Committee Opinion No. 628: Robotic Surgery in Gynecology

Visceral Adipose Tissue Percentage Compared to Body Mass Index as Better Indicator of Surgical Outcomes in Women With Obesity and Endometrial Cancer

STUDY OBJECTIVE

To assess the impact visceral adipose tissue percentage (VAT%) on surgical outcomes during minimally invasive surgery in obese women with endometrial cancer.

DESIGN

Retrospective observational cohort study.

SETTING

Mie University Hospital, Japan.

PATIENTS

Of the 73 women (body mass index [BMI] >30 kg/m2) with obesity and primary endometrial cancer, 52 underwent robotic surgery, while 21 underwent laparoscopic surgery between April 2014 and December 2022.

INTERVENTIONS

We investigated the correlation between surgical outcomes (operative time and blood loss) and obesity (BMI and visceral adipose tissue percentage [VAT%]).

MEASUREMENTS AND MAIN RESULTS

Abdominal fat-related parameters were measured at the level of the umbilicus using preoperative computed tomography. A weak negative correlation was found between BMI and VAT% (CC = -0.313, p = .001). Multivariate analysis showed that VAT% had a stronger correlation to total and practical operative time than BMI (β = 0.338 vs 0.267, β = 0.311 vs 0.209, respectively) and was an independent predictor of blood loss. VAT% was an independent predictive marker prolonged for operative time and increased blood loss during lymphadenectomy.

CONCLUSION

VAT% could be an indicator of surgical outcomes for patients with obesity and endometrial cancer.

[The Importance of Feedback in Proctoring in Robotic Surgery - a Cornerstone of the Concept of Success?]

Robot-assisted surgical methods are a development and supplement to conventional laparoscopy. Thus, appropriate training of surgeons in this specialty is indispensable. Especially for the initial phase, simulation programs - similar to those used in aviation - are ideally suited to introduce surgeons to the technically challenging surgical procedure. Later on, but still at the beginning of the learning curve, proctoring has proven its worth in order to allow the surgeon to be trained on site, to train him individually and to introduce him to more complex cases. An essential component of successful training concepts is the feedback: after some time and in written form, the surgeon to be trained receives a summary or a guideline, which describes the existing situation as well as suggestions for improvement and future potential. The implementation of such feedback allows the surgeon, in addition to the number of cases completed, to put his self-assessment into perspective and adjust development goals. Thus, feedback is the crucial interface between the beginning of a learning curve and advanced surgical skills, including the possibility of realistic self-assessment.

Development of an affordable, immersive model for robotic vaginal cuff closure: a randomized trial

Safe and secure closure of the vaginal cuff is a critical component of a robotic assisted hysterectomy procedure. Our aim in this study is to develop and validate a novel vaginal cuff closure model (VC) created from porcine heart that allows trainees to obtain competency in a low-risk environment. Ten expert and 20 novice robotic surgeons performed a cuff closure exercise on the VC model and on the dV-Trainer^®, a virtual reality simulator (VR). Performances were timed, videotaped, and scored using the modified Global Evaluative Assessment of Robotic Skills (mGEARS) score. Expert robotic surgeons completed the task faster on both the VR (531 vs. 814 s, p = 0.03) and the VC platforms (311 vs. 631 s, p < 0.001) and achieved higher mGEAR scores (32.25 vs. 22.07, p < 0.0001). Knot quality and suturing accuracy were better in the VC than in the VR environment in both groups. In a post-completion survey, both expert and novice surgeons expressed strong preference towards the VC model. In this study, the novel VC model proved to be a reliable simulation tool with high face, content, and construct validity. Due to its simplicity and low cost, this high-yield simulation exercise can easily be incorporated into robotic training curricula of obstetrics and gynecology residents.

A resident robotic curriculum utilizing self-selection and a web-based feedback tool

To describe an obstetrics and gynecology residency robotic curriculum, facilitated by a web-based feedback and case-tracking tool, allowing for self-selection into advanced training. Phase I (Basic) was required for all residents and included online training modules, online assessment, and robotic bedside assistant dry lab. Phase II (Advanced) was elective console training. Before live surgery, 10 simulation drills completed to proficiency were required. A web-based tool was used for surgical feedback and case-tracking. Online assessments, drill reports, objective GEARS assessments, subjective feedback, and case-logs were reviewed (7/2018-6/2019). A satisfaction survey was reviewed. Twenty four residents completed Phase I training and 10 completed Phase II. To reach simulation proficiency, residents spent a median of 4.1 h performing required simulation drills (median of 10 (3, 26) attempts per drill) before live surgery. 128 post-surgical feedback entries were completed after performance as bedside assistant (75%, n = 96) and console surgeon (5.5%, n = 7). The most common procedure was hysterectomy 111/193 (58%). Resident console surgeons performed portions of 32 cases with a mean console time of 34.6 ± 19.5 min. Mean GEARS score 20.6 ± 3.7 (n = 28). Mean non-technical feedback results: communication (4.2 ± 0.8, n = 61), workload management (3.9 ± 0.9, n = 54), team skills (4.3 ± 0.8, n = 60). Residents completing > 50% of case assessed as "apprentice" 38.5% or "competent" 23% (n = 13). After curriculum change, 100% of surveyed attendings considered residents prepared for live surgical training, vs 17% (n = 6) prior to curriculum change [survey response rate 27/44 (61%)]. Attendings and residents were satisfied with curriculum; 95% and recommended continued use 90% (n = 19).This two-phase robotic curriculum allows residents to self-select into advanced training, alleviating many challenges of graduated robotic training.

