Laparoscopy vs Robotic Surgery in Gynecology

[Dr. Amy Park]
Can you tell me, what are your criteria? How do you decide on who you're going to take for conventional laparoscopy versus robotic, what your thinking is and why do you choose conventional for the biggest and hardest cases? I'm curious about all of it.

[Dr. Mark Hoffman]
In general, the answer is just whatever room I'm in, it doesn't have a huge impact. The one type of case that really made me want to go back to the robot was myomectomy. There's a lot of sewing and it's a lot of weird angles. Sometimes you don't get to make your hysterectomy in the most comfortable angle for traditional laparoscopy because you're not going to have wristed instruments. If you're doing a vertical closure, it's a little bit of more of an angle potentially. You're sewing two and three and four layers on a closure of a hysterectomy. It's a lot. To be able to do that robotically is just a lot easier, honestly.

I don't know that it's better, it's just easier for me in doing this long cases. By the end of a long myomectomy with multiple fibroids and multiple hysterectomies, robots, that's the one case where I try to get those on the robot when I can. I also do a lot of mini-lap myomectomies too, if they're anterior pathology, if they're getting a c-section anyway, like why fight with all this equipment and then still have to make a three-centimeter or two-centimeter incision to get the fibroids out, when you could just do the entire thing through a four or five-centimeter incision, the mini-laparotomy is something I learned actually in residency. I had an attendant who did a bunch of abdominals or collages with unbelievably small mini-lap incisions, like crazy.

Got the residency and Syngeta Sinopoli at Chicago was the first mixed person I got to work with. I was like, this is going to be great. We'll do this robotic case and she did a mini-lap and I was like, that's so lame, and then we did it and it was like, okay, that was amazing. We did the entire case through a tiny little incision. A lot of it is just get your MRI and see where the pathology is. If it's posterior and low, I'm not going to be able to get that through a mini-lap. You're going to have to do--

Laparoscopy improves your ability to access those fibroids. It's 3D modeling using MRI in my mind, just visualizing the case before I do it, how am I going to get at this fibroid, where are the vessels, where's the ovary, where's the fallopian tube and where are my vessels? If I'm going to have to go anterior here, then posterior there, and trying to really imagine how many hysterectomies I'm going to have to make and what angle, if it gets to be more complex for me personally, just fatigue and things like that, the robot can make that a little more user-friendly, I think.

[Dr. Mark Hoffman]
That's not for myomectomy. How about for a hysterectomy? How do you decide?

[Dr. Amy Park]
For hysterectomy, it doesn't matter much for me. When I say big pathology, if it's a uterus that's above the umbilicus, two and three-kilo uteruses, what I like about traditional laparoscopy, and I know the XI, you can move the camera around. It's just more steps to like tell your assistant, to like take the camera out and move the arms around, whereas I can just put the camera in different port sites. Each step of a hysterectomy is going to be very different in a 3000-gram uterus. You're going to have to take each step a little differently, and that's where port placement matters and those kinds of things.

I think you can get into smaller spaces and you can get into little tighter areas with traditional laparoscopy. Again, I think the more I do, the more touches I get with the robot these days. We just did one the other day that was around two kilos. It was with a partner and did it robotically, that's the other thing. When my partners, someone asked me to come do a case with her and she does primarily robotics. I have a partner from colorectal surgery who does our endo cases together and he doesn't care to use the robot. We do those straight sticks. It's also with comfort, I know a lot of urologists are robot only. A lot of times if I'm doing a co-case, it depends on what the other person wants to use. I don't have a strong preference. Honestly, I don't have a comfort level with one versus the other where it makes me want to choose one versus the other.

[Dr. Amy Park]
Yes, absolutely. Tell me about when you go into the OR and what are your tips and tricks for positioning and getting access and all that stuff. I will say, just circling back to the point that you said about using the robot when you don't have assistants, I know a lot of our fellows who went into private practice, they just use the robot because it's just so much easier when you don't have a resident or fellowship. For me, since I'm pretty much always operating with a trainee, I like conventional because I get to operate.

