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Lund
Högteknologisk gynekologisk
kirurgi, var går gränsen?
Skall vi följa med och hur?
Jan Persson
Docent Överläkare
Kvinnokliniken Lund
Population 9.5 milj
Area 450 000 sqkm
6 health regions 0.89-2.15 milj
Free health care system
No private clinics
Health care cost 8,5% of BNP
Centralized gyneoncological
surgery
Map of Sweden
Jan Persson
1900 km
north to south
Da Vinci robot
Germany: (82milj)
Several private and public
care givers
<1 gynerobot / 10 miljon
UK: (62 milj)
More centralized gyneonc
surgery, health system requiring
proof of superiority
< 1 gynerobot /10 miljon
France: (65 milj)
Tradition of advanced trad
laparoscopy, different
care givers
~ 1 gynerobot / 5 miljon
Scandinavia (26milj)
Gyne-oncology centralized
to University hospitals
No private hospitals
1 gynerobot / 1 miljon
A
B
C
D
A+B= Da Vinci Standard
Oct 2005
1,5 days/week
60-80 cases a year
B+C= Da Vinci S
April 2007
2,5 days / week
150-175 cases a year
C+D= Da Vinci SI
June 2010
5 days a week
350-400 cases a year Jan Persson
Access to robot for
gynecological surgery in Lund
Technique, time
Logistics
Consolidation, expanded
indications
0
50
100
150
200
250
300
350
400
450 Radical hysterectomy +/- adnex +/-
nervesparing
Onc.simple hyst +/- adnex
pelvic LND +/- SN
Paraaortic LND
Resection of omentum
Transposition of ovaries
Abdominal cerclage
Removal of bulky nodes pre rad
Vaginal cuff recurrence
cx/parametrectomy
Removal pelvic sidewall tumor pre
rad
trachelectomy / fertility sparing
radical removal of lymphocyst
interval surgery/ ovarian ca
Pelvic exenteration
Robotic procedures for
malignancies
Robotic procedures for benign
disorders
0
20
40
60
80
100
120
140
160
180Simple hysterectomy +/- adnex
Enucleation of myomas
Resection av vaginal cuff
endometriosis
Resection of endometriomas
Suture of post cesarean
dehiscense
hemihysterectomy/ malformation
Scar pregnancy
Vaginosacropexia
Cerclage during pregnacy
Cervical pregnancy
Retroperitoneal ectopic preg
Surgery during pregnancy
Transvesical removal of mesh
Why use the robot!
Ergonomy / visualization / magnification / FULL FOCUS
Potential of better surgery- only after substantional time
Potential of quicker surgery- Only selected index cases
Increase proportion of women operated with a minimally invasive
technique
Jan Persson 2011
The role for robotic surgery depends on:
Case load of index procedures !!
Gyneocology only / mixed gyne unit
Economic / health system prerequisite
Previous laparoscopic experience
Access to robot / model of robot
Early- or experienced robotic phase
In general…
The more advanced
the procedure
The more
robot assistance
is motivated
Gynecological oncology
Index procedures ( complex enough to motivate robot assistance )
Hysterectomy +-nodal staging for endometrial ca
Radical hysterectomy for cervical cancer
Staging/restaging for early ovarian cancer
Nodal staging advanced cervical ca
Rob. Trachelectomy
Rare advanced cases in recurrent cancer
Potential nr onc index cases / 1 milj population
Cx cancer
50/year
50% suitable for robotic surgery
=25 cases a year
Endometrial cancer
140/year
80-85 % suitable for robotic surgery
=110 cases a year
Ovarian cancer
100/year
15% suitable for robotic surgery
= 15 cases a year
Total onc index cases a year / 1 milj population base
150 cases
Benign gynecology
Index procedures ( complex enough to motivate robot assistance)
Complex Hysterectomy (endometriosis, adhesions)
Various gyne procedures in morbidly obese
Deep infiltrating endometriosis
Selected myomectomies
Surgery during pregnancy
Malformation surgery
Various rare advanced procedures/prolapse
Varför INTE robot Hög investeringkostnad (16-20 miljoner SEK)
Hög årlig underhållskostnad (1.2-1.4 miljoner SEK /år)
Instrumentkostnad (10-13 000 SEK/operation)
Längre bytestider ( operationstider)
Ny inlärningskurva för TEAMET
Nytt spektrum av komplikationer,
spec första åren
Jan Persson 2011
Individual learning curve
Institutional learning curve
Requirements for a successful robotic program
>350-400 procedures/ year/ robot economy
Minimum 50 procedures / surgeon/year quality/economy
Minimum 200 procedures/ year/ speciality quality/economy/logistics
Robotteam 3-4 surgeons
3-5 OR nurses + 3-5 circulating
nurses / team
Dedicated anesthesia teams
Jan Persson aug 12
Årlig volym av 400 op
Avskrivning 7 år
Sparsamhet med instrument
Merkostnaden för en (1) robotoperation (ca 20 000SEK)
Motsvarar cirka 2 timmars opsalsanvändning
eller
5 dagars vårdtid
Det är bara vid traditionell öppna operationer med mycket
långa operationstider och/eller lång vårdtid där det teoretiskt
finns chans att få ekonomi vid övergång till robotkirurgi
ENDAST
under förutsättning att den årliga volymen av ingrepp som
motiverar robot är stor !!!!
