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In the second of a series on robotic assisted  surgery, gynaecological consultant and specialist at the Mater Hospital, Dublin, Bill Boyd, tells IMN reporter Rachel Cunningham how the advent of robots has totally transformed the practice of gynaecological procedures.

“There are four things that have changed the whole practice of gynaecological surgery; the marina coil, the endometrial ablation, the TVT tape, and now the robotic surgery,” Mr William (Bill) Boyd, a consultant at the Mater Hospital and a specialist in gynaecology, told IMN.

Mr Boyd explained that the robotic surgery option is especially suited to operating on an obese patient: “We are on target to becoming the most obese nation in Europe, particularly among the female population. There was a study that came out a few years ago indicating that, in adolescent girls, up to 38 per cent were morbidly obese. That’s extreme and we’re only going in one direction. We’re almost like the 51st state of America, we’re following the US trends rather than European ones.

“With gross obesity, usually located centrally, the risk of cancer or pre-cancer of the lining of the womb is increased. We’re finding now that a huge percentage of patients are coming in with a significantly high body mass index.

“Performing abdominal or pelvic surgery on people who have a grossly obese abdomen is technically very difficult. The old-fashioned technique, with an open incision, means that you end up making a huge incision and the patient must remain in hospital for many days. The risk of wound breakdown is very high because the weight of the abdominal wall pulls it apart. It might take three months to recover just from the incision in the abdomen.

“Central obesity is a huge problem anaesthetic-wise and for ventilation. All the weight of the abdomen would be sitting on the lungs in traditional surgery, so the anaesthetists have to use higher measures, increasing the risk involved. With the robot, the weight of the patient’s abdomen is supported on the arms; it’s easier to ventilate them.

“Now more and more we’re trying to do laparoscopy or minimally invasive surgery keyhole surgery, which is fine for very straightforward, short or diagnostic procedures, such as fertility investigations.  “The laparoscopy is what is called a ‘stick laparoscopy’ where you manipulate physical, rigid instruments. However, if you are operating on someone where the anatomy is very difficult or distorted, or if it is for cancer where you must get clear margins, and the patient is usually obese, those operations can be many hours long. Trying to hold onto two or three instruments for that length of time can cause significant surgical fatigue and most surgical complications are known to happen in the final quarter.

“It has been shown that some of the most famous ‘stick laparoscopy’ surgeons in the world have had to stop performing these surgeries for personal health reasons because their neck, knee, or back have become strained. It takes its toll on the surgeon”.

The changing face of gynaecology

“I’m one of a group of 16 specialising in gynaecological cancer or difficult gynaecological surgery, we do most if not almost all of the difficult gynaecological cancer surgery in Ireland. We are radical surgeons, not generalists, and we are part of the Ireland East network. We want people to send us patients with difficult problems.

“General gynaecology has really changed, for instance, in the advent of the marina coil. Now people think it’s for contraception but, in fact, it was originally designed for heavy periods as an alternative to hysterectomy. There is also another technique called an endometrial ablation, which delivers a superficial burn to the lining of the uterus, to be used for benign causes. Both of these techniques have almost taken away all non-oncology gynaecology from the surgical aspect, so hysterectomy rates in Ireland and worldwide have crashed by five fold.

“We rarely do hysterectomies compared to the volume that would have been done in the old days. Ireland used to have one of the highest hysterectomy rates in Europe about 25 years ago. Worldwide, we actually struggle to train our juniors because the straightforward hysterectomies that we used to do as standard treatment don’t exist any more because they are treated with non-surgical techniques. “What’s left now are the people either working with oncology or people with very abnormal anatomy; people with huge fibroids, bad endometriosis. The surgery that happens is not the old-fashioned obstetric gynaecology, which is correct and we all agree with that.

“The robotic platform means these patients can be better serviced; it’s a better product for patients. They are back driving within two weeks; it’s in our best interest to have patients back functioning in society, particularly as the mother is typically a central figure in the home, as well as contributing to the family income. The sooner they get back to work and in the home, the better.

“It is not necessarily a faster surgery but we regard it as quality, not quantity. We’re all about the least number of complications, more time in theatre, less time in the bed and ultimately less time in hospital. Sure, open surgery is quicker in the operating room but you spend much more time recovering.

