Robotic Surgery Case File
Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG
Case 5
A 35-year-old woman is noted to have severe menorrhagia over the past 2 years that is worsening and is associated with severe anemia. She has tried various medical therapies, including oral contraceptives and NSAIDs, which do not help. The patient has been diagnosed with uterine fibroids. She desires more children. On examination, her abdomen is normal with the exception of an irregularly shaped nontender uterus that is approximately 14-week size. She denies having previous surgeries. In counseling her, you review various surgical options. She has heard about robotic surgery and desires more information about this technique.
➤ What are your management options?
➤ What are the advantages and disadvantages of robotic surgery versus other techniques?
ANSWERS TO CASE 5:
Robotic Surgery
Summary: This is a 35-year-old woman with significant menorrhagia and anemia associated with uterine fibroids. Her symptoms have failed medical therapy. Her uterus is 14-week size.
➤ Management options: Myomectomy with options of open technique versus laparoscopy versus robotic surgery. She desires to preserve fertility; therefore, less invasive treatment should be at the top of the treatment plan list. Nonsurgical option, such as magnetic resonance–guided focused ultrasound (MRgFUS), is an option that must be considered, but few patients qualify as candidates. Normally, the procedure is reserved for premenopausal women who have completed childbearing1; therefore, myomectomy will provide the most benefit in this patient, with the laparoscopic approach providing faster recovery and similar pregnancy rates as the open approach.2
➤ Robotic surgery advantages:
- Less postoperative pain as compared to open laparotomy.
- Shorter hospitalizations.
- Better visualization (three-dimensional [3D] vision) versus open surgery and conventional laparoscopy.
- Improved dexterity and precision given the 3D visualization and replication of full range of motion of a surgeon’s hand.
- Reduction in surgeon’s fatigue.
- Decreased blood loss.
- Correction of tremor amplification.
- New concept in minimally invasive surgery (remotely performed surgery or telesurgery).
➤ Robotic surgery disadvantages:
- Expensive initial investment.
- Bulky equipment, therefore large-size ORs are required.
- Lack of haptics or tactile feedback.
- Limited uterine manipulation is less when compared with conventional laparoscopy.
ANALYSIS
Objectives
- Describe the advantages and disadvantages of robotic surgery versus laparoscopy and laparotomy.
- Describe the robotic manual dexterity capabilities.
- Describe the 3D visual capability of robotic surgery.
- Be aware of the limitations of robotic surgery.
Considerations
This 35-year-old woman with severe menorrhagia and anemia has failed medical management with oral control pills and NSAIDs. She has been diagnosed with uterine fibroids, and she desires future fertility. Therefore, procedures like endometrial ablation, uterine artery embolization, or hysterectomy are not options for treatment. Myomectomy is still considered the procedure of choice in women with severe symptoms due to fibroids who desire to preserve fertility. The aforementioned MRgFUS uses focused ultrasound directed into the substance of the large fibroid masses, leading to their degeneration. Unfortunately, many third-party carriers do not pay for this procedure, and many patients fail as candidates due to the nature, location, and size of the myomatous tumors. Management of the leiomyomas endoscopically is one of the major advances in minimally invasive gynecologic surgery, especially in a 35-year-old female patient with no previous abdominal surgery, although currently in the United States the majority of the cases are still performed using laparotomy.2.3
When comparing open myomectomy versus robotic approach, the robotic group had showed longer operative times and increased cost, but decreased blood loss and shorter length of stay.2 Also, comparison between conventional laparoscopy versus robotic myomectomy seems to raise some concerns about the level of difficulty encountered in order to enucleate fibroids and perform multilayer closure in the conventional group. Pregnancy rates after myomectomy are similar whether managed endoscopically (either conventional or robotic) or via laparotomy.2 Given these facts, usually the less invasive approach is indicated, especially in a 35-year-old patient with history of no previous surgeries.
APPROACH TO
Robotic Surgery
Surgical robotics were first used in 1985 in neurosurgery; applications soon followed in the fields of urology and orthopedics, but it was not until 1998 when the first robotic gynecologic surgery in a human patient was performed.4-6 Subsequently, the da Vinci Surgical System (Intuitive Surgical, Inc.,
Sunnyvale, California), the only system available in the market, received Food and Drug Administration (FDA) approval for gynecologic procedures in 2005, resulting in a steady increase in the number of surgical gynecologic procedures performed robotically (Figure 5–1). Multiple specialties in medicine
Figure 5–1. The da Vinci Surgical Robotic System. (Courtesy of Intuitive Surgical Inc.)
currently utilize robotics, and, in most centers, urologic surgeons are leading the way with radical prostatectomies.2 Other specialties such as general surgery, gynecology, cardiovascular surgery, orthopedics, and ENT (ear, nose, and throat) are rapidly incorporating robotics into their surgical procedures.
