Operating through tiny holes has always been the domain of the Gynaecologist. But no longer. Keyhole surgery is now used extensively by most surgical specialties. Its has become the best method of undertaking surgery with great recovery results.
In Gynaecology, keyhole surgery has come a long way. I use it these days to undertake the vast majority of my surgery. Its role ranges from diagnosing cause of pelvic pain through to major surgery like removal of ovarian cysts, treatment of endometriosis and hysterectomy.
Traditionally keyhole surgery involves multiple small cuts, less than 1 cm, in the tummy wall. These sites are called port sites. So called because tubular instruments (ports) are inserted through these cuts. We then insert our telescope and operating instruments through these ports to do the operation. Gas is put into the tummy to expand the space and helps to visualise the pelvic organs – womb, tubes, ovaries and bowel.
Whilst I still use the traditional Laparoscope in some of my operations, I now mainly utilise the Robotic technique of keyhole surgery for all my major keyhole surgery. Undertaken the same way as traditional Laparoscopy, the Robotic technique however differs significantly from the traditional laparoscope.
With Robotic surgery, a machine is used to handle all the instruments I use for the surgery. Usually this includes the telescope to look into the pelvis and 2-3 other instruments that does the intricate surgery. These instruments are inserted through the port sites. In the main, the instruments once inserted remain in place throughout the operation. I still will need to insert other instruments as we need to insert or remove things like stitches etc. Notwithstanding this point, the number of times additional instruments are required to be inserted is small compared to a normal Laparoscopy.
I control the instruments using a separate console. To do this, I sit down and using finger controls, I can then manipulate the robot to change the positioning of the instruments as I operate. This is an important aspect of Robotic surgery. In traditional Laparoscopy, some of the instruments are held by the Assistant surgeon. The Surgeon must verbally instruct the Assistant to change the instruments. With the Robot, I have total control (and no, this is NOT a Man thing). I do not have to continually think about asking my Assistant to move the instrument so I can operate. This allows me to focus fully on the task at hand.
The vision from the robot telescope is 3-D and the instruments are very flexible. I can move them like you would use your wrist to handle objects. In many situations, there can be difficulty getting the operating instruments to work well. Sometimes this is due to scar tissue tethering the organs close together or large lumps like fibroids or cysts that limit the space. In these situations, have instruments that are wristed is a godsend and it means the ends of the instruments can turn and twist in small spaces. With traditional laparoscopy, our instruments are not wristed, (there are now wristed instruments but in general they are not readily available).
With the degree of magnification that can be obtained, the operating field is more concentrated in a smaller area. Therefore, meticulous control of bleeding is very important otherwise my vision would be impaired. I am thus finding that blood loss is significantly less than that seen in laparoscopic and open surgery.
Sitting down is very important. This also applies to my Assistant surgeon and Theatre Nurse. They both get to sit and as some surgeries can be long, I find sitting down reduces tiredness and helps focus attention on the task at hand by all parties.
These all contrast with the traditional Laparoscope. Having used it extensively, I have come to appreciate the fineness of the Robotic equipment. It has allowed me to undertake successfully significantly complex surgery which previously may have ended up requiring a big cut if I had to rely on the traditional Laparoscope.
Does this mean traditionally Laparoscopic surgery is not appropriate? Not at all. I continue to use traditional laparoscopy as many of my patients will attest to. Many of my colleagues and surgeons in other specialties continue to use it even for difficult surgery. Robotic surgery can be time consuming as it can take longer to set up and do. Furthermore, it is not readily available due to the cost of the equipment though I believe over time its adoption will become widespread. However, given the experience I have accrued using Robotics over the last 10 years of operating, my preference in complex surgery is to use the Robotic technique.
Robotic surgery has many advantages including:
- Superior vision which is 3D
- Articulated wristed instruments which provide improved dexterity in performing the surgery.
- Once inserted, the instruments are infrequently required to be removed and changed, unlike normal Laparoscopy. This reduces the risk of inadvertent damage to internal organs with the constant changing of equipment.
- Less pain due to less manipulation of the incision sites.
- Better control of bleeding
- Ability to operate in difficult areas use to the use of wristed equipment
- Better control of the instruments by the operating surgeon
- Reduced tiredness for the surgeon.
In my experience, using the Robotic technique allows for surgery that may be difficult by normal Laparoscopy, to be performed. In addition, I have also noted an improvement in the recovery of my patients especially in relation to pain. It is now my standard technique for major pelvic Gynaecology surgery including:
- Hysterectomy
- Removal of significant endometriosis
- Removal of large or complicated ovarian cysts
- Removal of ovaries especially where there is significant scarring, tethering the ovary down
- Reversal of sterilisation for women
- Removal of fibroids – myomectomy
- Bladder stress incontinence
- Freeing of adhesions (scar tissue)
The suitability of keyhole surgery and type, will be dependent on the individual circumstance. For further information please make an appointment so your individual situation can be fully assessed.