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238 Pak J Med Sci 2012 Vol. 28 No. 1 www.pjms.com.pk
INTRODUCTION
The da Vinci robotic system (Intuitive Surgical
Systems, Inc., Sunnyvale, CA) is the most impor-
tant advancement in the minimally invasive sur-
gery of last decade. It was introduced by Intuitive
Surgical Systems in 1999 and was accepted by Food
and Drug Administration (FDA) in April 2005 for
gynecologic procedures. This technology is being
adopted rapidly to standard laparoscopic tech-
niques such as hysterectomy, myomectomy, sa-
cral colpopexy, lymph node dissection operations
performed in the U.S. Despite this system is being
used widely in the United States of America it is not
performed for most gynecologic interventions in all
over the world, especially in Asia.
The da Vinci Surgical System: The da Vinci surgi-
cal instrument contains the surgical console, robotic
1. Dr. Mustafa Kara,
Assistant Professor,
Department of Obstetrics and Gynecology,
Bozok University Medical Faculty,
Yozgat, Turkey.
Correspondence:
Dr. Mustafa Kara,
Assistant Professor,
Department of Obstetrics and Gynecology,
Bozok University Medical Faculty,
Yozgat, Turkey.
Address: Bozok University Medical Faculty,
Adnan Menderes Boulevard No. 190,
66200 Yozgat/ Turkey.
E-mail: mustafa.kara@bozok.edu.tr
opdrmustafakara@hotmail.com
* Received for Publication: August 19, 2011
* 1st Revision Received: August 27, 2011
* 2nd Revision Received: September 29, 2011
* 3rd Revision Received: December 20, 2011
* Accepted for Publication: December 21, 2011
Short communication
Robotic Surgery in Gynecology Practice:
Current Approaches
Mustafa Kara
ABSTRACT
Laparoscopic surgery has been widely used in gynecology practice for more than 20 years. Despite
the advent of laparoscopy led to advances, it has not been widely used in gynecology because
of some disadvantages, including two-dimensional imaging, unstable camera platform, limited
mobility of laparoscopic instruments. The aim of this study was to evaluate the advantage and
disadvantages of the robotic surgery, especially the da Vinci system. Robotic surgery utilization
in gynecology eld has been studied in many trials. The literature was searched, advantages
and disadvantages of robotic surgery were evaluated. This paper showed that previous studies
which have been done suggest robotic surgery can be used in gynecologic interventions. Two-
dimensional imaging is replaced with three dimensional technique in the da Vinci robot with
increased perception and magnication. Moreover, tremor and motion scaling which complicate
the operation are not seen in the robotic surgery and the surgical procedures that are typically
difcult can be done easier than laparoscopy. However, the price and the loss of tactual feeling
are accepted as big disadvantages of robotic surgeries. This manuscript will highlight the
science behind the robotic surgery, recent advances in minimally invasive surgery, the most
recent clinical trial results and important issues we need to consider prior to implementation
of the robot in Turkey.
KEY WORDS: Robotic surgery, da Vinci robot, Gynecology, Laparoscopy, Minimally invasive
surgery.
Pak J Med Sci January - March 2012 Vol. 28 No. 1 238-241
How to cite this article:
Kara M. Robotic Surgery in Gynecology Practice:Current Approaches. Pak J Med Sci
2012;28(1):238-241
Robotic Surgery in Gynecology Practice
Pak J Med Sci 2012 Vol. 28 No. 1 www.pjms.com.pk 239
cart, and the endoscopic stack (Fig.1). The surgical
console consists of binocular vision system, instru-
ment controllers, and foot pedals. The vision sys-
tem consists of two micro cameras and two optic
cables transforming the two-dimensional imaging
to the binocular imaging. The instrument control-
lers are commanded by thumb and index nger of
each hand. The surgeon is seated in an ergonomic
position and moving these two ngers lead to the
attached devices. There are ve foot pedals. These
pedals are used to adjust the instruments, camera
focus, bipolar and monopolar cautery.
The robotic cart contains four mechanical arms
and these arms are joined to the surgical console via
a channel. Each arm has three or four articulating
parts providing the movements easily. The central
arm contains the optic system. The weight of the
cart is nearly 500kg and it can be operated easily on
a wheel base. The endoscopic stack contains moni-
tor, light source, and CO2 insufator.
Firstly, the laparoscopic ports are placed and
docking the robotic arms, the surgeon manipulates
attached instruments. Two-dimensional imaging
is replaced with three dimensional in the da Vinci
robot with increased perception and magnication.
Moreover, tremor and motion scaling which com-
plicate the operation are not seen in the robotic sur-
gery and the surgical procedures that are typically
difcult can be done easier than laparoscopy.1,2
Finer and more dexterous movements due to wrist
like motion of the robotic arm allow to enable op-
erations which is difcult for traditional laparosco-
py with robot such as intracorporeal suturing and
knot tying. The bedside assistant can suction, grasp,
and pass suture through an accessory laparoscopic
port, as well as manipulate the uterus. The surgeon
is seated and more comfortable in robotic technol-
ogy than a standing and holding two instruments
laparoscopic surgeon. Consequently, the limiting
factors such as fatigue and frustration are less im-
portant for robotic surgeon. In addition potential
for telesurgery shorter hospital stay, minimal pain,
quick recovery, and decreased blood loss are other
advantegous of robotic surgery.3,4 The loss of tac-
tual feeling is the major problem of the surgeons
using da Vinci robot. The lack of tactile feeling and
high cost are limitations of this system.
