Chapter 28 Robotics
KEY POINTS
1 Robotic surgery is a form of facilitated laparoscopy that utilizes robotic technology to
enhance the performance of the operation by placing a computerized interface
between the patient and surgeon.
2 Two of the most important differences between conventional laparoscopic
instruments and robotic instruments are articulation and intuitive movements.
3 The robotic system offers advantages for the surgeon, but it is particularly useful in
the following circumstances: obese patients, long surgeries, operations requiring
extensive suturing and dissection, or high precision.
4 High precision and absence of tremor are useful for retroperitoneal
lymphadenectomy, adhesiolysis, parametrial ureteral dissection, and accurate
suturing, in such procedures as ureteral anastomosis or reimplantation, and
genitourinary fistula repair.
5 Applications of robotic technology include simple and radical hysterectomy,
myomectomy, appendectomy (in conjunction with other procedures), adnexectomy,
excision of severe pelvic and upper abdominal endometriosis, tubal anastomosis,
and rectovaginal or vesicovaginal fistulas.
6 Studies show the feasibility of robotics for the treatment of patients with cervical,
endometrial, tubal, and ovarian cancer, with apparent similar or better perioperative
outcomes compared to laparoscopy and with improved outcomes compared to
laparotomy.
[1] Robotic surgery as applied to laparoscopy utilizes robotic technology to
facilitate the performance of the operation by placing a computerized interface
between the patient and surgeon. Although originally designed for cardiovascular
1612surgery and approved for that use by the U.S. Food and Drug Administration
(FDA) in 2003, it has found applications in urology and gynecology, and in
otolaryngology, general surgery, plastic surgery, and colorectal surgery.
There are studies showing that the use of robotic technology for the
performance of preset laboratory exercises results in faster performance
times, increased accuracy, enhanced dexterity, easier and faster suturing,
and fewer errors when compared to conventional laparoscopic
instrumentation (1–4). The physical stress for medical students learning robotics
is significantly less than what they encounter when learning the same tasks by
laparoscopy (5). The technologic advantages of robotics can facilitate learning
surgical techniques when compared to acquiring similar skills in laparoscopy, as
demonstrated by a shorter learning curve for robotic surgery. There is a flattening
of the operating time after 20 to 50 robotic hysterectomies, while for
laparoscopically assisted vaginal hysterectomy (LAVH) a similar facility with the
requisite skills does not occur until after 80 procedures (6–9). In gynecologic
oncology, a flattening of the operating time was noted after approximately 20
procedures for endometrial cancer when using the robotic technology, compared
to nearly 50 cases when using conventional laparoscopy (10,11).
ROBOTIC TECHNOLOGY AND DIFFERENCES WITH
LAPAROSCOPY
There is only one robotic system available, brand-named da Vinci (Intuitive Inc.,
Sunnyvale, CA), which received FDA approval for the performance of
hysterectomy in 2005. A second generation of the device, the da Vinci S, was
released in 2006, and the third generation of the da Vinci robotic system, the Si
model, was released in 2009 and it incorporates a resident teaching console. The
fourth-generation robotic system (Xi model) was released in 2014 and allows for
multiquadrant abdominal access. Both the Si and Xi models allow for single-site
robotic surgery.
A robotic system is composed primarily of a robotic column, which holds the
robotic arms (Fig. 28-1) and a surgeon’s console (Fig. 28-2). The robotic arms
that hold the robotic instruments (Fig. 28-3) are fastened to the robotic trocars
(Fig. 28-4A–C). Commonly used robotic instruments for gynecologic surgeries
are shown in Figure 28-5A–I.
For single-site robotic surgery, a single-site port is placed through a 1.5-cm
fascial incision. The robotic trocars are placed through the port and cross midline.
The robotic technology allows the surgeon’s hands to be associated with the
opposite trocar to allow for natural movement of the instruments. Commonly used
robotic instruments for single-site surgery are shown in Figure 28-5H–I and
1613include Maryland bipolar forceps, fenestrated bipolar forceps, monopolar hook,
and wristed needle driver. With the exception of the needle driver, single-site
robotic instruments do not have wristed movement (28).
Robotic Column
The robotic column has four robotic arms (Fig. 28-1). The fourth arm is
extremely useful for assisting with tissue retraction. The robotic arms function
toward the direction of the robotic column and not away from it. For this reason,
the robotic column must be positioned strategically in response to the location of
the surgery that will be performed.
For pelvic surgery the robotic column is commonly side-docked over the
patient’s hip, while for upper abdominal surgery it is positioned over the
patient’s shoulder (Fig. 28-6) (28). Side-docking allows easy access to the
entrance of the vagina and rectum.
An advantage of the Xi model is that it allows for multi-quadrant abdominal
access. The Xi robotic column can be side-docked over the patient’s hip to allow
for pelvic surgery. If upper abdominal access is needed for procedures such as
resection of diaphragmatic endometriosis or aortic lymphadenectomy, the robotic
boom can be rotated without repositioning of the robotic column.
