International Medical Conference Endometriosis 2025:
Endometriosis 2025: Your Mother Should Know, Your Doctor Should Know Better!
Robotic Surgery in Endometriosis Surgery: Is It Worthwhile? - Horace Roman, MD, PhD
I am honored to present Dr. Horace Roman, who's a professor and surgeon at the Endometriosis Center in Bordeaux, France, specializing in minimally invasive surgical management of endometriosis. Dr. Roman has authored more than 300 scientific abstracts and original articles in peer review journals such as Fertility Sterility, American Journal of Obstetrics and Gynecology, human Reproduction and the Journal of Minimally Invasive Gynecologic Surgery given numerous lectures, performed numerous live surgeries and essentially amongst the best surgeons in the world. They say that Dr. Roman is probably the best for colorectal endometriosis and I'm honored to present him today.
Thank you very much. I think it is very difficult now to say to state who's the best because there is a huge number of excellent surgeons who are doing an excellent job. So me, I try to do the best what I know to do, meaning the endometriosis surgery. And I started consecrating my activity on focusing at a hundred percent in endometriosis 20 years ago after one year spent in the Department of Gynecology of Michel Canis in Clairmont Farro. So it is my absolute pleasure to be here with you and to answer affirmatively to the invitation of my friend Tamer. Second, because our destiny is, are somehow similar. He immigrated from Turkey in the United States and me from Romania in France and everything is very similar except the onset of this adventure because he preceded me more or less 10 years earlier. So he asked me to speak about the robotic surgery in endometriosis and to try to demonstrate if it is worldwide.
So I have a conflict of interest because I am surgeon and I am an intuitive proctor. It means I receive fees for training over, so I'm paid to show how I do the robotic surgery. However, these fees represen present less than 1% of the income of my company. So neglectable and far from more to use the robot. I pay fees to the clinic which are threefold higher. So the balance is negative. That's why I think it demonstrates that it is my own opinion to promote the robotic surgery. Now the objective of my presentation or to provide arguments which supports the use. So the idea is to provide arguments, favorable robotic surgery and also to identify some, I will try to focus on surgical arguments and not on financial arguments. Now the title of this meeting is Your model should Know, your Doctor Should Know better.
So let's imagine what's happened every day when patients come to me and said, okay, one told me that I need an endometriosis surgery. You are doing robotic surgery. Is it worthwhile? And my answer will be, well, it depends. It depends because the surgery may be successfully done by laparoscopy in more than 99% of cases. I have done it in laparoscopy before starting the robotic surgery. You saw Mario Mals half an hour ago. Someone, one of my fellows told me that he was attending a meeting where someone asked Mario Malone, do you think the robot is useful? And he answered yes, to hang my coat. Okay. So it was a joke, but for sure, for very skilled laparoscopic surgeons, the robot may seems only too much expenses for not advantages. However, in very specific localization of the disease, I strongly believe that we can do better, better and safer using the robotic surgery.
Now, performing the randomized trial and waiting for the results of randomized trial, which demonstrates the robotic surgery was better than the laparoscopy is very challenging and you have to wait for a long time because we will compare robotic surgery to laparoscopy surgery, which works very well. So we expect to have only small differences between the robotic and laparoscopic arm. So we need hundreds and hundreds of patients. So I advise you to start if you're interested in robotic surgery before waiting for randomized trial or even to try to do them. Now there are some folks about the robotic surgery. It is said that it is not useful to surgeons who are skilled in laparoscopy.
