Robotic Surgery in Gynecology

learn how robotic surgery is performed in areas of gynecology and women's health from Dr. John R. Wooley
learn how robotic surgery is performed in areas of gynecology and women's health from Dr. John R. Wooley

What is robotic surgery?

Robotic surgery is a variant of minimally invasive laparoscopic surgery. The Da Vinci surgical system was approved by the FDA in 2005. Dr. Barbie Sullivan and I were two of the first gynecologists in this area to be trained in the use of the Da Vinci robot. After returning home from Houston Texas, where we had extensive hands-on training, my wife commented that she had not seen me that excited “since medical school”. The technology is amazing and there is potential for significant patient benefit.

Where did robotic surgery begin?

The robotic technology which preceded the Da Vinci robot started in the military. The Stanford Research Institute and the defense department developed the Da Vinci system so that surgeons sitting remotely from the battlefield could perform surgery on the wounded.

How does it work?

The Da Vinci robot is composed of 3 components: The surgeon’s console, the patient’s side cart with 4 robotic arms, and a high definition 3-dimensional vision system. Articulating surgical instruments are mounted on robotic arms, which are introduced into the body through laparoscopic cannula.

What are the advantages of this technology?

The advantages of robotic technology are smaller incisions, leading to lower morbidity, less postoperative pain, and shorter hospital stays. These advantages are similar to any minimally invasive laparoscopic surgery, however there are several specific advantages of robotic surgery. Robotics have an edge in complicated procedures where extensive dissection is required. The Endo wrist technology allows the laparoscopic instruments to move just as your hand would move allowing an edge in complicated procedures where extensive dissection and suturing is required. The dual camera optics allows for magnified zoom visibility and three-dimensional depth perception which offer a tremendous benefit. The precision offered by robot assisted surgeries also can result in less blood loss and lower risk of infection, all of which result in a faster return to normal activities.

How does this benefit the gynecology field?

Robotic surgery offers advantages to both Gynecological surgeons and their patients. Often utilized in performing laparoscopic hysterectomies, oophorectomies (removal of ovaries), myomectomies (removal of uterine fibroids) as well as complicated surgeries involving treatment of ovarian pathology, endometriosis, or extensive pelvic abdominal adhesions. It is also now utilized extensively in Gyn Oncology, Urology, and General surgery.

The inherent benefit of the Da Vinci robot (improved visibility, dexterity, and smaller incisions) along with the availability of preoperative regional nerve blocks, and the utilization of ERAS (enhanced recovery after surgery) protocols have all facilitated improved postoperative pain, earlier ambulation, and faster return of normal bladder and bowel function. The majority of patients are now able to go home the same day as their surgery, and most return to work in 2-3 weeks as compared to 4-6 weeks with open surgical approaches.

How long does the robotic surgery take vs. other approaches?

The operative time for Da Vinci robotic cases varies depending on the pathology present. A Robot assisted hysterectomy averages 1 1⁄2 to 2 1⁄2 hours which is roughly 20-70 minutes longer than other approaches. This disadvantage is definitely offset by the patient’s improved recovery.

Can anyone receive a robotic surgery?

Not all patients are good candidates for laparoscopic hysterectomies. There are cases where the volume and location of the pelvic pathology preclude a minimally invasive approach. There are cases where an open approach is the safer option.

Can you give an example of a past patient who received a robotic surgery?

An example of a recent high-risk case: 47-year-old with an 8 cm cystic pelvic mass. Past surgical history included an open laparotomy 15 years ago with multiple myomectomies (fibroids removed) through a midline vertical scar. Hospitalized for 3 days postop. Ten years ago, she underwent an abdominal hysterectomy for a very large (10 times normal size) fibroid uterus. This required the same open midline vertical incision. Patient was noted to have extensive pelvic abdominal adhesions at that time as well as endometriosis. She was hospitalized 4 days postop.

She recently underwent a Da Vinci robot assisted laparoscopic removal of both ovaries and removal of extensive pelvic and intraabdominal adhesions. She was discharged home 4 hours postoperatively with minimal pain, voiding and tolerating her diet.

Without the advantages offered by the Da Vinci robot she would have required another open procedure with a much more prolonged recovery.

In conclusion

As surgeons here at The Woman’s Clinic, there is nothing more rewarding than for us to have our patients do well postoperatively. Those difficult and complicated cases that we can accomplish through a minimally invasive approach are the most satisfying of all.

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