Robot-Assisted Laparoscopic Myomectomy

Dr. Antonio R. Gargiulo, Medical Director of the Center for Robotic Surgery of Brigham and Women’s Health Care in Boston, Massachusetts talks to Kal Kaur at AZoRobotics about Robot-Assisted Laparoscopic Myomectomy.

On October 22 you have successfully completed a live surgery for a highly qualified audience of hundreds of physicians at the annual meeting of the American Society for Reproductive Medicine (ASRM) in San Diego, CA. This robot-assisted laparoscopic myomectomy – to treat a patient suffering from uterine fibroids – was performed at Brigham and Women’s Hospital in Boston and employed laser energy carried into the body through a minute flexible fiber. Can you describe the functional principle to the BeamPath^® Robotic fiber by OmniGuide that was used to perform the robotic myomectomy?

Simply stated, the OmniGuide BeamPath^® Robotic is a hollow fiber built of a polymer interspersed with innumerable micro-mirrors. This polymer is built as a layer that is subsequently rolled up around a hollow core several times and later stretched through a furnace to obtain a hollow structure that is just a couple of millimetres wide and 150–180 cm long. The laser beam travels within the hollow flexible fiber thanks to the reflecting inner surface (micro-mirrors).

The CO₂ generator sits on a trolley and is usually set at one of the patient’s sides, away from the surgeons’ action field. The photonic energy emerges from the open tip of the fiber and provides excellent cutting energy at very close range (between 3 and 10 mm). Beyond that, the divergence of the laser beam is evident and the energy produced can be used as a good coagulator. The fiber itself is contained within an armoured FlexGuide Ultra device (a flexible 3 mm metallic fiber that protects users and patients from the unlikely escape of photonic energy from a damaged BeamPath^®.

How does the BeamPath^® Robotic fiber help perform precise surgical incisions when employed in association with a robotic surgical platform?

Currently, only one robotic surgical platform is commercially available and FDA cleared for use in gynaecologic surgery, the da Vinci Surgical System by Intuitive Surgical, Inc. This is a complex machine and its description is not focal to our discussion. However, it is important to know that the da Vinci Surgical System allows a fully three-dimensional endoscopic vision and seven degrees of freedom in instrument movement (insertion, grip, rotation pitch and yaw of the arm and pitch and yaw of the wrist). This is very different from current conventional laparoscopic technology, which operates in a bi-dimensional system and with instruments allowing only five degrees of freedom (the natural pitch and yaw at the wrist, responsible for the finer surgical skills, are lost in conventional laparoscopy).

To make full use of the dexterity allowed by robotic platforms it is necessary that the energy form employed in our operations be operated with seven degrees of freedom. This brings us to the fact that the choice of energy sources when it comes to robotic surgery are basically electrosurgical instruments and ultrasonic instruments. Neither are ideal for surgeries involving precise dissection of delicate and irreplaceable reproductive structures (such as the tubes, ovaries or the uterus): electrosurgical instruments produce significant thermal injury (up to several millimetres wide) which will cause tissue destruction well beyond the intended target area, and ultrasonic instruments (that produce much smaller delayed thermal injury) are based on a straight metal rod oscillating a high frequency: hence, they preclude the introduction of wristed movements.

A flexible laser device is therefore the only form of energy that can deliver precise cutting and coagulation power and still allow the full dexterity introduced by the current robotic surgical platform.

How does the surgeon guide this flexible CO₂ laser system to perform the surgical procedure and what type of training is involved for the surgeon?

The surgeon holds the BeamPath^® Robotic through its dedicated metal carrier, the FlexGuide Ultra. This armoured carrier has a spatula tip for manipulation of the fiber by common robotic instruments, as well as a dedicated area that fits the tips of a robotic needle driver. Once the tips are set, the tip of the fiber will move together with the robotic needle driver and the flexible fiber will allow all movements.

Surgeons operating a da Vinci Surgical System must be trained laparoscopists and must undergo a standardized training pathway which includes simulation (dry lab or digital), live animal surgery, human case observations and several proctored cases at their institution. Any surgeon employing a CO₂ laser system, including the BeamPath^® Robotic, must undergo laser training and certification as required by the Laser Safety Officer at their institution.

Are there any aspects of the robot that still need further research and development to help improve its performance?

Current robots are already a quantum leap in surgical technology achievement but are by no means perfect machines. First of all, they lack any degree of programmable automation (i.e., they are passive robots); also, they are very large. Miniaturization and reduction of the ports of entry needed to perform complex pelvic operations will be highly welcomed improvements.

