What's the Deal with ... Robotic Surgery for Endometriosis?

By Dr Brendan Miller, Blue and Pink Obstetrics

Most of us are familiar with the laparoscopy for endometriosis, it's usually how we come to our diagnosis! We've heard gynaecologists trained in advanced laparoscopic techniques emphasise the importance of excision surgery for treatment of endometriosis, but have you heard of robotic surgery? In robotic surgery, most commonly using the Da Vinci surgical system, the surgeon guides the procedure from a master console which controls robotic arms with attached surgical instruments. The improved ergonomics helps to overcome the limitations of traditional laparoscopy, and is associated with reduced surgical time, and improved, and safer, resection of endometriosis in delicate tissues such as the bowel, bladder and and ureters. Obstetrician and gynaecologist Dr Brendan Miller is a fellow of the Australian Gynaecological Endoscopy Society (AGES) and developed an interest in robotic surgery for endometriosis, as well as other gynaecological conditions, after his experiences in the United States. Dr Miller presented at the Women's Health Expo on the subject of robotic surgery and has been kind enough to share with QENDO his experiences with robotic surgery and how it can help women with endometriosis with both pain management and fertility. 

I was inspired to learn robotic surgery after observing some robotic cases in the United States in 2014. These were performed at the Creighton Medical Centre in Omaha Nebraska by Dr Thomas Hilgers and by three robotic fellows that he had working for him. These operations involved resection of endometriosis and they were performed to improve the fertility of these patients. At that stage I was in the second year of an AGES fellowship in advanced laparoscopic surgery at Flinders Medical Centre in Adelaide, Australia. When I returned to Australia I did attempt to incorporate some of the techniques I had seen performed in Omaha laparoscopically. However the straight stick laparoscope does not allow the level of precision and fine detail that the robot can achieve. For example, in Omaha I watched the robot perform a fallopian tube reimplantation using 7/0 prolene sutures – sutures that are difficult to see with the naked eye – let alone manipulate surgically, something one couldn't achieve with a conventional laparoscope.

Unfortunately there were a number of barriers to commencing robotic surgery in Australia. Firstly access to a robot. This was one of the reasons that I established my practice in Toowoomba. I had ready access to the robot simulator at St Andrews almost whenever I wanted it. The next impediment was the extra cost to patients for the surgery, and thus access to the procedure. This is no longer an issue. At the moment there is no difference in cost to patients between laparoscopic and robotic surgery for endometriosis.

I am now beginning to see pregnancies among patients that I have performed robotic procedures for fertility – including robotic resections of endometriosis and ovarian wedge resections for polycystic ovarian syndrome. Of course I have used the robot for many other indications in the last two and one half years – including hysterectomy, myomectomy, prolapse surgery and treatment for urinary stress incontinence. I now have patients coming from all over Australia for robotic surgery for infertility and along with other gynaecologists in Toowoomba we are looking to establishing a centre of excellence in these procedures.

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