One of the most significant developments in medical technology in the past decade is the advent of Robot-assisted laparoscopic surgery. Laparoscopic surgery has distinct advantages over conventional open surgery, and most gynecological procedures can now be performed by the laparoscopic route. However, the popularity and acceptance of laparoscopic surgery is far from universal, mainly due to the technical difficulties in the procedure. Laparoscopic surgery requires training and skill, and has a long learning curve. Robot-assisted surgery may help overcome some of these problems.

1. Robot-assisted laparoscopic surgery: Just another toy?

2. Apollo Medicine 2012 September
Volume 9, Number 3; pp. 239e241 Review Article
Robot-assisted laparoscopic surgery: Just another toy?
Bhaskar Pal*
ABSTRACT
One of the most significant developments in medical technology in the past decade is the advent of Robot-assisted
laparoscopic surgery. Laparoscopic surgery has distinct advantages over conventional open surgery, and most
gynecological procedures can now be performed by the laparoscopic route. However, the popularity and acceptance
of laparoscopic surgery is far from universal, mainly due to the technical difficulties in the procedure. Laparoscopic
surgery requires training and skill, and has a long learning curve. Robot-assisted surgery may help overcome some of
these problems.
Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
Keywords: Robot-assisted laparoscopic surgery, Gynecological procedures
INTRODUCTION
Laparoscopic surgery in gynecology: current
status
Laparoscopic surgery, in comparison to traditional open
surgery, offers a less invasive option in most gynecological
procedures. Hysterectomies, myomectomies, removal of
adnexal masses, tubal anastomosis, radical hysterectomies
and lymphadenectomies can all be performed by the laparo-scopic
route. Compared to open surgery, the hospital stay is
significantly shorter, recovery is quicker and mean blood
loss is less with laparoscopic surgery with comparable
complication rates and operating times in experienced
hands. Current evidence suggests that laparoscopic hyster-ectomy
is preferable to abdominal hysterectomy for benign
conditions.1
However, the majority of hysterectomies worldwide are
still performed by the abdominal route. In the first half of
the last decade, about 80% of hysterectomies were per-formed
by the abdominal route in one state of the USA.2
The lack of popularity of laparoscopic surgery among
majority of gynecologists has two several reasons. Firstly,
laparoscopic surgery has a steep and extended learning
curve. Secondly, many advanced gynecological surgeries
by the laparoscopic route are technically challenging. These
in turn are due to several factors:
d Using long instruments through a fixed entry point
accentuates small movements and tremors.
d The limited range of movement of instruments requires
ergonomically challenging positions at times.
d An unstable camera, especially when held by an inexpe-rienced
assistant, hampers visualization.
d The two-dimensional optics causes loss of depth
perception.
d Long procedures, due to these reasons, add to fatigue.
ROBOTS: WHAT AND WHY?
The robotic system does away with several of the disadvan-tages
of laparoscopic surgery. The da Vinci Robotic system
(Intuitive Surgical, Sunnyvale, CA, USA) was approved by
the US FDA for use in gynecology in 2005. It consists of
three components: the surgeon’s console, which directs
the movements of the robotic arms, the stack, and the
patient-side cart, which in the latest system has four arms.
After port placements and docking the patient-side cart,
Senior Consultant Gynecologist, Apollo Gleneagles Hospital, 58, Canal Circular Road, Kolkata 700054, India.
* Tel.: þ91 9831298236, email: palbas@hotmail.com
Received: 22.6.2012; Accepted: 29.6.2012; Available online: 5.7.2012
Copyright 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.apme.2012.06.001

