Endometriosis Foundation of America
Medical Conference – 2012
Endometriosis Surgery: The Next Frontier in Robo-Assisted Surgery
Arnold Advincula, MD
I want to thank Dr. Seckin as well as Ms. Lakshmi as well as the rest of the Endometriosis Foundation for the absolute honor of being able to come here today, not only to sit and learn from all the esteemed speakers but also to share with you an area that I am passionate about. Not only have I spent a lot of time, essentially most of my career, dealing with endometriosis but I have also spent a lot of time in my career trying to understand the evolution of technology and how we can leverage that to improve what it is we do in patient care.
What I am going to talk to you about this afternoon is endometriosis surgery and the application of robotics as being one of the next frontiers for that technology.
These are my disclosures for this afternoon.
It is interesting you know as I said I before I spent most of my career running an endometriosis center. I started at the University of Michigan and for the last two and a half years I have run a center out of Celebration Health down in Florida. One of the things that I have gleaned from that is with more time spent working with patients who have this disease you really begin to realize what are the deficits that we have in our armamentarium, whether that be medical or surgical in terms of treating these patients.
A lot of folks often wonder where I am located in terms of the center. We are actually about ten minutes away from the main gates of the Magic Kingdom, so we are very close to Mickey Mouse. But at the end of the day we are not here to talk about Mickey Mouse we are really here to talk about where is that potential intersection between robotic technology and the management of endometriosis?
What I would like to do then is basically cover with you some issues surrounding the surgical management of deep infiltrating endometriosis from the perspective I have gleaned over the years. We will talk about a natural evolution that occurs in surgical technology, we will summarize the rationale behind why robotics may be utilized for reproductive surgery for endometriosis. Certainly it is absolutely an honor to be speaking in this panel this afternoon because Drs. Koh and Miller have been very influential in a lot of the thinking that I have had. It is going to be great to follow up with someone who talked a lot about preservation and then also integrating our understanding of evidenced based medicine.
We will go over some potential perceived limitations of robotics. I want you to leave with the idea that a lot of this is disruptive technology and it is disruptive thinking.
I am not going to spend any time going over definitions because clearly everybody in this room understands that. But what I do want to say is certainly when we talk about endometriosis one of the things that we are struggling with on a day-to-day basis is the fact that when we treat it surgically we have to address the fact that it can be found in more than just one place. It is not just something present in the pelvis. We also see it, as we spoke earlier, in places like the lungs, in the bowel and the genital urinary system. It is important to make the accurate diagnosis. As a clinician I place extreme emphasis on the history in physical exam for these patients. We can make presumptive diagnoses but at the end of the day we need to do a laparoscopy to really help confirm those presumptions or those assumptions that we make with the patients that we see.
Now as I said before when it comes to evaluation, and again, all this is going to tell you is a bit of a story that is going to lead into why I think we need to look at some new disruptive ways of thinking and disruptive technologies. Certainly when we look at evaluation, as I said before, history and physical exam - extremely important because you need to understand that very well before you take somebody to the operative theatre. Of course with a good history and physical exam with that we also need to understand the pathophysiology of how this disease works. Because that is really, at the end of the day, what sets up the work environment that we enter when we go into that surgical field. We end up with patients who present to us with issues regarding pain and infertility. With that pathophysiology one of the things that I look for as a surgeon are the signs of that disease, the manifestations, not just the clinical history but also the physical exam findings. I am looking for things, like subtle findings, like a laterally deviated cervix, or nodularity within the pelvis. If there is something that I feel in the rectovaginal examination that leads me to think that there is something going on that is going to be more than meets the eye when I get in to do that surgical evaluation and treatment.