Robotic Console
The surgeon sits at the console (Fig. 28-2) away from the patient (Fig. 28-7) and
the assistant remains at the bedside next to the patient. The surgeon has a
stereoscopic image, which is different from the laparoscopic image, and controls
the movements of the robotic arms using two hand controls and several foot
pedals. The movements of the robotic arms are managed by the hand controls and
allow for wristed movement of the robotic instruments. The finger controls allow
the camera to be focused and have a clutch feature that permits ergonomic
repositioning of the hand controls throughout the surgery (Fig. 28-8). Robotic
movements are intuitive; the tip of the instrument mimics the movement of the
surgeon’s hands, in contrast to the experience in laparoscopy when the
movements of the tip of the instrument are counterintuitive, opposite to the
movements of the surgeon’s hands. The three foot pedals controlled by the left
foot include clutch, camera, and arm swap. The four foot pedals controlled by the
right foot allow for energy activation (i.e., monopolar, bipolar, vessel sealing)
(Fig. 28-9). The left aspect of the surgeon console allows for ergonomic
adjustments and the right aspect houses the power and emergency stop buttons
(Fig. 28-10A–C).
1614FIGURE 28-1 Robotic column with robotic arms.
1615FIGURE 28-2 Robotic console with hand controls and foot switches.
Because the surgeon is separated from the patient, there is a time delay that
permits the performance of telesurgery, as long as the latency time does not
exceed 150 ms. The surgeon can control the movements of the robotic arms and
1616instruments in a patient located at a different geographic location (12).
Telementoring allows the mentor surgeon to guide another surgeon through a
surgical procedure at a remote location by using superimposed electronic signals
(telestration), direct voice commands, and control of the laparoscope via joystick
and the electrosurgical instruments (13).
Other technologic advantages include downscaling of movements, absence of
tremor, and stillness. In laparoscopy the amplitude of movement of the tip of the
instrument is the same as the amplitude of the movement of the surgeon’s hands,
whereas in robotics it can be downsized, resulting in increased precision. The
computerized interface between surgeon hands and robotic instruments eliminates
unwanted tremor, increasing precision. When placed in a specific position, such
as for retracting bowel or uterus, the robotic instruments remain in place until
repositioned, which can be different from human assistance.
The lack of tactile feedback (haptics) is a drawback for the neophyte, but the
stereoscopic view rapidly compensates for it. There is a degree of resistance felt
at the hand controls of the console, which, coupled with the stereoscopic view,
allows the surgeon to obtain visual haptics and determine the consistency of
tissues, whether soft or hard, such as “to palpate” the rim of the cervical cup of a
uterine manipulator, or “feel” a hard probe introduced in the rectum. The lack of
tactile feedback is an advantage when operating in obese patients, because the
surgeon cannot feel the resistance of the instruments being inserted through a
thick abdominal wall, a difference from laparoscopy.
1617FIGURE 28-3 Robotic laparoscope and two robotic arms with robotic instruments
inserted. The tip of the instruments can be appreciated in the insert.
161816191620FIGURE 28-4 The robotic trocars are metallic. A: daVinciS and Si trocars. The three
types of available trocar obturators are on the left of the picture: blunt (left), tissuespreading (middle) and cutting (right). B: daVinci Xi trocar. C: daVinci Single-Site curved
trocar.
Another potential advantage of the robotic laparoscopy technique compared to
laparoscopy without the assistance of robotics is that it may decrease the number
of injuries in surgeons. There are multiple reports of laparoscopic-related surgeon
morbidity syndromes, resulting from the unnatural forced position of wrists,
fingers, elbows, and shoulders and the awkward standing position of the surgeon
(14). A lower number of surgeon injuries and lower perception of surgeon’s pain,
numbness, and fatigue has been shown to occur when using robotics compared to
conventional laparoscopy (15). Both physical and cognitive ergonomics are
significantly improved with robotic surgery as compared to laparoscopic surgery
(16).
Instrumentation
[2] Two of the most important differences between conventional laparoscopic
instruments and robotic instruments are articulation and intuitive movements. The
tip of a laparoscopic instrument is rigid and the instrument has only 4 degrees of
freedom. With the exception of single-site instruments, the tips of robotic
instruments are articulated with 7 degrees of freedom, reproducing the
movements of the human wrist and fingers (Fig. 28-5A–I) (EndoWrist
Instruments, Intuitive Surgery Inc., Sunnyvale, CA). The articulation allows the
performance of complex maneuvers in small spaces; it accommodates the
instrument to the correct plane of dissection (instead of forcing the tissue to the
direction of the instrument as in laparoscopy), eliminates changing instruments
from one port to another as in conventional laparoscopy, and facilitates suturing
and intracorporeal knot tying. As indicated above, the movement of the robotic
instruments is intuitive, following the movement of the surgeon hands.
16211622162316241625162616271628FIGURE 28-5 Robotic instruments commonly used in gynecologic surgeries. A:
Monopolar curved scissors. B: Monopolar spatula. C: PK (plasma kinetic) dissecting
forceps, bipolar. D: ProGrasp forceps, bipolar. E: Tenaculum forceps used for
myomectomy. F: Needle grasper used for suturing. G: Vessel sealer. H: Single-site
monopolar hook. I: Single-site needle grasper.
TYPES OF INSTRUMENTS
Robotic instruments useful for gynecologic surgery include ProGrasp forceps, PK
dissecting forceps, tenaculum forceps, SutureCut needle driver, monopolar curved
scissors, monopolar cautery spatula, and vessel sealer (Fig. 28-5A–I).
