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Technology Review

This page will review currently available and upcoming Reproductive and Gynecologic Minimally Invasive Surgical technology, the pro’s and con’s, and the page will be updated periodically as new developments emerge. Discussion divided into three sections:

» Laparoscopy / Microlaparoscopy

» Robotics (Laparoscopy)

» Laparotomy

Laparoscopy / Microlaparoscopy:

For a general discussion of technique, see definitions page.

The ability to avoid an open surgery and a hospital stay, yet still have a major surgery has been the greatest advancement in surgical history. Microlaparoscopy is making its way into traditional laparoscopy as a result of better instrumentation. The sizes of trochars include 12, 10, 8, 5 and now 3mm diameters. At JCRM, we moved exclusively to 5mm in the mid 1990’s when the optics of the 5mm scope equalled that of a 10mm scope. When healed, only minimal incision scars are left. The approach has been well tolerated and appreciated by patients for years.

The first generation 3mm instruments were so fine and delicate that they didn’t hold up and were insufficient for most procedures. Despite this, for the past five years, we have utilized microlaparoscopy to enable us to perform laparoscopic tubal reversal surgery. The smaller instruments are necessary in order to use the extremely small suture needed to have successful outcomes putting the tubes back together. Otherwise, open surgery is necessary. We have been able to use 3mm instruments and the magnification property of the scope to do the exact same laparoscopically and get patients home, back to work and trying for pregnancy much sooner. We are very excited at JCRM now to also utilize microlaparoscopy in most of our endometriosis and other cases at the Southpoint Surgery Center.

As discussed below, many technologies have been marketed to surgeons over the years under the claim of being safer to use. In most cases, safety relates to the surgeon and his/her understanding of the instrument and not the instrument itself. The best example is the scalpel for cutting where the instrument is sharp and can damage tissue if used improperly.

» Energy Sources for Laparoscopy (Cautery):

Since the early 1900’s, electrical energy has been utilized in the form of cautery to stop bleeding during surgery. Cautery uses electrical current that flows to the field generating heat from tissue resistance, thereby causing the so-called “cautery” effect. For those who have been in our waiting room, we have an old cautery machine made around 1925, making this the longest utilized form of surgical energy. More modern cautery generators can vary the frequency and amplitude of the waveform to change the tissue effect greatly improving surgical outcome.

Bipolar energy was the next in line of adaptations of traditional cautery. This instrument has two paddles that are electrically separated, allowing the current to flow from paddle to paddle in order to decrease the lateral spread of the energy. While this reported benefit was minimal, this instrument allowed for sealing of larger vessels and paved the way for hysterectomy via laparoscope. In the late 1980’s, when this technology came to the market, a whole host of bipolar instruments were developed and sold as being safer than traditional cautery. However, because they were expensive and offered little benefit, they gradually disappeared from production, except for the basic bipolar cautery device. This device has since been altered to add a cutting aspect and adding different generators that pulsed the energy to decrease heat produced, hence the collateral (unwanted) damage. This too hasn’t proven to be of significant clinical benefit and today we’ve migrated back to the traditional generator, a change that has significantly decreased cost.

Subsequent cautery technologies include the Ligasure device that utilizes a more advanced bipolar energy delivery system than previously available, the Harmonic Scalpel utilizing ultrasonic energy, and the Enseal device which uses a very high crushing force combined with controlled cautery of tissue. These devices provided only 1-2 mm of lateral spread advantage over traditional instrumentation at a much higher cost. With careful dissection and attention to anatomy, these slight advantages are not of any significant clinical benefit. It is this attention to detail that makes our surgical expertise important and allows for cost effective use of surgical resources. Certainly when necessary, we utilize technologies that can enhance our surgical outcomes.

» Laser Energy:

Laser energy became available for laparoscopy in the late 1980’s and was marketed as “safer, with less collateral damage” when used for destruction of endometriosis. While this was strictly true, as with many such claims, it was not clinically significant. The machines were expensive, cumbersome and required extra personnel to protect members of the surgery team from the laser. Rapid marketing of the laser created a demand from patients for this new “space age technology” despite its lack of improvement over existing technology. Patients today, some 20 years after the laser left the operating rooms around the country, still ask if the surgery will be performed using the laser. Soon after its introduction into the operating room, surgeons became disillusioned with the apparatus and the majority returned to the traditional cautery treatment. At that point, the $250,000 laser machines began collecting dust around the country. Today these machines are occasionally used for skin and external lesions.

Recently a flexible laser instrument (Omniguide) for use in laparoscopy has been developed. The technology is the same but the delivery system is more user friendly than the traditional laser due to easier movement of the laser within the abdomen making aiming much easier. This doesn’t change, however, the fundamental problem of laser therapy for endometriosis. Laser is still not a curative methodology no matter how it’s delivered (see Endometriosis) and adds a great deal of cost. It is no more effective than cautery treatment which is much less costly, yet both therapies are very inferior to peritoneal excision of the disease. This is yet another example of instrument companies marketing efforts to doctors and patients utilizing the persistent lure of star wars technology but again it unfortunately is not helpful in advancing the treatment of endometriosis.

