Robotic surgery in gynecology: an updated systematic review

The application of robotics in plastic and reconstructive surgery: A systematic review

BACKGROUND

Robotic assisted surgery (RAS) has seen significant advancement in many surgical specialties, although the application of robotics in plastic and reconstructive surgery remains to be widely established. This systematic review aims to assess the role of RAS in plastic and reconstructive surgery.

METHODS

The review protocol was published and registered a priori as CRD42024507420. A comprehensive electronic search for relevant studies was performed in MEDLINE, Embase and Google scholar databases.

RESULTS

Overall, 132 studies were initially identified, of which, 44 studies satisfied the eligibility criteria with a cumulative total of 239 patients. RAS demonstrated a high degree of procedural success and anastomotic patency in microvascular procedures. There was no significant difference in periprocedural adverse events between robotic and manual procedures.

CONCLUSION

RAS can be feasibly implemented in plastic and reconstructive surgery with a good efficacy and safety profile, particularly for microsurgical anastomosis and trans-oral surgery.

Exploring the Evolution of Robotic Surgery in Obstetrics and Gynecology: Past, Present, and Future Perspectives

Robotic surgery has emerged as a transformative technology in obstetrics and gynecology, offering enhanced precision and minimally invasive techniques for various procedures. This paper explores the evolution of robotic surgery in obstetrics and gynecology, examining its historical development, current applications, and prospects. Through a comprehensive review of the literature and case studies, we highlight the benefits of robotic surgery, including reduced trauma, improved patient outcomes, and increased surgeon capabilities. However, cost, training requirements, and regulatory concerns hinder widespread adoption. Continuing technological innovation is expected to enhance the efficacy and applicability of robotic-assisted procedures. Collaboration between healthcare professionals, researchers, and industry stakeholders is essential to address these challenges and ensure optimal patient care. By embracing the opportunities presented by robotic surgery while addressing associated challenges, practitioners and researchers can contribute to the continued advancement of this transformative technology in obstetrics and gynecology.

Robotic retroperitoneal para-aortic lymphadenectomy via single-site port

Para-aortic staging is sometimes a standard feature in the management of pelvic cancers. Minimal invasive approach is recommended. Several routes are possible: extra-peritoneal or intraperitoneal depending on the expertise of the surgeon. We performed several extraperitoneal para-aortic lymphadenectomy using the Da Vinci Xi robotic system through single-site incision. We have developed a step-by-step guide from patient installation, installation of the Gelpoint V monotrocar, docking of the robot arms, to surgery, with the aim of performing the most efficient and safest procedure. The surgery does not differ from standard laparoscopic extraperitoneal lymphadenectomy. The advantages of minimally invasive robotic surgery in this indication are comparable to those of the standard laparoscopy approach. But through single-site incision, the Da Vinci Xi robot improves video quality, plus its wristed tools facilitates movements compared to conventional laparoscopy.

Advancements in Robotic Surgery: A Comprehensive Overview of Current Utilizations and Upcoming Frontiers

Robotic surgery, a groundbreaking advancement in medical technology, has redefined the landscape of surgical procedures. This comprehensive overview explores the multifaceted world of robotic surgery, encompassing its definition, historical development, current applications, clinical outcomes, benefits, emerging frontiers, challenges, and future implications. We delve into the fundamentals of robotic surgical systems, examining their components and advantages. From general and gynecological surgery to urology, cardiac surgery, orthopedics, and beyond, we highlight the diverse specialties where robotic surgery is making a significant impact. The many benefits discussed include improved patient outcomes, reduced complications, faster recovery times, cost-effectiveness, and enhanced surgeon experiences. The outlook reveals a healthcare landscape where robotic surgery is increasingly vital, enabling personalized medicine, bridging healthcare disparities, and advancing surgical precision. However, challenges such as cost, surgeon training, technical issues, ethical considerations, and patient acceptance remain relevant. In conclusion, robotic surgery is poised to continue shaping the future of health care, offering transformative possibilities while emphasizing the importance of collaboration, innovation, and ethical governance.

Surgical Frontiers: A Comparative Review of Robotics Versus Laparoscopy in Gynecological Interventions

This review comprehensively examines the current state and future directions of gynecological surgery, focusing on the comparative analysis of laparoscopy and robotic surgery. The overview highlights the evolution of these surgical techniques, emphasizing their impact on patient outcomes, procedural efficiency, and safety profiles. The analysis encompasses critical factors such as cost-effectiveness, learning curves, and implications for postoperative recovery. The future of gynecological surgery is envisioned through emerging technologies, including augmented reality, single-incision laparoscopy, and artificial intelligence. The coexistence of laparoscopy and robotics is explored, acknowledging their respective strengths and roles in shaping women's healthcare. In conclusion, the dynamic nature of the field is underscored, emphasizing the need for a patient-centered and adaptable approach. Collaboration between healthcare professionals, engineers, and researchers is pivotal in unlocking these innovations' full potential, ensuring continued advancements in gynecological surgery for improved outcomes and enhanced patient care.

Risk of Reintervention or Postoperative Bleeding after Laparoscopy for Benign Gynecological Disease: A Clinical Prediction Model

OBJECTIVE

The objective of the study was to develop a clinically applicable prediction tool to early seek for postoperative major complications after laparoscopic surgery for benign pathologies.

DESIGN

Retrospective analysis of prospectively collected data was performed.

SETTING

The study was conducted at Tertiary Care University Hospital.

PARTICIPANTS

The participants of this study were reproductive-aged women undergoing laparoscopy for benign conditions.

METHODS

Anamnestic, intraoperative, and postoperative characteristics from January 2019 to December 2021 were retrospectively reviewed. Patients with postoperative complications (reintervention or postoperative bleeding) were matched in a 1:2 ratio with women with same surgical indications without complications. Cases and controls were matched for preoperative hemoglobin, hematocrit, weight, height, body mass index, age, and blood volume. A prediction model was created by inserting multiple independent modifying factors through logistic regression. The receiver operating characteristic (ROC) curve was used to evaluate the predictive accuracy of the model, and the Hosmer-Lemeshow (H-L) test was carried out to evaluate the goodness-of-fit, and a calibration curve was drawn to confirm the predictive performance. A nomogram was depicted to visualize the prediction model.

RESULTS

Thirty-nine complicated procedures were matched with 78 uncomplicated controls. According to the multivariate logistic regression analysis findings, the prediction model was developed using C-reactive protein (CRP), intraoperative blood loss, and 24 h postoperative urinary volume, therefore a nomogram was generated. The area under the ROC curve of the prediction model was 0.879, depicting good accuracy, the sensitivity was 60.00%, while specificity reached 93.59%. The H-L test (χ2 = 4.45, p = 0.931) and the calibration curve indicated a good goodness-of-fit and prediction stability.

