Laparoscopic vs. Robotic Surgery for Endometriosis

Contrary to the common expectation that robotic assistance can improve the outcomes of endometriosis surgery, a study found no evidence it is either superior or inferior to traditional laparoscopic technique.

“Both robotic and laparoscopic surgery improve quality of life and relieve pain when the procedures are done by experts in endometriosis,” says Tommaso Falcone, MD, Chairman, Ob/Gyn & Women’s Health Institute at Cleveland Clinic.

This conclusion is the result of a multicenter, randomized clinical trial comparing the use of traditional laparoscopic surgery with robot assisted surgery in women with endometriosis. The primary outcome was operative time. Secondary outcomes included perioperative complications and quality of life.

No difference in operative time was seen between the two groups. Nor were there differences in blood loss, intraoperative complications, postoperative complications, rates of conversion to laparotomy or quality of life improvement.

Details were published in the April 2017 issue of Fertility & Sterility.

Surgeon’s experience trumps technology

The equality of the two operative techniques did not surprise Dr. Falcone. An experienced endometriosis surgeon, he has co-edited multiple textbooks on robotic and laparoscopic technique. He feels the surgical approach does not matter as much as how well the disease is understood.

“Due to the complex nature of pain in endometriosis, knowledge of the disease process and what the disease looks like in a patient plus familiarity with the anatomy are more important to outcomes than the surgical technique or technology used,” he says.

He admits that robotic surgery has a certain cachet. However, he emphasizes that the technology itself does not improve outcomes.

“If you are a good driver, it’s unlikely that a more expensive car like a Ferrari will make you drive better. It’s the same with surgery,” he says. “The robot isn’t magical.”

Either technique an excellent option

Gynecologists know endometriosis as a chronic, inflammatory, estrogen-dependent disease associated with significant quality-of-life challenges, including pain and infertility, and a substantial economic impact in terms of decreased productivity and health care costs.

Although endometriosis has a high recurrence rate after surgical treatment, the study found surgery was largely successful in relieving pain and restoring quality of life, regardless of the approach used.

Patients in both groups reported significant but equal improvement on condition-specific quality of life outcomes at six weeks and six months, as measured by the Short Form 12 health survey and Endometriosis Health Profile-30 questionnaire.

“We want to reinforce that surgery for endometriosis works,” says Dr. Falcone. “However, the pain associated with endometriosis is complex, and no single technology is going to make a difference in the long run.”

Who might benefit from robotic surgery?

In the era of cost savings, it may be difficult to justify the additional cost of a robotic procedure for the average endometriosis patient. Nevertheless, there are times when robotic technique could be helpful.

“In complex endometriosis cases requiring ureter and bowel resections, the robot could be an advantage,” says Dr. Falcone. “However, in this study we didn’t test it to see if it might add value.”

Nor did the study evaluate whether a robot could increase the level of care provided by surgeons who are less experienced with conventional laparoscopic surgery.

“Our study was not designed to evaluate this. But if an endometriosis surgeon is already skilled in laparoscopic technique, the robot will make no difference,” Dr. Falcone concludes.

Read more about endometriosis from Cleveland Clinic Ob/Gyn & Women’s Health Institute.