the case as a cosmetic surgery. "Instead of the typical long scar across the chest with mastectomy, the patient has the same scar as a breast lift patient, which tends to heal nicely and not be obvious," says Dr. Ortega.

Patients with a strong family history of breast cancer who are considering the removal of the breast prior to the diagnosis of cancer (prophylactic mastectomy) need to be aware of SPAIR. "This is very important," says Dr. Ortega, as few people know this option is available, including many family physicians. "If there is no cancer, the plastic surgeon can often avoid removing the patient's nipple, which combined with a SPAIR approach can result in a reconstructed breast so natural looking that the patient may fool her primary care doctor."—J.S.

The Experts
PIEDMONT HOSPITAL: www.piedmonthospital.org
SAINT JOSEPH'S HOSPITAL: www.stjosephsatlanta.org
DR. SIRINI TUMMALA at Vascular & Cosmetic Specialists www.drtummala.com
DR. AMY Ortega at Aesthetic Specialists of Atlanta www.ASAbeautiful.com

Hysterectomy:
Information from the National Library of Medicine www.nlm.nih.gov/medlineplus/ency/article/002915.htm

The Treatment of Leg Veins:
The American College of Phlebology www.phlebology.org/brochure.htm