Robotic-Assisted Surgery for the Treatment of Breast and Cervical Cancers

Background:

Robotic-assisted surgery facilitates the performance of numerous, complex procedures, namely conferring precision, flexibility, and control that is otherwise unavailable with conventional laparoscopy; and compared to open surgery, robotic-assisted surgery is ostensibly associated with fewer complications, reduced intraoperative complications, and shorter hospital stay duration. Nevertheless, the American College of Obstetricians and Gynecologists and the Food and Drug Administration have criticized the pervasive acceptance of robotic-assisted surgery, given the absence of randomized clinical trial data compared to traditional laparoscopy and open procedures, not to mention the increased surgical cost.

Conclusions:

While the research data continue to be borne out, surgeons should exercise considerable discretion in selecting the surgical approach from which their patients would derive the greatest clinical benefit.

Surgeon satisfaction and outcomes of tele-proctoring for robotic gynecologic surgery

Surgical proctoring requires increasing resources in growing healthcare systems. In addition, travel has become less safe in the era of COVID-19. This study demonstrates surgeon satisfaction and safety with tele-proctoring in robotic gynecologic surgery. This pilot study assesses surgeon satisfaction and operative outcomes with a novel operative tele-proctoring system with a continuous two-way video-audio feed that allows the off-site surgeon to see the operating room, surgical field, and hands of the robotic surgeon. After thorough system testing, two experienced surgeons underwent tele-proctoring for hospital credentialing, completing 7 total cases. Each completed pre- and post-surveys developed from the Michigan Standard Simulation Experience Scale. Surgical characteristics were compared between tele-proctored cases and 59 historical cases proctored in-person over the last 8 years. Surgeons reported unanimous high satisfaction with tele-proctoring (5 ± 0). There were no major technologic issues. Five of the tele-proctored cases and 35 of controls were hysterectomies. Mean age was 48.2 ± 1.4 years, mean BMI was 29.6 ± 0.9 kg/m², and mean uterine weight was 152 ± 112.3 g. Two-thirds had prior abdominal surgery (P > 0.1). Tele-proctored hysterectomies were 58 ± 6.5 min shorter than controls (P = 0.001). There were no differences in EBL or complication rates (P > 0.1). Tele-proctoring resulted in high surgeon satisfaction rates with no difference in EBL or complications. Tele-mentoring is a natural extension of tele-proctoring that could provide advanced surgical expertise far beyond where we can physically reach.

Residents' Confidence in Performing Robotic Hysterectomy in Obstetrics and Gynecologic Training Programs

STUDY OBJECTIVE

To compare residents' perceptions of readiness to perform robotic-assisted laparoscopic hysterectomy with the perceptions of residency program directors in obstetrics and gynecology programs throughout the United States.

DESIGN

A survey was administered to all residents taking the 2019 Council on Resident Education in Obstetrics and Gynecology Exam and concurrently to program directors in all Accreditation Council for Graduate Medical Education-accredited training programs.

SETTING

The survey was designed to assess resident confidence to perform robotic hysterectomies by the time of graduation.

PATIENTS

No patients were included in the study.

INTERVENTIONS

The only intervention was administration of the survey.

MEASUREMENTS AND MAIN RESULTS

De-identified survey data were analyzed using chi-squared and Fisher's exact tests. A total of 5473 resident respondents and 241 residency program directors were included in the study. Fifty-two percent of graduating residents reported that they felt they were given surgical autonomy to perform robotic hysterectomies, and 53.7% reported that they could perform one independently (if it was an "emergency" and they had to). By the time of graduation, only 59% of residents reported confidence performing a robotic hysterectomy, and only 56% reported they felt that it would be an important procedure for their future career. Program directors were significantly more likely to report that their residents were given autonomy to perform robotic hysterectomy by graduation (61.0% [95% confidence interval (CI), 54.3-67.3]), could perform a robotic hysterectomy independently (60.9% [95% CI, 53.9-67.6]), or could perform a robotic hysterectomy by graduation (70.2% [95% CI, 63.5-76.3]) than residents themselves (38.6% [95% CI, 37.2-40.0], 22.8% [95% CI, 21.6-24.0], 62.6% [95% CI, 61.2-64.0], respectively).

CONCLUSION

At the time of graduation, residents' confidence in performing robotic hysterectomy independently is lower than their confidence in performing all other approaches to hysterectomy.

Senhance surgical system in benign hysterectomy: A real-world comparative assessment of case times and instrument costs versus da Vinci robotics and laparoscopic-assisted vaginal hysterectomy procedures

OBJECTIVES

Comparison of retrospective, learning curve benign hysterectomy cost and case time data from Senhance total laparoscopic hysterectomy (TLH) cases with similar da Vinci robot cases and laparoscopic-assisted vaginal hysterectomy (LAVH) cases.

METHODS

Instrument costs, console time, and case time analysis from six surgeons at four U.S. and European hospitals compared with retrospective, sequential da Vinci TLH and standard laparoscopic LAVH cases extracted from the CAVAlytics database.

RESULTS

Senhance Gyn surgeons in their learning curve when compared to da Vinci learning curve Gyn surgeons achieved lower median instrument costs ($559 vs. $1393, respectively, p < 0.001) with comparable console times (91.5 vs. 96 min, p = 0.898); Senhance and LAVH case costs were comparable ($559 vs. $498, p = 0.336).

