Laparoscopy, a minimally invasive surgery (MIS), has revolutionized the surgical management of gynecologic disorders. It offers a less invasive approach to surgery for benign gynaecological diseases and in selected gynaecological malignancies. This approach has several advantages over abdominal surgery that benefit both the patient and the surgeon. However, except for some basic laparoscopic surgeries the majority of gynecological operations are still being performed through a traditional abdominal incision. This may be due to the limitations and technical difficulties of traditional laparoscopy such as the loss of depth perception due to the two-dimensional image compromising surgical precision, the limited degree of freedom of movement of the instrument tips restricting the surgical angles in accessing the organs and tissues planes, and the compromised ergonomic position of the surgeon causing fatigue and discomfort. These limitations make suturing and knot tying, a basic surgical skill, quite difficult which further contributes to the slow learning curve often seen with advanced laparoscopic surgery. Robotic technology seems to overcome these limitations of laparoscopic surgery. Since the introduction of the da Vinci Robotic System, (DRS) and its approval by the United States Federal Drug Administration (FDA) for gynecologic surgery in 2005, there has been a worldwide steady increase in the use of this surgical system. Many surgeries that would have been done with an abdominal incision are now being performed with minimally invasive techniques utilizing the da Vinci Robotic System.
The Robot enables surgeons to perform complex and delicate procedures through very small incisions with great precision. The surgeon gets a three-dimensional steady view of the operating field with about ten times magnification. The use of the DRS is expected to result in smaller scars, less blood loss, less post-operative pain, faster recovery, shorter hospital stay, and fewer complications. Operating is facilitated by the following:
- The 3 D camera is under the surgeon’s control and moved only by the surgeon. This gives a non-shaky, steady view of the operating field. The surgeon is not dependent on the assistant for a desired view.
- The EndoWrist instruments used in the da Vinci system mimic the full range of the surgeon’s hand movements.
- By adjusting movement scaling, hand tremors are not transmitted to the instrument tip increasing operative precision.
- The da Vinci Si system has three operating arms under the surgeon’s control that can be switched easily using the control pedals. Even the non operating arm proves very useful for maintaining traction on grasped tissues.
- The robot cart holds the trocars with instruments and the camera freeing the surgeon for surgery.
- Changing operating instruments is speedy.
- Avoids surgeon fatigue and frustration experienced in traditional laparoscopic surgery. The surgeon operates descrubbed, relaxed and seated with arms rested.
- Robotic surgery has a much shorter learning curve than traditional laparoscopic surgery.
There is an ever increasing list of indications for this surgical technique in Gynaecology. da Vinci Robotic surgery can be extremely useful in procedures to enhance fertility, or in preserving fertility when operating in the proximity of the vital organs and vessels to the genital organs. The following are some such indications..
- Endometriosis: Separation of bowel adhesions and excision of endometriotic implants from the pelvic peritoneum in close proximity with the ureter, the rectum and vessels, can be performed with great precision using a da Vinci Robot.
- Fibroids: Laparoscopic myomectomy can be challenging in cases of big fibroids and when fibroids are situated in difficult to access areas. The difficulty in enucleation of a fibroid, subsequent repair of the defect in the uterine wall and blood loss may lead to a high conversion rate from laparoscopy to laparotomy. Robotic surgery overcomes this difficulty and brings down this conversion rate. It also enables the surgeon to perform a good repair of the uterus thus reducing the risk of scar dehiscence later.
- Tubal reanastomosis is another application that benefits from the fine dissection and suturing possible with the use of a Robot.
- Sacrocolopexy for Vaginal Vault Prolapse
- Pelvic Masses
- Obese patients: Robotic surgery in obese patients is technically easier as a wider area is available on the abdomen for port placement.
- Endometrial Cancer needs special mention. Obesity is the biggest risk factor for endometrial cancer. As the prevelance of obesity is increasing, the risk of endometrial cancer is increasing too. Performing abdominal cancer surgery in obese women is quite difficult. These women often have associated co-mobidities and run higher anaesthetic and surgical risks. Considering these risks and the advantage of minimally access surgery using the Robot over open surgery, Robotic Surgery seems to have a special role in endometrial cancer surgery (Hysterectomy +Bilateral Salpingo-oophorectomy+/- Lymphadenectomy ).
Disadvantages of the da Vinci system
- Cost of the da Vinci Robot which includes the initial cost of the system, the maintenance cost and the recurring cost of the EndoWrist instruments, is the biggest challenge. However, the cost per case is expected to decrease as the number of cases performed increases.
- There is no haptic (touch) sensation but with practice a surgeon develops the skill to handle tissues without that sensation.
- Multi-quadrant surgery is not possible.
The da Vinci Robot has made minimally invasive surgery possible even in the most complicated cases by allowing the surgeon to access difficult to reach areas. Using the Robot even a less skilled laparoscopic surgeon can perform an advanced procedure safely without converting to laparotomy.
The 3 D vision and the instruments with wrist like movements make the technique easier to learn, making the learning curve short.
The numerous advantages of the robot system are beneficial to both the patient and the surgeon. The main disadvantage of the da Vinci system is cost which can be expected to reduce when there is completion in the market.
Women undergo open surgery when minimally invasive surgery cannot be performed due to lack of expertise in advanced laparoscopy or the case is too complex to handle safely laparoscopically even by expert laparoscopists. The da Vinci system makes minimally invasive surgery possible in both these situations. With training and skill robotic surgery can be beneficial in properly selected patients. However, in the absence of large randomized control trials and long term outcome data, it is premature to to say with certainty that robotic surgery is superior to laparoscopic and open surgery.
Contact Dr Ranjana Sharma @ +91 9015811800