Trocars
The robotic trocars are 8 mm, metallic and have three different types of
obturators: blunt, tissue-spreading, and cutting (Fig. 28-4A–C). The robotic
trocars are placed in a different configuration than conventional laparoscopy
trocars because of technical limitations imposed by the robotic arms. They
are usually placed at the level of the umbilicus or higher for pelvic surgery and
must be 10 cm away from each other and from the laparoscope to prevent
collision of the robotic arms (Fig. 28-11). If an assistant trocar is necessary, it
1629must be placed 3 to 5 cm away from any of the other trocars. The trocar
configuration, when using the S or Si models, is in the shape of an “M” directed
toward the target anatomy. When using the Xi model, the trocar configuration is a
line parallel to the target anatomy.
Docking
Docking is a robotic term defined as the attachment of the robotic arms to
the robotic trocars inserted in the patient. A mean docking time of about 3
minutes was reported in an initial study of 93 patients undergoing robotic
hysterectomy (6). Docking times per surgeon improved progressively after groups
of 10 patients each.
CERTIFICATION AND CREDENTIALING IN ROBOTICS
There is a mandatory training course of 2 days to obtain certification in robotics
provided by the manufacturing company Intuitive, Inc. (Sunnyvale, CA) in
centers located in the United States, Europe, and Asia. The gynecologist learns
the robotic system and logs about 8 hours of dry and animal laboratory tasks.
Residents or fellows completing training programs with robotics must
demonstrate proficiency with documented basic robotic training and successfully
perform a minimum of 10 robotic surgeries, preferably of the same type, and
obtain a letter from the program director attesting to their level of robotic
proficiency. Credentialing is dependent on each hospital credentialing body and is
different for each institution: while some require robotic practice in five animals
and having a proctor for the first five robotic surgeries, others mandate having a
proctor for only two to five robotic procedures prior to obtaining robotic
privileges.
Assistant
An assistant is needed for docking, exchanging robotic instruments, solving
robotic arm collision, retrieving small specimens, and retracting tissue. The
assistant must be trained in robotics and be very knowledgeable about the
procedure, because the surgeon is seated in a separate place and not scrubbed.
TEACHING ROBOTICS
The robotic teaching console allows the surgeon and the resident or fellow to each
have his or her own console while having dual control. The surgeon is able to
demonstrate the performance of a specific task to the trainee, or to assist the
resident with one robotic arm, or prevent an imminent injury by disengaging the
1630robotic arms from the resident’s hands, while both surgeon and resident are seated
and viewing the stereoscopic image. Use of a teaching console versus single
console in training programs has been shown to improve perioperative outcomes
(17).
Previous laparoscopic experience was considered an advantage to learning
robotics. Multiple reports show that transitioning from laparotomy to robotics is
easier than transitioning from laparoscopy to robotics (18). A large number of
gynecologic oncologists and gynecologists incorporated robotics into their daily
practice without having incorporated laparoscopy into their practice or performing
advanced laparoscopic procedures. In one study the initiation of robotics in a
gynecologic oncology program reduced laparotomy from 78% to 35% in the first
year of implementation and it increased the number of minimally invasive
procedures from 22% performed by laparoscopy to 65% being robotic assisted
(18). Robotic technology is relatively easy to use, associated with a short learning
curve, and comfortable for the surgeon (18–20). It is less stressful to learn
robotics than laparoscopy. Reduced stress and ease of learning with robotics
compared to laparoscopy was demonstrated when 16 medical students were
exposed to both techniques (5).
ROBOTIC APPLICATIONS IN BENIGN GYNECOLOGY
[3] The robotic system offers advantages for the surgeon, but it is
particularly useful in the following circumstances: obese patients, long
surgeries, and operations requiring extensive suturing or high precision.
There is no resistance felt by the surgeon’s hands during the movement of the
robotic instruments, regardless of the thickness of the patient’s abdominal wall.
Suturing and intracorporeal knot tying are greatly facilitated by the articulation of
the robotic instruments. The surgeon’s fatigue is decreased when seated for long
operations. [4] High precision and absence of tremor is useful for
retroperitoneal lymphadenectomy, adhesiolysis, parametrial ureteral
dissection, and accurate suturing, such as for ureteral anastomosis or
reimplantation and genitourinary fistula repair. [5] Applications of robotic
technology include simple hysterectomy, myomectomy, appendectomy (in
conjunction with other procedures), adnexectomy, excision of severe
endometriosis, tubal anastomosis, and rectovaginal or vesicovaginal fistulas,
especially those in the upper vagina (1,4). Robotic surgery is associated with a
similar or shorter surgical time than conventional laparoscopy for the
performance of simple hysterectomy and myomectomy, with reduced blood loss,
complication rates, and hospital stays (2,4).
1631FIGURE 28-6 The robotic column is positioned over the patient’s hip for pelvic surgery
and over the patients shoulder for upper abdominal surgery as shown here.
1632FIGURE 28-7 The surgeon is seated at the console and is able to maintain a relaxed
position for the arms and legs.
Hysterectomy
Laparoscopic-assisted vaginal hysterectomy was introduced in 1989.
Laparoscopic approach to hysterectomy peaked at 15.5% of all hysterectomies in
2006 (21). By contrast, 5 years after FDA approval of robotic hysterectomy in
2005, 8.2% of hysterectomies were performed robotically in 2010 (21).
1633FIGURE 28-8 The finger controls allow the camera to be focused and have a clutch
feature for ergonomic repositioning of the hand controls.
