Page 40 - Laparoscopic Surgery Online Journal

Mokoena Martins Mohosho

Also, robotic instruments have 7º of freedom, similar to recent studies show significantly higher cost with robotic
the human arm and hand, while rigid conventional than laparoscopic hysterectomy. The study by Frey et al 6
instruments have 4º of freedom. While there are newer showed higher cost with robotic than laparoscopic
flexible laparoscopic needle holders which move around in hysterectomy with $2995 vs with $3735 (p = 0.003).
7º (e.g. Autonomy Laparo-Angle™), movements with these
DISCUSSION
are not intuitive and their use requires additional training.
• Stabilization of instruments within surgical field: In This comparison between robotic and laparoscopic
conventional laparoscopy, small movements from the hysterectomy is apparently important, as worldwide robotic
surgeon are amplified (including errors or hand tremor). procedures are gaining more and more interest in
Robot-assisted surgery minimizes surgeon tremor. gynecological surgery. But there are only few comparative
• Improved ergonomics for the operating surgeon: The studies on this subject and most are retrospective with a
surgeon can be seated with telerobotic systems. This low case load.
avoidance of long-term standing during surgery could Both of them are minimally invasive procedures with
possibly be particularly beneficial to surgeons who are the only difference being the use of the robot. Costs are
pregnant and have orthopedic limitations. significantly higher for robotic hysterectomy and the
difference per case adds up to approximately 2500 USD
Limitations of Robotic Surgery
excluding the cost for investment and amortization. 15
Limitations of robotic technology include: 15
Robotic hysterectomy is easy to learn for the experienced
• Additional surgical training
laparoscopic surgeon, but to reach operating times of the
• Increased costs and operating room time
conventional laparoscopic hysterectomy, a learning curve
• Bulkiness of the devices 13
of at least 50 cases seems to be needed. Robotic
• Instrumentation limitations (e.g. lack of a robotic suction
hysterectomy may not offer a benefit for expert laparoscopic
and irrigation device, size, cost)
surgeons as well as the clinical outcome is most likely not
• Lack of haptics (tactile feedback)
better, but it might be a tool which offers an opportunity to
• Risk of mechanical failure
perform a minimally invasive hysterectomy to more
• Limited number of energy sources (i.e. less than
surgeons and also to give more patients the advantages of
conventional laparoscopy)
this minimally invasive surgery.
• Not designed for abdominal surgery involving more than
Recent studies show that the clinical outcome seems to
two quadrants (the device has to be redocked and
be the same for robotic and conventional laparoscopic
repositioned to operate in the quadrants it is not facing).
hysterectomy. Operating times are slightly higher and costs
In this article the comparison of robot-assisted hysterec- 7,8,10,12,13
are significantly higher for that robotic procedure.
tomy to conventional laparoscopic hysterectomy for benign
A few studies indicated that the robotic hysterectomy carries
and malignant indications is reviewed with the recent
less risks and can be performed easier in patients with
data available. 5,7
increased BMI than laparoscopic hysterectomy. It was
RESULTS also demonstrated in a single study 9 that there are less
musculoskeletal strain injuries among surgeons performing
The main focus of this comparison between these two
minimally invasive procedures is on the clinical outcome robotic procedures than conversional laparoscopic procedures.
It is clear from recent reports that this prolonged operative
and the costs.
In earlier studies the robotic hysterectomy was superior times and higher cost are the two main drawbacks of robotic
to laparoscopic hysterectomy in less conversion rate, less hysterectomy against laparoscopic hysterectomy. 4,13,14 The
blood loss, shortened hospital stay. However, it was found robotic operative time can be improved with training of
that operative time was longer and the costs were higher gynecologic surgeons. Despite these promising results, the
with robotic than laparoscopic hysterectomy. 1-3 The proportion of robotic hysterectomies is disappointingly low
incidence of complication was the same in both procedures. weighed against laparoscopic hysterectomies worldwide;
Only in one study the less cost and shorter operative time consequently laparoscopic hysterectomy continues to be the
6
was found in robotic than laparoscopic hysterectomy. In most common minimal access surgical approach in nearly
3
the study by Thomas et al the robotic hysterectomy was all countries worldwide. This is because of most likely the
superior with blood loss of 113 vs 60.9 ml (p < 0.0001); limited exposure to robotic surgery in several hospitals in
hospital stay of 1.6 vs 1.1 days (p < 0.007); conversion rate which gynecologic surgeons are educated and trained. To
of 9 vs 4%, but inferior to conversional hysterectomy with overcome this drawback of robotic hysterectomy, intensive
operative time of 92.2 vs 78.7 minutes. Both earlier and training of surgeons is required. To attain training and
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