Dear Editors,

I read the article about robotic surgery (The state of gynecologic robotic surgery, Contemporary OB/GYN®, November 2020) and I am dismayed that the American College of Obstetricians and Gynecologists and the ob/gyn world has embraced the robot despite the evidence for hysterectomy that transvaginal hysterectomy (THV) is safer. We are justifying less safe surgical options because the robots are available?

Why are we not training based on evidence-based medicine? No trainee in ob/gyn residency should be allowed to use a robot unless it is for surgery that is enhanced by robot technology, such as endometrial cancer and lymph node dissection. I have never been able to understand this disconnect from evidence-based care.

We promote TVH as the surgery of choice for hysterectomy, yet we bemoan the fact that trainees are not being trained in TVH skills. WHY? Have we lost our sense of direction and all focused on the bright lights of the robots?

I personally forced myself to develop my TVH skills. First, I was trained to do TVH as the surgery of choice for benign conditions; that helped.

I had a 90%+ TVH rate for hysterectomies. Previous c/s did not keep me from doing a basic TVH, nulliparous cervix did not prevent me from attempting TVH and uterine size rarely prevented me from attempting and successfully completing TVH.

I even developed a new technique to complete a failed TVH. Start the TVH, enter the anterior and posterior cul-de-sac and if unable to complete the TVH I would then close the cuff vaginally and then a simple laparotomy to complete the procedure and the cuff was already closed, which made it a very simple procedure and took less than 30 minutes.

Most TVHs took less than 40 minutes and blood loss was usually less than 50 cc.

I developed our outpatient TVH program and well over 600 patients successfully went home after surgery the same day.

Related: Surgeons Panel Discussion

My complication rate was lower than the rest of our department and I was a high- volume surgeon, performing more cases than all other members of our gyn department with fewer complications and no mortalities in over 25 years.

I believe that we have sold out to the robots and we have neglected our patients in the process. Robot cases are performed because the robot is available and it is “fun.” What happened here? Fun trumps safety and evidence. No pride in developing our specialty trademark surgery?

We need to go back to basics and train our new doctors on TVH skills and then and only then should they be allowed to advance to robot surgery.

Robots need to be reserved for the specialties that use them to improve care such as gyn oncology and infertility. Stop now while we still have the surgical skills available to train the new doctors.

I feel like we have been sold out to the robot companies and they now control our patients’ care. The evidence does not support this. Let’s go back to the gold standard for benign conditions and train our new doctors.

Just my two cents.

Elizebeth Harmon, MD, MBA, FACOG

Gynecologist and Founder,
Salem Women’s Clinic Inc.

SALEM, OR

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Response

We would like to thank Dr. Harmon for the letter, and congratulate her on the skill and passion in offering a minimally invasive option to the vast majority of her patients. In skilled hands, vaginal hysterectomy is an excellent option for surgeons and patients.

All surgeons strive to provide the best surgical care for their patients; however, graduating residents are not getting as much experience in vaginal hysterectomy during their training as they used to; the data on this is clear.

In addition, we now have 4 options (abdominal, vaginal, laparoscopic, robotic) for hysterectomy instead of two (abdominal and vaginal), and the goal is always to provide more minimally invasive options and avoid laparotomy. In addition to that, fewer hysterectomies are being performed annually and we have graduated over 300 fellows from Minimally Invasive Gynecologic Surgery fellowships that are taking care of a large portion of patients that require hysterectomy.

Other subspecialists such as gynecologic oncologists and urogynecologists also are doing large volumes of hysterectomies. All of these factors make it harder and harder for graduates of residency programs to develop and maintain their skills in vaginal surgery.

Laparoscopic hysterectomy has become the go-to procedure and it does have its merits. The surgeon can take on any pelvic pathology, including endometriosis and ovarian cysts, and OR times in laparoscopic hysterectomy have been decreasing and are often similar to what they are for vaginal hysterectomy. With any minimally invasive approach, patient outcomes are comparable.

Therefore, some have argued that the ob/gyn specialist has to ideally pick one technique in order to become proficient at it and that makes many of them pick the laparoscopic or robotic approach.

In an ideal world, it would be great to have the vaginal hysterectomy expert take on most cases and refer the hard cases to the laparoscopic surgeon since this would minimize cost and reduce the number of abdominal hysterectomies even further.

This, however, is not a real world situation. In the real world, the vaginal surgeon expert will take on most cases vaginally, but the really hard cases will be performed via a laparotomy. This is what reduces the reproducibility of the vaginal approach compared to laparoscopic and robotic approaches, where the laparoscopic expert can often do close to 100% of his or her cases in a minimally invasive fashion.

We agree with Dr. Harmon that robotic surgery has at times been oversold; but robotic surgery is not just in the sphere of vaginal surgery. It also provides a valuable option to a group of gynecologists who are not proficient in vaginal or straight-stick modalities, to shift their cases from laparotomy to a minimally invasive approach.

High-volume, well trained robotic surgeons provide excellent care to their patients, and this technology allows more surgeons to offer a minimally invasive approach and decrease the comorbidities associated with open surgery.

Jon Einarsson, MD, MPH, PHD

Robert K. Zurawin, MD

Gaby Moawad, MD