In a nutshell, instead of a six-inch incision required by traditional surgery (or even the three to four smaller half-inch incisions utilized in standard laparoscopic surgery), SILS surgery is accomplished through a single small incision in the belly button.

The following operations can be performed by SILS:

• Removal of uterus (hysterectomy)
• Removal of ovary (oophorectomy)
• Removal of gallbladder (cholecystectomy)
• Removal of appendix (appendicectomy)
• Repair of paraumbilical or incisional hernia
• Diagnostic laparoscopy with biopsy

Beginning Sunday, May 19, each evening at 8 and 10 pm, you can view this very infomative segment. Health Talk is Norwalk Hospital’s TV show which broadcasts on Cablevision Local Programming Channel 84.

If you have questions about SILS or need more information, call my office at 203-855-3535.

Here at Garofalo Ob/Gyn, we’ve already had several patients ask about what this means to them, and whether they should undergo genetic screening for the BRCA1 mutation. We’ll do our best to answer some of these questions here.

What are BRCA1 (and BRCA2) genes?

Genes are molecular instructions that hold the information for the human body to build and pass along bodily characteristics such as blood type and eye color. When genes are improperly formed, it’s called a mutation. Mutations can occur during a lifetime or they can be hereditary — inherited from a parent.

Everyone has BRCA1 and BRCA2 genes. (The BR comes comes from “breast” and the CA comes from “cancer.”) In normal cells, these genes play a role in protecting the body against the development of cancer. But individuals with mutations in either of these genes have increased cancer risks, most notably for breast cancer and — for women — ovarian cancer.

What is BRCA testing and what does a positive result mean?

BRCA testing is a genetic blood test that checks the sequence of the BRCA1 and/or BRCA2 genes. It takes about three weeks to get results. A positive result means that the person has a genetic mutation that increases the risk of cancer. Specifically, a positive BRCA1 result for a woman can mean a 60%-80% lifetime risk of breast cancer and a 30%-45% lifetime risk of ovarian cancer. A positive BRCA2 result for a woman can mean a 50%-70% lifetime risk of breast cancer and a 10%-20% lifetime risk of ovarian cancer. For men, the mutation can mean a higher likelihood of prostate cancer, testicular cancer, pancreatic cancer and male breast cancer.

How much does BRCA testing cost?

BRCA testing is usually covered by insurance if certain criteria are met. For example, testing can be less expensive once a mutation has been identified within your family.

What can be done if I have the BRCA1 or BRCA2 mutation?

This is the kind of question that should be discussed with a genetic counselor. The answer may depend on many factors, including your age, health and family history. Since ovarian cancer screening tends to be unreliable, ovarian removal is recommended for BRCA1 and BRCA2 carriers, ideally between the ages of 35 and 40. On the other hand, regular breast screening is good at picking up breast cancers early, and it may be a reliable alternative to mastectomy.

Dr. Garofalo is very experienced in risk-reduction bilateral salpingo-oophorectomy (the surgical removal of both ovaries and the Fallopian tubes) for women who are BRCA1 or BRCA2 positive. This surgery can be done laparoscopically or with the da Vinci Surgical System, as an outpatient procedure with rapid recovery.

Do I need to be tested for BRCA1 and BRCA2?

Here at Garofalo Ob/Gyn, we can help determine whether if and when genetic testing is appropriate by exploring your personal and family history. For example, people of Ashkenazi Jewish ancestry are more likely than other groups to have the mutation, as are people with Norwegian, Dutch and Icelandic ancestry.

It’s important to remember that these mutations are relatively uncommon, and that not everyone with one of these mutations develops cancer. However, we encourage all of our patients to be aware of their health conditions and of the risks they may face.

If you have more questions about genetic mutations and cancer risk, just let us know.

About the practice

Laury Berwitt is a nurse practitioner specializing in women’s health in Fairfield County, Connecticut. Laury has a passion for providing quality women’s health care in a safe and comfortable manner by creating a trusting patient-practitioner relationship. She has been in practice for 10 years, caring for women of all ages.

Dr. John Garofalo, M.D., is a gynecologist located in Fairfield County, Connecticut. He has more than 20 years of practice and surgical experience covering many facets of obstetrics and gynecology.

For more information, go to www.garofaloobyn.com. John Garofalo, MD and Laury Berkwitt, APRN can be reached for personal consultations by calling 203.803.1098.

What is Nexplanon?

One option that’s becoming increasingly popular is a method called Nexplanon. Many of our patients choose Nexplanon because it is discreet, effective, long-acting and convenient. Nexplanon provides long-term, easily reversible contraception that remains effective as it steadily releases hormones over the course of three years.