LIMITATIONS

The retrospective design, moderate sensitivity, and study population limit the generalization of the findings, requiring additional research.

CONCLUSIONS

This prediction model based on CRP, intraoperative blood loss, and 24 h postoperative urinary volume might be a potentially useful tool for predicting reintervention and postoperative bleeding in patients undergoing planned gynecological laparoscopy.

Uterine Neoplasms, Version 1.2023, NCCN Clinical Practice Guidelines in Oncology

Adenocarcinoma of the endometrium (also known as endometrial cancer, or more broadly as uterine cancer or carcinoma of the uterine corpus) is the most common malignancy of the female genital tract in the United States. It is estimated that 65,950 new uterine cancer cases will have occurred in 2022, with 12,550 deaths resulting from the disease. Endometrial carcinoma includes pure endometrioid cancer and carcinomas with high-risk endometrial histology (including uterine serous carcinoma, clear cell carcinoma, carcinosarcoma [also known as malignant mixed Müllerian tumor], and undifferentiated/dedifferentiated carcinoma). Stromal or mesenchymal sarcomas are uncommon subtypes accounting for approximately 3% of all uterine cancers. This selection from the NCCN Guidelines for Uterine Neoplasms focuses on the diagnosis, staging, and management of pure endometrioid carcinoma. The complete version of the NCCN Guidelines for Uterine Neoplasms is available online at NCCN.org.

Potential Contenders for the Leadership in Robotic Surgery

Purpose: To summarize the scientific published literature on new robotic surgical platforms with potential use in the urological field, reviewing their evolution from presentation until the present day. Our goal is to describe the current characteristics and possible prospects for these platforms. Materials and Methods: A nonsystematic search of the PubMed, Cochrane library's Central, EMBASE, MEDLINE, and Scopus databases was conducted to identify scientific literature about new robotic platforms other than the Da Vinci^® system, reviewing their evolution from inception until December 2020. Only English language publications were included. The following keywords were used: "new robotic platforms," "Revo-I robot," "Versius robot," and "Senhance robot." All relevant English-language original studies were analyzed by one author (R.F.) and summarized after discussion with an independent third party (E.M., S.Y., S.P., and M.A.). Results: Since 1995, Intuitive Surgical, Inc., with the Da Vinci surgical system, is the leading company in the robotic surgical market. However, Revo-I^®, Versius^®, and Senhance^® are the other three platforms that recently appeared on the market with available articles published in peer-reviewed journals. Among these three new surgical systems, the Senhance robot has the most substantial scientific proof of its capacity to perform minimally invasive urological surgery and as such, it might become a contender of the Da Vinci robot. Conclusions: The Da Vinci surgical platform has allowed the diffusion of robotic surgery worldwide and showed the different advantages of this type of technique. However, its use has some drawbacks, especially its price. New robotic platforms characterized by unique features are under development. Of note, they might be less expensive compared with the Da Vinci robotic system. We found that these new platforms are still at the beginning of their technical and scientific validation. However, the Senhance robot is in a more advanced stage, with clinical studies supporting its full implementation.

An interdisciplinary team-training protocol for robotic gynecologic surgery improves operating time and costs: analysis of a 4-year experience in a university hospital setting

Main aim of this study is to assess the effect of a structured, interdisciplinary, surgical, team-training protocol in robotic gynecologic surgery, with the gradual integration of an advanced nurse practitioner. Data from all robotic surgical procedures were prospectively acquired. The surgical team consisted of one experienced surgeon and two surgical fellows and the scrub nurse team from three advance nurse practitioners, specialized in robotic surgery. The training was performed in a four-phase manner over 4 years and included theoretical training, hands-on training and team-communication skills enhancement. Scrub nurses increasingly adopted an active role during surgery. For a period of 4 years, 175 patients could be included in the analysis. All of them underwent a robotic gynecologic procedure. Mean docking time decreased from 45.3 to 27.3 min (p < 0.001), mean operating time from 235 to 179 min (p = 0.0071) and costs per case from 17,891 to 14,731 Swiss Francs (p = 0.035). There were no statistically significant changes in perioperative complications and conversions to laparotomy. An interdisciplinary long-term training protocol for high specialized robotic surgery within a “fixed” team with the gradually addition of an advanced study nurse improves the efficacy of the procedure in terms of time and costs. Although the surgery is performed quicker, the same performance and quality of surgical care could be reached.

Cholecystectomy using the Revo-i robotic surgical system from Korea: the first clinical study

This study evaluated the safety and efficacy of the newly developed Revo-i (Meerecompany, Yongin, Republic of Korea) robotic surgical system during robot-assisted cholecystectomy. This prospective, phase I clinical study involved 15 patients with gallbladder-related disease. The primary outcome evaluated was the intraoperative safety of the Revo-i; the secondary outcomes measured were the 30-day postoperative complications and patient satisfaction with the Revo-i's performance. Between August 17 and December 23, 2016, we performed 15 robot-assisted cholecystectomies. The operations were successfully completed, without any conversions to open or laparoscopic approaches. The mean patient age (53.07 years), mean operative time (115.3 ± 17.31 min [± standard deviation]), docking time (10.6 ± 3.16 min), console time (49.7 ± 15.41 min), actual dissection time (33.1 ± 10.53 min), and estimated blood loss (3.33 ± 6.17 mL) were determined. There were no intra- or postoperative complications, including gallbladder perforations. The mean hospital stay was 2.0 ± 1.00 days. Most patients reported satisfaction with the Revo-i's performance. Performing robot-assisted cholecystectomies using the Revo-i is feasible and safe. This report describes the first clinical study of the Revo-i robotic surgical system in human patients.

Feasibility of robotic radical hysterectomy (RRH) with a new robotic system. Experience at Galaxy Care Laparoscopy Institute

The main objective of this study was to assess in a series of 30 patients, the feasibility, oncological safety and efficacy of radical hysterectomy by a new robotic system. Prospective study design. Galaxy Care Laparoscopy Institute and Multispeciality Hospital. We performed Robotic Radical Hysterectomy in patients from August 2019 through February 2020. All the surgeries were performed by a single surgeon (Puntambekar S). Since August 2019, 30 patients with early cervical cancer/endometrial cancer were selected for radical hysterectomy. All patients were in good general condition with controlled medical comorbidities. The mean operative time was 104 min, with mean total lymph node yield of 24.7. The average blood loss was 60 ml and the hospital stay was 2.1 days, and majority of the patients were catheter free by 1 week. Two patients developed uretero-vaginal fistula on the 8th day of surgery. One was managed with Double J stenting and in the other we did laparoscopic ureteroneocystostomy. Our study has demonstrated the feasibility, safety and efficacy of RRH by the Versius robotic systems.