Jan Persson aug 12
Ekonomi vid robotkirurgi
Kompenserar en robot ett litet patientunderlag?
Är robot en rättvisefråga mellan sjukhus och
doktorer?
Vilka är bevekelsegrunderna för lobbying för
operationsrobotar?
Är marknadsföringen vederhäftig?
Samvetsfrågor
Det som bör diskuteras är inte hur svåra ingrepp
som motiverar robot
utan hur lätta !!!!!
och
om en fortsatt spridning av robotkirurgi ger bäst sjukvård till patienten
och bäst utnyttjade skattemedel?
Är fortsatt utbyggnad av robotkirurgi
inom gynekologi önskvärd?
Time for surgery and use of OR for open and robot assisted radical
hysterectomy
and pelvic lymphadenectomy
0
50
100
150
200
250
300
350
400
Open Robot 1-40 Robot 41-80 Robot 81-120 Robot 121-160
OR time
Operation time
Reynisson Persson May 2011
Inpatient days for open and robotic radical hysterectomy including
readmission for adverse events
6,1
4,2
3,4
2,5 2,8
0,8
0,9
0,5
0,5 0,6
0
1
2
3
4
5
6
7
8
Open Robot 1-40 Robot 41-80 Robot 81-120 Robot 121-160
Readmission
Primary
Reynisson Persson May 2011
Number of robot instruments used for robot assisted radical
hysterectomy
0
1
2
3
4
5
Open Robot 1-40 Robot 41-80 Robot 81-120 Robot 121-160
Reynisson Persson May 2011
Cost for open radical hysterectomy
USD/unit median cost
OR time (minutes) 26 302 7852
Operation time 235
Inpatient day 615 6,9 4243,5
Blood 135 0,7 94,5
Total cost 12 190
Factors influencing costs for robotic radical hysterectomy
Robot 1-40 Robot 41-80 Robot 81-120 Robot 121-160
USD
/unit median cost median cost median cost median cost
OR Time
(minutes) 26 375 9750 347 9022 279 7254 267 6942
Operation time 291 0 253 0 197 0 194 0
Inpatient day 615 5,1 3136,5 3,9 2398,5 3 1845 3,4 2091
Robot instrument 380 4,6 1748 4,1 1558 3,8 1444 3,4 1292
Maintenance and
depreciation 1130 1 1130 1 1130 1 1130 1 1130
Robot draping 108 3 324 3 324 3 324 3 324
Blood 135 0,2 27 0 0 0 0 0 0
Total cost 16 116 14 433 11 997 11 779
Reynisson Persson May 2011
Jan Persson January 2009
Fertility sparing surgery
Cervical cancer
Cervical cancer
Radical trachelectomy
3/4 of the cervix removed
+
parametria
+
Upper vagina
Vagina reattached
+
Permanent cerclage
Tumors <2cm
Adequate margin to inner os
Jan Persson May-11
Remaining cx
cerclage
Position of cervical cerclage
and length of the remaining
cervix
Jan Persson MD PhD
Department of Ob&G
University Hospital of Lund
Sweden
Jan Persson oct 2010
Robotic radical trachelectomy – surgical steps
Developing of pararectal and paravescial space to
isolate upper paracervical tissue and visualize anatomy
Identification of sentinel
lymph nodes- FS
Separate dissection of
upper paracervical tissue
sparing the uterine artery
Separate dissection and
removal of upper
paracervical tissue
sparing of the uterine artery
Jan Persson May-11
Jan Persson May-11
Robotic radical trachelectomy
Surg steps contd
Robotic radical trachelectomy
Surg steps contd
Dissection of lower paracervical
tissue (kept on specimen)
Ureter retracted with vessel
loop to facilitate dissection
Identify desc uterine artery
for ligation ( not shown)
Jan Persson May-11
www.practicumroboticschool.org
3 masterclasses during autumn 2012
Visit website for more info
Studyvisits and/or
proctorings
Jan Persson
www.sergs2012.org
Why not use the robot! High cost for investment, maintenance and instruments
Approx 3500USD additional cost/procedure compared with laparotomy if 400
procedures/year
= cost for 2 hours OR time or 5 inpatient days
Longer set up time
Affects OR turnover
New learning curve for surgeons and teams
New spectrum of complications ?
Jan Persson 2011
