Robotic-assisted laparoscopic microsurgical tubal anastomosis: a human pilot study

Robotics in laparoscopic surgery - A review

Because of the increasing use of laparoscopic surgeries, robotic technologies have been developed to overcome the challenges these surgeries impose on surgeons. This paper presents an overview of the current state of surgical robots used in laparoscopic surgeries. Four main categories were discussed: handheld laparoscopic devices, laparoscope positioning robots, master–slave teleoperated systems with dedicated consoles, and robotic training systems. A generalized control block diagram is developed to demonstrate the general control scheme for each category of surgical robots. In order to review these robotic technologies, related published works were investigated and discussed. Detailed discussions and comparison tables are presented to compare their effectiveness in laparoscopic surgeries. Each of these technologies has proved to be beneficial in laparoscopic surgeries.

Is there any difference between pregnancy results after tubal reanastamosis performed laparotomically, laparoscopically, and robotically?

INTRODUCTION

Tubal reanastamosis offers hope to conceive again. However, there are many factors that affect the success of this procedure. In our study we aimed to compare the pregnancy rates of the surgical methods used for tubal reanastamosis in pregnancy requested after tubal sterilization.

METHODS

In our study we compared the rates of pregnancies after reanastamosis retrospectively in female patients under the age of 40 who underwent reanastamosis between 2010 and 2019 with laparotomic, laparoscopic and robotic methods. A single layer of 4 quadrant 6/0 number polydioxanone absorbable sutures were used in all surgical methods. A similar surgical technique was used.

RESULTS

In surgical methods (laparotomy, laparoscopy, and robotics), there was a statistical difference between the three groups in terms of operation times of surgical methods used for tubal reanastamosis (p < 0.05). Laparotomy, laparoscopy, and robotics pregnancy rates were 52.6% (n = 41), 67.3% (n = 37), 61.2% (n = 63), respectively. There was no statistical difference between groups in terms of pregnancy rates. However, odds ratio (OR) values of the laparoscopy group and robotics group probability of conception were 1.536 (95% confidence interval [CI], 0.813-2.898), 1.111 (95% CI, 0.656-1.879) higher, respectively.

CONCLUSIONS

Although there is no statistical difference between the surgical methods used for tubal reanastamosis, we think that the laparoscopic surgical method may be preferable due to the shorter hospital stay. We think that the previous method of bilateral tubaligastion (BTL), the site of reanastasis, and the time between BTL and reanastomosis were effective in pregnancy success.

Robotic-assisted laparoscopic tubal anastomosis: Single institution analysis

BACKGROUND

Tubal anastomosis has similar pregnancy rates regardless of approach. Historically, robotic anastomosis has been associated with increased cost and operative time. We sought to perform a contemporary study of these metrics.

METHODS

One hundred and nine patients were identified who underwent robotic-assisted laparoscopic tubal anastomosis. Retrospective analysis of medical records was performed. Phone survey was conducted.

RESULTS

The mean operative time decreased from 140.7 ± 27.0 min in 2013 to 60.0 ± 9.1 min in 2018, with significant downward trend (p < 0.001). The mean cost was $7153.46 ± $1484.41. The pregnancy rate was 59% (35/59), and tubal patency rate was 81% (42/52). Seventy-two percent of patients under 37 years became pregnant.

CONCLUSIONS

There is significant improvement in operative time of robotic-assisted tubal anastomosis with surgical experience. Robotic tubal anastomosis outperformed historical metrics of laparoscopy and laparotomy with regard to operative time and cost in this series.

Trends in the diffusion of robotic surgery in prostate, uterus, and colorectal procedures: a retrospective population-based study

This study aimed to propose quantifiable metrics on the adoption lifecycle of robotic-assisted surgery (RAS) within and across prostate, hysterectomy, and colorectal procedures. This was a retrospective population-based cohort study of commonly performed RAS procedures in the US conducted from July 2001 to July 2015. The patients were identified from the Premier Hospital Database using International Classification of Diseases, 9th revision, Clinical Modification codes denoting prostate, uterus, and colorectal procedures. The Diffusion of Innovations theory was applied to percent RAS utilization to determine discrete eras of technology adoption. Overall and by-era patient baseline characteristics were compared between robotic and non-robotic groups. This study included a total of 2,098,440 RAS procedures comprising prostate (n = 155,342), uterus (n = 1,300,046), and colorectal (n = 643,052) procedures. Prostate (76.7%) and uterus (28.9%) procedures had the highest robotic utilization by the end of the study period and appear to be in the last adoption era (Laggard). However, robotic utilization in colorectal procedures (7.5%) was low and remained in the first era (Innovator) for a longer time (15 vs 60 vs 135 months). Whites, privately insured, patients with fewer comorbidities, and those admitted in large teaching hospitals were more likely to undergo RAS in the early study period. AS-associated patient and hospital profiles changed over time, suggesting that selected patient cohorts should be contextualized by overall adoption of a novel medical technology. The time-discretized analysis may also inform patient selection criteria and appropriate timing for clinical study stages proposed by the Idea, Development, Exploration, Assessment, Long-term study-Devices framework.

From laparotomy to laparoscopy to in vitro fertilization

Before the modern era of in vitro fertilization, reproductive surgery to deal with pelvic disease was the key intervention in the management of infertility. A series of clinical observations and animal experiments led to the development of microsurgical principles, which were applicable to all forms of gynecologic surgery. The evolution of endoscopy permitted minimally invasive approaches to most pelvic pathology. Assisted reproductive techniques now have primacy in the management of infertility, but women deserve to have fertility-enhancing or fertility-sparing surgery performed by a surgeon with relevant training. Thus, we have an obligation to maintain formal training programs in reproductive surgery.

