Is a Robot-Assisted Hysterectomy a Better Hysterectomy?

Everywhere you turn, there are articles and advertisements touting the benefits of robotic surgery, so it’s no surprise that my patients routinely ask if their scheduled hysterectomy will be performed using a robot. But who really benefits from robotic surgery? Contrary to hype, it may not always be the patient.

Robotic surgery is a minimally invasive technique (i.e. uses tiny incisions) that was originally developed as a way to operate on wounded soldiers who couldn’t get to an expert surgeon. With robotics, the surgeon can operate remotely, sitting at a console miles away and moving levers to control the robots “arms” and maneuver instruments, which are placed into the patient by an on-site surgeon.

While robotic surgery was originally designed to be performed from a distance, most robotic surgery is currently performed with the primary surgeon sitting at a console in the same room as the patient, and a second surgeon standing in the traditional spot next to the patient. Robotic instruments can do things traditional laparoscopic instruments cannot, like twist, turn and maneuver around corners. In addition, the technology allows the surgeon to have a magnified 3-D perspective, almost like standing inside the body while operating.  The result is the ability to see and do things that can’t be done otherwise. In the event that a procedure can’t be completed robotically and an incision needs to be made, both surgeons are in the room and can proceed.

So what’s the down side?

The benefits of robotic hysterectomy are clear when being performed in order to avoid an abdominal incision. But, if a robotic surgery is being offered to replace a laparoscopic hysterectomy, another minimally invasive method, the advantage has not been established. The truth is that, in most cases, laparoscopic surgery usually has all the benefits of a robotic surgery, but with a much lower price tag. Whether a hysterectomy is performed robotically or laparoscopically, the patient has minimal pain and a speedy recovery. Complication rates are the same in experienced hands.

If a laparoscopic procedure is not possible and a traditional abdominal incision is the only option,  that’s where robotics comes in and is truly beneficial. This is typically the case if someone has cancer, a lot of scar tissue, or a very large uterus so even skilled laparoscopic surgeons can’t get the visualization they need to do highly technical work. In these cases, the result of using robotics is shorter operating times, less blood loss, fewer complications, and much shorter recoveries (assuming your surgeon is skilled and very experienced at doing robotic surgery). However, if your doctor says your surgery can be safely performed laparoscopically, there is likely no benefit (beyond the “cool factor”) to a robotic procedure.

While few hospitals currently own the very expensive equipment that is required to perform robotic hysterectomies, many are expected to offer this new procedure within the next few years. If it is no better, safer or more cost effective than a laparoscopic hysterectomy, why is this happening?  The answer is easy: marketing. Patients want the newest and most high-tech methods, even if the benefits have not been established.  Hospitals and doctors get paid the same thing whether a hysterectomy is performed laparoscopically or robotically, but hospitals that don’t offer robotics are worried that patients will simply take their uteruses elsewhere.

Every year 600,000 hysterectomies are performed, but only 15% are performed using a minimally invasive technique. Expert laparoscopic surgeons are able to perform roughly 80% of hysterectomies laparoscopically without a robot. To me, it makes far more sense to train surgeons to become expert laparoscopic surgeons than to buy million-dollar robots to do what can be done using far less expensive instruments.

This is a controversial area and there are gynecologic surgeons who will disagree with me. But the scientific literature has not yet shown a benefit to robotic surgery over laparoscopic surgery for non-cancer hysterectomies. More studies are needed. I am currently participating in such a study comparing patient outcomes in traditional laparoscopy vs. robotic surgery …  so stay tuned.

For more information on laparoscopic hysterectomy and alternatives to hysterectomy, check out my book, The Essential Guide to Hysterectomy.