Robot-Assisted Surgery for Noncancerous Gynecologic Condition
Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Describe the benefits vs limitations of robot-assisted surgery for the management of noncancerous gynecologic conditions 2. Discuss the educational aspects regarding the training associated with the safe use of robot-assisted surgery
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from through , participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.25 contact hours.
Minimally invasive surgery is optimal for patients. It provides quicker recovery time, decreased length of stay, and better outcomes. Robot-assisted surgery, approved by the FDA in 2005, can offer improved visualization and ergonomics, especially with higher BMI patients, and is quickly becoming a part of the minimally invasive arsenal. ACOG and SGS have evaluated the platform and put forth recommendations and conclusions, including resources on independent robot-assisted courses for current physicians. ACOG recommends the following
Robot-assisted gynecologic surgery has outcomes equivalent to laparoscopy and improved compared to laparotomy
Selection of robot-assisted cases should be based on improved outcomes compared to other surgical approaches, with consideration to cost
Informed consent should include surgeon’s experience with robot-assisted surgery and potential risks and benefits compared with other surgical approaches
ACOG and SGS recommend a registry of robot-assisted gynecologic procedures and database to report adverse events
Vaginal hysterectomy is still the approach of choice whenever feasible
Benefits and Limitations
Improved visualization and dexterity
Elimination of tremor
Improved ergonomics (e.g., including possible less neck, shoulder and back discomfort for surgeons)
Lack of haptic (sense of touch) feedback
Non-standardized and variable training across residency programs and surgeons
Difficulty measuring cost-value due to the heterogeneity of various studies
Previous literature, comparing all modalities of hysterectomy, suggest that the robot-assisted cohorts, compared to laparotomy and vaginal cohorts, generally have
Higher rates of adhesive disease, morbid obesity, and larger uteri
Lower intraoperative complications and shorter hospital stays
Clinical outcomes are associated with surgical volume
Robot-assisted vs laparoscopic hysterectomies have equivocal outcomes for the following
Operation time | Post-operative recovery | Complications including vaginal cuff dehiscence
All myomectomy routes are safe with a well-trained surgeon
Robot-assisted vs laparotomy
Longer operative times
Lower rates of blood loss, transfusion, and length of hospital stays
Robot-assisted vs laparoscopic approach
Laparoscopy led to a 4.5 times increased risk of conversion to open approach in previous literature
Long term outcomes
Data limited, including fertility and myoma recurrences
Robot-Assisted Management of Endometriosis
Robot-assisted camera vs laparoscopy
Effective for resection of deep infiltrating endometriosis
Better detection of endometriosis lesions | Near-infrared technology can potentially identify any atypical endometriosis lesions
RCTs of robot-assisted vs laparoscopy have not shown differences for the following
Operative time | Blood loss | Complications | Quality of life at 6 weeks and 6 months
Robot-assisted vs abdominal approach studies have demonstrated
Decreased length of stay and 10% cost savings due to decreased costs of hospitalization day with lower complications rates
Laparoscopic versus robot-assisted sacrocolpopexy
No significant differences seen in anatomic and functional outcomes at 6 months to 1 year
Greater operating time and post-operative pain in the robotic group
Low-Complexity Gynecologic Procedures
ACOG and SGS recommend against the use of robot-assisted surgery for procedures that are of low complexity and short duration, such as
Simple ovarian cystectomy
Surgical management of ectopic pregnancy
Diagnostic laparoscopy or other surgeries when diagnosis is unknown
Learning Curve and Credentialing
Improved visualization and instrument control allow for a faster surgical curve compared to conventional laparoscopy
Improvements in surgical technique with robot-assisted devices are seen throughout the first 100 surgeries
Efficiency in surgical times is attained after 20 to 30 cases
Standardized curricula have been developed, but are not mandatory
Fundaments of Robotic Surgery
Robotic Training Network (robotictraining.org)
Currently, AAGL has developed guidelines for robot-assisted credentialing and privileging for hospitals | However, there is not yet a standardized credentialing process, but varies between institutions
Residencies should include a complete didactic educational program, such as
Approved online training modules
Hands-on training including docking, bedside assisting, and sitting at the console
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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