TECHNOLOGY
Is robotics practical for gynecologic surgery? And will laparoscopy become obsolete?
IN THIS ARTICLE
ROBOTICS IN GYNECOLOGY
Selected studies
- Bocca S, Stadtmauer L, Oehninger S. Uncomplicated fullterm pregnancy after da Vinci-assisted laparoscopic myomectomy. Reprod Biomed Online. 2007;14:246–249.
- Elliott DS, Chow GK, Gettman M. Current status of robotics in female urology and gynecology. World J Urol. 2006;24:188–192.
- Fiorentino RP, Zepeda MA, Goldstein BH, John CR, Rettenmaier MA. Pilot study assessing robotic laparoscopic hysterectomy and patient outcomes. J Minim Invasive Gynecol. 2006;13:60–63.
- Magrina JF. Robotic surgery in gynecology. Eur J Gynaecol Oncol. 2007;28:77–82.
NOTES takes “minimally invasive” to a new level
Imagine performing surgery for ectopic pregnancy or endometriosis in your office, without anesthesia. Think this is impossible? Think again!
A newer, perhaps better, and definitely less invasive version of endoscopic surgery is on the horizon—natural orifice transluminal endoscopic surgery, or NOTES. In May, a surgeon in Portland, Oregon, performed a cholecystectomy by dropping an endoscope through the patient’s mouth into the stomach, drilling an opening in the gastric wall, and placing small instruments through that opening to perform the surgery. The specimen was then pulled through the small opening in the stomach and retrieved through the patient’s mouth! The stomach was closed with an endoscopic stapling device.
NOTES appears to be the next true advance in minimally invasive surgery. This should come as no surprise to gynecologists. We are the champions of transcervical and transvaginal surgery. General surgeons and gastroenterologists are recognizing what we have long known—that operating through these natural orifices is less uncomfortable for the patient and provides faster, less complicated recovery. They are also recognizing the challenges involved in such an approach.
A new generation of instruments is in the works
Clearly, operating through the vagina, cervix, or stomach necessitates excellent visualization and instruments flexible enough to navigate through tiny openings but strong enough to transect and retrieve tissue. Many of our industry partners are working diligently to create and perfect new instrumentation for NOTES procedures, and research is under way at many centers in this country and overseas into transgastric and transrectal procedures.
Consider what we might be able to achieve with this technology! By eliminating the need for transabdominal access, we can vastly reduce the risk of intestinal and major vessel injury and eliminate the risk of hernia. We can also markedly reduce the discomfort associated with abdominal incisions.
How might this technology be applied in gynecology? I anticipate that ovarian pathology, endometriosis, and ectopic pregnancy will be managed transvaginally or via a small opening in the uterus. Transvaginal hydrolaparoscopy—in which warm saline is used as the distention medium instead of carbon dioxide, and access to the pelvis is achieved through a small culpotomy—has been around for many years but is limited by the rigid instrumentation and restricted visualization now available. With flexible instruments that can “see” around corners yet provide a wide visual field, microrobots that can be placed through a tiny opening and then deployed to accomplish the surgical task, and systems to achieve hemostasis, NOTES may be the next revolution in gynecologic surgery.
Still in a very early stage of development, natural orifice transluminal endoscopic surgery (NOTES) has generated considerable enthusiasm among physicians leading research and development efforts. Hoping to steer these efforts in a responsible direction—and avoid the problems encountered during the early days of laparoscopic surgery, when many inexperienced practitioners began adopting the technique prematurely—a working group from the American Society of Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons was formed in 2005, calling itself the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR). So far, this group has convened two international conferences and penned two white papers, noting that “the overwhelming sense [at the first international conference]…was that NOTES will develop into a mainstream clinical capability in the near future.”1
Some of the needs NOSCAR has identified are:
- determining the optimal technique and site to achieve access to the peritoneal cavity
- developing a gastric closure method that is 100% reliable
- reducing the risk of intraperitoneal contamination and infection, given the transgastric route that has dominated NOTES so far
- developing the ability to suture
- maintaining spatial orientation during surgery, as well as a multitasking platform that would allow manipulation of tissue, clear visualization, and safe access
- preventing intraperitoneal complications such as bleeding and bowel perforation
- exploring the physiology of pneumoperitoneum in the setting of NOTES
- establishing guidelines for training physicians and reporting both positive and negative outcomes.
In the meantime, NOSCAR recommends that all NOTES procedures in humans be approved by the Institutional Review Board and reported to a registry.
So far, the technology has been used to perform appendectomy and cholecystectomy in humans. Research grants totaling $1.5 million have been pledged by industry.
Reference
1. NOSCAR Working Group. NOTES: gathering momentum. White Paper. May 2006. Available at: https://www.noscar.org/documents/NOTES_White_Paper_May06.pdf. Accessed July 3, 2007.
