This chapter should be cited as follows:
Wasson M, Glob. libr. women's med.,
ISSN: 1756-2228; DOI 10.3843/GLOWM.420773

The Continuous Textbook of Women’s Medicine Series – Gynecology Module

Volume 8

Gynecological endoscopy

Volume Editors: Professor Alberto Mattei, Director Maternal and Child Department, USL Toscana Centro, Italy
Dr Federica Perelli, Obstetrics and Gynecology Unit, Ospedale Santa Maria Annunziata, USL Toscana Centro, Florence, Italy

Chapter

Robotic Surgery in Gynecology: Techniques and Indications

First published: October 2024

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INTRODUCTION

Over the last two decades, robotic technology has progressed significantly and is now commonly used for the treatment of benign and malignant gynecologic conditions. Current robotic platforms afford the surgeon the advantage of three-dimensional (3D) visualization, wristed instrumentation, and decreased tremor, which together can result in increased precision. Previous limitations of robotic technology included limited access to multiple quadrants of the abdomen and inability to move the camera to alternative robotic ports. These have been overcome with new generations of the robotic system and ever-evolving technology. Most recently, in 2021, the United States Food and Drug Administration authorized a robotically assisted surgical device for performing transvaginal hysterectomy. Since its inception, the introduction of robotic surgery to gynecology has resulted in a rapid decline in laparotomy rates and increased use of minimally invasive surgery.¹

ROBOTIC SYSTEM

The most commonly utilized robotic system that is approved for gynecologic procedures in the United States is comprised of the surgeon console, patient cart, and the vision cart. The surgeon console sits remote from the patient and is not part of the sterile field. The surgeon console allows for customized surgeon settings, including ergonomic and electrosurgery settings. Adjustments to the intensity of the light source, the direction of the 30-degree endoscope, application of fluorescence imaging, and image capturing can be controlled at the surgeon console. Through the surgeon console, a stereoscopic image is visualized, and hand controls are used to manipulate the robotic arms and instrumentation. The movement of the surgeon’s hand mimics movement of the surgical instruments in a wristed fashion. Through use of foot pedals on the left, the surgeon is able to adjust positioning of the camera, ergonomically reposition the hands, and swap between robotic arms. Depending on the instrumentation being utilized, foot pedals on the right allow for application of electrosurgery, stapling, clip application, and vessel sealing. Ergonomic repositioning of the hands can also be achieved using the finger controls.

The patient cart consists of the robotic arms that attach, or “dock,” to the abdominal trocars. The patient cart is brought from the left or right side of the patient for lateral docking. This facilitates vaginal, bladder, and rectal access that may be necessary during gynecologic procedures. The robotic instrumentation is then passed through the trocars and connected to the robotic arms. Robotic instrumentation includes the option of a 0-degree or 30-degree endoscope and a variety of instruments that can be utilized in the working arms. These include atraumatic or traumatic graspers, instruments with bipolar electrosurgery or monopolar electrosurgery capability, advanced energy devices, stapling devices, suction irrigators, clip appliers, and needle drivers. Instrument selection is based on the surgical procedure and surgeon preference with typical placement consisting of a bipolar instrument in the left hand, a monopolar instrument in the right hand, with or without a tissue grasper in the fourth arm. The vision cart connects the patient cart to the surgeon console and holds the vision and energy technology integral to robotic surgery.

PATIENT POSITIONING

To facilitate robotic surgery, positioning is dependent on the target anatomy. Most commonly, in gynecology, the patient is placed in dorsal lithotomy positioning with steep Trendelenburg and the arms tucked at the side parallel to the body. Alternatively, if targeting upper abdominal anatomy, the patient may be placed in reverse Trendelenburg positioning. As in conventional laparoscopy, if positioning is not performed correctly, nerve injury can occur as a result of nerve stretching or compression.² The overall incidence of peripheral nerve injuries in robotic surgery for gynecologic indications is between 0.16% and 10.0%, with the highest incidence occurring in the lower extremities (0.2–10%).² Risk factors for peripheral nerve injuries include extremes of body mass index and prolonged surgical times.² Ensuring safe positioning during robotic surgery is of paramount importance as the positioning cannot be adjusted after the robot has been docked.

