Robotics in GynecologyAnthony R. DeSalvo, M.D.

1842 E Market StWarren, OH 44483

330.856.7212warren-obgyn.com

Anthony R. DeSalvo, M.DBachelor of Science – Kent State UniversityMedical Degree – Northeastern Ohio

Universities College of MedicineResidency – Beth Israel Medical Center, New

York, NYBoard Certified – American Board of

Obstetrics and GynecologyPersonal informationProfessional information

Why am I here?Educate the public some common

gynecologic conditions that may require an operation

Discuss the types of operations that are available

Introduce the concept of robotic surgery to the publicDispel some common myths about robotic

surgery

Common conditions treated by hysterectomyHeavy menstrual bleedingPelvic painFibroid uterusEndometriosisProlapseCancer

Heavy menstrual bleedingDefined as bleeding that lasts for longer than

7 days per month or greater than 80 mL per cycle

Difficult to estimate the true amount of blood loss

Bleeding that soils clothes, bed sheets or requires the significant planning

Very subjective but usually a person knows it when it happens to them

Pelvic painChronic pelvic pain refers to pain of at least

six months' duration that occurs below the belly button and is severe enough to cause functional disability or require treatment.

In the United States, this problem accounts for approximately 10 % of all visits to a GYN.

It is considered the principal indication for approximately 20 % of hysterectomies performed for benign disease.

Fibroid uterusFibroids are tough balls of muscle that form in the

uterus People sometimes refer to fibroids as “tumors.” But

fibroids are not a form of cancer. They are simply abnormal growths in the muscle of the uterus

Fibroids often cause no symptoms at all. When they do cause symptoms, they can cause:•Heavy periods•Pain, pressure, or a feeling of “fullness” in the belly •The need to urinate often •Too few bowel movements (constipation)•Difficulty getting pregnant

EndometriosisEndometriosis occurs when tissue normally found in

a woman’s uterus grows outside of the uterus .This tissue, which does not belong outside the uterus,

can then break down, bleed, and cause symptomsSome women with endometriosis have no symptoms.

But most have pain in the lower part of the belly that can occur:•Before or during monthly periods•Between monthly periods•During or after sex•When urinating or having a bowel movement (often

during monthly periods)

ProlapseWhen tissues that support the organs in the lower belly

relax. The organs drop down and press against or bulge into the vagina.

If the bladder bulges into the vagina,, this is a“cystocele.” If the rectum bulges into the vagina, it’s a “rectocele.” Uterine prolapse means the uterus has bulged into the vagina.

Many women with this problem have no symptoms. But some women with pelvic organ prolapse have symptoms that include: •Fullness or pressure in the pelvis or vagina •A bulge in the vagina or coming out of the vagina •Leaking urine when they laugh, cough, or sneeze •When they use the toilet, some women need to press on the

bulge in the vagina with a finger to get out all their urine or to finish a bowel movement.

CancerAs a benign gynecologist, I do not treat

women with gynecologic cancersThese women are best served by a referral to

a GYN oncologistWe are very fortunate to have several world

class cancer centers within a 1 hour drive

ProceduresHysterectomy – removal of the uterusTotal hysterectomy – removal of the

uterus and cervixSub-total hysterectomy (Supracervical) –

removal of uterus only with the cervix left in place

Oophorectomy – removal of the ovariesConfusing terms – complete , partial and

total

Hysterectomy factsApproximately 525,000 hysterectomies are

performed each year in the U.S. for non-cancerous conditions

By age 60, 1 in 3 women in the U.S. will have had a hysterectomy2

90% are performed for elective benign indicationsFibroidsAbnormal uterine bleedingEndometriosisChronic pelvic pain

Route of SurgeryAbdominalRequires a

large abdominal incision

Usual hospital stay is 2 to 4 nights

6 to 8 weeks of recovery

Vaginal hysterectomyThe entire operation is performed

through the vaginaRequires good access to the uterusMore challenging in patients with prior

abdominal surgery or previous cesarean section

More challenging if the uterus is enlargedLimited visualization of the pelvis and

ovaries

Laparoscopic hysterectomyBetter visualizationShorter hospitalizationShorter recoveryGood visualization of the pelvic

organsCan be performed in a wide variety

of patientsTraditional laparoscopy requires a

unique skill set and commitment to the procedure

US Hysterectomy Modalities 2005 vs. 20124

Vag – 22%

Lap – 14%

2005Jan 1,

The Impact on Hysterectomy

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

0%

10%

20%

30%

40%

50%

60%

70%

80%

Adoption of MIS for Hysterectomy

Laparoscopy

da Vinci

Vaginal

Open

Year

Ad

op

tio

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Farquhar et al. "Hysterectomy Rates in the United States: 1990–1997" Obstet Gynecol 2002;99:229 –34Becker et al. "Inpatient Surgical Treatment Patterns for Patients with Uterine Fibroids in the United States, 1998-2002" Journal of the National Medical Assn.

Vol. 97 (10) October 2005Wu et al. "Hysterectomy Rates in the United States, 2003" Obstet & Gyn VOL. 110, NO. 5, NOVEMBER 2007Solucient data through 2010 for Lap, Open and Vaginal Trends

Natural Evolution of Technology

Natural Evolution of Technology

Evolution of Technology

Konrad Zuse’s Z1 (1938)First binary computerMechanical calculator

UNIVAC I – UNIVersal Automatic Computer (1951)First commercial computer

U.S. Census BureauOriginal price: $159,000

Ultimate price: $1.5 million46 systems built and sold

IBM 701– (1953)First commercial IBM computer

$15,000/month rental feeOnly 19 systems built and sold

Evolution of Technology

Altair (1974)Scelbi (1974)

First personal computerKit that user had to put together, make it work,

and write software256 Byte RAM

$400

IBM 5100 – First IBM PC (1975)50 pounds

Programming language (APL or BASIC)64K storage version

$19,975

Which would you rather have?

Versus

RoboticsCurrent applications

Auto industrySpace industryMultiple other industriesMilitaryLaboratory test processingAutomated research equipmentRadiation therapyToys

What’s the difference?

The natural evolution of computers into the operating room

Minimally Invasive SurgeryBenign hysterectomy in the US 2003

Wu JF. Et al. Obstet Gynecol 2007;110:1091-1095.

Mean LOS=1.7 days*

Mean LOS=2.0 days*

Mean LOS=3.0 days*

*P-value<0.001

da Vinci® S Robotic Platform

da Vinci® Surgery (Minimally Invasive)

Robotic PlatformGeneral thoughts

A tool Not new surgery or procedureA tool that makes minimally

invasive surgery easierVery rare to have “robotic”

complication if used properlySurgeon who’s using the robot has

a complication as with any other tool

Advantages of robotic surgeryMuch improved 3D visualization over

traditional laparoscopyKeep in mind, that traditional laparoscopy was

still better than open surgeryFull wristing instruments with 7 degrees

range of motionComplete surgical control of the operative

instrumentsMimics the hand movements of open surgery

da Vinci® Awareness

President Obama(Cleveland Clinic)

The Doctors

Private Practice

The Daily Buzz

Jeopardy

Law & Order

CNN

SummaryThe addition of computer technology into the

operating arena is a natural evolution and progress

The addition of robotic platform for surgery is a continuation of this progress

Man’s tools continue to add great value to our lives

This tool will greatly reduce or nearly eliminate the need for open surgery

The societal benefits of a surgical platform are vast and numerous