Sunnybrook Magazine Sunnybrook Magazine – Fall 2017 Women's health

Keyhole surgery: a ‘game changer’ for complex gynecologic cases

gynecological surgery team

Sunnybrook’s gynecologic surgery team treats ‘last resort’ cases with minimally invasive surgery.

Having suffered from severe endometriosis since the age of 14, Ashley Adams-Jones held out little hope that the pain and fertility problems that plagued her would ever abate.

Numerous consultations with doctors led to various treatments, ranging from the removal of one of her fallopian tubes and an ovary to repeated operations to cauterize or burn some of the endometrial tissue twisted around her reproductive organs.

She even had her gallbladder taken out, with the suggestion that that would make things better. It didn’t.

“It was really just a cycle of pain,” recalls Ashley, now 30, who had become increasingly frustrated and was even turned away by hospitals unable to deal with the severity of the lifelong condition.

What made the difference, finally, was when she travelled in early 2015 from her home in Parry Sound, Ont., to Sunnybrook and participated in its gynecologic surgical program. There she underwent a laser procedure – via keyhole surgery, also known as laparoscopy, a type of minimally invasive surgery – in which the problematic endometrial tissue was removed via four tiny incisions in her abdomen under the direction of Dr. Jamie Kroft, one of Sunnybrook’s minimally invasive gynecology surgeons.

“Patients with endometriosis wait an average of nine to 10 years just to be diagnosed; then, it often takes even longer to receive adequate treatment,” says Dr. Kroft.

“It was a game changer”


“It was a game changer. I had pain relief almost immediately,” says Ashley. Even more important is that the treatment cleared the blockage caused by the disease in her remaining fallopian tube and ovary, allowing her to become pregnant with her third child, which she delivered in the nurturing and comforting environment at Sunnybrook.

“I couldn’t say enough about the care I got there. They had every resource that I needed.”

Sunnybrook uses minimally invasive surgical techniques for complex gynecologic problems such as stage 4 endometriosis, difficult hysterectomies, large fibroids, benign uterine masses, severe pelvic organ prolapse and bladder dysfunction.

The hospital’s gynecologic minimally invasive surgery program – one of only two in Canada accredited by the American Association of Gynecologic Laparoscopists – tends to some of the hardest-to-treat cases across the spectrum of reproductive health issues and at every age, ranging from women who are trying to conceive to those in menopause and postmenopause.

“We see a lot of ‘last-resort’ patients,” notes Dr. Patricia Lee, head of Sunnybrook’s Division of Gynecologic Surgery. She is a urogynecologist, a subspecialty that looks after women with bladder problems (such as urinary incontinence, voiding dysfunction), pelvic organ prolapse and other issues associated with weakness of the pelvic floor muscles.

Such conditions are common as women age and can seriously affect their enjoyment of life. Although, Dr. Lee points out, many aren’t quick to seek help. “A lot of people don’t want to talk about those ‘private-area’ issues. And they don’t know where to turn.”

The women’s health program at Sunnybrook offers such a place, with its 20-year history of laparoscopic procedures performed by an elite, cohesive team of gynecologists working alongside experts in related specialty fields such as urology and general surgery.

Mahjabeen Ali

Mahjabeen Ali, who had a long history of gynaecologic problems, was referred to Sunnybrook and treated for a benign mass and cyst with minimally invasive surgery. (Photo by Kevin Van Paassen).

Patients referred to Sunnybrook often have a lengthy history of previous gynecologic treatments and additional medical issues. Dr. Grace Liu, a specialist in minimally invasive management of endometriosis and large fibroids, notes that over the last several years, surgical cases are becoming increasingly difficult as medications improve and patients now opt for surgery only after medical therapy has failed. Previous surgeries can result in even more scarring and those with additional medical conditions, such as diabetes, cardiac conditions and obesity, can make intricate procedures even more complex.

“We are often the place where patients come after having been given multiple opinions that their surgery cannot be performed laparoscopically,” says Dr. Liu. The vast majority of such difficult cases are dealt with minimally invasively, with a strong emphasis on organ preservation.

Minimally invasive surgery offers the patient the benefit of a quicker recovery, reducing the pain, scarring and risks of complications compared with traditional open surgical procedures. It also decreases the associated health-care costs of surgery through less time in hospital.

“You’re in and out of the hospital on the same day,” says Mahjabeen Ali, 60, who, in March, underwent minimally invasive surgery by Dr. Rose Kung, one of Sunnybrook’s senior gynecologic surgeons, to remove a mass from one of her ovaries.

