Confessions from the Operating Room

The most challenging surgical cases

Have you ever wondered what sorts of situations in the OR might be unnerving even for surgeons? Well, we thought it might be an interesting topic to explore, especially because it could help prospective patients learn more about the different types of surgical techniques and technologies that Dr. Nezhat uses to restore health in the safest way possible. And so, in this week’s post, we review the following two kinds of surgical obstacles that the majority of surgeons would admit could be among the most challenging to face:

1) Excessive Cesarean Scar Tissue, and;
2) Initial Entry into the Abdomen in Laparoscopic Surgery in Some Patients

The reason that these two surgical obstacles rank high on the list is because they could be associated with an increased risk for complications and accidental injuries in surgery. However, Dr. Nezhat has introduced several new surgical techniques and technologies that enable surgeons to, hopefully, help decrease or avoid the potential complications that may arise in cases of excessive scar tissue and blind initial entry during laparoscopic surgery.  An overview of Dr. Nezhat’s safer surgical procedures is listed below.

Excessive Cesarean Section Scar Tissue

Among all the anatomical difficulties that surgeons can face, excessive scar tissue (also called adhesions) is considered one of the most challenging because it could significantly increase the risk of surgical complications. And, of all types of scar tissue, the kind that develops in the abdomen after multiple Cesarean sections could be especially difficult to navigate, as it could encase essentially all of the abdominal organs and structures in a dense network of thick, vascular adhesions. With the anatomy so severely distorted and entrapped in scar tissue, surgeons could have tremendous difficulty safely visualizing and accessing the diseased organs or tissue that need to be repaired or removed.  As a result, the risk of serious injuries to blood vessels, nerves, bowel, ureters, ovaries, fallopian tubes, uterus, bladder, and other serious complications could be increased considerably in women with prior Cesarean sections or other multiple abdominal surgeries. For example, one study found that women with a history of Cesarean sections experienced 5 times more complications from hysterectomy than the control group without a history of Cesarean sections. Another study  estimated that Cesarean scar tissue increased the odds of patients sustaining a serious injury to their bladder to 7.5% during vaginally-assisted laparoscopic hysterectomy. Contrast this to cases where Cesarean scar tissue is not present, in which case the odds of bladder injury are significantly reduced to a range of about 1-2% for laparoscopic hysterectomies.

Another difficulty is that, in a surgical setting, scar tissue can look similar to normal structures, such as ligaments, blood vessels, and the ureters in particular. This means that, during surgery, surgeons could be in constant danger of mistaking healthy structures for the scar tissue that they’re trying to remove. For example, accidental injury of the ureters is a particularly serious complication that could be more common in those with Cesarean scar tissue. As well, the crucial ligaments that hold the uterus in place – the cardinal, broad, and round ligaments – are also vulnerable to injury because they may be encased in scar tissue. In such cases, surgeons usually try to restore normal anatomy by carefully cutting the scar tissue away from the healthy ligaments.  However, because scar tissue can look similar to scar-tissue encased ligaments, this makes it more likely that accidental injuries could occur. This is why it’s so important to seek out the most advanced and experienced surgeon possible, if you have had previous abdominal surgeries, including Cesarean sections, or have conditions that can cause excessive adhesions, such as endometriosis.

Likewise, some of the most critical blood vessels in the abdomen – the inferior vena cava, the right and left external iliac veins, the hypogastric artery, and the inferior mesenteric artery – are equally susceptible to injuries that could lead to serious complications. In Figure 1 below, you can see a clear image of these blood vessels as they normally should look in the abdomen of a healthy, adhesion-free patient. Contrast Figure 1 to Figure 2, which shows the same anatomical area, only with excessive adhesions which have severely distorted the anatomy into the infamous “frozen pelvis.”

All told, some surgeons may end up declining to operate on patients who have had multiple Cesarean sections or other abdominal surgeries. We believe it’s actually the absolute right thing to do, for surgeons with limited experience to refer more difficult cases to more seasoned surgeons. In fact, those with excessive scar tissue are the ones that other surgeons do refer to Dr. Nezhat, who is known the world over for his legendary ability to navigate through even the most completely scar tissue-encased abdomens.

Dr. Nezhat’s Safer Surgical Technique

To reduce all of the risks we’ve outlined above, Dr. Nezhat developed an entirely new and safer surgical technique specifically for a subset of patients with excessive Cesarean scar tissue who have elected to have a hysterectomy.

Why is Dr. Nezhat’s version safer?

In the traditional method of performing hysterectomy on patients with excessive Cesarean scar tissue in the abdomen, surgeons are taught to start the surgical procedure from the top of the patient’s uterus, which means starting from the top of the abdomen. (In surgery, the top of the patient is usually referred to as the superior position, and the back or bottom of the patient (toward the spine) is usually referred to as the inferior position).

The problem with attempting to perform surgery in this traditional, top-to-bottom (superior to inferior) approach is that the Cesarean scar tissue grows on top of the patient’s uterus and abdominal area, where it stands in the way, like an impenetrable fortress of fibrotic mesh,  blocking off the surgeon’s safe access and visibility to all the pelvic organs that lie underneath, such as the bladder for example. As a result, surgeons have been forced to go through the risky step of first disentangling all of the top layers of abdominal and uterine scar tissue before even starting the actual procedure. In this scenario, there could be substantial risk of causing serious injuries to the vital organs or structures that have been encased or otherwise obscured by all the tangles of scar tissue.

This old, traditional method of accessing the abdomen directly through C-section scars always struck Dr. Nezhat as unnecessarily risky! As a result, many years ago he developed an entirely new way to address these adhesions. Unlike the old method, Dr. Nezhat instead addresses all of the scar tissue that is at the top of the uterus, bladder, and abdomen, by accessing the abdominal organs from the side of the patient. Utilizing the side entry approach, the surgeon can access all abdominal organs from underneath the scar tissue, performing surgery from bottom to top (inferior to superior). In this way, all of the abdominal organs, blood vessels, and other vital structures can now be easily viewed and therefore more easily freed from any of the scar tissue which rests on top. Dr. Nezhat had been teaching and using this safer surgical method for many years. However, recently one of his colleagues noticed it for the first time and convinced him to publish about his experience, so that an even wider audience of surgeons could learn Dr. Nezhat’s techniques. The article is titled, ‘Reverse Vesicouterine Fold Dissection for Laparoscopic Hysterectomy After Prior Cesarean Deliveries”, and can be found in the September 2016 issue of the distinguished journal, Obstetrics and Gynecology.

Of course, developing this new surgical technique was not as easy as it sounds. The side entry access did call for identifying a new surgical plane or space within the abdominal area. Surgical planes or spaces are pockets of space inside of the body that act as a sort of anatomical landmark, lighthouse and staging area, all in one. These pockets may exist naturally or can be made artificially. The crucial aspect of a surgical space is that it must be a place where surgeons can insert and move their instruments in a safe way and at a safe distance from any blood vessels, vital organs, or other structures that could be inadvertently damaged.

For years, it was believed that all of the safe and useful surgical spaces in the abdomen had already been identified. In fact, with the exception of Dr. Nezhat’s own surgical textbooks and latest article on the subject, you won’t find any other anatomy books or medical literature which describes this previously overlooked surgical space. This is why Dr. Nezhat’s identification of this new anatomical landmark is considered an important contribution that will help reduce surgical complications and improve surgical outcomes. With the new landmark now identified, there is a clear roadmap for surgeons to follow, which will allow them to perform the new method of inferior to superior dissection so that excessive Cesarean scar tissue can be managed in a much safer way. You can see Dr. Nezhat’s new technique in this surgery video.