12
Robotic surgery – Advance or gimmick?

https://doi.org/10.1016/j.bpobgyn.2012.12.005Get rights and content

Robotic surgery is increasingly implemented as a minimally invasive approach to a variety of gynaecological procedures. The use of conventional laparoscopy by a broad range of surgeons, especially in complex procedures, is hampered by several drawbacks. Robotic surgery was created with the aim of overcoming some of the limitations. Although robotic surgery has many advantages, it is also associated with clear disadvantages. At present, the proof of superiority over access by laparotomy or laparoscopy through large randomised- controlled trials is still lacking. Until results of such trials are present, a firm conclusion about the usefulness of robotic surgery cannot be drawn. Robotic surgery is promising, making the advantages of minimally invasive surgery potentially available to a large number of surgeons and patients in the future.

Section snippets

Definition and history of robots in medicine

The term ‘robot’ was first used in 1921 in a play by the Czech playwright Karel Čapek, entitled Rossom's Universal Robots. The word ‘robot’ is derived from the Czech word ‘robota’, which means ‘forced labour’ or ‘serf’.1, 2 One of today's definitions of the term robot is ‘a device that automatically performs complicated often repetitive tasks’.3 Thus, only the earlier inventions, such as PUMA 560, PROBOT, and ROBODOC® are robots true to the official meaning, as they carry out tasks

The da Vinci® Surgical System

Intuitive Surgical, Inc. was founded in 1995. After securing licenses on the technologies developed by several institutions and merging ideas and inventions into a commercially available medical device, the first version of the da Vinci® Surgical System was launched in 1999. In July 2000, the device received US Food and Drug Administration approval for laparoscopic surgery.15 The da Vinci® system consists of three core components: a surgeons console, a patients-side cart and a high-definition,

Conventional laparoscopy

Minimally invasive surgery has many well-known advantages, including reduced blood loss, less pain, fewer infections, reduced hospital stay, and faster return to normal life.26 Conventional laparoscopy, however, is associated with disadvantages for the surgeon, thus hampering the widespread use of this minimally invasive approach.27, ∗28 Learning laparoscopic skills and being confident in advanced laparoscopic actions, such as suturing, is a challenging and often time-consuming task.

Advantages of the da Vinci® Surgical System

The da Vinci® Surgical System has several special functions aimed at overcoming the limitations of conventional laparoscopy and to mimic characteristic features known from open surgery. The three-dimensional, high-definition imaging allows stereotactic vision of the operation field, making depth perception possible. Additionally, the area of interest can be magnified up to 10 times. The surgeon's hand movements can be scaled (5:1, 3:1, or 1:1)10 so that large movements of the surgeon's hand are

Disadvantages of the da Vinci® Surgical System

Despite the numerous advantages of the da Vinci® Surgical system, it certainly has substantial drawbacks that hinder the widespread implementation of its usage. Although the learning curve for robotic surgery is less steep than for laparoscopy, extensive training is also needed before surgeons can operate on patients. Additionally, the theatre team also need training to become familiar with the device set up as well as with the solution of potential problems during procedures. Hence, the

Learning and training

It is assumed that robotic surgery is associated with a less steep learning curve than conventional laparoscopy, owing to the more intuitive handling of robotic instruments and three-dimensional vision. In fact, in-vitro studies comparing learning curves for laparoscopically and robotically performed exercises (e.g. knot tying or paper cutting) revealed faster learning curves and better performances in the robotic groups.37, 38, 39, 40 Differences in learning curves were most significant for

Costs

A reliable statement about the expected costs for hospitals aiming to introduce robotic surgery is difficult to make, as various components influence cost calculations, including factors related to hospital and healthcare systems. Cost calculations can be approached in different ways, depending on inclusion or exclusion of the initial purchase costs of the robot, the inclusion of societal costs associated with lost work time of the patient or, in general, on the parameters included in the

Studies

At present, evidence for safety and efficacy of robotic surgery can be largely obtained only from retrospective studies often containing just a small number of participants or including the first cases of robotic surgeries carried out where the surgeons are at the beginning of their learning curves. Therefore, the results of these studies must be interpreted with caution, which makes it difficult to draw any firm conclusion on the efficacy of robotic surgery compared with other approaches.∗28,

Conclusion

Robotic surgery offers certain advantages for the surgeon, but the validation of equal or better patient outcomes compared with laparoscopy and laparotomy through RCTs is still lacking. Results from such trials are urgently needed to draw any firm conclusions about the efficacy of robotic surgery. As to the question whether robotic surgery is an advancement or just a technical gimmick, the advantages and disadvantages must be weight against each other in the light of the respective expertise

Conflict of interest

None declared.

