Robotic surgery

Robotic surgeryHWR Schreuder, RHM Verheijen

Department of Women and Baby, University Medical Centre Utrecht, Utrecht, the Netherlands

Correspondence: Prof RHM Verheijen, Department of Woman and Baby, University Medical Centre Utrecht, PO Box 85500, Room F05-126, 3508

GA, Utrecht, the Netherlands. Email [email protected]

Accepted 12 October 2008.

Over the past decade, there has been an exponential growth of

robot-assisted procedures and of publications concerning robotic-

assisted laparoscopic surgery. From a review of the available

literature, it becomes apparent that this technology is safe and

allows more complex procedures in many fields of surgery, be it at

relatively high costs. Although randomised controlled trials in

gynaecology are lacking, available evidence suggests that

particularly in gynaecology robotic surgery might not only reduce

morbidity but also be cost effective if performed in high-volume

centres. Training in robotic surgery and programs for safe and

effective implementation are necessary.

Keywords Gynaecology, laparoscopy, robotics, robotic surgery,

training.

Please cite this paper as: Schreuder H, Verheijen R. Robotic surgery. BJOG 2009;116:198–213.

Introduction

The use of robots is rapidly increasing with a market growth

worldwide from less than 5 billion in 2000 to an expected 25

billion in 2010.1 Robotic technology offers the unique oppor-

tunity to control the operational process outside the actual

location, with the skilled and often expert operators not nec-

essarily being physically present. Probably, more important

than the teleoperating features are opportunities for ext-

remely precise, controlled and fatigueless acts of the robot.

This will make it possible to replace human movements that

are limited both in time and in space to make complicated

processes more secure and safe. Interestingly, until recently

robotic technology was mainly applied in manufacturing pro-

cesses but is now becoming increasingly important in

machines for personal use. It is expected that after the current

surge in the public domain, the medical field will also start to

make increasing use of robotics.

In this paper, we review the use of surgical robots in lap-

aroscopy applied in different subspecialties and in gynaecol-

ogy in particular. An inventory of the current applications is

made on the basis of published series. The efficacy, costs,

training and future developments are discussed.

Search strategy

Over the past two decades, the number of publications on

robotic surgery has risen exponentially (Figure 1). A com-

puter aided and manual search for systematic reviews of rand-

omised controlled trials, prospective observational studies,

retrospective studies and case reports published between

1970 and 2008, assessing robotic surgery was carried out

defined by search strings including ‘robotics’ or ‘robot’ or

‘robot-assisted’ or ‘da Vinci’. Different searches were per-

formed for each of the specific subspecialties.

Data sourcesWe searched the following computerised bibliographic data-

bases from 1970 to 2008: MEDLINE, Embase, the Cochrane

Database of systematic reviews, the Cochrane controlled trials

register, the specialist register of trials maintained by Cochrane

Effective Practice and Organisation of Care Group, NHS

Economic Evaluation Database, Database of Abstracts on

Reviews and Effectiveness.

MethodsThe search was performed with the limits English and reports

published between 1 January 1970 and July 2008. Full reports of

each study likely to be relevant were then assessed including the

reference lists. First randomised controlled trials were searched

and subsequently prospective case–control studies, prospective

cohort studies, retrospective studies and case reports were

assessed. Finally, we included all different types of relevant

clinical research because little (randomised) data were available.

History

The first concept of surgical robotics was developed in the late

1980s at the National Aeronautics and Space Centre (NASA).2

Together with the Stanford Research Institute, virtual reality

198 ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology

DOI: 10.1111/j.1471-0528.2008.02038.x

www.blackwellpublishing.com/bjogReview article

and surgical robotics were integrated and the first steps

towards telepresence surgery were made. The commercialisa-

tion of robotic surgery started in the early 1990s. The next

step was the development of complete robotic systems. The

Zeus robotic system (Computer Motion, Goleta, CA, USA)

and the da Vinci robotic system (Intuitive Surgery, Mountain

View, CA, USA) were introduced in the late 1990s. Both

systems have remote manipulators that are controlled from

a surgical workstation; in less than 20 years’ time, there had

been a major development in robotic surgery (Table 1). In

2003, Computer Motion was taken over by Intuitive Surgery

and today the Zeus system is no longer commercially avail-

able. The da Vinci platform is the only telerobotic system

currently commercially available. The da Vinci system was

approved for general surgery by the US Food and Drug

Administration (FDA) in 2000, for the use in urology in

2001 and for gynaecology in 2005.

Description of technique

The da Vinci robotic system (Intuitive Surgery) has three

major components (Figure 2). The first component is the

surgeon console. The surgeon sits ergonomically behind the

console and controls the robotic system remotely. The con-

sole can be placed anywhere in or even outside the operating

room. While operating, the surgeon is viewing a stereoscopic

image projected in the console and controls the robotic arms

with hand manipulators and food pedals. The position pro-

vides an optimal hand–eye alignment. The surgeon has lim-

ited haptic feedback, so one should rely on visual feedback.

The second component is the Insite Vision System�

(Figure 3). A three-dimensional (3D) view is created with

the use of two camera control units and two light sources,

built in the unit. A 12-mm endoscope (0� or 30�) is used. Theviewer gives a six to ten times magnification of the operating

field. Because of the 3D view, the visual feedback is excellent

and allows the surgeon to work very precisely, even without

haptic feedback. High-definition vision is available in the

robotic visualisation system, providing higher resolution

and improved clarity and detail. Finally, the digital zoom

reduces the interference between endoscope and instruments.

The third component is the patient side cart with the

robotic arms. The first series of da Vinci systems had three

robotic arms, and the new series all have four robotic arms.

