Robot-assisted laparoscopy for benign uterine disease. Feasibility, outcome and hospital cost

University dissertation from Department of Obstetrics and Gynecology, Lund University

Abstract: The introduction of the laparoscope was a milestone within gynecologic surgery. Despite evidence of better perioperative outcome compared to laparotomy, laparoscopy is mostly performed for less advanced surgical procedures and the uptake of laparoscopic hysterectomy has been slow. An effort to preserve the clinical benefits of laparoscopic surgery and facilitate the performance of more advanced surgery has led to the development of robot-assisted laparoscopic surgery. Technical progress has been advantageous for the patient from a historical point of view, but this cannot be assumed without proper evaluation. As for all surgical approaches, it is important to recognize the possible applications of robotic surgery as well as proper patient selection both from a clinical and economical point of view. The overall aim of this thesis was to investigate the possible applications, clinical outcome and hospital cost of robot-assisted laparoscopic surgery for benign uterine disease at a single institution following the introduction of robotic surgery. Study I: Evaluating the first 1000 robotic surgeries performed showed that a surgical robot provides the possibility to offer minimally invasive surgery to a larger patient population with low rates of conversions and intraoperative complications. Study II: 31 women with symptomatic, deep intramural myomas and either otherwise unexplained infertility or myomas with a possible effect on conception had a pregnancy rate following robotic myomectomy of 68%. Study III: All women (n=114) with a BMI ≥ 30 kg/m2 who underwent a simple hysterectomy by robotics or laparotomy during the study period were included. Robot-assisted laparoscopic hysterectomy in obese women was associated with shorter hospital stay, less bleeding, and fewer complications and longer operative time compared to laparotomy although the operative times for morbidly obese women were similar between robotics and laparotomy. Study IV: 122 women planned for minimally invasive hysterectomy for benign disease were randomly allocated to either robot-assisted- or traditional, minimally invasive hysterectomy in a 1:1 proportion with vaginal hysterectomy as a primary choice in the latter. From the perspective of hospital costs, robotic-assisted hysterectomy is not advantageous for treating non-complex benign conditions when a vaginal approach is feasible in a high proportion of patients. A similar hospital cost is attainable for laparoscopy and robotics when the robot is a preexisting investment. Study V: Complication rates in 949 women planned for robotic hysterectomy for malignant (75%) and benign (25%) gynecological disease over an 8-year period with special awareness of complications possibly related to robot specific risk factors. Intraoperative- and postoperative complications and complications possibly related to the robotic approach diminish with training, experience and refinement of practice. Study VI: All women (n=483) undergoing hysterectomy for benign disease during 2013 and 2014. Vaginal hysterectomy was associated with the lowest hospital cost and robotic hysterectomy with the lowest rate of perioperative complications. Procedure-specific proficiency influences outcome. Robotic hysterectomy for benign disease is clinically advantageous and economically feasible in complex cases, when performed by high volume surgeons.