Robot-assisted surgery in gynaecology

BACKGROUND

This is an updated merged review of two originally separate Cochrane reviews: one on robot-assisted surgery (RAS) for benign gynaecological disease, the other on RAS for gynaecological cancer. RAS is a relatively new innovation in laparoscopic surgery that enables the surgeon to conduct the operation from a computer console, situated away from the surgical table. RAS is already widely used in the United States for hysterectomy and has been shown to be feasible for other gynaecological procedures. However, the clinical effectiveness and safety of RAS compared with conventional laparoscopic surgery (CLS) have not been clearly established and require independent review.

OBJECTIVES

To assess the effectiveness and safety of RAS in the treatment of women with benign and malignant gynaecological disease.

SEARCH METHODS

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via Ovid, and EMBASE via Ovid, on 8 January 2018. We searched www.ClinicalTrials.gov. on 16 January 2018.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing RAS versus CLS or open surgery in women requiring surgery for gynaecological disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, and extracted study data and entered them into an Excel spreadsheet. We examined different procedures in separate comparisons and for hysterectomy subgrouped data according to type of disease (non-malignant versus malignant). When more than one study contributed data, we pooled data using random-effects methods in RevMan 5.3.

MAIN RESULTS

We included 12 RCTs involving 1016 women. Studies were at moderate to high overall risk of bias, and we downgraded evidence mainly due to concerns about risk of bias in the studies contributing data and imprecision of effect estimates. Procedures performed were hysterectomy (eight studies) and sacrocolpopexy (three studies). In addition, one trial examined surgical treatment for endometriosis, which included resection or hysterectomy. Among studies of women undergoing hysterectomy procedures, two studies involved malignant disease (endometrial cancer); the rest involved non-malignant disease.• RAS versus CLS (hysterectomy)Low-certainty evidence suggests there might be little or no difference in any complication rates between RAS and CLS (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.54 to 1.59; participants = 585; studies = 6; I² = 51%), intraoperative complication rates (RR 0.77, 95% CI 0.24 to 2.50; participants = 583; studies = 6; I² = 37%), postoperative complications (RR 0.81, 95% CI 0.48 to 1.34; participants = 629; studies = 6; I² = 44%), and blood transfusions (RR 1.94, 95% CI 0.63 to 5.94; participants = 442; studies = 5; I² = 0%). There was no statistical difference between malignant and non-malignant disease subgroups with regard to complication rates. Only one study reported death within 30 days and no deaths occurred (very low-certainty evidence). Researchers reported no survival outcomes.Mean total operating time was longer on average in the RAS arm than in the CLS arm (mean difference (MD) 41.18 minutes, 95% CI -6.17 to 88.53; participants = 148; studies = 2; I² = 80%; very low-certainty evidence), and the mean length of hospital stay was slightly shorter with RAS than with CLS (MD -0.30 days, 95% CI -0.53 to -0.07; participants = 192; studies = 2; I² = 0%; very low-certainty evidence).• RAS versus CLS (sacrocolpopexy)Very low-certainty evidence suggests little or no difference in rates of any complications between women undergoing sacrocolpopexy by RAS or CLS (RR 0.95, 95% CI 0.21 to 4.24; participants = 186; studies = 3; I² = 78%), nor in intraoperative complications (RR 0.82, 95% CI 0.09 to 7.59; participants = 108; studies = 2; I² = 47%). Low-certainty evidence on postoperative complications suggests these might be higher with RAS (RR 3.54, 95% CI 1.31 to 9.56; studies = 1; participants = 68). Researchers did not report blood transfusions and deaths up to 30 days.Low-certainty evidence suggests that RAS might be associated with increased operating time (MD 40.53 min, 95% CI 12.06 to 68.99; participants = 186; studies = 3; I² = 73%). Very low-certainty evidence suggests little or no difference between the two techniques in terms of duration of stay (MD 0.26 days, 95% CI -0.15 to 0.67; participants = 108; studies = 2; I² = 0%).• RAS versus open abdominal surgery (hysterectomy)A single study with a total sample size of 20 women was included in this comparison. For most outcomes, the sample size was insufficient to show any possible differences between groups.• RAS versus CLS for endometriosisA single study with data for 73 women was included in this comparison; women with endometriosis underwent procedures ranging from relatively minor endometrial resection through hysterectomy; many of the women included in this study had undergone previous surgery for their condition. For most outcomes, event rates were low, and the sample size was insufficient to detect potential differences between groups.

AUTHORS' CONCLUSIONS

Evidence on the effectiveness and safety of RAS compared with CLS for non-malignant disease (hysterectomy and sacrocolpopexy) is of low certainty but suggests that surgical complication rates might be comparable. Evidence on the effectiveness and safety of RAS compared with CLS or open surgery for malignant disease is more uncertain because survival data are lacking. RAS is an operator-dependent expensive technology; therefore evaluating the safety of this technology independently will present challenges.

Robotic Single-Site Tubal Reanastomosis: The Robotic Factor

STUDY OBJECTIVE

To investigate the advantages of using robotic assistance in tubal reanastomosis surgery.

DESIGN

A narrated instructional video.

SETTING

University Hospital, Baylor College of Medicine, Houston, Texas (Canadian Task Force Classification III).

PATIENT

A 33-year-old woman, G2P2003, who regretted her prior tubal ligation; she continued to request for a tubal reversal with a desire to conceive in the near future. A single-site approach was decided on when she expressed concern for the cosmetic aftermath of multiport surgery.

