In this webinar, Dr Elias Tsakos, FRCOG, Medical Director at EmbryoClinic, Thessaloniki, Greece, discussed laparoscopy and robotic surgery, diagnosis, indications and how it can increase chances of pregnancy.
Fertility endoscopy refers to hysteroscopy and laparoscopy. Hysteroscopy is the endoscopic assessment of the uterine cavity while, Laparoscopy, on the other hand, involves the examination of the abdominal cavity, particularly focusing on the internal pelvic organs in gynaecological cases.
Laparoscopy can be either conventional, utilizing traditional technology including cameras, instruments, and optics, or it can involve Da Vinci Robotic Laparoscopic surgery, which integrates robotic technology into the conventional laparoscopic approach. It has largely been replaced by endoscopy, which is more technologically advanced and polite.
Endoscopy entails smaller or even no incisions, making it more beneficial for patients compared to traditional methods such as laparoscopy and robotic surgery, which still necessitate tiny incisions.
This method is utilized to assess the female reproductive organs and system. Unlike male organs, which are predominantly external and easily examined, female anatomy comprises internal genital organs. These include the cervix, the uterine lining, ovaries, and fallopian tubes. Additionally, there is a layer of tissue surrounding these internal organs known as the peritoneum.
Indications for Fertility Endoscopy:
Nearly all fertility patients could potentially benefit from fertility endoscopy. It is suggested to consider the option of fertility endoscopy: for:
However, it’s important to note that laparoscopy isn’t always necessary for fertility patients.
The laparotomy refers to an open incision surgery, which was replaced by laparoscopy in the last 30 years.
However, fibroids are usually removed by laparotomy in fertility patients, which is detrimental because it not only causes pain, bleeding, scars, and prolonged hospitalization but may also impair fertility by creating adhesions. The decision to use this technique depends on the nature of the endometriosis and the patient’s medical history.
It is estimated that perhaps 20 or 30% of surgeries are still performed by laparotomy, which should be replaced entirely by laparoscopy and robotic surgery.
Laparoscopy is a minimally invasive operation through tiny incisions, traditionally through the belly button, in which a camera is inserted into the instruments. In most cases, it is possible to perform it on an outpatient basis. The patient is discharged within 24 hours, and the recovery at home is very rapid, as well as the return to normal activities.
Indications:
Therefore, the indications for virtually any fertility surgery could be carried out using laparoscopy, whether traditional or robot-assisted.
The main indications include:
Here we can observe the advantages of laparoscopy over laparotomy.
Limitations of conventional laparoscopy encompass several factors:
It poses a significant challenge for laparoscopic surgeons with over 20 years of experience, often leading to tendon problems or arthritis in the shoulder and wrist due to the ergonomic strain of daily complex surgeries. This not only affects surgical efficiency, but is also unfair to patients, particularly those scheduled later in the day. These limitations have been addressed over the past two decades, leading to the advancement of robotic surgery technology.
The fourth generation of robotics, exemplified by the latest da Vinci system, has become accessible in recent years.
The Da Vinci system presents a multitude of advantages and mitigates the drawbacks of conventional laparoscopic surgery for both male and female reproductive procedures. Specifically in the realm of female reproductive surgeries, the da Vinci system finds application in the treatment of endometriosis.
The advantages of the da Vinci system are significant: it offers magnification of the field, 3D imaging, high definition, and a stable camera. These features create an ideal environment for the surgeon, alleviating much of the fatigue caused by a moving image, especially in challenging and high-volume cases. With the da Vinci system, complex surgeries and microsurgical procedures can be performed with confidence, thanks to the highest technology available. Additionally, the system helps reduce potential complications, eliminating the need for an experienced assistant.
There are indeed some disadvantages of the da Vinci system. One of them is its initial cost, although this can be outweighed by considering factors such as the complication rate, pain rate, and the quick return to normal activities experienced by patients. Additionally, the minimal chance of conversion to open surgery, which is typically considered a complication by default, should also be considered.
Minimal access to surgical application’s hysterectomy:
Endometriosis is highly prevalent in the general population, affecting approximately 50%, or 1 in 2, of infertile women. It can be a debilitating condition with varying stages and consequences. Treatment often involves a combination of approaches, including surgery.
Symptoms:
Treatment:
It is a very complex algorithm, but the surgical approach plays a central and crucial role in the management of endometriosis. Modern surgical techniques typically involve laparoscopy and robotics.
Clearly, it is a very complex algorithm, but the surgical approach plays a central and crucial role in the management of endometriosis. Modern surgical techniques typically involve laparoscopy and robotics.
The actual guidelines underscore the limited efficacy of medical treatments, especially for endometriosis, particularly for those seeking fertility. Instead, proper fertility surgery, such as excision of the endometrioma capsule, is emphasized. This procedure is delicate and challenging, especially in cases of complex anatomy or prior surgeries. Preservation of every follicle on affected ovaries is crucial, often necessitating laparoscopic or robotic surgery to refine techniques.
