Robotic Hysterectomy

   It’s hard to believe that robots can do a better job of operating on us than surgeons. And while a robot needs a skilled surgeon driving it, the robotic approach is gaining more kudos for difficult cases.    

Dr. Fareesa Khan, a urogynecologist who does gynecologic surgery at Missouri Baptist Hospital and St. John’s Mercy Medical Center, says she mostly uses the da Vinci robotic system for hysterectomies in uterine prolapse cases. “We have seen the standard approach for hysterectomy go from vaginal to abdominal, then back to vaginal, and now, very often, laparoscopic,” Khan says. “The da Vinci system takes laparoscopic surgery to a new level.”

    She says some of the advantages are that it is a three-dimensional system, high-definition, and much higher magnification than traditional laparoscopic surgery. With the robotic system, the surgeon has more dexterity than with straight laparoscopic. It allows total wrist movement and more accuracy. However, Khan says that while the da Vinci can be used for most hysterectomy, the expense is not worth it for routine cases.

    ”We don’t want to unnecessarily inflate the cost of health care just because we have a cool tool,” Khan says. Cancer and prolapses remain the best applications for da Vinci hysterectomies, she says.

    The system requires a specially trained operating room team. Through very small incisions, the surgeon puts the camera and instruments into the patient, and then docks the robotic arms to the instruments.

    Dr. Matthew Powell, a gynecologic oncologist with Washington University and Siteman Cancer Center, has been using the da Vinci system for more than three years. He says while people might think that an open incisional hysterectomy would give the best visualization, that’s not necessarily true. ”We actually get better lymph node counts on laparoscopic surgery,” says Powell. “Because of the magnification, we can see tiny blood vessels and coagulate them before they bleed, making it bloodless surgery. Sometimes, though, we have more control of the surgical field using the da Vinci system on very large or heavy patients.”

    Powell uses the system for lymph node resection, cancer staging, and to surgically treat cervical cancer, uterine cancer, and suspected ovarian cancer. With the da Vinci laparoscopic approach, patients have significantly less pain, less blood loss, less scarring and an earlier return to normal activities, compared to open surgery. Besides cancer surgeries, the robotic system can be used for intrauterine procedures such as myomectomy, removal of non-cancerous uterine masses, and resupporting the uterus or vaginal walls. Powell says he, too, does not use the system for cases that can be done well through traditional laparoscopic techniques.

    Dr. Teresa Knight, an ob/gyn specialist with Women’s Health Specialists, has been trained to use the da Vinci system and says it is a great tool for precision. “It was originally presented as a means for treating bladder cancer and then expanded to other surgical applications,” she explains. “It isn’t appropriate for routine cases because it requires more entry ports into the body, five as opposed to three for traditional laparoscopic surgery. It also requires more time for the patient to be asleep while positioning and hooking up equipment to the computer before starting the surgical procedure. For the surgery I do, the da Vinci isn’t needed.”

    She says laparoscopic hysterectomies, in general, offer advantages to patients in shorter recovery and less pain because so many fewer nerves are interrupted. She does, however, see where the da Vinci technology is going and says it is exciting. “The technology exists to be able to do the surgery remotely,” Knight says. “For instance, I could be sitting in St. Louis and operating on someone in a war zone. That has wonderful implications for areas of the world without skilled surgeons.”