A Frank Ob/Gyn's Message

An honest assessment of all things medical and ethical.

What is the da Vinci Robot?

Today, we’ll shift gears slightly and talk about some of the great advances in gynecologic surgery. Lest anyone mistake my appeal to sound medical ethics as a rejection of technology and innovation, I’d like to discuss a few modern developments that help me to better care for my patients.

The Ob/Gyn specialty is unique in that it is the fusion of what was traditionally a medical specialty (obstetrics) and a surgical specialty (gynecology). As a surgeon, I sometimes find it necessary to use a scalpel to effect the necessary cure for my patients. However, I still believe strongly in that noble dictum of Hippocrates “Primum non nocere,” famously translated “first do no harm.” Therefore, when I do find a surgical procedure needed, I strive to perform the surgery in way that is least painful and scarring for the patient. Accordingly, I advocate a principle know as minimally invasive surgery.

In the last 30 years, laparoscopic surgery has revolutionized surgery for both general surgeons and gynecologists. In the last 5 years, the da Vinci Robot has revolutionized urologic surgery for men and gynecologic surgery for women is currently undergoing the same dramatic transition. For men, a prostatectomy for prostate cancer used to require a large (greater than 12 cm abdominal incision) laparotomy. Now with the assistance of robotic equipment, this procedure can be accomplished with a laparoscope through a few incisions (3-5) each less than 1 cm. In a similar way, gynecologic procedures such as hysterectomy, removal of fibroids (myomectomy), and even removal of advanced cancer can be more frequently be completed through the same type of small abdominal incisions.

How has the da Vinci robot system been so important? In the past, in order to perform may surgery, we needed to make an incision large enough for at least 2 sets of hands, the surgeon and the assistant. Such incisions ranged anywhere from 12-30 centimeters in length. Now, many if not most of these same procedures can be performed with laparoscopic equipment. These incisions only need be as large as the diameter of the laparoscopic instrument (approx 8mm or the size of a nice pen). While traditional laparoscopic instruments have been available for decades, they are much more difficult to use because of limitations with their maneuverability. The robotic tools on the other hand, are capable of performing hand-like movements in direct response to the surgeon’s precise movement using specialized hand controls. In other words, the robotic system is simply the most highly advanced set of tools available to perform laparoscopic surgery.

The benefits to the patient of such minimally invasive surgery are many. Less pain, less blood loss, fewer infections, and shorter convalescence are some of the most important benefits. Like many advances in medicine, however, such benefits do come at a significant upfront cost. The initial investment of the robotic equipment and the ongoing maintenance expenses has been criticized by some as being not affordable or worse—wasteful. Such criticism, though, is short-sited and fails to appreciate the whole picture in terms of cost. Good cost analysis studies are now coming forward that actually show monetary savings when all the factors are considered as a whole. For example, shorter hospital stay and fewer re-admissions for infectious complications alone are usually enough to more than make up for the initial higher equipment costs. When you factor in less use of pain medication and sooner return to work, the cost benefit analysis even more strongly favors the robot-assisted surgical approaches. Hence, sometimes, even the most utilitarian of arguments will support an approach that is not only best for society, but most importantly best for the individual person.

Sincerely,

Dr. Frank (gynecologic surgeon)

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