Robotic vs laparoscopic hysterectomy: Is there a place for both?

At the Samuel A Cosgrove Memorial Lecture on May 6, 2017, a debate about robotic versus laparoscopic hysterectomy was collegially undertaken by Arnold P Advincula, MD, of the Sloane Hospital for Women at New York Presbyterian/Columbia University Medical School in New York, New York, arguing for the use of the robot in hysterectomy and Matthew Siedhoff, MD, MSCR, at Cedars-Sinai-Medical Center in Los Angeles, California, arguing against using the robot.

At the beginning of the debate, attendees were asked if they used laparoscopic or robotic surgery, with about 50% doing the hysterectomy procedure laparoscopically. They were then asked why they didn’t use the robot. Very few said that size of uterine pathology was the reason for avoiding the robot, while cost and experience were the mostly likely reasons for avoiding the devices.

Dr Advincula, who said that he’s been using robotics since 2001, stated that the robot should be seen as one step in the evolution of the laparoscopic procedure. When approaching the use of the robot, surgeons should do what they do best and cautioned that no piece of surgical technology can replace the knowledge that a surgeon brings to a procedure. He also said that the cost of the robot is not what one would think, as the device is not used just in the ob/gyn unit of the hospital, but other units will use it as well. Dr Advincula said that with the negative publicity that has surrounded the robot, attention has come to focus on cost, the learning curve associated with the device, and experience. He closed by pointing to a 1992 editorial in Obstetrics & Gynecology in which the author wondered if laparoscopic surgery was more than a gimmick and to a follow-up in 2010 in which the author said that laparoscopic surgery had become useful.

When starting his side of the debate, Dr Siedhoff said simply that robotics is not needed in gynecologic surgery. He argued that the aggressive push by device companies had made hospitals and surgeons feel like they had to offer robotics or be left behind, but that it brings with it technical demands and opens up more opportunities for risk. He said that one of the biggest problems with research into efficacy is that there’s incredible difficulty working around bias because randomized controlled trials are not possible and that the literature can be interpreted to fit the bias of the reader. In addition, he pointed out that the difficulties inherent in evaluating robotic surgery because of the many variables, such as a surgeon’s record and the possibility that skill with the technology would improve over an individual’s career. Dr Seidhoff closed by saying that the robot is not necessary but asked if the robot can be used ethically. Given sufficient volume, judicious instruction of trainees, and investment in a teaching team, the technology might provide results equivalent with laparoscopy.

During the course of his rebuttal, Dr Advincula said that the two sides of the debate were fairly close to each other. High volume and the surgeon’s skill set, he said, were important for either robotic or laparoscopic surgery. Dr Advincula said when comparing the cost in his department between the two types of surgery, they were roughly equivalent and that the cost of the surgeon’s time often is not factored in. Dr Siedhoff said that he felt that conventional laparoscopy was easier to replicate for trainees and teaching them anatomy was easier than instruction on the robotic platform.

Following the debate, attendees were asked if the debate had altered how they might operate in the future and there was some movement with more people saying that they might start to use the robot more often. Forty-two percent said that lack of experience with the robot was the reason they would avoid the technology. Roughly 30% of attendees said that the debate would affect how they approached minimally invasive surgery in the future.