TROCAR PLACEMENT

For most gynecologic procedures, three or four trocars are utilized. One trocar is placed through the umbilicus and serves as the optical trocar. Two or three additional robotic trocars are placed for the robotic arms and instrumentation. The last trocar serves as the assistant port and can be 5 mm or 10 mm. It is essential to strategically place robotic trocars to allow adequate space between robotic arms and facilitate mobility without collision with other arms, the assistant, and the patient. A common trocar arrangement consists of all robotic trocars in a straight line placed parallel to the target anatomy. For procedures focused in the pelvis, such as hysterectomy or excision of endometriosis, the trocars will be placed in a straight line at the level of the umbilicus, with one robotic trocar on the left or right side of the abdominal wall and two trocars on the opposite side. The assistant port is placed 3 cm cranial, midway between the umbilical trocar and the lateral robotic trocar on the side with only one robotic arm. Selection of two robotic arms on the left or right is at the discretion of the surgeon. Decision to use two or three instrumented robotic arms is largely based on the need for tissue retraction. If limited retraction is necessary, use of all robotic arms may not be necessary.

ROBOTIC INSTRUMENTATION

Robotic Instrumentation affords the surgeon the advantage of instrument articulation that mimics the movement of the surgeon’s hand. The seven degrees of freedom with robotic instrumentation overcomes the rigidity associated with the four degrees of freedom with conventional laparoscopic instrumentation. Articulation allows instrumentation to be maneuvered with precision in areas of the abdomen or pelvis that otherwise would have limited access. Increased mobility and ability to achieve more difficult angles provides increased flexibility and decreases the need for frequent instrument exchanges to alternative ports as compared to conventional laparoscopy. Intracorporeal knot tying and suturing is also facilitated. This provides a great advantage when suturing in more challenging areas, such as the posterior aspect of the cervix or uterus.

SURGICAL ASSISTANT

Throughout obtaining abdominal access, placing trocars, docking the patient cart, and inserting robotic instruments, both the surgeon and a surgical assistant are at the surgical field. After these steps are completed, the surgeon will unscrub and move to the surgeon console for the surgical procedure. The surgical assistant remains at the bedside to facilitate the procedure and ensure the ongoing safety of the patient. Through the assistant port, he or she will also be able to retrieve specimens, retract tissue, pass suture material, etc. It is critical that the surgical assistant must have a sound understanding of the robotic technology. The surgical assistant commonly performs instrument exchanges and troubleshooting of the robotic platform. Additionally, in the case of an emergency or critical failure of the robotic platform, the assistant must be able to quickly and safely undock the patient care while the surgeon rescrubs and returns to the surgical field.

HAPTIC FEEDBACK

The tactile sensation that allows surgeons to feel traction, tension, tissue density, and force during surgery conventionally relies on haptic feedback. Due to tele-manipulation with robotic technology, this sensation is not present with robotic surgery and requires the surgeon to rely on visual cues, or visual haptics, to have similar feedback. The surgeon must observe the manner in which tissue responds to manipulation to achieve the same sensations that otherwise would be obtained with direct haptic feedback. This allows the surgeon to identify structures such as a colpotomy ring during hysterectomy, fibroid during myomectomy, or deeply infiltrating endometriotic nodule. The ability to effectively utilize visual haptics does increase with experience and expertise.³

SURGEON ERGONOMICS

Surgeon positioning in a seated, ergonomic position during robotic surgery has been proposed to decrease the risk of surgeon injury. Overall, surgeons report less pain with robotic surgery compared to open or laparoscopic approaches. However, robotic surgery has been shown to be associated with eye, trunk, wrist, and finger strain with work-related musculoskeletal disorders at a rate of 23–80%.⁴ To decrease the risk of positioning-related injuries for the surgeon, frequent clutching of the robotic instrumentation is essential to maintain ergonomic positioning. Correct positioning begins with adjustment of the armrest to facilitate the forearm being parallel to the ground with the elbows relaxed at the side. The chair height should allow the surgeon to be seated with a 90-degree flexion of the knee. The head should rest gently with minimal forehead pressure on the console and the head should be flexed no more than 20 degrees.⁴