CONCLUSION

In benign hysterectomy, the Senhance system may present a lower-cost approach with equivalent case times compared with similar da Vinci robotic cases.

Robotic-Assisted Laparoscopic Hysterectomy for Endometrial Hyperplasia or Grade 1 Endometrial Adenocarcinoma: A 10-year, Single-Centre Experience

OBJECTIVE

To describe the outcomes of patients undergoing robotic-assisted laparoscopic hysterectomy for grade-1 endometroid endometrial cancer or endometrial hyperplasia at our centre.

METHODS

Retrospective chart review was completed for 160 patients who underwent robotic-assisted laparoscopic hysterectomy by 5 general gynaecologists in a tertiary care setting between September 2008 and September 2018. Outcomes collected included operative time, estimated blood loss, length of stay, perioperative complications, readmissions, and recurrences. Subgroup analysis was completed after stratifying by body mass index (BMI; 3 groups: A, <40 kg/m²; B, 40-50 kg/m²; and C, >50 kg/m²). Subgroups were compared with ANOVA or Fisher exact test.

RESULTS

The intraoperative complication rate was 3%. The rate of conversion to laparotomy was 2%, and the rate of bowel injury, 1%. The postoperative complication rate was 8%. The rate of major postoperative complications was 4%, and 3% of patients required readmission postoperatively. The mean BMI was 43 (range 21-71) kg/m². There were no differences in perioperative complication, readmission, or recurrence rates between subgroups. Groups B and C were more likely to have had an ASA of 3-4, suggesting a higher burden of comorbidity. Operating room time, procedure time, and estimated blood loss were higher in group C.

CONCLUSION

Despite this cohort's mean BMI falling within the category of class III obesity, complication and conversion rates were similar to those reported in the literature and did not increase with BMI, despite an increased comorbidity burden. These results suggest that robotic surgery is a safe and effective method for providing minimally invasive surgery to a technically challenging population.

Conversion rate of laparoscopic or robotic to open sacrocolpopexy: are there associated factors and complications?

OBJECTIVES

To evaluate the conversion rate of laparoscopic or robotic to open sacrocolpopexy and to identify associated factors in a large population-based database.

METHODS

We used Health Care Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) databases 2005-2014. We extracted data on apical suspension and synthetic mesh with laparoscopy or robot in adult women using International Classification of Diseases, ninth edition, Clinical Modification (ICD-9-CM) codes. We evaluated the rate of conversion and used logistic regression to study the association with risk factors.

RESULTS

We identified 3295 women with laparoscopic or robotic sacrocolpopexies. There were 2777 robotic procedures with 37 conversion (1.33%) and 518 laparoscopic procedures with 37 conversions (7.14%), with an overall conversion rate of 2.2%. Median age was 62 years [interquartile range (IQR) = 55-69]. Concomitant hysterectomy was significantly more frequent in the robotic than laparascopic group (41.7% versus 13.9%, p < 0.01) and was not associated with conversion. Factors associated with lower conversion included a robotic approach (adjusted odd ratio (aOR) 0.32 [95% CI 0.19-0.54]) and private insurance (aOR 0.53 [95% CI 0.32-0.86]). Factors associated with higher conversion were obesity (aOR 3.27 [95% CI 1.72-6.19]) and lysis of adhesions (aOR 3.32 [95% CI 1.89-5.85]). Accidental organ puncture was significantly associated with conversion (14.9% versus 3.8%; p < 0.01).

CONCLUSION

In this American database, the rate of conversion of laparoscopic or robotic to open sacrocolpopexy was low. The majority (84%) of minimally invasive sacrocolpopexies used a robotic approach, which was associated with a lower risk of conversion. Obesity and lysis of adhesions were associated with a higher risk of conversion.

Robotic versus laparoscopic hysterectomy in morbidly obese women for endometrial cancer

Surgery is the mainstay treatment for endometrial cancer and complex atypical endometrial hyperplasia. These conditions are more common in the obese women and as such these patients pose additional risks and challenges to surgery. Laparoscopic hysterectomy (LH) is preferred over open surgery in obese patients as it reduces surgical morbidity. However, more recently, robotic-assisted hysterectomy (RH) has been used in morbidly obese patients to overcome the limitations of conventional laparoscopy. To compare the surgical outcomes of morbidly obese patients undergoing LH or RH for endometrial cancer or complex atypical hyperplasia. A retrospective analysis of morbidly obese patients (BMI > 40 kg/m²) who underwent LH or RH for endometrial cancer or complex atypical hyperplasia at the Chris O'Brien Lifehouse Gynaecological Oncology Unit from 2015 to 2019 was performed. Data was collected from the prospectively maintained gynaecology oncology database and descriptive analysis was performed. 33 (51.6%) underwent LH and 31 (48.4%) had RH. More LHs were performed 2015-2017 period, whereas there were more RHs performed in 2018-2019 period (p = 0.01). The difference between theatre time use and operating time for LH surgery compared to RH was significantly shorter (45.7 for LH versus 61.9 min for RH, p = 0.009). RH was performed more commonly when BMI was > 50 kg/m² (p = 0.02). There has been an increase in the use of RH in morbidly obese patients, particularly for women with a BMI > 50 kg/m².

Robotic versus laparoscopic hysterectomy; comparison of early surgical outcomes

Objective

To compare early surgical outcomes of robotic assisted laparoscopic hysterectomy with laparoscopic hysterectomy for benign diseases, in terms of operation time, estimated blood loss (EBL), perioperative complications, hospital stay and first gas discharge.

