Robot-Assisted Surgery Can Offer Precise Endometriosis Treatment

NEW YORK – With improvements in light sources, hand instrumentation, and energy devices, robot-assisted minimally invasive surgery now offers a level of precision and finesse for treating endometriosis that was not previously available, according to Dr. Arnold Advincula.

"We know that endometriosis tends to compromise anatomical spaces," he said. "Robot-assisted minimally invasive surgery allows you to dissect in the plane of the compromised tissue, thereby minimizing trauma, which is advantageous when dissecting around the ureter or bowel."

Photo Courtesy Dr. Arnold Advincula

Conventional laparoscopic techniques offer limited degrees of motion for the surgeon and 2-D visualization. With robot-assisted surgery, the surgeon sees a 3-D view of the operating field. Additionally, the "endowrist" laparoscopic instruments used in the da Vinci surgical system mimic the full range of human wrist movement, allowing the surgeon 7 degrees of movement compared with 4 degrees of movement with conventional or "straight-stick" laparoscopic surgery; the conventional approach is limited by the "fulcrum effect" in which the hands move left as the instrument tip moves right. With robotic-surgery, the instruments follow the exact movements of the surgeon’s hands. The instrumentation also filters tremors and scales motion, improving precision.

Robotic surgery also offers ergonomic advantages. The surgeon can sit with arms rested. If the surgeon’s arms become hyperextended or flexed during surgery, the arm controls can be temporarily disengaged from the instrument tips to allow a change to a more comfortable position.

Robotic surgery makes it possible to get around obstacles and offers such control that surgeons can carefully dissect and excise diseased tissue layer by layer, said Dr. Advincula, medical director of gynecologic robotics at the Celebration Health Endometriosis Center at Florida Hospital. Robot-assisted surgery can be particularly useful for deeply infiltrating endometriosis of the pelvic peritoneum or ovary (endometriomas). A major strength lies in the robotic system’s ability to be an excellent tool for anatomical surgical dissection. It also can be helpful when accessing difficult-to-reach areas, such as endometriosis within the rectovaginal septum, which can be quite challenging with rigid nonarticulating instrumentation, Dr. Advincula said at the annual congress of the Endometriosis Foundation of America.

In cases where safe peritoneal access cannot be accomplished or significant comorbidities preclude an endoscopic approach, robot-assisted surgery may not be useful.

One criticism of robot-assisted surgery is the lack of tactile cues (haptic feedback). In addition to changes in coloration, endometriosis can be fibrotic, nodular, or cystic and feel thicker than normal tissue, especially if it is infiltrative. Dr. Advincula said he relies on visual cues combined with the knowledge of anatomical structures and dissection planes when performing excisional surgery via robotics. He cautioned that several years of robotic surgery experience are needed to understand and overcome this limitation.

Outcomes research comparing traditional laparoscopic surgery and robotic-assisted endometriosis surgery is limited, he noted. ACOG’s 2009 Technology Assessment in Obstetrics and Gynecology No. 6 on robot-assisted surgery suggested that randomized trials were needed to compare the respective outcomes and costs of robot-assisted surgery with those of traditional laparoscopic, vaginal, or abdominal surgery, and to pinpoint the best applications of robotic technology (Obstet. Gynecol. 2009;114:1153-5). A systematic review published in 2011 (Int. J. Med. Robot. 2011 Dec. 9 [doi:10.1002/rcs.451]) identified only three case reports and one cohort study that used the da Vinci surgical system for endometriosis, and concluded that few studies had been published in the field to date and evidence regarding long-term outcomes was lacking.

In a not-yet-published review of the literature, Dr. Advincula and his colleagues found 21 publications, mostly single cases or case series and one comparative controlled cohort study. The literature is clearly lacking in the area of using robotics for endometriosis surgery, he said. That is why the Celebration Health Endometriosis Center is involved in a multicenter collaboration to track outcomes and determine where advantages and disadvantages exist. As robotic technology evolves, it must be critically evaluated to determine its appropriate applications in endometriosis surgery.