LEARNING CURVE

Robotic approach to gynecologic procedures has been reported to have a rapid learning curve, which facilitates quick adoption of this approach to gynecologic pathology. For hysterectomy, the steepest learning typically occurs in the first 23 cases, followed by rapid decline in total operative time.⁵ This is followed by competence in the next 36 cases, and mastery in the next 29 cases.⁵ With this learning curve, a surgeon can transition from novice to master in 88 total robotic cases. When the learning curve is specifically assessed for hysterectomy in the setting of gynecologic tumors, similar outcomes are found with proficiency being reached after 33 cases.⁶ A rapid learning curve holds true for newer robotic platforms, such as the Hugo^TM RAS (MEDTRONIC Inc, United States).  After 13 cases, proficiency is achieved as evidenced by significant reduction in robot docking time.⁷ In contrast, when assessing the learning curve for conventional laparoscopic hysterectomy, decline in the operative time does not occur until after the first 71–80 cases.⁸ In the number of surgical cases that are required to achieve competence in conventional laparoscopic hysterectomy, one can nearly become a master in robotic hysterectomy.

DUAL CONSOLE

To assist with education and training in robotic technology, a dual console for the da Vinci Surgical System was released in 2009. This platform allows two surgeons to simultaneously operate with seamless transitioning of control of the instrumentation between the two surgeons. Each surgeon is able to either take or give control of the robotic instrumentation at any given time throughout the procedure. When the dual console platform is used in training scenarios with a senior surgeon and a trainee, advantages from an educational perspective have been shown. The trainee has increased console time and is able to perform a greater proportion of the surgical procedure without increased complications or surgical time as compared to single console use.⁹ Teaching with adequate supervision appears to be optimized with use of a dual console.⁹

INDICATIONS IN BENIGN GYNECOLOGY

The robotic system can be used to perform a breadth of gynecologic procedures including hysterectomy, myomectomy, ovarian cystectomy, adnexectomy, excision of endometriosis, and sacrocolpopexy. The technology provides distinct advantages when addressing advanced pathology that necessitates prolonged surgical times, high precision, and extensive suturing.

HYSTERECTOMY

Hysterectomy involves separating the round ligaments, utero-ovarian ligaments, fallopian tubes, and broad ligaments bilaterally. The uterine vasculature is then sealed and transected, followed by creation of a bladder flap and colpotomy. After the uterus is fully separated and removed from the abdomen, the vaginal cuff is then closed. These basic steps are the same regardless of if the procedure is being performed with or without robotic assistance.

Minimally invasive approach to hysterectomy continues to be performed at higher rates than vaginal or abdominal approach. In 2018, 65.65% of all hysterectomies in the United States were performed via conventional laparoscopy or with robotic assistance.¹⁰ When comparing conventional laparoscopic and robotically assisted hysterectomy, no evidence of difference between the approaches has been shown. This included no difference in the return to normal activities, intra-operative visceral injury, intra-operative complications, or wound infection. Neither modality has significant advantage over the other.¹¹

MYOMECTOMY

Uterine-sparing surgical treatment of uterine fibroids includes myomectomy. When fibroids are intramural, subserosal, transmural or pedunculated (FIGO Leiomyoma Subclassification System Type 3 through Type 7), a laparoscopic, robotically assisted, or laparotomic approach can be considered.¹² Regardless of the surgical approach, the technique for completing a myomectomy involves creating a hysterotomy and exposing the myoma capsule. The myoma is then bluntly enucleated from the surrounding myometrium and fully separated from the uterus and the hysterotomy site is closed.