Perioperative Complications and Safety Evaluation of Robot-Assisted Radical Hysterectomy of Cervical Cancer After Neoadjuvant Chemotherapy

Purpose

To evaluate the perioperative complications of patients with cervical cancer who are treated with robot-assisted radical hysterectomy (RRH) and to further evaluate the safety of patients undergoing NACT.

Methods

A total of 805 consecutive cervical cancer patients undergoing RRH were involved in this report. Their clinical characteristics were retrieved from hospital medical records. Perioperative complications were subdivided into intraoperative and postoperative complications, which were graded according to the Clavien-Dindo classification (CDC), and the complications of grade III and above were defined as severe complications. Furthermore, the two-level logistic regression model was used to estimate the risk factors of perioperative and severe complications and to further confirm the relationship between NACT and perioperative and severe complications.

Results

The perioperative complication rate and severe complications were 45.09% and 7.83%, respectively. Poorly differentiated tumor and NACT were identified as independent risk factors for perioperative complications by multifactor analysis. Furthermore, we concentrated on the relations between NACT and complications. The risk of perioperative complications of the group with NACT (OR = 11.08, 95% CI: 5.70-21.54) was significantly higher than the group without NACT, especially in postoperative complications (OR=17.65, 95% CI: 8.63-36.08), even after adjusting confounding factors. However, there was no statistically significant difference in terms of severe complications (OR=1.68, 95% CI: 0.64-4.41) and intraoperative complications (OR=0.51, 95% CI: 0.18-1.41). Moreover, as the times of NACT increase, the impact on perioperative complications is more pronounced. A similar trend was observed in postoperative complications, while this statistical difference was still not observed in intraoperative and severe complications.

Conclusion

This result demonstrates the feasibility and safety of RRH of cervical carcinoma after NACT in generally, since it only causes mild complications, not severe complications.

Learning curve could affect oncologic outcome of minimally invasive radical hysterectomy for cervical cancer

BACKGROUND/OBJECTIVE

Recent prospective studies have shown poorer oncologic outcomes following minimally invasive surgery, which has led many surgeons to deeply inspect their practices. We reviewed our experience and evaluated the results of radical hysterectomy in patients with early stage cervical cancer.

METHODS

This retrospective study included patients with early stage cervical cancer (Ia1 - IIa1) who were treated with radical hysterectomy from May 2006 to Dec 2016. Patients were divided into three groups according to the surgical approach: radical abdominal hysterectomy (RAH), laparoscopic radical hysterectomy (LRH), and robot-assisted radical hysterectomy (RRH).

RESULTS

Learning curves of each type of surgery were obtained using the cumulative sum method. Survival rates were compared using Kaplan-Meier curves. To analyze the learning curve of a single surgeon, 89 patients were selected from the whole population. Learning curves of each group showed two distinct phases. The minimum number of cases required to achieve surgical improvement were 16 in RAH, 13 in LRH, and 21 in RRH. Progression-free survival (PFS) and overall survival did not vary between RAH and minimally invasive surgery (MIS) (p = .828 and p = .757, respectively). However, when stratified by the phases of the learning curves, patients included in the early phase of MIS showed a poorer PFS (p = .014).

CONCLUSIONS

Surgical proficiency could significantly affect the oncologic outcome in MIS. A prospective study regarding sufficient surgical competence is necessary for elaborate analysis of the feasibility of minimally invasive radical hysterectomy.

Method for the Detection of Tumor Blood Vessels in Neurosurgery Using a Gripping Force Feedback System

Avoiding unnecessary bleeding during neuroendoscopic surgeries is crucial because achieving hemostasis in a narrow operating space is challenging. However, when the location of a blood vessel in a tumor cannot be visually confirmed, unintentional damage to the vessel and subsequent bleeding may occur. This study proposes a method for tumor blood vessel detection using a master-slave surgical robot system equipped with a force sensor in the slave gripper. Using this method, blood pulsation inside a tumor was detected, displayed as a gripping force wave, via the slave force sensor. The characteristics of gripping force due to blood pulsation were extracted by measuring the fluctuation of the force in real time. The presence or absence of blood vessels was determined on the basis of cross-correlation coefficients between the gripping force fluctuation waveform due to blood pulsation and model fluctuation waveform. Experimental validation using two types of simulated tumors (soft: E = 6 kPa; hard: E = 38 kPa) and a simulated blood vessel (E = 1.9 MPa, radius = 0.5 mm, thickness = 0.1 mm) revealed that the presence of blood vessels could be detected while gripping at a constant angle and during transient gripping.

Validity evidence for procedural competency in virtual reality robotic simulation, establishing a credible pass/fail standard for the vaginal cuff closure procedure

BACKGROUND

The use of robotic surgery for minimally invasive procedures has increased considerably over the last decade. Robotic surgery has potential advantages compared to laparoscopic surgery but also requires new skills. Using virtual reality (VR) simulation to facilitate the acquisition of these new skills could potentially benefit training of robotic surgical skills and also be a crucial step in developing a robotic surgical training curriculum. The study's objective was to establish validity evidence for a simulation-based test for procedural competency for the vaginal cuff closure procedure that can be used in a future simulation-based, mastery learning training curriculum.

METHODS

Eleven novice gynaecological surgeons without prior robotic experience and 11 experienced gynaecological robotic surgeons (> 30 robotic procedures) were recruited. After familiarization with the VR simulator, participants completed the module 'Guided Vaginal Cuff Closure' six times. Validity evidence was investigated for 18 preselected simulator metrics. The internal consistency was assessed using Cronbach's alpha and a composite score was calculated based on metrics with significant discriminative ability between the two groups. Finally, a pass/fail standard was established using the contrasting groups' method.

RESULTS

The experienced surgeons significantly outperformed the novice surgeons on 6 of the 18 metrics. The internal consistency was 0.58 (Cronbach's alpha). The experienced surgeons' mean composite score for all six repetitions were significantly better than the novice surgeons' (76.1 vs. 63.0, respectively, p < 0.001). A pass/fail standard of 75/100 was established. Four novice surgeons passed this standard (false positives) and three experienced surgeons failed (false negatives).

CONCLUSION

Our study has gathered validity evidence for a simulation-based test for procedural robotic surgical competency in the vaginal cuff closure procedure and established a credible pass/fail standard for future proficiency-based training.

Prediction of perioperative complications after robotic-assisted radical hysterectomy for cervical cancer using the modified surgical Apgar score

BACKGROUND

Although there has been marked development in surgical techniques, there is no easy and fast method of predicting complications in minimally invasive surgeries. We evaluated whether the modified surgical Apgar score (MSAS) could predict perioperative complications in patients undergoing robotic-assisted radical hysterectomy.