Robotic Surgery; DaVinci Surgical System:

We encourage all readers to consider that the advantages of the robot have been related only to the conversion of open surgery (laparotomy) to laparoscopy utilizing robotic technology. Those being, a shorter hospital stay, quicker return to work, the possibility of outpatient status, and less post operative pain. Be very careful when interpreting touted advantages of the robot compared to traditional laparoscopy. Existing studies do not support any advantage of the robot over traditional laparoscopy for those highly skilled in laparoscopy. In our view, the benefits of the robot are limited as described below. It is simply another surgical tool and its effectiveness depends on the skill and judgment of the surgeon, not the technology itself. Robotics news is confusing and it’s hard for non medical and even many medically oriented people to sort out the nuances of these comparisons. Anytime one considers surgery, the most skilled surgeon is the first priority and let the surgeon decide on the technology best suited for the procedure. Based on marketing, one would think the robot could magically perform the surgery with less complications, but so far this simply isn’t the case.

The robot is the most advanced laparoscopic instrument ever developed. It is actually not a true robot. Robots technically act independently from human control, thinking and acting independently like the robots seen in Star Wars and other Sci Fi movies. This instrument, in contrast, uses the robotic motion technology equating to the arms and legs on the robots we see in the movies. This instrument creates an interface between the surgeon and the surgical instruments, similar to the way Windows interfaces between the computer user and the computer files and hardware. The interface allows for steadied movements and based on machine settings, a reduction in the ratio of hand movement to instrument movement. For surgeons with a tremor or difficulty utilizing traditional laparoscopic instruments, angles, and complicated technique such as suturing, the robot allows for safer movement of the instruments and overall the ability to do things that they wouldn’t be able to otherwise successfully do. The technology is based on “wrested instrument movement” whereby the robotic instruments can move in a similar fashion to the wrist of the surgeon, allowing versatility in angles of movement. Traditional laparoscopic instruments are straight shafted and less maneuverable during surgery. At JCRM, with experience and innovation, utilizing traditional laparoscopic techniques and instruments, all Reproductive and Gynecologic procedures can be efficiently and safely performed. Robotic technology has advantages in certain cases over traditional laparoscopy. The robot is still in its earliest phases of development and with further innovation the robot may become a preferable method in more situations.

The primary advantage of the robot is to convert an open surgery to a laparoscopy (minimally invasive). Most hysterectomies in the U.S. were performed via laparotomy or open surgery. The robotic technology has allowed those same surgeons in some cases, to perform hysterectomy via laparoscopy, making the recovery and hospital time much shorter. For those surgeons and patients, this change has been a great advancement in hysterectomy care. At JCRM, we have been performing total laparoscopic hysterectomies (without the robot) for 7 years now on an outpatient basis with excellent results. In endometriosis, for those less experienced in recognizing endo and peritoneal irregularities, the added stereoscopic visualization does allow for better visualization. Our experience, however, allows us to diagnose endometriosis equally well with traditional 2D systems that are now HD with improved optics and by bringing the scope close to the peritoneal surface, can magnify up to 8X giving superb visualization.

Although the most advanced instrument ever developed, the robot doesn’t necessarily generate any real advantage to the already advanced laparoscopic surgeon. The primary disadvantages of the robot is cost and the lack of any tactile feedback from the instruments. It has been the most expensive technology introduced into the OR in many years (see Statement on Robotic Surgery by ACOG President James T. Breeden, MD). In our current system of decreasing funds for healthcare, the robot will need to become more cost effective and most likely will over time. In the realm of changing laparotomies to laparoscopy, there may be overall savings despite the added cost. With traditional laparoscopic instruments (held by the surgeon) the resistance and pressure of the instrument on the tissue, as well as the firmness of the tissue can be immediately perceived. This is especially important for endometriosis surgery where it is common to encounter fibrotic or scarred tissue that needs to be excised during the surgery.

A brand new, yet completely untested and not FDA approved process, is the use of fluorescent indigo cyamine dye that is administered via IV and and can be visualized in the tissue under fluorescent light where there is increased vascularity (presumed higher likelihood of endo). In theory, this might aid in diagnosis of very subtle or invisible disease. We think this may help identify the uterine surface disease that has a very different appearance than peritoneal endometriosis. We will be monitoring this carefully as more information emerges.

Laparotomy:

There have been no significant changes to laparotomy (open surgery) over the last 30 years. At JCRM, we have utilized a very innovative combination of local anesthesia blocks on the abdominal wall and surgery sites to minimize post operative pain. For most patients this allows for outpatient status and a quicker recovery. Obviously not as fast as laparoscopy but faster than traditional laparotomy. At JCRM, we have always worked hard to minimize post operative pain for our patients which allows for outpatient surgery and quicker return to work.