Mahjabeen has a long history of gynecologic issues. Years ago, she had difficulty conceiving and went through special procedures to have her two sons. This time, she put off seeing a doctor, ignoring months of lethargy that was uncharacteristic for her, as well as the ever-sharper pains in her abdomen.

“It became so excruciating that I threw up. I lived on painkillers for a while,” she remembers. Even worse, she worried all the time that she had cancer, but she still couldn’t bring herself to seek help. “We women go through so much and are often too scared to find out things.”

“They had every resource that I needed.”


Eventually, she went to her family physician and then had an ultrasound, which revealed the ovarian mass, as well as a cyst on the other ovary. Then, rather than wait almost two months for further testing at her local hospital, Mahjabeen was referred to Sunnybrook. A week after her first visit there, the keyhole surgery was performed to remove the cyst and the mass, which proved to be benign.

“They dealt with it right away,” she says. “It’s great to have it out. I feel better, I feel energetic.” She recalls too that for patients with what she calls “female problems,” the atmosphere at Sunnybrook is warm and personalized.

“They see how scared and sensitive you are, how shy you are about your body and that you want it covered…. The surgery team is fantastic and everything is explained to you,” says Mahjabeen.

Dr. Lee has heard this before. Minimally invasive surgical procedures can be “life-changing,” providing welcome relief for patients who’ve had conditions like debilitating pelvic pain or even urinary incontinence. “No one dies of a leaky bladder, but it has a significant impact on quality of life,” says Dr. Lee. “To be able to help somebody with that problem is amazing.”

For many women, getting help from the gynecologic surgical program at Sunnybrook also means an end to a long search for answers. “They get bounced around from doctor to doctor,” Dr. Kung points out. “But if they happen to land with someone who is knowledgeable, they may actually benefit from treatment.”

Also of note is how Sunnybrook is offering ambitious postgraduate programs to teach gynecologists across Ontario and beyond, including urogynecology and minimally invasive surgery fellowship training.

Dr. Kung was instrumental in establishing these training programs. In fact, Sunnybrook surgeons often get referrals from other University of Toronto teaching centres for cases that cannot be done there.

“We’re teaching the teachers,” Dr. Kung says. “There will be more access available to women in terms of minimally invasive surgery for complex gynecologic problems.”

The group of gynecologists at Sunnybrook are especially committed to minimally invasive surgical techniques, she reports, and they work as a team to allow for more complex and challenging laparoscopic procedures.

Ashley, for one, can’t praise enough the “very take-charge” surgical team that took care of her at Sunnybrook and their strong spirit of collaboration. For example, she recalls how, when complications in her urinary tract developed during surgery, a urologist came in right away. “They all really work together.”

Her rapid recovery and the significantly reduced pain following the surgery, as well as the fact that the incisions on her abdomen were so small, all made a big positive difference to her well-being. “I can’t even see my scars!” she says.

Ashley expects that the effort to control her endometriosis will continue into her menopausal years. Meanwhile, she notices that it really helps to stay fit and eat healthy, which keeps her hormones in check.

And she’s relieved after so many years of pain and worry to find there are effective, minimally invasive ways at Sunnybrook to treat her condition. She’s also grateful for the knowledge, expertise and sensitivity of the doctors she’s met there.

“It’s a comforting feeling, knowing you’re well taken care of and they know what they’re doing in this specialized area,” says Ashley.

The ‘unspoken problem down there’ for women

It’s a condition that affects half of all women who have had children. But while pelvic organ prolapse is common, no one openly talks about it, says urogynecologist Dr. Patricia Lee. With pelvic organ prolapse, organs such as the bladder, uterus and rectum “droop,” forming a bulge in the vagina and sometimes pushing right out of it.

“Pelvic organ prolapse is common because childbearing is common,” says Dr. Lee, noting too that there are surgical and non-surgical procedures to deal with this “unspoken problem,” so women with the condition should consult their physician.

The numbers:

  • 50% of women who have had children have some prolapse; 10–20% are symptomatic. Even if you have not had children, you could still be at risk.
  • 10–20% of women have a lifetime risk for surgery because of pelvic organ prolapse; 30% need repeat surgeries.
  • 5–7% of women develop prolapse of the top of the vagina, called the vaginal vault, after having a hysterectomy.

If you a have prolapse, you might notice these symptoms:

  • a bulge at the vaginal opening
  • a feeling of fullness or heaviness in your pelvic region
  • problems with urination or with bowel movements.

Non-surgical treatments:

  • A silicone rubber or plastic device, called a pessary, can be inserted in the vagina to support the uterus, bladder and rectum, so they don’t drop down.
  • Pelvic floor physiotherapy can help in exercising and strengthening the muscles and ligaments of the pelvis. There are also specific techniques to stimulate the