Robotics in Reconstructive Pelvic Surgery

What is Robotic Surgery?

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Robotic surgery is a variation of conventional laparoscopic surgery in which the surgeon uses a computer to control the surgical instruments. It is an incredibly impressive & elegant tool. The FDA approved the “DaVinci” robot made by Intuitive Surgical for use in gynecologic surgery in 2005 .

Conventional, or “straight stick,” non-robotic laparoscopy has been performed for decades in many surgical specialties for procedures such as removing the gallbladder or appendix, & performing a hysterectomy or cancer surgery. In laparoscopy, a lighted thin telescope is placed through a small incision, usually around the belly button, & a camera is attached to it to display the inside of the abdomen on a video monitor.  Some smaller incisions  may be made above or below this to use other surgical instruments. The advantages of using a laparoscope to avoid making a large abdominal incision are numerous & well-established. There is less pain, less time in the hospital, & a much quicker recovery & return to your usual activities. A skilled laparoscopic surgeon may be able to perform the surgery with fewer complications, less blood loss, & less time.  The down side is that laparoscopic surgery may be more difficult for many surgeons to learn, particularly if advanced skills such as being able to suture & tie knots are involved.

In robotic surgery the surgeon places the laparoscopic instruments in the usual way, & then a robot with several arms is “docked,” or attached, to the camera & instruments in the other incisions. The surgeon sits in a console away from the  patient looking at a screen,  controls the camera & instruments  attached to the robot using his/her hands & feet, & communicates to the surgical team using a microphone. Assistants at the table may change the instruments attached to the robot during the surgery.

What are the advantages of robotic surgery?

Like regular  laparoscopy, the main potential advantage of using a robot in gynecologic surgery is to  to avoid a large abdominal incision (“laparotomy”). There is no question that avoiding an abdominal incision has many advantages as outlined above. By avoiding the usual large  incisions, robotic surgery has revolutionized the surgery for many types of cancer & thoracic surgery.

Using the robot can make the surgery easier for the surgeon. The surgeon is able to sit during the surgery & does not have to wear a surgical gown. In the future, the surgeon may be able to perform the surgery from a remote location bringing these services to rural or combat situations. Some surgeons with limited skills suturing laparoscopically are able to do that using the robot. It is much easier for the surgeon to sew & tie sutures using a robot due to the mechanical dexterity of the instruments. The view is much better as well as it is essentially 3D & much easier to remain orientated & manipulate objects compared to the 2D display of regular laparoscopy.

The advances & proliferation of  laparoscopic surgery have led to the development of Minimally Invasive Gynecologic Surgery (MIGS) as a new subspecialty. Most gynecologic surgeons perform minimally invasive procedures on a regular basis. Surgeons who complete additional training in MIGS have developed advanced surgical skills, including the use of robotic surgery. Our newest partner, Dr Megan Daws is the only surgeon in our region who has completed a fellowship in MIGS, & she is a certified instructor to teach other surgeons how to perform robotic surgery.

One of the major benefits of robotic in gynecologic surgery is the treatment of uterine fibroids when the uterus is so enlarged that it may may not be possible to perform the procedure using conventional laparoscopy. The robot allows the surgeon more manual dexterity to remove the fibroids without making a large incision. Similarly, the robot can allow the surgeon to perform a hysterectomy in a woman with an enlarged uterus that would be very difficult if not impossible to remove safely vaginally. Other areas in which the robot provides major advantages is in treating women with advanced endometriosis or other conditions where scarring can distort pelvic anatomy.

What are the disadvantages of robotic surgery?

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Unfortunately, like many new technologies, the companies that make these devices have been very aggressive in their marketing trying to get surgeons to use them for procedures where they are not needed. Hospitals are often pressured  to get robots to remain competitive with neighboring hospitals. Surgeons  may feel pressured to use the robot to remain “cutting edge” & competitive with other surgeons in the area who promote themselves as robotic surgery “experts.”  Each robot costs around 2 million dollars & maintenance is about $150,000 per year.

There is considerable debate in the gynecologic surgical community right now about the appropriate use robotically-assisted surgery. To read the president of the American College of Obstetricians & Gynecologists comments about robotic gynecologic surgery click here. Due to increasing complications the state of Massachusetts medical board just released an advisory to hospitals regarding robotic surgery.

While robotic surgery is no more inherently dangerous in gynecologic surgery than conventional laparoscopy, there have been an increase in complications which were rare with conventional laparoscopy. This includes the upper vagina  rupturing (“dehiscence”) after hysterectomy, which can be life-threatening.

The problem is that while the robot can make some surgeries easier to perform than conventional laparoscope,  the robot does not make a surgeon skilled. Some surgeons get hospital privileges to perform robotic surgery buy paying thousands of dollars to the company which makes the robot to attend a short learning course. If they are inexperienced in advanced laparoscopy they will most likely have more complications. As you can predict in our current litiginous medicolegal society, numerous lawsuits have sprung up from patients who have had problems following  robotic surgery. “Robotic injury attorneys,” like “vaginal mesh” attorneys, have proliferated as the surgery has become more prevalent. More surgery = more complications. Every surgeon knows that no surgery is without potential complications, & many of the complications of robotic surgery are possible with conventional surgery. It is unclear who will be held responsible for poor outcomes: the surgeon? the hospital which allows an inexperienced surgeon to operate? the company that pushes the robot to perform the procedure? the FDA for allowing it on the market? Time will tell.

What About Using the Robot for  Vaginal Prolapse Surgery?

The robot is  used in the area of Urogynecology  mainly for performing procedures which support the upper vagina. This surgery is called a vaginal vault suspension. One of the most effective procedures is an abdominal sacral colpopexy which restores normal vaginal support by attaching a mesh to the upper vagina & attaching the mesh to the bone over the sacrum. This is a very strong & safe procedure with decades of studies showing that it works. To read more about this surgery, see here.  Like many other studies outside of gynecology comparing the use of the robot to conventional laparoscopy, studies have shown that robotic sacral colpopexies take a lot longer (up to 2 or 3 times), are much more expensive (at least $2000), & provide no benefits to the patient in terms of discomfort, blood loss, hospital stay, or recovery. Some studies have shown that patients have more pain after robotic surgery.

Performing a sacral colpopexy with conventional laparoscopy requires advanced surgical skills. Given the large number of women who are referred to us from other doctors, we perform this procedure frequently, usually 2 or 3 times a week. In the last year, we have performed 99% of our sacral colpopexies laparoscopically. Depending largely on the presence of scar tissue in the pelvis, it  usually takes us between 1 & 2 hours to complete the surgery, which is about the same or faster than it used to take to perform the surgery using a large abdominal incision. Studies of robotic sacral colpopexies have operating times in the 4 to 8 hour range, 2 to 3 times that  of a conventional laparoscopic colpopexy. As a technology, the robot is very cool. In this day of increasing health care expenses, we feel that we need to be financially responsible & not use devices that increase expense with improving outcomes. From a patient outcome perspective, however, it has no benefits, takes a lot more time, & is way too expensive. If future technology advances show that the robot is safer, improves our patients outcomes, & is cost-effective, we will consider using it. It would be nice to sit down.

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