Laparoscopic and Robotic surgery

Laparoscopy is surgery with a laparoscope. 

We use lots of scopes in science and medicine: microscopes, laparoscopes and telescopes, to name a few. A laparoscope is just a scope made to view the interior of the abdomen through a small incision. 

Before the 1990s the vast majority of surgery was done through large open incisions. During my training between 1990 and 1994, the profession of Ob/Gyn made a large scale transition to laparoscopy. Even so, this new technology took a long time to diffuse, and only recent grads utilized it regularly. Until perhaps 2010, there were still a significant number of gynecologic surgeries being done through open incisions. Nationwide, it was somewhat slow to catch on as open surgery was perceived as easier and safer. Well, as in many things, it's easy when you know how. 

It turns out laparoscopy is safer than open surgery in many ways. Additionally, as it evolved over the next twenty years to Robotic surgery, laparoscopy allowed us to do even more detailed and refined surgery than ever before. And for patients, it was a whole new scenario in terms of their recovery. Post operative mobilization, pain control, and return to normal activities was much better. Here is how it's done. 

Laparoscopy 101

The patient requires general anesthesia for laparoscopy. A spinal is not sufficient. 

Once anesthesia is underway, time is taken for a verbal confirmation of the case details. This is called a "time out". 

The patient is place on the operating table, and various spots like elbows are padded. A warmer may well be used. 

The surgical site is cleaned, perhaps marked. A urinary catheter is placed. 

Pelvic surgery often begins by using an instrument to affix to the uterus to move it strategically during the case.

Above on the abdomen, the central incision is made above or below the belly button. This allows the scope to be placed and CO2 gas to be installed to lift the abdominal wall, providing a clear view of the pelvis. The main incision can vary from 1-2.5 cm. Lateral port sites are then made. For conventional laparoscopy, they are usually one to a side. These vary from 8-12 mm in size. 

With conventional " straight stick " laparoscopy, long straight instruments with tools on the ends can be introduced into the abdomen to do the work. One surgeon is on the right and the assistant surgeon is on the left. There is also a scrub tech or scrub nurse at the foot of the bed. The work is accomplished, the gas is let out and the incisions are closed and dressed. The patient is awakened and taken to recovery. 

Robotic surgery 

How would you like to operate on a large curved uterus with a straight instrument ? It can be done and done well, but it requires some strain on both the patient and the surgeon. In such circumstances I can recall yearning for the old days when you just reached your five fingered hand in there through an incision the size of Kansas and delicately separated one structure from another just so. But I knew that would be riskier and more painful for the patient postoperatively, and so we soldiered on with our sticks. Like caveman. 

Enter the Robot

Talk about having your cake and eating it too. The Robot takes the laparoscopic approach, and instead of 2 straight sticks, it gives you four curved articulating instruments with 16 degrees of freedom! And yes, these instruments are attached to a large computerized Robot called the Da Vinci. Because... that's how much machinery and software is needed to perform movements remotely similar to YOUR HAND. 

With the Robot, the surgeon sits at a widescreen console and inserts her hands in the little jointed rings, and simply moves her hands as she would "in real life" through an open incision. This is how she controls the arms of the robot. She can control two of the four at once, and can easily switch tools with a pedal on the floor of the console. The arms move smoothly and pivot around a stationery point where the instrument sits in the abdominal wall. Since the instrument shaft is not being torqued all around as in straight stick laparoscopy, there is less post op pain for the patient. The view is spectacular, infinitely better than conventional laparoscopy and, even better than an open incision. Furthermore the surgeon sits, so fatigue does not come into play. 

As with the introduction of any new technology, there were pros and cons. Pros had to do with more precise (better) surgery, less post op pain, and shorter recovery time. Cons had to do with increased cost, and learning curves. 

It is worth a moment to discuss learning curves and adoption curves. A learning curve is the rate over time that it takes a person to learn something. Take knitting, for example. Initially the learning curve is rather flat, since your hands can't even hold the sticks. Once you get that down, you're making scarves for everyone. The learning curve accelerated upward, but if you just keep making scarves, it plateaus, or rises slowly, since maybe your stitches get more even. 

There was a fear that it would take surgeons too long to learn to use the Robot. There was some early data showing that complication rates and blood loss were overly high in a surgeon's first several cases. It turns out these initial studies were predominantly done with residents, who were learning surgery in the first place. As the Robot "diffused" into the community and was adopted, it was put into the hands of experienced laparoscopists, who, as a whole, did not turn out to see this slow learning curve and high complication rates. The adoption rate of the DaVinci Robot has accordingly accelerated over time. Currently it is the favored tool of gynecologists and other surgeons in large centers all over the country.

I can say without reservation that the Robot has made me a much better surgeon. Oftentimes my post op patients feel so decently that they overdo it. My biggest post op challenge is keeping them down. 

For a post op Precaution and Instruction Sheet for after a Robot assisted hysterectomy, click on the instruments: