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