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Laparoscopy vs Robotic Surgery in Gynecology

Author Taylor Spurgeon-Hess covers Laparoscopy vs Robotic Surgery in Gynecology on BackTable OBGYN

Taylor Spurgeon-Hess • Jun 10, 2024 • 38 hits

In the dynamic field of gynecologic surgery, the decision between laparoscopy vs robotic surgery methods is not just about choosing a tool; it's about tailoring the approach to each patient's unique needs. The decision-making process should consider factors such as patient anatomy, pathology, and the nuances of the surgical environment. Gynecologists Drs. Amy Park and Mark Hoffman delve into their processes and discuss considerations for patient positioning and special patient populations.

This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable OBGYN Brief

• The choice between surgical methods hinges on the specific requirements of the procedure (such as the complexity of myomectomy cases or the size of the uterus for hysterectomy) and the surgeon’s comfort with each technology.

• Robotics offers a significant advantage in complex myomectomies due to its ability to manage intricate sewing and angles more easily compared to traditional laparoscopy.

• For larger hysterectomies, traditional laparoscopy can be preferable due to its flexibility in camera and port placement, allowing surgeons to navigate tighter spaces.

• In patients with a larger BMI, robotic surgery can be more beneficial, providing ergonomic advantages and reducing fatigue during lengthy procedures.

• While the presence of endometriosis is a complicating factor, it does not solely dictate the choice of surgical method. The decision also depends on team dynamics and surgical expertise.

• Effective patient positioning and operating room setup, including aspects like arm tucking and preoperative preparations, play a crucial role in the success of gynecological surgeries.

• A well-coordinated surgical team is essential, especially in laparoscopic surgeries and cases involving complex conditions like endometriosis.

Laparoscopy vs Robotic Surgery in Gynecology

Table of Contents

(1) The Difference Between Laparoscopy & Robotic Surgery

(2) Special Considerations for Laparoscopy vs Robotic Surgery: BMI & Endometriosis

(3) Tips & Tricks for Proper Patient Positioning

The Difference Between Laparoscopy & Robotic Surgery

The decision between laparoscopy vs robotic surgery is often influenced by the type of procedure and the surgical setting. For complex myomectomies, the robotic approach is favored due to its ease in managing challenging suturing and angles, a significant advantage over traditional laparoscopy. In contrast, when handling large hysterectomies, laparoscopy may be preferred for its adaptable camera and port placements, allowing surgeons to navigate more effectively through varying surgical steps. The choice is nuanced, weighing factors such as the location of pathology and the surgeon's expertise with each technology.

[Dr. Amy Park]
Can you tell me, what are your criteria? How do you decide on who you're going to take for conventional laparoscopy versus robotic, what your thinking is and why do you choose conventional for the biggest and hardest cases? I'm curious about all of it.

[Dr. Mark Hoffman]
In general, the answer is just whatever room I'm in, it doesn't have a huge impact. The one type of case that really made me want to go back to the robot was myomectomy. There's a lot of sewing and it's a lot of weird angles. Sometimes you don't get to make your hysterectomy in the most comfortable angle for traditional laparoscopy because you're not going to have wristed instruments. If you're doing a vertical closure, it's a little bit of more of an angle potentially. You're sewing two and three and four layers on a closure of a hysterectomy. It's a lot. To be able to do that robotically is just a lot easier, honestly.

I don't know that it's better, it's just easier for me in doing this long cases. By the end of a long myomectomy with multiple fibroids and multiple hysterectomies, robots, that's the one case where I try to get those on the robot when I can. I also do a lot of mini-lap myomectomies too, if they're anterior pathology, if they're getting a c-section anyway, like why fight with all this equipment and then still have to make a three-centimeter or two-centimeter incision to get the fibroids out, when you could just do the entire thing through a four or five-centimeter incision, the mini-laparotomy is something I learned actually in residency. I had an attendant who did a bunch of abdominals or collages with unbelievably small mini-lap incisions, like crazy.