Attached to the robotic arms are the EndoWrist� instru-

ments. These instruments are one of the key components of

the system. The wrist has a total of 7 df similar to the human

hand (Figure 4). The surgeon’s hand (fingertip) movements

are translated by the computer to the same movements of the

instruments. Motion scaling (up to 1:10) is making it possible

to perform very precise tasks. The computer also filters out

normal physiological hand tremor and avoids the reverse-

fulcrum effect that occurs in traditional laparoscopy. Depend-

ing on the type of surgery to be performed, there are various

instruments available (Figure 5). The software is important

not only for the functioning of the robot but also to provide

safety features, such as a multi-input display allowing an inte-

grated view of patient critical information and the built-in

telestration for proctoring and team communication.

Robotics in nongynaecological surgery

UrologyRadical prostatectomy has been the fastest growing applica-

tion of robotic surgery in urology and becoming standard

procedure in many centres in the United States.11 Robot assis-

tance is also applied for cystectomy, pyeloplasty, adrenalec-

tomy,12,13 renal surgery,14 radical nephrectomy,15 donor

nephrectomy,16 urogynaecology and paediatric urology.17

Since the first da Vinci robot-assisted radical prostatectomy

was published in 2000,18 multiple large prospective trials

(300–2652 cases) have been published.19–23 Reviewing these

data, Box and Ahlering concluded that the robot-assisted rad-

ical prostatectomy is superior in preventing excessive blood

loss, major surgical complications and the development of

venous thromboembolic events. Oncologic outcomes suggest

Table 1. Robotic surgery in time

1985 First robot used for stereotactic brain surgery3

1989 PROBOT, first robot used for prostatectomies4

1992 ROBODOC use for hip replacement5

1993 AESOP, first commercially available robot

approved by the FDA6,7

1996 ARTREMIS, master slave manipulator system8

1996 EndoAssist, robot camera holder9

1998 Zeus robotic system commercially available10

2000 da Vinci robotic system FDA approved

0

200

400

600

800

1000

1200

1400

Nu

mb

er

of

art

icle

s

1980 1990 1995 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Articles published

Figure 1. Publications about robotics in www.embase.com (search terms

robot or robotics).

Robotic surgery (efficacy, costs and training)

ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 199

that in experienced hands, the percentage of positive surgical

margins in the robot-assisted procedure is equivalent or bet-

ter compared with the open radical prostatectomy. Conti-

nence rates achieved with the robot-assisted procedure are

excellent and the return of sexual function is very good.24

Other reviews draw almost the same conclusions.11,25,26 The

technique of the robot-assisted radical prostatectomy is

described in detail by Tewari and Menon.27,28 The adoption

of the robotic-assisted radical prostatectomy on a large scale

in Europe is slower than in the USA. This could be a related to

Figure 2. da Vinci S HD robotic system (surgeons console, patient side card with robot arms, InSite� vision system) (ª[2008] Intuitive Surgical, Inc.).

Figure 3. InSite� Vision, three dimensional view, with console master

(ª [2008] Intuitive Surgical, Inc.).

Figure 4. EndoWrist� instrument, 7 df, just like the human wrist (ª[2008]

Intuitive Surgical, Inc.).

Schreuder, Verheijen


the high level of experience in conventional laparoscopy

already available in Europe. Also, Europeans are more expec-

tant for more evidence to show the advantage above conven-

tional laparoscopy. The high costs of setting up a robotic

program could also be a burden for centres. Randomised

clinical trials comparing the open with the robot technique

are unlikely to take place and other tools of assessment are

needed.29 Randomised clinical trials between different robot-

assisted procedures are more likely to take place.30 In 2008,

Lam et al. started to write a Cochrane review about the sur-

gical management of prostate cancer. This review will also

address the issues concerning robot surgery.31 Cystectomy is

mainly used for the treatment of bladder cancer. The first

robot-assisted laparoscopic radical cystectomy was described

in 2003.32 Since then several other authors have published

their initial experiences with this procedure.33–36 The proce-

dure is safe with acceptable operating times and good short-

term functional and oncological results.37–40 In 2008 Elhage

et al. described their surgical technique and looked at the

financial aspect from a British perspective.41 Another difficult

laparoscopic procedure in urology is the ureteropelvic junc-

tion reconstruction (pyeloplasty). Although short-term

results seem to be similar to those of the conventional lapa-

roscopic pyeloplasty42–45 and open repair,46 for experienced

laparoscopists, there was no significant clinical advantage

using robot assistance.47

General surgeryRobotic-assisted laparoscopy is used forNissen fundoplications,

cholecystectomies, gastric bypass surgery,48,49 colectomies,50

mediastinal lymphadenectomy and esophagectomy,51,52

mediastinal parathyroidectomy and thymectomy.53 In 1997,

the first robot-assisted Nissen fundoplications for gastro-

esophageal reflux were performed.54 Notably, this is the only

robotic procedure in which proper randomised trials are

published. Four, relatively small, randomised trials found

no differences in terms of feasibility and outcome, but the

costs of the robot-assisted procedure were higher.55–58 How-

ever, in contrast to primary procedures, repeat fundoplica-

tions are often more demanding and could benefit by robot

assistance.59 The first studies addressing the robot-assisted

cholecystectomy were performed using the Zeus robotic sys-

tem60–62 and later studies with the da Vinci robotic system.63–66

Based on these studies, there is not enough evidence for

routine use of the robot for this procedure.64 A Cochrane

review concerning robotic surgery for the cholecystectomy is

under way.67

Other subspecialtiesRobot assistance is used in cardiovascular surgery for mitral

