Robotic Hysterectomy
All of these findings—from reduced operating times to shorter hospitalizations and fewer complications—have applied to our experience with robotic radical hysterectomy as well. In one analysis of 16 patients undergoing robotic radical hysterectomy, we found that total operating time was 66 minutes shorter than it had been for laparoscopic radical hysterectomy.
An increased body mass index did not prolong operating times in any of our patient groups. In fact, we have noticed that for patients who are obese, surgical time is longer with laparoscopy than with robotics. This reflects one of the advantages of the robotic approach: It bypasses the fulcrum effect, which is inherent to conventional laparoscopy and which is especially challenging in patients with a thick abdominal wall. Surgeons using the articulated instrumentation of a robotic system will use the same manual effort regardless of how thick the abdominal wall is.
The lack of tactile feedback is viewed by some as a limitation of robotics, but after a short time of practice, it is easily compensated for by the depth of perception that three-dimensional vision affords.
In addition, the articulation of the instruments facilitates dissection of the tissues and suturing, such as closure of the vaginal cuff in hysterectomies. And as with other gynecologic surgeries, the downscaling of the surgeon's movements in a 3:1 or 5:1 ratio leads to increased accuracy and precision. (In such downscaling, when the surgeon's hand moves 3 cm or 5 cm, the tip of the instrument moves only 1 cm.)
We still believe that when the hysterectomy can be performed vaginally, the vaginal approach is preferable to robotics or to laparoscopy. This is because any study that has compared vaginal hysterectomy with another approach has demonstrated a faster operating time with the vaginal procedure, as well as lower cost.
When a patient is not a candidate for a vaginal hysterectomy, or when the gynecologist is not comfortable with the approach, however, then the robotic approach is indeed preferable to conventional laparoscopy.
Four robotic trocars are placed in preparation for pelvic surgery with the da Vinci robotic system.
The da Vinci robotic system is shown in operation, with the assistant sitting to the left of the patient.
The Zeus robotic system consists of two working arms and another to hold the laparoscope. Photos courtesy Dr. Javier Magrina
Robotics: Enabling Technology for the Gyn.
The first proponents of robotics in surgery were the cardiac surgeons, but it was the urologists who truly popularized robotic surgery. Hospitals around the country have purchased the da Vinci surgical system mainly for urologists who wanted to perform robot-assisted radical prostatectomies. Interestingly enough, the robot has enabled physicians who were virtually untrained in laparoscopic surgery to feel comfortable with a laparoscopic approach.
Even though gynecologists were the first surgical specialists to perform laparoscopic surgery on a routine basis, the acceptance of minimally invasive gynecologic surgery within our specialty remains dismally low. In a recent study submitted to the National Women's Health Resource Center by the Lewin Group, only 15% of more than 600,000 hysterectomies performed per annum in the United States are accomplished via a minimally invasive technique. This is especially sobering when one considers that 80% of the cholecystectomies are performed laparoscopically.
Given the above, it is interesting to speculate on the potential impact of robotic surgery in gynecology. Initially, it appears that gynecologists who were not previously performing advanced minimally invasive surgery are able to do so with this enabling technology.
I have put together a minisymposium on robotic surgery in gynecology that will be covered in the next four issues. With my esteemed faculty, I will discuss the topics of robotic-assisted laparoscopic hysterectomy, robotic-assisted laparoscopic myomectomy, robotic-assisted laparoscopic sacrocolpopexy, and robotic-assisted node dissection.
The first author is Dr. Javier Magrina, head of the division of gynecologic oncology, director of female pelvic medicine and reconstructive surgery, and professor of obstetrics and gynecology at the Mayo Clinic, Scottsdale, Ariz.
Dr. Magrina has written extensively and lectured throughout the world on robotic surgery, from a standpoint of both benign as well as malignant disease. For the past 2 years, he has served on the board of trustees of the AAGL and remains very active in the Society of Gynecologic Oncologists and the Society of Laparoendoscopic Surgeons.
It is a pleasure to have Dr. Magrina as the author of our Master Class in Gynecologic Surgery on robotic-assisted laparoscopic hysterectomy.