3. 240 Apollo Medicine 2012 September; Vol. 9, No. 3 Pal
the surgeon sits at the console and operates. The camera
system is controlled by the surgeon through foot pedals
and arm movements. At the console, the surgeon controls
the robotic arms and the EndoWrist instruments with
natural hand and wrist motions that mimic movements per-formed
in open surgery. The foot pedals control swapping
in and out the third robotic arm, moving and focusing the
camera, and controlling monopolar and bipolar currents
connected to the EndoWrist instruments.
ADVANTAGES OF THE DA VINCI ROBOTIC
SYSTEM
d At the console, the surgeon has a binocular three-dimen-sional
view of the pelvis in High Definition. This gives
a perception of depth.
d The camera remains still, and is controlled by the
surgeon’s foot pedal when necessary.
d The console has armrests and, adjustable height and
eyepieces. These reduce surgeon fatigue.
d Motion scaling converts very large movements of the
surgeon’s hand to very fine movements of the instruments.
d At the console, the surgeon controls the robotic arms and
the EndoWrist instruments with natural hand and wrist
motions that mimic movements performed in open
surgery.
d The EndoWrist instruments are designed with seven
degrees of motion, one more than the human hand.
d The three operating arms are controlled by the surgeon
who can switch between instruments using the control
pedal. On disengaging one arm to use another, the disen-gaged
arm remains stationary but maintains tension on
the grasped tissue.
d Changing operating instruments can be done quickly, as
the new instrument returns to the same place as the
removed one.
d The energy sources are controlled by the surgeon
through foot pedals.
d Additional ports can be introduced to use alternative
energy sources or for morcellation.
d Uterine manipulator inserted vaginally adds to the ease
of operating.
DISADVANTAGES OF THE DA VINCI ROBOTIC
SYSTEM
d Cost is the biggest disadvantage. This includes the initial
cost, the cost of instruments and the cost of maintenance.
d Setting up and docking takes time, but gets quicker with
use.
d There is a loss of tactile sensation, hence the amount of
force to be used comes with experience.
d There is a learning curve, although it is shorter than lapa-roscopic
surgery.
d Staff needs to be trained in set up of the system and
cleaning of instruments.
APPLICATIONS IN GYNECOLOGY
The da Vinci Robotic system has been used to perform
hysterectomies, myomectomies, tubal anastomosis, sacro-colpopexy,
advanced endometriosis including rectovaginal
disease, radical hysterectomy with lymphadenectomy and
other procedures. In centers practicing robotic surgery, the
rates of abdominal surgeries have reduced; more patients
can be offered the benefit of minimally invasive surgery.
TRAINING
Laparoscopic surgery, as discussed earlier, has a long and
extended learning curve. In comparison, robotic surgery
has a shorter learning curve and can be taught to surgeons
who are not well-versed in advanced laparoscopy. This will
lead to more robotic surgeons than experienced laparo-scopic
surgeons, as it easier and quicker to train residents
in Robotic surgery than conventional laparoscopic surgery.
One study demonstrated a more rapid learning curve, for
both experienced and inexperienced surgeons, in the perfor-mance
of drills using a robotic system.3 Another study
demonstrated that laparoscopic drills were performed
more quickly using a robotic system compared to tradi-tional
laparoscopy and that novice surgeons on the robot
performed as quickly, and in some cases more quickly,
than expert surgeons with traditional laparoscopy.4
EVIDENCE
In some countries the da Vinci Robotic surgery has been
widely and rapidly adopted. There are evidences of
declining rates of abdominal as well as laparoscopic hyster-ectomies
with a proportionate rise in robotic surgery.5
However, there is a paucity of good quality data address-ing
the superiority of robotic surgery over laparoscopic
surgery. Most of the data consist of retrospective case
series, some with historical controls and several review arti-cles
summarizing these data. There are hardly any random-ized
trial, and most case series use historical controls of
abdominal surgery. There are some studies in which the
controls are laparoscopic surgeries performed by experts.
None of the studies established a cost-benefit with robotic
surgery. It is also too early to get long-term data, especially

4. Robot-assisted laparoscopic surgery Review Article 241
in gynecological oncology. A recent meta-analysis of
observational studies has looked at the evidence in different
gynecological procedures.6 While robotic surgery has the
same advantages over conventional open surgery as lapa-roscopy,
ie quicker recovery, less mean blood loss, shorter
hospital stay, the operating times are usually longer, with
similar complication rates. In the few studies comparing
laparoscopic with robotic surgery, there is less mean blood
loss and fewer conversions to open surgery in the latter
group. This reinforces the point that complex problems
where laparoscopic surgery may be long and tiring for the
surgeon, robot-assisted surgery will have a better chance
of success. In all the studies, the operating time with robotic
surgery is longer, but it tends to decrease as the number of
cases goes up. Robotic surgery is also significantly more
expensive than laparoscopic surgery.
CONCLUSION
Robotic surgery has great potential to revolutionaries the
practice of minimal access surgery, making it possible for
more gynecologists to learn and perform minimal access
surgery, although cost is a big deterrent especially in
a developing country. However, any new innovation comes
with great potential for harm, and Robotic surgery is no
exception. With proper training and skill, along with judi-cious
patient selection, robot-assisted laparoscopic surgery
can be highly advantageous. However, in the past, many
innovations had become dangerous tools in the hands of
untrained or poorly trained operators. Long-term safety
and cost-effectiveness data are still awaited for robotic
surgery, and till then it should be used judiciously. Accord-ing
to ACOG7 “further studies as well as additional cost-effective
analyses need to be done to critically evaluate
the role of robotic surgery in gynecology before it is adop-ted
as common practice in managing gynecologic diseases.”
However, in private healthcare patients often demand the
best, and Robot-assisted surgery will continue to be used
more frequently by doctors for whom it is the more
comfortable option.
CONFLICTS OF INTEREST
The author has none to declare.
REFERENCES
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3. Prasad SM, Maniar HS, Soper NJ, et al. The effect of robotic
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