INTERVENTIONS

Robotic single-site tubal reanastomosis.

MEASUREMENTS AND MAIN RESULTS

We performed robotic single-site tubal reanastomosis on the patient. We used the energy instruments of the monopolar hook and the bipolar slotted grasper. Entry was performed in the umbilicus, after which an abdominal survey was conducted to determine and locate the blocked fallopian tubes. A cold scissor, to avoid additional damage to the tubes, was used to resect the portion of the right blocked tube, and a neonatal feeding tube was inserted though both sections of the tube to ensure proper alignment during the repair. Additionally, a figure of eight suture was placed in the mesosalpinx to reduce the amount of tension during the tubal reanastomosis. We used 4 interrupted 5-0 PDS sutures, with 2 wristed needle drivers, to establish and precisely align the 2 sections of tube, first in the mucosal layer and then in the serosal layer, to achieve proper retention. Upon successful chromopertubation with methylene blue dye, the process was repeated on the left side. A successful tubal reanastomosis was completed and chromopertubation clearly demonstrated that the tubes were patent. Total operation time was approximately 100 minutes, resulting in a successful surgery. Estimated blood loss was only 20 mL. At 2 months after surgery a fluoroscopic hysterosalpingogram was conducted to verify the patency of the tubes. We concluded that both tubes were patent.

CONCLUSIONS

The single-site robotic approach provides a potent and valuable method for tubal reanastomosis, rendering difficult surgical techniques more accessible.

Tubal anastomosis after previous sterilization: a systematic review

BACKGROUND

Female sterilization is one of the most common contraceptive methods. A small number of women, however, opt for reversal of sterilization procedures after they experience regret. Procedures can be performed by laparotomy or laparoscopy, with or without robotic assistance. Another commonly utilized alternative is IVF. The choice between surgery and IVF is often influenced by reimbursement politics for that particular geographic location.

OBJECTIVE AND RATIONALE

We evaluated the fertility outcomes of different surgical methods available for the reversal of female sterilization, compared these to IVF and assessed the prognostic factors for success.

SEARCH METHODS

Two search strategies were employed. Firstly, we searched for randomized and non-randomized clinical studies presenting fertility outcomes of sterilization reversal up to July 2016. Data on the following outcomes were collected: pregnancy rate, ectopic pregnancy rate, cost of the procedure and operative time. Eligible study designs included prospective or retrospective studies, randomized controlled trials, cohort studies, case-control studies and case series. No age restriction was applied. Exclusion criteria were patients suffering from tubal infertility from any other reason (e.g. infection, endometriosis and adhesions from previous surgery) and studies including <10 participants. The following factors likely to influence the success of sterilization reversal procedures were then evaluated: female age, BMI and duration and method of sterilization. Secondly, we searched for randomized and non-randomized clinical studies that compared reversal of sterilization to IVF and evaluated them for pregnancy outcomes and cost effectiveness.

OUTCOMES

We included 37 studies that investigated a total of 10 689 women. No randomized controlled trials were found. Most studies were retrospective cohort studies of a moderate quality. The pooled pregnancy rate after sterilization reversal was 42-69%, with heterogeneity seen from the different methods utilized. The reported ectopic pregnancy rate was 4-8%. The only prognostic factor affecting the chance of conception was female age. The surgical approach (i.e. laparotomy [microscopic], laparoscopy or robotic) had no impact on the outcome, with the exception of the macroscopic laparotomic technique, which had inferior results and is not currently utilized. For older women, IVF could be a more cost-effective alternative for the reversal of sterilization. However, direct comparative data are lacking and a cut-off age cannot be stated.

WIDER IMPLICATIONS

In sterilized women who suffer regret, surgical tubal re-anastomosis is an effective treatment, especially in younger women. However, there is a need for randomized controlled trials comparing the success rates and costs of surgical reversal with IVF.

Robot-assisted laparoscopic myomectomy: current status

Robotic-assisted surgery has seen a rapid development and integration in the field of gynecology. Since the approval of the use of robot for gynecological surgery and considering its several advantages over conventional laparoscopy, it has been widely incorporated especially in the field of reproductive surgery. Uterine fibroids are the most common benign tumors of the female reproductive tract. Many reproductive-aged women with this condition demand uterine-sparing surgery to preserve their fertility. Myomectomy, the surgical excision of uterine fibroids, remains the only surgical management option for fibroids that entails preservation of fertility. In this review, we focus on the role of robotic-assisted laparoscopic myomectomy and its current status, in comparison with other alternative approaches for myomectomy, including open, hysteroscopic, and traditional laparoscopic techniques. Several different surgical techniques have been demonstrated for robotic myomectomy. This review endeavors to share and describe our surgical experience of using the standard laparoscopic equipment for robotic-assisted myomectomy, together with the da Vinci Robot system. For the ideal surgical candidate, robotic-assisted myomectomy is a safe minimally invasive surgical procedure that can be offered as an alternative to open surgery. The advantages of using the robot system compared to open myomectomy include a shorter length of hospital stay, less postoperative pain and analgesic use, faster return to normal activities, more rapid return of the bowel function, and enhanced cosmetic results due to smaller skin incision sizes. Some of the disadvantages of this technique include high costs of the robotic surgical system and equipment, the steep learning curve of this novel system, and prolonged operative and anesthesia times. Robotic technology is a novel and innovative minimally invasive approach with demonstrated feasibility in gynecological and reproductive surgery. This technology is expected to take the lead in gynecological surgery in the upcoming decade.

