A minimally invasive laparoscopic hysterectomy technique could be key to helping some women avoid conversion to open (and riskier) surgery.
Women who undergo a laparoscopic hysterectomy with the help of a robotic surgical platform are less likely to require conversion to an abdominal, or "open" laparotomy due to unforeseen complications that might arise during surgery, a University of Michigan study has found.
A laparoscopic hysterectomy, which involves a surgeon making several small incisions on the abdomen, can be performed with or without use of the robotic surgical platform. A traditional laparoscopic hysterectomy, which does not use the robotic platform, has a 5.4 percent predicted risk of conversion compared to 0.8 percent with use of the robotic platform, according to the study.
That could be an important distinction for hysterectomy patients, as open surgery like laparotomy can harbor a greater number of hazards.
"We know the benefits of minimally invasive surgery," says Courtney Lim, M.D., an assistant professor of obstetrics and gynecology at U-M. "The benefits include decreased pain and blood loss as well as decreased complications. Therefore, it's our goal to try and get all of our patients to have a minimally invasive approach when recommended."
Such patients are also less likely to develop infections and tend to recover more quickly, she says.
Another advantage is cosmetic: a laparotomy incision might stretch 10 to 12 centimeters; those from laparoscopic hysterectomy (robotic or otherwise) could be just 5 to 12 millimeters, Lim says.
And while doctors have debated the effectiveness and necessity of robotic surgical platform for some procedures, results of the U-M survey could help shift attitudes.
The study, co-authored by Lim and published in December in Obstetrics & Gynecology, examined the data of 6,992 women treated at 52 hospitals across Michigan. Data encompassed an 18-month period in 2013-14 and was taken from the Michigan Surgical Quality Collaborative, a statewide initiative that helps surgical teams improve patient care.
Of that group, 3.93 percent were converted from an attempted laparoscopic hysterectomy to laparotomy for various reasons.
Some of these patients required an open surgery due to a surgical complication, while others may have been due to unforeseen issues such as excess scar tissue or unexpected findings.
It's our goal to try and get all of our patients to have a minimally invasive approach when recommended.Courtney Lim, M.D.
Benefits and precautions
The robotic option, controlled remotely by hand, is similar in procedure and objective to a standard laparoscopic hysterectomy. The former method, though, involves insertion of a 3-D camera and "arms" that can move with a 360-degree motion.
Still, Lim notes, the robotic tools aren't the sole guarantee of a better outcome.
Whether laparoscopic hysterectomies are performed by high-volume surgeons, the survey data showed, was an added — and important — factor.
The high-volume surgeons in the study (those in the top third of surgeons) were almost half as likely to face conversion (at a rate of 1.4 percent versus 2.25 percent, respectively).
Still, no matter a surgeon's background, the use of the robotic platform procedure comes with caveats. The technology does cost more and, as a result of added time to prepare and insert the equipment, can extend the time to complete the surgery.
The greatest barrier shouldn't be only cost or length of time in the operating room, Lim says.
"Training is a barrier," she says. "A lot of gynecologists may not feel comfortable offering laparoscopic hysterectomy for people who have scar tissue or bigger uteruses with fibroid tissue."
Those circumstances, Lim says, typically inhibit a vaginal hysterectomy, often the first course of action — and what the American Congress of Obstetricians and Gynecologists recommends. A laparoscopic route, then, may follow.
Doing so with use of the robotic platform has increased in frequency but remains divisive among some clinicians.
In prior studies elsewhere, no difference was found in conversion rates between the use of the robotic surgical platform and traditional laparoscopy, Lim says.
Which is why the new U-M findings ought to help push the dialogue — even if a robotic route isn't right for the patient at hand.
"This finding should not be taken as a recommendation for all patients to undergo robotic surgery," Lim says. "There is likely a complex relationship between surgical volume, use of the robotic platform and risk of conversion in patients undergoing laparoscopic hysterectomy, but the goal should be balancing these to achieve high-quality surgical care for patients."
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