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Will Robotic Hysterectomy Catch On?

Surgeons Weigh the Benefits and Costs of This New Type of Surgery

New York (May 15, 2009)

Patient and doctor in operating room

The benefits of robotic surgery have been well documented: smaller incisions, less blood loss, shorter hospital stays, and a faster recovery. These advantages have been widely observed among surgeons using the technique to remove prostate cancers. In more recent years, gynecologic oncologists at NewYork-Presbyterian Hospital have been utilizing surgical robots to perform hysterectomies in patients with endometrial and cervical cancers.

"The dexterity of the robot tools and the three-dimensional magnified view of the surgical field bring all of the comforts of open abdominal surgery to the minimally invasive setting," explained Kevin Holcomb, MD, an obstetrician and gynecologist at NewYork-Presbyterian Hospital.

The benefits of robotic hysterectomy have been documented by others too. For example, University of North Carolina researchers showed that patients with early-stage cervical cancer who had the robotic approach experienced a shorter operative time, less blood loss, a shorter inpatient stay (1 vs. 3.2 days), and less than half the incidence of complications (7.8 percent vs. 16.3 percent) compared with those who had conventional open abdominal hysterectomy. The robotic approach also enabled surgeons to remove more lymph nodes for analysis.

Robots Good, But Skilled Surgeons Still Needed

Like other technological advances in surgery, the robot is but a tool that still requires the skill of a trained surgeon. During the procedure, the surgeon sits comfortably at a console, viewing the surgical field through the robot's "vision system." He uses hand and foot controls to operate the various arms and cameras of the robot, which are placed into position by surgical assistants.

The hand controls scale down the surgeon's movements into precise micro-movements with a 360-degree range of motion, and also enable the surgeon to zoom the camera in or out of the surgical field. The foot pedals allow the hand controls to switch between manipulating the camera and the robotic arms. The foot pedals are also used to manipulate cautery instruments that control bleeding.

During robotic hysterectomy, the incisions are made in the abdomen and the uterus is removed through the vaginal canal; the operation takes about four hours for the hysterectomy plus removal of pelvic lymph nodes to analyze them for cancer cells.

Who Qualifies for a Robotic Hysterectomy?

Not all hysterectomy patients are candidates for the robotic approach, however. Thomas Herzog, MD, also an obstetrician and gynecologist at NewYork-Presbyterian, explained that the technique is especially well suited for obese patients (which accounts for most patients with endometrial cancer) and for the removal of certain pelvic lymph nodes. "However, the robotic system does enable surgeons who are more familiar with conventional open hysterectomy than laparoscopy to perform minimally invasive procedures, making this approach available to more patients," he added.

Dr. Holcomb offers the robotic approach to any of his patients who are candidates for laparoscopy (a minimally invasive abdominal surgical approach), but he does not use it for anything less than a hysterectomy. "We have to draw the line where robotics is overkill," he noted. "There are cost concerns to consider."

Dr. Herzog also emphasized that the high cost of the robotic platform needs to be taken into consideration when choosing the best gynecologic surgery for a patient. "The robotic approach is not necessarily better than conventional laparoscopy in all cases," he said. "We need to do more cost studies to determine the most appropriate use, especially in this era of healthcare reform."

"Robotics is not a fad. It's here to stay," concluded Dr. Holcomb. "I think it's going to grow in use and acceptance."

Faculty Contributing to this Article:

Kevin Holcomb, MD is an Associate Attending Obstetrician and Gynecologist at NewYork-Presbyterian Hospital, and an Associate Professor of Clinical Obstetrics and Gynecology at Weill Cornell Medical College.

Thomas Herzog, MD is an Attending Obstetrician and Gynecologist at NewYork-Presbyterian Hospital, and a Professor of Clinical Obstetrics and Gynecology at Columbia University College of Physicians and Surgeons.

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