Optimizing the Surgeon-Robot Interface: The Effect of Control-Display Gain and Zoom Level on Movement Time

While many advances have been made in surgical robotics technology, even for surgeons with relatively high levels of robotic surgery experience, many tasks take less time to perform manually. Although there are other benefits to surgical robotics that may outweigh task completion time, relatively lower efficiency will hinder the adoption of this technology. This study focused on two interface parameters: Control-Display Gain (CDG, i.e., the amount of robot movement resulting from a given robot controller movement) and the optical Zoom level that defines the working field of view. Results from a study with 10 participants suggest that CDG is a promising interface parameter for optimizing movement time in robot-assisted surgical tasks. The results have implications for the development and implementation of intelligent surgeon-robot interface technology and hold the potential to greatly improve the efficiency of robotic-assisted surgery techniques.

Robot-assisted segmental resection of tubal pregnancy followed by end-to-end reanastomosis for preserving tubal patency and fertility: An initial report

The objective of this study was to evaluate whether robotic tubal reanastomosis after segmental resection of tubal pregnancy is a feasible means of preserving tubal integrity and natural fertility in those with compromised contralateral tubal condition.The study was performed at a university medical center in a retrospective manner where da Vinci robotic system-guided segmental resection of tubal ectopic mass followed by reanastomosis was performed to salvage tubal patency and fertility in those with a single viable fallopian tube. Of the 17 patients with tubal pregnancies that were selected, 14 patients with successful tubal segmental resection and reanastomosis were followed up. The reproducibility of anastomosis success and cumulative pregnancy rates of up to 24 months were analyzed.Patient mean age was 28.88 ± 4.74 years, mean amenorrheic period was 7.01 ± 1.57 weeks and mean human chorionic gonadotropin (hCG) level was 9289.00 ± 7510.00 mIU/mL. The overall intraoperative cancellation rate due to unfavorable positioning or size of the tubal mass was 17.65% (3/17), which was converted to either salpingectomy or milking of ectopic mass. Of the 14 attempted, anastomosis for all 14 cases was successful, with 1 anastomotic leakage. One patient wishing to postpone pregnancy and 2 patients where patency of the contralateral tube was confirmed during the operation, were excluded from the pregnancy outcome analysis. Cumulative pregnancy rate was 63.64% (7/11), with 3 (27.27%) ongoing pregnancies, 3 (27.27%) livebirths, and 1 missed abortion at 24 months. During the follow-up, hysterosalpingography (HSG) was performed at 6 months for those who consented, and all 10 fallopian tubes tested were patent. No subsequent tubal pregnancies occurred in the reananstomosed tube for up to a period 24 months.For patients with absent or defective contralateral tubal function, da Vinci-guided reanastomosis after segmental resection of tubal pregnancy is feasible for salvaging tubal patency and fertility.

Robot-Assisted Radical Hysterectomy in Cervical Carcinoma: The Belgian Experience

Objective

The purpose of this study was to report the experience and oncological outcome of robot-assisted radical hysterectomies (RRHs) for cervical cancer performed in Belgium.

Methods

Patients undergoing RRH for cervical cancer (n = 109) were prospectively collected between July 2007 and April 2014 in the 5 Belgian centers performing RRH for cervical cancer.

Results

The median age of the patients was 46 years (range, 31–80 years). Histological types included squamous cell carcinoma in 61 patients, adenocarcinoma in 22 patients, adenosquamous in 8 patients, endometrioid carcinoma in 2 patients, and other types (n = 16). The International Federation of Gynecology and Obstetrics stage distribution was IA (n = 9), stage IB1 (n = 71), stage IB2 (n = 4), stage II (n = 24), and unknown (n = 1). Twenty-four patients received adjuvant therapy, 17 patients underwent radiochemotherapy, and 7 underwent adjuvant radiation. Eighteen patients relapsed, and 5 died of disease. The median follow-up was 27.5 months (range, 3–82 months). The 2- and 5-year overall survivals were 96% and 89%, respectively. The 2- and 5-year disease-free survivals (DFSs) were 88% and 72%, respectively. The 2-year DFS per stage was 100% for IA, 88% for IB1, 100% for IB2, and 83% for II. The 5-year DFS per stage was 100% for stage IA and 75% for IB1. The complications were as expected for radical hysterectomy.

Conclusions

This series confirms the feasibility and safety of RRH not only in cervical cancer stage IA to IB1, but also after neoadjuvant chemotherapy in stage IB2 to IIB.

WITHDRAWN: Robotic assisted surgery for gynaecological cancer

This review is being withdrawn as now superceded by a new review covering both malignant an benign disease: Lawrie TA, Liu H, Lu D, Dowswell T, Song H, Wang L, Shi G. Robot‐assisted surgery in gynaecology. Cochrane Database of Systematic Reviews 2019, Issue 4. Art. No.: CD011422. DOI: 10.1002/14651858.CD011422.pub2 (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011422.pub2/full )

The editorial group responsible for this previously published document have withdrawn it from publication.

WITHDRAWN: Robotic surgery for benign gynaecological disease

This review is being withdrawn as now superceded by a new review covering both malignant an benign disease: Lawrie TA, Liu H, Lu D, Dowswell T, Song H, Wang L, Shi G. Robot‐assisted surgery in gynaecology. Cochrane Database of Systematic Reviews 2019, Issue 4. Art. No.: CD011422. DOI: 10.1002/14651858.CD011422.pub (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011422.pub2/full ).

The editorial group responsible for this previously published document have withdrawn it from publication.

