Robot-Assisted Gynecologic Surgery. Gynecologic Surgery

Transcription

1 Robot-Assisted Gynecologic Surgery Alison F. Jacoby, MD Department of Obstetrics, Gynecology and Reproductive Sciences University of California, San Francisco Robot-Assisted Gynecologic Surgery Clinical advancement or Expensive gadget?

2 Learning Objectives Robotic Surgery Why do we need it? What can you do with it? What does it cost? Who should use it? Why do we need a robot for laparoscopy?

3 Conventional Laparoscopy vs. Laparotomy L/S Advantages: Shorter hospital stays Faster return to activities Less post-op op pain and narcotic use Less intra-op blood loss Mais V et al Laparoscopic versus abdominal myomectomy: a prospective randomized trial to evaluate the benefits in early outcome. Am J Obstet Gynecol 1996;174:654-8 Paraiso MF et al Laparoscopic and abdominal sacral colpopexies: a comparative cohort study. Am J Obstet Gynecol 2005;192: Conventional Laparoscopy Limitations: Steep learning curve Long operative times Counter-intuitive hand motions 2-dimensional image Limited range of motion for instruments Challenging ergonomics Tremor amplification Unsteady camera support

4 Conventional vs. Robotic Laparoscopy Steep learning curve Long operative times Counter-intuitive hand motions 2-dimensional image Limited range of motion for instruments Poor ergonomics Unsteady camera support Tremor amplification Steep learning curve Even Longer operative times Natural hand motions 3-dimensional image Wristed instruments Superior ergonomics Unless you re the assistant! Steady camera support Tremor elimination davinci robot and surgeon console

5 Port placement

6 Robot-Assisted Laparoscopy Limitations No tactile feedback Fewer electrosurgical instrument options Inability to operate in lower and upper abdomen simultaneously Inability to change patient position intra-op Equipment size requires large OR Expensive More on this topic later in the presentation What can a robot do? A Partial List: Urology Radical prostatectomy, partial nephrectomy,, radical cystectomy, adrenalectomy Cardiac Surgery CABG, mitral valve surgery General Surgery Gastric bypass, colectomy, achalasia Neurosurgery Brain and spine procedures Vascular Surgery Aortobifemoral bypass

7 What can gynecologists do with a robot? Gynecologic Oncology Radical hysterectomy Pelvic and aortic lymphadenopathy Benign Gynecology Myomectomy Sacrocolpopexy Tubal reanastamosis Hysterectomy Goal of Robotic Surgery: To convert cases from laparotomy to laparoscopy Examples: Myomectomy- Multi-layer layer closure of uterine defect extremely challenging for all but the most accomplished laparoscopic surgeons Sacrocolpopexy- Improved dexterity for positioning and securing mesh Tubal reanastamosis- Ability to perform microsurgical techniques Avoid using robot if conventional L/S is feasible and safe

8 Video of Robot-Assisted L/S Myomectomy What is the evidence for robot-assisted laparoscopy

9 Robot-Assisted L/S Myo vs. Abdominal Myomectomy RALM N=29 Abd Myo N=29 P value EBL (ml) 196 +/ / LOS (d) / /- 1.5 <.0001 OR Time (min) 231 +/ /- 43 <.0001 Advincula AP et al. J Minim Invasive Gynecol. 2007;14(6): Robot-Assisted L/S Myo vs. Conventional L/S Myo RALM N=15 L/S Myo N=35 P value EBL (ml) 370 ( ) 500) 420 (110-75).20 LOS (d) 1.00 (1-1) 1) 1.05 (1-3).12 OR time (min) 234 ( ) 445) 203 (95-330).03 Complications NS Nezhat C et al. Fertil Steril. 2009; 91(2): 556-9

10 Robot-Assisted L/S Sacrocolpopexy vs. Abdominal Sacrocolpopexy Robot SCP N=73 Abd SCP N=105 P value EBL (ml) 103 +/- 96 ml 255 +/- 155 ml <.001 LOS (d) <.001 OR time (min) 328 +/- 55 min 225 +/- 61 min <.001 Complications NS Geller EJ et al. Obstet Gynecol. 2008; 112(6): Robot-Assisted L/S Tubal Reanastomosis vs. Out-Pt Mini-lap Tubal Reanastomosis Robot Tubal Reanastomosis N=26 Mini-lap Tubal Reanastomosis N=41 P value EBL, < 100 ml (%) 19 (73) 31 (80).48 LOS (min) 99 (52-159) 142 (82-349).14 OR time (min) 229 ( ) 252) 181 ( ).001 Time out of work (wk) 0.8 ( ) 2.8 ( ).013 Pregnancy rates (%) Rodgers AK et al. Obstet Gynecol. 2007;109:

