Robotic Gynecologic Surgery

Overview

Located at the University of Washington Medical Center, UW Medicine has the most advanced da Vinci robotic systems available in the Puget Sound area. Two new robots were purchased in the spring of 2010, including a two person robotic system so that two experienced surgeons can operate together to maximize patient out comes. In the Department of Obstetrics and Gynecology, there are four board certified gynecologic cancer surgeons and three gynecologists with advanced expertise in robotic gynecologic surgery.

The da Vinci robotic surgical system was first approved for use in gynecologic surgery by the U.S. Food and Drug Administration in 2005. Since that time, robotic technology has been applied to a wide variety of gynecologic surgery, particularly those that previously required open abdominal surgery. Gynecologic procedures that have increasingly been performed with robotic assistance include hysterectomy for fibroids, uterine cancer, and cervical cancer, myomectomy (removal of fibroid tumors from the uterus), lymph node removal in those with gynecologic cancers, and vaginal prolapse surgery (sacral colpopexy).

Gynecologic surgery can now be performed through several routes: vaginal, laparoscopy, robot-assisted laparoscopy, combination of laparoscopic and vaginal, and open abdominal approach. Currently, more than 60% of hysterectomies performed in the U.S. are via the abdominal route. Robot-assisted laparoscopic approach is potentially most beneficial and cost-effective when applied to surgical cases that would otherwise require open abdominal approach, but should not replace vaginal hysterectomy when this route is possible. The ultimate decision regarding the route and method of surgery depends on which is the safest for the patient’s underlying gynecologic condition, taking into account patient factors such as obesity, accessibility to the uterus, underlying medical conditions, and surgeon’s experience and surgical skill.

The daVinci robotic surgical system is composed of three parts:
  • Robot which is attached to ports in the patient’s abdominal wall and its robotic operative instruments extend into the patient’s pelvis. The robotic instruments are “wristed” at the ends which mimics the intricate movement of the human hand, allowing the surgeon greater dexterity and full range of motion.
  • Master console where the surgeon sits to operate using a combination of hand controls and foot pedals and is remote from the patient’s bedside. The console provides the surgeon with a high definition and 3-D view of the operative field.
  • Vision cart which holds a tower of electronic equipment.
The robotic surgeon must be skilled and experienced at performing the surgical procedure as the robot serves only as an extension of the surgeon’s hands. Additionally, a skilled assistant is required at the patient’s side to introduce different instruments and suture, manipulate pelvic organs, and keep the surgical field clear.

Effectiveness

Studies on benign gynecologic and gynecologic cancer surgery suggest that robotic-assisted surgery is associated with less wound complications, lung-related complications, faster return of bowel function, less bleeding, and clot formation compared to the open abdominal approach (laparotomy). Robotic surgery is comparable to laparoscopic surgery for blood loss, operative time, length of hospital stay, and surgical and postoperative complications. However the robotic approach often allows the surgeon to perform cases that they wouldn’t otherwise be able to do laparoscopically. Many otherwise abdominal surgeries can be converted to a laparoscopic approach using the robot giving the patient the associated benefits of a less invasive operation.

Some of the advantages of robot-assisted gynecologic surgery compared to open abdominal surgery:
  • Faster return to normal activities
  • Shorter duration of hospital stay
  • Lower blood loss during surgery
  • Less postoperative pain
  • Fewer wound complications such as infection
  • Improved cosmetic results (4-5 small incisions compared to 1 very large one)
  • High definition 3-D enhanced visualization enhances ability of surgeon to identify tissue planes, blood vessels, nerves, and other critical structures.

Risks

Intraoperative surgical risks associated with robotic approach is related primarily to the surgical procedure performed, the patient’s underlying gynecologic condition, and pre-existing medical conditions.
See Hysterectomy Risks

Some of the disadvantages of robot-assisted gynecologic surgery:
  • Cost associated with equipment, operating time, personnel training
  • Limited availability of da Vinci robotic system in some hospitals
  • Lack of tactile feedback for the surgeon
  • Limited number of robotic trained surgeons
  • Increased operative time and anesthesia with potential associated side effects