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Guest Editorial JUNE 2007

Technologic Changes in Gynecologic Surgery: Can Too Much, Too Fast Be a Bad Thing?

Arnold P. Advincula, MD

Renowned historian Daniel J. Boorstin once said, “Technology is so much fun, but we can drown in our technology. The fog of information can drive out knowledge.”1 As OB/GYN surgeons practicing in the age of rapid technologic developments, are we “drowning”—in essence, unable to keep up? My own career, since I started as a resident in the mid-1990s, has been influenced by numerous advancements in gynecologic surgery. The impact of these changes can be seen in the way gynecologic pathology and procedures are now handled. Consider the example of dysfunctional uterine bleeding (DUB). During my residency I learned how to conservatively manage DUB medically with hormones, and surgically with conventional operative hysteroscopy (eg, rollerball ablation, loop electrode resection). Even before the end of my residency, though, second-generation technology arrived. The concept of global endometrial ablation was introduced with a system that utilized hot water in a balloon to destroy the endometrium. Now four additional devices have been approved by the US Food and Drug Administration that boil, freeze, microwave, or electrocauterize the endometrium.2 Is this an example of “too much”? How many methods do we need for destroying the endometrium?

Hysterectomy has also evolved in a short period of time. For years, the transabdominal and vaginal approaches were the mainstay of gynecologic surgery. Then the laparoscopic-assisted vaginal hysterectomy was introduced in the late 1980s, followed by the laparoscopic supracervical and total laparoscopic hysterectomy3-5—all made possible by advancements in minimally invasive surgery and laparoscopy. However, Farquhar and Steiner reported that only 10% of hysterectomies were performed via minimally invasive laparoscopy as of 2002.6 So despite the definite trend toward laparoscopic hysterectomy since the 1990s, hysterectomy via laparotomy remains the most common choice.

Why is laparotomy still the preferred route for hysterectomy? Technologic developments clearly permit safe removal of the uterus in a minimally invasive fashion, and the benefits over laparotomy are well known. This may be an example of an area where changes have occurred so fast that surgeons have not had the chance to catch up.

Multiple factors are hampering the ability to assimilate and process all of this new technology in surgery. The first and most logical to me is that residency training remains four years, despite the rapidly growing body of knowledge. In addition, there is the dominance of obstetrics in residency-training programs, a reduced volume of surgical cases in many institutions, 80-hour work week restrictions, and primary care requirements. It’s no wonder surgeons in training can’t keep up. Once out in the real world, there are also economic pressures, hospital credentialing/privileging guidelines, and learning curves to overcome. So where can the practicing gynecologist obtain further training on new surgical techniques? Is a weekend postgraduate course enough? Probably not. And although surgical fellowships exist (eg, gynecologic endoscopy), there are less than two dozen—not enough to meet the current need.

Today, technology is introduced so quickly that surgeons do not have enough time to properly evaluate it and determine its safety and efficacy prior to patient use. An example in the field of urogynecology is the application of various surgical mesh materials to correct stress urinary incontinence and pelvic organ prolapse. This area of surgical technology has exploded so rapidly that many materials have been used without proper clinical trials and long-term data, resulting in unnecessary complications such as mesh erosions and failures.7

These various hurdles raise many important issues and questions that should prompt us to re-examine our training processes and how to best assimilate technologic developments in surgery. We also need to remember to view technologic advancements with a healthy sense of skepticism, and not to be so quick to embrace them. Appropriate studies must be conducted prior to clinical implementation.

Over the past 100 years, the advancements in medicine and surgery have been astounding. Today, surgeons not only perform complex procedures with tiny endoscopic instruments, but even use computer-assisted devices and robots. Although much of this technology is industry-driven, it is the physicians who should have the final say about its use. We cannot avoid technologic change. The amount of technology and the speed of introduction will not decrease. As with computers—6 months after purchasing my laptop, companies were introducing faster processors and bigger hard drives. We must support forward progress while intermittently Àputting on the brakes” to slow things down so that we know where we are going, how to arrive there safely, and how to get the most out of technology for our patients.

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References

1. Daniel J Boorstin Quotes. Brainy Quote Web site.
   http://www.brainy quote.com/quotes/authors/d/ daniel_j_boorstin.html. Accessed May 14, 2007.
2. Morgan H, Advincula AP. Global endometrial ablation: a modern day solution to an age-old problem. Int J Gynaecol Obstet. 2006;94(2):156-166.
3. Reich H, Decaprio J, McGlynn F. Laparoscopic hysterectomy. J Gynecol Surg. 1989;5(2):213-216.
4. Donnez J, Nisolle M. Laparoscopic supracervical (subtotal) hysterectomy (LASH). J Gynecol Surg. 1993;9(2):91-94.
5. Reich H, McGlynn F, Sekel L. Total laparoscopic hysterectomy. Gynecol Endosc. 1993;2:59-63.
6. Farquhar CM, Steiner CA. Hysterectomy rates in the United States 1990-1997. Obstet Gynecol. 2002;99(2):229-234.
7. Huebner M, Hsu Y, Fenner DE. The use of graft materials in pelvic floor surgery. Int J Gynaecol Obstet. 2006;92(3):279-288.

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