Obesity and robotic-assisted surgery (RAS)

Dr Anna Fagotti, Director of the Ovarian Cancer Unit at Polyclinico Gemelli, President-elect of the European Society of Gynecological Oncology, Associate Editor of the International Journal of Gynecologic Cancer and Scientific Editor of the European Society of Gynecological Oncology shared some of her insights about the challenges of surgically treating obese patients and how she uses robotic-assisted surgery (RAS) to overcome some of those challenges. 

What is your vision and how are you impacting your patients’ surgery?

My goal is always to help patients. It’s why I became a doctor.  I’m a doctor and a surgeon first, so I treat the problem at hand. I am also very committed to supporting research, science, and education for how to better treat and support my gynecological patients.

My vision is really about how to improve care for women–how to treat them in the best way, ideally less invasively and more efficiently. I think that any way we can be less aggressive, while maintaining efficacy should be a goal for all of us.

What are some of the challenges you see when treating patients who are obese? 

If I compare my activity today to the same activity 20 years ago, more and more of our patients are obese with endometrial issues. Often these patients have other problems, as well. So, when we treat them, those additional problems bring a whole set of specific challenges.

One of the surgical challenges we encounter when a patient is obese is gaining access to the abdominal cavity and the pelvis. It is also difficult to perform some gynecological surgeries which require more manipulation, often causing more bleeding. 

In terms of post-operative challenges related to obesity, we tend to see more surgical site infections, both deep and superficial. 

What are some the key considerations when thinking about a laparoscopic approach for obese patients?

Performing endoscopic procedures present some significant challenges for the surgeon. One of the problems is that we don’t have the same tactile feel or the three-dimensional vision that we have with an open procedure. Also, removing some types of tissue by laparoscopy can be a challenge due to the time needed to gain access to the abdomen. 

There are also some difficult ergonomic challenges for the surgeon. We use a pelvic trocar which requires the right shoulder raised up in a very uncomfortable position. After doing this for years, I have developed a condition called “frozen shoulder” caused by continually being in this position. 

How can robotic-assisted surgery help solve these challenges? 

One of the big advantages of robotic surgery versus endoscopic is vision. The quality of imaging has improved so much in the 20 years since I first started doing robotic procedures. 

I also prefer controlling the camera myself. With endoscopic procedures I must rely on an assistant to do it for me. Early in my career, the surgeon I assisted told me ‘You are my eyes. If you don’t follow me, I cannot do surgery.’  With robotics, I have control of my own ‘eyes.’ I think this is a great advantage of robotic-assisted surgery over laparoscopy. 

Another advantage of RAS is the articulation of the instruments instead of using straight laparoscopic instruments. It makes the procedure easier and safer, and allows me to be more radical, achieving clear margins with less manipulation.

What challenges still exist with current robotic systems and what do you think would be helpful in future robotic systems? 

For the hospital, the main challenge is still cost – both the cost of purchasing the system, but also per procedure costs, such as the lack of reusable instruments. 

I think that to be able to use a robotics platform in the best way possible, it would be important to have smaller or modular parts in the future.

Do you have any closing thoughts?

I think that technology is our friend, not our enemy. So, we need to use technology as much as possible in order to achieve the best results for our patients, first of all, and then for surgeons, too. And by making robotic-assisted surgery more accessible, by removing cost barriers and making the technology more flexible, I believe this will be possible.