It is useful only for surgeons who do not or not aware or not skilled in laparoscopy. And this may avoid to do an open surgery. It is said that the expenses which are significant or not justified and also there is a loss of time. Now this debate between laparoscopy and robotic surgery recalls me the debate between vaginal hysterectomy and laparoscopy hysterectomy 20 years ago when a laparoscopies had to demonstrate that it costs maybe more, it takes more time, but there is an advantage. So we are more or less in the same situation. The question is what can make an experienced laparoscopy surgeon who's able to do what several he wishes in laparoscopy, what can determinate him to move to the laparoscopy to the robotic surgery and in which cases the robotic surgery may be superior. So I started the robotic surgery in 2011, but for six or seven years I was looking for the good indication because at that time I was convinced that I am doing this. I was doing the same or better in laparoscopy than neuro robot, but I did not stop the robotic surgery and I'm very satisfied by my decision at that time. In my opinion, there are obvious advantages for robotic assistance related to six major indications. The diaphragmatic endometriosis, the low rectal resection and anastomosis, the large disc excision in big rectal nodule, particularly on the lower rectum in ileocolonic resection and anastomosis in excision of bladder or ureteral endometriosis where we have to reimplant and definitively in the excision of nodules involving the sacral plexus and sciatic nerve.
Why to what disadvantages are related? First to the instruments, we have instruments with seven degrees of freedom with a very small size, which recalls the microsurgery and to ability to work with two instruments in very, very small volumes. Because the articulation allow two instruments to move without touching each over then to the view, the view is very stable. We can flip the camera up to down and down to up and we have the three division, which is however provided by some laparoscopic towers. And then we can a last advantage I discovered recently, the instruments, the arm of the robot can hang the abdomen and you can do the laparoscopy gas less with the abdomen open or the vagina widely open, which is very difficult in conventional laparoscopy. Now I said that I found that the robotic assistance is very useful in diaphragmatic endometriosis because of the seven degree of freedom of the instruments which allows to work behind the liver.
Everybody has already done excision of the diaphragm in laparoscopy, knows how it is difficult to suture behind the liver with the straight instruments because of the liver. Now these difficulties are completely ruled out with the robot and we can do the robot incredible surgeries, which I cannot imagine to do in a laparoscopy. So for me it is definitively a very good indication for the pragmatic endometriosis, the large rectal disc excision. So when you know that when you go on the rectum to remove nodules and you have to perform a rec resection, you may expect to have a low anti rectory resection syndrome, which is a terrible syndrome, which may get worse. The life of our patient worse than previous the surgery. So we cure the disease, but the patient does not feel better. This low anterior action syndrome may be reduced by the use of a disc excision.
However, you have to be able to do the disc excision in the very, very deep space. This with the robot is possible. And with the robot we push the limit of the disc excision over the three centimeter Mario told you about because we can do a very deep sheaving, we can prepare rectal wall into the depth and we can remove patches as large as five centimeter or five centimeter and a half with good functional outcomes. And this is due to the mobility of the instruments to the stability of the view to the capacity to flip the view up and down and not the last to the small size of the instruments which allow microsurgical surgery. So this kind of surgery takes usually one hour. So it is not waste of time when compared to laparoscopy low rectal anastomosis. Sometimes we cannot do the disc excision because the nodule is circumferential or there is a second nodule three or four centimeter more proximal.
So we have to do a low rectal resection. In this case, the robot is very useful if you want to perform a nose as Mario show you previously, because we can thanks to the robot, we can slip into the depth of the of vaginal space to remove the nodules of the parum and the vagina and then to cut very specifical and very precise and very economically the rectum around the nodule and to perform nose rectal dissection. So we introduced the anvil, we placed the anvil into the rectum, then we perform a suture full string suture, which is anyway easily easier with the robot than with the straight instruments. And we perform a very low rectal resection with good outcomes. So here for me, it's a clear indication of the robot. We have the ilio colonial action. Again, Mario showed you how he can do this in laparoscopy. I think in robotic surgery is easier, so the steps or the same, but again, the flexibility of the instruments allows a more faster and easier suture of and anastomosis of the ilium to the rectum. So we cut the ilum muca rectum and then we create this anastomosis with the stapler, but we have to suture at the end a hole with about two centimeter. And this definitively is easier with the robot in this space.
Then we have some very difficult bladder endometriosis nodules, which are trigonal, which may involve the ureteral mitus or may stop to five millimeter from the ute. And this case we used to perform a robotic surgery combined with the cystoscopy, meaning that the urologist performed the cystoscopy and anci is the mucosa of the bladder around the nodule taking care at the ureteral mitus. And then the robot will allow to perform thanks to the flexibility of the instruments, allows to perform a suture which catches very precisely the five millimeter available of the muscular detrusor. And in this case, we can, I think easier with more success we can avoid a reimplantation of the ureter into the bladder.