Another problem for patients is that access to surgeons well trained in both the management of endometriosis and the proper use of robotics in gynecologic surgery is limited. "Clearly, when you have 10-20 million women affected by the disease, you can’t have just a handful of people capable of treating the disease. We need skilled surgeons who understand reproductive medicine, are familiar with applying surgical principles to complex cases, and who work in a multidisciplinary fashion in a specialized center to take advantage of a technology like this," said Dr. Advincula.

He said he encourages gynecologists and surgeons who wish to learn more about robot-assisted gynecologic surgery to attend conferences and workshops, such as the World Robotic Gynecology Conference, which provides opportunities to engage in both hands-on training and classroom teaching. Other alternatives are working with a surgical mentor or completing a fellowship in minimally invasive surgery that incorporates the surgical management of endometriosis.

"In the right hands and within the right infrastructure, robotics has the potential to provide women better options and access to cutting-edge care, especially in the area of endometriosis surgery. But as a new surgical frontier, don’t be lulled into thinking robotics per se will make you a better surgeon without the proper training and skill set," cautioned Dr. Advincula.

He said he is a consultant for Cooper Surgical, Ethicon Women’s Health and Urology, and Intuitive Surgical, and that he has received royalties from Cooper Surgical.

NEW YORK – With improvements in light sources, hand instrumentation, and energy devices, robot-assisted minimally invasive surgery now offers a level of precision and finesse for treating endometriosis that was not previously available, according to Dr. Arnold Advincula.

"We know that endometriosis tends to compromise anatomical spaces," he said. "Robot-assisted minimally invasive surgery allows you to dissect in the plane of the compromised tissue, thereby minimizing trauma, which is advantageous when dissecting around the ureter or bowel."

Photo Courtesy Dr. Arnold Advincula

Conventional laparoscopic techniques offer limited degrees of motion for the surgeon and 2-D visualization. With robot-assisted surgery, the surgeon sees a 3-D view of the operating field. Additionally, the "endowrist" laparoscopic instruments used in the da Vinci surgical system mimic the full range of human wrist movement, allowing the surgeon 7 degrees of movement compared with 4 degrees of movement with conventional or "straight-stick" laparoscopic surgery; the conventional approach is limited by the "fulcrum effect" in which the hands move left as the instrument tip moves right. With robotic-surgery, the instruments follow the exact movements of the surgeon’s hands. The instrumentation also filters tremors and scales motion, improving precision.

Robotic surgery also offers ergonomic advantages. The surgeon can sit with arms rested. If the surgeon’s arms become hyperextended or flexed during surgery, the arm controls can be temporarily disengaged from the instrument tips to allow a change to a more comfortable position.

Robotic surgery makes it possible to get around obstacles and offers such control that surgeons can carefully dissect and excise diseased tissue layer by layer, said Dr. Advincula, medical director of gynecologic robotics at the Celebration Health Endometriosis Center at Florida Hospital. Robot-assisted surgery can be particularly useful for deeply infiltrating endometriosis of the pelvic peritoneum or ovary (endometriomas). A major strength lies in the robotic system’s ability to be an excellent tool for anatomical surgical dissection. It also can be helpful when accessing difficult-to-reach areas, such as endometriosis within the rectovaginal septum, which can be quite challenging with rigid nonarticulating instrumentation, Dr. Advincula said at the annual congress of the Endometriosis Foundation of America.

In cases where safe peritoneal access cannot be accomplished or significant comorbidities preclude an endoscopic approach, robot-assisted surgery may not be useful.

One criticism of robot-assisted surgery is the lack of tactile cues (haptic feedback). In addition to changes in coloration, endometriosis can be fibrotic, nodular, or cystic and feel thicker than normal tissue, especially if it is infiltrative. Dr. Advincula said he relies on visual cues combined with the knowledge of anatomical structures and dissection planes when performing excisional surgery via robotics. He cautioned that several years of robotic surgery experience are needed to understand and overcome this limitation.

