It is so difficult in today's healthcare environment for patients to truly understand all the different options available to them for their care. The internet is an easily accessible source for information on all types of medical treatments. New advancements in surgery are promoted online with marketing by physician practices, hospitals, and more recently directly by the companies that manufacture surgical devices and technology. Patients can even watch videos of surgical procedures on these sites and on YouTube. One of the newest developments in surgical advances has been robotic surgery, with the DaVinci robotic system as developed by Intuitive Surgical.
Intuitive has spent millions of dollars in marketing its robotic device to physicians as well as to patients. There is no doubt that robotics play a useful role in some types of surgical procedures. Examples are for radical prostate surgery, thoracic surgery, and other very complicated surgical procedures for which the robot provides assistance for the surgeon in these delicate operations. THE USE OF THE ROBOT FOR GYN SURGERY, HOWEVER, IS OF NO BENEFIT. Information on the Intuitive website makes it clear that robotic surgery is better than open surgery. There is no disagreement about this. Open surgery should be abandoned as a method to treat patients for almost all GYN conditions except some cancers. Robotic surgery, however, is not the best option for patients needing laparoscopic GYN surgical care. In fact, it is the most invasive of all laparoscopic surgeries, requiring the most incisions, with total incision length longer than standard laparoscopy, and much longer than Dualport procedures. In addition, robotic surgery is not supported by research trials over standard laparoscopy. A large study by Pasic showed clearly that the role for robots in GYN surgery was unclear.* Other studies have shown similar results.* Robotic surgery is also extremely expensive and takes a long time to accomplish in comparison to Advanced Laparoscopic Surgery and DualportGYN techniques. These factors increase health care costs dramatically.
*Click here to view the study of Laparoscopy vs. Robotic Hysterectomy
At CGS, robotic surgery is not used for any surgical procedures. Compared to advanced laparscopic surgery and Dualport procedures, Robotic surgery requires a larger number and size of incisions, takes much longer to perform, and results in more pain and longer recovery. The cosmetic result is far worse due to incision placement throughout the abdomen and pelvis. Robotic surgery increases the time of the procedure, is more invasive, is less cosmetically appealing, and is more expensive, making it an inferior option when compared to ALS and Dualport procedures.
The purpose of this article is to explain to patients why the robot has become popular with OBGYN surgeons, and to fully illustrate the significant disadvantages of robotic surgery when compared to Advanced Retroperitoneal Laparoscopic Surgery and DualportGYN procedures. In this healthcare climate of marketing directly to patients, especially now with for profit companies marketing online, patients have to become better educated as to what the best options are. The philosophy of CGS is to empower patients through education to make the correct decisions regarding their health care. The following points hopefully will provide some insight as to why robotics have been adopted by OBGYN physicians. They will also point out why robotic surgery is actually an inferior, more invasive, and more costly option that is not necessary if a skilled fellowship trained laparoscopic surgeon is providing surgical care.
- Specialty Training
Patients need to understand that the robot is not doing the surgery. The robot is only as good as the surgeons’ knowledge of techniques and the anatomy. The surgeon controls the robot, and the robot cannot compensate for the lack of knowledge and training of the surgeon. Simply stated, the robot is not a substitute for anatomical knowledge or good surgical techniques. The surgeon’s training is the most important factor in achieving the best result possible. At CGS, training in Advanced Retroperitoneal Laparoscopic Surgery and DualportGYN procedures places CGS surgeons at the highest possible level. Introducing the robot to CGS would be detrimental by creating increased incision size, a greater number of incisions, longer surgical time, and a poor cosmetic result all at increased cost. This would result in increased pain and complications, longer recovery, longer anesthesia time and potential complications for the patient without any benefit toward patient care or safety. - Total Incision Length
Total incision length refers to the length of all the incisions combined for a surgical procedure, and is one of the best indicators of how invasive a surgical procedure is.
The robot requires five incisions, three at 8 mm, and two at 12 mm for a total incision length of 48 mm, or 1.9 inches.
Standard laparoscopy requires four incisions, two at 5mm and two at 10 mm for a total incision length of 30 mm or 1.2 inches.
Dualport GYN procedures require 2 incisions at 5 mm each, for a total of 10mm, or 0.4 inches.
