Ovarian Cancer Surgery for ovarian cancer requires access to all four abdominal quadrants. The ability to operate in all four quadrants using robotics can only be achieved by rotating the operating table and positioning the robotic column at the patient’s head. In this position it is possible to excise the aortic lymph nodes to the level of the renal vessels and to perform resection of upper abdominal metastases, including small bowel, diaphragm, liver, and supracolic omental disease. Initial experience with 21 patients with ovarian cancer who underwent operations by robotics was reported (76). Included were 12 primary, 4 interval, and 5 secondary cytoreductive surgeries for ovarian cancer. In addition to primary tumor excision, major procedures included modified posterior pelvic exenteration, rectosigmoid resection, small bowel resection, diaphragm resection, and resection of liver metastases. The operating times had a wide range (103 to 454 minutes) resulting from the extent of procedures. Blood loss was low (25 to 300 mL). Postoperative complications were low but increased with the number of procedures.
There are reports of robotics for ovarian cancer consisting of an occasional patient included within a series of patients with different types of gynecologic cancers and with no comparison
Disadvantages of Robotics to laparoscopy or laparotomy (77–81). Robotics may be useful for selected patients with ovarian cancer. Because of the need for operating table rotation and the insertion of additional trocars, it may not become widely accepted. The use of the surgical robotic system can be advocated in the case of isolated recurrences of ovarian cancer, such as in the pelvis, or in the upper abdomen, diaphragm, liver, and spleen. Isolated left liver metastases were removed successfully in three patients with recurrent ovarian cancer with no complications (82).
In conclusion, robotics and laparoscopy have advantages compared to laparotomy for selected patients with cervical, endometrial and early ovarian cancer. Although prospective randomized trials are desirable, the retrospective evidence supports the selected use of minimally invasive surgery for endometrial and cervical cancer patients and selected patients with primary or recurrent ovarian cancer.
Complications Unique to Robotics
Because there is no tactile feedback, the robotic arms can injure any organ not under visual control. The potential for injury is higher with the fourth retracting arm when out of the visual field and repositioned without visual control. Constant visual control of the robotic instrument position is mandatory for the prevention of injuries. Collision of the robotic arms is felt as an unwanted resistance, which is realized when the instruments are brought under view.
Constant pressure of the robotic arms on the patient thighs or arms may result in injury.
This can be prevented during positioning of the trocars and robotic arms. A rapid move by the surgeon on any robotic instrument may result in hitting the assistant near the operating table with the robotic arm. Moving a robotic arm by anyone other than the surgeon may result in patient internal injury.
Because the robotic trocars are fastened to the robotic arms, and the arms are fixed to the robotic column, any sudden loss of the pneumoperitoneum may result in the instruments being pulled off the anterior abdominal wall as it becomes ﬂattened. Similarly, any sliding of the patient on the operating table as a result of the Trendelenburg position will result in pressure at the trocars site and potential injury or increased postoperative trocar site pain. The robotic column must be positioned at the level of the patient’s feet or lateral to the legs in order to prevent access to the vagina, rectum, or urethra.
The present robotic system has limited surgical field reach. It allows for pelvic or abdominal surgery, but not both, unless the robotic column is repositioned from the patient’s feet to the patient’s head. This repositioning increases surgical time and requires the insertion of additional trocars.