Robotic-assisted laparoscopic surgery for hysterectomy and pelvic organ prolapse repair
2014; Elsevier BV; Volume: 102; Issue: 4 Linguagem: Inglês
10.1016/j.fertnstert.2014.08.010
ISSN1556-5653
Autores Tópico(s)Minimally Invasive Surgical Techniques
ResumoThe robotic platform is a tool that has enabled many gynecologic surgeons to perform procedures by minimally invasive route that would have otherwise been performed by laparotomy. Before the widespread use of this technology, a larger percentage of hysterectomies and sacrocolpopexies were completed via the open route because of the lack of training in traditional laparoscopic suturing, knot tying, and retroperitoneal dissection. Additional deterrents of traditional laparoscopic surgery adoption have included the lengthy learning curve associated with development of advanced laparoscopic skills; and surgeon preference for the open route because of surgical ergonomics, decreased operative time, and more experience with laparotomy. Level I evidence regarding robotic-assisted laparoscopy in benign gynecology is sparse, with most of the data supporting robotic surgery comprised of retrospective cohorts. The literature demonstrates the safety and efficacy of robotic-assisted laparoscopy for hysterectomy and pelvic organ prolapse repair; however, most level I data show increased operative time and cost. The true indications for robotic-assisted laparoscopy in benign gynecology have yet to be discerned. A review of the best available evidence is summarized. The robotic platform is a tool that has enabled many gynecologic surgeons to perform procedures by minimally invasive route that would have otherwise been performed by laparotomy. Before the widespread use of this technology, a larger percentage of hysterectomies and sacrocolpopexies were completed via the open route because of the lack of training in traditional laparoscopic suturing, knot tying, and retroperitoneal dissection. Additional deterrents of traditional laparoscopic surgery adoption have included the lengthy learning curve associated with development of advanced laparoscopic skills; and surgeon preference for the open route because of surgical ergonomics, decreased operative time, and more experience with laparotomy. Level I evidence regarding robotic-assisted laparoscopy in benign gynecology is sparse, with most of the data supporting robotic surgery comprised of retrospective cohorts. The literature demonstrates the safety and efficacy of robotic-assisted laparoscopy for hysterectomy and pelvic organ prolapse repair; however, most level I data show increased operative time and cost. The true indications for robotic-assisted laparoscopy in benign gynecology have yet to be discerned. A review of the best available evidence is summarized. Discuss: You can discuss this article with its authors and with other ASRM members at http://fertstertforum.com/paraisom-robotic-surgery-hysterectomy-pelvic-organ-prolapse/ Discuss: You can discuss this article with its authors and with other ASRM members at http://fertstertforum.com/paraisom-robotic-surgery-hysterectomy-pelvic-organ-prolapse/ The benefits of minimally invasive surgery for benign gynecologic conditions include a shorter hospital stay, faster recovery and return to baseline function-ing, less intraoperative blood loss, and less postoperative pain (1Nieboer T.E. Johnson N. Lethaby A. Tavender E. Curr E. Garry R. et al.Surgical approach to hysterectomy for benign gynaecological disease.Cochrane Database Syst Rev. 2009; : CD003677PubMed Google Scholar, 2Wright K.N. Jonsdottir G.M. Jorgensen S. Shah N. Einarsson J.I. Costs and outcomes of abdominal, vaginal, laparoscopic and robotic hysterectomies.JSLS. 2012; 16: 519-524Crossref PubMed Scopus (82) Google Scholar, 3Warren L. Ladapo J.A. Borah B.J. Gunnarsson C.L. Open abdominal versus laparoscopic and vaginal hysterectomy: analysis of a large United States payer measuring quality and cost of care.J Minim Invasive Gynecol. 2009; 16: 581-588Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar, 4Barbash G.I. Glied S.A. New technology and health care costs: the case of robot-assisted surgery.N Engl J Med. 2010; 363: 701-704Crossref PubMed Scopus (677) Google Scholar, 5Bandera C.A. Magrina J.F. Robotic surgery in gynecologic oncology.Curr Opin Obstet Gynecol. 