This Clinician’s View opinion piece is written by Steven D. McCarus, MD, Chief of Gynecological Surgery at AdventHealth Winter Park and obstetrics and gynecology surgeon at AdventHealth for Women.
Hysterectomy is one of the most common gynecologic surgical procedures performed with an estimated 33% of women in the U.S. over age 60 having had one. While it can be performed for either benign or malignant indications, approximately 70% of hysterectomies are for benign causes. Over the years, surgical techniques have evolved, and the emergence of robotic surgical systems has allowed us to employ the latest technological advancements to enhance our capabilities as surgeons. AdventHealth has led in this realm and continues to explore and expand this medical frontier.
The Evolution of Surgical Approaches to Hysterectomy
Today we have four primary approaches to hysterectomy: abdominal, vaginal, total laparoscopic and robotic. For many decades, abdominal hysterectomy was the only option available to women. Over time, vaginal hysterectomy was introduced and has become the preferred approach whenever feasible because it is associated with better outcomes. However, it has historically only been used in about 16 percent of hysterectomies due to anatomical and technical limitations.
Laparoscopic hysterectomy was first described by Harry Reich, MD, in 1989. Along with smaller incisions and better cosmesis, this minimally invasive approach to surgery brought shorter hospitals stays and quicker recovery times compared to abdominal surgery. I began using the laparoscopic approach in 1990 and as the tools became smaller, the procedures became even more minimally invasive. While this approach revolutionized the way gynecologists performed surgery, it is technically challenging and comes with steep learning curves. To help address these limitations, robotic approaches soon began to emerge.
Robotic Gynecologic Surgery — the daVinci® Surgical System
The first robotic surgical platform, Robotic Assisted Laparoscopy (RAL), was developed in the 1970s as a project by the U.S. military and NASA. The U.S. Food and Drug Administration (FDA) approved the first RAL-type systems for general surgery in 2000, including the daVinci® Surgical System. In 2005, the FDA approved the daVinci® robot for use in gynecologic surgery, and AdventHealth Orlando became an early adopter of this revolutionary new approach.
Within gynecology, the daVinci® system was initially used only for malignant surgical cases. The surgical indications later expanded to include simple hysterectomy, myomectomy and advanced endometriosis procedures. I began performing robotic hysterectomies with the daVinci® system in 2009. For surgeons, the primary benefit of a robotic approach is the ability to facilitate minimally invasive surgery and assist with complex tasks in confined areas of the body with more precision, flexibility and control than is possible with conventional techniques. As with any laparoscopic approach, the daVinci® system came with a learning curve and presented a few challenges, including increased operating procedure time and loss of haptic feedback. However, like many surgical techniques, the platforms and tools have continuously improved over the years.
The Senhance® Surgical System
In 2017, the FDA approved the Senhance® Surgical System, providing us a second robotic tool for gynecologic surgery. AdventHealth Winter Park acquired one soon after, and I began using it as well. With its most recent updates, this system has further enhanced the robotic approach to gynecological surgery in several ways:
- Allowing for use of smaller trocars (3 mm and 5mm) to facilitate micro-laparoscopy
- Providing haptic feedback
- Employing retinal screening for unique eye tracking
As our laparoscopic tools have become smaller, the procedures have become more minimally invasive, enhancing the precision while helping to minimize tissue damage and scar formation. The use of smaller trocars (≤ 5 mm), in particular, has been associated with less postoperative pain, reduced postoperative pain medication, less risk of vascular injury, less risk of trocar site herniation, and smaller scars, which enhances patient satisfaction.
The Anovo™ Surgical System
Approved by the FDA in February 2021, the Anovo™ Surgical System is the first surgical robot designed to enable the minimally invasive transvaginal approach for benign gynecological procedures. AdventHealth Celebration OB/GYN Erica Stockwell, DO, began using it in August 2022, becoming the first in Central Florida to do so. The Anovo™ system was authorized for hysterectomy, salpingectomy, oophorectomy, adnexectomy and ovarian cyst removal. This hybrid surgical approach combines the technologic benefits of laparoscopy with the ergonomics of robotics and the optimal patient outcomes of vaginal surgery. AdventHealth is a primary site for the ongoing registry of clinical outcomes using the Anovo™ system.
Determining the Best Gynecologic Surgical Approach to Optimize Patient Outcomes
While robotic-assisted gynecologic surgical procedures have proven safe and effective, there have been limited randomized controlled trials comparing them to other approaches. The American College of Obstetricians & Gynecologists (ACOG) issued its latest set of clinical guidance recommendations on this topic in 2020. Based on available clinical studies, they concluded that robot-assisted gynecologic surgery can be performed safely in centers with experienced surgeons and that this approach has perioperative outcomes equivalent to laparoscopy along with improved outcomes compared with laparotomy. They also issued the two following key recommendations:
- Further comparative studies to assess long-term outcomes and patient safety, and to identify specific subgroups of patients who would benefit from a robot-assisted approach
- Development of a registry of robot-assisted gynecologic procedures and the use of the U.S. Food and Drug Administration’s (FDA) Manufacturer and User Facility Device Experience Database (MAUDE) to report adverse events
Providing Leadership, Training and Patient Choice
AdventHealth has now acquired more than two decades of experience using robotic technologies for gynecologic surgery, and we believe in shared decision-making with our patients, providing them with education and choices about their surgical treatment options. We are currently the only hospital system in Central Florida that has all three robotic platforms — da Vinci®, Senhance® and Anovo™.
We also believe that with experience, comes responsibility. As a result, from 2003-2011, we offered a fellowship in minimally invasive gynecologic surgery and graduated 10 OB/GYNs through the program. In recent years, the AdventHealth Nicholson Center located in Celebration, Florida, has served as a living laboratory for providing robotic education and training to physicians from around the world. The center currently offers a Certificate in Advanced Robotic Surgery (CARS) as well as an Online Master of Science in Robotic Surgery offered in partnership with AdventHealth University.
The Next Frontier in Robotic Gynecologic Surgery — Augmented Intelligence
I believe the future of robotic surgery will entail increasingly intelligent tools to inform, enhance and extend our capabilities as surgeons. Augmented intelligence, a subset of artificial intelligence (AI) machine learning, is designed to improve human decision-making but not replace it. Surgeons will remain in control. The aim is to minimize human bias and error while also detecting patterns and trends, which will help to optimize patients’ surgical experience and outcomes. For gynecological surgery, this means advancements like 3D measurements and tagging of structures. We are already seeing applications of augmented intelligence in the latest enhancements to the Senhance® Surgical System, providing us with real-time, actionable information that positively affects the way we operate.
AdventHealth remains at the forefront of robotic gynecologic surgery, and I’m excited about what lies ahead. As surgeons, we pledge to continue learning, improving, evaluating and evolving to provide the best possible treatment options and customized care for all of our patients.
