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

Faculty:

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.

Read Disclaimer & Fine Print

SUMMARY:

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 

• Advantages include
  • Improved visualization and dexterity
  • Elimination of tremor
  • Improved ergonomics (e.g., including possible less neck, shoulder and back discomfort for surgeons)
• Limitations include
  • 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

Robot-Assisted Hysterectomy 

• 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
• Outcomes
  • 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

Robot-Assisted Myomectomy

• 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
  • Equivocal outcomes
  • 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
• Outcomes
  • 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 Sacrocolpopexy

• 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
• Outcomes
  • 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
  • Tubal ligation
  • Simple ovarian cystectomy
  • Surgical management of ectopic pregnancy
  • Bilateral salpingo-oophorectomy
  • Bilateral salpingectomy
  • 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

Learn More – Primary Sources:

ACOG Committee Opinion 810: Robot-Assisted Surgery for Noncancerous Gynecologic Conditions

Related ObG Topics:

Is There a Benefit to Robotic Teams for Minimally Invasive Sacrocolpopexy Surgeries?

Robotic Surgery and Informed Consent

Results from the LAROSE Study: Robotic Surgery vs Laparoscopy for Endometriosis

Pelvic Organ Prolapse: Uterosacral Ligament Suspension or Robotic Sacrocolpopexy?

Robotic vs Vaginal vs Open Surgery for Vaginal Prolapse – How Do They Compare?