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the cutting edge

Robotics: The Next Step in the Evolution of Minimally Invasive Gynecologic Surgery

Arnold P. Advincula, MD

Welcome to The Female PatientÍs new department, "The Cutting Edge." At no other time in history have surgical advancements occurred as rapidly as today. The introduction of new technologies to virtually every aspect of gynecologic surgery makes it difficult—even daunting—for clinicians to keep pace with new developments. The goal of this series is to provide readers with concise, up-to-date reviews of the latest advances in surgical technology and their clinical relevance to gynecology. Invited experts will provide the latest available scientific data, as well as technical "pearls" on subjects ranging from electrosurgery to surgical simulation. It gives me great pleasure to launch this series with an overview of the current state of surgical robotics.

Technologic advancements in minimally invasive surgery (MIS) have had a major impact on the field of gynecology. It was only 70 years ago that Bosch described the first gynecologic use of laparoscopy with tubal sterilization.1 By the early 1970s, laparoscopy had revolutionized gynecology. Since then, MIS has become increasingly popular among both gynecologic surgeons and patients.

Modern improvements in laparoscopy include high-intensity light sources, three-chip cameras, and refinements in hand instrumentation. As a result, surgeons can now address an ever broader range of gynecologic pathology in a minimally invasive fashion. In turn, studies clearly show that laparos-copic surgery affords faster recovery with less postoperative pain. Despite these strides, more complex surgery—such as treatment of advanced endometriosis and procedures that require extensive suturing (eg, myomectomy, tubal reanastomosis—are typically still managed by laparotomy.

Hysterectomy represents another procedure where laparotomy has remained the preferred route. Although pioneers such as Reich introduced the laparoscopic-assisted vaginal hysterectomy in the late 1980s, Farquhar and Steiner reported in 2002 that only 10% of hysterectomies were performed with laparoscopic assistance.2,3 This is surprising, given the increasing acceptance of laparoscopy in gynecology and the definite trend toward laparoscopic hysterectomy during the 1990s.

One major obstacle to the more widespread acceptance and application of minimally invasive techniques to gynecologic surgery has been the limitations encountered with conventional laparoscopy. These include counterintuitive hand movements, two-dimensional visualization, and the restricted degree of instrument motion within the body. Another explanation for this slow acceptance has been the learning curve with conventional laparoscopy and its associated complications. Advanced pathology (eg, pelvic adhesions, altered surgical anatomy field) is also a limiting factor to applying conventional laparoscopic techniques to gynecologic pathology.

Additional challenges have been issues surrounding the surgeon’s level of expertise, training, and acquisition of advanced skills. As a result of these obstacles, gynecologic surgeons have begun to add robotic technology to their endoscopic armamentarium.

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HISTORY


Robotics is not new to gynecologic surgery. Evidence of its early use in the field goes back to the voice-activated Aesop robotic arm, which served primarily to operate the camera during laparoscopic surgery. In an interesting study that compared the system to a surgical assistant holding the laparoscope,4 the authors found that surgery was faster and more efficient with the robotic camera holder because it allowed two surgeons to use both hands for operating.

as Zeus. In addition to a voice-activated robotic camera holder, this system allowed the surgeon to sit remotely at a console that interfaced with two operating arms. The surgeon wore special glasses with a polarizing filter to obtain enhanced visualization on the video monitor. Early studies reported its successful application to tubal reanastomosis. In one prospective study,5 pregnancy rates were evaluated in 10 patients with previous tubal ligations who underwent laparoscopic tubal reanastomosis using the identical technique used at laparotomy. A postoperative tubal patency rate of 89% was demonstrated in 17 of the 19 tubes anastomosed using the Zeus system, with pregnancy rates of 50% at 1 year and no complications or ectopic pregnancies.

Since the advent of these early devices, the use of robotic technology to facilitate laparoscopic procedures in gynecology has increased rapidly over the past 5 years—particularly with the introduction of the latest and only US Food and Drug Administration-approved platform in surgical robotics, the da Vinci surgical system. Numerous studies across various surgical disciplines have reported that this is a safe, effective alternative to conventional laparoscopic surgery, especially when dealing with complex pathology. In the area of gynecology, there are multiple reports of robot- assisted laparoscopy with the da Vinci system for a wide range of pathologic conditions.