Robot-assisted surgery in gynaecology

BACKGROUND

This is an updated merged review of two originally separate Cochrane reviews: one on robot-assisted surgery (RAS) for benign gynaecological disease, the other on RAS for gynaecological cancer. RAS is a relatively new innovation in laparoscopic surgery that enables the surgeon to conduct the operation from a computer console, situated away from the surgical table. RAS is already widely used in the United States for hysterectomy and has been shown to be feasible for other gynaecological procedures. However, the clinical effectiveness and safety of RAS compared with conventional laparoscopic surgery (CLS) have not been clearly established and require independent review.

OBJECTIVES

To assess the effectiveness and safety of RAS in the treatment of women with benign and malignant gynaecological disease.

SEARCH METHODS

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 5) and the Cochrane Gynaecological Cancer Review Group Trials Register. We also searched MEDLINE and EMBASE databases, to complement the searches of the original malignant and benign disease reviews (conducted up to July 2010 and November 2011, respectively), from July 2010 to June 2014.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of RAS compared with CLS or open surgery in women requiring surgery for gynaecological disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion and risk of bias, and extracted study data and entered them into an Excel spreadsheet. We subgrouped data according to type of procedure and pooled data using random-effects methods in RevMan 5.3. We performed sensitivity analyses by excluding studies at high risk of bias.

MAIN RESULTS

We included six RCTs involving 517 women. Most were at low to moderate overall risk of bias; one was at high risk of bias. Four studies evaluated RAS for hysterectomy (371 women), and two studies evaluated RAS for sacrocolpopexy (146 women). All studies compared RAS with CLS, except for one study, which compared RAS with CLS or a vaginal surgical approach for hysterectomy. Confidence intervals for the risk of intraoperative and postoperative complications included benefits with either approach when they were analysed together (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.46 to 1.99; participants = 513; studies = 6; I(2) = 74%) and separately (low-quality evidence). Moderate-quality evidence was found for the effects of RAS on intraoperative injury when compared with CLS (RR 1.23, 95% CI 0.44 to 3.46; participants = 415; studies = 5; I(2) = 0%), along with low-quality evidence for bleeding and infection complications.Mean total operating time was consistent across procedures and on average was about 42 minutes longer in the RAS arm compared with the CLS arm (95% CI 17 to 66 minutes; participants = 294; studies = 4; I(2) = 82%; moderate-quality evidence). Mean hospital stay for hysterectomy procedures was on average about seven hours shorter in the RAS arm than in the CLS arm (mean difference (MD) -0.30 days, 95% CI -0.54 to -0.06; participants = 217; studies = 2; I(2) = 0%; low-quality evidence). The estimated effect of conversion with RAS compared with CLS was imprecise (RR 1.28, 95% CI 0.40 to 4.12; participants = 337; studies = 4; I(2) = 0%; moderate-quality evidence). Limited data from two studies suggest that RAS for sacrocolpopexy may be associated with increased postoperative pain compared with CLS; this needs further investigation. We identified five ongoing trials-four of cancer surgery.

AUTHORS' CONCLUSIONS

We are uncertain as to whether RAS or CLS has lower intraoperative and postoperative complication rates because of the imprecision of the effect and inconsistency among studies when they are used for hysterectomy and sacrocolpopexy. Moderate-quality evidence suggests that these procedures take longer with RAS but may be associated with a shorter hospital stay following hysterectomy. We found limited evidence on the effectiveness and safety of RAS compared with CLS or open surgery for surgical procedures performed for gynaecological cancer; therefore its use should be limited to clinical trials. Ongoing trials are likely to have an important impact on evidence related to the use of RAS in gynaecology.

Cost assessment of robotics in gynecologic surgery: a systematic review

AIM

The application of robotics is an innovation in the field of gynecologic surgery. Our objective was to evaluate the currently available literature on the cost assessment of robotic surgery of various operations in the field of gynecologic surgery.

MATERIAL AND METHODS

PubMed and Scopus databases were systematically searched in order to retrieve the included studies in our review.

RESULTS

We retrieved 23 studies on a variety of gynecologic operations. The mean cost for robotic, open and laparoscopic surgery ranged from 1731 to 48,769, 894 to 20,277 and 411 to 41,836 Euros, respectively. Operative charges, in hysterectomy, for robotic, open and laparoscopic technique ranged from 936 to 33,920, 684 to 25,616 and 858 to 25,578 Euros, respectively. In sacrocolpopexy, these costs ranged from 2067 to 7275, 2904 to 69,792 and 1482 to 2000 Euros, respectively. Non-operative charges ranged from 467 to 39,121 Euros. The mean total costs for myomectomy ranged from 27,342 to 42,497 and 13,709 to 20,277 Euros, respectively, for the robotic and open methods, while the mean total cost of the laparoscopic technique was 26,181 Euros. Conversions to laparotomy were present in 79/36,185 (0.2%) cases of laparoscopic surgery and in 21/3345 (0.62%) cases of robotic technique. Duration of robotic, open and laparoscopic surgery ranged from 50 to 445, 83.7 to 701 and 74 to 330 min, respectively.

CONCLUSION

Robotic surgery has the potential to become cost-effective in centers with many patients while industry competition could reduce the cost of the robotic instrumentation, making robotic technology more affordable and cost-effective.

Technology advances in hospital practices: robotics in treatment of patients

Laparoscopic cholecystectomy is widely considered as the treatment of choice for acute cholecystitis. The safety of the procedure and its minimal invasiveness made it a valid treatment option for a patient not responding to antibiotic therapy. Our research shows that patients positively assess this treatment method, but the world's tendency is to turn to a more sophisticated method utilizing robot-assisted surgery as a gold standard. Providing patient with minimally invasive surgical procedures that utilize the state-of-the-art equipment like the da Vinci Robotic Surgical System underscores the commitment to high-quality patient care while enhancing patient safety. The advantages include minimal invasive scarring, less pain and bleeding, faster recovery time, and shorter hospital stay. The move toward less invasive and less morbid procedures and a need to re-create the true open surgical experience have paved the way for the development and application of robotic and computer-assisted systems in surgery in Poland as well as the rest of the world.

