Master Class

Robotic Hysterectomy


 

Since the first published report of a robotic hysterectomy appeared in 2001, we have gained enough experience to know that next to vaginal hysterectomy, which I believe is still the preferred approach whenever possible, the robotic approach is the next-best technique that gynecologic surgeons can offer patients.

The robotic system we use today—the da Vinci surgical system—was designed to overcome the surgical limitations of conventional laparoscopy. Indeed, it has.

My colleagues and I at the Mayo Clinic, and others elsewhere, have seen similar operating times, reduced blood loss, and shorter hospitalization for both simple and radical hysterectomies as compared with the laparotomy approach. We have experienced firsthand the increased accuracy and precision that robotics promised. Suturing is easier with robotics than with laparoscopy. The advantages of robotics—from instrument articulation to the steady three-dimensional vision—have been more than expected, surpassing the advantages of conventional laparoscopy. Our operating time for robotic radical hysterectomy, in fact, is significantly shorter than that of laparoscopy.

The learning curve for performing robotic hysterectomy, moreover, seems surprisingly short. In a case-series analysis of robotic simple hysterectomies, we found it interesting that the time spent in the operating room flattened after 20-25 cases.

A prospective, randomized study comparing robotic hysterectomy with conventional laparoscopic surgery should be completed at the Mayo Clinic by the end of this year. In the meantime, robotic hysterectomy is generally offered to patients at Mayo as an alternative whenever a laparoscopic hysterectomy is being considered.

Patients are beginning to ask for it, and indeed, there are instances when we strongly prefer the robotic approach regardless of patient demand—for example, when patients have a history of adhesions, advanced endometriosis, gynecologic cancer, or genitourinary fistula, or when we have to perform pelvic floor repair procedures or other additional procedures that require extensive suturing. Obesity is an excellent application for robotic technology, which is something we have learned as our operating time has not been influenced by a patient's body mass index.

Evolution of Robotics

We started performing hysterectomies with the Zeus MicroWrist surgical system in 2003. The system, which was approved by the Food and Drug Administration in 2002 for general and laparoscopic surgery, enabled the surgeon to operate three robotic arms while sitting a distance away from the operating table.

This Zeus system was an advance over the Aesop robotic device, a voice-activated robotic arm designed to operate the laparoscope. Released in 1994, Aesop was the first robotic system approved to assist in laparoscopic procedures. With Aesop, the surgeon would direct the robotic movement of the laparoscope through voice commands while working manually with regular instruments. Video quality thus improved, and the need for an assistant was obviated when only two instruments were needed.

With the development of the Zeus system, surgeons gained two more robotic arms (in addition to the laparoscope-operating arm) as well as some of the other advantages afforded by robotics, such as articulating tips and a downscaling of movement.

The da Vinci surgical system that we use currently is an improvement over Zeus. It was originally approved for procedures in the abdominal and pelvic cavity, but in 2005 it received special approval for the performance of robotic hysterectomy. At this point, because of various changes in the industry's structure, it is the only robotic system manufactured for laparoscopic procedures.

In an evolution that reflects likely future changes as well, a second generation of the da Vinci system, released in 2006, has longer instruments, lighter arms, and increased flexion-extension and lateral excursion, among other improvements.

Instrumentation and Process

We now refer to the approach as “robotic” hysterectomy rather than “robotic-assisted” laparoscopic hysterectomy because—although a surgical assistant is still needed for several key functions, such as suction and irrigation—the procedure is, with these latest advancements, largely robotic in nature.

With most hysterectomies, as with most pelvic operations, four trocar sites are used: three for the robotic arms (one of which is for the laparoscope) and one for the assistant, who will manually perform suction, irrigation, vessel sealing, tissue retraction, and specimen retrieval. When we have a patient with cancer, obesity, a large uterus, advanced endometriosis, or adhesions, we add a fourth robotic arm. This additional arm allows for the added retraction of tissues.

We use the open Hasson technique to place a 12-mm robotic trocar (the first of the three main trocars) in the umbilical area for the laparoscope. Two 8-mm robotic trocars are then placed bilaterally, 10 cm to the right and left of the umbilicus. This placement provides an operative field that extends, in most patients, from the lower pelvis up to the inferior mesenteric artery.

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