Material and Methods

Medical records of 146 patients who either underwent laparoscopic (n=84) or robotic assisted laparoscopic hysterectomy (n=62) for benign diseases were extracted from records. Demographic characteristics and operation time, EBL, length of hospital stay and first gas discharge were compared between the groups.

Results

Mean age and mean body mass index of both groups were comparable. The difference in the mean EBL was not statistically significant between laparoscopic (91±65 mL) and robotic group (80±37 mL, p=0.43). The difference in the mean first gas discharge time was not statistically different between laparoscopic (15±5 hours) and robotic group (17±6 hours, p=0.33). The length of hospital stay was comparable between groups (1.4±0.5 vs 1.5±0.7 days, p=0.64). The mean operation time was longer for the robotic group (150±180 minimum) when compared with laparoscopic group (105±18 minimum, p<0.01). The mean uterine weight of the robotic group was significantly heavier compared with laparoscopic group (234±157 grams vs 153±119 grams, respectıvely, p<0.01).

Conclusion

Early surgical outcomes of robotic assisted laparoscopic and laparoscopic hysterectomy were comparable in terms of EBL, first gas discharge and hospital stay. Operation time was longer for robotic hysterectomy.

Short-term outcomes of robot-assisted versus conventional laparoscopic surgery for early-stage endometrial cancer: A retrospective, single-center study

AIM

We compared the short-term outcomes between conventional laparoscopic surgery (CLS) and robot-assisted surgery (RAS) to assess the technical feasibility of the latter for early-stage endometrial cancer.

METHODS

We retrospectively compared the perioperative outcomes between two groups of 223 patients (CLS group, n = 102; RAS group, n = 121) with early-stage endometrial cancer. Surgical procedures included hysterectomy, bilateral salpingo-oophorectomy and retroperitoneal lymphadenectomy. We analyzed the data from intrapelvic surgery alone because para-aortic lymphadenectomy was performed via conventional endoscopic extraperitoneal approach without robot for both groups.

RESULTS

No differences were identified in patients' age and body mass index. The mean operative time was 133 ± 28 versus 178 ± 41 min (P < 0.01), mean blood loss was 196 ± 153 versus 237 ± 146 mL (P = 0.047), mean length of postoperative hospital stay was 9 ± 4 versus 8 ± 3 days (P = 0.01) and mean rate of perioperative complications of Clavien-Dindo grade III or higher was 2.0 versus 3.4% (P = 0.53) for the CLS versus RAS groups, respectively. There was no significant difference in the number of resected lymph nodes.

CONCLUSION

The operative time was significantly longer and blood loss was significantly greater in the RAS group than in the CLS group, without a significant difference in the number of resected lymph nodes. These differences are within an acceptable clinical range, showing that RAS is feasible and safe for early-stage endometrial cancer, providing short-term outcomes comparable to those of conventional surgery. Future studies are warranted to compare the long-term oncological outcomes by extending the observation period and including para-aortic lymphadenectomy data.

Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214

Pelvic organ prolapse (POP) is a common, benign condition in women. For many women it can cause vaginal bulge and pressure, voiding dysfunction, defecatory dysfunction, and sexual dysfunction, which may adversely affect quality of life. Women in the United States have a 13% lifetime risk of undergoing surgery for POP (). Although POP can occur in younger women, the peak incidence of POP symptoms is in women aged 70-79 years (). Given the aging population in the United States, it is anticipated that by 2050 the number of women experiencing POP will increase by approximately 50% (). The purpose of this joint document of the American College of Obstetricians and Gynecologists and the American Urogynecologic Society is to review information on the current understanding of POP in women and to outline guidelines for diagnosis and management that are consistent with the best available scientific evidence.

Achieving robotic program best practice performance and cost versus laparoscopy: Two case studies define a framework for optimization

BACKGROUND

Robotic surgery is seen by many hospital administrators and surgeons as slower and more expensive than laparoscopic surgery despite the implementation of commonly held robotic best practices. Multiple factors, including surgeon learning curves and program governance, are often overlooked, precluding optimal robotic program performance.

METHODS

An assessment of several leading robotic surgery publications is presented followed by real-world case studies from two US hospitals: an existing robotic program in a mid-sized, regional hospital system and a small, rural hospital that launched a new program.

RESULTS

Improvements in robotic surgery costs/program efficiency were seen at the hospital system vs baseline at 18 months post-implementation; and high-performance robotic efficiency and cost benchmarks were matched or surpassed at the rural hospital at 1 year post-launch.

DISCUSSION

When best practices are utilized in robotic programs, surgical case times, costs, and efficiency performance metrics equaling or exceeding laparoscopy can be achieved.

Laparoscopic and robotic hysterectomy in endometrial cancer patients with obesity: a systematic review and meta-analysis of conversions and complications

OBJECTIVE DATA

Robotic assistance may facilitate completion of minimally invasive hysterectomy, which is the standard of care for the treatment of early-stage endometrial cancer, in patients for whom conventional laparoscopy is challenging. The aim of this systematic review was to assess conversion to laparotomy and perioperative complications after laparoscopic and robotic hysterectomy in patients with endometrial cancer and obesity (body mass index, ≥30 kg/m²).

STUDY

We systematically searched MEDLINE, EMBASE, and Evidence-Based Medicine Reviews (January 1, 2000, to July 18, 2018) for studies of patients with endometrial cancer and obesity (body mass index, ≥30 kg/m²) who underwent primary hysterectomy.