Minimally invasive approach to myomectomy is superior to an open approach and has been associated with less blood loss and shorter hospitalization.¹³ Among minimally invasive approaches, intraoperative and postoperative outcomes as well as operative time have been shown to be similar between conventional laparoscopic and robotically assisted myomectomy.^14,15 However, the challenges associated with lack of haptic feedback may pose challenges for patients with a high number of uterine fibroids. Compared to abdominal myomectomy, robotically assisted myomectomy is associated with a higher residual fibroid burden.¹⁶ It has been shown that robotically assisted myomectomy is associated with fewer postoperative hematomas and may be associated with a more optimal uterine repair when compared to conventional laparoscopy. Ongoing research is being performed to fully understand postmyomectomy pregnancy implications including uterine rupture risk.¹⁷

ADNEXAL SURGERY

Laparoscopy has been accepted as the standard of care for benign adnexal surgery due to its known reduction in morbidity, pain, length of hospitalization, and overall decreased healthcare costs.¹⁸ Adnexal surgery includes salpingectomy, oophorectomy, salpingo-oophorectomy, and ovarian cystectomy. When performing salpingectomy, oophorectomy, or salpingo-oophorectomy bipolar electrosurgery or a vessel-sealing device is utilized to secure the blood supply to the structure to be removed. Monopolar electrosurgery, scissors, or a cutting feature on a vessel-sealing device is then used to separate the target tissue from surrounding anatomy. With ovarian cystectomy, an incision is made on the ovary to expose the underlying cyst wall. The cyst wall is then bluntly separated from the overlying ovarian stroma using traction and counter-traction with care taken to minimize use of electrosurgery and damage to the ovary.¹⁹ Suturing should be used to obtain hemostasis if needed.¹⁹

From 2009 to 2012, robotically assisted oophorectomy increased from 3.5% to 15.0% and robotically assisted ovarian cystectomy increased from 2.4% to 12.9%.²⁰ There have been mixed results when comparing outcomes of conventional laparoscopy to robotically assisted adnexal surgery. It has been reported that there are no differences in blood loss, intraoperative and postoperative complications, and length of hospital stay.²¹ In contrast, a nationwide database analysis showed similar rates of overall complications, but a slightly higher rate of intraoperative complications (2.1% laparoscopic oophorectomy vs. 3.4% robotically assisted oophorectomy) (0.9% laparoscopic ovarian cystectomy vs. 2.0% robotically assisted ovarian cystectomy).²⁰ When considering outcomes for obese patients, advantages have been shown with robotic assistance.²¹

ENDOMETRIOSIS

Minimally invasive surgery for treatment of endometriosis has been utilized since the 1970s.²² Over time, techniques in treating endometriosis throughout the abdomen, pelvis, and thoracic cavity through laparoscopy or with or without robotic assistance have advanced. Excision, or removal, of superficial and deep infiltrating endometriosis involving the bowel, bladder, ureter, abdominal wall, liver, diaphragm, lung, and other locations using a minimally invasive approach have been documented.

Metanalysis comparing robotically assisted treatment of endometriosis to conventional laparoscopy surgery has shown no difference in blood loss, complications, or hospital stay.²³ Furthermore, a prospective randomized controlled trial showed no significant differences in perioperative outcomes, including blood loss, intraoperative and postoperative complications, conversion to laparotomy, and long-term quality-of-life outcomes.²⁴

SACROCOLPOPEXY

The gold standard surgical treatment for pelvic organ prolapse is the sacrocolpopexy. This procedure involves securing a graft to between the anterior longitudinal ligament on the sacrum and vaginal cuff or cervix. to facilitate support of the vaginal apex. Commonly, a synthetic mesh is utilized with placement of permanent suture. This approach has high success rates with long-term durability.