valve repair, atrial fibrillation surgery, coronary revascularisa-

tion, left ventricular lead placement and congenital heart dis-

ease surgery.68–70 In 2005, the FDA approved the da Vinci

robot for mitral valve surgery and it has become an accepted

procedure.71 The da Vinci robot is also used for aortobife-

moral bypasses72 and aortoileac reconstruction.73 The use of

robotics in paediatric surgery is rapidly growing and it is now

used in the field of general surgery, urology and cardiotho-

racic surgery.74–76 A pilot randomised controlled trial between

robot and conventional laparoscopic fundoplication in chil-

dren was performed.57 A recent overview of the current status

of robot-assisted surgery in children is given by Sinha and

Haddad.77 Other areas where the da Vinci system has been

used include otolaryngeal surgery (FDA approval is expected

this year); endocrine surgery, where the first cases have been

described78,79 and neurosurgery, where results are not yet

published.80 One of the major problems for these robots is

the different types of tissue, bone and soft tissue to be hand-

led. Different robots are used in neurosurgery for microscopy,

navigation, instrumentation, optics and imaging.81–83 The da

Vinci system is not used in orthopaedics, but different robots

are used.84

Robotics in gynaecology

Reproductive surgeryTubal reanastomosisAlthough this microsurgical operation seems to suit the fea-

tures of robotic surgery, there is not much literature available.

The first complete robotic-assisted tubal anastomosis in

humans was performed in 1997 with the Zeus robotic sys-

tem in Cleveland, USA.85 In 2003, Goldberg and Falcone

compared the robotic-assisted procedure with conventional

laparoscopic procedure. The operation time was 2 hours

longer with the robot, and there were no significant differ-

ences in tubal patency and clinical pregnancy rates.86 The

tubal anastomosis by robotic assistance was compared with

Figure 5. EndoWrist� instruments belonging to the da Vinci Robotic

system (ª[2008] Intuitive Surgical, Inc.).



minilaparotomy by Rodgers et al. They performed 26 robot-

assisted cases and 41 minilaparotomy cases. Mean anaesthesia

time and surgical time were 283 and 229 minutes, respectively,

for the robot group compared with 205 and 181 minutes for

the minilaparotomy group. There were no differences in hos-

pital stay, pregnancy rates and ectopic pregnancy rates. Costs

were significantly higher in the robot group and return to

normal activity was significantly shorter in the robot group.87

The first reanastomosis with the da Vinci robotic system were

published by Degueldre et al. After a feasibility series of eight

women,88 they evaluated 28 women in 2001. The mean oper-

ating time for bilateral anastomosis was 122minutes, and there

were no complications.Median hospital stay was 1 day (1–2).89

MyomectomyA laparoscopic approach to myomectomy results in less

postoperative pain and faster recovery compared with

laparotomy.90 There is no significant difference between

laparotomy and laparoscopy concerning pregnancy rates,

miscarriage rates, preterm delivery or caesarean section.91

Laparoscopic myomectomy is an advanced procedure that

needs multilayer laparoscopic suturing, resulting in a long

learning curve. This could be the main reason laparotomy

still remains the primary access route to surgical treatment

of intramural and subserosal fibroids. Nevertheless, the robot

could be very helpful with enucleation and suturing. The first

experience with robot-assisted laparoscopic myomectomy

was published in 2004.92 In a case series of 35 women, this

was presented as a promising new technique that may over-

come the surgical limitations of conventional laparoscopy.

A second series by the same author was a retrospective case

matched (age, body mass and myoma weight) analysis of 58

women treated with robot-assisted laparoscopy and laparo-

tomy.93 The robotic approach had less blood loss, shorter

hospital stay and lower complication rates but was more

expensive. The technique of the robotic-assisted laparoscopic

myomectomy used in these two studies is explained in detail.94

A case of a robot-assisted enucleation of a large myoma is

described by Mao et al.95 Sroga et al. described 15 women in

whom they performed a robot-assisted myomectomies and

found operative time to range from 159 to 389 minutes, with

an average blood loss of 160 mL.96 In a retrospective matched

control study of 15 cases comparing robot-assisted laparo-

scopic myomectomy and laparoscopic myomectomy, no dif-

ference in blood loss, hospital stay and postoperative

complications was found. The robot procedure took little,

but significantly, longer (234 versus 203 minutes).97

General gynaecologyAlthough robot assistance in general gynaecology is most

widely used for hysterectomy, no randomised trials have been

reported. The first robot-assisted hysterectomy was published

in 2001.89 The first series of the robot-assisted hysterectomy

for various indications was described in 2002 by Diaz-Arrastia

et al., who performed the procedure in 11 women including

a 10-hour case of full staging for ovarian cancer where repo-

sitioning of the robot was needed twice.98 Three years later,

Beste et al. published their first ten cases, with an operative

time similar to the standard laparoscopic hysterectomy; they

reported that the robot has unique advantages for knot tying,

suturing and adhesiolysis.99 In the same year, Marchal et al.

published 30 cases (18 benign and 12 endometrial cancer

stage I). The mean set-up time for the robot was 30 minutes,

the mean operative time was 185 minutes and the mean robot

use time was 120 minutes. There was no morbidity related to

the robotic system.100 Twenty cases were described in 2006 by

Fiorentino et al.Mean operative time was 200 minutes, mean

blood loss was 81 ml and hospital stay was 2 days. There were

two conversions due to poor visualisation.101 Sixteen cases of

a robot-assisted laparoscopic hysterectomy were published by

Reynolds et al. Their mean operative time was 242 minutes

(170–432) and mean hospital stay was 1.5 days.102 The details

of their technique have been described separately.103 Robot

assistance can be particular of help in difficult cases to over-

come the surgical limitations of conventional laparoscopy. Six

cases with scarred or obliterated anterior cul-de-sac under-

went a robot-assisted hysterectomy without conversion with

satisfactory outcome.104 Nezhat et al. described his first expe-

rience in robot-assisted surgery in a diverse case series of 15

women (hysterectomy, endometriosis, lysis of adhesions and

cystectomy). The visualisation, great surgical precision,

decreasing fatigue and tension tremor of the surgeon and

added wrist motion appeared an advantage. The costs added

operating time and the bulkiness of the equipment were con-

sidered a disadvantage.105 A large prospective study of 91

women was published by Kho et al. Robot-assisted laparo-

scopic hysterectomy took a mean operating time of 128

minutes, with a mean console time of 73 minutes. As

expected, console time decreased with experience and was

significantly associated with uterine weight and adhesiolysis.