The applications of robotic surgery in gynecology are very broad, including benign gynecology (robotic-assisted hysterectomy, tubal anastomosis, myomectomy, sacrocolpopexy, oophorectomy, ovarian cystectomy, major lysis of adhesions and tuboplasty), gynecologic oncology (radical hysterectomy, lymph node dissections), and even obstetrics (robotic-assisted abdominal cerclage). Traditionally, robotic-assisted gynecologic procedures have been associated with longer OR times, secondary to the learning curve associated with new technology, but generally similar clinical outcomes when compared to open and conventional laparoscopy.7 This likely will not be an issue as more and more gynecologists receive training across the country. The main, widely agreed upon advantages of robotics in gynecologic procedures include decreased blood loss, shorter hospitalization time, improved surgeon’s dexterity, 3D vision, and precision.3,7-9
As of today, there is only one FDA-approved robotic surgical system, known as the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, California). This system basically consists of four components that are standard for all the available different models. These are the following: (1) Surgeon console which is essentially from where the surgeon operates. (2) Patient side cart that executes all the commands and movements performed by the surgeon that is achieved through four robotics arms, camera, and up to three EndoWrist instruments. (3) Vision system which is a high-resolution 3D endoscopic camera that provides the true-to-life 3D images of the operative field. (4) EndoWrist instrument (Figure 5–2) that attaches to the patient side cart and mimics the dexterity of the human hand and wrist. Besides all the aforementioned instruments, the operative assistant provides instrument exchanges, suction and irrigation, suture introduction and retrieval, and additional retraction.7
USE IN BENIGN GYNECOLOGY
Robotic-Assisted Hysterectomy
Vaginal hysterectomy continues to be the route of choice for benign pathology whenever technically possible, as morbidity appears to be lower than that of any other method.10 Hysterectomy by laparotomy remains the most common route in gynecology at the present day.11 As an alternative, endoscopic surgical approaches have made inroads into the laparotomy percentages and effectively decreased the number of open cases. Robotic laparoscopic technology appears to offer the surgeon a feasible method of surgery that allows for more difficult cases that otherwise may not be challenged by conventional laparoscopic techniques. Robotic surgeons speak of the increasing difficulty in
Figure 5–2. EndoWrist instrument allows for the reproduction of the human hand dexterity. (Courtesy of Intuitive Surgical Inc.)
certain cases being handled much more easily and precisely than with conventional laparoscopic technology.
Myomectomy
The majority of these procedures are performed by laparotomy because of the complexity encountered during enucleation and multilayer closure with confidence when approached by laparoscopy. Robotic closure allows for confidence in dissection as well as multilayer closure of the myoma bed.12,13 The EndoWrist instruments allow for the technical aspects of the procedure that only a few
Figure 5–2.
laparoscopic surgeons possess. Cost-benefit ratios remain to be seen regarding this approach when taking into account time away from regular activity.
Sacrocolpopexy
Robotic-assisted sacrocolpopexy (RAS) offers a reproducible, minimally invasive technique for vaginal vault prolapse with similar short-term durability compared with open sacrocolpopexies.7 RAS is associated with longer operative time but decreased blood loss and decreased hospital stay. The robotic approach does not rival those surgeons who are capable of performing this procedure by conventional laparoscopy, but it does introduce EndoWrist movement which can facilitate the procedure.
Tubal Anastomosis
When compared to conventional laparoscopy and minilaparotomy, roboticassisted tubal anastomosis appears to have similar success rate and shorter recovery time, but longer operative time and higher cost.14,15 Only few comparative studies have been done.
USE IN GYNECOLOGY ONCOLOGY
The use of robotics in gynecology oncology has been limited to basically two main procedures that involve staging of endometrial cancer and radical hysterectomy for cervical cancer. Other procedures that lack sufficient data include the staging of ovarian cancer and radical trachelectomy.
