Page 28 - WJOLS - World Journal of Laparoscopic Surgery

Role of Robotic Surgery in Gynecologic Oncology in India
being performed with DRS. Department of Gynecology is not Cervical Cancer and Robotic Surgery
lagging behind with scores of surgeries being performed with For stage 1A-2 and 1B cervical cancer, radical hysterectomy with
robotic assistance, to mention among those are the gynecologic pelvic lymphadenectomy is the standard operative treatment.
oncology surgeries. The utility of DRS is more so in urology and The complication rate, amount of blood loss and mean hospital
gynecology as robotics is best for single quadrant surgery and for stay was comparatively lesser. Except for initial studies, other
fixed structures. Other surgical fields are also making promising studies show lesser operative time, which may be due to the initial
progress with the total number of robotic surgeries on the rise learning curve. For women with undiagnosed cervical cancer who
worldwide. underwent a simple hysterectomy, radical parametrectomy and
lymphadenectomy have been suggested as suitable alternatives to
robotIc surgery In gynecoLogy pelvic radiation. This procedure has also been tried through robotics
In gynecology, hysterectomy remains the hallmark surgery. Though at a centerin Houston. Another area of interest is fertility-sparing
noteworthy advances are being made in general gynecology, trachelectomy with pelvic lymphadenectomy. There is not much
reproductive gynecology, and reconstructive gynecology, much information available yet on this topic.
5
of the focus still remains on gynecologic oncology and the role of In a study by Puntambekar et al. in Pune, 80 cases were
DRS in gynecology is still expanding. performed robotically. They state that their operative time and
It was noted that in hysterectomies done for benign conditions, estimated blood loss were considerably lower when compared
with robotics there were significantly lesser operative times, blood with those of other standard international studies. There was no
loss and conversion rates. Since robotics gives better results with conversion to open surgery; furthermore no major intraoperative
intracorporeal suturing, it is especially useful in tubal anasthamosis or postoperative complications were noted.
6
that requires precision and extensive suturing. But further studies Many other studies, also suggest that robotic radical
are needed to validate its use and consequent pregnancy outcomes. hysterectomy (RRH) is preferable over laparoscopic radical
In myomectomy, robotic surgery offers many advantages compared hysterectomy (LRH) due to the decrease in blood loss, hospital stay,
with traditional laparoscopy in the form of better enucleation recovery time, and complications. However, it also depends
due to better dexterity, better intracorporeal suturing, less blood significantly on the skill of the surgeon.
7
loss, and hospital stay. DRS is expected to play a significant role Larger series—notably among them Boggess et al. and
8
in the most recent upcoming subdivision of Obstetrics and Lowe et al. —concluded that there were no transfusions, length
Gynecology—Pelvic Reconstructive Surgery. Particularly procedures of stay in the hospital not more than a day and on the whole the
such as sacrocolpopexy and vesicovaginal fistula repair are well complication rates were significantly lower when compared with
suited for robotics given the necessity of intracorporeal suturing. open or laparoscopic approaches.
In their experience with 164 oncological surgeries by
9
Puntambekar et al. 35 patients come under the purview of
roLe of robotIc surgery In gynecoLogIc gynecology. They state in their series that the mean operative time
oncoLogy was lesser possibly because of extensive open and laparoscopic
The role of DRS becomes highly significant in oncology, as the tumor experience, hybrid techniques, and team effort. They also report
clearance gets translated into survival benefits. Total hysterectomy that the blood loss was comparatively lesser and they were able
and staging for endometrial cancer and radical hysterectomy or to achieve a comparable parametrial, distal vaginal margin and
10
trachelectomy and pelvic lymphadenectomy for cervical cancer adequate nodal clearance.
are surgeries where robotic surgery is advised. In most of the studies, DRS was seen to be associated with lesser
blood loss and subsequent blood transfusions with mean hospital
Endometrial Cancer and Robotic Surgery stay being significantly lesser. The operative time was comparable
The standard treatment in most centers is hysterectomy and bilateral between the two groups. More studies need to be done to shed
salphingo-oopherectomy with pelvic and aortic lymphadenectomy. more light on this matter.
Tumor grade, depth of invasion, tumor size and lymphovascular
space invasion are the main factors deciding the risk of metastasis. cost fActor
The most common limiting factor for comfortable and optimum The main limiting factor hindering the utilization of this technology
lymphadenectomy is obesity. The procedure remains a difficult task to its full extent is the cost. The total cost of the surgery can be
when approached through laparoscopy. A few reasons cited by divided into the following categories:
the surgeons are: prolonged operating times, fatigue and difficult
learning curve. Owing to the better ergonomics and easier learning • Equipment: the DRS (which is being marketed by the Intuitive
curve, DRS is fast replacing laparoscopy and open techniques in the Surgical Systems, Inc.) is right now the only robotic system
treatment of endometrial cancer. Most of the recent studies report available. Owing to the patent that has not yet expired, the
a favorable report except for the longer operating time. market is under monopoly. The capital amount and yearly
Some of the limiting factors noted in laparoscopic surgeries maintenance costs are hence fixed and exuberant.
are obesity, narrow pelvis and bulky tumors. Endometrial cancer is • Instrument costs: since most of the working instruments are
commonly associated with obesity and this offers a challenge due to disposable, they add significantly to the final cost.
difficult exposure during aortic lymph node dissection and difficulty • Operation theatre cost: as the working staff, the sterilization
with ventilating in the steep Trendelenberg position. In such cases, techniques and other minor costs remain the same in both, this
robotics has given better results and is now more preferred over does not add significantly to the final cost. A question may be
the laparoscopic approach. raised regarding the possible longer operating hours in robotics

136 World Journal of Laparoscopic Surgery, Volume 11 Issue 3 (September–December 2018)