Nerve-Sparing Surgery The Long-Range Benefits

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Have you heard about nerve-sparing surgery?

Although not a new concept, it was a little-known approach until recently. And as surgeons become increasingly skillful at preserving critical nerves during gynecologic and pelvic procedures, patients are realizing long-term benefits to their health and lifestyle.

For the past five years, my colleagues and I have taught the latest in nerve-sparing laparoscopic techniques. Our goal is to help our doctors understand the extensive network of tiny-but-critical nerves surrounding the tissue they are excising. We educate both fellows and residents on newer techniques in preserving these nerves, an approach that can benefit the patient in several ways.

The pelvic area is comprised of not one but a plexus of nerves. A successful nerve-sparing procedure is only possible when the surgeon is aware and knowledgeable not just of anatomy and of organ functions, but of how they interconnect.

Our goal is to bridge the gap between the basics that doctors learn in medical school or early residency and the finely tuned skills they can apply in the operating room today. And we work to help our patients understand the importance of this expertise as well.

Long-Term Effects of Conventional Approaches

Early in the 21^st century, doctors grew more and more skilled at laparoscopic procedures for hysterectomy and for excision of endometriosis. But at that time, the profession was focused mainly on the mechanics of performing these procedures and performing them well. In the course of surgery, doctors routinely dissected many tiny hair-like pelvic nerves, without realizing the potentially adverse, long-term effect on the patient.

Over time, it was found that some patients gradually had trouble with bladder or bowel control (loss of urine, difficulty voiding or constipation), or perhaps a gradual decline in overall sensitivity during sexual function. Such dysfunctions were often simply attributed to the natural aging process, rather than that earlier surgery where certain essential nerves were cut.

Hypogastric nerves, very inconspicuous, were frequently severed; today, we better comprehend how they innervate central pelvic organs—such as the bladder and rectum—and can also affect sexual sensitivity. We realize how crucial it is to avoid damaging adjoining nerves during hysterectomy procedures, or during vaginal-wall or bladder prolapse rectifications (a procedure in which the urogynecologist suspends the top of the vagina or the bladder so it doesn’t drop).

Today’s Advances

Here at MedStar Washington Hospital Center, we’re focused on minimally invasive laparoscopies that reduce the possibility of long-term side effects for the patient. We’re adept at protecting the large collection of pelvic nerves present in every patient, particularly during procedures where a good deal of dissection may be needed.

Our techniques, instrumentation, cameras and screens have evolved significantly in recent years. Armed with high-definition laparoscopic screens during surgery, we have an excellent view of tiny capillaries, even the red blood cells running through them, giving us the visibility needed to preserve them.

We concentrate not just on the procedure itself, but on precisely where to cut to spare these nerves. Perhaps this calls for a change in navigation during surgery: maybe we’ll choose a slightly different angle to achieve a better, safer level of dissection. And in a procedure like endometrial surgery, we can spare essential nerves even while completely excising areas of deep infiltration.

Tiny Incisions, Faster Recovery

Years ago, pelvic surgeries routinely required a large incision. Today, all the work is completed via tiny incisions, using a set of laparoscopic instruments.

In a nerve-sparing laparoscopic procedure, the surgeon inserts the camera into a small incision located within, or just adjacent to, the navel, depending on the patient’s anatomy and the surgical objective. The laparoscopic instruments are then inserted into two or three accessory 5-millimeter incisions, situated along the bikini line.

The camera gives us a clear view of the area to be treated and lets us place and manipulate the instruments to dissect the necessary tissue and control any bleeding at the surgical site.

Because nerve-sparing surgery calls for greater care and precision, it takes up to 15 minutes longer to perform than conventional surgery did. But those extra few minutes are time well spent when we consider the long-term wellness benefits to the bladder, bowel and sexual function.

After Surgery

For most of our patients, nerve-sparing laparoscopy is an outpatient surgery. If our patient is fully functional and can visit the bathroom, walk outside and climb stairs, we send her home the same day. The patient can then typically return to work and other normal activities in 7–14 days. Full healing occurs over about six weeks—much quicker than recovery from open surgery, which can take three months.

We perform 15–20 nerve-sparing procedures a month at the Hospital Center, and I’ve noticed that women’s long-term outcomes have been much better with this type of surgery. Five or six years after their procedure, they’re very happy, with no sign of that gradual decline in bowel or bladder function.

Our team is well equipped to review, recommend, and provide treatment for even complex cases. Patients can count on our expertise as one of the leading teams for nerve-sparing surgery in the mid-Atlantic region.