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Robot-assisted laparoscopy for benign uterine disease. Feasibility, outcome and hospital cost.

Aardal Lönnerfors, Celine LU (2015) In Lund University, Faculty of Medicine Doctoral Dissertation Series 139.
Abstract
The introduction of the laparoscope was a milestone within gynecologic surgery. Despite evidence of better

perioperative outcome compared to laparotomy, laparoscopy is mostly performed for less advanced surgical

procedures and the uptake of laparoscopic hysterectomy has been slow. An effort to preserve the clinical benefits

of laparoscopic surgery and facilitate the performance of more advanced surgery has led to the development of

robot-assisted laparoscopic surgery. Technical progress has been advantageous for the patient from a historical

point of view, but this cannot be assumed without proper evaluation. As for all surgical approaches, it is important

to recognize the possible... (More)
The introduction of the laparoscope was a milestone within gynecologic surgery. Despite evidence of better

perioperative outcome compared to laparotomy, laparoscopy is mostly performed for less advanced surgical

procedures and the uptake of laparoscopic hysterectomy has been slow. An effort to preserve the clinical benefits

of laparoscopic surgery and facilitate the performance of more advanced surgery has led to the development of

robot-assisted laparoscopic surgery. Technical progress has been advantageous for the patient from a historical

point of view, but this cannot be assumed without proper evaluation. As for all surgical approaches, it is important

to recognize the possible applications of robotic surgery as well as proper patient selection both from a clinical and

economical point of view. The overall aim of this thesis was to investigate the possible applications, clinical

outcome and hospital cost of robot-assisted laparoscopic surgery for benign uterine disease at a single institution

following the introduction of robotic surgery.

Study I: Evaluating the first 1000 robotic surgeries performed showed that a surgical robot provides the possibility

to offer minimally invasive surgery to a larger patient population with low rates of conversions and intraoperative

complications. Study II: 31 women with symptomatic, deep intramural myomas and either otherwise unexplained

infertility or myomas with a possible effect on conception had a pregnancy rate following robotic myomectomy of

68%. Study III: All women (n=114) with a BMI ≥ 30 kg/m2 who underwent a simple hysterectomy by robotics or

laparotomy during the study period were included. Robot-assisted laparoscopic hysterectomy in obese women was

associated with shorter hospital stay, less bleeding, and fewer complications and longer operative time compared

to laparotomy although the operative times for morbidly obese women were similar between robotics and

laparotomy. Study IV: 122 women planned for minimally invasive hysterectomy for benign disease were

randomly allocated to either robot-assisted- or traditional, minimally invasive hysterectomy in a 1:1 proportion

with vaginal hysterectomy as a primary choice in the latter. From the perspective of hospital costs, robotic-assisted

hysterectomy is not advantageous for treating non-complex benign conditions when a vaginal approach is feasible

in a high proportion of patients. A similar hospital cost is attainable for laparoscopy and robotics when the robot is

a preexisting investment. Study V: Complication rates in 949 women planned for robotic hysterectomy for

malignant (75%) and benign (25%) gynecological disease over an 8-year period with special awareness of

complications possibly related to robot specific risk factors. Intraoperative- and postoperative complications and

complications possibly related to the robotic approach diminish with training, experience and refinement of

practice. Study VI: All women (n=483) undergoing hysterectomy for benign disease during 2013 and 2014.

Vaginal hysterectomy was associated with the lowest hospital cost and robotic hysterectomy with the lowest rate of perioperative complications. Procedure-specific proficiency influences outcome. Robotic hysterectomy for

benign disease is clinically advantageous and economically feasible in complex cases, when performed by high

