Minimally invasive surgery may be performed in most instances whether or not a woman has mild, moderate or severe endometriosis. Endometriosis is a chronic condition for which patients are likely to require more than one surgical intervention during their lifetime; hence, minimally invasive options that decrease the chance of complications not only for the current but also for possible future surgeries should be considered. Moreover, invasive open surgery is associated with pelvic adhesions at a rate that is much greater than that of minimally invasive surgery. Adhesions involving the female pelvic organs have been associated with infertility. Since nearly all women suffering from endometriosis are of reproductive age, adhesion prevention is a serious consideration.
Endometriosis in almost all of its forms, is one of the most challenging surgical conditions. From scattered endometrial lesions or implants in the pelvic cavity, to deep infiltrative nodules or deep ovarian cysts, to the dreaded “frozen pelvis” (a major alteration of pelvic anatomy caused by severe spontaneous or surgically induced adhesions), endometriosis can challenge even the most skilled minimally invasive surgeon. This is because both open (invasive) surgery and laparoscopic (minimally invasive) gynecologic surgery have limitations. The main sensory limitation of laparoscopy is the loss of our natural three-dimensional vision. The surgeon must look into a surgical instrument called a laparoscope to visualize lesions in the pelvic cavity. Mechanical limitations can be simply explained by considering the small size of the incision (in the abdominal wall), that the instruments(s) must enter. These sensory and mechanical limitations make minimally invasive surgery techniques more difficult to master compared to open surgery or laparoscopy (when a much longer cut is made to view the pelvic cavity).
New technology combining the practical usefulness of open (invasive) surgery and the minimal invasiveness of laparoscopic surgery is now an option at some large hospitals. The FDA has approved the use of robotic computer assisted surgery for gynecologic surgery. A team of specially trained gynecological surgeons at the Center for Infertility and Reproductive Surgery at the Brigham and Women’s Hospital have pioneered this technique to preserve fertility in women with endometriosis and performed over 600 complex gynecologic operations to date. Of note, none of the procedures required additional invasive surgery. Computer-assisted laparoscopic surgery can be performed using the “Da Vinci Surgical System.” This system is designed to overcome most of the sensory and mechanical limitations that come with both laparoscopy or laparotomy. Using this unique system, the surgeon guides the movements of a robotic device from a master console where floating hand controls allow intuitive upper limb movements that send signals to the robotic arms and instruments connected to them so they can move. Results have shown that surgical ergonomics as well as the surgeon’s ability to perform complex laparoscopic routines are much improved with this type if procedure. Additionally, robotic surgery takes less time than other procedures.
Robotic surgery has many uses particularly in the treatment of endometriosis despite limited scientific reports to date. Lack of research is likely due to the fact that only a few advanced robotic surgical teams have gained the technical expertise necessary to effectively and safely treat complex endometriosis using this new tool. Safe robotic removal of deep infiltrating endometriosis as well as endometriosis of the bowel, bladder and ureters has been described in medical journals. The team at the Brigham and Women’s Hospital’s Center for Infertility and Reproductive Surgery has published reports on the new use of special flexible microfibers carrying laser energy to the most difficult to get to areas of the pelvis to allow the removal of endometriosis with essentially no damage to the health tissue surround the lesions.
Future developments of computer-assisted surgery are still hard to predict but are likely to include further procedures that will be considered even less invasive (ultra-minimally invasive surgery) as well as the use of new light sources (such as UV light in association with luminescent biomarkers) that will help to further identify peritoneal and even deep infiltrating or uterine endometriosis from healthy surrounding tissue.
The Boston Center for Endometriosis is a world leader in robotic applications of reproductive surgery, including endometriosis surgery.
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