Staging of Endometrial Cancer
All literature available in this field seems to be very optimistic regarding the use of robotics in uterine cancer. When compared to laparoscopy or laparotomy, robotic-assisted hysterectomy for endometrial cancer staging yields similar outcomes such as lymph node retrieval, blood loss, and complication rates. Robotic outcomes are comparable to, or even better than, the other two surgical techniques.16,17 Robotic and conventional laparoscopic operative times are comparable and are slightly longer than open approaches.
Staging of Cervical Cancer/Radical Hysterectomy
Robotic-assisted radical hysterectomy has been shown to have shorter or similar operative times than laparotomy or conventional laparoscopy.18,19 Major advantages of robotics in this procedure are shorter hospitalization, decreased blood loss, and faster recovery to normal activities. Robotic laparoscopic surgery applies to a very broad scope of applicability, and more and more gynecologic surgeons seem to be incorporating robotics in their practices.20,21 Although there is not a national consent about the development and training of this innovative technology, it is definitely here to stay.
Comprehension Questions
5.1 A 50-year-old woman has a history of menorrhagia refractory to medical treatment. She has been diagnosed with uterine polyps by hysteroscopy. Her endometrial biopsy is negative for malignancy. She requests a hysterectomy with salpingo-oophorectomy. Her past surgical history includes three prior cesarean sections, an appendectomy secondary to ruptured appendix, and an exploratory laparoscopy for the evaluation of chronic pelvic pain. The pelvic examination reveals a large 14-week-size uterus, which is fixed and not very mobile and somewhat tender. Which of the following would be the best surgical approach for this patient?
A. Vaginal hysterectomy with bilateral salpingo-oophorectomy
B. Laparoscopic-assisted vaginal hysterectomy with sacrocolpopexy
C. Total abdominal hysterectomy with bilateral salpingo-oophorectomy
D. Robotic-assisted supracervical hysterectomy
5.2 With regard to robotic-assisted gynecologic procedures, which of the following statements is true?
A. As compared to the open technique, robotic-assisted myomectomy has better outcomes.
B. Robotic-assisted radical hysterectomy for early stages of cervical cancer has the same operative time as open procedure and shorter times than conventional laparoscopy.
C. Robotic-assisted sacrocolpopexy has better outcomes and less blood loss than open sacrocolpopexy.
D. When adhesive disease is suspected in a patient, laparoscopic approach is preferred over robotic.
5.3 Which of the following statements is most accurate?
A. Robotic machinery is more precise than conventional laparoscopy because of the bulkiness and initial investment.
B. If vaginal hysterectomy is feasible, this approach should be offered first rather than robotics.
C. Robotic-assisted sacrocolpopexy has longer operative time than laparoscopy sacrocolpopexy.
D. Disadvantages to the robotic technology include the lack of the option of morcellation.
ANSWERS
5.1 C. Total abdominal hysterectomy with bilateral salpingo-oophorectomy would be the safest choice in this patient, given her extensive past surgical history that includes possible endometriosis and extensive postoperative adhesions. Laparoscopic-assisted vaginal hysterectomy could be considered, except for the fact that this patient has an enlarged uterus which would be less likely to be amenable to vaginal approach; sacrocolpopexy is not indicated in this patient. Roboticassisted supracervical hysterectomy would be a substandard treatment since the patient desires total hysterectomy that includes cervix, tubes, and ovaries.
5.2 B. Data available today suggest that robotic-assisted radical hysterectomy for early cervical cancer stages has similar operative times as the open approach and shorter operative times than conventional laparoscopy. Considering that this procedure is minimally invasive, faster recovery and less blood loss are major advantages. Option A robotic myomectomy has similar short-term outcomes when compared to open approach. Option C robotic-assisted sacrocolpopexy has similar outcomes when compared to open and also less blood loss. Finally, when postoperative or postinflammatory adhesions are suspected, option D, that is, the use of robotics, would be a better option, given the improved dexterity, precision, and improved visualization (3D).
5.3 B. Whenever technically feasible and medically appropriate, patients requiring hysterectomy should be offered the vaginal approach because morbidity appears to be lower than any other method.12
Clinical Pearls
See Table 1-2 for definition of level of evidence and strength of recommendation
➤ Robotic sacrocolpopexy has demonstrated similar short-term vaginal vault support compared with abdominal sacrocolpopexy, although with longer operative time, less blood loss, and shorter length of stay (Level B).