2009; 21: 25-30Crossref PubMed Scopus (61) Google Scholar, 6Wright J.D. Ananth C. Lewin S.N. Burke W.M. Lu Y.S. Neugut A.I. et al.Robotically assisted versus laparoscopic hysterectomy among women with benign gynecologic disease.JAMA. 2013; 309: 689-698Crossref PubMed Scopus (384) Google Scholar). Adoption of minimally invasive surgery has greatly increased with implementation of the robotic platform since its 2005 FDA approval in gynecologic surgery. Robotic-assisted laparoscopic surgery has allowed more surgeries to be performed by a minimally invasive route because it is easier to learn than traditional laparoscopic surgery. Although, use of the robotic platform has been shown to be safe and feasible in procedures for benign hysterectomy and pelvic organ prolapse, good evidence is lacking to show its superiority or clear indications for its use (7AAGL Advancing Minimally Invasive Gynecology Worldwide AAGL position statement: robotic-assisted laparoscopic surgery in benign gynecology.J Minim Invasive Gynecol. 2013; 20: 2-9Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar). The objective of this review is to summarize the best available evidence regard-ing robotic-assisted laparoscopy for hysterectomy and pelvic organ prolapse repair and to enhance the reader's knowledge regarding these procedures. The trend toward increased minimally invasive hysterectomy with widespread adoption of robotic-assisted laparoscopic hysterectomy (RLH) and an increase in traditional laparoscopic hysterectomy has been eloquently chronicled in a retrospective cohort study by Wright et al. (6Wright J.D. Ananth C. Lewin S.N. Burke W.M. Lu Y.S. Neugut A.I. et al.Robotically assisted versus laparoscopic hysterectomy among women with benign gynecologic disease.JAMA. 2013; 309: 689-698Crossref PubMed Scopus (384) Google Scholar). The investigators analyzed over 260,000 women who underwent hysterectomy for benign gynecologic disorders in 441 hospitals across the United States from 2007 to 2010 and demonstrated that the rate of laparoscopic and robotic hysterectomies increased significantly, while the rates of vaginal hysterectomy stayed stable and abdominal hysterectomy declined. Robotically assisted hysterectomy increased from 0.5% to 9.5% of all hysterectomies from 2007 to 2010. During the same period, laparoscopic hysterectomy rates increased from 24.3% to 30.5%, and abdominal hysterectomy rates decreased from 53.6% to 40.1%. Vaginal hysterectomy rates declined minimally from 21.7% to 19.8%. The overall complication rates were similar for robotically assisted and laparoscopic hysterectomies. With regard to the specific indications for RLH, certain subgroups—obese women (8Nafawl A.K. Orady K. Eisenstein D. Wegienka G. The effect of body mass index on robotic-assisted total laparoscopic hysterectomy.J Minim Invasive Gynecol. 2011; 18: 328-332Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar) and patients with large uteri (9Orady M. Nafawl A.K. Wegienka G. Does size matter? The effect of uterine weight on robot-assisted laparoscopic hysterectomy outcomes.J Robotic Surg. 2011; 5: 267-272Crossref Scopus (11) Google Scholar) in retrospective cohorts—have been shown to potentially benefit from robotic-assistance compared with conventional laparoscopy. A retrospective cohort study by Nawfal et al. (8Nafawl A.K. Orady K. Eisenstein D. Wegienka G. The effect of body mass index on robotic-assisted total laparoscopic hysterectomy.J Minim Invasive Gynecol. 2011; 18: 328-332Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar) examined the outcomes of 135 patients undergoing RLH. Of these women, 23.4% were of normal weight (body mass index [BMI] 30), and 27.1% were morbidly obese (BMI ≥35). The investigators found no association with BMI of blood loss, duration of surgery, length of stay, or complication rates. Similar findings have been reported with laparoscopic hysterectomy in obese women. Orady et al. (9Orady M. Nafawl A.K. Wegienka G. Does size matter? The effect of uterine weight on robot-assisted laparoscopic hysterectomy outcomes.J Robotic Surg. 2011; 5: 267-272Crossref Scopus (11) Google Scholar) retrospectively reviewed outcomes of patients undergoing RLH for enlarged uteri. They found a correlation between increasing uterine size and procedure duration. However, an increase in procedure duration did not translate into an increase in length of stay or complications. A few investigations demonstrated improved outcomes in the subgroups listed herein, including reduced blood loss, decreased postoperative pain, and shorter hospital stay, that were associated with RLH compared with vaginal hysterectomy, laparoscopic-assisted vaginal hysterectomy, and total laparoscopic hysterectomy (9Orady M. Nafawl A.K. Wegienka G. Does size matter? The effect of uterine weight on robot-assisted laparoscopic hysterectomy outcomes.J Robotic Surg. 2011; 5: 267-272Crossref Scopus (11) Google Scholar, 10Payne T.N. Dauterive F.R. Pitter M.C. Giep H.N. Giep B.N. Grogg T.W. et al.Robotically assisted hysterectomy in patients with large uteri: outcomes in five community practices.Obstet Gynecol. 