1634FIGURE 28-9 The foot pedals controlled by the left foot include clutch, camera, and arm
swap. The foot pedals controlled by the right foot allow for energy activation (i.e.,
monopolar, bipolar, vessel sealing).
A report on 569 women who underwent robotic hysterectomy and 230 women
who underwent laparoscopic hysterectomy showed reduction in estimated blood
loss and hospital length of stay with the robotic approach. No difference was
noted in surgical time (117.2 vs. 118.3 minutes respectively) (22). Rates of
conversion were four times greater in laparoscopic approach compared to robotic
hysterectomy (22).
Myomectomy
Laparoscopic myomectomy provides less morbidity and a shorter recovery
time compared to open myomectomy in two prospective randomized studies
(23,24). Similarly, robotic myomectomy morbidity and recovery times appear
preferable to open myomectomy. In a comparison of both techniques, robotic
patients experienced less blood loss, no blood transfusions, lower postoperative
complications, and shorter hospital stays. The operating time and cost were
increased in the robotic group (25). A series of 575 myomectomies (393
abdominal, 93 laparoscopic, 89 robotic) was evaluated (26). Surgical time was
1635greatest in robotic approach when compared to abdominal or laparoscopic (181,
155, 126 minutes respectively) (23). Estimated blood loss (100, 150, 200 mL) and
hemoglobin decrease (1.3, 1.55, 2 g/dL) were least in robotic myomectomy (26).
Hospital length of stay and need for blood transfusion were superior in both the
robotic and laparoscopic myomectomy groups (26).
Robotic myomectomy provided comparable perioperative results to
laparoscopy in three retrospective studies of patients with symptomatic
myomas (26–28). No significant differences were noted between both groups for
blood loss, complications, and hospital stay. The robotic operating time was
longer than laparoscopy in two of the studies and no different in the other (26–
28). In our comparison study, we noted differences favorable to the robotic group
relative to operating time (141 vs. 166 minutes), blood loss (100 vs. 250 mL), and
hospital stay more than 2 days (12% vs. 23%). There were no significant
differences between groups when patients were adjusted for uterine size and
myoma weight. There were no differences in intra- or postoperative
complications. Postmyomectomy pregnancy rates, uterine rupture, and late
operative complications using robotics remain undetermined.
Adnexectomy
Numerous studies show the benefits of laparoscopy over laparotomy for
patients with an adnexal mass. Robotics provides similar perioperative
outcomes when compared to laparoscopy for patients with an adnexal mass.
Outcomes were improved with robotics for obese patients (body mass index
[BMI] ≥30) with an adnexal mass. In a comparison series of 176 patients with an
adnexal mass, 85 operations were by robotics and 91 by laparoscopy (29). The
operating time was 12 minutes longer for the entire robotic group (83 vs. 71
minutes), but it was similar to laparoscopy when comparing only patients with a
BMI 30 or more (80 vs. 71 minutes). Blood loss was similar for both groups (39.1
vs. 41.2 mL), but lower for the robotic group when comparing only obese patients
(BMI ≥30) (39 vs. 60 mL). The length of hospital stay, as measured by the
number of patients staying longer than 2 days (0 vs. 3) was similar for both
groups.
Endometriosis
Robotics has been shown to be feasible for the resection of pelvic endometriosis.
A prospective randomized trial showed no differences in perioperative outcomes
and quality of life issues between robotics and laparoscopy for patients with
pelvic endometriosis or pelvic pain without endometriosis (30). In a retrospective
study comparing robotics and laparoscopy for stage III and IV pelvic
1636endometriosis, there was a 16% reduction of operating time with robotics when
the number and type of procedures were accounted for (31).
Tubal Reversal
Robotic tubal reversal may be preferable to laparotomy. In a prospective study
comparing both techniques on patients with a previous tubal ligation, the
operating time was longer using robotics (201 vs. 155 minutes), but the hospital
stay (4 hours vs. 1.3 days), and recovery time to normal activities (11.1 vs. 28.1
days) were improved for robotic patients (32). Both groups had similar pregnancy
rates (62.5% vs. 50%). In another retrospective case-control study of outpatient
tubal anastomosis performed by robotics or minilaparotomy, perioperative
outcomes were similar except for a longer operating time, increased cost, and a
shorter time to patient’s recovery with robotics (33).
Appendectomy
Reported results on 107 robotic appendectomies performed in conjunction with
other pelvic procedures had a mean time for appendectomy of 3.4 minutes. No
perioperative complications related to appendectomy were encountered. Increased
abnormal pathologic findings were observed in patients with pelvic pain
compared to those without pain (37% vs. 15%, respectively). Appendiceal
metastases were found in 43% of patients with ovarian malignancy (34).
16371638FIGURE 28-10 The wrist level of the surgeon console houses the control panel (A). B:
The left controls ergonomic adjustments. C: The right controls the power and emergency
stop buttons.
Sacrocolpopexy
The robotic approach to sacrocolpopexy facilitates ease of suturing and
intracorporeal knot tying. A report of feasibility experience with 80 patients
demonstrated total operating time of 197.9 minutes, and most patients underwent
additional procedures at the same surgical setting (35). There was a 25.4%
decrease of the operating time after the first 10 surgeries. Complications were
minimal. Other reported operating times are 317 and 328 minutes (36,37).
