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?
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?
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;192:1752-8 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
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
Port placement
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
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
Video of Robot-Assisted L/S Myomectomy What is the evidence for robot-assisted laparoscopy
Robot-Assisted L/S Myo vs. Abdominal Myomectomy RALM N=29 Abd Myo N=29 P value EBL (ml) 196 +/- 229 365 +/- 473.0112 LOS (d) 1.48 +/- 0.95 3.62 +/- 1.5 <.0001 OR Time (min) 231 +/- 85 154 +/- 43 <.0001 Advincula AP et al. J Minim Invasive Gynecol. 2007;14(6):698-705 Robot-Assisted L/S Myo vs. Conventional L/S Myo RALM N=15 L/S Myo N=35 P value EBL (ml) 370 (150-500) 500) 420 (110-75).20 LOS (d) 1.00 (1-1) 1) 1.05 (1-3).12 OR time (min) 234 (140-445) 445) 203 (95-330).03 Complications NS Nezhat C et al. Fertil Steril. 2009; 91(2): 556-9
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) 1.2 2.7 <.001 OR time (min) 328 +/- 55 min 225 +/- 61 min <.001 Complications NS Geller EJ et al. Obstet Gynecol. 2008; 112(6):1201-6 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 (205-252) 252) 181 (154-202).001 Time out of work (wk) 0.8 (0.5-2.9) 2.8 (1.0-3.4).013 Pregnancy rates (%) 61 79.10 Rodgers AK et al. Obstet Gynecol. 2007;109:1375-80
Robot-Assisted L/S Adnexectomy vs. Conventional L/S Adnexectomy Robot-Assisted N=85 Conventional L/S N=90 P value EBL (ml) 39 +/- 32 41 +/- 30.65 LOS (d) 0.15 0.28.25 OR time (min) 83 +/- 31 71 +/- 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) 61 113 <.0001 LOS (d) 1.0 1.6 <.007 OR time (min) 119.4 92.4 <.0001 Intra-op conversion to laparotomy (%) 4 8.013 Payne TN, Dauterive FR. J Minim Invasive Gynecol. 2008;15;286-91
Caution: Vaginal Cuff Dehiscence Year 2004 No. of Robotic Procedures 61 No. of Vaginal Cuff Dehiscences 0 Incidence (%) 0 2005 71 1 1.5 2006 97 2 2.1 2007 119 7 5.9 2008 162 11 6.8 Total 510 21 4.1 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
What does robotic surgery cost? davinci Surgical Systems Robot equipment: $1.3 1.65 million Hospital service contract: ~ $150,000 /yr Direct costs per case: $950-1400 Re-usable instruments: $2000 each Expire after 10 cases Each instrument costs $200 per case
Charges and Reimbursement ($) RALM N=29 Abd Myo N=29 P value Professional Charges 5946 +/- 1447 4664 +/- 6689.0002 Hospital Charges 30,084 +/- 6689 13,400 +/- 7747 <.0001 Professional Reimbursement 2263 +/- 1354 1841 +/- 827 NS Hospital Reimbursement 13,181 +/- 10,752 7015 +/- 3467 NS Advincula AP et al. J Minim Invasive Gynecol. 2007;14(6):698-705 Select Itemized Hospital Charges ($) RALM N=29 Abd Myo N=29 P value Operating Room 16,915 2165 <.0001 Anesthesia 445 364.0005 Nursing 1332 2371 <.0001 Laboratory 113 139 NS Pharmacy 255 322 NS Recovery Room 445 474 NS Advincula AP et al. J Minim Invasive Gynecol. 2007;14(6):698-705
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 25-623 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
The Learning Curve Lenihan JP et al. J Minim Invasive Gynecol. 2008;15(5):589-94 Operative Times for Robot-Assisted Hysterectomy Mean Operative Time (min) 180 160 140 120 100 80 60 40 160 134 106 173 145 113 157 118 86 113 79 49 Anesthesia Time Skin to Skin Time Robot Time 20 0 1-25 26-50 51-75 >75 Case Number Payne TN, Dauterive FR. J Minim Invasive Gynecol. 2008;15;286-91
Operative time for 100 Conventional TLH vs. last 25 Robotic TLH cases Mean Operative Time (min) 140 120 100 80 60 40 20 129 114 92.4 78.9 Conventional Robotic 0 Anesthesia Skin-to skin Payne TN, Dauterive FR. J Minim Invasive Gynecol. 2008;15;286-91 Keys to a successful robotic program Dedicated OR team High surgical volume Appropriate patient selection Cooperation between surgical specialties
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