Mean blood loss was 79 ml and the mean hospital stay was 1.3

days. There were no conversions, no bladder or urethral inju-

ries occurred, but one enterotomy was repaired robotically.

Six women were readmitted postsurgically because of ileus,

pneumonia, vaginal cuff abscess, colitis and two for pain con-

trol. From this large series, it can be concluded that robot-

assisted laparoscopic hysterectomy can be performed safely

and effectively with acceptable operating times. The robot

overcomes many limitations of the conventional laparos-

copy.106 In 2008 an equally large retrospective comparison

between 100 women who underwent a total laparoscopic hys-

terectomy and 100 women who underwent a robot-assisted

laparoscopic hysterectomy was published. Overall, the oper-

ating time was 27 minutes longer in the robot group. But the

last 25 robotic cases compared with the conventional



laparoscopy cohort had a significant shorter operating time of

79 versus 92 minutes. The mean blood loss was significantly

less in the robot group (61 versus 113 ml), the mean length of

hospital stay significantly shorter (1.1 versus 1.6 days), while

the incidence of adverse events was the same. The conversion

rate in the robot group was lower (4 versus 9%). Others have

also found that once the learning curve is completed, there is

a reduced operative time, reduced blood loss and a reduced

hospital stay in patients treated robotically.107

Other procedures performed successful with robot assis-

tance are ovarian transposition.108 A recent innovative and

promising application is abdominal cerclage for cervical

insufficiency.109

Pelvic surgery (urogynaecology)Robot-assisted surgery with the da Vinci robot is used in

vesicovaginal fistula repair, sacrocolpopexy and rectovagino-

pexy. Laparoscopic repair of vesicovaginal fistulas is rarely

performed because of its technical difficulty, and there are

few case reports reporting robot-assisted repair.110,111 A case

series of five was performed with a mean operative time of 233

minutes and a blood loss of less than 70 ml, with a 100%

closure rate.112 Robot-assisted laparoscopic sacrocolpopexy

was first described in 2004.113 In 20 women, the mean oper-

ative time was 212 minutes.114 In a subsequent series of 31

women, the same author reported exactly the same mean

operative time of 212 minutes.115 At 1-year follow up, 4 of

30 of these cases had recurrence of prolapse or extrusion of

mesh.116 Ayav et al. described 18 consecutive cases of pelvic

organ prolapse successfully operated with the da Vinci robotic

system. They concluded that using the da Vinci robotic sys-

tem is feasible, safe and effective for the treatment of pelvic

organ prolapse.117 Robot-assisted rectovaginopexy was

described in 15 women by Draaisma et al.118 Median set-up

robot time was 10 minutes, and median skin-to-skin operat-

ing time was 160 minutes, median blood loss less than 50 ml

and median hospital stay was 4 days. Two other small series of

six and ten women also showed the feasibility of this

procedure.119,120

Gynaecological oncologyLaparoscopy can be safely and adequately used in the treat-

ment of endometrial, ovarian and cervical cancer.121 The ini-

tial experience and the first publications of robot assistance in

gynaecological oncology date from recent years. Reynolds

et al. performed seven staging procedures in ovarian and

endometrial cancer patients, with a mean operating time of

257 minutes.122 Twelve hysterectomies for endometrial cancer

(stage I) were performed by the group of Marchal et al.;

robotic surgery was safely performed and had a major advan-

tage for the surgeon’s ergonomics.100 A series of 20 diverse

procedures in gynaecological oncology has been described by

Field et al.123 Boggess presented 43 robotic versus 101 laparo-

scopic staging procedures for endometrial cancer at the

American College of Surgeons. There were no conversions

in the robotic group versus 3% in the laparoscopic group.

In the robot group, the operative time was significantly

shorter (163 versus 213 minutes), significantly more nodes

were received (30 versus 23), there was significantly less blood

loss (63 versus 142 ml) and shorter hospital stay (1 versus 1.2

days). Notably, surgeons were better able to perform compre-

hensive staging on obese women with the robot.124 A large

series was published by Seamon et al.125 Seventy women with

endometrial cancer underwent a robot-assisted hysterectomy

with pelvic and para-aortic lymphadenectomy. Next to a very

detailed overview of their set-up protocol including patient

positioning, trocar placement and instruments used, they also

included video material in the online publication. Such visual

presentations can certainly help others to shorten their learn-

ing curve. For all women in whom the robotic procedure

could be completed, the median total time skin-to-skin time

was 257 minutes (159–380). The average time from entering

the theatre to incision was 45 minutes, the average time from

incision to docking robot was 25 minutes, the time for the

hysterectomy with bilateral salpingectomy was 86 minutes

and the time for the pelvic and aortic lymphadenectomy

was 45 minutes each. When comparing the first ten cases with

the last ten, there was a significant improvement, with short-

ening in time at all different stages of the procedure. The

conversion rate was rather high (9.86%), mean blood loss

was 75 ml and mean hospital stay was 1 day. Veljovich et al.

