The robotic system offers advantages for the surgeon, but it is particularly useful in four circumstances: obese patients, long surgeries, and operations requiring extensive suturing or high precision. There is no resistance felt by the surgeon hands to the movement of the robotic instruments, regardless of the thickness of the patient’s abdominal wall. Suturing and intracorporeal knot tying are greatly facilitated by the articulation of the robotic instruments. Surgeon’s fatigue is decreased when seated for long operations. High precision and absence of tremor is useful for retroperitoneal lymphadenectomy, adhesiolysis, parametrial ureteral dissection, and accurate suturing, such as for ureteral anastomosis or reimplantation and genitourinary fistula repair. Applications of robotic technology include simple hysterectomy, myomectomy, appendectomy (in conjunction with other procedures), adnexectomy, excision of severe endometriosis, tubal anastomosis, and rectovaginal or vesicovaginal fistulas, especially those in the upper vagina (1,4). Robotic surgery is associated with a similar or shorter surgical time than conventional laparoscopy for the performance of simple hysterectomy and myomectomy, with a reduced blood loss, complication rates, and hospital stays (2,4).
Hysterectomy Laparoscopic-assisted vaginal hysterectomy was introduced in 1989. By 2005, only 14% of hysterectomies in United States were laparoscopic (18). By contrast, 3 years after FDA approval of robotic hysterectomy in 2005, 10% of hysterectomies were performed robotically in 2008 (Intuitive, Inc).
A report on 91 patients undergoing a robotic simple hysterectomy demonstrated a mean surgical time of 127.8 minutes, blood loss of 78.6 mL, and hospital stay of 1.4 days. One enterotomy was repaired robotically. There were no conversions to laparoscopy or laparotomy. Postoperative complications included single instances of exacerbation of congestive heart failure, ileus, vaginal cuff abscess, and Clostridium difficile colitis (19). A retrospective comparison of robotic and laparoscopic hysterectomy showed a longer operating time for robotics (27 minutes) but a lower blood loss and shorter hospital stay (19). Postoperative complications were similar. The conversion rate was higher for laparoscopy compared to robotic operations (9% vs. 4%, respectively).
Myomectomy Laparoscopic myomectomy provides less morbidity and a shorter recovery time compared to open myomectomy in two prospective randomized studies (20,21). Similarly, robotic myomectomy morbidity and recovery times appear preferable to open myomectomy. In a comparison of both techniques, robotic patients experienced less blood loss, no blood transfusions, lower postoperative complications, and shorter hospital stays. The operating time and cost were increased in the robotic group (22). In an initial series of 35 patients undergoing robotic myomectomy, the mean operating time was 230.8 minutes, mean blood loss was 169 mL, and median hospital stay was 1 day (23). Two patients (8.6%) required conversion to laparotomy, resulting from inadequate robotic instrumentation for myomectomy.