Robot-Assisted Surgery for Noncancerous Gynecologic Condition

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