Outcomes research comparing traditional laparoscopic surgery and robotic-assisted endometriosis surgery is limited, he noted. ACOG’s 2009 Technology Assessment in Obstetrics and Gynecology No. 6 on robot-assisted surgery suggested that randomized trials were needed to compare the respective outcomes and costs of robot-assisted surgery with those of traditional laparoscopic, vaginal, or abdominal surgery, and to pinpoint the best applications of robotic technology (Obstet. Gynecol. 2009;114:1153-5). A systematic review published in 2011 (Int. J. Med. Robot. 2011 Dec. 9 [doi:10.1002/rcs.451]) identified only three case reports and one cohort study that used the da Vinci surgical system for endometriosis, and concluded that few studies had been published in the field to date and evidence regarding long-term outcomes was lacking.

In a not-yet-published review of the literature, Dr. Advincula and his colleagues found 21 publications, mostly single cases or case series and one comparative controlled cohort study. The literature is clearly lacking in the area of using robotics for endometriosis surgery, he said. That is why the Celebration Health Endometriosis Center is involved in a multicenter collaboration to track outcomes and determine where advantages and disadvantages exist. As robotic technology evolves, it must be critically evaluated to determine its appropriate applications in endometriosis surgery.

Another problem for patients is that access to surgeons well trained in both the management of endometriosis and the proper use of robotics in gynecologic surgery is limited. "Clearly, when you have 10-20 million women affected by the disease, you can’t have just a handful of people capable of treating the disease. We need skilled surgeons who understand reproductive medicine, are familiar with applying surgical principles to complex cases, and who work in a multidisciplinary fashion in a specialized center to take advantage of a technology like this," said Dr. Advincula.

He said he encourages gynecologists and surgeons who wish to learn more about robot-assisted gynecologic surgery to attend conferences and workshops, such as the World Robotic Gynecology Conference, which provides opportunities to engage in both hands-on training and classroom teaching. Other alternatives are working with a surgical mentor or completing a fellowship in minimally invasive surgery that incorporates the surgical management of endometriosis.

"In the right hands and within the right infrastructure, robotics has the potential to provide women better options and access to cutting-edge care, especially in the area of endometriosis surgery. But as a new surgical frontier, don’t be lulled into thinking robotics per se will make you a better surgeon without the proper training and skill set," cautioned Dr. Advincula.

He said he is a consultant for Cooper Surgical, Ethicon Women’s Health and Urology, and Intuitive Surgical, and that he has received royalties from Cooper Surgical.

NEW YORK – With improvements in light sources, hand instrumentation, and energy devices, robot-assisted minimally invasive surgery now offers a level of precision and finesse for treating endometriosis that was not previously available, according to Dr. Arnold Advincula.

"We know that endometriosis tends to compromise anatomical spaces," he said. "Robot-assisted minimally invasive surgery allows you to dissect in the plane of the compromised tissue, thereby minimizing trauma, which is advantageous when dissecting around the ureter or bowel."

Photo Courtesy Dr. Arnold Advincula

Conventional laparoscopic techniques offer limited degrees of motion for the surgeon and 2-D visualization. With robot-assisted surgery, the surgeon sees a 3-D view of the operating field. Additionally, the "endowrist" laparoscopic instruments used in the da Vinci surgical system mimic the full range of human wrist movement, allowing the surgeon 7 degrees of movement compared with 4 degrees of movement with conventional or "straight-stick" laparoscopic surgery; the conventional approach is limited by the "fulcrum effect" in which the hands move left as the instrument tip moves right. With robotic-surgery, the instruments follow the exact movements of the surgeon’s hands. The instrumentation also filters tremors and scales motion, improving precision.