2010; 115: 535-542Crossref PubMed Scopus (42) Google Scholar, 11Orady M. Hrynewych A. Nawfal A.K. Wegienka G. Comparison of robotic-assisted hysterectomy to other minimally invasive approaches.JSLS. 2012; 16: 542-548Crossref PubMed Scopus (35) Google Scholar, 12Shashoua A.R. Gill D. Locher S.R. Robotic-assisted total laparoscopic hysterectomy versus conventional total laparoscopic hysterectomy.JSLS. 2009; 13: 364-369PubMed Google Scholar). Another indication is surgeon preference because many surgeons who are not well trained in traditional laparoscopic hysterectomy or vaginal hysterectomy may prefer RLH. Additional research comparing standard laparoscopic and robotic-assisted laparoscopic surgery is needed to help characterize the advantages and disadvantages of robotic laparoscopic surgery and to determine concurrently which patient groups would benefit from robotics over other methods (7AAGL Advancing Minimally Invasive Gynecology Worldwide AAGL position statement: robotic-assisted laparoscopic surgery in benign gynecology.J Minim Invasive Gynecol. 2013; 20: 2-9Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar). Robotic-assisted laparoscopy was developed to overcome the technical difficulties encountered with conventional laparoscopy, yet there are limited, well-designed data that investigate this premise. There have been a few retrospective cohorts that directly compare conventional laparoscopic with RLH. The largest published retrospective study compared 100 patients who underwent conventional laparoscopic hysterectomy before adoption of the robotic platform compared with 100 patients who underwent RLH (13Payne T.N. Dauterive F.R. A comparison of total laparoscopic hysterectomy to robotically assisted hysterectomy: surgical outcomes in a community practice.J Minim Invasive Gynecol. 2008; 15: 286-291Abstract Full Text Full Text PDF PubMed Scopus (222) Google Scholar). The mean operative time (skin to skin) was 27 minutes longer in the RLH group than for the conventional laparoscopic hysterectomy group (P<.001). However, the prerobotic cohort had longer operative times when compared with the last 25 surgeries in the robotic cohort (92.4 minutes vs. 78.7 minutes; P=.03). The conventional laparoscopic hysterectomy group had twice the mean blood loss, a 0.5-day longer hospital stay, and a twofold higher rate of conversions to laparotomy when compared with the robotic group. Nezhat et al. (14Nezhat C. Lavie O. Lemyre M. Gemer O. Bhagan L. Laparoscopic hysterectomy with and without a robot: Stanford experience.JSLS. 2009; 13: 125-128Crossref PubMed Scopus (36) Google Scholar) compared 26 RLH procedures with 50 matched controls who underwent laparoscopic hysterectomies. Mean surgical time for RLH was 276 minutes compared with 206 minutes for traditional laparoscopic hysterectomy. Blood loss, length of stay, and postoperative complications were not statistically significantly different. The first published prospective cohort included 40 women undergoing RLH with conventional laparoscopic hysterectomy and showed mean operating times of 109 minutes in the robot group versus 83 minutes in the conventional laparoscopic group (P<.05) (15Sarlos D. Kots L. Stevanovic N. Schaer G. Robotic hysterectomy versus conventional laparoscopic hysterectomy: outcome and cost analyses of a matched case-control study.Eur J Obstet Gynecol Reprod Biol. 2010; 150: 92-96Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar). Despite a slightly increased hospital stay for conventional laparoscopic hysterectomy versus RLH (3.9 days vs. 3.3 days, respectively), the cost was statistically significantly less for the conventional laparoscopic hysterectomy group ($2,861 vs. $5,410). The same investigators evaluated a randomized trial comparing RLH and conventional laparoscopic hysterectomy in 95 patients (16Sarlos D. Kos L. Stevnovic N. von Felten S. Schär G. Robotic compared with conventional laparoscopic hysterectomy: a randomized, controlled trial.Obstet Gynecol. 