Acessibilidade / Reportar erro

Safety Model for the Introduction of Robotic Surgery in Gynecology

Modelo de segurança para a introdução da cirurgia robótica em ginecologia

Abstract

Objective

To analyze the perioperative results and safety of performing gynecological surgeries using robot-assisted laparoscopy during implementation of the technique in a community hospital over a 6-year period.

Methods

This was a retrospective observational study in which the medical records of 274 patients who underwent robotic surgery from September 2008 to December 2014 were analyzed. We evaluated age, body mass index (BMI), diagnosis, procedures performed, American Society of Anesthesiologists (ASA) classification, the presence of a proctor (experienced surgeon with at least 20 robotic cases), operative time, transfusion rate, perioperative complications, conversion rate, length of stay, referral to the intensive care unit (ICU), and mortality. We compared transfusion rate, perioperative complications and conversion rate between procedures performed by experienced and beginner robotic surgeons assisted by an experienced proctor.

Results

During the observed period, 3 experienced robotic surgeons performed 187 surgeries,while 87 surgeries were performedby 20 less experienced teams, always with the assistance of a proctor. The median patient age was 38 years, and the median BMI was 23.3 kg/m2. The most frequent diagnosis was endometriosis (57%) and the great majority of the patients were classified as ASA I or ASA II (99.6%). The median operative time was 225 minutes, and the median length of stay was 2 days. We observed a 5.8% transfusion rate, 0.8% rate of perioperative complications, 1.1% conversion rate to laparoscopy or laparotomy, no patients referred to ICU, and no deaths. There were no differences in transfusion, complications and conversion rates between experienced robotic surgeons and beginner robotic surgeons assisted by an experienced proctor.

Conclusion

In our casuistic, robot-assisted laparoscopy demonstrated to be a safe technique for gynecological surgeries, and the presence of an experienced proctor was considered a highlight in the safety model adopted for the introduction of the robotic gynecological surgery in a high-volume hospital and, mainly, for its extension among several surgical teams, assuring patient safety.

Keywords:
robotics; robotic surgical; procedures/adverse effects; gynecologic surgical procedures/methods; endometriosis/surgery; gynecology

Resumo

Objetivo

Analisar os resultados perioperatórios e a segurança da realização de cirurgias ginecológicas por laparoscopia robô-assistida durante a implementação da técnica num hospital comunitário ao longo de 6 anos.

Métodos

Este foi umestudo retrospectivo observacional, comanálise dos prontuários de 274 pacientes que se submeteramà cirurgia robótica de setembro de 2008 a dezembro de 2014. Avaliamos idade, índice de massa corpórea (IMC), diagnóstico, procedimentos realizados, classificação da Sociedade Americana de Anestesiologia (ASA), presença de um preceptor (cirurgião experiente, compelomenos 20casos robóticos), tempocirúrgico, taxa de transfusão, complicações perioperatórias, taxa de conversão, tempo de internação, encaminhamento para Unidade de Terapia Intensiva (UTI) e mortalidade. Comparamos taxa de transfusão, complicações perioperatórias e taxa de conversão entre procedimentos realizados por cirurgiões experientes com a técnica e cirurgiões iniciantes na robótica, sempre assistidos por um preceptor experiente.

Resultados

Durante o período observado, 3 cirurgiões experientes realizaram 187 cirurgias, enquanto que 87 cirurgias foram realizadas por 20 equipes menos experientes, sempre com a presença de um preceptor. A mediana da idade foi 38 anos, e a mediana do IMC foi 23,3 kg/m2. O diagnósticomais frequente foi endometriose (57%) e a grande maioria das pacientes foi classificada como ASA I ou ASA II (99,6%). O tempo de cirurgia teve uma mediana de 225 minutos, e o tempo de permanência hospitalar teve uma mediana de 2 dias. Observamos 5,8% de taxa de transfusão, 0,8% de taxa de complicações perioperatórias, 1,1% de taxa de conversão para laparoscopia ou laparotomia e não houve pacientes encaminhadas à UTI, nem óbitos. Não houve diferença nos índices de transfusão, complicações e conversão entre cirurgiões experientes e cirurgiões iniciantes na robótica, assistidos por umpreceptor experiente.

Conclusão

Em nossa casuística, a laparoscopia robô-assistida demonstrou ser uma técnica segura para cirurgias ginecológicas, e a presença de um preceptor experiente foi considerada um ponto de destaque no modelo de segurança adotado para a introdução da cirurgia robótica em ginecologia num hospital de grande volume e, principalmente, na sua expansão entre diversas equipes cirúrgicas, mantendo a segurança das pacientes.