STUDY APPRAISAL AND SYNTHESIS METHODS

We determined the pooled proportions of conversion, organ/vessel injury, venous thromboembolism, and blood transfusion. We assessed risk of bias with the Institute of Health Economics Quality Appraisal Checklist for single-arm studies, and Newcastle-Ottawa Quality Scale for double-arm studies.

RESULTS

We identified 51 observational studies that reported on 10,800 patients with endometrial cancer and obesity (study-level body mass index, 31.0-56.3 kg/m²). The pooled proportions of conversion from laparoscopic and robotic hysterectomy were 6.5% (95% confidence interval, 4.3-9.9) and 5.5% (95% confidence interval, 3.3-9.1), respectively, among patients with a body mass index of ≥30 kg/m², and 7.0% (95% confidence interval, 3.2-14.5) and 3.8% (95% confidence interval, 1.4-9.9) among patients with body mass index of ≥40 kg/m². Inadequate exposure because of adhesions/visceral adiposity was the most common reason for conversion for both laparoscopic (32%) and robotic hysterectomy (61%); however, intolerance of the Trendelenburg position caused 31% of laparoscopic conversions and 6% of robotic hysterectomy conversions. The pooled proportions of organ/vessel injury (laparoscopic, 3.5% [95% confidence interval, 2.2-5.5]; robotic hysterectomy, 1.2% [95% confidence interval, 0.4-3.4]), venous thromboembolism (laparoscopic, 0.5% [95% confidence interval, 0.2-1.2]; robotic hysterectomy, 0.5% [95% confidence interval, 0.1-2.0]), and blood transfusion (laparoscopic, 2.8% [95% confidence interval, 1.5-5.1]; robotic hysterectomy, 2.1% [95% confidence interval, 1.6-3.8]) were low and not appreciably different between arms.

CONCLUSION

Robotic and laparoscopic hysterectomy have similar rates perioperative complications in patients with endometrial cancer and obesity, but robotic hysterectomy may reduce conversions because of positional intolerance in patients with morbid obesity. Existing literature is limited by selection and confounding bias, and randomized trials are needed to inform practice standards in this population.

The current state and the future of robotic surgery in female pelvic medicine and reconstructive surgery

In this article, we review the current uses and future directions of robotic surgery in the field of female pelvic medicine and reconstructive surgery. Pelvic surgery is ideal for the use of surgical robots, which provide improved visualization and ease of suturing deep within the pelvis. Robots have been successfully used for the treatment of pelvic organ prolapse, in procedures such as sacrocolpopexy, sacrohysteropexy, and uterosacral ligament plication. Surgeons have used the robotic successfully to treat various etiologies of female pelvic pain including fibroids, endometriosis, and nerve entrapment. Robotic repair of iatrogenic injury has been described with excellent outcomes and avoidance of conversion to open surgery in the event of an injury caused using the robotic platform. While more data is needed on this topic, there has been increasing interest in using the robot for urologic reconstruction including repair of vesico-vaginal fistula, cystectomy, augmentation cystoplasty, and continent and non-continent diversions. Recently the use of the robot has been described in the treatment of stress urinary incontinence in females, with robotic placement of an artificial urinary sphincter. While robotic surgery is associated with increased cost, the outcomes of robotic surgery in female urology are promising. More studies that properly evaluate the benefits of robotic surgery as compared to open and laparoscopic approaches are needed.

Hospital factors strongly influence robotic use in general surgery

BACKGROUND

We hypothesized that general surgeons are more likely to use a robotic surgical platform at hospitals where more urologic and gynecologic robotic operations are performed, suggesting that hospital-related factors are important for choice of usage of minimally invasive platforms.

METHODS

We queried the National Inpatient Sample from 2010 to 2014 for patients who underwent stomach, gallbladder, pancreas, spleen, colon and rectum, or hernia (general surgery), prostate or kidney (urologic surgery), and ovarian or uterine surgery (gynecologic surgery). Hospitals were grouped into quartiles according to percent volume of robotic urologic or gynecologic operations. Multivariable logistic regression modeling determined independent variables associated with robotics.

RESULTS

Survey-weighted results represented 482,227 open, 240,360 laparoscopic, and 42,177 robotic general surgical operations at 3,933 hospitals. Robotics use increased with each year studied and was more likely to be performed on younger men with private insurance. The odds of a general surgery patient receiving a robotic operation increased with urologic and gynecologic use at the hospital. Patients at top quartile hospitals for robotic urologic surgery had 1.34 times greater odds of receiving robotic general surgery operations (confidence interval 1.15-1.57, P < .001) and 1.53 times greater odds (confidence interval 1.32-1.79, P < .001) at top quartile robotic gynecologic hospitals. These findings were independent of study year, surgical site, insurance type, and hospital type and persisted when only comparing laparoscopic to robotic procedures.

CONCLUSION

Use of robotics in general surgery is independently associated with use in urologic and gynecologic surgery at a hospital, suggesting that institutional factors are important drivers of use when considering laparoscopy versus robotics in general surgery.

The age of robotic surgery - Is laparoscopy dead?

Introduction

Robot-assisted laparoscopic surgery (RALS) has become a widely used technology in urology. Urological procedures that are now being routinely performed robotically are: radical prostatectomy (RP), radical cystectomy (RC), renal procedures - mainly partial nephrectomy (PN), and pyeloplasty, as well as ureteric re-implantation and adrenalectomy.