2012; 120: 604-611Crossref PubMed Scopus (129) Google Scholar). In all cases, two surgeons expert in both routes performed the procedures. The study found longer operating times in the RLH group compared with the conventional laparoscopic hysterectomy group (106 vs. 75 minutes). Although there was a greater improvement in postoperative quality of life 6 weeks after RLH versus conventional laparoscopic hysterectomy, there was no difference in postoperative analgesic use or return to normal activities. A randomized trial comparing 53 patients undergoing RLH and conventional laparoscopic hysterectomy showed statistically significantly longer operative time (skin to skin) and surgical time (wheels in to wheels out) in the robot group (77 minutes longer and 72 minutes longer, respectively) (17Paraiso M.F. Ridgeway B. Park A.J. Jelovsek J.E. Barber M.D. Falcone T. et al.A randomized trial comparing conventional and total laparoscopic hysterectomy.Am J Obstet Gynecol. 2013; 208: 368.e1-368.e7Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar). All cases were performed in part by an expert conventional laparoscopic staff surgeon who had performed at least 10 prior RLH procedures with a gynecologic fellow or resident in training. Most investigations have demonstrated increased costs associated with RLH (16Sarlos D. Kos L. Stevnovic N. von Felten S. Schär G. Robotic compared with conventional laparoscopic hysterectomy: a randomized, controlled trial.Obstet Gynecol. 2012; 120: 604-611Crossref PubMed Scopus (129) Google Scholar, 18Pasic R.P. Rizzo J.A. Fang H. Ross S. Moore M. Gunnarsson C. Comparing robot-assisted with conventional laparoscopic hysterectomy: impact on cost and clinical outcomes.J Minim Invasive Gynecol. 2010; 17: 730-738Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 19Jonsdottir G.M. Jorgensen S. Cohen S.L. Wright K.N. Shah N.T. Chavan N. et al.Increasing minimally invasive hysterectomy: effect on cost and complications.Obstet Gynecol. 2011; 117: 1142-1149Crossref PubMed Scopus (73) Google Scholar). Wright et al. (6Wright J.D. Ananth C. Lewin S.N. Burke W.M. Lu Y.S. Neugut A.I. et al.Robotically assisted versus laparoscopic hysterectomy among women with benign gynecologic disease.JAMA. 2013; 309: 689-698Crossref PubMed Scopus (384) Google Scholar) reported that the total cost associated with RLH was $2,189 more per case than for conventional laparoscopic hysterectomy. Most investigators have attributed the increased cost to the lengthier operative times and disposable equipment. Critical analyses of comparative trials often include surgical bias as a limitation of the investigations. It is common to have faster operative times for procedures in which surgeons are expert as compared to procedures that they are new to or learning. Moreover, it is reported that the learning curve affects operative times in robotic surgery, showing that times continue to improve and plateau after 40 to 50 cases (20Geller E.J. Lin F.C. Matthews C.A. Analysis of robotic performance times to improve operative efficiency.J Minim Invasive Gynecol. 2013; 20: 43-48Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar). The second randomized trial previously mentioned (17Paraiso M.F. Ridgeway B. Park A.J. Jelovsek J.E. Barber M.D. Falcone T. et al.A randomized trial comparing conventional and total laparoscopic hysterectomy.Am J Obstet Gynecol. 2013; 208: 368.e1-368.e7Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar) has been criticized for surgical bias because the investigators had only performed 10 RLH procedures before patient enrollment. Vaginal cuff dehiscence is a serious complication of laparoscopic hysterectomy, and robotic assistance appears to be a major risk factor, possibly due to electrosurgical techniques during colpotomy or vaginal closure technique. Symptoms of postoperative vaginal cuff dehiscence include vaginal pressure, sudden fluid leakage from the vagina, vaginal bleeding, and pelvic pain. Rates of vaginal cuff dehiscence vary between 1.7% and 4.1% at a mean posthysterectomy interval of 1.5 to 4.3 months in retrospective cohorts, which included RLH procedures (21Kho R.M. Akl M.N. Cornella J.L. Magtibay P.M. Wechter M.E. Magrina J.F. Incidence and characteristics of patients with vaginal cuff dehiscence after robotic procedures.Obstet Gynecol. 2009; 114: 231-235Crossref PubMed Scopus (126) Google Scholar, 22Nick A.M. Lange J. Frumovitz M. Soliman P.T. Schmeler K.M. Schlumbrecht M.P. et al.Rate of vaginal cuff separation following laparoscopic or robotic hysterectomy.Gynecol Oncol. 2011; 120: 47-51Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar). In a systematic review, Uccella et al. (23Uccella S. Chezzi F. Mariani A. Cromi A. Bogani G. Serati M. et al.Vaginal cuff closure after minimally invasive hysterectomy: our experience and systematic review of the literature.Am J Obstet Gynecol. 