Robots and Excision (L.A.P.E.X.) of Endometriosis
When?  Why Not Now?

By Robert B. Albee, Jr., MD, FACOG, ACGE
Medical Director, Center for Endometriosis Care

The currently available robot, referred to as the ‘da Vinci®’, is a wonderful surgical tool that adds an increased degree of instrument control remotely. It has usefulness in many surgical subspecialties, where it adds a degree of exactness to virtually every instrument motion. This has been well demonstrated in the field of urology, where at the time of robotically-assisted radical prostatectomy, nerve sparing is significantly improved.

Although Dr. Sinervo and I have had the basic training in use of the robot, we are not using it at present for compelling reasons. I do, however, expect the majority of the obstacles to be removed over time. Here are some current reasons:

1. LASER ADAPTATION: At present, there is not a carbon dioxide laser adaptation to the robot. Excision of Endometriosis can certainly be accomplished with many different sources of energy; however, in my opinion, there is nothing as versatile as the CO₂ laser.
    
2. CUMBERSOME MOVEMENT OF THE MAIN SUPPORTING EQUIPMENT: Widespread Endometriosis from pelvic sidewall to sidewall and bladder to bowel requires easy movement from one area to the other. The da Vinci® is a large piece of equipment, and often, the entire machine must be moved when a different area is going to be worked on.
    
3. INCREASED TIME: The set-up time for the robot takes longer, even after support staff training is complete. Currently, it is not a quick ‘on and off’ system. This means longer anesthetic and associated risks.
    
4. EXPENSE: The robot is an expensive instrument that adds considerably to the cost of surgery. Since the end result of excision with the robot is not different or better than our laser excision (L.A.P.E.X.), there is really no reason to ask patients to incur such expense.
    
5. EXTRA PORTS: The robot requires at least one - and many times more - extra ports (incisions) in a patient’s abdomen. Most of our surgeries require only three incisions. If we used the da Vinci®, we would need to use four or five ports.  Fewer ports (and often smaller ones), results in much less pain and shorter recovery.

As the manufacturer addresses these issues to our satisfaction, I do think there is a possibility that we will be using the da Vinci® robotic-assisted surgical system in the future, but it is not ready for us at this time.