Robotic Surgery

Excision surgery should be done via laparoscopy (minimally invasive surgical procedure using small incisions) and not via laparotomy (surgical procedure which involves a large incision in the abdomen). Excision surgery can be via robotic surgery or a standard laparoscopy – both techniques can potentially give the patient a good outcome with low complication rates. What’s most important is not if it’s robotic or standard laparoscopy, but rather the surgeon’s ability to recognize endometriosis in all its colors, appearances, and locations, and to safely excise it from all locations. There are excellent excision surgeons with great patient outcomes and low complication rates who use the robot, and excellent surgeons who don’t.

“Robotic surgery is still just laparoscopy. That is the first hurdle that needs to be understood. There is nothing magical about the robot, but there are many benefits to robotic surgery in comparison to standard laparoscopy. Patients have stated that they did not want robotic surgery, because they wanted the surgeon’s hands “doing” the surgery. Even in laparoscopy, the surgeon does not touch the tissue with his hands. The surgeon uses instruments, and often the same type of instruments as standard laparoscopy, to perform the surgery.”

-Quote from Dr. John Dulemba, excision surgeon via his article Robotic Surgery.

Dr. John Dulemba has done over 3,500 standard laparoscopic cases for endometriosis and over 1,400 endometriosis cases using the robot. In his expert opinion, some advantages of the robot vs standard laparoscopy for endo are: 

• The surgeon’s comfort when operating, reducing their fatigue. This can be especially important during long, complex excision surgeries. 2. Better visualization. Davinci robot is 3D versus 2D for standard laparoscopy: “This helps with dissection, excising endo, and separating organs and adhesions.”

He says that, “A complaint [about the DaVinci] is that there is a loss of tactile sense (touch and feel). Over time, the brain adapts, and the surgeon seems to develop a visual tactile sense. I can detect soft and hard tissue. The visual tactile sense allows me to be as gentle as normal hands and laparoscopic hands.”

“[Loss of haptic touch] doesn’t limit a good robotic surgeon’s ability to identify deeper margins of disease or even deep disease. When one sense is taken away, our brains adapt! With robotics I still use vision, grasping strength, tissue mobility, and visual comparison of areas to detect deep endometriosis.”

-Quote from Dr. Jeff Arrington, excision surgeon via his IG post on 1/2/23. Dr. Arrington has done both standard laparoscopy and robotic surgery, and has been doing robotic surgery for the last 12 years.

The robot is just a tool.

It’s not about the tool – it’s about the surgeon using that tool and their skills.

It doesn’t make or break your surgery, or mean that you will have any better or worse surgery because of it. However, if the surgeon does robotic surgery, it’s important to know that using the robot is also a skill in itself, and it can take 150+ surgeries for a surgeon to become skilled at using the robot. Therefore, you should also ask them questions to gauge their skills using the robot, such as how many surgeries they’ve done using it, how many excisions, how much training they’ve had, etc.

• Can they recognize all forms/colors of endo?
• Can they safely excise endo from all locations that it’s found?
• What is their complication rate?
• What are their patient outcomes?
• What kind of training in excision do they have?
• What kind of training in using the robot do they have?
• How many excision surgeries have they done?
• How many excision surgeries using the robot?

Remember, not all excision surgeons have the same skill level or experience. It’s still imperative to vet your surgeon, look at patient reviews/lawsuits, and ask them questions to make sure they have the appropriate skill level to treat your case. You can use Google, social media, endometriosis FB groups, Reddit, Open Payments, and more to gather information on your surgeon to decide if they are the right fit for you.

There are multiple small studies evaluating safety and efficacy of robotic surgery for endometriosis.

They show that robotic surgery and standard laparoscopy have:

• comparable perioperative outcomes.
  
  
• comparable intraoperative and postoperative complication rates (no evidence of increased complication rates for robotic surgery.)
  
  
• A few of these studies also looked at quality of life improvements and found them to be similar for excision via the robot or standard laparoscopy.