Robotic & Minimally Invasive Surgery
A revolutionary method of performing minimally invasive gynecologic procedures
I am a staunch advocate of using laparoscopy to perform complex gynecologic procedures such as hysterectomy or myomectomy. In the last few years Intuitive Surgical’s DaVinci Robotic System has been utilized in the field of gynecology to accomplish more challenging surgical procedures performed previously through large abdominal incisions. At John Muir Medical Center, robotic surgery has recently been added to the cutting edge Minimally Invasive Surgery Program, of which I am a proud member.
I have performed over a 1000 procedures with the DaVinci Robotic System and have trained other gynecologic surgeons in complex procedures. My goal is that the majority of gynecologic surgical procedures will be performed in a minimally invasive fashion.
Laparoscopy refers to surgery performed through four small half-inch abdominal incisions instead of one that is 7-10 inches in length. A camera is placed through a half-inch incision made in the umbilicus. Several other “ports” are placed in the lower abdomen through which instruments are used to perform the surgery. Once port placement is completed, the arms of the DaVinci Robot are attached. The surgeon is then positioned at a console located across the room from the patient. Hands are placed within the controller so that the surgeon can articulate the arms and "hands" of the robot to complete the procedure with incredible precision. The surgeon looks through the “view-finder” to view the pelvic structures in high definition 3D. The working instruments of the robot mimic the full range of motion of the human hand with incredible precision. For this reason, the DaVinci Robot is superior to traditional laparoscopy for complex procedures, such as myomectomy or complex hysterectomy.
For the hysterectomy procedure, the ligaments attached to the uterus and blood vessels providing blood to the uterus are cauterized and separated. When the uterus has been completely freed from it’s attachment to the lower pelvis, it is removed through a 3/4-inch incision (regardless of the size) and sent to a pathologist for histologic evaluation (to confirm the presence of fibroids or polyps, but also to assure the absence of an undetected cancer).
HOW IT IS DONE
View video of a Hysterectomy procedure
View video of the Myomectomy procedure
Myomectomy is a procedure that surgically removes fibroids while leaving the uterus behind. The reason for leaving the uterus behind and taking out only the fibroids is to retain the capacity for fertility. To be very clear, the medical indication for myomectomy is fertility conservation in the face of complicating fibroids. The other reason for myomectomy is for the patient who wants treatment for fibroids but wants to retain the uterus, even though fertility is not desired.
Once the fibroids are identified and the decision to proceed with the laparoscopic approach is made, the uterus is injected with a medication that contricts blood vessels. This reduces surgical blood loss, something quite common with myomectomy procedures. In the same manner as with the abdominal approach, an incision is then made over the fibroid, which is then shelled out and removed. Think of making a cut in an avocado, scooping out the seed, then sewing up the avocado. Once all of the fibroids are shelled out, we sew up the defects in the uterus in multiple layers using dissolvable suture. Using the DaVinci Robotic System enables the surgeon to suture in the same way as if through a large abdominal incision.
The fibroid or fibroids are then removed from the abdomen by using a device called a morcellator. This instrument removes fibroids of any size by cutting them into strips of tissue that are easily removed through a small ¾ inch incision. Fibroid tissue is always sent for histologic confirmation to assure the benign nature of the tumors.
These procedures generally take from one (1) to three (3) hours, depending difficulty involved.
BENEFITS OF ROBOTIC SURGERY
The benefits of robotic minimally invasive are similar to traditional laparoscopy: Small abdominal incisions lead to shorter hospital stay and quicker return to normal activity. Traditional “open” hysterectomy or myomectomy will lead to a 3-4 day hospitalization with a 6-week recovery. When these procedures are performed in a minimally invasive fashion with traditional laparoscopy or with the DaVinci Robot, most women will leave the hospital either the same day or the next day, and should expect a much shorter two-week recovery!!! The risks of bleeding, infection, and surgical injury are less than traditional surgery. My average blood loss during these procedures is approximately 25 mls, compared to 150-200 mls for open procedures.
With specific regard to myomectomy procedures, where the goal is to remove troublesome fibroids while leaving the uterus behind, robotic surgery is superior to traditional laparoscopy. The robot obviates the need for traditional open myomectomy with few exceptions. As a result, women can still have minimally invasive surgery with all of its benefits. One reason for this is that suturing with the DaVinci system is more like conventional suturing. As I mentioned, the instruments articulate much like the human hand. As a result, healing is much better. Bleeding is less, and recovery is much quicker.
AFTER THE PROCEDURE
Following the Robotic procedures, nearly all of my patients are ready and able to be discharged from the hospital the same day or the following day. Rarely, patients may require a two day stay in the hospital following surgery. Usually, recovery lasts for 7 – 14 days. This is much different from the usual 6 weeks for vaginal or abdominal hysterectomies or myomectomies. Most of my patients are able to get around normally without strenuous activity in 3 – 4 days. I do, however, encourage them to rest for longer. I find the most irritating side effect from surgery to be fatigue. I always share with my patients that this type of surgery is deceiving. Even though there are only 3 – 4 small incisions, it still is major abdominal surgery! To some degree, the body undergoes something like a marathon while asleep under anesthesia. For that reason, it takes weeks to recovery from basic fatigue. Even though physically my patients feel fine, they do complain of feeling tired. The treatment for this is, of course, rest and sleep.
OTHER OPTIONS TO CONSIDER
Although I feel strongly that these procedures should be done in a minimally invasive fashion, I would still urge women to consider other options if possible. I am happy to explore these options with you.