A randomized controlled study evaluating robotic versus laparoscopic
sacrocolpopexy showed laparoscopic approach to be superior for operating room
time (199 vs. 265 minutes), sacrocolpopexy time (162 vs. 227 minutes) and
sacrocolpopexy suturing time (68 vs. 98 minutes) (38). Hospital stay was similar
for both groups (38).
Robotic sacrocolpopexy is preferable to laparotomy because of improved
perioperative outcomes and similar anatomical results. A comparison of 73
robotic with 105 laparotomy sacrocolpopexies for vaginal and uterine prolapse
revealed a longer operating time (328 vs. 225 minutes) but reduced blood loss
1639(103 vs. 255 mL) and shorter hospital stay (1.3 vs. 2.7 days) for the robotic group.
Anatomical improvement was similar for both groups as determined by pelvic
organ prolapse quantification (POP-Q) C point (−9 vs. −8) (see Chapter 30) (37).
Late complications, such as erosion rate and long-term anatomical results of
robotic sacrocolpopexy are unknown.
FIGURE 28-11 Trocar position for robotic pelvic surgery. The optical trocar is at the
umbilicus. Two robotic trocars are placed 10 cm lateral to the right and left of the
umbilicus, respectively. The assistant white trocar is 3-cm cranial and equidistant between
the umbilical and left robotic trocar. An additional robotic trocar is 3-cm cranial and
equidistant between the umbilical and the right robotic trocar.
GYNECOLOGIC ONCOLOGY
[6] Studies show the feasibility of robotics for the treatment of patients with
cervical, endometrial, tubal, and ovarian cancer, with apparent similar or
better perioperative outcomes, compared to conventional laparoscopy and
with improved outcomes compared to laparotomy (39–45). A survey of
1640Society of Gynecologic Oncologists members indicated 24% are regular users of
robotics and 66% believed their use would increase (39).
Endometrial Cancer
Laparoscopy provides similar or longer operative times, less blood loss, fewer
postoperative complications, shorter hospital stay and recovery times, with similar
recurrence and survival rates compared to laparotomy (40–45). The laparoscopic
approach is now considered standard for endometrial cancer. Robotic technology
may be preferable to conventional laparoscopy in selected patients for surgery for
endometrial cancer, especially in morbidly obese patients. In expert hands, the use
of minimally invasive techniques—laparoscopy and robotics—may facilitate the
operations.
Studies comparing robotics to laparotomy suggest improved perioperative
outcomes for robotics. Operative times are similar or longer, blood loss and
hospital stay are reduced, the number of lymph nodes is comparable or higher,
and postoperative complications are similar or decreased with robotics (18–
20,46–51). Studies comparing robotics with conventional laparoscopy for
endometrial cancer show similar or superior results for robotics. Some showed
reduced blood loss, shorter hospital stay, increased lymph node yield, and lower
morbidity with robotics compared to conventional laparoscopy (47,51). Others
reported longer operating time but reduced blood loss, lower transfusion rate,
lower conversion rate to laparotomy, and reduced hospital stay, even though the
robotic patients had a higher BMI compared to laparoscopy (50,51). Robotics, as
with laparoscopy, resulted in a shorter recovery time for endometrial cancer
patients compared to laparotomy (46,51,52).
In an initial review of 38 patients with robotics operations, the perioperative
outcomes were similar to patients treated by laparoscopy (n = 22). Results were
similar to patients treated by laparotomy (n = 16) other than a larger blood loss
and longer hospital stay for this group of patients. The operating times were
similar for the three groups, blood loss was lower for the robotic and laparoscopy
groups (283, 222, and 517 mL), and length of hospital stay was shorter for the
robotic and laparoscopy groups (2, 2.5, and 6 days). There was no difference
relative to the number of lymph nodes removed (18.4, 26.3, and 18.4, for robotics,
laparoscopy, and laparotomy, respectively), number of lymph node metastases,
positive cytologic findings, or tumor recurrence. Postoperative complications
were comparable among the three groups.
Boggess et al. compared 103 robotic patients with 81 laparoscopy patients and
138 laparotomy patients (47). The operating times for robotic and laparoscopy
procedures were similar, but longer than laparotomy (191.2 minutes, 213.4
minutes, and 146.5 minutes, respectively). The blood loss, hospital stay, and
1641number of nodes were all improved for the robotic group. Bell et al. compared a
group of 40 robotic patients with 30 patients operated by laparoscopy and 40
patients operated by laparotomy (46). Robotic and laparoscopy operating times
were comparable (184 minutes and 171 minutes, respectively) and longer than
laparotomy (108.6 minutes). Blood loss was similar to laparoscopy, and both
were lower than the laparotomy group. The number of lymph nodes removed was
similar among the three groups. Postoperative complications were lower in the
robotic group compared to the other two groups (7.5%, 27.5%, and 20%,
respectively).
Another study evaluated the results of robotics and conventional laparoscopy
for obese and morbidly obese patients (BMI 30 to 60) with endometrial cancer
(48). Robotics was found to be preferable to the laparoscopic approach because of
a shorter operative time, reduced blood loss, increased number of lymph nodes
removed, and shorter hospital stay. The benefits of robotics for obese patients
were noted with simple robotic hysterectomy, where the operating time remained
unchanged in spite of the patient’s increased BMI (6). This may result from the
absent awareness of the resistance of the robotic instruments being inserted
through a thick abdominal wall because of the lack of tactile feedback.
