Appropriate Patient Selection Remains Key Criterion for
This article originally appeared in Pathways, a magazine
published for physicians and the community by UMass Memorial Medical
UMass Memorial Medical Center is one of a
growing number of hospitals using the robotic da Vinci® Surgical System for
gynecologic surgery. The Medical Center has used this advanced technology for
urologic surgery for the past three years (see accompanying sidebar), and it is
now available to a growing number of women as a minimally invasive alternative
to open surgery for hysterectomy, cervical and uterine cancers, uterine
fibroids, endometriosis and pelvic organ prolapse.
"I do all my endometrial cancer patients robotically, using it for
hysterectomy and staging," said UMass Memorial gynecologic oncologist Antonella
Leary, MD. "The only patients I exclude are those with significant
cardiopulmonary disease who can't withstand the Trendelenburg position or those
who can't tolerate having their abdomen insufflated.
"I've even used the robotic procedure in patients with a BMI of 60," she
added. "In fact, larger patients often benefit most because they come out with a
very small incision, so the likelihood of it separating is very low versus a
larger incision with open surgery."
Benefits for the surgeon and patient alike
Dr. Leary is an ardent proponent of the robotic technique, even compared to
traditional laparoscopy. "The robot gives me three-dimensional visualization and
a binocular view when I'm looking inside," she explained. "Typical laparoscopy
is uni-dimensional, and I'm looking through a monocular scope, so I get only
that view. Plus, with the robot, it's magnified 10 times, so I can easily see
all the small vessels that can cause bleeding. It's a much clearer view.
"I think it's a wonderful instrument for appropriate purposes," she added.
"It takes a while to set up, and you need staff who is familiar with it. But
it's worth it."
Her patients think so, too. It confers significant benefits, including less
pain and blood loss, fewer complications, less scarring, a shorter hospital stay
and a quicker return to regular activities.
"My patients go home the next day, they're back on their feet within a week,
and back to work within two to three weeks," Dr. Leary noted. "Compare that with
a six-week recovery for an open hysterectomy. Plus, most of my patients take
post-op pain medication for maybe two days; with the open approach, they're on
pain meds a lot longer than that."
A minimally invasive option for myomectomy and tubal
Brian Clark, MD, chief of reproductive endocrinology and infertility at UMass
Memorial, takes a similarly careful approach to patient selection. The primary
indications for use of the robot in his specialty are myomectomy and tubal
reversal, and it is a consideration for hysterectomy.
"When it comes to hysterectomy, the lines are blurring between laparoscopic
and robotic surgery, while the advantages are clearer when you compare the
minimally invasive approaches to open surgery," he said, noting that he
currently performs virtually all hysterectomies laparoscopically - some 50 per
"In myomectomy, each case is different," he continued. "For a lone, large
fibroid, or many small myomas, the robot can be advantageous since it makes it
easier to suture like you can when it's open. On the other hand, if it's a
pedunculated fibroid, the traditional laparoscopic approach is good. It just
depends on the circumstances." Dr. Clark has performed about six robotic
myomectomies to date.
"In tubal reversal, it's a different animal," Dr. Clark said. "The robot
combines magnification, 3-D visualization and the ability to stitch like in the
open procedure. I believe it's a better approach because you get a quality
repair and less invasion to the body even compared to standard laparotomy.
"A good tool in appropriately selected cases"
"UMass Memorial has a number of physicians who are able to use robotics and
laparoscopy in gynecological applications," he added. "The technology plays a
role in minimizing the invasiveness of certain gynecologic procedures, and
patients certainly benefit from a less invasive approach. It's a good tool in
appropriately selected cases."