Trend to Watch: The Rise of Robotic Hysterectomy

Women undergo hysterectomies for a variety of reasons, including benign gynecologic conditions and ovarian cancer. “My approach is to use the surgical technique that’s the best fit for an individual patient,” says Bruce Kahn, MD, director of the Scripps Fellowship in Minimally Invasive Gynecologic Surgery at Scripps Health in San Diego. That includes performing vaginal surgery and laparoscopic procedures, both of which work well and benefit patients, according to Dr. Kahn. However, he prefers to operate with the robot because of the benefits the technology provides.

Surgeons are afforded 3D views of the surgical field, letting them zoom in to see target anatomy in greater detail. They enjoy increased maneuverability with instrumentation thanks to the robot’s six degrees of movement — the in-out, open-close, twist-right, twist-left action of conventional laparoscopic tools plus wrist-like movements to get around corners and improve access to anatomy. “It’s like working with your hands inside the patient,” says Dr. Kahn. “The technology helps surgeons operate more effectively.”

Over the past 16 years, Dr. Lenihan has transitioned to operating almost exclusively with the robot, regardless of the perceived complexity of the procedure. “The advantage of operating with robotic assistance is that you can take on all cases, especially as more involved procedures move to the outpatient setting,” he says. “I think robots will have an influence on the continued migration of cases to ambulatory facilities. There’s no question Enhanced Recovery After Surgery protocols are a big part of that trend, but the robot is playing a part.”

Outcomes in terms of cancer resections and survival rates are comparable between laparoscopic and robotic procedures, according to Dr. Lenihan, but he says patient satisfaction tends to be higher when the robot is used. He once performed a robotic hysterectomy on a female police officer whose mother had a conventional procedure performed a week earlier by another surgeon. “I saw the daughter at her two-week checkup and cleared her to go back on active duty,” says Dr. Lenihan. “Meanwhile, her mother still needed assistance walking up and down stairs and was upset with the difficulty of the recovery.”

Some surgeons believe the vaginal approach is still the most minimally invasive of all the hysterectomy techniques. However, Dr. Lenihan points to studies and his own experience to note that vaginal surgeries are physically taxing for surgeons. The laparoscopic approach is less physically demanding, although ergonomic issues inherent to the technique can cause significant repetitive strain injuries and cut short the careers of high-volume surgeons.

Operating with the robot essentially eliminates those concerns and takes the procedure to another level, according to Dr. Lenihan. “The robot lets surgeons perform better surgeries,” he says. “They have better vision, improved access to the surgical field and better control of the instruments. They can operate more effectively and more comfortably.”

Performing robotic surgery is a learned skill, one Dr. Lenihan equates to flying a plane. He had been operating for 30 years before he started performing robotic hysterectomies. “It was like being a rookie surgeon all over again,” he says. “Trying to learn completely new skill sets is difficult for established surgeons who are trying to build patient volumes or keep pace with current caseloads.”

Plus, points out Dr. Lenihan, many gynecologists focus their practice on labor and delivery and women’s health issues, and therefore aren’t necessarily highly skilled surgeons — at least compared to other specialties. That means some low-volume surgeons don’t have the repetitions needed to master robotic techniques. Dr. Lenihan points to emerging virtual reality training platforms that could flatten the learning curve for surgeons and increase their use of the technology, and ultimately increase access to it for their patients.

Machine learning and artificial intelligence will be incorporated into future generations of robots to help guide surgeons to complete more accurate and safer surgeries, according to Dr. Lenihan. “They will still perform the actual dissections and resections, but the robots will use infrared guidance and overlays to identify the exact locations of instruments in relation to anatomy and exactly where they need to cut,” he explains.

Outpatient hysterectomy is still a developing trend based on the acceptance of the practice among patient populations in specific regions of the country and the preferences of individual surgeons, according to Dr. Kahn. He says Scripps is one of the few programs in the country that performs most hysterectomies on an outpatient basis. 

The health system is now planning to turn an old hospital structure into a surgery center that will house robotic equipment. The new space will allow surgeons to schedule robotic hysterectomies in an outpatient facility where dedicated teams will perform a high volume of procedures. “A team-based approach is one of the keys to success in robotic surgery,” says Dr. Kahn. 

Increasing numbers of robotic platforms will expand use of the technology in the surgery center setting. Younger surgeons who are training on the platforms will also help drive more widespread adoption. “The da Vinci will continue to be the gold standard for the next five to 10 years, but the other platforms, especially those offered by larger companies, will begin to find niches in the market and work their way into more surgical facilities,” says Dr. Lenihan. “I believe we’ll look back to the adoption of robotic hysterectomy in much the same way we now view the move from open to laparoscopic procedures.” OSM