The robotic revolution: Coming soon to a facility near you?

Key Points

Gynecologic surgery has typically evolved toward better outcomes with less morbidity. Isn't the measure of a "great" surgeon, after all, the ability to apply the tools at his or her disposal at the appropriate time for the appropriate disease to improve their patients' quality of life?

Gynecologists' use of laparoscopy and minimally invasive surgery for almost 30 years grew out of a desire to reduce surgical injuries and improve quality of life. And laparoscopic techniques have consistently done just that, reducing postoperative pain, length of hospital stay, and recovery time-by limiting the abdominal cavity's exposure to dehydration, eliminating the need for intestinal packing, and reducing muscle injury from retraction, while enhancing visualization.¹

That said, laparoscopic surgery has its limitations:

Telesurgery drove the first development of robotic surgical platforms. Conceptualized by NASA and the military to provide surgical expertise to remote locations, telesurgery had some success, but has been held back by communication bandwidth limitations.^2,3Telepresence surgery, on the other hand, has proven effective first in cardiac and then urologic cancer surgery.^4,5 Cardiac surgeons have shown that mitral valve surgeries can be performed with greater than 90% efficacy, low morbidity, and average hospital stays of 3 to 4 days.⁴ Robotic radical prostatectomies have been widely accepted in the urologic community with efficacy equal to or better than open techniques, and better postoperative neurologic outcomes.⁵ Here the surgeon is close to the patient, but operates at an ergonomic console equipped with 3D vision and autonomous control of wristed laparoscopic instruments and energy sources. There's growing interest in applying this technology to gynecology. Our goal here is to outline the history of robotics in gynecology and its current and future applications for the obstetrician/gynecologist.

Early robotics in gynecology

The first robotic-assisted surgery in gynecology used the foot-controlled AESOP system (Computer Motion, Goleta, Calif.), which was developed to control the laparoscope only. Later becoming a voice-controlled system, it freed surgeons to use both hands, while the robot held the camera steady. If the surgeon wished the camera to move, he spoke pre-programmed commands into a headset, which then moved the camera.

In the late 1990s, German surgeons used the AESOP system for procedures that included ovarian cystectomy, hysterectomy, and myomectomy. When they compared their AESOP-assisted procedures to their conventional laparoscopic ones, they found shorter operative times overall with the robot-controlled camera. Other patient outcomes, though, were essentially unchanged.⁶