Tubal adhesions are caused by infection, which can lead to potential damage to the tubes. To a certain degree, they can be managed, treated, improved, or even sometimes cured through surgery. This surgery can be performed using either conventional laparoscopy or robotic surgery.
Hydrosalpinx represents the extreme of tubal damage, where the tube becomes bloated and completely damaged by inflammation, often resulting in the formation of a cyst. This condition is a reservoir of inflammatory factors and requires accurate diagnosis, typically achieved through laparoscopy, which is considered the gold standard. Treatment may be attempted, but success isn’t guaranteed. In cases where surgical repair isn’t feasible, the damaged tube may need to be removed. In such instances, assisted reproductive techniques like in vitro fertilization (IVF) with embryo transfer become necessary to bypass the damaged tube.
Myomas, or fibroids, become more common with advanced female age, especially in women older than 40. The decision to treat them depends on various factors such as size, impact on the uterine lining, and other characteristics, which are typically assessed through procedures like hysteroscopy or laparoscopy. Large fibroids can have a detrimental effect on fertility and may require surgical removal.
However, there’s some controversy regarding the management of small fibroids, and sometimes observation without intervention is preferable. Large fibroids often need to be removed as they can significantly affect fertility. The primary goal is to remove the fibroids while preserving the uterus.
Unfortunately, many women worldwide have undergone hysterectomy due to fibroid surgery, which eliminates their chance of fertility.
Therefore, our focus is on removing fibroids using the best possible methods to reduce pain, bleeding, and potential complications, ultimately aiming to preserve the uterus for a healthy pregnancy and delivery. This can be a significant challenge, especially when dealing with multiple large fibroids.
Tubal Re-anastomosis is indeed a growing trend, with robotic surgery playing a significant role.
Thousands of women worldwide, especially in the Western world, have undergone tubal sterilization. When they seek reversal, the primary option typically offered has been in vitro fertilization (IVF) with robotic surgery.
These women now have a better option. Here, you can see the initial robotic system developed more than 20 years ago compared to the modern da Vinci system.
Tubal Re-anastomosis is poised to become a valid option, with robotic technology expected to yield very good results. Naturally, there are specific criteria that patients must meet before attempting tubal anastomosis. Currently, thousands of women in the UK, US, and Europe who have undergone tubal ligation may now have another valid option: surgical correction without resorting to IVF.
The first robotic anastomosis was performed over 20 years ago since then, advancements in technology and knowledge have led to improved results. The introduction of the amazing new da Vinci one-stitch technique, successfully implemented about seven years ago with the previous generation system, represents a significant leap forward. With this technique and the latest da Vinci system, we now have even better technology to perform tubal anastomosis with fairly good results, which are comparable with IVF.
Reversal vasectomy, a fertility surgery procedure, may also benefit from robotic technology for men who wish to have more children. At present, it is estimated that around 50 million men worldwide have undergone sterilization via vasectomy. In the United States, statistics indicate approximately half a million vasectomies are performed annually, with around 11% of married men opting for vasectomy. Considering the 50% divorce rate, one can calculate the staggering number of sterilized men. An interesting piece of statistics from the UK is that male sterilization, often referred to as ‘the snip,’ has become more common than female sterilization (tubal ligation) over the last 20 years. This trend is an interesting piece of information.
Robotics are applied in myomectomy procedures because they offer greater confidence in removing fibroids with precision. When stitching the uterus back together, robotic technology ensures excellent repair, allowing women to pursue natural or assisted conception with confidence.
Robotic myomectomy is expected to replace conventional laparoscopic myomectomy, despite the impressive results achieved by some highly experienced laparoscopic surgeons. Robotics are here to stay, and even for experienced laparoscopic surgeons, they offer a superior tool for delivering optimal outcomes to patients.
In fertility surgery, there’s a highly specialized section representing a significant challenge, involving fertility-sparing surgery for oncology cases. Here, robotics can be immensely valuable, offering women who have survived cancer the opportunity to conceive naturally or with assistance in the future.
Another emerging area is ovarian tissue transplantation for various indications, which has been successfully performed and published robotically in recent years. This advancement opens new possibilities for patients.
In addition, uterine transplantation, alongside ovarian tissue transplantation, holds promise for women who have lost their uterus or were born without one to conceive and experience pregnancy. There’s immense potential for improvement with robotics in this field in the future.
In conclusion, fertility endoscopy plays a crucial role, with both IVF and fertility surgery offering avenues for conception. Tubal anastomosis is gaining popularity with the advancements in robotic technology, opening new possibilities for patients. Productive fertility specialists play a vital role in offering these options to patients, ensuring comprehensive care.
When it comes to robotics, it’s important to note that robotics isn’t here to compete with laparoscopy but rather to supplement it. Conventional laparoscopic surgery has its limitations, including the skills of the surgeon and challenges with difficult patients, obesity, complex pathologies, and prior surgeries. Robotic technology provides significant potential for improving infertility treatment and is becoming increasingly prevalent worldwide. While robotic surgery won’t replace conventional laparoscopy, it will complement it, particularly for complex and challenging cases.
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.