Port Placement: The recommendations about port
placement by the Intuitive Surgical Company which
developed and marketed the da Vinci surgical
robot as follows: da Vinci endoscope port (12mm)
are placed directly above the umbilicus. Right da
Vinci instrument (8mm) is placed on the patient’s
right side, 2-3 cm from the anterior superior iliac
spine, along a line to the umbilicus. Left da Vinci
instrument port (8mm) is placed on the patient’s
left side, offset superiorly on a 15 degree angle from
the camera port, 8cm from the endoscope port and
at least 8cm from the 4th arm port. This port not
used with 3 arm system. The fourth arm da Vinci
Fig.1: The da Vinci robot. (A) The surgeon console
(B) Robotic cart (C) Endoscopic stack.
Fig.2: Robotic port placement for benign
gynecologic conditions.
Fig.3: Robotic hysterectomy.
240 Pak J Med Sci 2012 Vol. 28 No. 1 www.pjms.com.pk
port (8mm) is placed on the patient’s left side, 2-3
cm from the anterior superior iliac spine, along a
line to the umbilicus. This is the port location for
the left instrument arm when using a 3 arm system
(Fig.2).
Gynecologic Robotic Procedures: There is limited
data about the usage of the robotic surgery in
gynecology eld. Literature consists of descriptive
retrospective case series. Large, randomized,
prospective studies to evaluate the outcomes of
the surgeries and costs are needed. Information
is insufcient to suggest that robotic-assisted
procedures might be superior than other techniques.
Mostly heterogenous, small retrospective studies
have shown safety and feasibility for tubal
reanastomosis, hysterectomy, prolapse, myomas up
to 2000gm, adenomyosis, lymph node dissection,
ovarian remnant syndrome, endometriosis,
adhesion, and pelvic pain. Future prospective
studies are required.5-8
The robotic learning curve for a single surgeon
was found to be steep in a study reported by Bell
et al.9 Nezhat et al reported that robotic-assisted
surgery was found to be effective for endoscopic
surgery. Learning curve for suturing is faster in this
procedure and the quality of the image is better.3
The rst 20 cases were more important than other
cases because the surgeons acquired their surgical
skills in these rst cases. Lenihan et al reported that
the learning curve for experienced surgeons was
shorter than beginners it was dened as 50 cases.4
Guru and co-workers compared the robotic and
laparoscopic surgery in their study. Although the
robotic procedures were more time consuming
the suturing process were performed in a shorter
time in with robot than laparoscopy. Suturing with
laparoscopy was dened difcult and impossible
in 73% and 9% of the participants, respectively
in the same study.10 Robotic surgery was found
to be successful for hysterectomy as much as
standard laparascopic hysterectomy (Fig.3). It
contains technologic convenience such as remote
telesurgery, and easiness of teaching endoscopic
surgery.11,12 Boggess et al reported that robotically
assisted total hysterectomy for benign gynecologic
indications is capable and requires low morbidity
and a short hospital stay. Their study suggests
that robotic approach is easier than conventional
procedures and minimally invasive for high-risk
patients.13 Advincula et al14 compared with robot-
assisted laparoscopy and traditional laparotomy
and analyzed the cost of these two operations.
The blood loss and hospital stay were found to
be less in robotic group than laparoscopic group.
However, the cost of the operation was higher in
robotic myomectomy group than the other one.
Bedient et al15 assessed the success of robot-assisted
and laparoscopic myomectomy. Short-term
surgical outcomes were similar according to their
data. Nezhat et al16 compared with robot-assisted
and standard laparoscopic myomectomy in a
retrospective matched control study (Fig.4). They
reported the same short term outcomes in these two
groups.
Robotic surgery contains various benets for
pelvic oor reconstructive surgery (Fig.5). The
usage of robotic surgery in urogynecologic surgery
will increase and this technology is an enabler in
laparoscopic surgery, especially in microsurgical
and suture-intensive operations.17,18
CONCLUSION
Advanced laparoscopic surgery is a milestone at
the beginning of minimally invasive pelvic surgery.
Mustafa Kara
Fig.4: Robotic myomectomy. Fig.5: Robotic sacrocolpopexy.
Pak J Med Sci 2012 Vol. 28 No. 1 www.pjms.com.pk 241
Robotic Surgery in Gynecology Practice
The limited mobility of the laparoscopic instru-
ments, two-dimensional imaging, unstable camera,
long learning curve, and a poor ergonomic position
are the disadvantages of the laparoscopy. These
difculties caused to the invention of the da Vinci
robot. Robotic surgery is a new milestone. The da
Vinci robot has a lot of technical advantages includ-
ing easy manipulation, high image quality, ease of
use. Furthermore, it is convenient for inexperienced
surgeons and the learning curve is short. However,
high cost associated with this technology, neces-
sity of extra time to set up and docking (variable
team effort), lack of tactile feedback and sensation,
inability to reposition the patient (Trendelenburg
position), and bulkiness of the current system (uter-
ine manipulation) are main disadvantages. Despite
these limitations much attention should be paid to
the promise of the robotic surgery.
ACKNOWLEDGEMENTS
I am grateful to Assoc. Prof. Dr. Ceana Nezhat
who works at Endoscopy Laser Institute of Atlanta
for his kind assistance to improve my professional
surgical training.
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