Telemedicine and telesurgery in cancer care: inaugural conference at MD Anderson Cancer Center

BACKGROUND

Despite the growing incidence of cancer worldwide, there are an insufficient number of primary care physicians, community oncologists, and surgeons to meet the demand for cancer care, especially in rural and other medically underserved areas. Teleoncology, including diagnostics, treatment, and supportive care, has the potential to enhance access to cancer care and to improve clinician education and training.

OBJECTIVES

Major cancer centers such as The University of Texas MD Anderson Cancer Center must determine how teleoncology will be used as part of strategic planning for the future. The Telemedicine and Telesurgery in Cancer Care (TTCC) conference was convened to determine technologically based strategies for addressing global access to essential cancer care services.

RESULTS

The TTCC conference brought policy makers together with physicians, legal and regulatory experts to define strategies to optimize available resources, including teleoncology, to advance global cancer care.

CONCLUSIONS

The TTCC conference discourse provided insight into the present state of access to care, expertise, training, technology and other interventions, including teleoncology, currently available through MD Anderson, as well as a vision of what might be achievable in the future, and proposals for moving forward with a comprehensive strategy.

Tubal factor infertility: diagnosis and management in the era of assisted reproductive technology

Tubal factor infertility accounts for a large portion of female factor infertility. The most prevalent cause of tubal factor infertility is pelvic inflammatory disease and acute salpingitis. The diagnosis of tubal occlusion can be established by a combination of clinical suspicion based on patient history and diagnostic tests, such as hysterosalpingogram, sonohysterosalpingography, and laparoscopy with chromopertubation. Depending on several patient factors, tubal microsurgery or more commonly in vitro fertilization with its improving success rates are the recommended treatment options.

Neoadjuvant chemotherapy followed by simultaneous robotic radical trachelectomy and reversal of tubal sterilization in stage IB2 cervical cancer

INTRODUCTION

The aim of this study was to report a case of cervical cancer stage IB2 treated with neoadjuvant chemotherapy, followed by simultaneous robotic-assisted radical trachelectomy and reversal of tubal sterilization.

CASE DESCRIPTION

This case occurred in a university hospital involving a 31-y-old woman with stage IB2 cervical cancer treated using neoadjuvant chemotherapy, robotic surgery, and tubal anastomosis to determine cancer disease status and achieve restoration of tubal patency.

DISCUSSION

A successful radical trachelectomy with patent tubes was done bilaterally. Cancer and fertility procedures can be simultaneously implemented and achieved.

Robot-assisted tubal reanastomosis: initial experience in a single institution

OBJECTIVE

To assess surgical outcomes for robot-assisted tubal reanastomosis in a single institution.

MATERIALS AND METHODS

Between March 2009 and January 2010, 10 patients underwent robot-assisted tubal ligation reversal (TLR) with a da Vinci S surgical system. Patient demographic data, including operative times, operative and postoperative complications, hospital stay, conversion to laparotomy and pregnancy rates were recorded.

RESULTS

Mean age and body mass index for the patients were 37.7 (35-42) years and 28.9 (23.9-36.3) kg/m(2), respectively. The mean console time was 102.5 min and the mean total operation time was 130.6 (102-164) min. The mean hospital stay was 1.2 (1-2) days. There were no significant intra-operative or early-postoperative complications. All surgeries were completed robotically with no conversion to laparotomy. There were seven subsequent pregnancies in the study participants, representing a pregnancy rate of 70%, of which five were intrauterine pregnancies, one was an ectopic pregnancy, and one was an abortus.

CONCLUSION

Robot-assisted TLR is safe and feasible. This procedure may facilitate minimally invasive treatment for patients who want to regain their fertility without the aid of artificial reproductive techniques.

New developments in reproductive surgery

The introduction of in-vitro fertilisation within reproductive medicine has prompted questions to be asked about the relevance of reproductive surgery. Reproductive surgery is more than a competing discipline; it is complementary to the techniques of in-vitro fertilisation. As a complementary discipline, reproductive surgery covers the field of tubal and ovarian pathology and correction of uterine alterations. In recent decades, more attention has been paid to the importance of the uterus in the process of conception and implantation. The place of reproductive surgery and the existing controversies in the treatment of uterine congenital and acquired pathology, tubal, and ovarian surgery are discussed. Continuous training and accreditation programmes for reproductive technologies and surgery are more important than ever.

Advances in male reproductive surgery: robotic-assisted vasovasostomy

It is estimated that 3-6% of all vasectomised men request vasectomy reversal for different reasons. Microsurgical vasovasostomy is the gold standard technique of vasectomy reversal. However, the microsurgical technique is time-consuming and challenging to most urological surgeons. Therefore, alternative methods of vasal anastomosis have been studied including robotic-assisted vasovasostomy. This review discusses the feasibility and practice of robotic-assisted vasovasostomy. Based on the available studies robotic-assisted vasovasostomy is feasible. The reported rate of vasal patency associated with this new technique is similar to that of microsurgical vasovasostomy. There is no clear difference between the 2 approaches in terms of operating time. Robotic-assisted vasovasostomy does not appear to afford significant advantages in the era of vasectomy reversal.

