Clinical opinion published in American Journal of Obstetrics and Gynecology

When a woman requires gynecologic surgery, she and her surgeon have several minimally invasive surgical options, including robotic surgery. In recent years, the use of robotic surgery has become more and more common. But questions have arisen about the potential overuse of robotic surgery and its advantages over traditional laparotomy for hysterectomy.

A clinical opinion by Charles Rardin, MD, a urogynecologist in the Division of Urogynecology and Reconstructive Surgery and director of the Robotic Surgery Program for Women at Women & Infants Hospital of Rhode Island, director of Minimally Invasive Surgery at Care New England, and associate professor of obstetrics and gynecology at The Warren Alpert Medical School of Brown University, entitled "The debate over robotics in benign gynecology," is published this month in the American Journal of Obstetrics & Gynecology.

"Robotic surgery certainly provides some advantages to some surgeons and has contributed to a decline in laparotomy (large incision) rates for hysterectomy," said Dr. Rardin. "But robotic surgery for benign gynecology needs to be considered as just one of several forms of minimally invasive surgery (MIS) that can be used to provide the best care to patients."

Dr. Rardin explained that specific features of the patient (ie obesity), the surgeon (ie his or her experience with laparoscopic surgery), or the case (ie the possibility of significant and technically challenging suturing, such as required for a fistula repair) may make the robotic approach preferable over laparoscopic or vaginal surgery.

"However, an institution that adopts a policy of promoting robotic surgery over other forms of minimally invasive surgery is at risk of becoming a 'robotic factory' and allowing volume and quality of vaginal or laparoscopic surgeries to dwindle," he said.

In his opinion piece, Dr. Rardin suggests that other organizations consider the approach taken at the Care New England hospitals (Kent, Memorial and Women & Infants), which focuses on the ability to provide the full spectrum of MIS procedures to each individual patient presenting for surgical care. He outlines how hospitals and physicians could promote a balanced approach to MIS by considering four issues:

• The development of rigorous and self-determined processes of quality management and feedback to surgical staff, as well as credentialing systems based on training, skills, peer support, and ongoing volume
• The development of case criteria, reserving the use of the robot to cases in which specifics of the patient, the surgeon or the case warrant it
• The ability to identify and address imbalances in surgical technique by monitoring the use and relative rates of MIS techniques for gynecology as well as the related patient outcomes data
• Providing structure and support for all forms of MIS, not just robotics, for trainees (residents and fellows) as well as those who have already completed formal training programs

This year, Women & Infants Hospital was designated a Center of Excellence in Minimally Invasive Gynecology (COEMIG) by the Surgical Review Corporation, an affiliate of the American Association of Gynecologic Laparoscopists (AAGL), for its commitment to offering women the most effective diagnostic and therapeutic techniques in minimally invasive surgery.

Covering the full spectrum of the specialty, American Journal of Obstetrics & Gynecology, "The Gray Journal," presents the latest diagnostic procedures, leading-edge research, and expert commentary in maternal-fetal medicine, reproductive endocrinology and infertility, gynecologic oncology, and urogynecology, as well as general obstetrics and gynecology.