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.

Why Use Laparoscopy for Complex Surgery

I am frequently asked about why a surgeon would use laparoscopy for complex pelvic and abdominal surgery when it could be performed through a laparotomy or open incision in less time. It is true that in most cases, a hysterectomy for a very large 16-22 week size uterus can be completed in less time open than laparoscopically. Also complex cases such as large, non-cancerous ovarian cysts, severe endometriosis, and large or multiple fibroids can be completed through either open surgery or laparoscopy.

It is usually true that surgery for a large uterus, fibroids, or large ovarian cysts takes less time with an open incision (this is not always the case). Surgery for adhesions or severe endometriosis is difficult and long no matter the surgical approach.

When I am asked why I would take 2-3 hours to perform a hysterectomy laparoscopically or with robotic assistance instead of performing a laparotomy for a uterus the size of a 16-24 week pregnancy, my answer is clear, "My patients and I like the trade off!"

With the assistance of laparoscopy either to complete the entire operation or to convert from a large vertical incision to a small 3-5 cm mini-laparotomy incision, patients trade time spent in the operating room for a quicker recovery. Rarely do surgeries for even the most complex pathology take longer than three hours to perform laparoscopically. Most open surgeries for the same conditions average 1.5-2 hours. Frequently a laparoscopic surgery can be completed in that amount of time. When it is longer, a laparoscopic approach may add up to an additional 1.5 hours depending on what is done.

In the case of hysterectomy for a very large uterus, the uterus must be cut into small pieces to remove it in a minimally invasive fashion. This aspect of surgery often is longer than the actual hysterectomy itself.

In the beginning of my private practice, I often wondered if the extra time was worth it after a difficult, long surgery. I got my answer the next morning while rounding on the patients. They were doing well with minimal pain medicine requirement. They were walking and ready to go home within 24 hours of the completion of the surgery. This was reiterated when I saw them at their postoperative visits. They were already back to work and feeling normal again.

Laparoscopy can also make a big difference in patients who have some complicating medical conditions. Patients with obesity can benefit by a lower risk of wound infections. Diabetics are frequently out of the hospital before their regimen is interrupted. Patients with a history of blood clots in their legs or lungs are up walking the same day of surgery.

Yes, there are increased risks and cost with longer operative times under anesthesia. In my five years of practice after fellowship, I have not seen an anesthesia related complication. The higher operative cost is more than offset by the decrease in hospital stay by 2-3 days. The cost benefit to the patient is further increased by allowing them to return to work faster after release from the hospital.

A recent patient summed it up best when she wrote, "I am grateful that I was made to switch doctors at the last moment. My inconvenience turned out to be a huge blessing!!! To think that I went from being told I would need an abdominal hysterectomy to what you were able to accomplish is amazing. Thank you for being concerned about my healing and taking the time with the longer procedure. Your success was my gain."