Historically, this has been performed through a laparotomic approach. However, when compared to abdominal sacrocolpopexy, laparoscopic sacrocolpopexy has shown similar outcomes, including estimated blood loss, hospital length of stay, and complication and reoperation rates.²⁵ Minimally invasive approach to sacrocolpopexy continues to grow as the preferred approach. Robotically assisted sacrocolpopexy affords advantages over conventional laparoscopic approach in respect to suturing and has made a minimally invasive approach more feasible for many surgeons.²⁶ In a prospective randomized comparative effectiveness trial, robotic approach to sacrocolpopexy was associated with a 24.4-minute shorter operative time, similar blood loss and intraoperative complications, and similar long-term outcomes, including measurements for pelvic organ prolapse assessment.²⁶

INDICATIONS IN GYNECOLOGIC ONCOLOGY

The robotic system can be used to perform a span of procedures for treatment of gynecologic malignancy including cervical, endometrial, and ovarian cancers (encompassing primary peritoneal and tubal malignancies). Similar to the advantages afforded for benign gynecologic conditions, the technology provides distinct advantages when addressing multiple quadrants of the abdomen, including the upper abdomen and diaphragms. Near-infrared imaging can be utilized in a variety of applications, including sentinel lymph node mapping and assessing for vascular perfusion at bowel anastomosis sites. Specific applications for various gynecologic malignancies will be discussed.

CERVICAL CANCER

According to the National Comprehensive Cancer Network (NCCN), patients presenting with early-stage cervical cancer are recommended to undergo radical hysterectomy with pelvic lymphadenectomy.²⁷ It has been shown that robotic radical hysterectomy was associated with lower blood loss, shorter length of hospital stay, and less morbidity compared to abdominal robotic hysterectomy.²⁸ However, controversy surrounding utilization of minimally invasive approaches to radical hysterectomy in this population arose following the results of the Laparoscopic Approach to Cervical Cancer (LACC) Trial. This was a multicenter, randomized trial that showed that, when compared to laparotomic radical hysterectomy, minimally invasive radical hysterectomy (laparoscopic or robotic) was associated with lower disease-free survival and overall survival.²⁷ A subsequent systematic review and meta-analysis similarly showed that a minimally invasive approach to radical hysterectomy compared to a laparotomic approach in the setting of early-stage cervical cancer was associated with a higher risk of disease recurrence and death.²⁹ Following the LACC trial and subsequent studies, the NCCN updated guidelines to indicate that the preferred and standard approach should be laparotomy for radical hysterectomy.³⁰

Controversy remains regarding the impact of factors including tumor size, stage, surgeon impact, and preoperative evaluation. Specifically, the importance of tumor containment has been highlighted. Avoiding exposure of the tumor to the intraperitoneal cavity has been emphasized as a key element to avoid negative sequelae of radical hysterectomy in the setting of cervical cancer.³⁰ This can be facilitated by using a uterine manipulator or protectively closing the vaginal canal.³¹ Use of a uterine manipulator at the time of minimally invasive radical hysterectomy for early-stage cervical cancer was associated with 2.76 times higher hazard of disease relapse. In those who underwent a minimally invasive radical hysterectomy without the use of a uterine manipulator or with a protective closure of the vagina, disease-free-survival was similar to the laparotomic surgery group.³¹ Ongoing study is being completed to assess outcomes of robotic vs. open radical hysterectomy for cervical cancer. In the interim, shared decision-making between patient and surgeon is key to ensure an optimal and well-informed outcome.

ENDOMETRIAL CANCER

Approximately 320,000 cases of endometrial cancer are diagnosed every year in North America, making it the most common gynecologic cancer.³² Surgical staging and pathologic evaluation are required in endometrial cancer.³³ For early staged endometrial cancer, minimally invasive total hysterectomy with bilateral salpingo-oophorectomy is recommended.³³ Sentinel lymph node (SLN) biopsy can be considered in all patients with endometrial cancer but should be completed with ultrastaging to increase detection of low-volume disease.³³ Lymph node staging via systematic lymphadenectomy or SLN biopsy is recommended in all patients deemed to be of intermediate or high risk.³³ For patients of low or intermediate risk, SLN biopsy can also be considered.³³ SLN biopsy has the advantage of low false-negative rate, increased overall detection of metastasis compared to routine lymphadenectomy, and decreased morbidity and lower extremity lymphedema.³²