Nexplanon comes in the form of a small, flexible plastic rod, about the same shape and size as a cardboard matchstick. This rod is placed just under the skin in the upper arm. This insertion is performed during a brief office procedure by a qualified nurse or physician.

Nexplanon’s progestin-only hormones work by preventing an egg from developing. They also thin the lining of the womb, making it hard for a fertilized egg to attach itself. It also thickens the mucus at the entrance of the womb, making entry more difficult for sperm.

Nexplanon was originally marketed under the brand name Implanon, but it was modified slightly — primarily to make insertion of the device easier — and it is now marketed as Nexplanon. Implanon and Nexplanon have been used in more than 30 countries, with more than 2.5 million devices prescribed.

How effective is Nexplanon?

With a success rate of more than 99%, Nexplanon is considered to be the most effective form of contraception currently available, mainly due to the fact that it doesn’t require you to do anything: Studies have shown that user-dependent methods such as birth control pills are 22 times as likely to be associated with unintended pregnancies as Nexplanon. There’s no remembering to take a pill every day or applying a patch or worrying about a vaginal device shifting or falling out of place. You simply have it inserted into your arm — usually a painless procedure — and forget about it for the next three years. After three years, the device can be removed and replaced, all in the same visit. Nexplanon costs between $400 and $800 and is covered by many insurance plans.

What are the side-effects of Nexplanon?

Other than slight, temporary bruising from the procedure, most women experience no negative side-effects from Nexplanon. As with other hormonal contraceptives, many women who have the implant find that their periods become lighter or less frequent. However, in one study about 15 percent of women discontinued use of Nexplanon due to unscheduled or increased bleeding. Other possible side-effects — all relatively uncommon — include headaches, acne, weight gain, breast tenderness, moodiness and abdominal pain. In these cases, or if you wish to become pregnant, Nexplanon can be easily removed. If not replaced by another hormonal contraceptive method, fertility tends to return within a few weeks.

Additional information on Nexplanon

If you think Nexplanon might be a good choice for you, give our office a call. We can provide additional information and help you decide if Nexplanon might be a good choice for your body and your lifestyle. In the meantime, more information on Nexplanon can be found on the Merck & Co. website, at www.nexplanon-usa.com/en/consumer/index.asp.

About the practice

Laury Berwitt is a nurse practitioner specializing in women’s health in Fairfield County, Connecticut. Laury has a passion for providing quality women’s health care in a safe and comfortable manner by creating a trusting patient-practitioner relationship. She has been in practice for 10 years, caring for women of all ages.

Dr. John Garofalo, M.D., is a gynecologist located in Fairfield County, Connecticut. He has more than 20 years of practice and surgical experience covering many facets of obstetrics and gynecology.

For more information, go to www.garofaloobyn.com. John Garofalo, MD and Laury Berkwitt, APRN can be reached for personal consultations by calling 203.803.1098.

Laury joins us after working in New York for the last 10 years where she managed the gynecological care for women of all ages.  Laury has extensive experience in providing routine well woman exams as well as managing and treating common gynecological complaints such as abnormal bleeding and vaginitis.   Laury graduated with a Bachelor of Science degree in nursing from The University of Vermont in 1999 and practiced as registered nurse in New York City for three years. She received her Master of Science degree in nursing from Columbia University in 2003. She will spend ample time with her patients helping them to find the best contraceptive method for their unique bodies and needs.  She also has a special interest in the care of adolescent women.  A woman’s first gynecological exam can be a daunting experience, but I am confident that Laury’s calm and nurturing demeanor will help put patients at ease.

Laury is available to see patients and can be reached at 203-855-3535

Many Thanks, John M. Garofalo, M.D.

Last month I went to a conference in Chicago that focused on an exciting new type of surgery — one that has the potential to reduce scarring and recovery times, along with other potential benefits. The conference was the 7th International NOTES® Summit, sponsored by the American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons.

What is NOTES?

Why is NOTES important?

• lower risk of infection
• less anesthesia required
• less pain
• lower risk of disability
• shorter hospital stays
• faster recovery time, and
• no visible scarring

Why isn’t NOTES used more?

While NOTES techniques have great potential, this is an area that is still in development, especially for more complicated procedures. Surgeons need training and new, flexible medical instruments must be developed. Computer-assisted 3-D imaging systems similar to those used in the da Vinci Surgical System must be created or refined to allow surgeons to see inside the patient’s body during procedures. In addition, research is being conducted to determine the best techniques for closing internal incisions and preventing infections.