[Dr. Mark Hoffman]
I also think teaching is a lot easier because I go back and forth, but I think with traditional operations, I can grab their hand and be like," Hold this way, move that way," you're right there, and with the robot, there's a little bit of separation. I think OR setup, and whenever I have a new student or any new learner and interns and stuff, it's the same talk every time. This is the part of surgery that isn't super exciting and fun, but it's certainly one of the most important parts of any case, it's just getting your room ready. Number one, go back to the room before the patient gets there. It makes me nuts when residents are strolling in after the patient's asleep.

I'm like, "We're halfway done." We've already done the setup for them, whether you have a pink pad or whether you have egg crate foam or whatever, go back and make sure. In my case this morning, they had the sheets and the egg crate foam not how I want it. I know how to make a bed, I know how to put the sheets on and make sure it's right, because once the patient's on the bed, now getting it fixed is super tough. I would say, after you talk to your patient, go through everything, beat them to the OR, and make sure things are set up. You have the instruments. Do you have the tools you need to do the job? You said, team, team, team.

My goodness, am I lucky in my job to have a team that I'm pretty reliably or consistently operating with? I'll get texts at 6.30, "What's the deal today for this case," they'll pull stuff ahead of time. They know my routine, they know what we need and if there are certain variables, are we going to need the tissue extraction bag, is this a big one, is this endo, what are we dealing with? The team is a huge part of the setup. Knowing who we got, making sure, I know we are-- I don't know if you do this. I walk into ORs, I always look to see who else is operating that day. Who are the other surgeons around? Who can I call, who can run over if I need something, just to know who's around?

I think having that in your mind of like, is this a case where I'm going to need something? I don't call folks in the OR very often, but it's nice to just have that habit so you know who's around. OR Setup, understand how you want your patients positioned, but again, I use, we just got the pink pad strapped to the bed for a long time, it was just cheap egg crate foam. I always position the patients myself with the residents. I don't stroll in once they're asleep and drape. How they're positioned can make an easy case hard and can make a hard case impossible laparoscopically.

We talked a little bit about this, but once the patients are asleep, they need to be in-- I always use some Allen stirrup, something like that every time, yellow fins or something., slide them down so their sacrum is supported, but their butt's hanging off the edge, arms tuck at the side. Always, I cannot for the life of me, figure out why people still-- Like every once in a while, I'll hear someone who's like, we'll have an arm out for laparoscopy and I cannot figure it out.

There are a few reasons why arm tucking is such a huge part of it. Number one, that's where I'm standing. If the arms are out, I'm not comfortable, I'm going to be in pain. We've been lucky to hear you tell us about ergonomics, but you got to go have the arms tuck. I don't usually use sleds unless I have to. Even pretty big patients, we can tuck arms. Make sure the elbows, and wrists are padded, the thumbs are up, arms tuck to the side and really it's pushing on that elbow, like tucking the elbow a little bit underneath them, straightens the arm and keeps stuff from falling off. If it's a loose tuck, you get a nap. If their elbows are falling off the bed, we start over. I'll do that myself too with the residents. I'm like, all right, this is what we want, feel this, because those are the things you can't really rely on other people to know how to do because when teams change and rotate, you got to go own that. You got to go own how the patients are on the bed. Again, early on, someone else does it, and then the patients are sliding under the drape and you're getting to a hard part of the case and start getting some bleeding, now you got to go take them out of T-burg because the patient's sliding off the bed, it's a never event in my OR.

You got to go be able to focus on the variables, which is the patient. Once the patient comes in, I try to keep variables at a minimum. Everybody gets an OG. I don't care if they've had no surgery and we're going to go through them. I may end up having to go through Palmer's point, but I don't want to have to remember to put an OG in. Everybody gets an OG, I give all my hysterectomies peridium pre-op, like an hour or two before they get a dose of peridium. When we systole later, their pee's orange, a lot of the folks when they get their OG and they're like, "What, did they drink orange drink," I'm like, "No, that's just the peridium."