METHODS

All patients with cervical cancer undergoing robotic-assisted radical hysterectomy at our institution between January 2011 and May 2017 were included. Their clinical characteristics were retrieved from their medical records. The surgical Apgar score (SAS) was calculated from the estimated blood loss, lowest mean arterial pressure, and lowest heart rate during surgery. We modified the SAS considering the lesser blood loss typical of robotic surgeries. Perioperative complications were defined using a previous study and the Clavien-Dindo classification and subdivided into intraoperative and postoperative complications. We analyzed the association of perioperative complications with low MSAS.

RESULTS

A total of 138 patients were divided into 2 groups: with (n = 53) and without (n = 85) complications. According to the Clavien-Dindo classification, 49 perioperative complications were classified under Grade I (73.1%); 13, under Grade II (19.4%); and 5, under Grade III (7.5%); 0, under both Grade IV and Grade V. Perioperative complications were significantly associated with surgical time (p = 0.026). The MSAS had a correlation with perioperative complications (p = 0.047). The low MSAS (MSAS, ≤6; n = 52) group had significantly more complications [40 (76.9%), p = 0.01]. Intraoperative complications were more correlated with a low MSAS than were postoperative complications [1 (1.2%) vs. 21 (40.4%); p < 0.001, 13 (15.1%) vs. 25 (48.1%); p = 0.29, respectively]. We also analyzed the risk-stratified MSAS in 3 subgroups: low (MSAS, 7-10), moderate (MSAS 5-6), and high risks (MSAS, 0-4). The prevalence of intraoperative complications significantly increased as the MSAS decreased p = 0.01).

CONCLUSIONS

This study was consistent the concept that the intuitive and simple MSAS might be more useful in predicting intraoperative complications than in predicting postoperative complications in minimally invasive surgeries, such as robotic-assisted radical hysterectomy for cervical cancer.

Surgical and Pathological Outcomes of Laparoscopic Versus Abdominal Radical Hysterectomy With Pelvic Lymphadenectomy and/or Para-aortic Lymph Node Sampling for Bulky Early-Stage Cervical Cancer

BACKGROUND AND OBJECTIVES

The aim of this study was to compare the feasibility, morbidity, and recurrence rate of total laparoscopic radical hysterectomy (LRH) with those of abdominal radical hysterectomy (ARH) for bulky early-stage cervical cancer.

METHODS

We performed a retrospective cohort study of 112 patients with stage IB1 or IIA2 cervical cancer in which the tumor diameter was 3 cm or greater. All patients underwent LRH (n = 30) or ARH (n = 82) with pelvic lymphadenectomy and/or para-aortic lymph node sampling between May 2011 and November 2014. Perioperative outcomes were compared between the 2 surgical groups.

RESULTS

The laparoscopic approach consisted of 4 trocar insertions. Age, tumor diameter, and pelvic lymph nodes significantly differed between the 2 cohorts. Body mass index, International Federation of Gynecology and Obstetrics stage, histologic type and grade, deep stromal invasion, lymphovascular space invasion, positive margins, and adjuvant therapy were not significantly different between the 2 cohorts. Laparoscopic radical hysterectomy exhibited favorable results compared with ARH in terms of operating time, blood loss, intestinal exhaust time, and length of hospital stay. In addition, recurrence was observed in 5 LRH patients (16.7%) and 9 ARH patients (11.7%).

CONCLUSIONS

The surgical outcomes of LRH with pelvic lymphadenectomy and/or para-aortic lymph node sampling exhibited a similar therapeutic efficacy to those of the ARH approach.

A Swedish population-based evaluation of benign hysterectomy, comparing minimally invasive and abdominal surgery

OBJECTIVE

The aim was to evaluate surgical routes for benign hysterectomy in a Swedish population, including abdominal and minimally invasive surgery.

STUDY DESIGN

Prospectively collected data from the Swedish National GynOp Registry 2009-2015: 13 806 hysterectomy cases were included: abdominal (AH, n = 7485), vaginal (VH, n = 3767), conventional laparoscopic (LH, n = 1539) and robotically-assisted (RAH, n = 1015).

RESULTS

The VH group had the shortest operation time at 75 min, AH 97 min and RAH 104 min. LH was longest at 127 min (p < 0.005). The mean estimated blood loss was higher in the AH group (250 ml) compared to all minimally invasive surgery (MIS, 65-172 ml); p < 0.005). Conversion rates were 10% for LH, 4.8% for VH and 1.6% for RAH (p < 0.005). Hospitalization and patient-reported time to normal activities of daily living (ADL) were longer for AH compared to MIS (p < 0.005). Time to return to work was eight days longer in the AH group (35 days) compared with the MIS groups (p < 0.005). Complications were fewest in the VH group at 5.4% compared with AH 7.6% and RAH 8.7% (both p < 0.001), but did not significantly differ from the LH group at 6.6%. Overall patient satisfaction was reported to be 86-94% one year after surgery.

CONCLUSION

Women operated on for benign hysterectomy with minimally invasive methods in Sweden 2009-2015 had reduced length of hospitalization, as well as time to resuming normal ADL and return to work, compared to AH. Postoperative outcome measures were improved by minimally invasive methods and MIS should preferably be used.

Robot-assisted hysterectomy for endometrial and cervical cancers: a systematic review

Total and radical hysterectomies are the most common treatment strategies for early-stage endometrial and cervical cancers, respectively. Surgical modalities include open surgery, laparoscopy, and more recently, minimally invasive robot-assisted surgery. We searched several electronic databases for randomized controlled trials and observational studies with a comparison group, published between 2009 and 2014. Our outcomes of interest included both perioperative and morbidity outcomes. We included 35 observational studies in this review. We did not find any randomized controlled trials. The quality of evidence for all reported outcomes was very low. For women with endometrial cancer, we found that there was a reduction in estimated blood loss between the robot-assisted surgery compared to both laparoscopy and open surgery. There was a reduction in length of hospital stay between robot-assisted surgery and open surgery but not laparoscopy. There was no difference in total lymph node removal between the three modalities. There was no difference in the rate of overall complications between the robot-assisted technique and laparoscopy. For women with cervical cancer, there were no differences in estimated blood loss or removal of lymph nodes between robot-assisted and laparoscopic procedure. Compared to laparotomy, robot-assisted hysterectomy for cervical cancer showed an overall reduction in estimated blood loss. Although robot-assisted hysterectomy is clinically effective for the treatment of both endometrial and cervical cancers, methodologically rigorous studies are lacking to draw definitive conclusions.