Outlook for NOTES acceptance

Additional information on NOTES

What is SILS?

An acronym for single incision laparoscopic surgery, SILS made its way onto the medical scene in the late 1990s. You may have heard of by a different name: “belly button surgery”. SILS has risen to the forefront of abdominal surgery in recent years along with the development of related technology. While few physicians have received training so far, SILS is gradually catching on.

What are the advantages of SILS?

With SILS, only one umbilical incision is needed to perform the procedure. Using SILS technology, multiple instruments including the telescope can be placed through the incision. (In standard laparoscopy, the umbilical port is used only for observation through the “telescope”. In order to manipulate tissue and place sutures, standard laparoscopic techniques require the placement of two or three additional abdominal ports/incisions.) Compared to traditional port placement, SILS offers a lower risk of complications and additional postoperative pain.

How does SILS work?

Simply stated, SILS makes surgery less invasive. Instead of a six-inch incision required by traditional surgery (or even the three to four smaller half-inch incisions utilized in standard laparoscopic surgery), SILS surgery is accomplished through a single small incision in the belly button. A specially designed “SILS Port” instrument is then inserted into the abdomen. Soft and flexible, the SILS Port is equipped with three distinct openings which allows for the use of three surgical devices at the same time.

Which operations can be performed with SILS?

The following operations can be performed by SILS:

• Removal of uterus (hysterectomy)
• Removal of ovary (oophorectomy)
• Removal of gallbladder (cholecystectomy)
• Removal of appendix (appendicectomy)
• Repair of paraumbilical or incisional hernia
• Diagnostic laparoscopy with biopsy

As the technique and instrumentation are refined and developed, even more operations will be added to this list.

SILS for hysterectomies and oophorectomies

The SILS procedures I’ll be performing in the next few months will be primarily hysterectomies and oophorectomies. Hysterectomies typically fall into three categories — subtotal, total and radical — all of which can be performed using the SILS technique.

What are the benefits, risks and costs associated with SILS?

The potential benefits of SLS include less scarring, faster recovery and less pain. However, because SILS involves the use of specialized equipment, it is slightly more expensive than traditional laparoscopic surgery. Also, in 5% to 10% of cases, technical difficulties may prevent the operation’s safe completion via SILS. When this happens, I can simply add one or two ports and complete the procedure in the traditional laparoscopic manner. Very rarely, it may be necessary to convert to an open operation. Finally, there are the risks that are associated with the underlying procedure. These issues can all be discussed during your consultation.

Who can undergo SILS surgery?

Not all patients are candidates for the SILS approach. It depends on many factors, including:

• the size of your liver or gallbladder,
• your body mass index, and
• previous surgeries.

Additional information on SILS

More information on SILS can be found at www.sils.com.

Dr. John Garofalo, M.D., is a gynecologist located in Fairfield County, Connecticut. For more information on Dr. Garofalo and his medical practice, go to www.garofaloobyn.com. Dr. Garofalo can be reached for a personal consultation at 203.803.1098.

As a Connecticut ob/gyn for the past 20-plus years, I’ve seen a several trends develop. One of the most disappointing trends has been a widespread increase in the frequency of preterm births, or babies born before the 37^th week of pregnancy. Preterm births are closely associated with developmental disabilities, other complications and infant mortality during the first year after birth. Preterm births in the United States have increased by an estimated 36% since 1981, partly due to the increased use of assisted reproductive technology. In the United States and Europe, approximately 1 million “preemies” are born every year.

Good News for Preventing Preterm Births

With all of this in mind, I was encouraged to see a recent article in the February 2012 American Journal of Obstetrics & Gynecology (ACOG), which described a study that pooled the results of several independent tests around the world from the past few years — and found remarkably consistent results. The focus of the study was progesterone (a hormone involved in menstruation and pregnancy), and its relation to the cervix (the lower, narrow portion of the uterus where it joins with the top of the vagina). This ACOG article on preventing preterm births made several important points, including the following:

-       When a woman’s progesterone levels decline, labor often follows soon afterwards. When progesterone levels are low or if they decline early, preterm births often occur.

-       Low progesterone levels are associated with short cervical length.

-       The shorter the cervix and the earlier in pregnancy the short cervix is detected, the higher the risk of a preterm birth.

-       Vaginal application of progesterone to women with a cervical length of 10-20 millimeters can reduce the rate of preterm births (and related complications) before 33 weeks of pregnancy by 42% or more. There was also a significant reduction in the risk of preterm birth before 35, 34, and 28 weeks.

