Between 1986 and 1992, we have reiterated in various publications that “wherever in the body a cavity exists or a cavity can be created, operative laparoscopy is indicated and probably preferable[…the predominate limitation to operative laparoscopy is the surgeon’s imagination.”1-8 In support of these statements, we have presented and published the first case series of laparoscopic bowel,4-12 bladder13-14 and ureter2 resections and reanastomosis, as well as the first paraaortic and pelvic node dissection, radical hysterectomy,15 and sacral colpopexy.13
In the past, operative laparoscopy and its proponents have faced significant opposition.16-17 More recently, in 2004, a randomized study of laparoscopically assisted and open colectomy for colon cancer in the New England Journal of Medicine, demonstrated beneficial results in favor of laparoscopy, even for bowel resection.18 The editor of the journal, Dr. Pappas, wrote, “Surgeons must progress beyond the traditional techniques of cutting and sewing, to a future in which minimal access to the abdominal cavity are only the beginning.”18 Surprisingly, this proclamation came nearly sixteen years after the first reported laparoscopic bowel resection in 1988.4 Currently, there is a substantial body of evidence to support the laparoscopic approach as the preferred method for practically all procedures, including surgery for malignancies. It is admirable that even those who in the past opposed operative laparoscopy now are endorsing it.19
Need for increased use of laparoscopy in the community
Despite the clear advantages of minimally invasive surgery, the majority of procedures performed in the community, such as hysterectomies and bowel resections, still are done by laparotomy. This preference for open procedures is likely due to the lack of trained endoscopic surgeons, the difficulty in obtaining proper instruments and the long learning curve of operative laparoscopy. The recent advent of computer enhanced technology, more sophisticated instruments and energy sources as well as new inventions will provide the bridge necessary for those in the surgical community to incorporate laparoscopic surgery into their practice.
Since our collaborative work with robotic pioneers Ajit Shah and Phil Green from the Stanford Research Institute who developed the Da Vinci robot in the 1990s, many have successfully applied this technology to various fields. The “robot” enables visualization of the surgical field in three dimensions, eliminates tremors, has more wrist motions, and decreases the learning curve for suturing all while allowing the surgeon to sit and operate in a 3D environment. Using the advantages of the robot, community surgeons who might otherwise feel uncomfortable with laparoscopy may be able to convert some of their laparotomies to laparoscopies. Thus, the robot has the potential to bring a wave of change in the pattern of surgery with more and more open surgeries being performed as laparoscopies.
Patient Outcomes: Is the Robot (Da Vinci System) associated with better results?
To date, patient outcomes after minimally invasive surgeries with and without the robot in the hands of experienced laparoscopists who are equally experienced in the use of the robot have been the same.20-27 Recently, we published a retrospective cohort study of 78 patients who underwent treatment of endometriosis, 40 by robot assisted laparoscopy (RAL) and 38 by standard laparoscopy (SL). We were surprised to find that RAL did not have better outcomes than SL, as we have always believed if you can see more and see better you can do more and do better.23 Adding the robot to laparoscopy did not produce any advantage when performing a hysterectomy, radical hysterectomy, myomectomy or in the treatment of endometriosis when analyzed with respect to patient outcomes.20-23 Thus, one might argue that an expert laparoscopist may not need to add the Da Vinci robot to his or her armamentarium to be able to perform operative laparoscopy. That said, we would encourage even the expert laparoscopist to explore the use of this technological advance in their surgical practice. If one has only a hammer one will see only nails to pound. It remains imperative that we, as surgeons, continue to explore each new advance and push our discipline further forward.
In summary, the Da Vinci system is an enabling device. It can assist the community surgeon who cannot effectively perform operative laparoscopy with straight instruments and convert their laparotomies to laparoscopies. By contrast, the expert laparoscopist may not need to add the Da Vinci System to accomplish surgical goals they can already reach with standard instruments during laparoscopy. The final outcome of surgery depends more on the surgeon than on the instrument she or he uses. However, we would encourage our colleagues to explore each new technology, including the Da Vinci System, thereby possibly enhancing not only their own practice, but the utility of the technology itself.
1. Nezhat C, Crowgey SR, Garrison CP. Surgical treatment of endometriosis via laser laparoscopy (1). Fertil Steril. Jun 1986;45(6):778-783.
2. Nezhat C, Nezhat F, Green B. Laparoscopic treatment of obstructed ureter due to endometriosis by resection and ureteroureterostomy: a case report. J Urol. 1992 Sep;148(3):865-8.
3. Nezhat C, Nezhat FR. Safe laser endoscopic excision or vaporization of peritoneal endometriosis. Fertil Steril. Jul 1989;52(1):149-151.
4. Nezhat C Nezhat F. Evaluation of safety of videolaseroscopic treatment of bowel endometriosis. Paper presented at: Scientific Paper and Poster Sessions, 44th Annual Meeting of the American Fertility Society.; October 8-13, 1988; Atlanta, Georgia.
5. Nezhat F, Nezhat C, Pennington E, Ambroze W, Jr. Laparoscopic segmental resection for infiltrating endometriosis of the rectosigmoid colon: a preliminary report. Surg Laparosc Endosc. Sep 1992;2(3):212-216.