Let’s pause for one second, let’s not talk about history and physical and evaluation of the patient, but let’s now switch gears to technology. At the same time that we have a better understanding of disease processes we are also seeing a natural evolution in surgical technology. We are moving from what I call generation 1 surgeons, generation 1 surgical mentality, which is traditional, invasive, open surgery laparotomy. We have moved into generation 2 surgery, which is the ability to now take what we know from open surgical technique and miniaturize that, do that in a less invasive fashion through laparoscopy. And that is really where we sit today. Generation 2 is in rapid flux. It is constantly evolving and it is changing as you will see here shortly. With generation 2 technology we have seen a lot of improvements. We have great light sources, we have excellent hand instrumentation, we have energy devices that let us do amazing things and you have seen that all day today as you watched those surgical videos from our esteemed colleagues who have spoken earlier.
But with that, with that advancement in technology as a clinician I am always aware of the fact that there are obstacles that stand in our way. We have the surgical field as you can see from those videos; dealing with distorted anatomy, complex pathology; a large uterus for example, obesity in our country; as you can see from this map there is really not one state in the United States that is immune from this epidemic. Instrumentation as I said earlier is an issue, learning curves, surgeon experience, as well as things like training. All these things impact our ability to leverage generation 2 technology.
At the same time if I go back to the clinical side of things what are we faced with? We are faced with trying to understand how to visualize the disease. We have a disease that takes on many forms, it is very enigmatic. You need to have a well trained eye to be able to visualize the different manifestations. We also recognize that endometriosis is not just one entity. It is three different entities. We deal with implants, we deal with ovarian disease and we deal with rectovaginal disease. It is like football for example. You cannot say the word football and have it mean the same thing in different parts of the world, right? It does take on different manifestations.
We also have seen this reiterated several times again. It is just the “tip of the iceberg” what you often see. That is something I am going to go back to when we talk about the advent of a lot of this new technology and our ability to see beyond what is on the surface and to go deeper into the tissues. When we look at instrumentation that we have by traditional means, and you spent the whole day today looking at what we call traditional laparoscopic instrumentation, we have some limitations. Certainly it is not the most ergonomic way to operate. It is two dimensional imaging. So in other words, when I look at something, and I can look at this ornamental shrub here on the side of me, and because I have three dimensional imaging I can tell that there is depth to this, that there are differences in where the leaves are oriented and I know there is depth. With two dimensional imaging it would be very difficult to appreciate that. We have things like a fulcrum. When we operate in the pelvis, the pelvis is like a rice bowl turned on its side. When we operate in there we operate essentially, and I often you use this analogy, with straight chopsticks, trying to operate with a rigid instrument through the curvature of the pelvis. These are some of the limitations that we are faced with with traditional laparoscopic instrumentation.
This is where robotic surgery may have a role to play. I have spent the last ten and a half years developing this area of minimally invasive surgery, did a lot of the initial work ten and a half years ago, worked with the FDA trials, and so really have grown to really understand how this may potentially benefit patients. 1) Although we operate remotely, which is disruptive way of thinking we do have some assets that we gain, one being three dimensional imaging. In other words, now I can look at this ornamental shrub and appreciate the fact that there is depth here. A common criticism is the lack of tactile sensation. We often believe that you have to feel everything because the disease can be very difficult to diagnose and treat. But what is interesting is we develop something called visual haptics. When you look at the literature regarding sensation and vision, for one thing when you lose a particular sense you gain it in other ways, one being visual. The other thing is you would be surprised in the literature how much of what you feel is actually based on what you see. Probably more than half of what your brain tells you about what you feel is based on memory of what you actually see as opposed to actually physically touching the tissue. We eliminate things like the fulcrum effect and of course there are ergonomic things that we gain in the process as well.
Certainly robotics over the last several years has been applied through the gamut of GYN surgery as you can see here. And certainly endometriosis resection is one of the areas that I have been developing and aggressively researching because of some of the benefits that I believe exist.