published their first year experience, performing 118 robot-

assisted oncology procedures for different gynaecologic onco-

logic conditions. They compared their robot procedures with

open and conventional laparoscopic procedures. They found

less blood loss, shorter hospital stay and longer operating time

in the robot procedures (but operating time significantly

decreasing with experience).126 The technique of the robotic

retroperitoneal para-aortic lymphadenectomy has been

described by Vergrote et al.127

The first radical hysterectomy in cervical cancer with robot

assistance was described by Sert and Abeler.128 They con-

cluded that radical dissection could be performed much more

precise than with conventional laparoscopy. In 2007, they

described 15 women with early-stage cervical cancer as a pilot

case–control study and compared robotic-assisted laparo-

scopic radical hysterectomy with conventional total laparo-

scopic radical hysterectomy. There was a significant difference

in mean operating time (241 minutes in the robot group and

300 minutes in the conventional group). No difference in the

number of lymph nodes and size of parametrial tissue was

found. In the robot group, there was significant less bleeding

and shorter hospital stay.129 A prospective analysis of 27

women with early-stage cervical cancer undergoing a robotic

radical hysterectomy was performed by Margina et al., and

a comparison was made with matched patients operated by



conventional laparoscopy and laparotomy. They concluded

that operating times for robot surgery and laparotomy were

similar (189 and 166 minutes) and significantly shorter com-

pared with laparoscopy (220 minutes). Blood loss and length

of hospital stay were similar in robotics and laparoscopy and

significantly longer in laparotomy. At a mean follow up of 31

months, there were no recurrences at all.130 Kim et al. per-

formed robotic radical hysterectomy and pelvic lymphade-

nectomy in ten cases and found a mean operating time of

207 minutes. The mean docking time was 26 minutes, but

this was reduced significantly with experience (from 35 to 10

minutes).131 Kowalski et al. compared 14 robotic versus 17

open radical hysterectomies. Their mean operating time was

significantly longer in the robot group (204 versus 121

minutes).132 These small series, however, do not report the

outcome of surgery in terms of lymph node yield and radical-

ity and also lack sufficient oncological follow up. Boggess

found no difference in the operating time (242 versus 240

minutes).124 He performed 13 robot-assisted radical hysterec-

tomies and compared them with 48 open radical hysterecto-

mies. Significantly more lymph nodes were collected in the

robot group (33 versus 22). All the robotic patients were dis-

charged within 24 hours. He also describes how to set up

a robotic programme in gynaecological oncology. A robotic

radical hysterectomy in 20 women was described by Fanning

et al.Operating console time reduced from 8.5 to 3.5 hours in

20 cases. Less blood loss and shorter hospital stay was found.

There were no recurrences at a median follow up of 2 years.133

There are currently no randomised trials concerning robotic

surgery in gynaecological oncology, and none of the pub-

lished studies provides information on long-term effects, such

as survival, lymph oedema, continence and sexual function.

Robotics and anaesthesia

Danic et al. describe anaesthetic considerations in 1500 rad-

ical prostatectomies.134 Some special arrangements have to be

made when performing robot-assisted surgery in the pelvis.

Preoperatively, there is no need for a full bowel preparation,

but it is advisable to use a laxative on the day before surgery.

During the operation, special attention must be given to the

positioning of the patient. Cushioned stirrups should be used

to place the patient in lithotomy position. During the oper-

ation, 45� steep Trendelenburg position is used and the

patient is prone to slip of the table. One can use a chest

binding in an ‘x’-like pattern over the acromia to prevent this,

paying attention to pressure areas. The most common anaes-

thesia-related complication (3% of the cases) was corneal

abrasion, despite the use of eye tape. This could be signifi-

cantly reduced with the use of eye patches. Constant positive

airway pressure of 5 cmH2O preserves arterial oxygenation

during prolonged pneumoperitoneum.135 Baltayian pub-

lished a comprehensive overview of anaesthetic considera-

tions and detailed anaesthetic management for robot-assisted

radical prostatectomy. This could be of help for centres

starting a robotic program and where the anaesthetists are

not familiar with the specific measures for these type of

procedures.136

Cost-effectiveness

An important issue in robotic surgery are the higher costs

compared with regular surgery. Several costs comparisons

have been made in the past few years. We will only discuss

the costs for the use of the da Vinci robotic system since this is

the only robotic platform available at this moment. The latest

robotic da Vinci S system will cost approximately e1.5 million

in Europe plus e150.000 yearly for maintenance. Instruments

are available at approximately e250 per instrument used,

however, price changes are expected with current currency

fluctuations. Finally, extra costs for training, delay in set-up

and extraoperative time during the learning curve should be

anticipated. A recent description of the cost patterns using

a robotic system is given by Prewitt et al. They analysed 224

procedures in different subspecialties in a single institution

and found $1470 greater direct costs for the use of the robotic

system.137 Analyses of costs for different procedures are made:

for robot-assisted laparoscopic rectopexy, there was an

increase in operative costs of e557 or $745 (including material

and time).138 For tubal anastomosis, the increase was $1,446.87

For myomectomy,93 pyeloplasty,47 cholecystectomy64,139 and

Nissen fundiplication,58,140 higher costs were also found for

robot-assisted procedure. Most, if not all, cost-effectiveness

analyses do not or only partly take into account indirect costs.