Got the residency and Syngeta Sinopoli at Chicago was the first mixed person I got to work with. I was like, this is going to be great. We'll do this robotic case and she did a mini-lap and I was like, that's so lame, and then we did it and it was like, okay, that was amazing. We did the entire case through a tiny little incision. A lot of it is just get your MRI and see where the pathology is. If it's posterior and low, I'm not going to be able to get that through a mini-lap. You're going to have to do--

Laparoscopy improves your ability to access those fibroids. It's 3D modeling using MRI in my mind, just visualizing the case before I do it, how am I going to get at this fibroid, where are the vessels, where's the ovary, where's the fallopian tube and where are my vessels? If I'm going to have to go anterior here, then posterior there, and trying to really imagine how many hysterectomies I'm going to have to make and what angle, if it gets to be more complex for me personally, just fatigue and things like that, the robot can make that a little more user-friendly, I think.

[Dr. Mark Hoffman]
That's not for myomectomy. How about for a hysterectomy? How do you decide?

[Dr. Amy Park]
For hysterectomy, it doesn't matter much for me. When I say big pathology, if it's a uterus that's above the umbilicus, two and three-kilo uteruses, what I like about traditional laparoscopy, and I know the XI, you can move the camera around. It's just more steps to like tell your assistant, to like take the camera out and move the arms around, whereas I can just put the camera in different port sites. Each step of a hysterectomy is going to be very different in a 3000-gram uterus. You're going to have to take each step a little differently, and that's where port placement matters and those kinds of things.

I think you can get into smaller spaces and you can get into little tighter areas with traditional laparoscopy. Again, I think the more I do, the more touches I get with the robot these days. We just did one the other day that was around two kilos. It was with a partner and did it robotically, that's the other thing. When my partners, someone asked me to come do a case with her and she does primarily robotics. I have a partner from colorectal surgery who does our endo cases together and he doesn't care to use the robot. We do those straight sticks. It's also with comfort, I know a lot of urologists are robot only. A lot of times if I'm doing a co-case, it depends on what the other person wants to use. I don't have a strong preference. Honestly, I don't have a comfort level with one versus the other where it makes me want to choose one versus the other.

Listen to the Full Podcast

Laparoscopic Hysterectomy Tips & Tricks with Dr. Mark Hoffman and Dr. Amy Park on the BackTable OBGYN Podcast)
Ep 36 Laparoscopic Hysterectomy Tips & Tricks with Dr. Mark Hoffman and Dr. Amy Park
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Special Considerations for Laparoscopy vs Robotic Surgery: BMI & Endometriosis

When considering patient-specific factors such as BMI and endometriosis, the surgical approach can significantly vary. Higher BMI often necessitates the use of robotic surgery for its ergonomic benefits, especially in prolonged procedures. Conversely, the presence of endometriosis requires a careful, case-by-case assessment. While past abdominal surgeries like C-sections are less influential in decision-making, managing endometriosis demands a thorough evaluation of each scenario. In these instances, the proficiency of the surgical team becomes paramount, with an emphasis on collaborative problem-solving and adaptability in technique.

[Dr. Amy Park]
How about BMI or prior vertical midline or any of those things, endos like concomitant endo, does that make a difference?

[Dr. Mark Hoffman]
Yes. Again, it's been about six months, I think ask me again in a year or two, and I might have a different opinion. We've got a pretty good system and setup for those endo cases, especially when my colorectal colleagues are there and we're pretty efficient with it. I think with prior abdominal surgery, most of the adhesive disease we deal with is C-section-related, for the most part. That's the biggest reason why in terms of our uterine adhesions is C-section. That's something that I don't lose a whole lot of sleep about that part of the surgery. For me, there's the bowel involved in those kinds of things.

That's where there's a little bit more, it's a little less routine, you want to be more careful there and that's having, again, straight stick versus robotic, I'm not as worried about that either. It doesn't impact my decision too much between the two.

[Dr. Amy Park]
BMI doesn't matter to you either?

