Since launching the Robotic Surgery Program in Gynecologic Oncology at Memorial Sloan Kettering in 2007, we have observed increased use and application of robotic techniques for a range of gynecologic conditions.
When the program was introduced, our team had been using standard laparoscopy as a minimally invasive surgical approach for nearly 20 years, for procedures ranging from hysterectomy with nodal dissection for endometrial cancer to radical hysterectomy for cervical cancer and resection of localized tumor recurrence and complex ovarian masses.
While Memorial Sloan Kettering maintains a strong tradition in standard laparoscopy, robotics has complemented our surgical armamentarium and provided an opportunity to complete an increasing number of cases with a minimally invasive approach.
In an analysis of 752 patients who underwent primary surgical management for endometrial cancer at our institution between 2007 and 2010, the overall rate of laparotomy (planned or converted) was 54 percent lower in 2010 than before the introduction of robotics.(1) This reduction in laparotomy is attributed in part to the success of the robotic platform in hysterectomy for obese patients and for complex cases.
With robotics, our largest endometrial cancer patient requiring lymph node dissection had a BMI of 60.6; hysterectomy for endometrial cancer not requiring node removal can be performed on patients with a BMI of up to 70. A coordinated team approach between our surgeons and anesthesiologists has been used to manage the restrictive airways of morbidly obese patients in parallel with the Trendelenberg positioning required for robotic hysterectomy.
The ability to achieve a minimally invasive approach with robotics for these challenging cases has been beneficial in reducing wound complications, estimated blood loss, and length of stay. The overall 54 percent decrease in the rate of laparotomy for our patients with endometrial cancer may also be reflective of other technical factors, such as enhanced camera resolution, increased instrument range of motion and primary surgeon control, and improved surgeon ergonomics.
In a recent presentation on our experience with the use of robotics in morbidly obese patients (BMI ≥40 kg/m2), we reported that a minimally invasive approach was successfully achieved in greater than 80 percent of patients compared to <=10 percent before the robotic platform was used.(2)As a result of the reduction in complications (from 36 percent to 15 percent), patients experienced a significant decrease in the length of stay.(2) A similar decrease in laparotomy rates is now being realized in patients undergoing radical hysterectomy for cervical cancer and for other gynecologic procedures.
Another major advantage of the robotic platform has been the chance to incorporate enhanced technology during surgery. The robotic fluorescent camera is now being used on a regular basis as part of our sentinel lymph node mapping program. Harnessing the opportunity for radiographic image overlay on the surgical field is a new area we are exploring.
Case Selection for Robotics
After seven years of development and expansion of our robotics program, a variety of cases are now considered candidates for minimally invasive surgery with robotics. In addition to cases of endometrial and cervical cancer and hysterectomy for obese individuals, the robotic approach has been used for ovarian cancer staging and resection of isolated tumor recurrence. We also have successfully used robotics for fertility-sparing radical trachelectomy in young patients with early-stage cervical cancer.
Most recently, we used robotics to complete splenectomies and low anterior resections for isolated tumor recurrence. Given our patient base, many of our robotic cases have had multiple prior surgeries and even pelvic radiation due to a prior cancer history.
Not all cases are appropriate for robotic surgery, however. Currently, large-scale ovarian cancer tumor debulking is completed at Memorial Sloan Kettering by laparotomy, for example. The appropriate surgical approach for any given case is determined upon in-person consultation with the primary gynecologic cancer surgeon.
Misconceptions and Outcomes
When arriving for consultation, many patients are under the impression that robotic surgery takes longer than laparoscopy. While the literature is peppered with such reports, many compare the first 30 to 50 robotics cases at a center to the time required with standard laparoscopy — which has been available for decades.
In our analysis, operative times for endometrial cancer, our most common indication for robotic surgery, are equivalent after a learning curve of 40 cases by each primary surgeon.(1) Standardized patient positioning and port placement are used across the service to streamline the basic components of surgical setup. For console time, we have shown that our operative times for robotic and standard laparoscopy are equivalent among our high-volume robotic surgeons.
Nor has there been a difference in complication rates or oncologic outcomes between robotic cases and those performed by standard laparoscopy.
While cost is another potential issue with the robotic platform, there is in fact no surcharge for a robotic procedure. Furthermore, our data indicate that there is cost neutralization of robotics based on a decreased rate of laparotomy (Figure 1).(3)
The Future of Robotics
Our mission is to secure a successful oncologic outcome for our patients while minimizing the morbidity of surgical resection. To date, robotics has been a successful tool to achieve this goal for many of our patients.
Moving forward, additional adaptations and enhancements to the robotic platform are anticipated, and other (nonrobotic) surgical tools are also in development. The contribution of technology to the surgical arena will likely continue to expand, as it does elsewhere in our lives.