When comparing 67 robotic patients, 37 laparoscopic patients, 99 laparotomy
patients, and 47 vaginal/laparoscopic patients with endometrial cancer, robotics
was the preferred approach (51). Robotics, laparoscopy, vaginal/laparoscopy
techniques have longer operative times when compared to laparotomy (181.9,
189.5, 202.7, and 162.7 minutes respectively) (51). The vaginal/laparoscopic
approach is associated with the longest operating time. Mean blood loss (141.4,
300.8, 300.0, 472.6 mL respectively) and hospital length of stay (1.9, 3.4, 3.5, 5.6
days respectively) were superior (61). A major benefit of the robotic approach
was a lower conversion rate to laparotomy (2.9%) as compared to laparoscopy
(10.8%) (51). No significant differences were noted in perioperative
complications or recurrence rates (51).
The increased cost of this technology is a criticism of robotics. Because cost
is tied to frequency of use, when used on a regular basis the cost becomes similar
to laparoscopy and less expensive than laparotomy as a result of shorter hospital
stay. A comparison study of costs for robotics, conventional laparoscopy, and
laparotomy for endometrial cancer showed a significantly reduced cost for
robotics and laparoscopy compared to laparotomy and comparable costs for
robotics and laparoscopy with regular use of robotics (46).
Cervical Cancer
Early Cervical Cancer
1642Robotic and laparoscopic radical hysterectomy may provide patient benefits over
a laparotomy approach relative to blood loss, blood transfusions, and length of
hospital stay. Retrospective studies have shown lower or similar operating times
and postoperative complications (53–59). Recurrence and survival rates remain
unchanged when comparing the results of both techniques (53–55,58,59). An
international, multicenter, prospective randomized trial compared
laparoscopy/robotics with laparotomy (60). The trial included patients with
cervical cancer FIGO stage IA1 with lymphatic invasion to stage IB1. Minimally
invasive surgery had a worse recurrence and survival as compared to open
surgery (disease-free survival 3-year rate, 91.2% vs. 97.1%; hazard ratio for
disease recurrence or death from cervical cancer, 3.74; 95% CI, 1.63 to 8.58.
Overall survival 3-year rate, 93.8% vs. 99.0%; hazard ratio for death from any
cause, 6.00; 95% CI, 1.77 to 20.30) (60). It is important to emphasize that there
was no difference in recurrence or survival for patients with tumors <2 cm; all
recurrences occurred in 14 of the 33 participating centers; the recurrence rate with
open surgery was extremely low compared to most published rates; and out of the
319 patients assigned to the minimally invasive surgery only 45 (16%) were
operated by robotics.
Radical Hysterectomy
The surgical technique for robotic radical hysterectomy is described elsewhere
(61). A rapid learning curve is noted with robotic radical hysterectomy, with a 44-
minute reduction in operating time after the first 34 procedures in association with
a low complication rate and high nodal count (62).
In several retrospective studies comparing laparotomy with robotic radical
hysterectomy, there was a shorter, similar, or longer operating time; reduced
blood loss; shorter hospital stay; lower, similar, or higher number of lymph
nodes removed; and similar rate of postoperative complications (56,63–66).
In comparison with laparoscopy, robotics is associated with a shorter, similar, or
longer operating time; reduced blood loss; shorter hospital stay; similar or lower
postoperative complications; and comparable or higher number of nodes
(56,57,63,65).
Tumor recurrence does not appear increased with robotics compared to
laparoscopy. At a mean length of follow-up of 31.1 months (range, 10 to 50
months), none of the patients in the robotic group experienced recurrence, and
there was no difference with the laparoscopy group (57).
Radical Nerve-Sparing Hysterectomy
The technique of robotic nerve-sparing radical hysterectomy has been described
(67). In a comparison study with robotic radical hysterectomy there were no
1643differences with operating time, blood loss, complications, and length of hospital
stay (67). Studies with open nerve-sparing radical hysterectomy have shown no
differences with recurrence and survival.
Other Applications of Robotics for Cervical Cancer
Occult Cervical Cancer on an Extrafascial Hysterectomy Specimen
Radical parametrectomy is a surgical option for patients with an occult invasive
cervical carcinoma discovered on an extrafascial hysterectomy specimen with
negative margins and with no gross visible disease. The feasibility of robotic
radical parametrectomy was reported by Ramirez et al. in five patients with
minimal complications (68). There are no comparison studies of robotic radical
parametrectomy with laparoscopy or laparotomy (69).
Cancer of the Cervical Stump
Radical trachelectomy for cancer of the cervical stump is preferable to pelvic
irradiation in some patients because of the increased risk of bowel complications
from intestinal adhesions to the remaining cervix. The laparoscopic approach is
previously reported (70). The use of robotic radical trachelectomy in a patient
with a “cut-through” endometrial cancer discovered in the subtotal hysterectomy
specimen was reported (71).
