Understanding Laparoscopic & Robotic Surgery

To understand what a robotic prostatectomy entails, one must learn what laparoscopic surgery is. Laparoscopy literally means “scope in abdomen”, and is a surgical approach that has transformed minimally invasive abdominal surgery in general. Laparoscopy, popularized in the 1990’s, is a style of surgery that is designed to perform abdominal or pelvic surgeries without making large incisions. It accomplishes this through the placement of “ports” into the abdomen through very small incisions. The abdomen is inflated with carbon dioxide using a special needle, a camera is placed through one of these ports to allow visualization, and a wide assortment of instruments is then used through other ports to perform the surgery. The surgeon’s hands are outside the body, and the operation is performed on a video monitor.

A laparoscopic surgery accomplishes the exact same mission as its more invasive, open counterpart. The advantage of laparoscopy is usually better visualization, less blood loss, and strikingly improved recovery times. Laparoscopy has now become the preferred approach to kidney surgery, with or without robotic surgical assistance. In Dr. Engel’s practice, open surgery in the abdomen has become rare, and is reserved for only high risk kidney cases where a patient has only one kidney, particularly large tumors where maximum exposure is needed, or for bladder reconstruction.

However, laparoscopy can be a disadvantage during some surgeries. Laparoscopy can be difficult to master when previously trained to perform only open surgery. And, even when the surgeon is skilled at laparoscopy, it provides only 2-D visualization (which makes depth perception difficult) and its instruments are very limited with regard to what movements they can perform. One way to overcome this is to perform hand-assisted laparoscopy, which Dr. Engel performs regularly during renal (kidney) surgery.

To date, Dr. Engel has performed nearly two thousand robotic surgeries, and since founding the Urologic robotic surgery program at George Washington University Hospital he has seen major advantages and improvements in outcomes as demonstrated in the many scientific papers he has published on the topic.

However, the best way to overcome this would be to design laparoscopic instrumentation that provides 3-D visualization, and uses instruments that mimic the human hand in every way. These two major breakthroughs are what the Da Vinci laparoscopic robotic surgical system provides. With robotic instruments, after significant practice and learning, the surgeon and patient can enjoy the benefits of all the advantages of laparoscopy such as access to tight places like the human pelvis (where hands are too big to fit), perfect visualization with depth perception, less blood loss, and faster recovery, without the visual and manual limitations previously seen with standard laparoscopy.

With robotic surgery, the goal is now to perform an operation not the same but better than could ever be done through a large incision. Robotic surgery not only improves recovery time, but also seeks to improve outcomes. No one should ever think that robotic surgery is magic or that it eliminates the side effects that come with certain surgeries such as prostatectomy. Robotic surgery is just an evolution of technology that currently represents the pinnacle of instrumentation that allows a surgeon to perform surgery laparoscopically in as exact a way as possible. It is just a perfect set of tools for certain surgical tasks, particularly radical prostatectomy.

This video represents an actual Robotic Prostatectomy
Warning, Content is graphic

To date, Dr. Engel has performed nearly two thousand robotic surgeries, and since founding the Urologic robotic surgery program at George Washington University Hospital he has seen major advantages and improvements in outcomes as demonstrated in the many scientific papers he has published on the topic. His complication rate is one of the lowest in the country, as is his positive margin rate.

Through Dr. Engel’s research on erectile dysfunction after prostatectomy, he has shown a significant improvement over the open procedure regarding penile shrinkage after surgery (there is less in Dr. Engel’s series), and at least equivalent but probably better sexual outcomes when compared to the open approach. As has been known for some time, recovery time has also been drastically improved as well as other outcome parameters. If interested in learning more, please see Dr. Engel’s bibliography.