The integration of robotic surgery for routine use in gynecological surgeries, its advantages, disadvantages and cumulating experience on complications was one of the hot topics at the IX Congress of the Turkish German Gynecological Foundation held in Antalya-Turkey, May 4 - 8, 2011. Robotic assisted minimally invasive surgery has the potential to revolutionize the existing standards of the gynecological surgical procedures, especially the oncological interventions, both by greatly reducing postoperative morbidity and by preservation of the radicality and principles of oncological surgery.
A number of pending questions have to be addressed, eg, the assurance of the advantages of the robotic system by means of prospective controlled and randomized trials regardingshort-term parameters such as postoperative morbidity and amelioration of oncological outcome in long-term follow-up and improved quality of life by reduced prolonged or chronic surgery associated morbidity and arising costs. The feasibility of a multitude of gynecological surgical interventions has been partially proven in a small number of cases. The challenge now is to verify the advantages of robotic surgery in prospective trials.
The generation of a 3D sight by using a 12 mm wide angled endoscope containing two 5 mm cameras allows easy adaption to patient anatomy. The so-called “patient-side cart“ with the robotic arms and the attached trocars with the fixed special instruments results in tremor elimination, graduated grasps, more degrees of freedom in the flexibility of the surgical instruments, and a tremendous improvement of the surgical field vision by stereoscopic sight and the attainable magnification.
The main limitation is the high cost of initial investment in the robotic device. For simple procedures, it is not cost effective; and costs may not decrease until an acceptable alternative robotic system challenges the current monopoly. The insurance companies in many countries do not reimburse for the device. Patients are reluctant to pay for it since well-known alternatives exist. Technical limitations, such as the prolonged preparation time (positioning, setup, docking maneuver, etc.), the restricted haptic perception, and the reduced tactility as well as the barrier in the multiquadrant surgery have to be considered. At least three arms of the robot through three incisions are still needed.
The implementation of single incision laparoscopy to most of the robotic assisted procedures renders the robotic approach more invasive. Limited patient accessibility and the time required for undocking might be life threatening in cases of major blood vessel injury if the operator is not experienced in laparoscopic management of these complications. The system is not experienced in gasless abdominal lift devices where carbon dioxide pneumoperitoneum is not necessary. Currently, the robotic devices cannot use natural orifices.
The combination of single incision laparoscopy to most vaginal procedures will eliminate the concern about pelvic adhesions and lymph node sampling in indicated cases.
Overall, robotic assisted laparoscopic procedures need further evaluation in comparison to other less invasive procedures and newly developed techniques.