Dr. Petros Hirides,MD, PhD Colleague of GAIA.
Robotic surgery is the development of minimally traumatic surgery in which the operation is performed through very small skin incisions.
The value of conventional laparoscopic surgery is recognized. Despite its advantages, its usefulness is limited by the high degree of necessary skill, the limited movements, the two-dimensional and mirror-image projected movements, and biotechnological parameters, such as physiological tremor of the hands of the surgeon which is augmented through the long, rigid instruments, particularly when they have to be kept steady for long periods of time.
Robotic surgery is the spearhead of endoscopy, which is to bridge the gap between the laparoscopic and open surgery. The tele-surgery provides technical features such as three-dimensional vision, great maneuverability of robotic instruments and filtering of physiological tremor of the surgeon’s hands. These factors provide an ergonomic environment for the surgeon that allows performing complex laparoscopic procedures.
Some of the advantages of the daVinci robotic system include precise movements, extended range of motion, greater dexterity, improved vision and the possibility for intervention in small, inaccessible areas. Overall ergonomics of the system, makes the surgeon feel safer during surgery. Patients on the other hand, enjoy shorter hospital stay, less pain, less blood loss, minimized risk of infection, improved cosmetic results, quicker recovery and faster return to daily activities.
Nowadays there is a considerable number of publications in literature with respect to the use of robotic systems in gynecologic surgery. More specifically, more than 280 publications refer to daVinci gynecologic operations, while some compare its effectiveness with conventional laparoscopy. Currently, the entire spectrum of gynecologic surgery can be conducted robotically, including both benign indications such as fibroid enucleation, total and subtotal hysterectomy, endometriosis, as well as malignancies such as pelvic tumors and lymph node dissections.
Surgical treatment of fibroids includes, apart from hysterectomy, alternative surgical methods such as the enucleation, i.e. removal of fibroids while maintaining the uterine body. This method is recommended for women who wish to preserve fertility and those who refuse to have their uterus removed. Robotic myomectomy is performed with unparalleled accuracy, increased movement flexibility and incredible three-dimensional image within the body. Even for large fibroids, the operation is completed through four minimal skin incisions, each less than 1cm in length. The HD (High Definition) image allows optimal recognition of the separation plane during enucleation. The uterus is sutured in multiple layers with sutures of equal strength compared to open surgery. The fibroid is removed from the abdomen into pieces without the need of an additional incision.
The removal of the uterus (hysterectomy) is the most popular robotic operation in the US today. Although hysterectomy is carried out with conventional laparoscopy over the past 20 years, increased safety, was what prompted gynecologists to turn to the robotic approach. In recent reports, it seems that injuries to the ureters during hysterectomy occur much less frequently during robotic surgery in in comparison to open surgery or conventional laparoscopy. Also with robotic surgery, the large size of uterus ceases to be a limiting factor for minimally invasive surgery, since hysterectomies of large uteri over 1kg in weight are carried out with great success.
Endometriosis is a benign disease affecting 7% of women of childbearing age, especially younger ones between 25-40 years. The foci of endometriosis usually involve the pelvic organs however, sometimes they occur in remote locations such as the lungs, the kidneys, even the upper extremities. Emerging lesions resemble small "bumps" on the surface of organs. Ovarian cysts can be formed around the endometrial tissue (i.e. endometriomas) which can grow to the size of an orange. Endometriosis is a progressive disease but progression is slow, causing inflammation and pain leading in scarring and formation of adhesions. Recent studies from SERGS (Society of European Robotic Gynecologic Surgery) recommend that robotic surgery is the safest method for the management of advanced endometriosis. Also robotic surgery is valuable in cases where fertility is desired, because it allows a thorough cleaning of the abdomen while maintaining the normal ovarian epithelial tissue.
Radical hysterectomy is a classic and effective method for the treatment of early cervical cancer. Robotic assisted surgery allows a minimally invasive radical hysterectomy, with satisfactory results in terms of blood loss, duration of surgery, lymphadenectomy (removal of lymph vessels and nodes) and reduced hospitalization. In the treatment of endometrial cancer, the effectiveness of robotic method has already been recognized.
Regarding ovarian cancer, there is insufficient evidence regarding the robotic approach. However, experienced surgeons in certified oncology center introduce robotic surgery to both staging as well as treatment (debulking) of the disease. Minimally traumatic surgery not only ensures fewer complications, but also reduces morbidity therefore allowing a quicker onset of postoperative chemotherapy. The newer technology, "Firefly", which is available for the robotic system, facilitates recognition of lymph nodes, making it safer and more efficient in the processes of lymph node dissection.
Finally, it should be mentioned that for patients with morbid obesity, robotic surgery is superior compared to other approaches, both in reducing complications and in minimizing duration of surgery.
Single incision robotic surgery (Single-Site Robotic Surgery)is a recent innovation in the field of Laparoscopic Surgery. The surgeon is operating again using the robotic system, however now, all instruments enter the abdomen through a single, small incision of 15mm instead of four incisions. The insertion of surgical instruments through the same port, is technically very demanding, especially because all instruments lie on the same axis.With the evolution of technology, thinner, more flexible instruments are available and adapt on the Da Vinci system’s specially designed platform for single-site. The instruments cross each other at the point of entry and the system, electronically reverses the robotic arms (the right becomes left and vice versa) so that the movements of the surgeon are aligned, comfortable and natural.
Single Site robotic surgery is the least traumatic surgery available and ensures excellent cosmetic results.
Since 2006, when the daVinci surgical program initiated in Athens Medical Center, by the pioneer surgeon Dr. Konstantinos Konstantinidis and his team, more than 1,200 operations of various indications have been successfully completed and now, they are planned on a daily basis.
The vast experience of Dr. Konstantinidis in laparoscopy, served as the perfect background for the development of minimally invasive robotic surgery in challenging and demanding operations. These include operations for restoration of GERD (gastro - esophageal reflux disease), repair of hiatal hernias and esophageal achalasia, repair of ventral hernias of the abdominal wall, cholecystectomies and biliary operations, adrenalectomies, splenectomies, gastrectomies, colectomies, operations for morbid obesity such as the gastric bypass or the gastric 'sleeve' and removal of gastric bands. Also gynecologic operations discussed earlier, urologic operations such as prostatectomies and nephrectomies and even total cystectomies. Naturally, the spectrum of operations and the potentials are widening continuously.