Robotics in urological surgery: evolution, current status and future perspectives

CONTEXT

Robotic surgery is rapidly evolving and has become an essential part of surgical practice in several parts of the world. Robotic technology will expand globally and most of the surgeons around the world will have access to surgical robots in the future. It is essential that we are updated about the outcomes of robot assisted surgeries which will allow everyone to develop an unbiased opinion on the clinical utility of this innovation.

OBJECTIVE

In this review we aim to present the evolution, objective evaluation of clinical outcomes and future perspectives of robot assisted urologic surgeries.

ACQUISITION OF EVIDENCE

A systematic literature review of clinical outcomes of robotic urological surgeries was made in the PUBMED. Randomized control trials, cohort studies and review articles were included. Moreover, a detailed search in the web based search engine was made to acquire information on evolution and evolving technologies in robotics.

SYNTHESIS OF EVIDENCE

The present evidence suggests that the clinical outcomes of the robot assisted urologic surgeries are comparable to the conventional open surgical and laparoscopic results and are associated with fewer complications. However, long term results are not available for all the common robotic urologic surgeries. There are plenty of novel developments in robotics to be available for clinical use in the future.

CONCLUSION

Robotic urologic surgery will continue to evolve in the future. We should continue to critically analyze whether the advances in technology and the higher cost eventually translates to improved overall surgical performance and outcomes.

The centralization of robotic surgery in high-volume centers for endometrial cancer patients--a study of 6560 cases in the U.S

OBJECTIVE

To evaluate the hospital and patient factors associated with robotic surgery for endometrial cancer in the United States.

METHODS

Data was obtained from the Nationwide Inpatient Sample from the year 2010. Chi-squared and multivariate analyses were used for statistical analysis.

RESULTS

Of the 6560 endometrial cancer patients who underwent surgery, the median age was 62 (range: 22 to 99). 1647 (25%) underwent robotic surgery, 820 (13%) laparoscopic, and 4093 (62%) had open surgery. The majority was White (65%). Hospitals with 76 or more hysterectomy cases for endometrial cancer patients per year (4% of hospitals in the study) performed 31% of all hysterectomies and 40% of all robotic hysterectomies (p<0.01). 29% of Whites had robotic surgery compared to 15% of Hispanics, 12% of Blacks, and 11% of Asians (p<0.01). Patients with upper-middle and high incomes underwent robotic surgery more than patients with low or middle incomes (p<0.01). 27% of Medicare patients and 26% of patients with private insurance had robotic surgery compared to only 14% of Medicaid patients and 12% of uninsured patients (p<0.01).

CONCLUSIONS

The majority of robotic surgeries for endometrial cancer were performed at a small number of high-volume hospitals in the United States. Socioeconomic status, insurance type, and race were also important predictors for the use of RS. Further studies are warranted to better understand the barriers to receiving minimally invasive surgery.

Preparedness of Ob/Gyn residents for fellowship training in gynecologic oncology

Residency training in obstetrics and gynecology is being challenged by increasingly stringent regulations and decreased operative experience. We sought to determine the perception of preparedness of incoming gynecologic oncology fellows for advanced surgical training in gynecologic oncology. An online survey was sent to gynecologic oncologists involved in fellowship training in the United States. They were asked to evaluate their most recent incoming clinical fellows in the domains of professionalism, level of independence/graduated responsibility, psychomotor ability, clinical evaluation and management, and academia and scholarship using a standard Likert-style scale. The response rate among attending physicians was 40% (n = 105/260) and 61% (n = 28/46) for program directors. Of those who participated, 49% reported that their incoming fellows could not independently perform a hysterectomy, 59% reported that they could not independently perform 30 min of a major procedure, 40% reported that they could not control bleeding, 40% reported that they could not recognize anatomy and tissue planes, and 58% reported that they could not dissect tissue planes. Fellows lacked an understanding of pathophysiology, treatment recommendations, and the ability to identify and treat critically ill patients. In the academic domain, respondents agreed that fellows were deficient in the areas of protocol design (54%), statistical analysis (54%), and manuscript writing (65%). These results suggest that general Ob/Gyn residency is ineffective in preparing fellows for advanced training in gynecologic oncology and should prompt a revision of the goals and objectives of resident education to correct these deficiencies.

Robotic Surgery – A Personal View of the Past, Present and Future

Research into robotic surgery has been undertaken for over 25 years. In that period a small number of companies have been formed to exploit this research and have undertaken clinical trials on patients. However, far fewer clinical applications have been undertaken than would have been expected from the level of research activity. This paper puts forward a number of reasons for this, many of which are not to do with the technology but are a consequence of the clinical and business environments. Recommendations are provided that will hopefully increase the number of clinical systems being applied. Some predictions are made for the future which should increase the number of commercial systems and thus achieve patient benefits.

Evidence-based anesthesia for major gynecologic surgery

Studies on enhanced recovery after gynecological surgery are limited but seem to report outcome benefits similar to those reported after colorectal surgery. Regional anesthesia is recommended in enhanced recovery protocols. Effective regional anesthetic techniques in gynecologic surgery include spinal anesthesia, epidural analgesia, transversus abdominis plane blocks, local anesthetic wound infusions and intraperitoneal instillation catheters. Non-opioid analgesics including pregabalin, gabapentin, NSAIDs, COX-2 inhibitors, and paracetamol reduce opioid consumption after surgery. This population is at high risk for PONV, thus, a multimodal anti-emetic strategy must be employed, including strategies to reduce the baseline risk of PONV in conjunction with combination antiemetic therapy.

Evaluation of active camera control systems in gynecological surgery: construction, handling, comfort, surgeries and results

OBJECTIVE

Surgeon-controlled endoscope leading assistance systems are a novelty in endoscopic surgery. These systems were evaluated for their applicability and reliability in operative gynecology. In this regard, we evaluated possible methods of operation, operative time, setup time, and comfort for the surgeon, complications, blood transfusions, length of stay, hemoglobin levels, and demographic data.

METHODS

Two systems with technically identical camera control systems were applied, the SOLOASSISTTM system and the Einstein VisionTM 3D system. The arm systems are attached to the operating table and controlled by surgeon via a manual control, a remote control or a foot switch. Comfort for the surgeon was evaluated using a questionnaire (scale 1-5; 1 "very good", 5 "poor"). All data were collected prospectively in a database (IBM SPSS Statistics 20) and evaluated.

RESULTS

One hundred and four patients underwent surgery supported by an active control system. In 43 (41 %) cases, oncological interventions were performed. Average setup time was 7 (3-30) min. There was a significant learning curve regarding the mounting of the system after 20 operations (p = 0.045). Overall comfort was rated as "good", divided into control 2.2 (2-4), physical effort 2.1 (1-4), picture quality 1.6 (1-3), and overall satisfaction 2.1 (1-4). About 75 unwanted camera movements were noticed in 104 surgeries. Complications occurred in no case (0 %).

