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Practice Algorithm

Robot-Assisted Laparoscopy in Gynecologic Surgery: Getting Started

Arnold P. Advincula, MD

Technologic advancements continue to have a major impact on the field of minimally invasive gynecologic surgery, particularly with regard to robotics. Since the da Vinci gynecologic surgical system was approved by the FDA in April 2005, procedures such as hysterectomy have been undergoing an evolution.

The da Vinci system is a laparoscopic-assist device comprising three components (Figure). The first component is the surgeon’s console, which is located remotely from the patient bedside. Seated at this console, the surgeon is able to control robot-assisted tools in the operative field (EndoWrist instruments). These instruments are attached to the second component, the patient-side cart that is available with three or four robotic arms. One of the arms holds the endoscope, while the other two or three arms hold the various EndoWrist instruments (eg, needle drivers, scissors, graspers). These instruments are unique in that they possess a wrist-like mechanism that replicates the full range of motion of the surgeon’s hand, eliminating the fulcrum effect seen with conventional laparoscopy. The console affords the surgeon a stereoscopic view of the operative field through the third component, the InSite vision system, which provides three-dimensional imaging through a 12-mm endoscope. A newer model, the da Vinci S, provides surgeons with additional instrument range of motion as well as the option of high-definition imaging.

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FIGURE. The da Vinci Robotic System. From left to right: surgeon’s console, patient-side surgical cart, and InSite vision tower. ©2007 Intuitive Surgical, Inc. Used with permission.

As with any new technology, the surgeon must give careful consideration to the advantages and disadvantages of the laparoscopic surgical system before incorporating it into gynecologic practice. This author certainly advocates, first and foremost, having a strong rationale for its use. One such reason may be to model the laparoscopic approach more closely after tried-and-true open surgical techniques, thereby achieving more comparable surgical outcomes. This would be especially important in cancer surgery, where a compromise in technique or outcomes cannot be tolerated. Additionally, robotics may allow more laparotomy cases to be converted to laparoscopy; in fact, robotics has been shown in numerous studies to be an enabling technology that can shorten learning curves, level the ñplaying fieldî between the novice and expert surgeon, and facilitate the transition process.1 However (and most importantly), this technology should not replace proven, reliable, up-to-date techniques (eg, safe, efficient vaginal hysterectomy). Rather, it should be viewed as a powerful tool in the surgical armamentarium that can potentially provide new options for both patient and surgeon.

Although a solid rationale is paramount when adopting any new technology, surgeons must also look at their individual practices to see whether they have the case volume and comfort level to sustain the learning curve associated with robotics. Robotics is not a surgical approach for ñdabbling.î Commitment and consistency are essential for successful implementation. Technology cannot replace sound judgment and a solid understanding of anatomy and the principles of laparoscopic surgery. Given the proper conditions, there is a ñroadmapî that can facilitate the implementation of robotics in gynecologic practice. The algorithm presented here outlines key concepts for a successful start.

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Arnold P. Advincula, MD, is Associate Professor and Director of the Minimally Invasive Surgery Program and Fellowship, Department of Obstetrics and Gynecology, University of Michigan Medical Center, Ann Arbor.

References

1. Sarle R, Tewari A, Shrivastava A, Peabody J, Menon M. Surgical robotics and laparoscopic training drills. J Endourol. 2004;18(1):63-67.
2. Advincula AP, Song A. The role of robotic surgery in gynecology. Curr Opin Obstet Gynecol. 2007; 19(4):331-336.

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