Enter the robotic age
Manila, Philippines - EA, a 48-year-old businesswoman, has been in denial that she has a myoma diagnosed since 1994. She was mortified with the thought of undergoing the knife and scarring her stretch mark-free belly. She never sought consult with a gynecologist with the hope of not having to deal with her problem. However, one day, she came to read about robotic surgery in the newspapers. Suddenly, the concept of minimally invasive surgery did not seem scary anymore, with the prospect of a faster recovery time; minimal incisions, post-op pain, and scarring. She went for robotic surgery and was glad she did. She was able to rid herself of her 16cm myoma, which was just a benign tumor in her uterus, without the trauma and the difficult post-op course she had been fearing and imagining all these years. She was back to work in seven days, and was happy with her minimal scarring and minimal post-op pain. Had she not heard of robotic surgery, she would never have subjected herself to surgery and would still be living in denial.
Science and technology never stop researching for a better and more efficient way to do things. In the recent past, the best way to remove the diseased uterus with multiple myomas was to cut the abdomen with an 8-12cm incision. If it was lax enough to be accessed vaginally, that was done, too. The open technique was used for most gynecologic surgeries like the removal of myomas, re-anastomosis of the fallopian tubes, and surgeries to correct the prolapsed vaginal vault.
Then, entered the era of laparoscopic surgery. It then became possible to perform keyhole incisions utilizing a camera in the belly button and two to three instruments to perform most gynecologic surgeries. The skills for moving the instruments are counter-intuitive because of the so-called fulcrum effect, where the surgeon needs to move the instruments at mirror image, for instance. If she needs to grasp the ovary on the left, she will need to move the instrument to the right. Imagine stabbing a pencil halfway through an imaginary belly button. If you needed to point that pencil forward, you would have to move the top of the pencil backward. And if you had to move the tip to point to the right, you would have to move the top to the left. This is called the fulcrum effect. To complicate matters, traditional laparoscopic surgery is done looking through a two-dimensional TV monitor of the camera image projected from inside the abdomen, so there is no depth perception. The instruments are stiff and cannot move like the hand, which can rotate at the wrist so it makes it difficult and clumsy to suture the structures inside the abdomen.
What are the advantages of robotic surgery? Robotic surgery is a great improvement on laparoscopic surgery because of several features: 1) a three-dimensional vision system, 2) wristed instruments, and 3) ergonomic positioning for the surgeon doing the surgery.
The vision system is of a higher level because unlike the 2D camera of traditional laparoscopy, robotic surgery uses a three-dimensional camera with a high-definition system, providing the console surgeon the advantage of depth perception. The objects can be magnified 10-12 times, which is far better than what the human eye can see.
With traditional laparoscopic surgery, the instruments are straight and rigid, and therefore severely limit the ability of the surgeon to perform dexterous movements required for difficult dissections. In robotic surgery, the instruments used are wristed, meaning the tips of the instruments are capable of rotating as much as the wrist, allowing greater dexterity and seven degrees of rotation similar and even beyond what the human hand can do. With finger control on the console, the surgeon can perform more natural movements, which make especially suturing and knot tying way easier compared to traditional laparoscopy. The movements are finer and more precise, especially for performing delicate dissections. Best of all, it does not transmit the tremors of the surgeon so an experienced surgeon can continue to perform surgery even in his advanced years.
Ergonomics is an added advantage of robotic surgery. With traditional laparoscopic surgery, the surgeon stands on the operating table, manually moving the instruments by using a lot of upper arm movements, twisting and contorting to reach over the patient’s abdomen to manipulate the instruments, all of which can become tiring with a long, difficult surgery.
Robotic surgery minimizes fatigue because the surgeon sits comfortably at the surgical console and manipulates the hand controls using the fingers and foot pedals in an ergonomic position that is set to his/her liking. Every surgeon can have a different option for positioning the eyes, arms, and legs, and the robot saves the settings for every surgeon. So, the more complex a surgical procedure is, the better it is done robotically so fatigue will be minimized as a limiting factor to a successful surgery.
What gynecological problems can be addressed robotically? The following gynecological procedures can be done robotically: removal of uterus for benign or malignant condition, lymph node dissection, removal of ovaries or ovarian cysts, removal of myoma, repair of prolapsed vaginal vault.
With the advancements in science addressing the preservation of life, robotic surgery is rapidly revolutionizing the way surgery is performed. The standard of care is swiftly changing, old paradigms have to be altered to give way to removing diseased tissues and organs in the least invasive way to the human body. The era of robotic surgery has come of age, a welcome armamentarium and alternative to traditional surgery.
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Editor’s note: Dr. Rebecca B. Singson is a prolific writing advocate of female health issues. She is currently chairperson of St. Luke’s Global City Dept. of Obstetrics and Gynecology and head, Robotic Gynecologic Program. She also has clinics at Makati Medical Center and Asian Hospital & Medical Center. For inquiries, call 789-7700 local 7305.
