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Robotic surgery

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 DOI: 10.1111/j.1471-0528.2008.02038.x
www.blackwellpublishing.com/bjog
Robotic surgery
HWR 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 r.verheijen@umcutrecht.nl
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
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,
198 ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
Review article
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.
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 sources
We 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.
Methods
The 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
 Robotic surgery (efficacy, costs and training)

Articles published console and controls the robotic system remotely. The con-
1400 sole can be placed anywhere in or even outside the operating
1200
room. While operating, the surgeon is viewing a stereoscopic
image projected in the console and controls the robotic arms
Number of articles

1000
800
600
400
200
0
1980 1990 1995 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
Figure 1. Publications about robotics in www.embase.com (search terms
robot or robotics).
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
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. The
viewer 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.

The da Vinci robotic system (Intuitive Surgery) has three

major components (Figure 2). The first component is the Robotics in nongynaecological surgery
surgeon console. The surgeon sits ergonomically behind the Urology
Radical prostatectomy has been the fastest growing applica-
tion of robotic surgery in urology and becoming standard
Table 1. Robotic surgery in time procedure in many centres in the United States.11 Robot assis-
tance is also applied for cystectomy, pyeloplasty, adrenalec-
1985 First robot used for stereotactic brain surgery3
tomy,12,13 renal surgery,14 radical nephrectomy,15 donor
1989 PROBOT, first robot used for prostatectomies4
1992 ROBODOC use for hip replacement5
nephrectomy,16 urogynaecology and paediatric urology.17
1993 AESOP, first commercially available robot Since the first da Vinci robot-assisted radical prostatectomy
approved by the FDA6,7 was published in 2000,18 multiple large prospective trials
1996 ARTREMIS, master slave manipulator system8 (300–2652 cases) have been published.19–23 Reviewing these
1996 EndoAssist, robot camera holder9 data, Box and Ahlering concluded that the robot-assisted rad-
1998 Zeus robotic system commercially available10 ical prostatectomy is superior in preventing excessive blood
2000 da Vinci robotic system FDA approved
loss, major surgical complications and the development of
venous thromboembolic events. Oncologic outcomes suggest

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

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

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 3. InSite
Vision, three dimensional view, with console master Figure 4. EndoWrist
instrument, 7 df, just like the human wrist (ª[2008]
(ª [2008] Intuitive Surgical, Inc.). Intuitive Surgical, Inc.).

200 ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology

Figure 5. EndoWrist
instruments belonging to the da Vinci Robotic
system (ª[2008] Intuitive Surgical, Inc.).
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 surgery
Robotic-assisted laparoscopy is used for Nissen 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
ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
Robotic surgery (efficacy, costs and training)
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 subspecialties
Robot 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 surgery
Tubal reanastomosis
Although 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
201
 Schreuder, Verheijen
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 122 minutes, and there
were no complications. Median hospital stay was 1 day (1–2).89
Myomectomy
A 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 gynaecology
Although robot assistance in general gynaecology is most
widely used for hysterectomy, no randomised trials have been
reported. The first robot-assisted hysterectomy was published
202 ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
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 oncology
Laparoscopy 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-
ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
Robotic surgery (efficacy, costs and training)
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
203
 Schreuder, Verheijen
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-
204 ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
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-
ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
Robotic surgery (efficacy, costs and training)
Figure 6. SEP da Vinci robotic simulator (ª[2008] SimSurgery).
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
205
 Schreuder, Verheijen
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
206 ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
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 naı̈ve
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
 Robotic surgery (efficacy, costs and training)

