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Laparoscopic Surgery: Robotic Surgery Techniques

Laparoscopic Surgery: Robotic Surgery Techniques

Traditional open gynecologic surgery using a large incision for access to the uterus and surrounding anatomy has for many years been the standard approach to many gynecologic procedures. Yet, with open surgery can come significant pain, trauma, a long recovery process, risk of adhesions, risk of incision breakdown, and threat to surrounding organs and nerves. For women facing gynecologic surgery, the period of pain, discomfort, and extended time away from normal daily activities that usually follows traditional surgery can understandably cause significant anxiety.

Fortunately, less invasive options are available. Some gynecologic procedures enable surgeons to access the target anatomy using a vaginal approach, which may not require an external incision. But for complex hysterectomies and other gynecologic procedures, a laparoscopic approach or robot-assisted surgery may be the most effective, least invasive treatment option.

Figure 1:  Surgeon at console

da Vinci laparoscopic surgery

Laparoscopic surgery has some limitations that are further overcome by the robotic approach. Some of the limitations of laparoscopy are reduced depth perception of the operative field caused by the use of 2D monitors; poor hand-eye coordination as a result of location of the monitor, variable amplification, mirrored movement, and misorientation; motion limitations due to trocar-induced invariant points, and reduced haptic feedback from the use of long and slender surgical instruments. Through tiny, 1-2 cm incisions, surgeons using robotic surgery (da Vinci Surgical System) can operate with greater precision and control using 180-degree hand movements, minimizing the pain and risk associated with large incisions while increasing the likelihood of a fast recovery and excellent clinical outcomes.

A wide variety of benign (noncancerous) conditions may affect a woman’s reproductive system, which consists of the uterus, vagina, ovaries, and fallopian tubes. Most of these conditions affect the uterus. Common types of gynecologic conditions, such as fibroids (noncancerous growths in the uterine wall), endometriosis (noncancerous growths of the uterine lining), or prolapse (falling or slipping of the uterus), can cause chronic pain and heavy bleeding as well as other disabling symptoms. When medication and other treatments are unable to relieve symptoms, hysterectomy—the surgical removal of the uterus—is often recommended to provide a more effective, definitive, long-term solution. In fact, this procedure is the second-most common surgical procedure for women in the United States, and an estimated one third of all US women will have a hysterectomy by age 60 years.

Figure 2a and 2b: Robotic instruments at work inside the patient abdomen

laparoscopic-myoma

robotic-laparoscopy

Robotic surgery is an emerging technology that is taking the surgical profession by storm. This article briefly lists gynecologic procedures applicable to robotics as well as some contraindications, tips for using the device in practice, and a short overview of training.

Gynecologic procedures applicable to robotics include:

Hysterectomy (total and subtotal)
     Simple and complex (pelvic adhesive disease, endometriosis, fibroids)
Cancer Staging (cervical and endometrial)
Reproductive Surgery
     Myomectomy
     Endometriosis resection
     Ovarian cystectomy or transposition
     Tubal reversal or reanastomosis
     Muellerian anomalies
Urogynecologic Surgery
     Sacrocolpopexy
     Uterosacral suspension

Benefits of Robotic Surgery

•Three-dimensional viewing for optimum viewing within the operative site.
•Seven degrees of instrument movements allowing the surgeon to reach difficult spaces.
•Ninety degrees of articulation making movements easier.
•Intuitive movements and ergonomics providing increased precision, control, and range of microinstruments.
•Tremor filtration, thus decreasing error.
•Comfortable seating for surgeon, thereby increasing surgeon longevity.
•Robotics minimizes need for multiple assistants due to improved access to and manipulation of organs, tissues, and nerves.
• Telesurgery and telementoring making remote surgery a possibility

When to Avoid Robotic Surgery

Physicians should avoid using robotic surgery in the following instances:

• If the patient has a medical condition such as cardiopulmonary disease, where risks of general anesthesia or the increased intraperitoneal pressure associated with laparoscopy or robotic surgery is unacceptable.
• If morcellation is likely to be required and uterine malignancy is known or suspected.
• If Trendellenberg positioning is dangerous or unacceptable for a particular patient.
• In circumstances where anatomy is so distorted that a minimally invasive approach is not deemed safe.
• If adequate training is not acquired by providers or trained providers are not present or accessible. Surgeons without the requisite training and skills required for the safe performance of such procedures should enlist the aid of colleagues who do or should refer patients to such individuals for their surgical care (see AAGL position statement).
• If the patient must not be in a fixed position for a given length of time.

One of the disadvantages to robotic surgery is that it is a new technology and therefore its uses and efficacy have not yet been well established. To date, mostly studies of feasibility have been conducted, and almost no long-term follow-up studies have been performed. Many procedures will also have to be redesigned to optimize the use of robotic arms and to increase efficiency.

Another disadvantage of these systems is their cost. With a price tag of a million dollars, the robotic device cost may be nearly prohibitive for some hospitals. Another question remains as to the status of upgrades and how often? As they gain widespread multidisciplinary use, these questions may become easier to answer.

The size of these systems is another potential drawback, with large footprints and relatively cumbersome robotic arms. One of the potential disadvantages identified is a lack of compatible instruments and equipment, which is being addressed slowly. Most of the disadvantages identified will be remedied with time and improvements in technology.

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