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Overview of Robotics in ObGyn Surgery

Elias D. Abi Khalil, MD; Daniel R. Grow, MD

Most readers are aware that ACOG recently issued an assessment of robot-assisted gynecologic surgery. This article presents the pros and cons of approaches for various conditions, comparing robotic advances with laparascopic and open procedures.

Over the past 20 years, laparoscopy has become an integral part of gynecologic surgery. Advances in instrumentation and technique have allowed us to progress from performing simple tubal ligations to advanced procedures, including hysterectomy, lymph node dissections, removal of broad-based fibroids, and support procedures for pelvic floor prolapse. Training and practice allow the laparoscopic surgeon to perform these advanced laparoscopic procedures that might otherwise require management by laparotomy. In 2005, the robotic surgical system was approved for use in gynecologic surgery; it allows greater dexterity with instrumentation, adding a wrist and 6 degrees of freedom to the otherwise “straight sticks,” provides high-definition 3D optics, and offers autonomy of camera control.1

Robot-assisted surgery has a number of downsides, however, and the most significant is cost. The typical robotic procedure adds $3,000 in expense per case when including the cost of the robot (>$1 million) and the disposable instruments, as well as the annual service fees. Robots are bulky and sophisticated, requiring larger operating rooms. The console allows room for only one surgeon, so residents in training are restricted from participating in most aspects of the procedure.2 The purpose of this article is to review recent literature concerning robotic applications in different gynecologic surgeries, to acknowledge the role of robotics in complex cases, and to confirm the importance and indispensability of conventional laparoscopy in gynecologic surgery, emphasizing the necessity of good training.

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Cervical Cancer

With the introduction of robot-assisted laparoscopic surgery to gynecologic oncologists, several case series have assessed the efficacy and outcome of robotic radical hysterectomy for the treatment of cervical cancer. Two case series showed that robotic radical hysterectomy, when compared to the open approach, was associated with lower mean estimated blood loss, less operative complications, and shorter stay in the hospital.3,4 One group demonstrated that laparoscopic and robotic surgeries are preferred over laparotomy in the performance of radical hysterectomy for the treatment of cervical cancer, and both techniques (laparoscopy and robotic) provided similar benefits for patients.5 Differences in prognosis and survival rates as well as cost-benefit analysis were not mentioned in the studies; these data will be essential to determine the long-term value of robotics in performing minimally invasive surgery for complex gynecologic diseases.

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Endometrial Cancer

Data from a large multi-institutional study showed that the treatment of endometrial cancer with the robotic approach has been associated with improved perioperative outcomes. However, long-term follow-up data regarding recurrence rates and overall survival rates, which are important in defining the role of robotics in the treatment of endometrial cancer, are not yet available.6 New evidence comparing the different surgical methods for staging endometrial cancer established that robot-assisted hysterectomy and lymphadenectomy are feasible and preferable over laparotomy, because of lower estimated blood loss, fewer postoperative complications, and shorter hospital stay.7,8 For robotic hysterectomy and pelvic-aortic lymphadenectomy, each operational segment has a unique learning curve; lymphadenectomy appears to be quickly mastered, while hysterectomy, and in particular vaginal cuff closure, seems to be the task demonstrating the longest learning curve; but overall, proficiency is achieved after 20 cases. Moreover, when comparing the learning curves of the robotic versus laparoscopic approach, novice surgeons demonstrated faster improvement for robotic surgery than laparoscopy, while experienced surgeons had similar learning curves.9 Though further trials comparing robotics to open surgery and laparoscopy are needed to determine which approach is superior in the staging and long-term survival of endometrial cancer, the robotic approach represents a great leap forward.10

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Urogynecologic Procedures

Currently, the gold standard for surgical correction of vaginal vault prolapse is abdominal sarcocolpopexy. Robotic sarcocolpopexy is associated with less blood loss and shorter length of stay than with surgical correction, but it has a longer operative time. Short-term vaginal vault support is similar in both techniques; however, follow-up studies are needed to assess the durability of the robotic approach to prolapse repair.11 Nevertheless, though robotic assistance in pelvic floor surgery is still in its infancy, early experiences are promising. Outcome data are needed to better assess the long-term promise of robotics in urogynecology.12

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Hysterectomy

ACOG has recently reemphasized past statements recommending the use of vaginal hysterectomy whenever feasible. The cost-effectiveness and speed of recovery make this the preferred approach.13 Unfortunately, the vaginal approach is becoming a “lost art” in many regions of the world. Laparoscopic hysterectomies have been reported by many authors in large series. The laparoscopic supracervical hysterectomy is most easily performed, as no suturing is required and the uterine body is “morcelated” quickly and efficiently with specialized 15-mm instruments.