[Dr. Mark Hoffman]
Yes, it's a good point. I think, where we are geographically in Kentucky, we have a much larger BMI than most patients. I do think there is a role for robotics just in terms of fatigue and things like that. Just trying to crank in those trocars and things like that over long cases, the robot can be a little bit more helpful, a little bit more reach probably with the da Vinci, with the robot compared to traditional laparoscopy. That's probably one area that the new robot tables move. Used to be you had to undock the robot, if you wanted to change Trendelenburg, you wanted to actually move the patient. That was a huge deal with the old systems. Now with the newer beds, it actually connects to the robot so you can move them around while the robots dock. That was a pretty big game changer, I think, for patients. A lot of times for our very large patients, getting T-burg can be tough, and getting the bowel out of the pelvis can be tough. You'll want to get them steep and then your anesthesiologist taps you through the drape and says, "Can we get her out of T-burg for a few minutes," and you're doing a bit of a dance. "Give me five minutes here. I'll get this side. We'll give you five minutes back," and going back and forth. I think it's less of a problem now. I think that's a good place for robotics is the larger BMI patients for sure. Do you use robots much for your-- What do you guys use?

[Dr. Amy Park]
I had a similar trajectory in terms of, I trained during fellowship. I did only a conventional laparoscopy. I trained at McGee, so it was Ted Lee and Suketu Mansuria doing a lot of conventional laparoscopy for endo and fibroids and hysterectomies. They don't do a lot of myomectomies, mostly hysterectomies. I came to fellowship and I did it during 2006 to 2009 and that's when the robot first came out. I trained doing the robot and we were all on the learning curve. These cases were taking a long time. The teams were not very framed up on the robot, so we were all learning together. Looking back on it, it's so painful. The teams are so much better now, so much better now.

Just laparoscopy in general and robotic teams. I can't say enough about how crucial it is. All surgeons know this, but it is so crucial [chuckles]. I'll say it again. It's crucial to have a good team. For open cases and vaginal cases, I think Kelly or Haney Clamps are pretty basic, but it's just really hard to function in laparoscopy without a team that can help troubleshoot because you're scrubbed in, and you know that, we all know that. Anyway, I trained doing both the robot and conventional laparoscopy doing sacrocopal pexis and HISS. Then I came out in fellowship and I did robotic cases, but I was so much faster doing a conventional.

[Dr. Amy Park]
Absolutely. You choose your agnostic on robotic versus conventional laparoscopy for your hysterectomy. It sounds like size or BMI maybe, but prior surgeries don't really phase you too much or endometriosis.

[Dr. Mark Hoffman]
Endometriosis will always phase me, but it's like if I had two giant strong friends going into a bar, I'd be less nervous about getting punched in the face, like going into a tough endo case with a colorectal surgeon or someone who's used to doing those cases with you, it makes those cases-- We're more prepared to do them. They're still tough, I still have a lot of respect for endometriosis for sure.

Tips & Tricks for Proper Patient Positioning

Effective patient positioning and operating room preparation are critical for the success of gynecological surgeries. Dr. Hoffman shares his practice of arriving to the operating room early to ensure a smooth setup and optimize the surgical environment. He also emphasizes best practices such as arm tucking and ensuring patient comfort and safety. In robotic surgeries, the role of uterine manipulators and the need for adept assistance are highlighted, illustrating the evolving nature of surgical teamwork. The approach to patient positioning should be hands-on, focusing on ensuring the best possible access and outcome for each procedure.

[Dr. Amy Park]
Yes, absolutely. Tell me about when you go into the OR and what are your tips and tricks for positioning and getting access and all that stuff. I will say, just circling back to the point that you said about using the robot when you don't have assistants, I know a lot of our fellows who went into private practice, they just use the robot because it's just so much easier when you don't have a resident or fellowship. For me, since I'm pretty much always operating with a trainee, I like conventional because I get to operate.

[Dr. Mark Hoffman]
I also think teaching is a lot easier because I go back and forth, but I think with traditional operations, I can grab their hand and be like," Hold this way, move that way," you're right there, and with the robot, there's a little bit of separation. I think OR setup, and whenever I have a new student or any new learner and interns and stuff, it's the same talk every time. This is the part of surgery that isn't super exciting and fun, but it's certainly one of the most important parts of any case, it's just getting your room ready. Number one, go back to the room before the patient gets there. It makes me nuts when residents are strolling in after the patient's asleep.