6. Nezhat C, Pennington E, Nezhat F, Silfen SL. Laparoscopically assisted anterior rectal wall resection and reanastomosis for deeply infiltrating endometriosis. Surg Laparosc Endosc. Jun 1991;1(2):106-108.
7. Nezhat C Nezhat F. Video laseroscopy for the treatment of upper, mid, and lower peritoneal cavity pathology. Audiovisual photography & TV- at the Annual meeting of AAGL in Novemeber 1990.
8. Nezhat CR, Nezhat FR, Silfen SL. Videolaseroscopy. The CO2 laser for advanced operative laparoscopy. Obstet Gynecol Clin North Am. 1991 Sep;18(3):585-604.
9. Fanfani F, Fagotti A, Gagliardi ML, Ruffo G, Ceccaroni M, Scambia G, et al. Discoid or segmental rectosigmoid resection for deep infiltrating endometriosis: a case-control study. Fertil Steril. 2010 Jul;94(2):444-9.
10. Nezhat C, Nezhat F, Pennington E. Laparoscopic treatment of infiltrative rectosigmoid colon and rectovaginal septum endometriosis by the technique of videolaparoscopy and the CO2 laser. Br J Obstet Gynaecol. Aug 1992;99(8):664-667.
11. Nezhat C, Nezhat F, Pennington E, Nezhat CH, Ambroze W. Laparoscopic disk excision and primary repair of the anterior rectal wall for the treatment of full-thickness bowel endometriosis. Surg Endosc. Jun 1994;8(6):682-685.
12. Nezhat F, Nezhat C, Pennington E. Laparoscopic proctectomy for infiltrating endometriosis of the rectum. Fertil Steril. May 1992;57(5):1129-1132.
13. Nezhat C, Nezhat F. Operative laparoscopy (minimally invasive surgery): state of the art. J Gynecol Surg. 1992 Fall;8(3):111-41
14. Nezhat CR, Nezhat FR. Laparoscopic segmental bladder resection for endometriosis: a report of two cases. Obstet Gynecol. May 1993;81(5 ( Pt 2)):882-884.
15. Nezhat CR, Nezhat FR, Burrell MO, Ramirez CE, Welander C, Carrodeguas J, et al. Laparoscopic radical hysterectomy and laparoscopically assisted vaginal radical hysterectomy with pelvic and paraaortic node dissection. J Gynecol Surg. 1993 Summer;9(2):105-20.
16. Pitkin RM. Operative laparoscopy: surgical advance or technical gimmick? Obstet Gynecol. 1992; 79: 441-2
17. Barham M. Laparoscopic vaginal delivery: report of a case, literature review, and discussion. Obstet Gynecol. 2000 Jan;95(1):163-5.
18. Laparoscopically assisted colectomy is as safe and effective as open colectomy in people with colon cancer Abstracted from: Nelson H, Sargent D, Wieand HS, et al; for the Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004; 350: 2050-2059. Cancer Treat Rev. 2004 Dec;30(8):707-9.
19. Pitin RM, Parker WH. Operative laparoscopy: a second look after 18 years. Obstet Gynecol. 2010 May; 115(5):890-1.
20. Nezhat FR, Datta MS, Liu C, Chuang L, Zakashansky K. Robotic radical hysterectomy versus total laparoscopic radical hysterectomy with pelvic lymphadenectomy for treatment of early cervical cancer. JSLS. 2008 Jul-Sep;12(3):227-37.
21. Nezhat C, Lavie O, Hsu S, Watson J, Barnett O, Lemyre M. Robotic-assisted laparoscopic myomectomy compared with standard laparoscopic myomectomy retrospective matched control study. Fertil Steril. 2009 Feb;91(2):556-9.
22. Nezhat C, Nezhat F. Evolving role and current state of robotics in minimally invasive gynecologic surgery. J Minim Invasive Gynecol. 2009 Sep-Oct;16(5):661-2.
23. Nezhat C, Lewis M, Kotikela S, Veeraswamy A, Saadat L, Hajhosseini B. Robotic versus standard laparoscopy for the treatment of endometriosis. Fertil Steril. 2010 May 25.
24. Cho JE, Nezhat FR. Robotics and gynecologic oncology: review of the literature. J Minim Invasive Gynecol. 2009 Nov-Dec;16(6):669-81.
25. Nezhat C, Saberi NS, Shahmohamady B, Nezhat F. Robotic-assisted laparoscopy in gynecological surgery. JSLS. 2006 Jul-Sep;10(3):317-20.
26. Nezhat C, Lavie O, Lemyre M, Gemer O, Bhagan L, Nezhat C. Laparoscopic hysterectomy with and without a robot: Stanford experience. JSLS. 2009 Apr-Jun; 13(2): 125-8.
27. Magrina JF, Espada M, Munoz R, Noble BN, Kho RM. Robotic adnexectomy compared with laparoscopy for adnexal mass. Obstet Gynecol. 2009 Sep;114(3):581-4.