Robotic vs Laparoscopic Surgery in Benign Gynaecology

Robotic vs laparoscopic surgery in benign gynaecology is a choice of keyhole technique; the robot adds three-dimensional magnification and wristed instruments. Dr. Deepika Aggarwal, Chief-Laparoscopic Gynae & Robotic Surgery, Artemis Hospitals, Gurugram, India, reports bowel, vessel and bladder injury rates below 0.5% robotically against around 1 to 2% laparoscopically, and puts the extra cost at about $1,000 to $1,200. She names three groups for whom the robot is clearly indicated.

Robotic vs laparoscopic surgery: what is the difference?

In laparoscopic surgery, the surgeon stands at the table holding long, rigid instruments passed through small incisions, and usually watches a two-dimensional screen. In robotic surgery, the same small incisions are used, but the surgeon sits at a console and controls instruments mounted on robotic arms, viewing the operation through a three-dimensional camera. The instruments have a wrist that turns through 360 degrees, and the robot reproduces the surgeon's hand movements exactly.

Dr. Aggarwal uses a driving analogy for the relationship between the two skills: a surgeon who has driven a manual car finds an automatic easy. The robot does not replace laparoscopic skill; it builds on it. The broader picture of what robotics does across fibroids (non-cancerous growths of the muscle of the uterus), endometriosis (tissue similar to the lining of the uterus growing outside it) and other benign conditions is in the complete guide to the role of robotics in benign gynaecology.

Open, laparoscopic or robotic: how the approach is chosen

Every patient needs a decision on approach, weighed against resources, cost and clinical need. Dr. Aggarwal's framework starts with the cases that decide themselves.

When open surgery is unavoidable. Fibroids so massive that they extend 4 to 5 cm above the umbilicus leave no space to insert the camera or move the instruments. Those are straightforwardly open operations. Open surgery is also still needed in certain ovarian cancers.

When laparoscopy becomes difficult. A uterus of around 18 to 20 weeks' size (as large as the uterus at 18 to 20 weeks of pregnancy) is tricky to operate on laparoscopically. That is where the robot comes in, because the surgeon can be confident of completing the operation robotically.

When precision decides the outcome. In severe endometriosis, dense adhesions bind the bowel, uterus and ovaries together. Separating them safely requires excellent precision, which the robot's magnified three-dimensional view, about 15 times the precision of a laparoscope in her account, and wristed instruments support.

The three clear indications for robotic surgery

Asked by a doctor from Nigeria how to distinguish clearly when robotic surgery should be preferred to laparoscopy, Dr. Aggarwal named three groups:

1. Severe endometriosis.
2. A uterus with multiple fibroids.
3. Obese women with a high BMI.

The third deserves explanation. A body mass index (BMI) of 30 or more defines obesity, and obese patients carry a higher anaesthetic risk. Dr. Aggarwal's priority for them is a shorter anaesthetic, which the robot achieves by shortening the operation. Fibroid cases, including the myomectomy that takes four to five hours laparoscopically and perhaps a couple of hours robotically, are discussed in robotic surgery for fibroids.

Is robotic surgery safe? Complication rates compared

Dr. Aggarwal considers robotic surgery safer than laparoscopy, and summarises the clinical case for the robot as less postoperative pain, faster recovery, less blood loss, fewer conversions to open surgery, fewer complications and fewer readmissions. She also cites hospital stay: about 90% of her patients go home one day after robotic surgery, against at least two to three days after laparoscopy and three to five days after open surgery.

Injury rates by type

For a gynaecologist, four injuries matter most: to the bladder, the bowel, the ureter (the tube that carries urine from the kidney to the bladder) and a major blood vessel. Dr. Aggarwal gave these figures:

• The overall risk of injury in robotic surgery is less than 1%.
• The risk of bowel, vessel and bladder injury with robotic surgery is less than 0.5%.
• With laparoscopic surgery, the comparable risk is around 1 to 2%.

Randomised trials and systematic reviews, however, have not shown a consistent difference in complication rates between robotic and laparoscopic hysterectomy for benign disease.