➤ Vaginal hysterectomy has the lower morbidity than any other method (Level A).
➤ Some advantages of robotic technology over conventional laparoscopy are better dexterity, precision, and 3D imaging (Level C).
REFERENCES
1. Stewart EA, Gedroyc WM, Regan L, et al. Focused ultrasound treatment of uterine fibroid tumors: safety and feasibility of a noninvasive thermoablative technique. Am J Obstet Gynecol. 2003;189:48.
2. Mohamed N, Akl MD, Javier Magrina MD. Will robots transform gynecologic surgery? Contemporary Ob/Gyn. 2009 Sep;54(9):26-32.
3. Senapati S, Advincula AP. Surgical techniques: robot-assisted laparoscopic myomectomy with the Da Vinci surgical system. J Robotic Surg. 2007;1:69-74.
4. Dharia SP, Falcone T. Robotics in reproductive medicine. Fertil Steril. 2005;84:1.
5. Satava RM. Robotic surgery: from the past to future- a personal journey. Surg Clin North Am. 2003;83:1491.
6. Falcone T, Goldberg J, Garcia-Ruiz A, et al. Full robotic assistance for laparoscopic tubal anastomosis: a case report. J Laparoendosc Adv Surg Tech A. 1999;9:107.
7. Anthony G, Visco MD, Arnold Advincula MD. Robotic gynecologic surgery. Obstet Gynecol. 2008 Dec;112(6):1369-1384.
8. Reynolds RK, Advincula AP. Robot assisted laparoscopic hysterectomy: technique and initial experience. Am J Surg. 2006;191:555-560.
9. Elizabeth J, Geller MD, Nazema Y, et al. Short term outcomes of robotic sacrocolpopexy compared with abdominal sacrocolpopexy. Obstet Gynecol. 2008 Dec;112(6):1201-1213.
10. American College of Obstetricians and Gynecologists, et al. Appropriate use of laparoscopically assisted vaginal hysterectomy. ACOG Committee Opinion No. 311. April 2005. Obstet Gynecol. 2005;105:929-930.
11. Wu JM, Wechter ME, Geller EJ, Nguyen TV, Visco AG. Hysterectomy rates in the United States, 2003. Obstet Gynecol. 2007;110:1091-1095.
12. Advincula AP, Song A. The role of robotic surgery in gynecology. Curr Opin Obstet Gynecol. 2007;19:331-336.
13. Manyonda I, Sinthamoney E, Belli AM. Controversies and challenges in the modern management of uterine fibroids. BJOG. 2004;111:95-102.
14. Goldberg JM, Falcone T. Laparoscopic microsurgical tubal anastomosis with and without robotic assistance. Hum Reprod. 2003;18:145.
15. Dharia Patel SP, Steinkampf MP, Whitten SJ, Malizia BA. Robotic tubal anastomosis: surgical technique and cost effectiveness. Fertil Steril. 2008;90:1175.
16. Veljovich DS, Paley PJ, Drescher CW, et al. Robotic surgery in gynecology oncology: program initiation and outcomes after the first year with comparison with laparotomy for endometrial cancer staging. Am J Obstet Gynecol. 2008;198:679.
17. Boggess JF, Gehrig PA, Cantrell L, et al. A comparative study of 3 surgical methods for hysterectomy with staging for endometrial cancer: robotic assistance, laparoscopy, laparotomy. Am J Obstet Gynecol. 2008;199:360.
18. Sert B, Abeler V. Robotic radical hysterectomy in early stage cervical carcinoma patients, comparing results with total laparoscopic radical hysterectomy cases. The future is now? Int J Med Robot. 2007;3:224.
19. Boggess JF, Gehrig PA, Cantrell L, et al. A case control study of robot-assisted type III radical hysterectomy with pelvic lymph node dissection compared with open radical hysterectomy. Am J Obstet Gynecol. 2008;199:357.
20. Nezhat C, Lavie O, Hsu S, Watson J, Barnett O, Lemyre M. Robotic-assisted laparoscopic myomectomy compared with standard laparoscopic myomectomy— a retrospective matched control study. Fertil Steril. 2009 Feb;91(2):556-559.
21. Magrina JF, Kho RM, Weaver AL, Montero RP, Magtibay PM. Robotic radical hysterectomy: comparison with laparoscopy and laparotomy. Gynecol Oncol. 2008;109:86-91.
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