Then of course the ureter endometriosis, everybody knows that the urologists now are less skilled or perform less frequently their implantation with the laparoscope. They almost always do it with the robot. So with the robot they can do it in 40 minutes very well. So in this case, the robot is very useful, particularly when the no by the nodule involves the parum. And we have also to preserve the nerve which are located several millimeter below the level of the pelvic curator. But a great indication of the robot, and this is obvious for me, it is the management of deep endometriosis of the parum involving the sacral plexus and the satic nerve. And why? Because in this case, the mobility of the instruments makes the difference. When you want to perform an excision of the nodule on the sacral plexus or satic nerve, but particularly on the sacral plexus, you have to go behind the network of vessels tributary to the internal iliac artery and vein.
And these vessels, particularly the veins, are very dangerous and they wait the first moment to bleed. And the bleeding is very difficult to control at this level with traced instruments. And the robot allows to place in a very precise manner, perpendicularly that clips on the right side. And for me, this indication is as obvious as I completely stopped to perform laparoscopy in patients coming with nodule of the parum involving the sacral plexus. So you see the control of the, and I almost never have intraoperative bleeding when I perform this surgery. So you have to cut off all these decals before reaching the sacral roots because the anatomy is like this. So I strongly defend the use of the robot, the usefulness of the robot in this very specific localization of the disease. And you see how the sacral plexus may be dissected once the veins for cut. So here the mobility of the instruments and the size of the instruments makes the difference. Then another wonderful surgery is the excision of nodule of the sacral plexus as tamr showed before.
Just a moment why it does not start. Yes. So we have no reach involved the satic nerve. So in this case, again, we have to control some vessels, the atory vessels, particular atory vessels, and then we have to go with the instruments on contact with the satic nerve. Here the flexibility of the instruments allows to progress tangentially with the nerve with a minimal manipulation of the nerve. And I imagine that in this case we reduce the risk of edema, postoperative edema and symptoms related to this muscular weakness and neuropathic pain. Now the take home message. So you understood that for me, the robot is a useful tool for advanced endometriosis surgery. Also, numerous colleagues use it as a marketing arguments. And if you have a look at the websites of several surgeon, you can see this image with the surgeon in the front of the robot, which is an argument for the quality of the surgery.
So I don't want to push the argument until saying that we do better. If you see a guy who performed robotic surgery, you may trust him better than a guy who performed a laparoscopic surgery. Using the robot is not a guarantee of a good job. But anyway, it is very useful in six specific indication where I think that the surgery is faster and easier and maybe safer thanks to the quality of the dissection, of the suture of the tree, placement of the nerve preservation. And when I say nerve preservation, of course I don't think about the sacral roots or satic nerve should be preserved because otherwise we have pulses. But I speak about the inferior hypogastric plexus where the injury of very thin nerves may lead to troubles of the bladder and the rectum. However, the learning curve is mandatory for everybody, even for very skilled laparoscopic surgeons.
And it is important to understand that during the first year of the robotic surgery, everything will be more difficult, less satisfactory in robotic surgery than laparoscopy. So it is very important for me to go over this first year in order to benefit from the advantages of the robot. The cost is a grid problem and it is related to each procedure. So the cost is something independent to the usefulness of the robot, and that's why I did not discuss it. And if you want to prove the superiority of the robot versus the laparoscopy, it'll be however very difficult because the laparoscopy is related to very, very good outcomes. So what I suggest is to try to find specific indication where you feel actually much more comfortable with the robot than with the laparoscopy. And of course we have to gather our serious in order to try to propose a randomized trial in very specific indication and to try to prove the superiority of the robot. Thank you very much. It is a pleasure for me to meet you again in Sydney or in Prague for the world Congress of endometriosis for the same meeting. And again, tamer is for me a friend, and I was very pleased to introduce to him my family. And that's why when he invited me to come here, it was obvious for me to answer affirmatively.
