What’s New in Gynecologic Surgery?

Giving more patients access to the benefits of robotic-assisted surgery is driving improvements on all fronts, including patient recovery and streamlined care in one outpatient space.

Two trends have remained steady in gynecologic surgery.

First, surgeons are more frequently choosing robotic-assisted approaches to offer their patients less post-op pain and faster recoveries. Second, patients and surgeons are preferring the outpatient setting for many routine procedures such as hysterectomy and ovarian cystectomies. The obvious setbacks of putting a large, million-dollar robot in an outpatient facility have made it difficult for many freestanding centers to provide robotic-assisted gynecologic care. However, some larger healthcare organizations have been able to construct freestanding specialty centers with robotic surgical technology that offer the best of both worlds, and a model for others to consider.

Take the new multispecialty freestanding Joseph S. & Diane H. Steinberg Ambulatory Care Center — Cobble Hill in Brooklyn, N.Y. This extension of NYU Langone Health’s hospital in Manhattan opened in March to provide the Brooklyn community better access to care and treatment — including robot-assisted gynecologic surgery.

Increasing access to care

NYU Langone’s new Cobble Hill Ambulatory Care Center (ACC) houses physicians’ offices, and provides radiology and imaging, cancer care, emergency care and surgical care. It also includes a state-of-the-art surgical robotic operating room, explains Perioperative Services Surgical Director and Gynecologic Surgeon Kathy Huang, MD. Dr. Huang is one of the highest-volume gynecologic robotic surgeons in the country, having performed more than 3,000 such surgeries. She is well-known for her robotic-assisted approaches to treat endometriosis and preserve fertility, as well as many other procedures such as hysterectomy.

The comprehensive care she can now offer her patients is unparalleled and a very exciting development, she says. “My patients can see me in clinic, get an MRI or other imaging I order for them and, if needed, undergo robotic-assisted surgery all in the same building.” Previously her patients needed to make multiple trips into Manhattan for these different appointments.

Dr. Huang approached the planning for Cobble Hill’s robotic surgical suite wearing both hats — as gynecologic robotic surgeon and surgical director of perioperative services. “We wanted a space that offered surgeons and our robotic perioperative team everything they are accustomed to in the main hospital to optimize patient care,” she says. Creating such a space required careful planning, including structural details to house the robot and logistical details such as exercises in collaboration with the ACC’s emergency department.

Building the strongest team

Team training for Cobble Hill robotic surgery staff was another critical piece of planning for the ACC. This included close mentoring from Dr. Huang’s team of very experienced robotic surgery nurses, surgical techs and other team members from the NYU Langone Manhattan hospital who have performed more than 30,000 robotic surgeries.

Training began six weeks before the new ACC opened to give the mentors time to teach the new outpatient staff at the main hospital. Once the new ACC opened, the training transitioned into mentee precepting. During this precepting the robotic surgical team huddled after each case to discuss the outpatient robotic team’s confidence and competency. “Our ultimate goal has been to transfer the same level of care we offer at the main campus in this new outpatient setting . We are achieving this.”

Looking ahead, Dr. Huang is considering new opportunities to leverage virtual reality education that can help more surgeons and their teams train on robotic-assisted procedures. Offering robotic surgery learning in simulation could, in turn, create new opportunities for patients to access the benefits of robotic-assisted gynecologic surgery.

Improving surgeon satisfaction

The Cobble Hill ACC is proving a preferred space for surgeons to operate. Dr. Huang recently received an unsolicited kudo from a surgeon who praised every aspect of operating at Cobble Hill, from the amazing lighting and setup in the robotic surgical suite to the perioperative team that facilitated a positive, safe, high-quality experience for her patient.

My patients can see me in clinic, get an MRI or other imaging I order for them and, if needed, undergo robotic-assisted surgery all in the same building.
Kathy Huang, MD

For Dr. Huang, meeting the needs of what technologies will evolve and what surgeons need from the technology was integral to planning the ACC. “We are optimizing for safety, quality and efficiency of the surgical care we deliver as well as the experience for the patient and the entire perioperative team,” she says.

Optimizing recovery

Bruce Kahn, MD, FACOG, FACS, also advocates a robotic-assisted approach for many gynecologic procedures. Dr. Kahn is a gynecologic surgeon at Scripps Health in La Jolla, Calif., and director of the Scripps Fellowship in Minimally Invasive Gynecologic Surgery.

As one of the first surgeons in the region to offer laparoscopic hysterectomy, Dr. Kahn now performs most hysterectomies on a minimally invasive, outpatient basis. He also leads research on new procedures and treatments to reduce pelvic pain and improve gynecologic care, including treatments for pelvic organ prolapse, urinary incontinence and endometriosis.

Robotic technology plays a key role in the care he provides as part of Enhanced Recovery After Surgery (ERAS) protocols. A minimally invasive approach for gynecologic surgery is recommended as part of ERAS to optimize patient care on many fronts, Dr. Kahn explains. These benefits include reduced blood loss during surgery, and decreased pain and narcotic use after surgery, which promotes earlier mobilization and return of bowel function.

While ERAS for gynecologic surgical procedures is not practiced across all health settings, Dr. Kahn says research has consistently identified how ERAS can help gynecologic patients achieve better outcomes, including safe, same-day discharge.

Planning ahead

GROWTH OPPORTUNITY Teaching robotic surgery using simulations allows new staff to become proficient on the technology quickly.

Dr. Kahn and Dr. Huang are closely investigating new technologies they can incorporate into surgical practice. Both established and emerging surgical robot manufacturers are developing new technologies to meet the different needs of surgeons, including robots with more sensitive haptics and machine learning. Meanwhile, some surgical robot manufacturers are developing smaller platforms that could come with smaller price tags, Dr. Kahn notes.

Dr. Kahn recognizes one of the major challenges in bringing robotic surgery to any facility is the size of existing operating rooms. “Current state-of-the-art surgical robots require a large footprint with enough space for a team to work comfortably and safely for the patient,” says Dr. Kahn. “Many existing facilities in hospitals and surgery centers are too small for existing platforms.” However, he predicts new robotic platforms will “likely make the technology available to more hospitals and more patients.”

Dr. Huang and her colleagues are looking at all robotic platforms and are carefully investigating all emerging technologies. Any new technology must allow her and her surgical teams to give patients the best outcomes in order to be successful. Equally important, she needs to understand how this technology can be adapted into day-to-day surgical practice.

While technology advances will drive the market, Dr. Kahn and Dr. Huang agree that it takes more to treat the whole gynecologic patient. They say surgeon expertise, team training in the safe and efficient use of the equipment and focusing on providing comprehensive care will be what ultimately drives the evolution of robotic gynecologic surgery. OSM.