Methods

This non-systematic review of the literature examines the effectiveness of RALS compared with conventional laparoscopic surgery for the most relevant urological procedures.

Results

For robot-assisted RP there seems to be an advantage in terms of continence and potency over laparoscopy. Robot-assisted RC seems equal in terms of oncological outcome but with lower complication rates; however, the effect of intracorporeal urinary diversion has hardly been examined. Robotic PN has proven safe and is most likely superior to conventional laparoscopy, whereas there does not seem to be a real advantage for the robot in radical nephrectomy. For reconstructive procedures, e.g. pyeloplasty and ureteric re-implantation, there seems to be advantages in terms of operating time.

Conclusions

We found substantial, albeit mostly low-quality evidence, that robotic operations can have better outcomes than procedures performed laparoscopically. However, in light of the significant costs and because high-quality data from prospective randomised trials are still missing, conventional urological laparoscopy is certainly not 'dead' yet.

Setting Benchmarks for the New User: Training on the Robotic Simulator

Background and Objectives:

Data showing the impact of the robotic simulator on fellowship training are limited. This study was conducted to determine whether simulator scores reflect the experience of the robotic gynecologic surgeon and to develop a simulator curriculum for trainees in gynecologic oncology.

Methods:

All faculty and fellows in the Department of Gynecologic Oncology and Reproductive Medicine were asked to participate. For phase 1, all participants were divided into 2 groups based on robotic surgical experience: beginner (0–50 cases) and experienced (>50 cases). Each participant completed 9 modules 3 times each to establish baseline data. Median module scores for the experienced group defined the benchmarks scores. In phase 2, all trainees who did not meet the benchmark score on a module were asked to repeat the module until they reached the score twice.

Results:

Twenty-four participants were included: 18 beginners and 6 experienced surgeons. For all modules, experienced surgeons received higher median scores than beginners. There was a significant difference between the scores of the 2 groups in the Energy Switching 1 (87.5 vs 92.5; P = .002) and Suture Sponge 2 (75.0 vs 87.3; P = .011) modules. Thirteen trainees participated in phase 2. For 8 of 9 of the modules, >75% of trainees met proficiency, with a median of 3 to 6 attempts (range, 2–24).

Conclusion:

Based on the findings, scores reflected each surgeon's experience. With repetition, most of the trainees were able to reach the benchmark scores. Further study is needed to determine the impact of surgical simulation on true intraoperative performance.

Best Practices for Robotic Surgery Programs

Background and Objectives:

Robotic surgical programs are increasing in number. Efficient methods by which to monitor and evaluate robotic surgery teams are needed.

Methods:

Best practices for an academic university medical center were created and instituted in 2009 and continue to the present. These practices have led to programmatic development that has resulted in a process that effectively monitors leadership team members; attending, resident, fellow, and staff training; credentialing; safety metrics; efficiency; and case volume recommendations.

Results:

Guidelines for hospitals and robotic directors that can be applied to one's own robotic surgical services are included with examples of management of all aspects of a multispecialty robotic surgery program.

Conclusion:

The use of these best practices will ensure a robotic surgery program that is successful and well positioned for a safe and productive environment for current clinical practice.

Time to consider integration of a formal robotic-assisted surgical training program into obstetrics/gynecology residency curricula

The objectives of the study were to describe robotic-assisted surgery training programs currently being used by ACGME-accredited obstetrics and gynecology (OB/Gyn) residency programs and to explore residents' attitudes towards their robotic surgery training curricula to evaluate resident desire for robotics training. We conducted a cross-sectional study of OB/Gyn residents for the 2015-2016 academic year. Participants completed a 31-item online questionnaire regarding their robotic-assisted surgical training and associated perspectives. Analyses of these data were primarily descriptive. In total, 98.9% of included respondents (N = 177) reported availability of a surgical robot at their training institution, and 35.0% of participants reported not having any structured robotics training program at their institution. The most commonly used training modalities included online modules (62.2%), dual-assist console (55.1%) and virtual reality simulation (50.3%). The most commonly reported barriers to completing a robots training were a lack of personal time (56.2%) and availability of the virtual reality simulator or access to the robotic equipment (29.2%). OB/Gyn residents desire robotics training and are exposed to a wide variety of training modalities. The ACGME should consider recommending the incorporation of a standardized formal robotics training program as part of the OB/Gyn residency curriculum.

The Essential Elements of a Robotic-Assisted Laparoscopic Hysterectomy

Robotic-assisted laparoscopic hysterectomies are being performed at higher rates since the da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA, USA) received US Food and Drug Administration approval in 2005 for gynecologic procedures. Despite the technological advancements over traditional laparoscopy, a discrepancy exists between what the literature states and what the benefits are as seen through the eyes of the end-user. There remains a significant learning curve in the adoption of safe and efficient robotic skills. The authors present important considerations when choosing to perform a robotic hysterectomy and a step-by-step technique. The literature on perioperative outcomes is also reviewed.

Perioperative surgical outcome of conventional and robot-assisted total laparoscopic hysterectomy

BACKGROUND

To evaluate surgical outcome in a consecutive series of patients with conventional and robot assisted total laparoscopic hysterectomy.

METHODS

A retrospective cohort study was performed among patients with benign and malignant indications for a laparoscopic hysterectomy. Main surgical outcomes were operation room time and skin to skin operating time, complications, conversions, rehospitalisation and reoperation, estimated blood loss and length of hospital stay.

