Robotic Surgery for Endometriosis

However, our bodies are amazingly adaptive!   I have noticed over time that other senses have come into play that compensate for the lack of ability to feel.  I have become more adept at noting how the tissue moves and the resistance it provides during retraction and dissection.

As a gynecologist with Fellowship training in advanced laparoscopy, “robotic surgery” was nowhere on my radar for the first 5 years of practice. Every surgery I currently perform robotically, I first learned with standard laparoscopy. Given that experience, I have always considered “the robot” as merely a surgical instrument.  Laser, Harmonic Scalpel, Ligasure are all instruments that various surgeons use to excise endometriosis. To me, robotic surgery falls in that same category.

I gained my first experience with robotic surgery 5 years into practice.  One local hospital jumped in and purchased a robotic system.  Over the next 9 years, I advanced my surgical practice to primarily robotic surgery. There are varied reasons that surgeons give for performing “robotic surgery” over standard laparoscopy.  I will share my own and try to pull in some of the things that we have looked at regarding robotics and endometriosis.

First and foremost, it is important to understand that robotic surgery IS laparoscopic or endoscopic surgery; surgery done by inserting a camera and instruments through small incisions to perform the same surgery that traditionally had been done through a larger, “open” incisions (laparotomy).  Except in rare cases, studies that compare outcomes of robotic surgery and standard laparoscopy show no difference in how patients do after surgery. In other words – they seem to be “equivalent” in most cases.

For many gynecologists, robotics has opened the door for them to learn a minimally invasive approach to a surgery they would have otherwise performed through laparotomy. For example, with hysterectomy, the benefits of laparoscopy are so well known that it is preferred over “open hysterectomy.” There are even some hospitals that won’t allow an open hysterectomy until it is reviewed for appropriateness.

For endometriosis, more and more surgeons are challenging themselves with excision because they feel more comfortable with the movement and function of the robotic system than with standard laparoscopy. Although full excision with laparoscopy can be learned, including suturing if necessary, the learning curve is much longer than it is with robotics. I have become primarily a “robotic surgeon.” Although many gynecologists discuss benefits that are pushed by the robotic companies, I have not found a significant difference in post-operative pain, “port site” trauma or pain, or blood loss. Also, after paying close attention to operative times and instrument cost both for myself and for a regional healthcare company, I have not seen a significant difference in instrument cost when comparing robotics and standard laparoscopy. With regard to operative time and cost, our hospital system showed slight improvements with robotic hysterectomy over laparoscopic. Again, this is looking at hysterectomy over a large number of surgeons operating at multiple hospitals. A cost-conscious robotic surgeon can actually get the instrument cost lower than what we see with some traditional laparoscopic surgeons.

There are some proclaimed benefits of laparoscopy over robotics such as the ability to feel the tissue one is grasping through the instrument.  This sensation is absent from the robotic surgeon.  However, our bodies are amazingly adaptive!   I have noticed over time that other senses have come into play that compensate for the lack of ability to feel.  I have become more adept at noting how the tissue moves and the resistance it provides during retraction and dissection.  Visualizing tissue planes and the ability of the robotic system to provide a 3D image are other adaptations.  The 3D view is a potential benefit that standard laparoscopy does not offer.  Just as there are ways a robotic surgeon can overcome the inability to feel tissue, laparoscopic surgeons also have techniques that allow their minds to picture 3D with a 2D view.

As we discuss robotic surgery and endometriosis, I would like to share my personal experience. Unfortunately, as the only advanced endometriosis surgeon in Utah, I did not have the luxury of bringing other surgeons “into the mix” when evaluating outcome data. Benefits of robotics that I noticed were mostly “selfish.” I noticed that my back, knees and hips did not hurt as they did with long days of standard laparoscopic surgery. Prior to robotics, I would have to wear compression stockings and still take ibuprofen and ice my knees when I got home after a day of surgery. I noticed less “mental fatigue” during long cases. I also noticed that I was more efficient during surgery. My operative times were faster. I suspect this is due to the fact that, with robotics, the surgeon can control 3-4 different surgical instruments. This means that instead of relying on an assistant to move and hold tissue a certain direction during excision, I can do all of that on my own.

Some laparoscopic surgeons have worked with the same assistant for so many years, that they proceed through the surgery with the same understanding. The assistant can predict what the surgeon will need next. I still found that I was able to move and retract tissue quicker and exactly as I wanted it when I did it myself. Over the time that I have been performing robotic surgery, I have also been able to get my surgical instrument costs below what most of my colleagues use with traditional laparoscopy.

As with most surgical procedures, most studies comparing robotics to standard laparoscopy show no difference in patient outcomes. In my mind, that makes complete sense, as they are essentially the same surgical approach, just different “tools.” Currently, my bottom line is that there are many approaches to performing good endometriosis excision surgery. There are some spectacular surgeons who operate with traditional laparoscopy. There are also some spectacular surgeons who operate robotically. We continue to look at best outcomes and practices. For now, the best for a patient is a surgeon who understands endo and knows how to remove it completely and safely – regardless of the technology or instrumentation that he or she uses.