Elise Everett, MD, is a gynecologic oncologist at Fletcher Allen and an assistant professor at the University of Vermont College of Medicine.
In the United States, one in three women will have a hysterectomy by the age of 60. For a wide range of gynecologic conditions including cervical and uterine cancer, uterine fibroids, endometriosis, uterine prolapse and menorrhagia (excessive uterine bleeding), surgery with a hysterectomy – removal of the uterus – is the most effective treatment when medical therapy and other non-invasive procedures have failed or are not appropriate.
Traditionally, hysterectomy has been performed using an open approach through a large abdominal incision. When compared to newer, minimally invasive techniques, open surgery leads to more tissue trauma, more pain, more narcotic usage, more postoperative complications, longer inpatient hospital stays and longer recovery times. For women facing gynecologic surgery, the extended discomfort and time away from work and other activities that usually follow traditional surgery can be stressful and burdensome.
Fortunately, multiple less invasive surgical options such as vaginal, laparoscopic, or robotic approaches are available. The type of surgery recommended will depend on the patient’s preoperative diagnosis, body habitus, clinical pelvic exam, previous surgery or radiation therapy, and other medical problems. The vaginal approach does not require an external excision and is a good option for women who have had multiple children vaginally and who have uterine prolapse.
For more complex hysterectomies and other gynecologic procedures, laparoscopic surgery may be the best surgical option. Robotic assisted or computer assisted surgery is a type of laparoscopic surgery. Laparoscopic surgery whether it is done with traditional instruments or robotically, is performed through multiple tiny 1cm incisions. Conventional laparoscopy is an effective surgical technique for many routine gynecologic procedures, but the two-dimensional imaging system, and long-handled, rigid instruments have limitations in more complex operations. Robotic surgery or computer-assisted surgery has been designed to overcome the limits of conventional laparoscopy with three-dimensional, high definition imaging and wristed instruments allowing surgeons to have better visualization and greater precision, dexterity, and control to perform more complicated operations.
The advantages of a minimally invasive surgery whether it is done laparoscopically, or robotically, are less pain, less narcotic use, fewer complications, less blood loss, shorter hospital stay, fewer postoperative complications, and quicker recovery and return to normal activities.
As described above there are clear advantages to minimally invasive surgery compared to open surgery, but why choose robotic surgery over laparoscopic surgery since they appear to have the same advantages? An improvement in outcomes of robotic surgery over laparoscopic surgery has been difficult to demonstrate. It has been hypothesized that robotic surgery is safer for several reasons.
First, the 3D imaging system mimics open surgery and real life and provides depth perception, a key component to a safe operation. Second, the wristed instruments with their improved precision and dexterity allow surgeons to perform more difficult cases that could not have otherwise been performed laparoscopically. Third, with robotic surgery, surgeons can now offer the benefits of a minimally invasive surgery to a larger proportion of their patients, not just to the young, healthy patients with no previous surgeries.
Finally, the learning curve for robotic surgery is much more rapid than for traditional laparoscopy. As a surgeon, who has learned both laparoscopic and robotic surgery, robotic surgery is easier to learn, easier to perform, offers more natural use of your hands, and improved visualization. All of these factors suggest that robotic technology is a better tool for the surgeon and therefore safer for patients.
Elise Everett, MD, is a gynecologic oncologist at Fletcher Allen and an assistant professor at the University of Vermont College of Medicine.
This is exactly the doctor- and technology-centered approach that leaves the patient entirely out of the question.
It is true that more and younger women are suffering thru uterectomy (let’s call it what it is); and that it is, after childbirth, a major income stream for debt-ridden corporations like FAHC – which cranks out 40 or 50 new OB surgeons every 10 years with huge debt loads, high income expectations, and a fascination with new procedures.
Dr. Everett’s claim that robotic surgery is less traumatic for the patient than laparascopic is questionable, given the reports from patients around here who’ve had tremendous complications, rehospitalizations, etc from this wildly expensive machine. No doubt those were the patients on the steep end of the learning curve.
This push to more robotic surgery is clearly more about income than outcome; they have to justify buying the things, so let’s take out everyone’s uterus (How do you get to be a surgeon? Practice! practice! practice!).
The costly fiasco with the vaginal-mesh sling in urogynecology is just one example of the overselling of unproven technology in a setting of oversupply of surgeons.
The question is not what’s the best way to perform uterectomies on one-third of the adult female population; but how to reduce the number of women who need them in the first place.
That would be patient-centered care
It is nevertheless admirable and generous of FAHC officers & providers to discuss their work so openly. We applaud this, and encourage less Kool-Aid drinking and more critical thinking on these issues, especially in women’s health. We hope that more women rising to the top of the field will change the culture of the specialty to a woman-centered one, where actual patient preferences and outcomes are first priority. We very much look forward to reading more posts.