In general, the longer the total incision length, the more pain, longer recovery, and worse cosmetic result. - Incision Size, Location, Cosmetic Result
There are 5 incisions for robotic surgery. Three of these are 8 mm, and two are 12 mm. This is the largest number and size of incisions used for any laparoscopic surgery. Because Robotic surgery requires five incisions to be placed in large half oval over the entire abdomen and pelvis, the increased number of incisions, incision size, and placement all result in more pain. Also, the incisions are placed through the abdominal wall muscles, often leading to “hematomas” or blood clots under the skin due to bleeding from the muscles. They also result in increased pain since they are located through the muscles, and are higher on the abdominal wall. The size of the incisions are quite large compared to Dualport incisions, and cause increased pain as well as possible herniations of bowel and fat through the incisions due to their increased size. The incision locations in robotics also lead to a much worse cosmetic result, with incisions obviously visible throughout the abdomen.
DualportGYN
Robotic Surgery
Dualport GYN incisions are located at the belly button and just above the pubic bone. They are much smaller with only two 5 mm incisions used, resulting in much less pain. In addition, these incisions are not penetrating the muscle since they are in the midline, almost completely eliminating hematoma formation, herniation, and pain. The incisions are also positioned to provide the best cosmetic result possible. - Procedure Time
Robotic procedures take far longer than DualportGYN procedures or standard laparoscopy. The setup of the robot takes longer and requires additional assistance during the surgery. Whereas robotic hysterectomy performed by an experienced robotic surgeon for a 15 week size fibroid uterus may take 2 to 3 hours in duration, a DualportGYN procedure for the same size uterus takes less than a hour to complete. This is because Dualport procedures use far fewer incisions and use Advanced Retroperitoneal Laparoscopic Techniques which are safer and faster than standard robotic surgery. Increased surgical time and time of anesthesia has been clearly shown to increase complications to include clot formation in the pelvis and lungs, swelling to the head and upper extremities due to extended time in the “head down” or Trendelenberg position needed for these surgeries, the potential for pneumonia due to aspiration, and other complications due to increased surgical time. - Safety
Robotic procedures are no safer than standard laparoscopy. Advanced Retroperitoneal Laparoscopic Surgery and DualportGYN procedures are safer than both robotic and standard laparoscopic approaches. These procedures use retroperitoneal dissection and extended procedures to fully visualize the anatomy of the pelvis, thereby greatly decreasing injury to the bladder, ureters, large vessels, and bowel. Bleeding during ARLS and DualportGYN procedures is also controlled better with ligation of the uterine artery during these procedures in the retroperitoneal space. Using smaller incision sizes and fewer incisions also avoids herniation of bowel through the incision sites, which can be a surgical emergency. The smaller incisions and location of the incisions with DualportGYN also greatly eliminates bleeding and pain at the incision sites. - Recovery
Recovery from surgery is dependent on several factors. For minimally invasive surgery, incision size and location, time of surgery, blood loss, and complications dictate recovery time. ARLS and Dualport procedures have the fastest recovery of all laparoscopic surgery by minimizing all of these factors. Any surgical approach that increases these factors will increase recovery time. Robotic approaches increase incision size and location, the time of the surgery, and complications by not using a retroperitoneal approach to the surgery for complete visualization of the anatomy and ligation of the uterine artery in the retroperitoneal space. - Cost
Last - but certainly not the least important issue - is the cost of robotic procedures. Robotic surgery is extremely expensive to develop and maintain. Each robotic device has a cost of 2 million dollars, and an annual maintenance of 200,000 dollars per year. In addition, the instruments require replacement every 10 uses with a very high replacement cost. It is obvious that Intuit Surgical has become very profitable with the placement of robotic systems in hospitals throughout the U.S. and world. For GYN surgery, however, robotic surgery is not beneficial or cost effective, and therefore increases healthcare costs without improvements in patient care or safety when compared to ARLS and Dualport procedures.
For additional reading: Click here for an article from Outpatient Surgery Magazine discussing robotic vs. laparoscopic hysterectomy, titled "Robotic Hysterectomy Is Costlier but No Safer Than Traditional Laparoscopy."