Morgan et al. compared all ‘in hospital’ costs for the use in

cardiac surgery. When leaving out the initial capital invest-

ment for the robotic system, there was no significant differ-

ence in costs between the robot procedure and the sternotomy

procedure.141 Most cost analyses have been performed for

radical prostatectomy. The cost of the open conventional lap-

aroscopic and robot-assisted radical prostatectomy has been

compared by different groups. Burgess et al. found signifi-

cantly higher operative costs for the robot-assisted procedure,

although these costs decreased after the learning curve was

completed.142 The intraoperative costs were higher in the

robot-assisted procedure but the shorter hospital stay in the

laparoscopic/robot procedure should be taken into

account.143 In relation to this, it is important to realise that

the costs of hospital beds vary between hospitals, especially

between community hospitals and academic medical centres.

So, a robotic program will be most competitive in a high-cost

hospital combined with a high volume of cases.144 An exten-

sive cost analysis for pyeloplasty by experienced surgeons

excluding the learning curve showed cost-effectiveness if

operating time is less then 130 minutes and the yearly cases

are above 500.145 Steinberg also concluded that after the initial



learning curve, a program of robot-assisted radical prostatec-

tomy, the procedure can be profitable, but that one should

maintain a high volume to pay for the robot and its service.146

The costs of the initial learning curve are high and can vary

widely. A theoretical model of the expenses of the learning

curve was made by including eight series. The costs of the

initial learning curve varied from $49,613 to $554,694 with an

average of $217,034. To overcome these high costs, the con-

cept of high-volume centres is of great importance. In such

centres, the learning curve can be rapidly traversed and costs

minimised.147

Training and education in robotics

With the implementation of robot-assisted laparoscopic sur-

gery, there is also an increasing need for training. Conven-

tional laparoscopic surgery requires different skills and

training compared with open surgery. Basic laparoscopic

skills can be obtained in a box trainer, in a cadaver or with

virtual reality.148 Training for specific procedures is possible

in a cadaver or in a virtual reality environment. In conven-

tional laparoscopy, the surgeon has a two-dimensional (2D)

view, while in robotic surgery, the view is 3D, allowing tasks

to be performed quicker and more efficiently.149–151 In con-

trast to open surgery, the basic laparoscopic and robotic skills

can improve significantly in a relatively short-intensive

course.152 Question is how to maintain this improvement

after a course and whether this improvement translates to

better surgery?

Robot-assisted surgery can be learned in different ways

than conventional laparoscopy. Training on human cadavers

still gives the best anatomic training, but fresh human cadav-

ers are not always available. Coordination for multiple

cadaver use increases the availability of human material and

is advisable.153 The advantage of using fresh tissue models

(like porcine intestine) is obvious in developing delicate tissue

handling. A complex sewing task, like a robotic-sutured in-

testinal anastomosis, can be reproduced successfully by

residents.154 For vascular surgery, a standardized and repro-

ducible training module, using pigs and rats, was devel-

oped.155 Robotic surgery is specifically suitable for virtual

reality training, as the operation itself is computer guided.

Different companies are developing virtual reality simulators

for robotic surgery and this is likely to be the training of

choice for the surgeons of tomorrow.156 The dV-trainer

robotic simulator (Mimic Technologies, Inc., Seattle, WA,

USA) has modules for system training and for skills train-

ing.157 Face, content and construct validity for the virtual

reality dV-Trainer were established.158,159 Another virtual

reality trainer is the SEP� robotic surgery simulator

(SimSurgery, Oslo, Norway, USA)160 (Figure 6). Training

on basic robot-assisted suturing skills using this simulator

equalled training using a mechanical simulator.161 At the Uni-

versity of Nebraska, a virtual reality trainer using da Vinci

instruments and training task platform (dry lab) has been

developed. This 3D virtual reality program can be projected

inside the actual console of the da Vinci robot. Some tasks

were adequately simulated but others need improvement in

the complexity of the virtual reality simulation.162 The same

group developed a more complex robotic surgical task, mesh

alignment, in virtual reality. There were no great differences

between the actual and the virtual environment, and a virtual

reality environment projected inside the console was found to

mimic more than any other surgical training system the actual

environment.163 At the University of Hong Kong, a compre-

hensive computer-based simulator for the da Vinci robotic

system is being developed. The simulator reproduces the

behaviour of the da Vinci system by implementing its kine-

matics and thus providing a promising tool for training and

a way to plan operations.164 Students of today easily and

readily adopt virtual reality as part of their regular training

program.165 The new generation of medical students has

grown up in the age of computer technology and it has been

shown that prior videogame experience can shorten the time

to learn basic skills in virtual reality simulation for minimal

invasive surgery,166 except for robotic suturing, where prior

videogame experience had a negative impact on robotic per-

formance.167 New developments are the use of a mentoring

console. The prototype of the da Vinci mentoring system was

tested by Hanly et al. It facilitates collaboration between the

mentor and the resident during robotic surgery. It improves

performance of complex three-handed tasks. This feature can

also contribute to the patient’s safety in hospitals with robotic

surgical training programs. On the other hand, it improves

resident participation and resident education.168 Other new

developments in training robotics are the use of augmented

visual feedback to enhance robotic surgical training.169 The

Figure 6. SEP da Vinci robotic simulator (ª[2008] SimSurgery).