Robotic compared with conventional laparoscopic hysterectomy: a randomized controlled trial

OBJECTIVE

To compare surgical outcome and quality of life of robot-assisted laparoscopic hysterectomy with conventional laparoscopic hysterectomy.

METHODS

For this controlled clinical trial, patients with benign indications for hysterectomy were randomized to receive either a robotic (robotic group) or conventional laparoscopic hysterectomy (conventional group). The primary end point was total operating time; secondary end points were perioperative outcome, blood loss, and the change in quality of life.

RESULTS

Ninety-five patients out of 100 randomized patients completed the study. Patient age, body mass index, and uterus weight showed no significant differences between both groups. All results are given as mean (± standard deviation; median). Total operating time for the robotic group was significantly higher with 106 (± 29; 103) compared with 75 (± 21; 74) (conventional group) minutes. Blood loss, complications, analgesics use, and return to activity for both groups were comparable. The change in preoperative to postoperative quality-of-life index (quality of life measured on a linear scale from 0 to 100) was significantly higher in the robotic group, with 13 (± 10; 13) compared with 5 (± 14; 5) (conventional group).

CONCLUSION

Robot-assisted laparoscopic hysterectomy and conventional laparoscopy compare well in most surgical aspects, but the robotic procedure is associated with longer operating times. Postoperative quality-of-life index was better; however, long-term, there was no difference. However, subjective postoperative parameters such as analgesic use and return to activity showed no significant difference between both groups.

The place of robotics in gynecologic surgery

Robot-assisted laparoscopic gynecologic surgery has undergone widespread development in recent years. The surgical literature on this subject continues to grow. The goal of this article is to summarize the principal indications for robotic assistance in gynecologic surgery and to offer a general overview of the principal articles dealing with robotic surgery for both benign and malignant disease.

Robotic surgery for benign gynaecological disease

BACKGROUND

Robotic surgery is the latest innovation in the field of minimally invasive surgery. In the case of robotic surgery, instead of directly moving the instruments the surgeon uses a robotic system to control the instruments for surgical procedures. Robotic surgical systems have been used in various gynaecological surgeries for benign disease, such as hysterectomy (removal of the uterus), myomectomy (removal of uterine leiomyomas) and tubal reanastomosis (the reuniting of a divided tube). The mounting evidence demonstrates the feasibility and safety of robotic surgery in benign gynaecological disease. Robotic surgery is advertised as having promising advantages including more precise vision and procedures, improved ergonomics and shorter length of hospital stay. However, the main disadvantages of the robotic surgical system should not be overlooked, including the high cost of disposable instruments and retraining for both surgeons and nurses.

OBJECTIVES

To assess the effectiveness and safety of robot-assisted surgery in the treatment of benign gynaecological disease.

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group's Trial Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2011), MEDLINE and EMBASE up to November 2011 and citation lists of relevant publications.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing robotic surgery for benign gynaecological disease to laparoscopic or open surgical procedures. RCTs comparing different types of robotic assistants were also included. We contacted study authors for unpublished information, but failed in obtaining a response.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion. The domains assessed for risk of bias were allocation concealment, blinding, incomplete outcome data and selective outcome reporting. Odds ratios (OR) were used for reporting dichotomous data with 95% confidence intervals (CI), whilst mean differences (MD) were determined for continuous data. Statistical heterogeneity was assessed using the I(2) statistic. We contacted the primary authors for missing data but failed in obtaining a response.

MAIN RESULTS

Two trials involving 158 participants were included. Since one included trial was published in conference proceedings, limited usable data were available for further analysis. The only analysis in this trial showed comparable rates of conversions to open surgery between the robotic group and the laparoscopic group (OR 1.41, 95% CI 0.22 to 9.01; P = 0.72). One RCT showed longer operation time (MD 66.00, 95% CI 40.93 to 91.07; P < 0.00001), higher cost (MD 1936.00, 95% CI 445.69 to 3426.31; P = 0.01) in the robotic group compared with the laparoscopic group. Also, both studies reported that robotic and laparoscopic surgery seemed comparable regarding intraoperative outcome, complications, length of hospital stay and quality of life.

AUTHORS' CONCLUSIONS

Currently, the limited evidence showed that robotic surgery did not benefit women with benign gynaecological disease in effectiveness or in safety. Further well-designed RCTs with complete reported data are required to confirm or refute this conclusion.

Robotic assisted surgery for gynaecological cancer

BACKGROUND

Robotic surgery is the latest innovation in the field of minimally invasive surgery. Robotic surgical systems have been used to perform surgery for endometrial, cervical cancer and ovarian cancer. There is mounting evidence which demonstrates the feasibility and safety of robotic surgery for gynaecological oncology.

OBJECTIVES

To evaluate the evidence for and against robotic assisted surgery in gynaecological cancer.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Review Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 2), MEDLINE and EMBASE (up to July 2010) and citation lists of relevant publications.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing robotic assisted surgery for gynaecological cancer to laparoscopic or open surgical procedures as well as RCTs comparing different types of robotic assistants.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion. No RCTs were identified, therefore data collection and analysis could not be performed.

MAIN RESULTS

No studies were found that met the inclusion criteria. Controlled clinical trials (CCTs) are summarised and analysed, but are not discussed in the main body of the review as they present a high risk of bias.

AUTHORS' CONCLUSIONS

Well-designed RCTs are required as only low quality evidence from CCTs is available. These studies support the use of robotic assisted surgery for endometrial cancer and cervical cancer, but these findings present a high risk of bias.