Let’s talk a little bit about medical versus surgical. I am going to focus on the surgical treatment of endometriosis with robotics because the question everybody has here I am sure sitting in the room is “what can robotics surgery do for the endometriosis patient?” Well certainly one thing I do want to point out is remember, this is laparoscopic surgery and a lot of people think robotic surgery is a whole new way of doing things. It is the same type of surgery you have seen all day today. It is laparoscopy. The difference is the tool has changed slightly. We have evolved in terms of the tool. I am still doing the same thing. We are doing an evaluation here. This is just showing you some mild endometriosis. But I am able to navigate around the pelvis. I have got wristed instrumentation as if I am moving my hands in there, moving my fingers and evaluating the tissue. You can see subtly there is some evidence of endometriosis on the vesicouterine reflection in the anterior cul-de-sac. Again, I have a steady image that I can zoom in, you have heard the phrase this morning, near contact laparoscopy. We can almost do that – essentially we do that basically with robotics. Unfortunately this is a two dimensional image, you do not get to appreciate what I do as a console surgeon who sees a three dimensional image of this pelvis.
That is mild disease, how about severe disease? We can certainly appreciate that with robotics we can see that. This is an example of looking into a pelvis where you barely see the uterus. You barely have any sense of being able to visualize any of the reproductive organs here because it is densely encased in significant pelvic adhesive disease.
Let me just highlight for you some examples of what it means to utilize this technology. Again, it is going to emphasize a lot of the principles and the techniques that you have heard about throughout the day today. One of which is being able to go back to the basics. One of the things robotics does for us is it provides us with an excellent dissecting tool that lets us adhere to the principles of good surgical technique. You can see here that one of the things that we want to be able to do is anatomically dissect in the plane that structures run. You can see here this is the right ureter along the right pelvic sidewall and what we are doing here is we are now dissecting away a dense plaque of endometriosis that was overlying the ureter. One of the advantages that we find is not only the ability to have a steady image of where you are working but also the ability to anatomically dissect in the plane of the contour of the way that ureter travels. Instead of putting a rigid instrument in there, although we have an assistant here who is going to retract subtly, the actual dissection is going to be done with a wristed instrumentation that allows us to follow the contour of that ureter and preserve its periureteric blood supply, so we have minimal trauma to that structure. Again, I do not have to feel that lesion to understand that anatomically. Again, anatomy is very important as an endometriosis surgeon, you have to know your anatomy. Because I know my anatomy I do not have to feel, I know that is a thick, rigid plaque of endometriosis. But what I am going to do is, because visually I can see very well I can create the wide resection margin of that endometriotic lesion and resect it out. I am just going to fast forward that a little bit so you can see how that can be done. You can see how very atraumatically we are able to preserve the attachments and the blood supply to that ureter and just work our way around this. Again, we use various different energy sources here. This is what we call a monopolar scissor that is going to dissect this plaque away. You are going to see I am going to fast forward just for the sake of time. I certainly do not want to belabor a point here. You can see the ability to wrist and to work in a very tight space in the posterior cul-de-sac along the right pelvic sidewall. You can see this lesion is almost completely off, down to what we call the fatty tissue and you can see that we have left the ureter intact and we have excised that lesion.
What about endometriomas? Certainly here again this is where you take the evidence based literature that Dr. Miller talked about where it is important to be able to understand that just puncturing and ablating a structure this large, this endometriotic lesion, is not going to give you the permanent fix. You are going to need to be able to not just puncture and drain, but you actually have to physically excise the endometriotic cyst from this particular ovary. I am going to demonstrate for you the ability, which is often a concern that we have is how do you try to minimally traumatize the ovary. You can see here our ability to do that. We have an endometrioma that is being gradually peeled off here. We are able to take that cyst, and again, without entering and traumatizing that ovary, the important part of the ovary, we are able to take that cystic structure, that endometrioma almost essentially intact with instrumentation. It is like peeling a grape. You want to be able to put your fingers in there and delicately pull something apart. That is what we are able to do when we work with this type of an approach to laparoscopic surgery.