“The quicker you can get a patient out of hospital, the better for both the patient’s physical health and mental health.“It’s a better operation, quicker recovery, cheaper for the healthcare provider so you’ve have to ask why isn’t a surgery being done robotically? Certain patients aren’t suitable for it, someone who has had multiple laparotomy scars, for instance, or patients with large ovarian tumours but these are the exceptions”.

An easier operation

“In an open procedure, you’re looking at a 2D screen and, while a small percentage of people are gifted and able to visualise the 3D version, the majority cannot. The learning curve to do difficult gynaecological surgery at consultant level is a long learning curve and some will never be able to do it, they might not have the physical dexterity to do it.

“With the robot, you sit down at a comfortable console and have a 3D view, as if you are doing genuine open surgery. And you are controlling the instruments; it’s much easier. The learning curve for a stick laparoscopy is huge whereas this is much more straightforward, if you’re good at open surgery, you’re going to be good at this.“Basically the robot enables you to do open surgery through a minimally invasive approach. All our training has been through open surgery but the robot definitely has its advantages. It’s wristed, so rather than moving in the opposite direction like with the stick laparoscopy; it moves with you, it actually has more movement than your wrist. It is like a mini hand, mimicking your movement, which makes the learning curve significantly shorter.

“From the point of view of surgery, its 3D and the learning curve is very short. In the US they have released statistics indicating that even in highly advanced units, using stick laparoscopies to do hysterectomies results in a maximum success rate of 30 per cent. If you use the robotic platform, and use it appropriately, there is a 70 to 80 per cent success rate. It’s a massive difference, and again most of these patients are obese. “The amount of procedures you can do in the pelvis is incredible. There’s a technique with vaginal prolapse that is very tricky to do with ‘stick laparoscopy’, whereas it is a far more straightforward, simple and effective procedure with the robot. If I had a choice, I would always go robot first. You’d have to have a reason not to use it”.

Game changer

“I think the robot is a complete game changer, not only is it more necessary as we become a growingly obese nation, we also have far less beds than we’ve ever had before in this country. In Dublin, we’re down at least 1,000 if not 1500 acute surgical beds than when I started this job over twenty years ago. There’s a serious misuse of beds and we should be trying to use them as efficiently as possible. Therefore, choosing the option where patients are in and out in 48 hours with low risk seems like an obvious choice.

“Our success rate would be much higher with the robotic approach and it would be easier to train people, there are just over 100 gynaecologists in Ireland, the success rate would be much higher using the robot. I would like to think that the success rates among my colleagues and I at the Mater are higher still than the 70- 80 per cent reported in the US, because this is all we are trained to do. “It’s not just about the surgeon either, to make this work you need the anaesthetists and the nursing staff in the theatre. They are crucial to making these surgeries a success. To start using this was almost seamless for me, it was as if I had been doing it for years, because the support of the nursing staff was so good and they were already so advanced.

“You have to educate the GPs, the patients, ourselves and the district nurses; there’s a lot of education involved so that people will buy into it. Ireland has a very medical-legal society, where doctors are at a high risk of being sued, therefore people want to make sure that this is a top of the range surgery.

“I’ve only performed 150 cases, which is a small number, because the only robot available has been at a private hospital and only three insurance companies are happy to cover this type of surgery. We’re in negotiation to get them to cover it, money is tight so they are waiting to see how the market goes. I presume they’ll have to take it once the robot is available in public hospitals and patients will be regarding it as their first choice of procedure. It will eventually become the default.

“Because there’s such an issue around the expense to run the robot, hospitals and insurance companies have been somewhat shy about taking them on. They’re expensive, like everything that starts off, but as the cost reduces, at least from a gynaecological point of view, it will be an absolute game changer. “At the moment the only one on sale is da Vinci but now that the patent is ending a few more will enter into the market which will be exciting because the prices will drop and we will find that they will be in every hospital in the world.

“The da Vinci, who designed the first robot, have been phenomenal and deserve a lot of credit but the competition is welcome. They have an engineer at all times and the device is extremely well monitored, which is correct. Their backup service is incredible, it’s a high end product and it has delivered every time. The next stage is for some healthy competition. Once it becomes affordable, you’d have to ask a hospital why they would not have a robotic platform, particularly for difficult surgery”.

“At the moment we continue to do open surgeries because we don’t have the robotic option available in the public platform. It looks like three of the public hospitals will be purchasing reconditioned models in anticipation that in the next two or three years we will be able to upgrade at a cheaper cost. “In 10 years time I anticipate that a lot of newer consultants will be robotically trained only and would be out of their comfort zone performing open surgery”.