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.