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THE DA VINCI SURGICAL SYSTEM

The da Vinci surgical system is a laparoscopic assistive device that is comprised of three components (Figure 1). The first component is the surgeon's console, which is located remotely from the patient's bedside. Seated at this console, the surgeon is able to control robot-assisted instruments in the surgical field with the aid of a stereoscopic viewer, hand manipulators, and foot pedals. The second component is the InSite vision system, which provides three-dimensional imaging through a 12-mm endoscope. Although a 5-mm endoscope is available, this only provides two-dimensional imaging. The third component is the patient-side cart with robotic arms and EndoWrist instruments. Currently, the da Vinci system is available with either three or four robotic arms. One of the arms holds the endoscope while the other two or three arms hold the various EndoWrist instruments, which come in 8-mm and 5-mm sizes. A newer model, the da Vinci S, functions on the same platform as its predecessor, but provides the surgeon with additional range of motion from longer instruments and increased pitch.

Figure not available online

FIGURE 1. The da Vinci robotic system. From left to right: surgeon’s console, patient-side surgical cart, and InSite vision tower. Courtesy of Intuitive Surgical, Inc.

The EndoWrist instruments are unique in that they possess a wrist-like mechanism that allows seven degrees of movement, thereby replicating the full range of motion of the surgeon's hand and eliminating the "fulcrum" effect seen with conventional laparoscopy. Although these instruments exhibit significant dexterity compared with those used in traditional laparoscopy, they lack haptic or tactile feedback, which may be a limitation for some surgeons. A series of EndoWrist instruments—eg, needle drivers, scissors, graspers—can be interchanged on either of the lateral robotic arms (Figure 2). Although dispos-able, these instruments typically last for 10 uses and cost approximately $2,500 each. The da Vinci surgical system retails for around $1,300,000 to $1,500,000.

Figure not available online

FIGURE 2. Example of EndoWrist instrument (tenaculum). Courtesy of Intuitive Surgical, Inc.

Prior to incorporating robotics into their surgical armamentarium, surgeons must first undergo device training, case observations, and proctoring of early cases. Much of the credentialing and privileging requirements for any robotics platform will depend largely on individual hospital policies. Critical to the success of a robotics program is a team-oriented approach, in addition to a willingness to undergo the learning curve associated with a new technical approach. Appropriate case selection is critical; the criteria utilized to determine safe candidacy for conventional laparoscopy should also be applied to any robotic case, including variables such as body habitus, surgical history, and anticipated size of the pathology.

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GYNECOLOGIC APPLICATIONS

Robotic applications in gyne- cologic surgery are quite varied. The majority of experience thus far has been in the area of hysterectomy. Specifically, the da Vinci surgical system has facilitated the completion of totally endoscopic hysterectomy (uterus/cervix or supracervical) as described by the American Association of Gynecologic LaparoscopistsÍ classification system.6 A broad range of benign indications have been addressed (Table 1). Although variables such as operative time were not improved, the overall safety and feasibility of the approach was confirmed.7-12 This experience was carried over into oncologic applications, an approach that holds promise for endometrial and possibly cervical cancer staging (Table 2).7,10,13

Table not available online

TABLE 1. Robot-assisted Laparoscopic Hysterectomy CIN = cervical intraepithelial neoplasia; CA = cancer; UTI = urinary tract infection.

Table not available online

TABLE 2. Robot-assisted Laparoscopic Cancer Staging CIN = cervical intraepithelial neoplasia; CA = cancer; UTI = urinary tract infection.

Although much of the early experience with robotics in gynecology has involved hysterectomy, more suture-based procedures have been investigated as well. Robot-assisted laparoscopic myomectomy holds great promise, given that most conservative surgery for leiomyomata in this country depends on laparotomy. In one study, Advincula et al14 were able to demonstrate both feasibility and an ability to adhere to open surgical techniques such as multilayer, sutured closure of a myometrial defect. Other, more complex suture-based applications have been in the areas of tubal reanastomosis and sacrocolpopexy.15,16 In an early study,16 20 patients undergoing robot-assisted laparoscopic sacrocolpopexy were found to have shorter hospital stays, low complication and conversion-to-laparotomy rates, and high rates of patient satisfaction despite a mean follow-up of 5.1 months (range 1 to 12 months).

