The value of laparoscopy and robotic surgery in fertility care

Firstly, we have to evaluate whether it is possible to be fixed. The question is, why do we want to fix them? If we want to fix them and achieve a natural pregnancy, we would have to assess the hormonal status of the female, but also, at least the sperm has to be fairly normal. In general, tubal surgery may not be that effective on any one of advanced reproductive age, and sadly the age of 43 is considered advanced reproductive age. Does it depend on what has caused the blockage? If the blockage is throughout the length of the tube or if the tubes contain fluid, it may not be possible to fix them. I think it’s a very difficult question to be answered.

The answers depend on the evaluation we do on the patient, the patient’s partner, it depends on the expectation the patient has and the availability of IVF and whether the IVF would be accepted or not. For example, if IVF is not accepted for reasons like religion, ethics, or whatever, and if IVF is out of the equation, then, of course, we would strongly consider some surgical approach. Although, it is not always possible, and perhaps the outcome and the results based on age may not be very high.

I do not particularly like the term hostile. I don’t think it’s a medical term, and to be honest, I will be very careful before using this term. I think it’s very difficult to call a uterus hostile, I haven’t met very many hostile uteruses, so I would hope that it’s not that hostile. The uterus consists of two elements. First is the uterine cavity. It can be assessed 100% by hysteroscopy.  Also, with biopsies and some histology tests, genetic tests and microbiology testing. The uterus consists of the wall, which is also very important and can be assessed via ultrasound and sometimes via laparoscopy. The uterus also consists of the connection with the tubes. For example, inflammation of the tubes or hydrosalpinx may affect the environment of the uterus. 

The uterus is a very important organ, it’s a  natural incubator, and it has to be assessed properly. It’s very difficult to call it impossible or very hostile, as you have been told. Some conditions are incurable such as very difficult adhesions or Asherman’s Syndrome or distorting fibroids or diaphragms, and so forth, so that’s about the uterus. You’ve mentioned you had  10 to 12 miscarriages. Miscarriages can be caused by a variety of factors. The uterine condition and the uterine environment may be one of the factors, but they may not be the only factor.

Another huge factor could be the genetics of the embryo and so forth. It sounds like a fairly complicated case, but, in the scope of today’s webinar, fertility endoscopy should be able to establish the condition of the female organs, the uterus,  the ovaries, tubes, the peritoneum, which is the surrounding tissue, and we should be able to diagnose that 100%, and we should be able to optimize it to a certain degree. We can’t fix everything, but we can certainly optimize as much as we can through fertility endoscopy.

There’s no surgery without potential complications, of course, even endoscopic surgery, even clipping your nails may have a potential complication. The advantage of robotic surgery, in my opinion, is that it is a type of surgery that, at the moment in the world, is only in the hands of very experienced surgeons. To become a certified and qualified robotic surgeon invariably, they have to go through very robust training. They have to go through amazing evaluation, evaluation skills, evaluation psychomotor skills evaluation and certification and so forth. Thankfully the company that’s distributing the da Vinci system has put in place very robust systems to ensure that the level of expertise of the robotic surgeon is at the highest level, and of course, you can understand that this is not always the case with a conventional surgeon. 

In various countries, for example, in Europe, with 4 or 5 years of training, one becomes a qualified surgeon, whether it’s a gyno-surgeon or a general surgeon and then following this fellowship or membership, then they are free to operate and sometimes unsupervised. This is not the case with robotic surgery, so for example, anyone can claim that they are very good surgeons just simply because they’re specialists, and they’ve been through four or five years of training, and of course, what happens after the training again depends on the country and the institution and the volume of surgery that each surgeon is managing every day, every week, every year. 

With robotic surgery, everything is very streamlined, so to become a robotic surgeon, you have to be at least in Europe,  I’m not very familiar with the U.S. system, although I understand that robotic surgery in the U.S. system is part of the basic training curriculum, in Europe at the moment robotic surgery is extracurricular. One has to be a specialist to start with. Not only you don’t have such an opportunity to train in robotic surgery, and not only one has to be a specialist and have to be experienced surgeons, and in particular, experienced in laparoscopy, but also to be high volume surgeons. With robotic surgery, you can’t just perform one robotic surgery a year or 5 times a year or 10 times a year and still be fit for the job, it’s more or less like flying to keep your pilot’s licence, you need a minimum of 50 hours a year. I don’t have a pilot’s licence, but I have a lot of friends who have it. That’s why in my opinion, robotic surgery is not that the robot operates, the surgeon operates with the assistance of the robot and what the robot does, it transfers the thought of the surgeon effectively into the operating field. If you ask how I feel when I do body surgery, I feel that the next movement I think of doing is translating into the operating field. Why? Because by using those masters with my fingers, what I see is being delivered through the robotic arms into the surgical field is exactly what I thought of. As opposed to a laparoscopic surgery which is the translation but not quite, it’s not 100% translation of my thought, it’s the translation of my movement, and the movement is a little different to my thoughts. 

There may be potential minor, medium, large complications, in general, the chance of them happening is minimal. The largest complication at the moment should be considered in the surgeon’s minds and the patients’ minds. The laparotomy by itself is a complication that’s why I would like to see laparotomy invalidated, there’s no place for a laparotomy in modern kind of surgery, at least in fertility surgery. When we’re performing a laparotomy without even giving the option to our patients, it’s giving them a complication before we start our procedure. Such complications can be minimized by two main factors. 

One is the surgeon’s experience and the everyday practice of the search. That’s why now in Europe, the majority of surgery is being performed by highly skilled and high volume surgeons. The second factor is the proper use of technology. I would not use the robotic da Vinci system to remove a 4 or 5-centimetre fibroid on any patient. However, I would use it to remove a 4 or 5-centimetre fibroid if this is deep into the myometrium if this is going into the endometrium cavity of the woman and if the woman is obese and if she has been operated on 3 times, and she has adhesions and if she has endometriosis. It’s not the surgeon, it’s not the technology, it’s not the patient it’s the proper surgery performed by a highly skilled surgeon who has all the spectrum of technology available to be applied for the individual patient.

I can’t think of any, to be honest, at the moment. I haven’t refused robotic surgery to anyone. I’m sure that there should be some situations, but there’s no contraindication whatsoever. Until some years ago, if the surgery was needed, laparoscopy was an option for 80-90% of cases. Laparotomy, so open incision for perhaps 10-20% of cases, with complex pathology.

We could always start with laparoscopy, and if that was technically impossible, then convert to open surgery. I can’t think of any particular situations in which we wouldn’t even attempt robotic surgery. However, robotic surgery indeed has the risk of converting into open laparotomy. I can share that we haven’t had this complication yet, I’m sure that it will happen at some stage. There should be some cases in which it may prove impossible, but I can’t think of any on the top of my head at the moment.