Robotic Surgery in Reproductive Medicine

The most important step in successful robotic surgery happens well before the patient is wheeled into the operating room. First of all, the patient must be a good candidate for the procedure. The best patients are healthy, with a strong heart and good lung capacity.

As opposed to other surgical approaches, weight is less of a factor and overweight patients generally do well with a robotic approach. The target organs – the uterus, ovaries and fallopian tubes – are imaged with ultrasound or MRI (or most often both) to characterize the nature of the abnormality.

If the patient is undergoing robotic surgery for uterine fibroids, their size, number and location must be characterized to make sure that the surgery will be possible with this novel approach. Ovarian cysts must similarly be assessed with imaging, so that the surgeon can anticipate the steps that need to be taken to excise any abnormality.

Primum non nocere- first do no harm- is the physician’s creed, and painstaking preparation for surgery can significantly reduce the chances for complications.

Once the patient is selected and taken into the operating room, she is placed on a well-cushioned surgical bed, and positioned with extraordinary care to make sure that joints, extremities and other tissues are not inadvertently harmed during a procedure that can take three or more hours.

As with traditional laparoscopy, a small incision is created in the umbilicus (the belly button) and carbon dioxide gas is injected into the patient’s abdomen. Without distension, the patient’s organs would all be squeezed together, and the surgeon could not see the target organs and the surgery would not be possible. The surgical bed is also tilted so that the patient is slightly head-down; this position pulls the intestines into the upper abdomen so that the surgeon can see the pelvic organs without obstruction. A lighted camera is then placed through the belly button or slightly above it, and a video monitor attached.

Four additional “ports,” the sleeves that will be used to admit the various instruments, are then placed. Each of these is between one quarter and half an inch in diameter. The small size is critical in reducing the length of time the patient will need to recover from the surgery. Once the ports are placed, the robot (technically the “patient-side cart”) is wheeled toward the patient and the robotic arms are attached to the ports. With the patient safely connected to the robot, the surgeon(s) remove their sterile gowns and gloves, and go to the console to perform the surgical procedure.

The intricate preparation will now pay off and the surgeon will take advantage of the sophisticated technology used in robotic surgery.

The instruments used in robotic surgery are unlike anything found in any other type of medical procedure. The instrument tips can grasp, pick up, cut, laser, sew or do almost anything the surgeon wishes, but does so with a degree of dexterity that is remarkable. This is largely because, using sophisticated software, the instruments can function like human wrists, sewing around corners and getting into restricted areas with much greater precision than can be achieved with traditional open or laparoscopic surgery.

Behind the console, the surgeon can see stereoscopically. This means that the surgeon maintains depth perception which allows for more precise handling of tissues and placement of suture to recreate normal anatomy. In removing fibroids or abnormal cysts, the surgeon can precisely distinguish between normal and abnormal tissue, removing the latter and leaving the former. Precise suture placement allows the surgeon to close defects and reapproximate tissues carefully. Surgeons can now mimic normal anatomy better than ever before.

Once the procedure is complete, the surgeons reapproach the patient bedside for a few finishing touches. If there is a large fibroid to remove, the surgeon can “morcellate” it using a special device that cores the fibroid and allows it to be removed through the small ports.

Abnormal cysts can similarly be removed using sterile “Ziploc” type devices. After a few small stitches or glue reapproximate the skin edges, the patient is awakened and taken to the recovery room. In the majority of cases, the patient can go home after a few hours. With traditional open surgery, the patient would usually stay for an average of three days.

In addition, multiple studies have shown that blood loss is less with robotic surgery than with an open approach. While not all patients are good candidates for robotic surgery, if, after careful preparation, the patient is found to be appropriate for this new approach, the benefits are significant.