Robotic surgery | Dr Phoebe Hong

The arrival of robotic surgical system at Cairns Private Hospital is truly exciting. As with standard laparoscopic a.k.a keyhole surgeries, robotic surgeries are done through small incisions using a small camera (laparoscope) and instruments. However, instead of the surgeon controlling the instruments directly with their hands, surgeon controls the movement of the robotic arms via a console away from the patient.

Robotic surgery is still a form of laparoscopic surgery or minimally invasive surgery. A more correct description is robot-assisted laparoscopic surgery, as robotic surgery may create a false impression of the surgery being performed entirely by a robot without human control.

Many of the benefits of a robot-assisted surgery, such as shorter hospital stay, less pain, and quicker recovery time compared to open surgery, are similar to the standard laparoscopic surgery as both surgeries are performed using small incisions. However, it does offer a number of advantages, including:
• 3-D vision, allowing surgeons to have a better depth perception of the surgical field
• Enable surgeons to maneuver the instruments in an otherwise awkward angle or difficult-to-reach area
• Smoother and more precise movement by eliminating hand tremor
• Better ergonomic for the operating surgeon
• Shorter learning curve for surgeons
• Less reliant on skill level of surgical assistants

As exciting and inspiring as robot-assisted surgeries are, we need to be aware of its disadvantages. Current limitations of robot-assisted surgeries are:
• Greater general anaesthetic and overall surgical time due to the longer set up time
• Greater overall and out-of-pocket costs from the patients
• Absence of touch or hand feedback from the instruments, making it difficult for surgeons to appreciate the fragility of the tissue or the force being applied on the tissue
• Unproven benefits over standard laparoscopic approach in most gynaecological surgeries, including hysterectomy, removal of ovaries or cyst, and treatment of endometriosis.

The higher cost associated with robot-assisted surgeries are multifactorial. Firstly, there is an extra charge from the hospital, which are not covered by most private health funds. Secondly, anaesthetic cost is time-based, hence longer operation will results in higher anaesthetic cost. Lastly, there may be higher surgeon’s fees as there are no specific health fund and MBS rebate for robot-assisted surgeries.

In the United States, approximately 433,000 hysterectomies are performed each year and the number robot-assisted hysterectomies has risen significantly, from 0.5% of all hysterectomies in 2007 to 9.5% in 2010. Despite the large numbers, the better quality and larger studies have not shown the robot approach to be superior to standard laparoscopic approach. The operating times were consistently longer with robot-assisted surgeries, with no clinically significant differences in blood loss, length of hospital stay, complication rates, pain levels, and recovery time.

In my experiences, most laparoscopic surgeries only require one night stay in hospital, with some staying an additional night, even after hysterectomy. Most patients can return to work after one to two weeks. For most uncomplicated gynaecological surgeries, gynaecological structures are generally not hard to reach with laparoscopic instruments, as opposed to urological or prostate procedures, especially women’s pelvis are wider than men’s. Also, as with any modern technology, there is possibility of machine failure. In such situation, surgeon would have to rely on their standard laparoscopic skills, including suturing.

It would be misleading to state that there is no place for robot-assisted surgery in gynaecology. There may be situations where robot-assisted surgery may be beneficial, but this should be driven by what is best for the patient, preferably determined by evidence-based medicine.

Here are some questions you may bring to your doctor when considering the best surgical modalities for your surgery:
• What are the benefits of robot-assisted surgery, standard laparoscopic surgery, and open surgery in your case?
• What are the cost differences, especially out-of-pocket cost for you for each options?
• Does the benefits justify the costs?
• Why robot-assisted surgery when standard operation offers similar benefits with lower costs and complexity?
• What is the surgeon’s experience in each approach?
• What happens when equipments, such as the robotic system, fails?

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