I'm like, "We're halfway done." We've already done the setup for them, whether you have a pink pad or whether you have egg crate foam or whatever, go back and make sure. In my case this morning, they had the sheets and the egg crate foam not how I want it. I know how to make a bed, I know how to put the sheets on and make sure it's right, because once the patient's on the bed, now getting it fixed is super tough. I would say, after you talk to your patient, go through everything, beat them to the OR, and make sure things are set up. You have the instruments. Do you have the tools you need to do the job? You said, team, team, team.

My goodness, am I lucky in my job to have a team that I'm pretty reliably or consistently operating with? I'll get texts at 6.30, "What's the deal today for this case," they'll pull stuff ahead of time. They know my routine, they know what we need and if there are certain variables, are we going to need the tissue extraction bag, is this a big one, is this endo, what are we dealing with? The team is a huge part of the setup. Knowing who we got, making sure, I know we are-- I don't know if you do this. I walk into ORs, I always look to see who else is operating that day. Who are the other surgeons around? Who can I call, who can run over if I need something, just to know who's around?

I think having that in your mind of like, is this a case where I'm going to need something? I don't call folks in the OR very often, but it's nice to just have that habit so you know who's around. OR Setup, understand how you want your patients positioned, but again, I use, we just got the pink pad strapped to the bed for a long time, it was just cheap egg crate foam. I always position the patients myself with the residents. I don't stroll in once they're asleep and drape. How they're positioned can make an easy case hard and can make a hard case impossible laparoscopically.

We talked a little bit about this, but once the patients are asleep, they need to be in-- I always use some Allen stirrup, something like that every time, yellow fins or something., slide them down so their sacrum is supported, but their butt's hanging off the edge, arms tuck at the side. Always, I cannot for the life of me, figure out why people still-- Like every once in a while, I'll hear someone who's like, we'll have an arm out for laparoscopy and I cannot figure it out.

There are a few reasons why arm tucking is such a huge part of it. Number one, that's where I'm standing. If the arms are out, I'm not comfortable, I'm going to be in pain. We've been lucky to hear you tell us about ergonomics, but you got to go have the arms tuck. I don't usually use sleds unless I have to. Even pretty big patients, we can tuck arms. Make sure the elbows, and wrists are padded, the thumbs are up, arms tuck to the side and really it's pushing on that elbow, like tucking the elbow a little bit underneath them, straightens the arm and keeps stuff from falling off. If it's a loose tuck, you get a nap. If their elbows are falling off the bed, we start over. I'll do that myself too with the residents. I'm like, all right, this is what we want, feel this, because those are the things you can't really rely on other people to know how to do because when teams change and rotate, you got to go own that. You got to go own how the patients are on the bed. Again, early on, someone else does it, and then the patients are sliding under the drape and you're getting to a hard part of the case and start getting some bleeding, now you got to go take them out of T-burg because the patient's sliding off the bed, it's a never event in my OR.

You got to go be able to focus on the variables, which is the patient. Once the patient comes in, I try to keep variables at a minimum. Everybody gets an OG. I don't care if they've had no surgery and we're going to go through them. I may end up having to go through Palmer's point, but I don't want to have to remember to put an OG in. Everybody gets an OG, I give all my hysterectomies peridium pre-op, like an hour or two before they get a dose of peridium. When we systole later, their pee's orange, a lot of the folks when they get their OG and they're like, "What, did they drink orange drink," I'm like, "No, that's just the peridium."

Podcast Contributors

Dr. Mark Hoffman discusses Laparoscopic Hysterectomy Tips & Tricks on the BackTable 36 Podcast

Dr. Mark Hoffman

Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.

Dr. Amy Park discusses Laparoscopic Hysterectomy Tips & Tricks on the BackTable 36 Podcast

Dr. Amy Park

Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.

Cite This Podcast

BackTable, LLC (Producer). (2023, October 12). Ep. 36 – Laparoscopic Hysterectomy Tips & Tricks [Audio podcast]. Retrieved from

Disclaimer: The Materials available on are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.



Laparoscopic Hysterectomy Tips & Tricks with Dr. Mark Hoffman and Dr. Amy Park on the BackTable OBGYN Podcast)



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