Robotic surgery in gynecologic oncology

Robotic surgery for the management of gynecologic cancers allows for minimally invasive surgical removal of cancer-bearing organs and tissues using sophisticated surgeon-manipulated, robotic surgical instrumentation. Early on, gynecologic oncologists recognized that minimally invasive surgery was associated with less surgical morbidity and that it shortened postoperative recovery. Now, robotic surgery represents an effective alternative to conventional laparotomy. Since its widespread adoption, minimally invasive surgery has become an option not only for the morbidly obese but for women with gynecologic malignancy where conventional laparotomy has been associated with significant morbidity. As such, this paper considers indications for robotic surgery, reflects on outcomes from initial robotic surgical outcomes data, reviews cost efficacy and implications in surgical training, and discusses new roles for robotic surgery in gynecologic cancer management.

Robotic tubal anastomosis: technical aspects

The authors conclude that robotic technology can facilitate the performance of robotic tubal anastomosis.

Objectives:

To describe the surgical technique of robotic tubal anastomosis.

Methods:

Retrospective chart and video review of the instrumentation and methodology used for robotically assisted tubal anastomosis.

Results:

All tubal anastomoses were performed with the use of 3 or 4 robotic arms, 3 or 4 robotic instruments, and 1 assistant trocar.

Conclusions:

Robotic technology facilitates the performance of robotic tubal anastomosis.

Advances in medical robotic systems with specific applications in surgery--a review

Although robotics was started as a form of entertainment, it gradually became used in different branches of science. Medicine, particularly in the operating room, has been influenced significantly by this field. Robotic technologies have offered valuable enhancements to medical or surgical processes through improved precision, stability and dexterity. In this paper we review different robotics and computer-assisted systems developed with medical and surgical applications. We cover early and recently developed systems in different branches of surgery. In addition to the united operational systems, we provide a review of miniature robotic, diagnostic and sensory systems developed to assist or collaborate with a main operator system. At the end of the paper, a discussion is given with the aim of summarizing the proposed points and predicting the future of robotics in medicine.

Incidence and characteristics of patients with vaginal cuff dehiscence after robotic procedures

OBJECTIVE

To estimate the incidence and characteristics of patients with vaginal cuff dehiscence after robotic cuff closure.

METHODS

We reviewed medical records from March 2004 to December 2008 of all patients with vaginal cuff dehiscence after a robotic simple and radical hysterectomy, trachelectomy, and upper vaginectomy using the robotic da Vinci Surgical System.

RESULTS

Twenty-one of 510 patients were identified with vaginal cuff dehiscence (incidence 4.1%, 95% confidence interval 2.3-5.8%). In nine patients, the robotic procedure was performed for a gynecologic malignancy. Coitus was the triggering event in 10 patients. Patients most commonly presented with vaginal bleeding and sudden gush of watery vaginal discharge. Bowel evisceration was associated in six patients. Median time to presentation was 43 days or 6.1 weeks. Nineteen cases were repaired through a vaginal approach and one combined vaginal and laparoscopic. Three of 21 patients experienced a repeat dehiscence and required a second repair.

CONCLUSION

Vaginal cuff dehiscence should be considered in patients with vaginal bleeding and sudden watery discharge after robotic cuff closure. The incidence is similar as previously reported for laparoscopic procedures. Contributing factors remain unknown but thermal effect and vaginal closure technique probably play major roles.

LEVEL OF EVIDENCE

III.

Evolving role and current state of robotics in minimally invasive gynecologic surgery

Advancements in conventional laparoscopy afford gynecologists the ability to treat disease with minimally invasive interventions. Procedures such as hysterectomy are still performed predominantly via laparotomy. Instrumentation, complex disease, and steep learning curves are often cited as obstacles to minimally invasive surgery. The advent of robotic technology may provide a means to overcome the limitations of conventional laparoscopy through the use of 3-dimensional imaging and more dextrous and precise instruments. Current studies clearly demonstrate the feasibility and safety of applying robotics to the entire spectrum of gynecologic procedures. Rigorous scientific studies and long-term data are needed to determine the appropriate applications of robotics in gynecology. Numerous questions still exist pertaining to costs, credentialing and privileging, and training.

A novel approach of robotic-assisted anterior resection with transanal or transvaginal retrieval of the specimen for colorectal cancer

BACKGROUND

The surgical robot (da Vinci S) is superior to conventional laparoscopy; it provides clearer, three-dimensional images and an extended range of motion for the instruments. We used this robot for laparoscopic surgery to perform a totally intracorporeal resection of the rectum and colorectal anastomosis, with transanal or transvaginal retrieval of specimens.

METHODS

We prospectively collected data on 13 patients who underwent robot-assisted rectal surgery by a single surgeon from January to March 2008. For low anterior resection (LAR), the splenic flexure was mobilized laparoscopically, followed by robotic rectal resection and anastomosis, and transanal removal of specimens in both male and female patients. We retrieved the specimen through the vagina in some female patients.

RESULTS

Eleven and two patients underwent LAR and anterior resection (AR), respectively. Mean operative time was 260.8 ± 62.9 (range 210-390) min with median robotic time of 118 ± 43.6 (range 122-186) min. There were three postoperative complications, in two patients. One patient had anastomotic bleeding and the other had anastomotic leakage following inferior mesenteric artery bleeding. The circumferential margins were clear. The tumor stage was I in four, II in two, and III in seven patients. In one patient, the distal resection margin was involved. The patients resumed an oral diet and were discharged on the third and seventh day after surgery.

CONCLUSION

Robotic-assisted laparoscopic methods were safe for AR in patients with colorectal cancer. This approach made it easier to perform a total mesorectal excision, anastomosis, and closure of the vaginal wall, and avoided the traditional abdominal incision.