First ever two incision robotic hysterectomy

I have posted a link to a new video showing the first ever two incision robotic hysterectomy. Two Incision Robotic Hysterectomy.  This hysterectomy is done through only two small incisions, one in the belly button for the camera and one just above the pubic bone for the instruments.  Both would be completely un-noticeable with swim wear.  With the help of my OR staff, we managed to work out the logistics of the robotic arms to allow this.

Single incision techniques have been developed that allow the surgery to be done all through the belly button, but the incision is much larger, between 2.5-3 cm in size.  These incisions are 1-1.2 cm and theoretically would have a lower risk of herniation.

There are limitations with this.  It likely is only possible with hysterectomy and possibly removal of ovaries. Any endometriosis would be difficult to treat this way with excisional approach.

With this technique it is possible to also perform laparoscopic supracervical hysterectomy and total laparoscopic hysterectomy with removal of tubes and ovaries.

I am so excited about this procedure that we can now offer with or without robotic assistance.

Robotic Surgery and Cost

Over the last few years there has been a significant increase in the number of hospitals starting up "robotic surgery" programs. In fact, robotic assisted surgery for prostate removal has become the "standard of care" for prostatectomy. Robotic surgery in gynecology has become more controversial. I think all providers would agree that the benefits of laparoscopic approach to surgery are much greater than by traditional laparotomy or open surgery. In my view, robotic assisted surgery is merely a laparoscopic surgery that is helped by robotic or computer assistance. Robotic systems have allowed many gynecologists the opportunity to offer a less invasive approach to surgery that would otherwise have been done by a large incision. These are gynecologists who were not trained to perform advanced laparoscopic procedures. With the "buzz" around robotic surgery, hospitals have had a difficult time understanding the appropriate use of the robotic system. From which procedures to allow to appropriate training of the surgeons, hospital systems are wading through new waters to provide a better service while assuring that patient safety and economic sensibility is maintained. Many published studies have shown that robotic hysterectomy is more expensive to the healthcare system than laparoscopic or open, abdominal, hysterectomy. These studies include the purchase price or depreciation of the robotic system for each surgery performed. In most cases, the additional amount applied to surgical cost is around $2500 per surgery. The major flaw with this approach to calculating cost of robotic surgery is that any hospital that commits to a robotic prostate program has to purchase the system. The cost of the system and the annual maintenance are fixed costs that are required if only one type of procedure is done. Allowing hysterectomy to be performed robotically, does not increase the cost that hospitals have already committed to a robotics program. In fact, at one of the hospitals I practice, we did an internal cost analysis of robotic hysterectomy compared to regular laparoscopic and abdominal hysterectomy. We were surprised to find out that the robotic approach was actually the least expensive for total hospital cost of the surgery. The cost of robotic hysterectomy is close to that of laparoscopic and is significantly less than that of abdominal or open. As each day passes patients are becoming more aware that regular "open" surgery really is a thing of the past. Most abdominal surgeries can be done and should be done in a less invasive way. New surgeons are constantly being trained as they see their patients seek out providers who can offer a less invasive treatment. Patients should understand that they have a right to find the least invasive option for treating their medical conditions. This may include robotic or laparoscopic surgery or, often, treatment with medicine that doesn't require surgery. If surgery is chosen, surgeon experience and outcomes are the two most important aspects to a safe surgery with expected outcomes. There is a large myth that robotic surgery is too costly and dangerous to use for more routine surgeries. The overall cost to the healthcare system is not increased, at least in my practice. The safety of robotic surgery depends on those aspects that the safety of any surgery depends on: surgeon experience, proven techniques, experienced operative team, appropriate decision-making and educated patients.

Endometriosis Foundation

I just returned from the World Congress of the AAGL. Our keynote speaker was Padma Lakshmi. She is a co-founder of the Endometriosis Foundation of America. She is better known for her show on Bravo network, Top Chef. She shared her endometriosis story with us and her devotion to education of this debilitating disease.

She suffered with pelvic and abdominal pain for 26 years before she was finally diagnosed with endometriosis. After finding a surgeon skilled in surgical excision of endometriosis she began her road to recovery. Three surgeries later she is now pain free and has a beautiful daughter.


I echo her statement and the opinion of the Endometriosis Foundation of America, that surgical excision is the "gold standard" treatment for endometriosis. The current average years to diagnosis is around ten years. As we educate parents and young women about the signs and symptoms of endometriosis, hopefully we can begin to prevent the most severe forms of the disease that can affect so many aspects of women's lives.