References (67)

  • J.P. Lenihan et al.

    What is the learning curve for robotic assisted gynecologic surgery?

    J Minim Invasive Gynecol

    (2008)
  • L.G. Seamon et al.

    A detailed analysis of the learning curve: robotic hysterectomy and pelvic-aortic lymphadenectomy for endometrial cancer

    Gynecol Oncol

    (2009)
  • M.A. Behera et al.

    Cost analysis of abdominal, laparoscopic, and robotic-assisted myomectomies

    J Minim Invasive Gynecol

    (2012)
  • P. Monod

    Financial aspects, or how to use a robot assistance without losing money. Perspectives from private practice

    J Visc Surg

    (2011)
  • L. Cormier

    Financial aspects, or how to use robot assistance without losing money. Perspectives from a public hospital

    J Visc Surg

    (2011)
  • M.C. Bell et al.

    Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques

    Gynecol Oncol

    (2008)
  • J.F. Boggess et al.

    A comparative study of 3 surgical methods for hysterectomy with staging for endometrial cancer: robotic assistance, laparoscopy, laparotomy

    Am J Obstet Gynecol

    (2008)
  • P.T. Soliman et al.

    Radical hysterectomy: a comparison of surgical approaches after adoption of robotic surgery in gynecologic oncology

    Gynecol Oncol

    (2011)
  • P.C. Lim et al.

    A comparative detail analysis of the learning curve and surgical outcome for robotic hysterectomy with lymphadenectomy versus laparoscopic hysterectomy with lymphadenectomy in treatment of endometrial cancer: a case-matched controlled study of the first one hundred twenty two patients

    Gynecol Oncol

    (2011)
  • J.F. Magrina et al.

    Robotic radical hysterectomy: comparison with laparoscopy and laparotomy

    Gynecol Oncol

    (2008)
  • R. Estape et al.

    A case matched analysis of robotic radical hysterectomy with lymphadenectomy compared with laparoscopy and laparotomy

    Gynecol Oncol

    (2009)
  • M.B. Sert et al.

    Robot-assisted laparoscopic radical hysterectomy: comparison with total laparoscopic hysterectomy and abdominal radical hysterectomy; one surgeon's experience at the Norwegian Radium Hospital

    Gynecol Oncol

    (2011)
  • A. Obermair et al.

    A phase III randomized clinical trial comparing laparoscopic or robotic radical hysterectomy with abdominal radical hysterectomy in patients with early stage cervical cancer

    J Minim Invasive Gynecol

    (2008)
  • Robot. Encyclopædia Britannica Online; 2012; http://www.britannica.com/EBchecked/topic/505818/robot [accessed...
  • Robot. Merriam-Webster Online Dictionary; 2012; http://www.merriam-webster.com/dictionary/robot [accessed...
  • D.R. Yates et al.

    From Leonardo to Da Vinci: the history of robot-assisted surgery in urology

    BJU Int

    (2011)
  • J. McEwen et al.

    The eighth combined meeting of the orthopaedic association of the English speaking world. Proceedings and reports of universities, colleges, councils, associations and societies. Implications of advanced robotics for orthopaedics

    J Bone Joint Surg

    (1988)
  • B. Day et al.

    Arthrobot - the world's first surgical robot. Presented at the International Arthroscopy Association

    (April 2, 1987)
  • Y.S. Kwoh et al.

    A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery

    IEEE Trans Biomed Eng

    (1988)
  • Research: mechatronics in medicine. The Probot

    (2012)
  • W.L. Bargar

    Robots in orthopaedic surgery

    Clin Orthop Relat Res

    (2007)
  • L. Mettler et al.

    One year of experience working with the aid of a robotic assistant (the voice-controlled optic holder AESOP) in gynaecological endoscopic surgery

    Hum Reprod

    (1998)
  • N.G. Hockstein et al.

    A history of robots: from science fiction to surgical robotics

    J Robotic Surg

    (2007)
  • View full text