Surgery is unique to each patient and procedure. How is the BeamPath® Robotic fiber designed to adapt to each patient and surgical procedure?

We perform robotic myomectomy with at least three majorly different surgical ports set-ups (a standard placement for most cases, a cosmetic placement for smaller pathology, a single-port placement for obese patients): the diminutive size and highly flexibility of the BeamPath^® Robotic allows us to deliver effective energy under the most ergonomically demanding of circumstances. Our first world report of successful single port robotic-assisted laparoscopic myomectomy could not have happened without this highly functional fiber.

How will application of the BeamPath® Robotic fiber and carbon dioxide laser system benefit the patient?

The expected benefits are less delayed thermal spread of delicate and irreplaceable reproductive tissues and less chance of postoperative adhesions.

Does the patient’s medical history determine whether or not this novel surgical approach can be applied?

Robotic myomectomy has applications that depend on the level of confidence of the individual robotic surgeon: our general guidelines here at BWH are that we will not consider the patient an adequate candidate if she has over 15 tumors or if any one tumor is significantly larger than 15 cm of diameter.

How will application of this robotic technology shape the way surgery is performed from now on? Are medical professionals across the globe in support of this technology or is there some resistance and if so why?

There is resistance to robotic technology from some of the gynecologic surgeons because of its overall high cost and because, due to its intrinsic enabling power, it allows surgeons to offer the laparoscopic approach almost universally, thereby challenging the old paradigms of open surgery being the main approach for most indications. There is also resistance on the part of hospital administrators, faced with cost-containment challenges posed by the new political approach to socialized healthcare. Truly, the only ones to benefit from robotic surgery are the patients who will avoid painful open surgery with long recovery and high chance of complications.

You have demonstrated application of the BeamPath^® Robotic fiber and carbon dioxide laser system to perform a laparoscopic myomectomy. Can this technology, or will it, evolve for a much wider application in surgery for any other cancerous or non-cancerous conditions?

BeamPath technology has already found applications in other areas of benign gynecology, such as resection of pelvic endometriosis. Surgical oncology applications are likely to follow.

In which medical fields do you see a greater demand for this type of robotic technology?

The BeamPath Robotic is a very precise cutting tool with good coagulation potential: its potential areas of application are very broad. Personally, I think that the greater demand for this kind of precision knife shall come from gynecologic, urologic and otolaryngologic fields.

What are the future goals for integrating robot technology into surgical practice and how will these challenges be accomplished?

I think that the main goal of robotics is to achieve a degree of miniaturization that will allow single incision surgery (preferably through natural orifices, such as the vagina for gynecology).

It appears that application of much of the advanced surgical robotic technology is starting to flourish in America. Geographically, where else will application of this type of technology start to emerge?

There is no doubt in my mind that the only drawback of robotic surgery is cost. Once the issue of cost is resolved (and it will be, in all areas of personal robotics, just as it has happened in the past twenty years for personal computers) surgical robotics will allow tremendous savings in all health systems, by allowing conversion of virtually every open surgery to its endoscopic counterpart and therefore decreasing the high costs of prolonged hospitalization and complication management. In such scenario, I think that universal adoption of surgical robotics will make the most sense in those health systems whose structures are strained by high population issues: China and India easily come to mind as countries who could be both producing and using surgical robots in the near future.

About Dr. Antonio R. Gargiulo

Dr. Antonio R. Gargiulo is the Medical Director of the Center for Robotic Surgery of Brigham and Women’s Health Care in Boston.

He graduated from the Medical School at the University of Naples, Italy in 1989. He completed a post-doctoral research fellowship in reproductive biology and his Obstetrics and Gynecology residency at the University of Texas Health Science Center in Houston between 1990 and 1996 and his fellowship in Reproductive Endocrinology and Infertility at Brigham and Women’s Hospital in 1998. He has been on the full-time faculty at Harvard Medical School since 1996, where he is currently assistant professor. Dr. Gargiulo and is a member of the Center for Infertility and Reproductive Surgery and of the Center for Assisted Reproduction at Brigham and Women’s Hospital.

Dr. Gargiulo is board certified in Obstetrics and Gynecology and in Reproductive Endocrinology and Infertility and practices with a strong focus on reproductive surgery. Dr. Gargiulo’s team has performed over 600 major robotic gynecologic operations since 2007, including the world’s first single incision robotic myomectomy in 2011, and has authored numerous publications on the subject. Dr. Gargiulo is a Charter Member of the Society of Robotic Surgery (SRS) and serves as the current Chair of the Robotics Special Interest Group of the American Association of Gynecologic laparoscopists (AAGL).