Since the approval of the robotic surgical system by the US Food and Drug Administration (FDA) in 2005, robotic-assisted laparoscopy has become widely marketed for use in gynecologic surgery. While the overall number of inpatient hysterectomies performed in the United States has decreased during the time period of 2008 to 2010, the percentage of robotic hysterectomies has increased from 0.9 percent to 8.2 percent. In addition to hysterectomy, the robotic platform has become a tool for various other gynecologic procedures including treatment of gynecologic cancers, pelvic organ prolapse and incontinence, fibroids, endometriosis, and adnexal surgery. The only currently available surgical system for robotic-assisted laparoscopic surgery is the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA). The robotic platform offers several advantages over conventional laparoscopy, including three-dimensional high-definition vision, wristed instruments with seven degrees of freedom, intuitive motion, scaling of movements, tremor reduction, and ergonomic positioning for the surgeon. Despite these improvements, disadvantages exist including the loss of haptic feedback, increased operating time, increased cost, and additional training requirements. While there is clear evidence to support the advantages of minimally invasive gynecologic surgery over the open abdominal approach, data are limited and controversy remains concerning the advantages of the robotic route over other minimally invasive techniques. This chapter will address the outcomes and cost associated with robotic-assisted gynecologic surgery as well as recommendations regarding training, credentialing, and privileging. Important perioperative considerations specific to robotic surgery will also be discussed.
Scope of the Problem
Although robotic-assistance has been advertised to offer improvements upon the minimally invasive approach of laparoscopy, concerns have arisen regarding the applicability, cost, and implications on trainee education when applying robotic-assisted gynecologic surgery in practice. Herein we explore a selection of the available evidence surrounding the use of robotic-assistance in gynecologic surgery. In addition, important perioperative considerations unique to robotic surgery are considered.
Outcomes and Cost
Hysterectomy for Benign Disease
Multiple sources have reported on the advantages of using a minimally invasive hysterectomy for benign disease. Vaginal hysterectomy is currently recommended as the route of choice by the American College of Obstetricians and Gynecologists (ACOG) when feasible due to better outcomes, fewer complications, and lower cost when compared to alternative approaches.