from country to country because of different healthcare sys- on robotic surgery including guidelines for training and cre-
tems and insurance systems. For the UK, some general impli- dentialing.197 The World Medical Association (WMA) made
cations, similar to those for the USA, for adoption of a robotic a statement on the ethics of telemedicine on their last meeting
surgery program are described by Goldstraw et al.29 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
Litigation and ethical issues
WMA is encouraging the development of national legislation
The increasing complexity of modern surgical technology will and international agreements on telemedicine.198
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 Pros and cons
of visual contact with the patient. The surgeon not only oper- The robotic surgical system has some clear advantages com-
ates through computer commands but there is also a physical pared with conventional laparoscopy. A summary of the
distance to the assistants attending the operation table. advantages and disadvantages of robot-assisted laparoscopic
Unfortunately, the current systems lack a satisfactory way to surgery is given in Table 2.
communicate between the operator and the assistants. As
with many new technological advances, communication
might appear the Achilles’ heel of robotic surgery. More Future of robotics in gynaecology
appropriate equipment of communication and more strict
Considering the development of robotics in general and assis-
discipline in follow up of the commands from the primary
ted surgery in particular, it is to be expected that the appli-
responsible person, the surgeon, will be essential for a safe and
cation of this technology will only increase.199 The
successful procedure.
exponential growth of the da Vinci robotic surgical system
With the possibility of telemedicine and robotics new legal
worldwide, with more than 867 systems sold up to march
and ethical issues arise. Telemedicine makes cross-border
2008,171 will lead to an exponential growth of procedures
treatment possible. How to deal with liability and licensure
performed (Figure 7). As with every innovation that introdu-
across borders? Cross-border care should not change usual
ces new technology, initial scepticism with respect to neces-
medical ethics but makes treatment possible of patients in
sity, applicability and affordability will mean a delay in wider
areas the specialist cannot reach in person. In this way, under-
introduction.
served regions and countries could be helped. But the tech-
In the near future, the robotic systems will become
nology could also aggravate migration of specialists from
smaller and easier to handle. Whereas they now constitute
poor to rich areas/countries.194 Also, the security of the trans-
stand-alone systems, it is expected that they will become
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 Table 2. Advantages and disadvantages of robotic surgery
transmission cuts, a breakdown of the system or instability
of the software? Malfunction of the robotic system will occur Advantage Disadvantage
more frequently with its increasing use; fortunately, it
Surgical system advantages High costs
appeared that less than 5% of device failures resulted in
Better InSIte
vision (3D) Robotic system
patient complications. In addition, the rate of open conver- Digital camera zoom Maintenance system
sions due to device malfunction decreased from 94% in 2003 Camera stability Start up
to 16% in 2007.195 Although robots seem to act autono- Greater df (Endowrist
) Bulky size of the robotic system
mously, all their movements and actions are operated by Improved dexterity Sometimes difficult access
the surgeon and as such do not differ from any other surgical to patient
equipment. Nevertheless, as with any complex system, safety Elimination of fulcrum effect Separation surgeon from the
operating field
precautions will be more essential than with the use of simple
Better ergonomics No tactile feedback
instruments. Local as well as national and international guide- for surgeon
lines will need to be developed to address specific issues. In Motion scaling Chance of breakdown
2007, the first policy guidelines for the robot-assisted prosta- Elimination of physiological Use of 8 mm ports
tectomy were suggested in an editorial by Valvo et al.196 The hand tremor
Society of American Gastrointestinal and Endoscopic Sur- Telesurgery possible Monopoly of single market
geons and the Minimally Invasive Robotic Association leader
Telementoring possible
believed that guidelines for the use of robotics were lacking.
To overcome this gap, they published a consensus statement

ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 207
 Schreuder, Verheijen

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

140 000 132454 multiple robotic arms or even multiple robots. So-called
120 000
swarm robots act coordinated and simultaneously. Such sys-
Number of procedures

tems may be trained to perform certain tasks independently

100 000
85447
and automatically if continuously trained by the computer by,
80 000 for example neurological networks.209 It remains fully specu-
60 000
lative when this would eventually lead to certain (parts of)
49038
operations being performed autonomously by robots.
40 000
26809 The exponential growth of robotic surgery, for example in
20 000
9500
16288
urology, with an increase in robot-assisted radical prostatec-
5075
0
127 321 1031 2478
tomies of more than 60% in 2007–2008210 is promising, as
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 such high-cost robotic systems are affordable by high-volume
Year centres. Thus, randomised studies will be possible to establish
Figure 7. Procedures worldwide performed with the da Vinci robotic more reliably the role of these new techniques. In gynaeco-
system until 2008 (the end of week 21). logy, robot-assisted surgery is also rapidly growing. In April
2007, the first World Robotic Symposium in Gynaecology was
integrated in minimal invasive operating theatres, for exam- organised in Michigan, heralding a bright future.211 At the
ple attached to the sealing. It may be expected that wider same time, the new Journal of Robotic Surgery was introduced.
availability of such systems will lead to more and more con- The challenges in robotic surgery are exciting and we are
ventional laparoscopic procedures to be performed with standing at the beginning of a new and inevitable phase in
robot assistance. In this respect, it should also be appreciated minimal invasive surgery.
that the next generations of doctors will have been raised with
computer technology as part of daily life and will therefore Disclosure of interests
more readily adopt computer-guided surgical techniques. For both authors, there is no financial interest.
Apart from more compact systems, the first adaptations to
be expected are the development of tactile feedback and the Contribution to authorship
use of cardanic transmission that will allow even more precise Both authors meet the criteria to qualify for authorship.
tissue handling. Also, fusion with imaging techniques like
computed tomography and magnetic resonance imaging Details of ethics approval
(MRI) are likely to be introduced200 allowing more precise Not applicable.
and safer surgery and thus more radical oncologic surgery
with minimal trauma. As the first MRI compatible robot Funding
was introduced in neurosurgery in 2007,201 it may also be None. j
expected to be introduced in pelvic and abdominal sur-
gery.202,203 Although robotic technology was initially devel- References
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