When is the robot truly the best option for gynecologic surgery?

Why the robot should be reserved for high-volume surgeons
Dr. Magrina: In my opinion, if you have a basic “bread and butter” practice, I don’t think you need to have a robot. The robot should be reserved for advanced surgery. And because of fixed costs with the robot, such as maintenance, you need to perform a sufficient number of cases per year to cover those expenses. At my institution, the minimum number of robotic cases per year is about 200. Our cost for robotic surgery is 8% higher than it is for laparoscopy. If we perform fewer than 200 robotic surgeries, the difference is even greater.

Dr. Falcone: I agree with everything you’ve said, Dr. Magrina. But if you consider that about 120,000 of the 500,000 hysterectomies performed each year are done for abnormal uterine bleeding in women who have a normal uterus and no other complexity, there’s no need for the robot for these cases. A lot of places—certainly not the Cleveland Clinic or the Mayo Clinic, but other places—use the robot to remove that little uterus. That’s when conventional laparoscopy should be the preferred route.

When it comes to endometriosis, which accounts for another 20% of cases, the robot might break even because it’s the length of surgery that is important. Still, although the robot might allow most community surgeons to perform routine endometriosis cases, complex cases are another matter. The robot is an enabling device for simple cases for the average gynecologist but not for complex cases. For those cases, it requires a different skill set—sophisticated skills of retroperitoneal anatomy, which the robot doesn’t teach you. It requires experience working in a different space, which the robot doesn’t give you.

Dr. Magrina: That’s an important point. If a surgeon came to me and said, “Look, at my institution, if I don’t perform 35 robotic cases a year, they’ll take my privileges away,” that would indicate to me that the surgeon is performing some cases robotically that might be better done laparoscopically or vaginally. But he is doing them robotically just to maintain his privileges.

I would suggest to him that if his caseload is not that high, maybe he shouldn’t be doing any robotic cases. Another option is for him to propose to his institution that he perform the 20 well-indicated cases on the robot and the other 15 laparoscopically. Then, to maintain his robotic skills and privileges, he could log in the equivalent of 15 or more robotic cases by simulation.

Gynecologic surgeons have strong preferences when it comes to the route of hysterectomy for benign disease—at least among OBG Management’s Virtual Board of Editors (VBE). When they were asked to weigh in on laparoscopic hysterectomy versus robotic assistance, VBE members tended to come down firmly on one side or another, with very little “fence-sitting.”

For example, Soheil Hanjani, MD, reported that he performs approximately 95% of benign hysterectomy cases using a minimally invasive approach, preferably robotic assistance.

“In the right hands, robotics is superior,” he said, adding that it gives him “better dissection control.”

Heather Hilkowitz, MD, agreed.

“I feel like the imaging is better with robotics, such that I can really see tissue and planes better than with 2D straight-stick laparoscopy. I also appreciate the wristed instrumentation of the robot, which allows me to do more difficult cases laparoscopically that I would have had to open in the past.”

Weighing in on the other side of the equation is Noor Ahmed-Ebbiary, MB, who practices in the United Kingdom. Dr. Ahmed-Ebbiary cites expense as a major disadvantage of the robot.

“If the surgeon is experienced in both vaginal and laparoscopic surgery, he or she should be able to manage the vast majority of hysterectomies without a robot. European countries are not as rich, and most of them cannot offer or justify the price of a robot,” he added.

Raksha Joshi, MD, uses a minimally invasive approach for about 50% of the benign hysterectomies she performs, favoring the vaginal route.

“Robotic surgery for hysterectomy for benign disease is ‘overkill,’” she says. “It’s expensive, takes much longer than laparoscopic surgery or a laparoscopically assisted vaginal approach, and does not give any outcomes advantage for the patient.”

Michael Kirwin, MD, prefers total laparoscopic hysterectomy, depending on the patient’s surgical history and anticipated abdominal conditions, because it allows him to “port-hop,” offers more options for energy instrumentation, is more economical than the robot, and yields smaller incisions.

John T. Armstrong Jr., MD, MS, prefers neither total laparoscopic hysterectomy nor robotic assistance. He opts instead for a straight vaginal approach or open hysterectomy through a minilaparotomy incision.

A look to the future
OBG Management: Now that cost pressures are beginning to discourage use of the robot for straightforward, low-complexity hysterectomy cases, do you anticipate that surgeons who lack laparoscopic skills will refer patients to minimally invasive surgical experts? Or are they likely to utilize abdominal hysterectomy more than in the past? In other words, what changes do you foresee as cost pressures increase?

Dr. Falcone: I think cost pressures will ensure that surgeons will think about their approach to a surgical procedure more critically. It will add the cost of the procedure to the conversation between doctor and patient of what is best for her.

Dr. Magrina: Cost pressures will force hospitals and gynecologists to change our present modus operandi. In general, high-volume surgeons have shorter operating times, fewer complications, and lower costs—a true fact among many different surgical specialties. Hospitals will start looking at the cost of specific procedures and compare costs among surgeons. Expensive surgeons may be asked to explore ways to reduce costs, and, if they don’t, may be denied privileges for specific procedures.

I envision ObGyn groups—so-called generalists—to be composed of physicians dedicated to obstetrics and gynecologists dedicated to office practice or surgery. The days when an ObGyn surgical practice offered care that encompassed both the delivery of babies and oncologic procedures, including urogynecologic, infertility, and complex operations, should be over. Our specialty is in need of a higher degree of focused practice.

Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.
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Learn directly from experts Tommaso Falcone, MD, Javier Magrina, MD, and Mark Walters, MD
2015 PELVIC ANATOMY AND GYNECOLOGIC SURGERY (PAGS) SYMPOSIUM
Thursday, December 10 – Saturday December 12, 2015
At Paris in Las Vegas
Preconference hands-on workshops on laparoscopic suturing, hysteroscopy, and ultrasound on Wednesday, December 9.
Visit: www.PAGS-CME.org