Robotic surgery also offers ergonomic advantages. The surgeon can sit with arms rested. If the surgeon’s arms become hyperextended or flexed during surgery, the arm controls can be temporarily disengaged from the instrument tips to allow a change to a more comfortable position.

Robotic surgery makes it possible to get around obstacles and offers such control that surgeons can carefully dissect and excise diseased tissue layer by layer, said Dr. Advincula, medical director of gynecologic robotics at the Celebration Health Endometriosis Center at Florida Hospital. Robot-assisted surgery can be particularly useful for deeply infiltrating endometriosis of the pelvic peritoneum or ovary (endometriomas). A major strength lies in the robotic system’s ability to be an excellent tool for anatomical surgical dissection. It also can be helpful when accessing difficult-to-reach areas, such as endometriosis within the rectovaginal septum, which can be quite challenging with rigid nonarticulating instrumentation, Dr. Advincula said at the annual congress of the Endometriosis Foundation of America.

In cases where safe peritoneal access cannot be accomplished or significant comorbidities preclude an endoscopic approach, robot-assisted surgery may not be useful.

One criticism of robot-assisted surgery is the lack of tactile cues (haptic feedback). In addition to changes in coloration, endometriosis can be fibrotic, nodular, or cystic and feel thicker than normal tissue, especially if it is infiltrative. Dr. Advincula said he relies on visual cues combined with the knowledge of anatomical structures and dissection planes when performing excisional surgery via robotics. He cautioned that several years of robotic surgery experience are needed to understand and overcome this limitation.

Outcomes research comparing traditional laparoscopic surgery and robotic-assisted endometriosis surgery is limited, he noted. ACOG’s 2009 Technology Assessment in Obstetrics and Gynecology No. 6 on robot-assisted surgery suggested that randomized trials were needed to compare the respective outcomes and costs of robot-assisted surgery with those of traditional laparoscopic, vaginal, or abdominal surgery, and to pinpoint the best applications of robotic technology (Obstet. Gynecol. 2009;114:1153-5). A systematic review published in 2011 (Int. J. Med. Robot. 2011 Dec. 9 [doi:10.1002/rcs.451]) identified only three case reports and one cohort study that used the da Vinci surgical system for endometriosis, and concluded that few studies had been published in the field to date and evidence regarding long-term outcomes was lacking.

In a not-yet-published review of the literature, Dr. Advincula and his colleagues found 21 publications, mostly single cases or case series and one comparative controlled cohort study. The literature is clearly lacking in the area of using robotics for endometriosis surgery, he said. That is why the Celebration Health Endometriosis Center is involved in a multicenter collaboration to track outcomes and determine where advantages and disadvantages exist. As robotic technology evolves, it must be critically evaluated to determine its appropriate applications in endometriosis surgery.

Another problem for patients is that access to surgeons well trained in both the management of endometriosis and the proper use of robotics in gynecologic surgery is limited. "Clearly, when you have 10-20 million women affected by the disease, you can’t have just a handful of people capable of treating the disease. We need skilled surgeons who understand reproductive medicine, are familiar with applying surgical principles to complex cases, and who work in a multidisciplinary fashion in a specialized center to take advantage of a technology like this," said Dr. Advincula.

He said he encourages gynecologists and surgeons who wish to learn more about robot-assisted gynecologic surgery to attend conferences and workshops, such as the World Robotic Gynecology Conference, which provides opportunities to engage in both hands-on training and classroom teaching. Other alternatives are working with a surgical mentor or completing a fellowship in minimally invasive surgery that incorporates the surgical management of endometriosis.

"In the right hands and within the right infrastructure, robotics has the potential to provide women better options and access to cutting-edge care, especially in the area of endometriosis surgery. But as a new surgical frontier, don’t be lulled into thinking robotics per se will make you a better surgeon without the proper training and skill set," cautioned Dr. Advincula.

He said he is a consultant for Cooper Surgical, Ethicon Women’s Health and Urology, and Intuitive Surgical, and that he has received royalties from Cooper Surgical.