use of 3D telestration technology during an actual operation

not only provides immediate feedback but it is also safer for

the patient through immediate guidance of the surgeon by

a more experienced mentor.170 Together with the approval of

the FDA, the manufacturer of the da Vinci robotic system

(Intuitive Surgery) was demanded to provide comprehensive

training for all teams and surgeons planning to use the robot

clinically. The registered training centres, located all over the

world, can be found on their website. Today 23 official train-

ing centres are noted.171 The first training curriculum for

robotic surgery was developed at the East California Univer-

sity, California.172

Special attention should be given to the training of resi-

dents and fellows. In the early days, the exposure of residents

to robotic training was low.173 In 2003, the interest of general

surgery residents in robotic training was 57%.174 In 2006,

already 75% of the residents surveyed would pursue a fellow-

ship robotic surgery.175 A growing interest is noticeable and

more attention is given to robotic training of residents and

fellows. A systematic approach should be used, starting as

table site assistant and followed by a stepwise approach of

the actual surgery as a console surgeon.176 Unlike open sur-

gery, robotic surgery provides safe and easy opportunity to

divide the operation into smaller segments, enabling partici-

pation as a console surgeon depending on the experience of

the resident or fellow. It is advisable to develop a structured

training program in advance. In this way, a complex opera-

tion can be incorporated in a residency or fellow training

program and has less influence on the total operating time

and patient safety.177 The surgical margins and blood loss are

not negatively affected when using a systematically stepwise

training approach.178

Another aspect of training is the learning curve. The term

‘learning curve’ is used to describe the process of gaining

knowledge and skills in the field of surgical technology. As

a minimum, reporting of learning should include the number

and experience of the operators and a detailed description of

data collection.179 There is a difference between the learning

curve of conventional laparoscopy and robot surgery. Sutur-

ing and dexterity skills can be performed quicker in robot-

assisted laparoscopy than in conventional laparoscopy.180 The

3D view in robotic surgery improves surgical performance

and learning compared with the traditional 2D view laparos-

copy.181 The learning curve for robotic surgical techniques is

therefore relatively short and may be even shorter for a new

generation as residents have a greater ability to interact with

the new robotic instruments.182 Several studies addressed the

issue of how learning of robotic skills best can be assessed. It is

important to identify objective variables for quantifying the

extent of proficiency. Hernandez et al. demonstrate a rapid

learning curve for suturing with the da Vinci robotic system.

Besides time and open structured assessment of technical

skills,183 they used motion analysis and found this a useful

tool.184 Other variables used to show the rapid learning curve

in robotic tasks are bimanual coordination and muscular

activation.185 A computerised assessment system (ProMIS�)

was used to demonstrate the faster and more precise perfor-

mance of the robotic system compared with conventional

laparoscopy.186 An overview of assessment of simulation-

based surgical skills training was published in the Journal of

Surgical Education.187 The learning curve for robot surgical

procedures varies widely. Factors of influence are experience

and expertise of the surgeon, type of surgery and volume of

the surgery. There are various variables that can be used to

define the end-point of the learning curve.188 Most data con-

cerning the learning curve in robotic surgery come from the

radical prostatectomy. They show a relatively short learning

curve if volume is high enough.189 The learning curve for

robot-assisted radical prostatectomy seems to be similar for

a fellowship-trained surgeon and a laparoscopically naıve

experienced surgeon of open radical prostatectomies.190 In

gynaecology, the issue of the learning curve has not yet been

properly described. However, from the small series that

describe reduced docking times and console time with

increased experience, it can be concluded that learning curves

are as steep as in other types of surgery.106 Finally, the rela-

tively large series from Seamon et al. clearly show a significant

effect of experience with gynaecological operations.125

Setting up a robotic program

With the growing interest in robotic surgery and the prom-

ising results, there is an increasing need for information how

to set up a robotic program. Palmer et al. describe five essen-

tial phases to set up a successful robotic program. The first

step is the development of a business plan, defining the initial

robotic program and arrange proper administrative support.

The second phase is the implementation in which one must

think of the theatre design, the theatre team, the purchase of

a robotic system, sterilisation facilities, marketing and an

expert lead surgeon.191 The third phase is the execution of

the program. Followed by a phase of maintenance. In this

fourth phase, one should have a proper data system for qual-

ity control and efficiency and outcomes as well as patient

satisfaction should be registered. A structured program for

training and education of fellow’s/residents should be avail-

able. The last phase is growth to make the program profitable,

where one could think of recruitment or training of new

surgeons working together with other subspecialties.192 Very

importantly, there is a need for a dedicated theatre team.193

Transforming an existing high-volume conventional laparo-

scopic program to a robot-assisted program for radical pros-

tatectomy can be achieved while maintaining reasonable

profits. However, equal profit is not possible without a sub-

stantial increase of caseload.146 All the above programs were

launched in the USA. The situation in Europe is different



from country to country because of different healthcare sys-

tems and insurance systems. For the UK, some general impli-

cations, similar to those for the USA, for adoption of a robotic

surgery program are described by Goldstraw et al.29

Litigation and ethical issues

The increasing complexity of modern surgical technology will

require more stringent guidelines for operation and practice

similar to the discipline exercised in aviation. Using a surgical

robot implies that the surgeon is no longer in direct physical

of visual contact with the patient. The surgeon not only oper-

ates through computer commands but there is also a physical

distance to the assistants attending the operation table.

Unfortunately, the current systems lack a satisfactory way to

communicate between the operator and the assistants. As

with many new technological advances, communication

might appear the Achilles’ heel of robotic surgery. More

appropriate equipment of communication and more strict

discipline in follow up of the commands from the primary

responsible person, the surgeon, will be essential for a safe and

successful procedure.