Ultrasound and Pregnancy

I was especially interested in these findings since a short cervix can be spotted during prenatal care visits using routine ultrasound tests. The authors of the study recommend ultrasound cervical measurement for women between 19 and 24 weeks of pregnancy to assess the risk of preterm delivery. In addition, vaginal progesterone is a less expensive and less invasive alternative than a common alternative treatment: placement of a cervical suture.

Most premature births occur in women with no risk factors, so the use of vaginal progesterone has the potential to significantly reduce the overall premature birth rate, as well as the wide variety of complications associated with premature birth, including cerebral palsy, respiratory distress, pneumonia, infection, anemia and jaundice.

In the words of American Journal of Obstetrics & Gynecology co-editor-in-chief Thomas J. Garite, M.D., these results “have the potential to result in a sea change in obstetrical practice in the U.S. and Europe and eventually in the rest of the world. Prematurity is the leading cause of death and damage for newly born babies and despite enormous efforts, no impact has been made in the rate of preterm birth, which is actually rising in recent years.”

Dr. John Garofalo, M.D., is a gynecologist located in Fairfield County, Connecticut. For more information on Dr. Garofalo and his medical practice, go to www.garofaloobyn.com. Dr. Garofalo can be reached for a personal consultation at 203.803.1098.

It’s important that you receive the GBS screening, because there is a risk of passing the bacteria to your baby during delivery. GBS can cause serious problems in a newborn, even death.

What GBS is and is not

Group B strep is not the same variety of strep that gives you strep throat. Also, GBS is not a sexually transmitted disease.

GBS is a common bacteria that usually does not cause infections in healthy adults. Some women develop a urinary tract infection or infection of the uterus, but few women ever know they have it. GBS doesn’t usually doesn’t come with symptoms.

How GBS is treated

To screen, the doctor will swab your vagina and rectum. The process is painless.

If you happen to have GBS, you will receive antibiotics during labor, not before. That’s because the bacteria can return shortly after an antibiotics treatment. While the bacteria will cause little harm to mom, it could cause great harm to the baby including lung infections, blood infections, and meningitis.

Late onset GBS

It is possible for your baby to acquire GBS after birth through contact with others. If your baby presents any of the following symptoms, talk to your doctor.

• Slowness or inactivity
• Irritability
• Poor feeding
• Vomiting
• High fever

This is one of several articles published as part of a series to discuss what moms-to-be can expect in Connecticut prenatal care from Dr. Garofalo. Check back regularly for more information.

Written by: Sara Lancaster

Creative Commons Image Attribution: Lady in waiting Project 365(2) Day 23 by Keith Williamson

Many of the appointments during the third trimester are routine appointments, which means your vital signs and fundal height will be taken but little else will be done. The exceptions to this are the diabetes screening already discussed here on the blog, the group B strep screening that we’ll discuss in our next blog post, and special fetal testing that you may need or want.

Why you might need special fetal testing

After 32 weeks of pregnancy the doctor will monitor you closely for potential problems, especially if you are at risk for delivering a stillborn baby or have any of the following problems:

• Blood disorders
• Thyroid disease
• Heart disease
• Lupus
• Kidney disease
• Diabetes
• High blood pressure
• Decreased fetal movement
• Too much or too little amniotic fluid
• Fetal growth problems
• Post-term pregnancy
• Multiple pregnancy, if there are complications

Types of special fetal testing

Most special fetal testing will check to see how active the baby is and how the baby is growing. The following is a brief overview of each test.

Fetal movement counts: This testing takes place at home and is up to you to complete. I will give you more specific instructions, but you’ll basically need to relax on your back for awhile and count the number of kicks/movements you feel. You should be able to count to 10 within two hours.

Nonstress test: Using electronic monitoring, we make an assessment of the baby’s health by comparing movements to heart rate.

Ultrasound: I often recommend an ultrasound to determine the size and position of the baby somewhere around 34 weeks of pregnancy. (Learn more about prenatal ultrasounds.)

Doppler ultrasound of the umbilical or other artery: This special ultrasound checks for blood flow and is done when the baby is at risk for anemia.

Biophysical profile (BPP):  Combining a nonstress test and ultrasound, the BPP assesses the health of the baby when you’ve gone past your due date or your baby is not growing the way I would like.

Contraction stress test: Not done often, the contraction stress test measures heart rate when the uterus contracts.

This is one of several articles published as part of a series to discuss what moms-to-be can expect in Connecticut prenatal care. Check back regularly for more information.

Creative Commons Image Attribution: Olga-12 by johnhope14