An operative hysteroscopy uses instruments that have tools attached--cutting or cauterizing devices, or lasers to cut off polyps or fibroids that cause the bleeding. After Swendiman had drifted into unconsciousness under general anesthesia, Fields inserted a resecto-scope. The television monitor showed a pink fibroid--a benign tumor common in premenopausal women--with a surface gorged with red vessels oozing blood into the uterus. Watching the monitor, Fields squeezed a trigger on the resecto-scope, releasing a tiny half-loop that appeared from beneath the camera's lens. He maneuvered the loop and applied an electric current to cut away part of the tumor that was the source of most of the bleeding. As he cut, bits and pieces of tumor disappeared from the TV screen, flushed away by a liquid that was continually pumped into the uterus. Forty-five minutes after entering the operating room, Swendiman was taken to a recovery room. In another 30 minutes, she dressed and went home.
"I had no problems with it at all," Swendiman said later. "I appreciated the quickness. I wanted to go home. I was up and about the next day."
In the past, if the D and C hadn't worked, Swendiman probably would have had a hysterectomy. With hysteroscopic technology now available, doctors estimate that 20% to 30% of this country's annual 500,000 hysterectomies, each of which requires four or five days of hospitalization and four to six weeks recovery at home, will become unnecessary.
"Often, physicians take out a uterus before a woman gets a chance to bear children," says Ana Murphy, a reproductive endocrinologist at the UC San Diego School of Medicine. "The problem may be as simple as a few polyps, and a lot of them can be removed through hysteroscopy and not hysterectomies."
Many outpatient procedures are more borrowed than new. Gynecologists and ear, nose and throat surgeons--who have been doing sinus endoscopies for about three years--adapted the endoscope from urologists. General surgeons, in turn, borrowed the laparoscope--essentially, an endoscope that is inserted surgically into the abdomen--from gynecologists.
Outpatient surgery is also being fueled by new developments in anesthesia. With some knee and shoulder operations, for example, post-operative pain is so intense for a day or two that patients must remain in the hospital simply so nurses can administer medication that can be given only intravenously or by injection, and can monitor such side effects as respiratory problems.
But with new drugs such as propofol, patients recover in 30 to 40 minutes instead of in five to 12 hours. And some patients can administer the drugs themselves at home, using a Walkman-size pump attached intravenously (although most must employ a nurse for a couple of days). Anesthesia is automatically delivered through the i.v. line in predetermined time increments. Patients have the option of self-injecting extra pre-measured medication between scheduled dosages, but cannot give themselves an overdose.
"This isn't suitable for everybody," says Houston anesthesiologist Carl Battaglia, president of the Federated Ambulatory Surgery Assn. and medical director of the Texas Outpatient Surgicare Center. "The person has to be responsible and have a responsible person at home the first 24 hours."
Outpatient surgery isn't for everyone, either. People who are over 60 years old, who have an acute infection of the diseased organ to be removed or other medical problems will have their surgery in a hospital, Reddick says. "And there's always a subset (of people) who simply don't want to be treated as outpatients," he adds.
There is also the problem of availability. Although outpatient surgery is popular, it is most common in cities where surgeons develop and perfect specific procedures. Reddick is so experienced at laparoscopic cholecystectomies that he's turned it into an outpatient procedure; 50% to 60% of his patients go home the day of surgery. Although surgeons in San Francisco and Los Angeles are doing the operation, they don't have Reddick's experience and thus choose to perform the surgery in a hospital.
Another problem is proper training. Many of the new gynecological procedures and the training for them emanate from Phoenix, where Loffer was one of the first to use the resectoscope, the half-loop cutting tool that Fields used on Swendiman; the YAG laser, used to stop bleeding by cauterizing endometrial tissue, and the "roller ball"--a small device that looks like a BB shot held between two wires--that also cauterizes endometrial tissue by delivering an electrical current as a surgeon rolls it across the uterine wall. Loffer has taught more than 500 doctors how to do laparoscopies.