Over its history, surgery has been defined by the tools available to practitioners. In our era, opportunities to offer patients minimally invasive surgery have expanded dramatically as methods of establishing visualization, achieving hemostasis, and performing tissue dissection have improved. (I remember trying to treat ectopic pregnancy laparoscopically in the early 1980s without benefit of a camera or suction irrigator!)
For surgeons of my generation, the ability to access the abdominal cavity minimally invasively and to clearly visualize the contents was a significant step forward. Hysteroscopic myomectomy was another tremendous incremental improvement for patients with submucous myomas. But there is much more in store for the coming years.
Where are we headed in the next wave of gynecologic surgery? Will patients require an incision at all? Is there room to advance beyond laparoscopy and hysteroscopy? What innovations will industry offer us in the 21st century?
In this article, I describe something that is fairly familiar to most of us by now, but which is not yet practical for routine gynecologic procedures—robotically assisted endoscopic surgery. I then move on to a phenomenon that, in many respects, is still being imagined—natural orifice transluminal endoscopic surgery, or NOTES.
Robotic systems are best suited for complex surgery
Laparoscopic surgery is limited by the two-dimensional view and need for hand control of long, rigid instruments through ancillary trocar sites. Although these impediments can be overcome with practice and experience, the inability to see in three dimensions and the compromised range of motion hamper optimal management of some surgical procedures.
A number of technological advances may significantly improve our ability to perform suture-intensive or anatomically challenging operations. Several companies are developing camera systems that will permit a three-dimensional view without the need for multiple visual ports. The technology is borrowed from the world of insects, which “see” through multiple lenses within the same eye. The application of such visual processing to optical systems for endoscopic surgery will be a huge advance for laparoscopy—one that is still being perfected by industry. In 2007, the da Vinci robot system (Intuitive Surgical) offers the best opportunity to achieve both three-dimensional visualization and an ability to “feel” tissue and manipulate instruments with markedly increased range of motion.
Cost is the limiting factor
Although the da Vinci system has revolutionized the practice of urology, enabling radical nerve-sparing prostatectomy, its utility in gynecology is still being investigated. Several centers use the robot for a significant percentage of their laparoscopic gynecologic surgery, but the setup time, learning curve, and intraoperative time required make the da Vinci system an impractical tool for many routine procedures. Its true advantage lies in suture-intensive procedures and in surgeries that require meticulous dissection close to major structures. In gynecology, the laparoscopic procedures most likely to benefit from the three-dimensional view and articulating instruments are sacral colpopexy, myomectomy (FIGURE), radical hysterectomy, and lymph node dissection.
Although it is interesting and enjoyable to use robotic technology for routine laparoscopic procedures, I believe the cost is prohibitive—several million dollars for each robot. If the financial barriers are removed, however, this system will be a welcome addition to the toolset for gynecologic laparoscopic surgery. Until then, we need to make intelligent use of this powerful tool.
FIGURE Robotic myomectomy
A: Using the da Vinci robot, the surgeon incises the myometrium down to the fibroid.
B: After grasping the fibroid, the surgeon dissects it away from the surrounding myometrium.
C: As the fibroid is freed, another small tumor becomes apparent at the bottom right, and is also removed.
D: The myometrium is sutured in layers after removal of the fibroids. Photos courtesy of Paul Indman, MD.Just as many of us were able to perform laparoscopic surgery without a three-chip camera and high-tech energy system for hemostasis until the cost of those technologies could be recouped in reduced operating room time and fewer conversions to laparotomy, so will today’s surgeons have to continue performing laparoscopic adnexal surgery, routine hysterectomy, and treatment of ectopic pregnancy the “old-fashioned” way. For complex procedures, however, the da Vinci system is proving to be a major advance in endoscopic surgery.
Look for other, perhaps less expensive, technologies coming down the road that will, at the very least, permit three-dimensional visualization without the need for robotics. In addition, as I discuss in the next section, miniaturization of robotics is on the horizon. Only our imagination limits our thinking about how robotic technology may be used in the not-too-distant future.