2011; 205: 199.e1-199.e12Abstract Full Text Full Text PDF Scopus (8) Google Scholar) found that the incidence of cuff dehiscence after laparoscopic hysterectomy is statistically significantly higher than that associated with an abdominal or vaginal approach (0.21% and 0.13%, respectively). Further, the systematic review indicates that RLH is associated with a higher incidence of cuff dehiscence relative to conventional laparoscopic hysterectomy (1.64% vs. 0.64%). The risk factors for cuff dehiscence after conventional laparoscopic hysterectomy appear to be malignancy and route of cuff closure, with vaginal suturing resulting in a significantly lower risk of dehiscence compared with laparoscopic suturing (24Cronin B. Sung V.W. Matteson K.A. Vaginal cuff dehiscence: risk factors and management.Am J Obstet Gynecol. 2012; 206: 284-288Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar). The latter finding regarding route of cuff closure has only been examined in conventional laparoscopic hysterectomy. The systematic review by Uccella et al. (23Uccella S. Chezzi F. Mariani A. Cromi A. Bogani G. Serati M. et al.Vaginal cuff closure after minimally invasive hysterectomy: our experience and systematic review of the literature.Am J Obstet Gynecol. 2011; 205: 199.e1-199.e12Abstract Full Text Full Text PDF Scopus (8) Google Scholar) is unique in that there was a mixed patient population, and thus these numbers and results may not apply to a benign gynecologic population. Furthermore, it is unclear whether inclusion of patients with malignancy introduces some bias. It is possible that more patients with malignancy underwent robotic-assisted hysterectomy compared with vaginal hysterectomy; hence, malignancy rather than route of surgery could be the risk factor attributed to cuff dehiscence. Recommended techniques to decrease the risk of vaginal cuff dehiscence include judicious use of electrocautery at the vaginal cuff, use of a blended cutting electrosurgical current rather than a coagulation current, and the use of a two-layer cuff closure or bidirectional barbed suture (24Cronin B. Sung V.W. Matteson K.A. Vaginal cuff dehiscence: risk factors and management.Am J Obstet Gynecol. 2012; 206: 284-288Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar). The U.S. Federal Drug Administration (FDA) recently released a safety communication discouraging the use of power morcellation in hysterectomy and myomectomy because of the risk of dissemination of undiagnosed uterine sarcoma (25U.S. Food and Drug Administration. Quantitative assessment of the prevalence of unsuspected uterine sarcoma in women undergoing treatment of uterine fibroids: summary and key findings. Silver Sprint, MD: FDA. 2014. Available from: http://www.fda.gov/downloads/MedicalSafety/AlertsandNotices/UCM393589.pdf. Last Accessed September 15, 2014.Google Scholar). The technology of power morcellation has enabled gynecologic surgeons to perform minimally invasive hysterectomy in 50,000 to 150,000 patients per year (26Wright J.D. Tergas A.I. Burke W.M. Cui R.R. Ananth C.V. Chen L. et al.Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation.JAMA. 2013; 309: 689-698Crossref PubMed Scopus (95) Google Scholar). There is an estimated range of 1:360 to 1:6,400 of undetected uterine malignancy in patients undergoing a planned hysterectomy for presumed benign disease with power morcellation (26Wright J.D. Tergas A.I. Burke W.M. Cui R.R. Ananth C.V. Chen L. et al.Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation.JAMA. 2013; 309: 689-698Crossref PubMed Scopus (95) Google Scholar, 27U.S. Food and Drug Administration, Center for Devices and Radiological Health, Medical Devices Advisory Committee. Obstetrics and Gynecology Devices Panel, July 10, 2014. Available from: http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/ObstetricsandGynecologyDevices/UCM408546.pdf. Last accessed September 15, 2014.Google Scholar). When discussing surgical alternatives with the patient, the benefit of maintaining small incisions for uterine specimen removal should be considered against the risk of abnormal pathology after morcellation. The recent withdrawal of a popular morcellation device from the U.S. market may decrease the rate of RLH and conventional laparoscopic hysterectomy in the United States during the next few years. This predicted decline will continue unless the sensitivity of diagnostic tests for uterine sarcoma improves or innovative devices, such as bags for uterine morcellation, are developed, adequately tested, and deemed safe and effective for power morcellation. Alternatives to power