volume surgeons. (Less)
Please use this url to cite or link to this publication:
author
supervisor
opponent
  • Professor Mäkinen, Juha, Turku University Hospital, Finland
organization
publishing date
type
Thesis
publication status
published
subject
keywords
hysterectomy, myomectomy, robotic surgery, complications, outcome, hospital cost
in
Lund University, Faculty of Medicine Doctoral Dissertation Series
volume
139
pages
72 pages
publisher
Department of Obstetrics and Gynecology, Lund University
defense location
Department of Obstetrics and Gynecology, SUS, Lund
defense date
2015-12-11 09:00
ISSN
1652-8220
ISBN
978-91-7619-219-1
language
English
LU publication?
yes
id
368a7b68-e04e-49b6-a47b-79e49ed812f4 (old id 8170931)
date added to LUP
2015-11-18 08:37:21
date last changed
2016-09-19 08:44:46
@phdthesis{368a7b68-e04e-49b6-a47b-79e49ed812f4,
  abstract     = {The introduction of the laparoscope was a milestone within gynecologic surgery. Despite evidence of better<br/><br>
perioperative outcome compared to laparotomy, laparoscopy is mostly performed for less advanced surgical<br/><br>
procedures and the uptake of laparoscopic hysterectomy has been slow. An effort to preserve the clinical benefits<br/><br>
of laparoscopic surgery and facilitate the performance of more advanced surgery has led to the development of<br/><br>
robot-assisted laparoscopic surgery. Technical progress has been advantageous for the patient from a historical<br/><br>
point of view, but this cannot be assumed without proper evaluation. As for all surgical approaches, it is important<br/><br>
to recognize the possible applications of robotic surgery as well as proper patient selection both from a clinical and<br/><br>
economical point of view. The overall aim of this thesis was to investigate the possible applications, clinical<br/><br>
outcome and hospital cost of robot-assisted laparoscopic surgery for benign uterine disease at a single institution<br/><br>
following the introduction of robotic surgery.<br/><br>
Study I: Evaluating the first 1000 robotic surgeries performed showed that a surgical robot provides the possibility<br/><br>
to offer minimally invasive surgery to a larger patient population with low rates of conversions and intraoperative<br/><br>
complications. Study II: 31 women with symptomatic, deep intramural myomas and either otherwise unexplained<br/><br>
infertility or myomas with a possible effect on conception had a pregnancy rate following robotic myomectomy of<br/><br>
68%. Study III: All women (n=114) with a BMI ≥ 30 kg/m2 who underwent a simple hysterectomy by robotics or<br/><br>
laparotomy during the study period were included. Robot-assisted laparoscopic hysterectomy in obese women was<br/><br>
associated with shorter hospital stay, less bleeding, and fewer complications and longer operative time compared<br/><br>
to laparotomy although the operative times for morbidly obese women were similar between robotics and<br/><br>
laparotomy. Study IV: 122 women planned for minimally invasive hysterectomy for benign disease were<br/><br>
randomly allocated to either robot-assisted- or traditional, minimally invasive hysterectomy in a 1:1 proportion<br/><br>
with vaginal hysterectomy as a primary choice in the latter. From the perspective of hospital costs, robotic-assisted<br/><br>
hysterectomy is not advantageous for treating non-complex benign conditions when a vaginal approach is feasible<br/><br>
in a high proportion of patients. A similar hospital cost is attainable for laparoscopy and robotics when the robot is<br/><br>
a preexisting investment. Study V: Complication rates in 949 women planned for robotic hysterectomy for<br/><br>
malignant (75%) and benign (25%) gynecological disease over an 8-year period with special awareness of<br/><br>
complications possibly related to robot specific risk factors. Intraoperative- and postoperative complications and<br/><br>
complications possibly related to the robotic approach diminish with training, experience and refinement of<br/><br>
practice. Study VI: All women (n=483) undergoing hysterectomy for benign disease during 2013 and 2014.<br/><br>
Vaginal hysterectomy was associated with the lowest hospital cost and robotic hysterectomy with the lowest rate of perioperative complications. Procedure-specific proficiency influences outcome. Robotic hysterectomy for<br/><br>
benign disease is clinically advantageous and economically feasible in complex cases, when performed by high<br/><br>
volume surgeons.},
  author       = {Aardal Lönnerfors, Celine},
  isbn         = {978-91-7619-219-1},
  issn         = {1652-8220},
  keyword      = {hysterectomy,myomectomy,robotic surgery,complications,outcome,hospital cost},
  language     = {eng},
  pages        = {72},
  publisher    = {Department of Obstetrics and Gynecology, Lund University},
  school       = {Lund University},
  series       = {Lund University, Faculty of Medicine Doctoral Dissertation Series},
  title        = {Robot-assisted laparoscopy for benign uterine disease. Feasibility, outcome and hospital cost.},
  volume       = {139},
  year         = {2015},
}