Singapore doctors remove 2 abnormal growths via single cut in rare surgery

With two abnormal growths in her body - a 2.5cm gallstone located near her right rib and a 9cm fibroid outside her womb - chemist Liou Sin Yi, 33, faced the prospect of undergoing surgery twice.

But in a rare operation here which lasted 3 1/2 hours, doctors removed both through one 2.5cm cut in her navel last December.

It saved her the hassle of undergoing surgery twice - each carrying its own risks related to anaesthesia use and infections.

It also meant that she was left with only a barely visible scar in the navel rather than two 10cm-long scars.

Traditionally, fibroids are removed through conventional surgery, which can leave a 10cm-long scar below the bikini line.

Alternatively, they can be removed using keyhole surgery, in which the surgeon makes three or four small cuts on the abdomen to allow medical instruments to be inserted.

Likewise, the surgical removal of the gall bladder and the gallstones within it can leave a 10cm-long scar below the right rib.

Ms Liou could have had the two-in-one operation through conventional keyhole surgery.

In this case, she would have four or five cuts on her abdomen, with one or two of them being 2cm each and the rest being 5mm each, said

Dr Anthony Siow, medical director of minimally invasive surgery at Parkway Gynaecology Screening & Treatment Centre at Gleneagles Hospital.

What she had instead was only one 2.5cm-long cut through the navel. The scar is expected to diminish over time.

Avoiding traditional open surgery

Ms Liou, who is single, discovered she had a fibroid at a routine screening in 2010.

Her doctor in Kuala Lumpur decided to monitor the 7cm-long, non-cancerous muscle growth sitting atop her womb.

Most fibroids do not cause problems and can be left untreated, unless they grow to an unwieldy size or give rise to symptoms.

Ms Liou had some symptoms, such as heavy menstruation, the need to urinate frequently and a nagging backache from the large growth, but, otherwise, the fibroid did not bother her much.

In May last year, her doctor found the fibroid had grown to 9cm and felt it was time to remove it.

Hoping to avoid traditional open surgery, she sought a second opinion from Dr Siow here last December.

Dr Siow offered to remove the fibroid, which was about the size of a grapefruit, through a single incision in the navel.

He deemed Ms Liou a suitable candidate for this single incision laparoscopy because of the location of her fibroid outside the womb and her weight.

Subserosal fibroids do not require cutting through too many muscles and the wound is easier to close with surgical tools, he said.

Also, as Ms Liou was obese, he would have more space to work within her abdominal cavity, which is usually pumped with carbon dioxide to inflate it, than he would with a skinny patient.

Surgery was scheduled for about two weeks later on Dec 27.

But three days after consulting Dr Siow, Ms Liou was kept awake at night by a sharp, stabbing pain in her stomach.

She was unsure of what it was due to, as she had been found to have a 2.5cm gallstone in 2004.

She also has been having occasional bouts of gastritis (inflammation of the stomach lining) since her schooldays.

Dr Quah Hak Mien, a colorectal surgeon at Gleneagles Medical Centre, estimated that a third of Singapore's population would have gallstones at some point in their lives.

Of these, only a minority would have symptoms and, hence, require surgery to remove the gall bladder and gallstones, he said.

Quicker recovery, smaller bill

Dr Siow suggested both the fibroid and the gall bladder be removed in the same operation, which he would do in tandem with Dr Quah.

With some encouragement from her parents, Ms Liou agreed.

In the first part of the surgery, lasting two hours, Dr Siow cut the large fibroid into 2cm-long strips, which were then removed through the navel.

The surgical team then repositioned the surgical apparatus for the second part, in which Dr Quah removed the gall bladder, located below the liver on the upper right side of the abdomen, through the same navel incision.

Dr Siow said a traditional open operation would have left Ms Liou with a vertical scar of 20 to 30cm, through which both growths could be removed.

A biopsy (test of sample of tissue) of the gall bladder after the surgery found that the gallstone had caused repeated inflammation to the gall bladder, known as chronic cholecystitis, leading to abdominal discomfort.

The total weight of her fibroid was found to be 340g.

Dr Siow said Ms Liou's surgical risk is no different from other types of surgery lasting three to four hours, such as that for gynaecological cancer or severe endometriosis (a condition in which cells that usually line the womb grow abnormally outside of it).

But rather than being put under general anaesthesia twice and staying in hospital twice, she had to recover from surgery only once.

Ms Liou could get out of bed and walk about two days after the operation.

For three days and two nights in a single room, together with surgery, her bill came up to more than $20,000, she said.

But she would have had to pay more for two separate operations.

A week after surgery, Ms Liou had pain which shot up from her abdomen to her right shoulder for about three days.

It was due to the remnant air and washing solution in the tummy irritating the diaphragm, a sheet of muscle that stretches across the bottom of the rib cage.

It causes a referred pain in the shoulder, which usually resolves on its own.

Ms Liou has no regrets.

She said: "Initially, I wanted to settle one thing at a time, but in hindsight, it's good to remove everything in one shot.

"I'm not bothered by the tiny scar in my navel now."

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