■ Robotic surgery reduces blood loss, decreases length of hospital stay, decreases postoperative pain, and improves recovery time.
■ Robotic surgery is particularly useful in gynecologic surgery because of the limited space within the pelvic cavity.
■ The versatility of robotic instruments has expanded the range of gynecologic conditions amenable to minimally invasive surgery.
■ The cost of setting up and maintaining robotic surgical systems can be prohibitive.
■ Studies that evaluate long-term outcomes of robotic surgery are needed to further validate the place of robots in the OR.
Over the past two decades, minimally invasive surgery has progressed beyond all expectations. Many operations that used to require laparotomy are now routinely performed using laparoscopic techniques. Appendectomies, cholecystectomies, and even hysterectomies are done through keyhole-size incisions that are aesthetically pleasing to the patient and less costly in terms of postoperative pain, length of hospital stay, and blood loss. Conventional laparoscopic surgery, however, is not without its limitations. Difficulties such as tremor amplification, reverse fulcrum, and loss of dexterity create problems for the surgeon, limiting the potential of the laparoscope.1 Fortunately, with the help of robotic technology, many of these problems can be overcome. With names that conjure up images of the great works of Italian masters, robots are challenging surgeons to learn the art and the science of a new type of surgery. Robotic technology is revolutionizing minimally invasive surgery.
HISTORY OF ROBOTIC SURGERY
Robotic surgery was first conceived as a way to facilitate surgery performed on military personnel injured in the field. The intent was to enable surgeons to operate remotely, reducing the risk to the surgeon and increasing the speed of delivery of potentially lifesaving treatment to the patient. With the development of a remote console (surgeon control center), a patient side cart (engages robotic arms), and a vision cart (camera display), surgery that did not require the surgeon to lay hands on the patient became possible. As robotic capabilities became more sophisticated, robotic surgery moved away from the battlefield and directly into the OR. Although many robotic models have been developed over the years, currently the only FDA-approved robotic platform is the da Vinci Surgical System. The da Vinci platform was approved for use in urology in 2000 and then for gynecology in 2005.2 This article focuses primarily on the application of robotic technology to gynecology, given the tremendous potential of robot-assisted laparoscopic surgery in this field.
INCREASED FLEXIBILITY AND PRECISION
IN GYNECOLOGIC SURGERY
Robotic surgery is particularly useful in gynecologic surgery because of its flexibility within the limited space of the pelvic cavity. Traditional laparoscopic instruments are awkward to maneuver in the tight confines of the pelvis. This difficulty
is compounded by other problems associated with conventional laparoscopy including the following: reverse fulcrum (counterintuitive movements), tremor amplification, ergonomic challenges, and tissue visualization that is only two-
dimensional (2D). Robotic platforms overcome many of these problems. The surgeon moves the robotic arms and cameras using hand controls and foot pedals. Movements of robotic instruments mimic those of the surgeon's hands, eliminating the reverse fulcrum effect. Previously, operators needed to move their hands in the opposite direction of the one they desired, but robotics allow surgeons to move their hands in the direction they want the instruments to move. This feature improves precision and control, facilitating procedures on very delicate tissues.3
The EndoWrist instrument tip of the da Vinci robotic system moves in multiple directions, offering the operator 7 degrees of freedom, greater articulation, and a degree of dexterity comparable to that of the human hand. This improves the surgeon's ability to grasp, cut, dissect, cauterize, and suture fragile tissues within the tight confines of the pelvic cavity. Tremor is eliminated as well.
IMPROVED VISUALIZATION AND COMFORT
The da Vinci Surgical System has cameras that provide the surgeon with 3D, high-definition images of the operative field, improving visualization of blood vessels, tissues, and nerves. The surgeon can magnify images and zoom in on targets while looking through the vision screen. This improved clarity increases accuracy and compensates somewhat for the loss of haptic (tactile) feedback that is inherent in robotic surgery.
Robotic technology also reduces the ergonomic challenges of classic laparoscopy. The surgeon is seated at the remote console, obviating the need to be a contortionist to manipulate the instruments into the desired position. This increases surgeon comfort and decreases fatigue, helping the surgeon focus attention on the work at hand and providing for complex gynecologic surgeries that require longer OR time. As a result of these developments, the range of gynecologic conditions amenable to minimally invasive surgery has increased along with the number of patients who benefit from this technique. Surgeries such as sacrocolpopexy, myomectomy, and cancer staging can now be done without laparotomy.4
RISKS AND BENEFITS
As the scope of robotic gynecologic surgery continues to expand, increasing numbers of patients will ask PAs about the risks and benefits of this surgery. Already, radio and television commercials promote robotics as a reason to select a particular hospital. Tuned-in patients will no doubt start to question PAs about the efficacy of robotic hysterectomy, tubal reversal, and myomectomy: Is my uterus really safe in the hands of a "droid"? Consequently, knowing some of the published data relating to this surgery is both useful and necessary.
Multiple research studies have shown that minimally in vasive surgery significantly reduces blood loss, decreases post operative pain, shortens hospital stay, and decreases morbidity. Patients need less analgesia, recover faster, and benefit from a quicker return to their usual activities. These benefits hold true for a wide range of gynecologic surgeries and apply to both robot-assisted and conventional laparoscopic surgery. Recent studies, however, demonstrate that the advantages for patients may be even greater using robotics.3-5
Several studies have shown that robotic surgery is superior to conventional laparoscopic surgery for suturing, knot tying, and lysis of adhesions. These findings support the premise that robot-assisted surgery is a cut above conventional laparoscopic surgery, especially for those patients who have scarring or adhesions.2Payne and Dauterive compared surgical outcomes for 200 total laparoscopic hysterectomies to robot-assisted hysterectomies. They concluded that robotic surgery halved blood loss, shortened hospital stay, and reduced conversions to laparotomy. Laparotomy remains the primary method of performing myomectomy, as conventional laparoscopy is difficult due to problems with enucleation, removal, and multi-layer suturing. Robotic surgery overcomes many of these problems, offering patients an effective treatment for their fibroids plus the advantages of minimally invasive surgery.4
Robot-assisted gynecologic surgery for cancer staging has many benefits. Boggess and colleagues compared robot-assisted staging with laparoscopic staging for endometrial cancer. The robotic approach was associated with decreased length of hospital stay, an increase in the number of nodes retrieved, and less blood loss. Robotics had the added benefit of allowing staging on obese women who otherwise would have needed laparotomy.6
As the United States population ages, PAs are likely to encounter increasing numbers of patients with pelvic organ prolapse. Repair of prolapse is not usually conducive to conventional laparoscopic techniques, as surgeons encounter technical difficulties with mesh placement, knot tying, tissue dissection, and suturing. The robotic approach alleviates many of these difficulties, making minimally invasive surgery a more viable option.7
OTHER FACTORS TO CONSIDER
Several other important factors need to be considered by PAs when discussing robotics with patients. Robotic surgery is more expensive than conventional laparoscopic surgery and laparotomy. Learning curves are steep for surgeons, initially resulting in longer operating times for patients as new skills are learned. Robotic surgery precludes haptic feedback, as it denies the surgeon the ability to palpate the tissues. The lack of direct physical and visual contact between the patient and operator may raise ethical concerns, particularly in situations where the surgeon is situated at a considerable distance from the patient. Information may not be secure and communication may break down. Finally, studies that evaluate long-term outcomes of robot-assisted gynecologic surgery are needed to assess survival, effects on quality of life, postoperative function, and durability.8 Nonetheless, a growing body of evidence supports the premise that robots represent a significant advance in the field of gynecologic surgery, reaping considerable benefits for patients and clinicians. Source: JAAPA