From Dr. Everett:
Katharine,
In direct response to your concerns I would argue that educating patients about less invasive surgical techniques available for hysterectomy (the purpose of this blog post) is at the very heart of patient centered care. A well-educated patient is an empowered patient and can make better decisions about their health. To be perfectly clear the use of robotic surgery at Fletcher Allen is not about money. The robot was actually a philanthropic gift to the organization. To date the hospital administration has declined multiple requests by the company that sells the robot, and by robotic surgeons, to purchase a second machine. Even if we had purchased the robot any extra cost of the robot for a procedure would not be incurred by the patient or by the insurance company. In fact, Fletcher Allen incurs the extra cost and does so willingly so that their patient population can receive the benefits of a minimally invasive surgery in situations where a patient would otherwise have had an open, more invasive, surgery. As you may know a robotic hysterectomy and a laparoscopic hysterectomy have the same charge codes for billing and are therefore reimbursed exactly the same by insurance companies.
It is certainly true that Fletcher Allen trains resident physicians in the field of Ob/Gyn. Every year, 3-4 residents graduate the training program and enter the workforce to provide high-quality, evidence-based obstetric and gynecological care to the women of Vermont. This is the only training program in the state and, we believe, an important service to the state to insure highly trained physicians remain available in the area to care for the women of Vermont.
We agree that robotic surgery is not necessary less traumatic than laparoscopy. However extensive data in the literature supports the statement that BOTH robotics AND laparoscopy are less traumatic forms of surgery than open surgery. Of course there are patients who have bad outcomes from robotic surgeries. Complications are associated with any surgical procedure. The real question is whether the rate of complications is higher or lower with a specific surgical approach. Overall the evidence suggests that the complication rate associated with robotic cases is very low compared to other surgical approaches.
I absolutely agree that the focus should be on reducing the number of hysterectomies in this country by finding other noninvasive, medical solutions to these problems through research. But, for those patients that need a hysterectomy, I think it is important that they know all of their surgical options so they can make an informed decision. We have actually found that it is actually the preference of some women to move to hysterectomy as a form of treatment to avoid the alternative forms of therapy which can include hormonal therapies which may involve systemic exposure over significant periods of time.
I am not advocating that robotics replace vaginal or laparoscopic hysterectomies because I agree that the benefits of robotics in these areas are questionable. But, as an example, for a patient who is morbidly obese and has had several previous surgeries and is being offered an open surgery with a 5 day hospital stay, 6 week recovery and a 50% wound complication rate, robotics has huge advantages – a one day hospital stay, a 3 week recovery and less than 10% wound complication rate. For this particular patient, robotics would provide a better patient outcome, which is the goal of patient-centered care.
There are many women who don’t have a choice about having a hysterectomy. They have health issues that are not preventable and surgery is not optional. Dr. Everett clearly stated that surgery is considered when medical therapy or minimally invasive treatments have failed or are not appropriate. No amount of effort by healthcare providers can eliminate the need for high quality, minimally invasive surgical options in the treatment of many gynecological conditions.
Uterine cancer is the most common cancer of the female reproductive organs according to the American Cancer Society. Hysterectomy can be a life saving surgery.
As a patient, I felt very fortunate to have the option of robotic hysterectomy at Fletcher Allen. I was given information on all appropriate surgical options and the corresponding risks and benefits of each procedure. I was not ” out of the question” as Dr. Hikel describes, but rather I felt included in all decisions regarding my care. My surgery was successful, I was discharged after one night in the hospital and I had no surgical complications. I was back to running within a few weeks and needed to keep reminding myself not to lift more than 10 pounds.
There is no arguing that a hysterectomy is a major surgery and should only be considered when non-surgical options have been ineffective or are not appropriate. When a hysterectomy is needed, the robotic approach offers the patient a minimally invasive procedure. I considered traveling outside of Vermont to obtain care but after careful research, I remain confident that I could not have received better care anywhere else. My family and I are tremendously grateful to Dr. Wong for his expertise utilizing the robotic approach, but more importantly for his sincere and thoughtful care of me as a patient.
Many thanks, Susan, for your thoughtful post! We are so happy to hear your surgery went well and your experience with us was a positive one.
I emphatically disagree with Dr. Hikel and honestly take offense to such a negative review of the doctors at Fletcher Allen.
I had my hysterectomy this past October at FAHC and I was lucky enough to be a candidate for the Da Vinci Robot. I can tell you that Dr. Wong is a hero of mine. He did not push me into any surgery that I didn’t want or need. In fact, he tried to talk me out of it and made me explore other options. Those options failed and I had my surgery.
I was back at work 6 days after my surgery. I had zero complications. My life is pain free now and I can’t express how happy I am that I had this done and grateful I am for having such a fantastic hospital in our backyard.
Just my 2 cents.