Robotic technology allows the use of near-infrared imaging and lymphatic mapping and indocyanine green.³² ICG is first injected into the cervix and the dye is immediately taken into the lymphatic channels where it accumulates in the uterine sentinel lymph nodes within 10 to 20 minutes.³² Near-infrared imaging is then activated at the robotic console and the SLN can be visualized.³² When compared to blue dye utilization, ICG is superior, especially in the obese patient population.³²

When compared to laparoscopic hysterectomy and staging in the setting of endometrial cancer, the robotic approach is associated with similar estimated blood loss, transfusion rates, postoperative hemoglobin levels, pain, and length of hospitalization.³⁴ However, the robotic approach was associated with shorter operative times (139 minutes vs. 170 minutes, p < 0.001) and less conversions to laparotomic approach (0 vs. 5, p = 0.027).³⁴ Based on surgical outcomes, successful surgical staging, and long-term morbidity, robotic surgery provides several advantages for treating endometrial cancer when compared to conventional laparoscopy.

OVARIAN CANCER

Most commonly, primary and secondary cytoreduction for ovarian cancer is performed via a laparotomic approach.³⁵ However, robotic surgery may be beneficial for select patients with ovarian cancer. The multi-quadrant access that is facilitated by the robot allows for excision of aortic lymph nodes and resection of upper abdominal metastases, including the supracolic omentum, diaphragm, spleen, and liver, are all facilitated by the robotic platform. Primary, interval, and secondary debulking with robotic technology are possible when disease is localized allowing for complete resection.

Research has shown that when robotic surgery was used in the setting of recurrent ovarian cancer, 91.7% patients did not require conversion to laparotomy and 82% were cytoreduced to no visible residual disease.³⁵ Appendectomy, large bowel resection, small bowel resection, liver resection, diaphragm resection, and splenectomy were all successfully performed via the robotic approach.³⁵ The procedures were completed in a median operative time of approximately 3 hours with a median estimated blood loss of 50 ml with median discharge on the first postoperative day.³⁵ It has also been shown that when primary tumor excision requires two or more major procedures, there is no perioperative outcome advantage of a robotic approach when compared to laparotomic approach.³⁶ However, perioperative outcomes are improved with robotics or laparoscopic when performing primary tumor excision that requires no or one major procedure.³⁶ It is essential to appropriately select patients for this approach with the ideal candidate having no carcinomatosis and localized disease.^35,36

HEALTHCARE COST CONSIDERATIONS

While adoption of robotic surgery continues to increase around the world, there are concerns regarding the impact on healthcare costs with greater fixed costs compared to laparoscopy. However, when direct cost, payment and profit are analyzed, robotic surgery is noted to be consistent with costs associated with traditional laparoscopic approaches.³⁷ Casarin et al. showed that national implementation of robotic surgery for treatment of endometrial cancer was pivotal and resulted in rapid increase in the utilization of minimally invasive treatment for endometrial cancer.³⁸ This in turn was associated with reduction in surgery-related complications.³⁸ Laparoscopic surgery and vaginal surgery were not able to have the same impact on surgical approach with less than 20% of patients with endometrial cancer in the United States being treated through a minimally invasive approach prior to widespread availability of robotic technology.³⁸ 

To decrease overall cost associated with robotic surgery, several strategies can be employed. Increased surgeon volume has been shown to decrease overall cost and increase profits due to increased efficiency with decreased length of surgery and lower complication rates.³⁷ A dedicated robotic team can significantly minimize the overall operating room time through reduction in docking and undocking time and turnover between cases, which reduces indirect costs.³⁷ When a dedicated robotic surgical team was created, mean docking time decreased by 18 minutes and overall operating time decreased by 56 minutes over a 4-year period of time without any negative impact on overall surgical quality.³⁹ Additionally, reducing instrument costs through utilization of fewer and reusable instruments, minimizing bedside assistant personnel and reducing overall robotic arm use from four to three total robotic trocars can be assist with cost containment.³⁷

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