RESULTS

A total of 294 patients were evaluated: 123 in the conventional total laparoscopic hysterectomy (TLH) group and 171 in the robot TLH group. After correction for differences in basic demographics with a multivariate linear regression analysis, the skin to skin operating time was a significant 18 minutes shorter in robot assisted TLH compared to conventional TLH (robot assisted TLH 92m, conventional TLH 110m, p0.001). The presence or absence of previous abdominal surgery had a significant influence on the skin to skin operating time as did the body mass index and the weight of the uterus. Complications were not significantly different. The robot TLH group had significantly less blood loss and lower rehospitalisation and reoperation rates.

CONCLUSIONS

This study compares conventional TLH with robot assisted TLH and shows shorter operating times, less blood loss and lower rehospitalisation and reoperation rates in the robot TLH group.

Randomized controlled trial comparing operative times between standard and robot-assisted laparoscopic hysterectomy

OBJECTIVE

To compare the operative time between robot-assisted laparoscopic hysterectomies and standard laparoscopic hysterectomies.

METHODS

A prospective, randomized controlled trial enrolled women aged 18-80 years attending Penn State Hershey Medical Center between April 23 and October 20, 2014 to undergo hysterectomy. Participants were randomized using a random number generator to undergo either robot-assisted or standard laparoscopic hysterectomy. The primary outcome was the total operative time (surgeon incision to surgeon stop, including robot docking time, if applicable). Intention-to-treat analyses were performed and the operative time was compared between the two treatments for non-inferiority, defined as a difference in operative time of no longer than 15 minutes.

RESULTS

There were 72 patients randomized to each treatment arm. The mean operative time was 73.9 minutes (median 67.0 minutes; interquartile range 59.0-83.0 minutes) in the robot-assisted hysterectomy group and 74.9 minutes (median 65.5 minutes; interquartile range 57.0-90.5 minutes) in the standard laparoscopic hysterectomy group. The upper bound of the 95% confidence interval of the difference in operative time was 6.6 minutes, below the 15-minute measure of non-inferiority.

CONCLUSION

When performed by a surgeon experienced in both techniques, the operative time for robot-assisted laparoscopic hysterectomy was non-inferior to that achieved with standard laparoscopic hysterectomy. CLINICALTRIALS.GOV: NCT02118974.

Surgical Competency for Robot-Assisted Hysterectomy: Development and Validation of a Robotic Hysterectomy Assessment Score (RHAS)

STUDY OBJECTIVE

To develop and validate a procedure-specific scoring algorithm to objectively measure robotic surgical skills during robot-assisted hysterectomy and to facilitate robotic surgery training and education.

DESIGN

(Canadian Task Force classification III).

SETTING

A National Comprehensive Cancer Network-designated comprehensive cancer center.

PATIENTS

Deidentified videos for robot-assisted hysterectomies were evaluated.

INTERVENTIONS

Videos from 26 robotic hysterectomies performed by surgeons with varying degrees of experience using the scoring system were evaluated. In phase I, critical elements of a robotic hysterectomy were deconstructed into 6 key domains to assess technical skills for procedure completion. Anchor descriptions were developed for each domain to match a 5-point Likert scale. Delphi methodology was used for content validation. A panel of 5 expert robotic surgeons refined this scoring system. In phase II, video recordings of procedures performed by surgeons with varying degrees of experience (expert, advanced beginner, and novice) were evaluated by blinded expert reviewers using the scoring system. Descriptive statistics were used to summarize the scores for each domain. Intraclass correlation was used to determine the interrater reliability. A p value <.05 was considered significant.

MEASUREMENTS AND MAIN RESULTS

The average score for the 3 classes of surgeon was 75.6 for expert, 71.3 for advanced beginner, and 69.0 for novice (p = .006). There were significant differences in scores of most individual domains among the various classes of surgeons. Novice surgeons took significantly longer than expert surgeons to complete their half of a hysterectomy (22.2 vs 12.0 minutes; p = .001).

CONCLUSION

This pilot study demonstrates the feasibility of using a standardized rubric for clinical skills assessment in robotic hysterectomy. Blinded expert reviewers were able to differentiate between varying levels of surgical experience using this assessment tool.

Robotic Surgery in Gynecology

Minimally invasive surgery (MIS) can be considered as the greatest surgical innovation over the past 30 years. It revolutionized surgical practice with well-proven advantages over traditional open surgery: reduced surgical trauma and incision-related complications, such as surgical-site infections, postoperative pain and hernia, reduced hospital stay, and improved cosmetic outcome. Nonetheless, proficiency in MIS can be technically challenging as conventional laparoscopy is associated with several limitations as the two-dimensional (2D) monitor reduction in-depth perception, camera instability, limited range of motion, and steep learning curves. The surgeon has a low force feedback, which allows simple gestures, respect for tissues, and more effective treatment of complications. Since the 1980s, several computer sciences and robotics projects have been set up to overcome the difficulties encountered with conventional laparoscopy, to augment the surgeon’s skills, achieve accuracy and high precision during complex surgery, and facilitate widespread of MIS. Surgical instruments are guided by haptic interfaces that replicate and filter hand movements. Robotically assisted technology offers advantages that include improved three-dimensional stereoscopic vision, wristed instruments that improve dexterity, and tremor canceling software that improves surgical precision.