Having a good understanding of anatomy is extremely important. You can see here again the ability to identify critical structures when you operate. It is tremendous. Now this is a case where unfortunately this is one of the more extreme cases where this patient instead of preserving, we literally had to actually do an extirpative procedure. But I want to show you the importance of being able to do an extirpative procedure that is done anatomically in order to minimize the morbidity and complications associated with this type of radical endometriosis surgery. You can see here what we are doing, I am going to fast forward because we are going to open the retroperitoneum in the pelvic sidewall here. Why do we need to do that, because we have to try to identify the anatomy. You can see that things are densely distorted, adherent on this particular patient. Here is the ureter. What do we want to do? We want to identify the ureter not from outside the retroperitoneum but we want to identify it physically within the retroperitoneum so we can follow it and know where its course is. You can see critical structures coming into view. The psoas muscle, genitofemoral nerve, we can see the iliac vessels here. I am going to time lapse this a little bit and follow it forward. You can see that we can open that retroperitoneal space like a book, we can read it like a book and understand where structures are heading. This allows us to do a much more meticulous precise surgery. You can see it allows us to minimize blood loss which again these are things that at the end of the day you want to have precision and finesse with how you do your surgeries. It is like the microsurgery that Dr. Koh talked about. Again, you are going to see here time lapse a little bit forward. There is the ureter, we are able to identify the ureter in its proper anatomical location. We can now follow that and address whatever it is that we need to do because we are adhering to principles of surgical anatomy and surgical dissection technique.
Let me share with a little bit of a story. I am going to share with you why I have become so convinced that this is the technology that is really going to be able to have a significant impact on our patients. I am going to show you a video of a case I just did this Friday. I saw a young woman who presented in my office and had been seen by several physicians, who had a main complaint of just deep dyspareunia. After seeing several physicians she was basically told that it was all in her head, that this is not something that really they can find anything wrong with that they can treat. She showed up to our endometriosis center and I evaluated her. This is where history and physical are extremely important, listening to the patient, doing a good history and a very thorough physical exam. One of the first things that I did when I did her physical exam was to do not only a traditional by manual exam but I did a very good speculum exam and a very good rectovaginal exam. With that I palpated something that I thought was strangely odd. I said, “Well you know, this is really interesting. I think I have an answer about why you are having so much pain, so much discomfort”. You can see here this is just an example of another patient with a similar presentation. This is a laparoscope inside the vagina with a speculum in, cervix and here is evidence of endometriosis within the vagina. I am going to play that again so you can see that. So this woman who is young, wants to be able to have a healthy relationship with her husband, thinking of fertility in the future, found to have an endometriotic lesion within the vagina, a very difficult place to access, very difficult surgery to do.
Let me play for you a video that I am going to time lapse a little bit. This is the actual case of what we did on Friday. This is a view of the pelvis. We have three robotic instruments in there. You can see that the posterior cul-de-sac does not look right. She also had a dermoid cyst, a 4 to 5 cm dermoid as well as a functional cyst in her right ovary. You can see here there is already something that as you look at it correlates very nicely with what I feel on exam and what I see visually in the vagina. What do we do? Basic surgical principles, restore the anatomy, right? Restore the pelvic anatomy. I am going to mobilize the rectosigmoid here because I am going to need to be able to manipulate it and move it as I do the surgery. I am going to do that again, I do not need to feel this, visually I see quite well. I can manipulate that tissue. It is laparoscopic surgery. That is another thing I want to emphasize, this is laparoscopic surgery, just with a different tool set. Here we are mobilizing the bowel.
