Robotic surgery in gynaecology

Abstract

Plain language summary The use of robotic‐assisted keyhole surgery in gynaecology has expanded in recent years owing to technical advances. These include 3D viewing leading to improved depth perception, limitation of tremor, potential for greater precision and discrimination of tissues, a shorter learning curve and improved comfort for surgeons compared with conventional keyhole and open abdominal surgery. Robotic‐assisted keyhole surgery, compared with conventional keyhole surgery, improves surgical performance without increasing operating time, minimises blood loss and intra‐ or postoperative complications, while reducing the need to revert to abdominal surgery. Moreover, surgeons using a robot experience fewer skeletomuscular problems of their own in the short and long term than those operating without a robot as an additional tool. This Scientific Impact Paper looks at the use of a robot in different fields of gynaecological surgery. A robot could be considered safe and a more effective surgical tool than conventional keyhole surgery for women who have to undergo complex gynaecology surgery or have associated medical issues such as body–mass index (BMI) at 30 kg/m2 or above or lung problems. The introduction of the use of robots in keyhole surgery has resulted in a decrease in the number of traditional open surgeries and the risk of conversion to open surgery after traditional keyhole surgery; both of which should be considered when examining the cost–benefit of using a robot. Limitations of robotic‐assisted surgery remain the associated higher costs. In womb cancer surgery there is good evidence that introducing robotics into the service improves outcomes for women and may reduce costs.

Level 1 Evidence for Robotic Surgery for Urological and Gynecological Pelvic Cancers: Where do We Currently Stand?

“…Technical advantages of robotics include a stable 3D vision with a camera that can constantly be adjusted by the sur-geon; an extended range of motion of the instruments and better ergonomics that may overcome the drawbacks of laparoscopy in complex cases and in narrow operative fields such as the pelvis. Actually, robotic surgery applies to all procedures requiring a precise dissection and/or complex reconstruction and is useful in anatomical sites far-off to be reached, such as male and female pelvis [1].…”

“…Robotic surgery has been used for the surgical removal of pelvic malignancies, including prostate cancer, bladder cancer, endometrial cancer, and cervical tumors [1,2].…”

The influence of proficiency-based progression training on peri-operative and survival outcomes in robot-assisted laparoscopic surgery for endometrial cancer: an observational cohort study.

“…In the last two decades, the use of minimally-invasive surgery for endometrial cancer has become widespread since the Laparoscopic Approach to Cancer of the Endometrium (LACE) trial and Gynecologic Oncology Group (GOG) LAP2 study established non-inferiority of laparoscopic versus laparotomic surgery for diseasefree and overall survival in endometrial cancer. [1][2][3] Robot-assisted laparoscopic (RAL) surgery was introduced in gynaecological surgery in 2005 4 and may provide more precision, better views, reduced patient morbidity and improved surgeon ergonomics compared to conventional laparoscopy. [5][6][7][8] These advantages are especially beneficial in obese patients undergoing open or laparoscopic hysterectomy as they are more prone to postoperative morbidity compared to non-obese patients.…”

Is robotic-assisted surgery a better choice in vaginectomy of complicated vaginal high-grade squamous intraepithelial lesions than conventional laparoscopic surgery?

“…Thus, the application of transvaginal vaginectomy is limited in complex vaginal surgeries that require greater precision because of the restricted space and complex anatomy of the vagina. In recent decades, minimally invasive laparoscopy has developed rapidly, including robotic-assisted laparoscopy, and is widely used in the eld of gynecology surgery [14,15]. Minimally invasive laparoscopy is characterized by magnifying the surgical eld, which contributes to identifying blood vessels and separating tissue spaces.…”

“…In addition, long-arm instruments with small end-effector simplify surgery in narrow spaces compared with the use of human hands and offer a certain degree of exibility. Unlike conventional laparoscopic surgery, the robotic-assisted laparoscopic process system has a three-dimensional view to better and more precisely visualize the surgical area; it also improves mobility and increases the range of motion of the instrument's end-effector [14]. The use of robotic-assisted laparoscopic vaginectomy (RALV) has likely increased due to these advantages, despite limited evidence in favor of RALV.…”