Cervical Cancer With Desire for Fertility
Radical trachelectomy is an alternative to radical hysterectomy for cervical cancer
in young patients desiring fertility and with a tumor size of 2 cm or less, no
lymphatic invasion or nodal metastases, and potential for preservation of the
upper portion of the cervix. The feasibility of robotic radical trachelectomy was
demonstrated in two patients with early-stage cervical cancer (72). The operative
times were longer (387 and 358 minutes), because of the novelty of the procedure
and the required waiting time for the frozen section. No intra- or postoperative
complications were observed. There are no comparison studies of robotic radical
trachelectomy with laparoscopy or laparotomy. A review of eight reported
patients until May 2009 showed a median operating time of 339 minutes, median
blood loss of 62.5 mL, no intraoperative complications, no blood transfusions, no
conversions to laparotomy, and a median length of hospital stay of 1.5 days (73).
The median number of pelvic lymph nodes removed was 20.
Advanced Cervical Cancer: Retroperitoneal Lymphadenectomy Prior to
Chemoradiation
The laparoscopic approach to pelvic and aortic lymphadenectomy prior to
1644chemoradiation for patients with advanced cervical cancer is well-documented,
both transperitoneal and extraperitoneal (74–79). There are many studies
discussing robotic pelvic and aortic lymphadenectomy for different types of
gynecologic malignancies, including cervical, endometrial, and ovarian
malignancies (19,56,57,62–66,80,81).
Transperitoneal
A novel technique and the results of robotic transperitoneal infrarenal aortic
lymphadenectomy in 33 patients with different gynecologic cancers have been
reported (82). This technique requires rotation of the operating table 180 degrees
and insertion of additional trocars in the lower pelvis after completion of the
robotic pelvic operation (82). The mean console time was 42 minutes, the mean
number of nodes 12.9, and the mean number of positive nodes 2.6. There was one
conversion to laparotomy caused by bleeding. These results are comparable to
those reported with laparoscopic aortic lymphadenectomy. Placing the robotic
column at the patient’s head and inserting additional trocars in the lower pelvis
were requirements to remove the infrarenal aortic nodes with robotics. Previous
attempts to remove the left infrarenal aortic lymph nodes in a frozen cadaver were
unsuccessful when the robotic column was stationed at the level of the patient’s
feet.
A comparison study of robotic versus laparoscopic transperitoneal infrarenal
aortic lymphadenectomy revealed similar operating times, blood loss, and
complications (83). However, the cost was higher for the robotics approach.
Extraperitoneal
The feasibility of the extraperitoneal robotic approach to aortic lymphadenectomy
has been reported (84,85). The development of the robotic extraperitoneal
technique in frozen cadavers, successfully applied to a patient with cervical
cancer stage IB2 presenting with enlarged left aortic lymph nodes, is reported
(84). It was noted that appropriate placement of the robotic trocars and the robotic
column is necessary to prevent robotic arm collision and to reach the different
aortic lymph nodal areas. The operating, docking, and console times were 103,
3.5, and 49 minutes, respectively. The blood loss was 30 mL. Selective removal
of five enlarged aortic lymph nodes as noted on CT scan revealed no evidence of
metastases.
Another study by Vergote et al. reported the development of their technique for
inframesenteric aortic lymphadenectomy in five patients (85). All console times
were less than 1 hour. The operating times and number of aortic lymph nodes in
both studies are within the range of those reported with the laparoscopic
approach. Both studies concluded that the robotic approach was technically easier
1645than the conventional laparoscopy procedure (84,85).
A comparison study of robotics versus laparoscopic extraperitoneal aortic
lymphadenectomy (86) revealed similar findings with both techniques. It was
noted that surgeon experience with either of the two techniques will provide
optimal results. Cost estimate was not evaluated in that study.
Recurrent Cervical Cancer: Robotic Pelvic Exenteration
Isolated reports with small numbers of patients have demonstrated the feasibility
of robotic pelvic exenteration for advanced primary and recurrent cervical cancer
(87). The latter are more difficult and longer surgeries because of the adhesions
from previous surgery and/or irradiation. A review of the literature revealed most
cancers are primary squamous cell carcinomas treated by anterior pelvic
exenteration (7), with only one patient receiving a total pelvic exenteration. The
operating time ranges from 375 to 600 minutes, blood loss from 200 to 550 mL
and hospital stay from 3 to 53 days. The operating times are longer than by
laparotomy, blood loss is markedly decreased, and hospital stay is usually similar,
although shorter in some cases. In some patients, a paramedian incision is used
for the creation of a urinary pouch (87).
Whether the robotic approach to pelvic exenteration will become routinely
preferable to laparotomy is debatable in the context of the longer operating time
and similar hospital stay. However, for selected patients it is a good alternative
with excellent results.
Ovarian Cancer
Surgery for ovarian cancer requires access to all four abdominal quadrants.
The ability to operate in all four quadrants using the da Vinci S or Si can be
achieved only by rotating the operating table, while maintaining the robotic
column on the same location. The recent da Vinci Xi system allows access to the
upper and lower abdomen by 180-degree rotation of the robotic arms instead of
moving the operating table. This makes it possible to excise the aortic lymph
nodes to the level of the renal vessels and resect upper abdominal metastases,
including diaphragm, liver, and supracolic omental disease.
Robotics is useful for selected patients with ovarian cancer. The optimal use of
the surgical robotic system for ovarian cancer is for early disseminated disease
localized in different areas, whether at primary, interval, or secondary debulking,
allowing complete resection.