CONCLUSION

The application of an active camera control system was evaluated to be safe for all gynecological laparoscopies. Picture blur is avoided even during prolonged complex procedures. Moreover, the assistant is able to support the surgeon with two instruments, with the result that the presence of a second assistant is not required for complex interventions. Causing only minimal setup time, the examined active control systems improve the effectiveness of surgeries. The physical effort required for the assistant decreases and, by reducing tiring operations and tremor, subsequently, higher precision is reached.

A novel locally operated master-slave robot system for single-incision laparoscopic surgery

PURPOSE

Single-incision laparoscopic surgery (SILS) provides more cosmetic benefits than conventional laparoscopic surgery but presents operational difficulties. To overcome this technical problem, we have developed a locally operated master-slave robot system that provides operability and a visual field similar to conventional laparoscopic surgery.

MATERIAL AND METHODS

A surgeon grasps the master device with the left hand, which is placed above the abdominal wall, and holds a normal instrument with the right hand. A laparoscope, a slave robot, and the right-sided instrument are inserted through one incision. The slave robot is bent in the body cavity and its length, pose, and tip angle are changed by manipulating the master device; thus the surgeon has almost the same operability as with normal laparoscopic surgery. To evaluate our proposed system, we conducted a basic task and an ex vivo experiment.

RESULTS

In basic task experiments, the average object-passing task time was 9.50 sec (SILS cross), 22.25 sec (SILS parallel), and 7.23 sec (proposed SILS). The average number of instrument collisions was 3.67 (SILS cross), 14 (SILS parallel), and 0.33 (proposed SILS). In the ex vivo experiment, we confirmed the applicability of our system for single-port laparoscopic cholecystectomy.

CONCLUSION

We demonstrated that our proposed robot system is useful for single-incision laparoscopic surgery.

Robotically assisted gynecologic surgery: 2-year experience in the French foch hospital

Robotically assisted laparoscopic surgery has seen rapid expansion over the past few years and it constantly evolves with a progressive enlargement of its range of indications. In the present paper we would like to share our 2-year experience regarding the use of robotics in various laparoscopic procedures, including hysterectomy, myomectomy, adnexal surgery, and sacrocolpopexy.

The safety and effectiveness of Da Vinci surgical system compared with open surgery and laparoscopic surgery: a rapid assessment

OBJECTIVE

The primary objectives of this rapid assessment were to assess the clinical evidence of Da Vinci surgical system (DVSS) comparing with open procedures and laparoscopic procedures, and in order to provide the evidence for health decision makers and clinician.

METHODS

A comprehensive search of electronic databases (EMbase, PubMed, The Cochrane Library, Web of Science, CNKI, VIP, CBM and Wanfang) and HTA websites were completed up to 9 October, 2013. Two reviews (Jiajie Yu and Yingqiang Wang) independently extracted data of the manuscripts, and assessed quality of included studies using AMSTAR tools. Qualitative description and GRADE were used to report the outcomes and evidence quality.

OUTCOMES

A total of 17 studies were included: 3 were HTA and 14 were SR/meta-analysis. The included studies focused on prostatectomy, nephrectomy, hysterectomy colorectal surgery, and cardiac surgery. DVSS was shown to be associated with statistically significant reduction in length of hospital stay, blood loss, and transfusion rate compared with open and laparoscopic surgery, but increase in operative time when compared with open surgery.

CONCLUSION

Based on the evidence included in this rapid assessment, DVSS has a limited impact on several clinical outcomes. Considering no available data from randomized controlled trials and much higher cost, decisions will be complex and need to be made carefully. Decision makers should cut down the quantity of purchasing and reasonable allocate them.

Indian experience of robotics in gynecology

AIMS:

To study the role of robotics in various gynaecological cases, benign and malignant.

MATERIALS AND METHODS:

A total number of 80 cases have been analyzed. Operative time, estimated blood loss, hospital stay, complications, conversion rates have been retrospectively studied in all cases. Nodal yield, vaginal margin and paracervical clearance have been studied in all malignant cases. This investigation was conducted at a single minimal access surgery institute.

RESULTS:

Of total 80 cases, 29 were benign and 51 were malignant cases. In benign cases, total robotic hysterectomies were 24, 2 cases of tubotuboplasty, 1 case of endometriotic cyst excision, 1 case of metroplasty and 1 case of rectovaginal fistula. In 51 cases, 37 of radical hysterectomy, 9 exenterations and 6 were parametrectomy. In benign cases, mean operative time was 80 min, estimated blood loss was 20 ml, mean hospital stay was for 1 day, no major complications and no conversions. In malignant cases, mean operative time was 122 min, estimated blood loss was 50-100ml, 2 cases of ureteric fistulas and no conversions, nodal yield was 30, vaginal margin was 2.5-3.8 cm and para cervical clearance was 3-3.5 cm.

CONCLUSIONS:

Ours is the largest series of robotic surgery in gynecological procedures in India. Benign and malignant cases were addressed robotically showing the feasibility.

Steep Trendelenburg position during robotic sacrocolpopexy and heart rate variability

OBJECTIVES

The objective of this study was to evaluate heart rate variability and hemodynamic parameters following steep Trendelenburg positioning during robotic sacrocolpopexy.

STUDY DESIGN

For 19 women, median age 57 (range: 45-72), blood pressure and ECG were recorded during surgery. From the ECG signals interbeat intervals were used to assess heart rate variability, analyzed in time and frequency domains using the Fast Fourier transform. The low frequency and high frequency spectral bands were used to assess sympathetic and parasympathetic pathways respectively.

RESULTS

All women underwent robotic supracervical hysterectomy and sacrocolpopexy. A statistically significant decrease in the mean values of the low-frequency and high-frequency spectral bands, representing sympathetic and parasympathetic activity, respectively were demonstrated 5min following Trendelenburg positioning of the patients (from 3.6±1.4 to 2.9±0.8ms(2)/Hz, and from 3.5±1.4 to 2.9±1ms(2)/Hz, P<0.05). These changes correlated with a mean 20% decrease in heart rate, which lasted for 30min, and with a second drop in sympathetic and parasympathetic activity and heart rate, commencing 2h from the start of surgery, and lasting until the end of the operation.

CONCLUSIONS

Steep Tredelenburg positioning during robotic urogynecology surgery results in significant changes in the autonomic nervous system modulation of heart rate variability and in other hemodynamic parameters.