The next thing we are going to do is we are going to focus to the posterior cul-de-sac where we are going to need to mobilize and get the ovary out of the way so we can look at this problem area right here. What we are going to do when we get to this area is try to normalize the anatomy in that part of the pelvis, which is entering perirectally, getting into what we call the rectovaginal space. This is where we start to see some advantages because operating underneath the uterus with a straight instrument is quite difficult. Not that it is not impossible to do you have seen very skilled surgeons today doing that but what I am able to find is that I can anatomically dissect in the plane of the tissue. That is the advantage we see and I subscribe to the school of being an anatomical surgeon. I like to orient instrumentation based on the anatomy of the patient to minimize trauma and to be able to find those tissue spaces. You can see here that I am gradually getting into that plane. Some of this is speeded up just for the sake of time so we do not belabor the video, this is an edited surgery that took about between 60 and 90 minutes start to finish to perform. Here we put a sizer that is going to go into the rectum. You can see where the bowel is attached to the posterior vagina. Here is that sizer being placed by my assistant.
Again, trying to operate anatomically, here we go, entering laterally to the bowel, getting into anatomical spaces. Endometriosis tends to compromise a lot of anatomical spaces so the goal as an endometriosis surgeon is you want to be able to go around those compromised spaces. But doing that requires having a good knowledge of your anatomy to be able to know where you can go. It is like seeing a road block here in the streets of New York City and if you understand how to get around other streets you can get from point A to point C. That is the analogy really. If you only know one way to get somewhere you are going to be limited once there is a roadblock. What we have been able to do with robotics is it allows us to take advantage of all the other avenues through which to get around an obstacle and then eventually free up that roadblock. In this case it is the rectovaginal disease that this poor woman has. You can see that we are using the sizer, here we have started to come around it. We are getting around the back side of that so I am able to go well behind it instead of barreling through it right away. Go well behind it and start to chisel the endometriosis and get it off the bowel and leave it more or less confined to the vaginal side, which is the part that I am going to do an excision of. I am going to do a partial vaginectomy in that area in order to excise that lesion. You can see that is what we are doing right here now, we are coming across that. Eventually, once we do this what we are going to see is my assistant’s hand that is going to be placed transvaginally, help delineate out where that exact lesion is. Here we are mobilizing the bowel, we are trying to do that atraumatically and one of the things that I hope you are appreciating here is, because we can operate anatomically we minimize the level of carbonization and what we call charring and thermal effect in the pelvis which I think is very important.
Here we have gotten the bowel down. This is the assistant who has now placed her fingers in the vagina, that is actually the back vaginal wall. You can see here that this is that deeply infiltrative lesion that goes full thickness in. We have left it on the vaginal side, taking it off the bowel side. The bowel is nicely freed, minimal thermal effect. We now have a sizer that is going to be placed in the vagina and I am going to go ahead and we are going to excise this now. We are going to make an incision with a wide margin.
One of the interesting things you are going to notice here is you are going to see endometrioma in the vagina. You are going to see the endometriotic fluid that is, that chocolate fluid that we talked about – right there. You can see that. Of course I am going to readjust where we are going to come around, we are going to come a little lower in order to get this out. We are going to excise that completely. Change the plane. I can operate anatomically, it is ergonomic. I am seeing this three dimensionally and I have complete control of the surgery because of my instrumentation. Here is the thickness of that nodule as we come around. Once we have that out then the next step, it is always a challenge, to suture. It is a challenge to suture low and deep in the pelvis. Here we go, we are going to pull that out. Deposit a specimen in the vagina and now we are going to suture. We have great technology today for suturing. Here we are using a very fine barbed suture to help evenly tension and re-approximate that vaginotomy incision. You can see that being done here. We are able to wrist, I am able to get underneath. You cannot appreciate the depth perception because this is 2D but you can sort of see it by looking at the uterus. We are literally operating underneath the uterus, which is serving as a shelf. We are underneath that and able to wrist and articulate as we do this repair.
Of course, once we have that done – I am going to fast forward this for the sake of time. You can see that we are just going to sew that closed. This is the finished product that we are left with. We now have the bowel completely mobilized and off the back of the vagina. The uterus is now better mobilized. Of course we still have to finish treating the ovary on this side but you can see the finished product here.