Primary Disease
Initial experience with 21 patients with advanced ovarian cancer whose
1646operations were by robotics was reported (88). Included were 12 primary, 4
interval, and 5 secondary cytoreductive surgeries for ovarian cancer. In addition
to primary tumor excision, major procedures included modified posterior pelvic
exenteration, rectosigmoid resection, small bowel resection, diaphragm resection,
and resection of liver metastases. The operating times had a wide range (103 to
454 minutes) resulting from the extent of procedures. Blood loss was low (25 to
300 mL). Postoperative complications were low, and directly related to the
number of prior procedures per patient.
Other reports of robotics for ovarian cancer consist of an occasional patient
included within a series of patients with different types of gynecologic cancers
(86,89–92).
A comparison of robotics, laparoscopy, and laparotomy for ovarian cancer
revealed advantages of laparoscopy and robotics over laparotomy for blood loss,
complications and hospital stay (86). The advantages were only for patients
requiring primary tumor removal including hysterectomy, bilateral salpingooophorectomy, lymphadenectomy, omentectomy, removal of tumor implants,
appendectomy, and one additional major procedure, such as diaphragm, small
bowel, sigmoid, liver or spleen resection. Patients requiring two or more major
procedures or with multiple peritoneal implants are best operated by laparotomy
because of similar complications and hospital stay.
Recurrent Disease
The benefits of a minimally invasive approach, robotics and laparoscopy, for
secondary cytoreduction compared to laparotomy, were demonstrated in an early
study (93). Robotics and laparoscopy provided similar results. Optimal candidates
for the minimally invasive approach are patients with localized recurrent disease
amenable to complete resection.
Similar findings and conclusions were reached in a subsequent multicenter
study including 48 patients. Optimal debulking was achieved in 82% of patients.
Conversion to laparotomy was required in 8.3% of patients (94). In cases not
requiring conversion, median operative time was 179.5 minutes, estimated blood
loss was 50 mL and length of stay was 1 day.
Summary
Robotics and laparoscopy have advantages compared to laparotomy for
selected patients with cervical, endometrial, and early ovarian cancer.
Prospective data has established a minimally invasive approach as standard
surgical treatment using laparoscopy or robotics. Although prospective
randomized trials are desirable, the retrospective evidence supports the use of
1647minimally invasive surgery for selected endometrial and cervical cancer patients
and those with patients with primary or recurrent ovarian cancer.
COMPLICATIONS UNIQUE TO ROBOTICS
There is a linear relationship with perioperative complications of robotic
gynecologic surgery as the complexity of the procedure increases, which is
directly related to the operator’s skill and patient’s pathology (89). This is no
different than previously noted for laparoscopic surgeries. There are
complications related to the robotic technology.
Because there is no tactile feedback, the robotic arms can injure any organ
not under visual control. The potential for injury is higher with the fourth
retracting arm when it is out of the visual field and repositioned without
visual control. Constant visual control of the robotic instrument position is
mandatory for the prevention of injuries. Collision of the robotic arms is felt as an
unwanted resistance, which is realized when the instruments are brought under
view. When the robotic arm is not under direct visual control, removal and
reinsertion of instruments can result in unintended injury.
Constant pressure of the robotic arms on the patient thighs or arms may
result in injury. This can be prevented during positioning of the patient and the
robotic arms. Movement of a robotic arm by anyone other than the surgeon may
result in patient internal injury. A rapid move by the surgeon on any robotic
instrument may result in hitting the assistant near the operating table with the
robotic arm.
Because the robotic trocars are fastened to the robotic arms, and the arms
are fixed to the robotic column, any sudden loss of the pneumoperitoneum
may result in the instruments being pulled off the anterior abdominal wall as
it becomes flattened. Similarly, any sliding of the patient on the operating table
as a result of the Trendelenburg position will result in pressure at the trocar site
and potential injury or increased postoperative trocar-site pain.
Insulation failures occur when the electricity escapes through small, usually not
visible, defects in the insulation material involving the shaft of monopolar and
bipolar instruments. This has resulted in unrecognized thermal bowel injuries
with subsequent bowel perforation. Insulation failures are more common with
robotic as compared to laparoscopic instruments (95).
Disadvantages of Robotics
The present robotic system has limited surgical field reach. It allows for pelvic
or abdominal surgery, but not both, unless the operating table, robotic column (da
Vinci S or Si) or boom (da Vinci Xi) is rotated 180 degrees. This repositioning
1648increases surgical time and, depending on the procedure, may require the insertion
of additional trocars.
An assistant versed in robotics is necessary at the patient’s side to be able to
provide the required assistance without the surgeon’s help other than verbal
directions, because the surgeon is not in surgical sterile condition. Tissue traction
is not as efficient as with conventional laparoscopic instruments, for instance for
myomectomies, when necessary. Because there is no tactile feedback when
grasping a tissue, there is only visual control of the traction exerted upon any
structure. While the lack of tactile feedback is an advantage in obese patients
it is a disadvantage when the instruments are not in the visual field.
Cost is a common reason why many institutions have delayed the initiation of
robotic programs. The initial purchase of the robotic system is high, and there is
an additional annual maintenance fee, and all reusable robotic instruments
become functionless after 10 uses. Some robotic instruments, such as the vessel
sealer, are only single use.
The robotic column and its arms are bulky, with a total weight of 1,200 lb. An
operating room must have adequate space, preferably about 600 square feet.
There must be a dedicated team for robotic surgery and preferably a specific team
for each surgical specialty
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