Delayed Presentation of Vaginal Cuff Dehiscence after Robotic Hysterectomy for Gynecologic Cancer: A Case Series and Review of the Literature

Background. Vaginal cuff dehiscence after hysterectomy has varying incidence according to surgical approach, with highest rates associated with laparoscopic surgery. Comparative data on timing of diagnosis describe a wide range of clinical presentation from weeks to years after hysterectomy. Limited reports have focused specifically on delayed presentation of vaginal cuff dehiscence. Cases. All cases of vaginal cuff dehiscence at our institution between 2005 and 2015 were collectively reviewed and three cases were identified of women who presented with cuff dehiscence greater than 180 days from index surgery. Diagnosis occurred at 342 to 461 days after operation. One patient presented with abdominal pain, a second case presented with vaginal discharge, and the third case lacked clinical symptoms altogether. Prior to diagnosis, one case received chemotherapy and external beam radiation for Stage IB1 cervical cancer and another case received external beam radiation alone for Stage II endometrioid adenocarcinoma. All cuffs were repaired vaginally with interrupted, early absorbable suture. Conclusion. Robotic total laparoscopic hysterectomy may be associated with increased risk of vaginal cuff dehiscence. Further studies are needed to determine risk factors and patient characteristics associated with delayed presentation of vaginal cuff dehiscence in robotic total hysterectomy as well as all surgical approaches.

Route of hysterectomy and surgical outcomes from a statewide gynecologic oncology population: is there a role for vaginal hysterectomy?

BACKGROUND

Recent policy changes by insurance companies have been instituted to encourage vaginal hysterectomy (VH) as the preferred route for removal of the uterus. It is not known if advantages of VH for benign indications apply to women with gynecologic cancer.

OBJECTIVE

The goal of this study was to assess trends in surgical approach to hysterectomy among gynecologic cancer patients and to evaluate outcomes by approach. We hypothesized that, among gynecologic oncology patients, postoperative complications and hospital stay would differ by surgical approach, and that advantages of VH for benign indications may not apply to gynecologic cancer patients.

STUDY DESIGN

We performed a population-based retrospective cohort study of cervical, endometrial, or ovarian/fallopian tube cancer patients treated surgically in Washington State from 2004 through 2013 using the Comprehensive Hospital Abstract Reporting System. Surgery was categorized as abdominal hysterectomy (AH), laparoscopic hysterectomy (LH), or VH. We determined rate of surgical approach by year and the association with length of stay, 30-day readmission rate, and perioperative complications.

RESULTS

We identified 10,117 patients who underwent surgery for gynecologic cancer, with 346 (3.4%) VH, 2698 (26.7%) LH, and 7073 (69.9%) AH. Patients undergoing AH had more comorbidities than patients with VH or LH (Charlson Comorbidity Index ≥2: 11.3%, 7.9%, and 8.1%, respectively; P < .001). From 2004 through 2013 AH and VH declined (94.4-47.9% and 4.4-0.8%, respectively; P < .001) while LH increased from 1.2-51.4% in 2013 (P < .001). Mean length of stay was 4.6 days for women undergoing AH and was 1.9 days shorter for VH (95% confidence interval, 1.6-2.3 days) and 2.6 days shorter for LH (95% confidence interval, 2.4-2.7 days) (P < .001). Risk of 30-day readmission for patients undergoing LH was 40% less likely compared to AH but not different for VH vs AH.

CONCLUSION

AH and LH remain the preferred routes for hysterectomy in gynecologic oncology. Over the past decade, there has been a significant shift to LH with lower 30-day readmission and complication rates. There may be a limited role for VH in select patients. Current efforts to standardize the surgical approach to hysterectomy should not apply to patients with known or suspected gynecologic cancer.

Robotic Versus Laparoscopic Hysterectomy for Benign Disease: A Systematic Review and Meta-Analysis of Randomized Trials

We conducted a systematic review and meta-analysis to assess the safety and effectiveness of robotic vs laparoscopic hysterectomy in women with benign uterine disease, as determined by randomized studies. We searched MEDLINE, EMBASE, the Cochrane Library, ClinicalTrials.gov, and Controlled-Trials.com from study inception to October 9, 2014, using the intersection of the themes "robotic" and "hysterectomy." We included only randomized and quasi-randomized controlled trials of robotic vs laparoscopic hysterectomy in women for benign disease. Four trials met our inclusion criteria and were included in the analyses. We extracted data, and assessed the studies for methodological quality in duplicate. For meta-analysis, we used random effects to calculate pooled risk ratios (RRs) and weighted mean differences. For our primary outcome, we used a modified version of the Expanded Accordion Severity Grading System to classify perioperative complications. We identified 41 complications among 326 patients. Comparing robotic and laparoscopic hysterectomy, revealed no statistically significant differences in the rate of class 1 and 2 complications (RR, 0.66; 95% confidence interval [CI], 0.23-1.89) or in the rate of class 3 and 4 complications (RR, 0.99; 95% CI, 0.22-4.40). Analyses of secondary outcomes were limited owing to heterogeneity, but showed no significant benefit of the robotic technique over the laparoscopic technique in terms of length of hospital stay (weighted mean difference, -0.39 day; 95% CI, -0.92 to 0.14 day), total operating time (weighted mean difference, 9.0 minutes; 95% CI, -31.27 to 47.26 minutes), conversions to laparotomy, or blood loss. Outcomes of cost, pain, and quality of life were reported inconsistently and were not amenable to pooling. Current evidence demonstrates neither statistically significant nor clinically meaningful differences in surgical outcomes between robotic and laparoscopic hysterectomy for benign disease. The role of robotic surgery in benign gynecology remains unclear.