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CONCLUSION

The use of robot-assisted technology may provide a means to overcome both advanced pathology and the surgical limitations of conventional laparoscopy by providing surgeons with improved dexterity and precision coupled with advanced imaging that allows for the completion of complex MIS procedures. The feasibility of approaching gynecologic surgery with robotics has been demonstrated clearly. Although prospective, randomized studies comparing this technology with traditional approaches have yet to be performed, the application of robotics to gynecologic surgery represents a promising advancement in MIS. Despite the expense and learning curve associated with such technology, as well as the absence of haptic instrument feedback, the potential long-term benefits to both patients and surgeons may still outweigh the initial investment and technical limitations.

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Arnold P. Advincula, MD, is associate professor and director, Minimally Invasive Surgery Program and Fellowship, Department of Obstetrics and Gynecology, University of Michigan Medical Center, Ann Arbor.

Disclosure
Dr Advincula reports that he has received grant research support from Intuitive Surgical, Inc.

References

1. Sklar AJ. Tubal sterilization. [eMedicine Web site]. August 7, 2004. Available at: http://www.emedicine.com/med/topic3313.htm. Accessed September 15, 2006.
2. Reich H, DeCaprio J, McGlynn F. Laparoscopic hysterectomy. J Gynecol Surg. 1989;5(2):213-216.
3. Farquhar CM, Steiner CA. Hysterectomy rates in the United States 1990-1997. Obstet Gynecol. 2002;99(2):229-234.
4. Mettler L, Ibrahim M, Jonat W. One year of experience working with the aid of a robotic assistant (the voice-controlled optic holder AESOP) in gynaecologic endoscopic surgery. Hum Reprod. 1998;13(10):2748-2750.
5. Falcone T, Goldberg JM, Margossian H, Stevens L. Robotic-assisted laparoscopic microsurgical tubal anastomosis: a human pilot study. Fertil Steril. 2000;73(5):1040-1042.
6. Parker WH, Cooper JM, Levine RL, Olive DL. The AAGL classification system for laparoscopic hysterectomy. J Am Assoc Gynecol Laparosc. 2000;7(3):439-440.
7. Diaz-Arrastia C, Jurnalov C, Gomez G, Townsend C. Laparoscopic hysterectomy using a computer-enhanced surgical robot. Surg Endosc. 2002;16(9):1271-1273.
8. Beste TM, Nelson KH, Daucher JA. Total laparoscopic hysterectomy utilizing a robotic surgical system. JSLS. 2005;9(1):13-15.
9. Advincula AP, Reynolds RK. The use of robot-assisted laparoscopic hysterectomy in the patient with a scarred or obliterated anterior cul-de-sac. JSLS. 2005;9(3):287-291.
10. Marchal F, Rauch P, Vandromme J, et al. Telerobotic-assisted laparoscopic hysterectomy for benign and oncologic pathologies: initial clinical experience with 30 patients. Surg Endosc. 2005;19(6):826-831.
11. Reynolds RK, Advincula AP. Robot-assisted laparoscopic hysterectomy: technique and initial experience. Am J Surg. 2006;191(4):555-560.
12. Fiorentino RP, Zepeda MA, Goldstein BH, John CR, Rettenmaier MA. Pilot study assessing robotic laparoscopic hysterectomy and patient outcomes. J Minim Invasive Gynecol. 2006;13(1):60-63.
13. Reynolds RK, Burke WM, Advincula AP. Preliminary experience with robot-assisted laparoscopic staging of gynecologic malignancies. JSLS. 2005;9(2):149-158.
14. Advincula AP, Song A, Burke W, Reynolds RK. Preliminary experience with robot-assisted laparoscopic myomectomy. J Am Assoc Gynecol Laparosc. 2004;11(4):511-518.
15. Degueldre M, Vandromme J, Huong PT, Cadiere GB. Robotically assisted laparoscopic microsurgical tubal reanastomosis: a feasibility study. Fertil Steril. 2000;74(5):1020-1023.
16. Elliott DS, Frank I, DiMarco DS, Chow GK. Gynecologic use of robotically assisted laparoscopy: Sacrocolpopexy for the treatment of high-grade vaginal vault prolapse. Am J Surg. 2004;188(4A suppl):52S-56S.

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