Her own results

Across more than 400 to 500 robotic operations, Dr. Aggarwal could not recall a single injury to the bladder, bowel or ureter, and none of her patients had needed intensive care.

Robotic surgery compared with open surgery

A doctor from Nigeria asked whether robotic surgery has better success rates than traditional open surgery. Dr. Aggarwal was emphatic that it does. Magnification of structures such as the ureter and the lymph nodes lowers the complication rate below that of open surgery, while open operations lose more blood and require a large incision that adds to the patient's morbidity. Having performed many open operations before 2000, then moved to laparoscopy and then to robotics, she makes that comparison from her own practice.

Conversion to open surgery: how often and why

A conversion happens when an operation started through small incisions has to be completed by opening the abdomen. With a very large fibroid or uterus, a laparoscopic surgeon sometimes has to warn the patient of a 5% risk of conversion, according to Dr. Aggarwal. Robotic conversion is rare.

She recalled one robotic conversion in three to four years. Robotic gynaecological surgery is performed with the patient tilted head-down at about 30 degrees (the Trendelenburg position), which pushes the abdominal contents up against the diaphragm. This patient had compromised lungs and could not maintain her oxygen saturation. The team undocked the robot (detached its arms from the patient), raised her head, waited 10 minutes and restarted, but her saturation kept falling, so they completed the operation open. Dr. Aggarwal described conversion as very rare, around one in 100 cases, but never zero.

What "failure" means in robotic surgery

A professor from DR Congo asked about the failure rate. Dr. Aggarwal first asked what failure means, because there are three distinct possibilities:

1. Conversion to open surgery, discussed above.
2. A complication, covered by the injury rates above.
3. A case that cannot be done robotically at all. An expert robotic surgeon should make that decision before the operation, not after docking the robot. It is a matter of preoperative planning: if the ultrasound report is not satisfactory, she obtains an MRI or CT scan before deciding.

The learning curve for robotic surgery

Dr. Aggarwal would expect a surgeon already experienced in the same operation laparoscopically to become proficient robotically after about 10 cases. Patient selection is, in her view, the single most important safeguard for surgeons beginning robotic work. Her advice is to select patients very carefully at first and to take on more complex cases gradually as experience grows.

An attendee cited data suggesting that proficiency in complex cases such as endometrial cancer may be reached in fewer than 10 cases robotically, against 40 for standard laparoscopy. Dr. Aggarwal's explanation is that most surgeons who train in robotics are already experienced laparoscopic surgeons; very few start robotic surgery without that background. A surgeon who has performed many laparoscopic endometrial cancer operations already knows the surgery and only needs to learn to drive the robot. Asked whether the data instead suggested laparoscopy has better outcomes, she said she was not aware of any such evidence: the evidence-based data she had prepared for the session show lower complication rates, readmission rates, blood loss and postoperative pain with robotic surgery.

Cost of robotic surgery vs laparoscopy

Robotic surgery costs more than laparoscopic surgery. Dr. Aggarwal put the difference at around $1,000 to $1,200 more than a conventional laparoscopic operation, depending on the type of surgery. Against that, the shorter stay (one day for about 90% of her robotic patients, compared with two to three days laparoscopically) reduces the accommodation and hospital days a travelling patient has to fund. Fees for related procedures are listed on the gynaecological procedures cost page.

When to refer, and when to manage locally

Many partner doctors already have open surgery, and often laparoscopy, available locally. Where a patient has the means to travel, Dr. Aggarwal's guidance is that the decision depends on local expertise for that particular case. Doctors should first gauge what their local surgeons and gynaecologists can do. Complex cases, such as big fibroids or severe endometriosis, where the local experts are not confident or feel the patient may need to be opened, are the ones to refer to a robotic centre. She invites doctors to share such queries with her directly.

The full exchanges with the doctors who asked these questions, including the questions on training gynaecologists in robotic and laparoscopic surgery, are on the Live Discussion page. Dr. Aggarwal's profile is on her doctor page, and related conditions are covered in the obstetrics and gynaecology specialty hub.