With the possibility of telemedicine and robotics new legal

and ethical issues arise. Telemedicine makes cross-border

treatment possible. How to deal with liability and licensure

across borders? Cross-border care should not change usual

medical ethics but makes treatment possible of patients in

areas the specialist cannot reach in person. In this way, under-

served regions and countries could be helped. But the tech-

nology could also aggravate migration of specialists from

poor to rich areas/countries.194 Also, the security of the trans-

mitted data between the surgeon and the (distant) robot is at

stake. Should data be treated the same way as written medical

records? Who is responsible if complications arise due to

transmission cuts, a breakdown of the system or instability

of the software? Malfunction of the robotic system will occur

more frequently with its increasing use; fortunately, it

appeared that less than 5% of device failures resulted in

patient complications. In addition, the rate of open conver-

sions due to device malfunction decreased from 94% in 2003

to 16% in 2007.195 Although robots seem to act autono-

mously, all their movements and actions are operated by

the surgeon and as such do not differ from any other surgical

equipment. Nevertheless, as with any complex system, safety

precautions will be more essential than with the use of simple

instruments. Local as well as national and international guide-

lines will need to be developed to address specific issues. In

2007, the first policy guidelines for the robot-assisted prosta-

tectomy were suggested in an editorial by Valvo et al.196 The

Society of American Gastrointestinal and Endoscopic Sur-

geons and the Minimally Invasive Robotic Association

believed that guidelines for the use of robotics were lacking.

To overcome this gap, they published a consensus statement

on robotic surgery including guidelines for training and cre-

dentialing.197 The World Medical Association (WMA) made

a statement on the ethics of telemedicine on their last meeting

in Copenhagen (October 2007). Included are principles for

the patient–physician relationship and confidentiality, the

responsibilities of the physician and the quality of care. The

WMA is encouraging the development of national legislation

and international agreements on telemedicine.198

Pros and cons

The robotic surgical system has some clear advantages com-

pared with conventional laparoscopy. A summary of the

advantages and disadvantages of robot-assisted laparoscopic

surgery is given in Table 2.

Future of robotics in gynaecology

Considering the development of robotics in general and assis-

ted surgery in particular, it is to be expected that the appli-

cation of this technology will only increase.199 The

exponential growth of the da Vinci robotic surgical system

worldwide, with more than 867 systems sold up to march

2008,171 will lead to an exponential growth of procedures

performed (Figure 7). As with every innovation that introdu-

ces new technology, initial scepticism with respect to neces-

sity, applicability and affordability will mean a delay in wider

introduction.

In the near future, the robotic systems will become

smaller and easier to handle. Whereas they now constitute

stand-alone systems, it is expected that they will become

Table 2. Advantages and disadvantages of robotic surgery

Advantage Disadvantage

Surgical system advantages High costs

Better InSIte� vision (3D) Robotic system

Digital camera zoom Maintenance system

Camera stability Start up

Greater df (Endowrist�) Bulky size of the robotic system

Improved dexterity Sometimes difficult access

to patient

Elimination of fulcrum effect Separation surgeon from the

operating field

Better ergonomics

for surgeon

No tactile feedback

Motion scaling Chance of breakdown

Elimination of physiological

hand tremor

Use of 8 mm ports

Telesurgery possible Monopoly of single market

leader

Telementoring possible



integrated in minimal invasive operating theatres, for exam-

ple attached to the sealing. It may be expected that wider

availability of such systems will lead to more and more con-

ventional laparoscopic procedures to be performed with

robot assistance. In this respect, it should also be appreciated

that the next generations of doctors will have been raised with

computer technology as part of daily life and will therefore

more readily adopt computer-guided surgical techniques.

Apart from more compact systems, the first adaptations to

be expected are the development of tactile feedback and the

use of cardanic transmission that will allow even more precise

tissue handling. Also, fusion with imaging techniques like

computed tomography and magnetic resonance imaging

(MRI) are likely to be introduced200 allowing more precise

and safer surgery and thus more radical oncologic surgery

with minimal trauma. As the first MRI compatible robot

was introduced in neurosurgery in 2007,201 it may also be

expected to be introduced in pelvic and abdominal sur-

gery.202,203 Although robotic technology was initially devel-

oped to allow telesurgery to be performed in areas difficult

or dangerous to access, this has not yet fully been imple-

mented. The first trans-Atlantic operation was reported in

2001 when surgeons in New York performed a cholecystec-

tomy in Strasbourg, but the main problem appeared to be the

limitation and delay over the satellite transmission.203,204 Fur-

ther research on long-distance telesurgery is being carried out

by NASA in the NASA Extreme Environment Mission Oper-

ations project, starting at NEEMO 9.205 The first robotic sys-

tem in a space station has been established for remote

emergency surgery.206 Further future developments will focus

on mobile in vivo robots to support minimal invasive surgery

in remote locations (battlefield, space). For example, the

in vivo robots can be placed in the abdominal cavity during

surgery and perform wireless imaging or task assistance.207

Together with the Jet Propulsion Laboratory, NASA is devel-

oping a robot-assisted microsurgery system for eye, ear, nose,

throat, face, hand, and cranial surgery.208 For the more com-

plicated procedures, it may be possible to make use of either

multiple robotic arms or even multiple robots. So-called

swarm robots act coordinated and simultaneously. Such sys-

tems may be trained to perform certain tasks independently

and automatically if continuously trained by the computer by,

for example neurological networks.209 It remains fully specu-

lative when this would eventually lead to certain (parts of)

operations being performed autonomously by robots.

The exponential growth of robotic surgery, for example in

urology, with an increase in robot-assisted radical prostatec-

tomies of more than 60% in 2007–2008210 is promising, as

such high-cost robotic systems are affordable by high-volume

centres. Thus, randomised studies will be possible to establish

more reliably the role of these new techniques. In gynaeco-

logy, robot-assisted surgery is also rapidly growing. In April

2007, the first World Robotic Symposium in Gynaecology was

organised in Michigan, heralding a bright future.211 At the

same time, the new Journal of Robotic Surgery was introduced.

The challenges in robotic surgery are exciting and we are

standing at the beginning of a new and inevitable phase in

minimal invasive surgery.

Disclosure of interestsFor both authors, there is no financial interest.

Contribution to authorshipBoth authors meet the criteria to qualify for authorship.

Details of ethics approvalNot applicable.

FundingNone. j

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