A systematic review and cost analysis of robot-assisted hysterectomy in malignant and benign conditions

In order to assess the effectiveness and costs of robot-assisted hysterectomy compared with conventional techniques we reviewed the literature separately for benign and malignant conditions, and conducted a cost analysis for different techniques of hysterectomy from a hospital economic database. Unlimited systematic literature search of Medline, Cochrane and CRD databases produced only two randomized trials, both for benign conditions. For the outcome assessment, data from two HTA reports, one systematic review, and 16 original articles were extracted and analyzed. Furthermore, one cost modelling and 13 original cost studies were analyzed. In malignant conditions, less blood loss, fewer complications and a shorter hospital stay were considered as the main advantages of robot-assisted surgery, like any mini-invasive technique when compared to open surgery. There were no significant differences between the techniques regarding oncological outcomes. When compared to laparoscopic hysterectomy, the main benefit of robot-assistance was a shorter learning curve associated with fewer conversions but the length of robotic operation was often longer. In benign conditions, no clinically significant differences were reported and vaginal hysterectomy was considered the optimal choice when feasible. According to Finnish data, the costs of robot-assisted hysterectomies were 1.5-3 times higher than the costs of conventional techniques. In benign conditions the difference in cost was highest. Because of expensive disposable supplies, unit costs were high regardless of the annual number of robotic operations. Hence, in the current distribution of cost pattern, economical effectiveness cannot be markedly improved by increasing the volume of robotic surgery.

Comparison of perioperative outcomes and cost between robotic-assisted and conventional laparoscopy for transperitoneal infrarenal para-aortic lymphadenectomy (TIPAL)

STUDY OBJECTIVE

To compare perioperative outcomes and cost of robotic-assisted and laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy (TIPAL) for treatment of gynecologic malignant conditions.

DESIGN

Prospective non-randomized study (Canadian Task Force classification II-2).

SETTING

Tertiary center for women's health.

PATIENTS

Sixty-two patients with gynecologic cancer operated on by the same surgical team.

INTERVENTIONS

Thirty-two patients underwent TIPAL via robotic-assisted laparoscopy, and 30 via conventional laparoscopy. Comparison analyses of perioperative outcomes and estimated costs were performed.

MEASUREMENTS AND MAIN RESULTS

There were no differences between robotic-assisted and laparoscopy insofar as age, body mass index, presurgical morbidity, operating time (92.5 minutes for robotics vs 96.6 minutes for laparoscopy), number of aortic nodes (12 vs. 12), hospitalization stay (2 vs. 2 days), or rate of complications (12.5% vs. 13.3%). Blood loss tended to be lower in the robotic group (75.0 vs. 92.5 mL; p = .08). Surgical cost was higher in the robotic group ($3.42 vs. $2.55; p < .001), although hospitalization cost was similar.

CONCLUSION

Robotic-assisted and laparoscopy provide similar perioperative outcomes. However, the robotic-assisted approach is associated with higher surgical cost.

Virtual reality robotic surgical simulation: an analysis of gynecology trainees

STUDY OBJECTIVE

To analyze the learning curves of gynecology trainees on several virtual reality da Vinci Skills Simulator exercises.

DESIGN

Prospective cohort pilot study.

SETTING

Academic hospital-based gynecology training program.

PARTICIPANTS

Novice robotic surgeons from a gynecology training program.

METHODS

Novice robotic surgeons from an academic gynecology training program completed 10 repetitions of 4 exercises on the da Vinci Skills Simulator: matchboard, ring and rail, suture sponge, and energy switching. Performance metrics measured included time to completion, economy of instrument movement, excessive force, collisions, master workspace range, missed targets, misapplied energy, critical errors, and overall score. Statistical analyses were conducted to define the learning curve for trainees and the optimal number of repetitions for each exercise.

RESULTS

A total of 34 participants were enrolled, of which 9 were medical students, 22 were residents, and 3 were fellows. There was a significant improvement in performance between the 1st and 10th repetitions across multiple metrics for all exercises. Senior trainees performed the suture exercise significantly faster than the junior trainees during the first and last repetitions (p = 0.004 and p = 0.003, respectively). However, the performance gap between seniors and juniors narrowed significantly by the 10th repetition. The mean number of repetitions required to achieve performance plateau ranged from 6.4 to 9.3.

CONCLUSION

Virtual reality robotic simulation improves ability through repetition at all levels of training. Further, a performance plateau may exist during a single training session. Larger studies are needed to further define the most high-yield simulator exercises, the ideal number of repetitions, and recommended intervals between training sessions to improve operative performance.

Robotic surgery basic skills training: Evaluation of a pilot multidisciplinary simulation-based curriculum

PURPOSE

Simulation-based training improves clinical skills, while minimizing the impact of the educational process on patient care. We present results of a pilot multidisciplinary, simulation-based robotic surgery basic skills training curriculum (BSTC) for robotic novices.

METHODS

A 4-week, simulation-based, robotic surgery BSTC was offered to the Departments of Surgery and Obstetrics & Gynecology (ObGyn) at the University of Toronto. The course consisted of various instructional strategies: didactic lecture, self-directed online-training modules, introductory hands-on training with the da Vinci robot (dVR) (Intuitive Surgical Inc., Sunnyvale, CA), and dedicated training on the da Vinci Skills Simulator (Intuitive Surgical Inc., Sunnyvale, CA) (dVSS). A third of trainees participated in competency-based dVSS training, all others engaged in traditional time-based training. Pre- and post-course skill testing was conducted on the dVR using 2 standardized skill tasks: ring transfer (RT) and needle passing (NP). Retention of skills was assessed at 5 months post-BSTC.

RESULTS

A total of 37 participants completed training. The mean task completion time and number of errors improved significantly post-course on both RT (180.6 vs. 107.4 sec, p < 0.01 and 3.5 vs. 1.3 sec, p < 0.01, respectively) and NP (197.1 vs. 154.1 sec, p < 0.01 and 4.5 vs. 1.8 sec, p = 0.04, respectively) tasks. No significant difference in performance was seen between specialties. Competency-based training was associated with significantly better post-course performance. The dVSS demonstrated excellent face validity.

CONCLUSIONS

The implementation of a pilot multidisciplinary, simulation-based robotic surgery BSTC revealed significantly improved basic robotic skills among novice trainees, regardless of specialty or level of training. Competency-based training was associated with significantly better acquisition of basic robotic skills.

A pilot study of surgical training using a virtual robotic surgery simulator

Training on a virtual reality robotic simulator dry lab robotic surgery platform resulted in significant improvement in time to completion and economy of motion for novice robotic surgeons.

Background and Objectives:

Our objectives were to compare the utility of learning a suturing task on the virtual reality da Vinci Skills Simulator versus the da Vinci Surgical System dry laboratory platform and to assess user satisfaction among novice robotic surgeons.

Methods:

Medical trainees were enrolled prospectively; one group trained on the virtual reality simulator, and the other group trained on the da Vinci dry laboratory platform. Trainees received pretesting and post-testing on the dry laboratory platform. Participants then completed an anonymous online user experience and satisfaction survey.

