Jason D. Wright, MD: I think we need more data on robotic surgery for benign gynecologic disease. To date, the majority of the data are retrospective, with most studies unable to demonstrate an advantage of robotic surgery over laparoscopy. These studies have shown that robotic-assisted surgery is substantially more costly, however. I think there are groups of patients who are likely to benefit from robotic surgery, but we need to better define this group of women.
Arnold P. Advincula, MD: I disagree. Despite some controversy, I believe that use of the robot is justified in hysterectomy for benign indications. In fact, it is in situations like the frozen pelvis from endometriosis, or the scarred anterior cul-de-sac from previous cesarean deliveries, that the robot adds value. Several studies speak to the feasibility, safety, and reproducibility of the robot under those circumstances.10,11 Of course, more recently, studies have challenged the use of robotics in benign gynecologic surgery, particularly hysterectomy. Those studies must be viewed with a critical eye. Individuals often can be swayed by the findings of randomized, controlled trials, but such studies are difficult to perform in surgery and there is really no way to be an expert in both conventional laparoscopy and robotic-assisted laparoscopy. As a surgical tool, a surgeon must commit to developing expertise with one or the other.
An often forgotten aspect that is critical to the success of both conventional laparoscopic surgeons and robotic surgeons is the presence of a well-run infrastructure and team to support the surgery. Without that, costs go up and patient outcomes go down for both approaches.
Jamal Mourad, DO: I agree. I believe there is a definitive justification for the use of the robot in benign gynecology. Most of the nearly 600,000 hysterectomies performed each year in the United States are still done by the open abdominal approach despite recognition that a minimally invasive approach (vaginal or laparoscopic) is the standard of care for benign hysterectomy. I incorporated robotic technology into a very busy laparoscopic practice in 2005. I continue to use laparoscopy as a very important tool in my armamentarium for minimally invasive surgery. As I mentioned earlier, robotic technology allows better visualization, dexterity, maneuverability, and control of the surgical field.
Ultimately, it is about taking care of our patients. Cost and efficiency are extremely important, but the patient is more important. The goal is excellence, not average care!
OBG Management: How would you advise clinicians about when to use the robot in gynecologic surgery?
Rosanne M. Kho, MD: Until the cost of robotic procedures declines (soon, I hope), clinicians need to be vigilant in the use of measures and techniques that help them remain efficient and work safely while performing robotic procedures. Such measures include training a dedicated robotic OR team (including a bedside assistant), optimizing trocar placement and docking time, reducing operative or console time, and minimizing the number of robotic and disposable laparoscopic instruments used per case. There are multiple excellent robotics courses that utilize simulation and cadaveric models that clinicians can make use of to advance their skills.
Cheryl B. Iglesia, MD: I would first advise surgeons to get appropriate training using modules, labs, or a robotic simulator—or all three—that is consistent with institutional and other guidelines.12 Second, get appropriate proctoring for your first few cases. Third, think vaginal first and laparoscopic second for straightforward hysterectomies. Robotic assistance has advantages if a lot of sewing is required (as in myomectomy or sacrocolpopexy) or a lot of dissection in small spaces is needed (such as in lymph node dissection in gynecologic oncology).
It is likely true that robotic training can be enabling technology and can improve a surgeon’s straight-stick laparoscopic skills. Mastering fundamentals of vaginal and laparoscopic surgery is the core to the foundation of gynecologic surgery. Robotic use can be narrowed to certain situations. I am not sure where single-port robotics will lead, but surgeons will need to assess that new technology as well. Most important, volume matters. High-volume surgeons and high-volume centers have the most experience with the fewest complications, as proven in multiple surgical subspecialties—not just gynecology.
Jason D. Wright, MD: I think gynecologic surgeons need to be aware of the lack of data for robotic gynecologic surgery and carefully choose which patients and procedures they utilize the robot for. Unfortunately, many of the claims of benefit of the robot are not supported by high-quality research.
Although the added costs of robotic surgery may not have an immediate impact, in the long term these costs will almost certainly be passed on not only to patients and hospitals but also to physicians.