When you examine the patient post-operatively now you feel a normal vaginal exam, a normal speculum exam and this woman will certainly see a significant improvement in her coital discomfort that she has had prior to presenting.
As we look at this technology we always have to ask ourselves four basic questions when we look at things that may potentially impact how we practice: 1) Is this a technology that will improve patient outcomes? 2) Will it improve my ability to render care for the patient? 3) Is it something that can be generalizeable? Can I train other surgeons to do this? Because clearly when you are looking at numbers like 10 to 12 million women affected by the disease you cannot have a handful of people only trying to treat 12 million people, there are going to be access issues. We need to be able to have a technology that we can use to train individuals who have the right ingredients, the right chemistry, to be able to do this well. As everybody said before you need to have the skilled surgeon who understands reproductive technology, who understands surgical principle, who works in a multi-disciplinary fashion in a center to take advantage of a technology like this to be able to do this. Can it be reproducible? And 4) What are the costs? We have to understand what the costs of these things are.
What does the literature show? I have the great pleasure of working with a visiting endometriosis surgeon from Copenhagen who is spending six months with me, Torur Dalsgaard, he is here in the audience. We are working on looking at what the literature is right now in this area. There are about 21 publications out there. Basically either cases or case series, there is one comparative controlled cohort study, still not a lot. We are certainly in the middle of a huge study right now looking at our experiences with this type of aggressive surgery. But it is important to understand that we are evolving, evolving as surgeons. When we look at things like robotics I often liken it as the parachute. We look at this new laparoscopic tool and people sometimes do not know what to do with it and they say, “What does the literature show?” Well, you know, I think most folks would not argue the value of a parachute when you jump out of an airplane. I think most folks will say, “I’m going to wear one of these if I jump out of an airplane.
If you look at the literature surrounding the value of a parachute there are no randomized controlled trials, right? People always talk, “I want a randomize control trial about this”. There is not one. This was actually published in the British Medical Journal, sort of poking fun at evidenced based medicine. We always have to temper our passion for evidence based medicine with things that just smack us in the face and say, “You know what? It’s the right thing to do”. I highly doubt that anyone would randomize themselves to jumping out of an airplane without a parachute.
Probably this is not coming out too well in the slide but this is an actual quote from a Western Union internal memo that talked about the telephone as having too many shortcomings to be seriously considered as a means of communication. This was actually a memo from Western Union. But yet we have things like the telephone, and I will go back to the rotary phone in a second but we have the telephone. In 1949 Popular Mechanics magazine said that computers may weigh no more than 1.5 tons. Yet we all sit here and I bet probably 75 percent of you have some sort of Smart Phone technology or iPhone. Not only do we have a computer in our hand but we have a telephone. This technology is laparoscopy but it is like the phone. To me traditional laparoscopy is like a rotary phone. Yes, you can call somebody with the rotary phone. You can get the job done but you have to dial it. Robotics is one of those evolutionary changes where now I can push the button and I can make my phone call. So it is not that we are not doing the same thing, or making the same phone call, we are just doing it slightly differently but same technology at the end of the day.
Certainly, we have to be responsible. This is one of the things I emphasize constantly. Not only do you need to be responsible clinicians in how we manage patients, particularly those with endometriosis, but we need to be responsible in terms of how you evaluate technology. And certainly our American College of OBGYN has stressed that to us and that is why a lot of us have worked in this arena to try to better understand what robotics will mean for all those millions of women who have endometriosis.
At the end of the day I appreciate your time. For anybody interested in learning more about this technology as well as further details clinically about endometriosis I certainly welcome those here in the audience to come visit us in Orlando in a couple of weeks where we are hosting two big meetings back to back. One by the International Society of Gynecological Endoscopy, which I know many of the surgeons here are members of, but also the 4th World Robotic Gynecology Congress.
Thank you very much for your time.