Despite its use, robotic hysterectomy might not be superior to laparoscopic hysterectomy; though it has a similar or slightly reduced (1.0 vs 1.4 days) hospital stay compared to conventional laparoscopy, robotic hysterectomy has comparable outcomes to laparoscopic hysterectomy in terms of estimated blood loss and hemoglobin drop.14 Robots significantly prolong operative time and room time. Furthermore, robotic total laparoscopic hysterectomy has been associated with increased risk of vaginal cuff dehiscence and small bowel evisceration, due to thermal spread and cuff tissue damage from monopolar electrosurgery used for colpotomy, whereas other modalities (harmonic) are typically used with conventional laparoscopy.15 Finally, another drawback for robotic hysterectomy is that the learning curve to stabilize operative time, at approximately 95 minutes in the hands of surgeons with advanced laparoscopic skills, is 50 cases.16

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Adnexal Mass

At present, the preferred operative approach for adnexal mass removal in the United States is laparoscopy. In an attempt to evaluate the application of robotic technology in the performance of adnexectomy, researchers compared surgical outcomes between patients undergoing laparoscopic and robotic adnexal removal.17 Laparoscopy provided similar results as robotics in terms of estimated blood loss, operative complications, and length of hospital stay but proved to be superior when operative times were compared. Consequently, the study authors concluded that they continue to prefer laparoscopy as a method to approach adnexal masses, especially large ones, since trocar placement is not restricted as in robots, making manipulation of masses easier. In addition, large benign cystic masses can be drained laparoscopically but not with robotic instruments.

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Tubal Reversal

Some patients desiring fertility after tubal ligation prefer tubal anastomosis over in vitro fertilization because of the higher cost, increased risk for multiple gestation and ovarian hyperstimulation syndrome, and additional regular office visits for monitoring associated with the latter. Recent studies show that robotic tubal anastomosis is feasible, with results that are comparable to the conventional open approach.18 However, the cost of the robotic approach is higher, the surgical time prolonged, and the rate of ectopic pregnancies increased.19 This makes robotic tubal anastomosis a second-choice procedure, reserved for patients who are not good candidates for tubal anastomosis by minilaparotomy.

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Myomectomy

Leiomyoma is the most common benign tumor in women. Laparoscopic myomectomy has provided an alternative to laparotomy for the treatment of intramural and subserous leiomyoma. A comparison between robot-assisted versus standard laparoscopic myomectomy showed that robotic procedures were significantly longer compared with standard laparoscopy.20 Furthermore, robotics required a bigger port-site incision; however, blood loss, hospitalization time, and postoperative complications were not significantly different between the approaches. Thus, robotic myomectomy may not offer any advantage over laparoscopic myomectomy in the hands of skilled laparoscopic surgeons.20 Suturing is made easier with the robot. Uterine dehiscence has been described with the robotic and laparoscopic approaches and is likely increased over the open approach. Tactile sensation for discovering hidden myomas may also be important in myomectomy cases and is not possible with either closed technique. The long-term role of the robot for this indication remains to be determined.

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Conclusion

Robotic technology can be helpful in complex procedures and for malignant conditions that traditionally have been treated using open techniques. Robots provide surgeons with the freedom of the human hand, facilitating the performance of surgical maneuvers that closely mirror open techniques. The robot may also serve during the initial learning period of endoscopic surgeons, as it is an enabling device for suturing in a 3D environment. In addition, it eases the learning curve and allows the novice endoscopic surgeon to master laparoscopic suturing earlier, without the time-intensive training required to learn suturing with “straight sticks.”

Nevertheless, the robotic system has some disadvantages. For example, for many benign procedures performed by a skilled laparoscopic surgeon, the disadvantages of the robot outweigh its benefits, which makes laparoscopy or vaginal surgery the most effective approach in general gynecology. Training to advance conventional laparoscopy skills still goes a long way and will improve the education of our next generation of gynecologic laparoscopists.

The authors report no actual or potential conflicts of interest in relation to this article.

Resources on Robotics in ObGyn For an in-depth discussion of robotics in ObGyn, consult these excellent resources: ACOG Committee on Gynecologic Practice. ACOG Technology Assessment No. 6: Robot-assisted surgery. Obstet Gynecol. 2009;114(5):1153-1155. Visco AG, Advincula AP. Robotic gynecologic surgery. Obstet Gynecol. 2008;112(6):1369-1384.

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Elias D. Abi Khalil, MD, is a recent graduate of American University of Beirut in Hamra, Beirut, Lebanon. Daniel R. Grow, MD, is Chairman, Department of Obstetrics and Gynecology, and Associate Professor, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA.

References

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2. ACOG Technology Assessment No. 6: Robot-assisted surgery. Obstet Gynecol. 2009;114(5):1153-1155.
3. Ko EM, Muto MG, Berkowitz RS, Felmate CM. Robotic versus open radical hysterectomy: a comparative study at a single institution. Gynecol Oncol. 2008;111(3):425-430.
4. Maggioni A, Minig L, Zanagnolo V, et al. Robotic approach for cervical cancer: comparison with laparotomy: a case control study. Gynecol Oncol. 2009;115(1):60-64.
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