morcellation include laparotomy with removal of an intact specimen, minilaparotomy with cold-knife morcellation, and vaginal-route cold-knife morcellation. In many institutions, there are requirements put in place for minimum annual robotic case volumes to maintain privileges. This minimum requirement does not exist for the other minimally invasive routes of surgery (vaginal and conventional laparoscopy). However, if an institution purchases this platform, it must guarantee its use because of initial cash outlay and cost of upkeep. As previously stated, a few investigations have shown that robotic hysterectomies are more costly than laparoscopic hysterectomies (6Wright J.D. Ananth C. Lewin S.N. Burke W.M. Lu Y.S. Neugut A.I. et al.Robotically assisted versus laparoscopic hysterectomy among women with benign gynecologic disease.JAMA. 2013; 309: 689-698Crossref PubMed Scopus (384) Google Scholar, 18Pasic R.P. Rizzo J.A. Fang H. Ross S. Moore M. Gunnarsson C. Comparing robot-assisted with conventional laparoscopic hysterectomy: impact on cost and clinical outcomes.J Minim Invasive Gynecol. 2010; 17: 730-738Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar), with one study finding an additional $3,000 in operative case per robotic versus laparoscopic hysterectomy (19Jonsdottir G.M. Jorgensen S. Cohen S.L. Wright K.N. Shah N.T. Chavan N. et al.Increasing minimally invasive hysterectomy: effect on cost and complications.Obstet Gynecol. 2011; 117: 1142-1149Crossref PubMed Scopus (73) Google Scholar). It is likely that cost would go down with decreased operative time and that operative time would go down with increased experience. An argument exists that a minimum number of cases are needed to practice cost-conscious medicine. In the present medicoeconomic climate, comparative cost has come under scrutiny with robotics due to the increased upfront cost, but would actually be applicable for any route of procedure that is new. In summary, based on evidence to date, there are no clear indications for RLH over other routes of minimally invasive hysterectomy for benign disease. At present, the criteria that have been suggested include patient obesity, uterine size, surgeon skill, surgeon preference, and institutional case requirement. For benign hysterectomy, level I evidence suggests that robotics offer few surgical advantages over laparoscopy in the hands of experts in conventional laparoscopy, at an increased cost (6Wright J.D. Ananth C. Lewin S.N. Burke W.M. Lu Y.S. Neugut A.I. et al.Robotically assisted versus laparoscopic hysterectomy among women with benign gynecologic disease.JAMA. 2013; 309: 689-698Crossref PubMed Scopus (384) Google Scholar, 16Sarlos D. Kos L. Stevnovic N. von Felten S. Schär G. Robotic compared with conventional laparoscopic hysterectomy: a randomized, controlled trial.Obstet Gynecol. 2012; 120: 604-611Crossref PubMed Scopus (129) Google Scholar, 17Paraiso M.F. Ridgeway B. Park A.J. Jelovsek J.E. Barber M.D. Falcone T. et al.A randomized trial comparing conventional and total laparoscopic hysterectomy.Am J Obstet Gynecol. 2013; 208: 368.e1-368.e7Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar, 28Liu H. Lu D. Wang L. Shi G. Song H. Clarke J. Robotic conventional laparoscopic surgery for benign gynaecological disease.Cochrane Database Syst Rev. 2012; : CD008978PubMed Google Scholar). However, insufficient data exist comparing robotics to conventional laparoscopy in the hands of nonexperienced surgeons. Many gynecologic surgeons who are not experienced in conventional laparoscopy are keen to adopt robotic surgery. It is unclear whether robotics offer some advantage over adopting conventional laparoscopy in this subgroup of physicians. Since the adoption of the da Vinci Surgery robotic platform in gynecology, there has been a decrease in hysterectomy performed by laparotomy (6Wright J.D. Ananth C. Lewin S.N. Burke W.M. Lu Y.S. Neugut A.I. et al.Robotically assisted versus laparoscopic hysterectomy among women with benign gynecologic disease.JAMA. 2013; 309: 689-698Crossref PubMed Scopus (384) Google Scholar); hence, the goal of converting open abdominal hysterectomies to minimally invasive access has been achieved. Despite lacking a clear definition of indications for use of robotic-assisted laparoscopy over other routes of minimally invasive hysterectomy (vaginal and conventional laparoscopy), a greater number of women have benefitted from minimally invasive hysterectomy because the robot is an easy to learn, rapidly adopted, minimally invasive tool.
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