Results:

We enrolled 20 participants. Mean pretest completion times did not significantly differ between the 2 groups. Training with either platform was associated with a similar decrease in mean time to completion (simulator platform group, 64.9 seconds [P = .04]; dry laboratory platform group, 63.9 seconds [P < .01]). Most participants (58%) preferred the virtual reality platform. The majority found the training “definitely useful” in improving robotic surgical skills (mean, 4.6) and would attend future training sessions (mean, 4.5).

Conclusion:

Training on the virtual reality robotic simulator or the dry laboratory robotic surgery platform resulted in significant improvements in time to completion and economy of motion for novice robotic surgeons. Although there was a perception that both simulators improved performance, there was a preference for the virtual reality simulator. Benefits unique to the simulator platform include autonomy of use, computerized performance feedback, and ease of setup. These features may facilitate more efficient and sophisticated simulation training above that of the conventional dry laboratory platform, without loss of efficacy.

Robotically Assisted Hysterectomy versus Vaginal Hysterectomy for Benign Disease: A Prospective Study

Objectives. A prospective study was carried out to compare vaginal hysterectomy (VH) and robotically assisted hysterectomy (RH) for benign gynecological disease. Materials and Methods. All patients who underwent hysterectomy from March 2010 to March 2012 for a benign disease were included. Patients' demographics per and post surgery results were collected from medical files. A questionnaire was also conducted 2 months after surgery. Results. Sixty patients were included in the RH group and thirty four in the VH one. Operative time was significantly longer in the RH group (132.1 ± 5.7 versus 75.3 ± 6.7 min; P < 0.0001). Blood loss and length of hospital stay were significantly reduced: 47 ± 7 versus 125 ± 20 ml; P < 0.01, and 2.4 ± 0.1 versus 3.3 ± 0.2 days; P < 0.0001, respectively. Less pain was reported at D1 and D2 by RH patients, and levels of analgesia were lower compared to those observed in the VH group. No differences were found regarding the rate of conversion to laparotomy, intra- or postoperative complications. Conclusion. Robotically assisted hysterectomy appears to reduce blood loss, postoperative pain, and length of hospital stay, but it is associated with longer operative time and higher cost. Specific indications for RH remain to be defined.

Uterine fibroids and current clinical challenges

Uterine fibroids (UF) are the most common gynecological tumors in premenopausal women. Hysterectomy remains the major and definitive therapeutic option. Minimally invasive surgical techniques for performing hysterectomy have many advantages over laparotomy. Current drug therapies for UF remain unsatisfactory. Unquestionably, continued investigation of novel agents is necessary. The currently used drugs for UF treatment which exclusively modulate a single target, typically either the estrogen or progesterone signaling pathways, are limited in their therapeutic effects. By contrast, multi-target drugs which simultaneously modulate multiple critical hubs in the network of the signaling pathways underlying UF pathogenesis should achieve robust and durable therapeutic effects.

Robotic single-site hysterectomy: feasibility, learning curve and surgical outcome

BACKGROUND

The field of laparoscopy has undergone several changes to improve the morbidity and cosmesis of laparoscopic surgery. The robotic single-site surgery is the inevitable hybridization of robotic technology with laparoendoscopic single-site surgery.

METHODS

Perioperative information of 12 robotic single-site hysterectomies (R-SSH) were collected to evaluate the surgical feasibility and the possible influence of the body mass index (BMI) and the uterine weight on operative times.

RESULTS

The mean operative time was 85 ± 33 min (range, 355 to 149 min), the mean docking time was 9 ± 3 min, and the mean console time was 76 ± 33 min. The mean blood loss was 80 ± 18 mL, and the median weight of resected uteri was 220 ± 45 g. No serious postoperative complications occurred. The CUSUM learning curve was observed to consist of two different phases: phase 1 (the initial 6 cases) and phase 2 (the last 6 cases) with significant reduction in operative and console time observed between the two phases. For BMI, no correlation was found with operative times, console times, and docking times, and no correlation was found between uterine weight and operative time.

CONCLUSIONS

This series, identifying two different phases of the learning curve and suggesting that the initial learning phase for the procedure can be achieved after six cases, confirms the feasibility and safety of a robotic approach for single-site hysterectomy. However, the limits of this study mainly rely on the limited casuistic and short follow-up, although the preliminary results appear promising. Larger series and prospective studies comparing R-SSH hysterectomy with standard robotic multiport hysterectomy are necessary to define properly the role of this innovative surgical technique.

Malpractice claims and avoidance of complications in endoscopic surgery

Laparoscopy has become a valuable tool for the gynaecologist in the diagnosis and treatment of a variety of gynecological disorders. Its quicker recovery time and other advantages has benefitted countless women. Laparoscopic procedures, however, have their own associated risks and complications, and the surgeon must become thoroughly familiar with these. This awareness will help reduce patient morbidity and mortality, and potentially avoid the stress and burden of litigation, which has been increasing in recent years. Complications of gynaecologic laparoscopy include entry-related problems, and injuries to bowel, urinary tract, blood vessels, and nerves. Although some of these complications have been well described, some have emerged recently in relation to new technology and techniques. In this chapter, we discuss some of the complications of endoscopic surgery, including their incidence, prevention, and medico-legal implications, and provide a brief overview of their management.

Robotic surgery - advance or gimmick?

Robotic surgery is increasingly implemented as a minimally invasive approach to a variety of gynaecological procedures. The use of conventional laparoscopy by a broad range of surgeons, especially in complex procedures, is hampered by several drawbacks. Robotic surgery was created with the aim of overcoming some of the limitations. Although robotic surgery has many advantages, it is also associated with clear disadvantages. At present, the proof of superiority over access by laparotomy or laparoscopy through large randomised- controlled trials is still lacking. Until results of such trials are present, a firm conclusion about the usefulness of robotic surgery cannot be drawn. Robotic surgery is promising, making the advantages of minimally invasive surgery potentially available to a large number of surgeons and patients in the future.

Anesthetic considerations in robotic-assisted gynecologic surgery

BACKGROUND

Robotic-assisted surgery has evolved over the past 2 decades with constantly improving technology that assists surgeons in multiple subspecialty disciplines. The surgical requirements of lithotomy and steep Trendelenburg positions, along with the creation of a pneumoperitoneum and lack of direct access to the patient all present management challenges in gynecologic surgery. Patient positioning requirements can have significant physiologic effects and can result in many complications.

METHODS

This review focuses on the anesthetic and surgical implications of robot-assisted technology in gynecologic surgery.

CONCLUSION

Good communication among team members and knowledge of the nuances of robotic surgery have the potential to improve patient outcomes, increase efficiency, and reduce complications.