11 Robot-Assisted L/S Adnexectomy vs. Conventional L/S Adnexectomy Robot-Assisted N=85 Conventional L/S N=90 P value EBL (ml) 39 +/ / LOS (d) OR time (min) 83 +/ /- 35 <.01 Complications NS Magrina JF et al. Obstet Gynecol 2009:114;581-4 Robot-Assisted vs. Conventional Total L/S Hysterectomy Robot TLH N=100 Conventional TLH N=100 P value EBL (ml) <.0001 LOS (d) <.007 OR time (min) <.0001 Intra-op conversion to laparotomy (%) Payne TN, Dauterive FR. J Minim Invasive Gynecol. 2008;15;286-91

12 Caution: Vaginal Cuff Dehiscence Year 2004 No. of Robotic Procedures 61 No. of Vaginal Cuff Dehiscences 0 Incidence (%) Total Kho RM et al. Incidence and characteristics of patients with vaginal cuff dehiscence aftre robotic procedures. Obstet Gynecol 2009;114:231-5 What is the evidence for robot-assisted laparoscopy? No randomized clinical trials Literature consists of retrospective case series with small numbers More research needed to confirm claims of clinical superiority

13 What does robotic surgery cost? davinci Surgical Systems Robot equipment: $ million Hospital service contract: ~ $150,000 /yr Direct costs per case: $ Re-usable instruments: $2000 each Expire after 10 cases Each instrument costs $200 per case

14 Charges and Reimbursement ($) RALM N=29 Abd Myo N=29 P value Professional Charges / / Hospital Charges 30,084 +/ ,400 +/ <.0001 Professional Reimbursement / /- 827 NS Hospital Reimbursement 13,181 +/- 10, / NS Advincula AP et al. J Minim Invasive Gynecol. 2007;14(6): Select Itemized Hospital Charges ($) RALM N=29 Abd Myo N=29 P value Operating Room 16, <.0001 Anesthesia Nursing <.0001 Laboratory NS Pharmacy NS Recovery Room NS Advincula AP et al. J Minim Invasive Gynecol. 2007;14(6):

15 Should YOU learn to operate with the robot? The Learning Curve How many cases to become proficient? Retrospective review by 2 gyn laparoscopists in private practice 113 pts in 22 months Case mix: 87% hysterectomies Mean wt- 184 gm (range gm) Conclusion: In the hands of surgeons w/ advanced laparoscopic skills, the learning curve to stabilize operative times is 50 cases Lenihan JP et al. J Minim Invasive Gynecol 2008;15(5):589-94

16 The Learning Curve Lenihan JP et al. J Minim Invasive Gynecol. 2008;15(5): Operative Times for Robot-Assisted Hysterectomy Mean Operative Time (min) Anesthesia Time Skin to Skin Time Robot Time >75 Case Number Payne TN, Dauterive FR. J Minim Invasive Gynecol. 2008;15;286-91

17 Operative time for 100 Conventional TLH vs. last 25 Robotic TLH cases Mean Operative Time (min) Conventional Robotic 0 Anesthesia Skin-to skin Payne TN, Dauterive FR. J Minim Invasive Gynecol. 2008;15; Keys to a successful robotic program Dedicated OR team High surgical volume Appropriate patient selection Cooperation between surgical specialties

18 Be aware/beware of Direct to Consumer Marketing Influences Examples: Hospital websites promoting robotic procedures to attract new patients National and local news stories championing robot technology Popular tv shows featuring robotic surgery Let s s await the results of well-designed, prospective studies to guide appropriate use of robotic surgery Conclusions Insufficient evidence to show a clinical advantage of robot-assisted compared to conventional laparoscopy Based on current data, OR time and expense increased w/ robot Expect long learning curve Make goal of robot-assisted surgery to reduce rates of traditional laparotomy