Gynecologic surgery’s future

Innovation is a major component of gynecologic surgery and surgeons at all levels play a role in progressing the specialty. As gynecologic surgery continues to evolve rapidly, it is easy to forget the origins of our specialty. Only 205 years ago, Conrad Langenbeck performed the first planned hysterectomy on record. It was a vaginal procedure done in the surgeon‘s living room with no assistants and he had to use his teeth at one point to tie suture. Miraculously the patient survived, but no one believed that Dr. Langenbeck actually performed this procedure until it was confirmed at autopsy several years later.

In today‘s environment, the laparotomy approach is still overutilized, but it is now gradually being replaced by laparoscopic and robotic surgery. The original minimally invasive method, the vaginal hysterectomy, is slowly on the decline despite efforts by the American College of Obstetricians and Gynecologists to turn the tide. There is no question that vaginal hysterectomy is a great minimally invasive approach, but with fewer surgeons capable of teaching this skill and a paucity of technological innovation in this space, vaginal hysterectomy has been left wanting compared with the laparoscopic approach. In this regard, other developments on the horizon, which I will discuss later, have the ability to further cement the laparoscopic minimally invasive visual approach as the primary mode of access for gynecologic surgery.

The impact of MIGS training and subspecialists

As compared with vaginal hysterectomy, one important factor tilting the scales is development of minimally invasive gynecologic surgery (MIGS) fellowship programs. Over 300 MIGS-trained subspecialists have graduated from fellowship since 2001, and every year 30 to 40 new MIGS-trained subspecialists pollinate the US landscape and start to operate on patients. Introduction of high-volume MIGS subspecialists is changing the landscape of gynecologic surgery, moving a large portion of the surgical volume away from generalist specialists to MIGS specialists. A similar evolution happened in gynecologic oncology a couple of decades ago with the advent of gynecologic oncology fellowships. Whether this is the ideal solution for the discipline as a whole can be argued, but it is likely that within the next 10 to 20 years, most complex benign gynecologic surgeries will be performed by subspecialists and several recent studies have demonstrated in multiple arenas that high-volume surgeons have better outcomes and fewer complications.

The robotic surgery landscape

Another exciting development is a new revolution in robotic surgery that we are about to witness. Until recently, Intuitive Surgical was the only game in town, but recently the Senhance surgical robotic system was launched in the United States. Other robotic systems are on the horizon, some from major players in the market such as Medtronic and J&J in collaboration with Google, but also a variety of systems from other companies. It seems evident that with increasing competition, innovation will be rapid and prices will come down. This will benefit patients and surgeons and reduce the overall cost of the healthcare system. While I have personally been critical of robotic surgery as a poor value proposition in its current iteration, I now see the possibility that in time, robotic surgery will be offered at a signficantly lower cost and offer true value such as automation and greater safety for patients.

Visual improvements

Augmented visualization is also going to be something we will see increasingly in the near future. Fluorescence-guided surgery is already in clinical use, but several companies are developing tools that incorporate augmented reality in which three-dimensional images from computed tomography or magnetic resonance imaging can be overlaid onto the surgeon‘s console or monitored in real time. This can help the surgeon better determine exactly where to make an incision and see healthy tissue margins.

Key Surgical Data Summary

• MIGS Fellowship Graduates: Over 300 since 2001.
• Annual Subspecialist Growth: 30 to 40 new surgeons per year.
• Emerging Robotic Players: Senhance, Medtronic, and J&J (with Google).
• Future Visual Tools: Fluorescence-guided surgery and 3D imaging overlays.