Palavras-chave:
robótica; procedimentos cirúrgicos robóticos/ efeitos adversos; procedimentos cirúrgicos em ginecologia/métodos; endometriose/ cirurgia; ginecologia

Introduction

In the 1990s, laparoscopy, previously relegated to diagnostic procedures, gained prominence in surgeries on the female reproductive system.11 García OF, Olvera HR, Montoya JJ. [Telemedicine and robotic surgery in gynecology]. Ginecol Obst Mex 2008;76:161-166 The evolution from open surgery to laparoscopy brought benefits for patients, and robotics represents a technological advancement in minimally invasive surgery.11 García OF, Olvera HR, Montoya JJ. [Telemedicine and robotic surgery in gynecology]. Ginecol Obst Mex 2008;76:161-166 The word robot refers to compulsory or mandatory work, and the term was created and first used by Karel Capek in 1920, in his play Rossum Universal Robots. The Robotics Institute of America defines a robot as a machine that has a human form of performing tasks, possibly with more precise skills.22 Rafiq A, Merrell RC. Telemedicine for access to quality care on medical practice and continuing medical education in a global arena. J Contin Educ Health Prof 2005;25(01):34-42. Doi: 10.1002/chp.7
https://doi.org/10.1002/chp.7...

Robotic surgery models emerged in the 1980s at the request of the United States Army, which sought alternatives for the surgical treatment of soldiers wounded on the battlefield.33 Satava RM. Looking forward. Surg Endosc 2006;20(Suppl 2): S503-S504. Doi: 10.1007/s00464-006-0057-9
https://doi.org/10.1007/s00464-006-0057-...
Robotic systems were continually created until the development of the da Vinci System (Intuitive Surgical, Sunnyvale, California, USA), which is now widely used for procedures in different specialties, including gynecology.44 Senapati S, Advincula AP. Telemedicine and robotics: paving the way to the globalization of surgery. Int J Gynaecol Obstet 2005;91 (03):210-216. Doi: 10.1016/j.ijgo.2005.08.016
https://doi.org/10.1016/j.ijgo.2005.08.0...
In Brazil, the Hospital Israelita Albert Einstein (HIAE) has pioneered the practice of robot-assisted laparoscopy in several specialties, including gynecology, and has performed a growing number of procedures since 2008.

Studies have compared the perioperative results of conventional, laparoscopic, and robotic surgeries in the field of gynecology, including benign and malignant surgeries, mainly hysterectomies.55 Fanfani F, Restaino S, Ercoli A, et al. Robotic versus laparoscopic surgery in gynecology: which should we use? Minerva Ginecol 2016;68(04):423-430 66 Cohn DE, Castellon-Larios K, Huffman L, et al. A prospective, comparative study for the evaluation of postoperative pain and quality of recovery in patients undergoing robotic versus open hysterectomy for staging of endometrial cancer. J Minim Invasive Gynecol 2016;23(03):429-434. Doi: 10.1016/j.jmig.2016.01.002
https://doi.org/10.1016/j.jmig.2016.01.0...
The disadvantages of conventional surgery over laparoscopy are clear in terms of abdominal incisions, length of stay, greater need for postoperative analgesia, and higher complication rates.55 Fanfani F, Restaino S, Ercoli A, et al. Robotic versus laparoscopic surgery in gynecology: which should we use? Minerva Ginecol 2016;68(04):423-430 66 Cohn DE, Castellon-Larios K, Huffman L, et al. A prospective, comparative study for the evaluation of postoperative pain and quality of recovery in patients undergoing robotic versus open hysterectomy for staging of endometrial cancer. J Minim Invasive Gynecol 2016;23(03):429-434. Doi: 10.1016/j.jmig.2016.01.002
https://doi.org/10.1016/j.jmig.2016.01.0...
77 Berlinger NT. Robotic surgery-squeezing into tight places. NEngl J Med 2006;354(20):2099-2101 On the other hand, when robot-assisted laparoscopy is compared with conventional laparoscopy, it would be expected that complex procedures become safer and more reproducible, as certain difficulties would be overcome. These include limitations on instruments range of motion, two-dimensional vision, tremor, ability to perform laparoscopic sutures, the need for an assistant to hold the camera, and a steep learning curve in the laparoscopy.44 Senapati S, Advincula AP. Telemedicine and robotics: paving the way to the globalization of surgery. Int J Gynaecol Obstet 2005;91 (03):210-216. Doi: 10.1016/j.ijgo.2005.08.016
https://doi.org/10.1016/j.ijgo.2005.08.0...
77 Berlinger NT. Robotic surgery-squeezing into tight places. NEngl J Med 2006;354(20):2099-2101

Robot-assisted laparoscopy can be used in many gynecological procedures, including myomectomies, hysterectomies, adnexal surgeries, treatment of endometriosis, sacrocolpopexies, tubal reanastomosis, and oncological surgeries, including pelvic and para-aortic lymphadenectomies.88 Dubin AK, Smith R, Julian D, Tanaka A, Mattingly P. A comparison of robotic simulation performance on basic virtual reality skills: simulator subjective versus objective assessment tools. J Minim Invasive Gynecol 2017;24(07):1184-1189. Doi: 10.1016/j.jmig.2017.07.019
https://doi.org/10.1016/j.jmig.2017.07.0...
99 Elliott DS, Frank I, Dimarco DS, Chow GK. Gynecologic use of robotically assisted laparoscopy: Sacrocolpopexy for the treatment of high-grade vaginal vault prolapse. Am J Surg 2004;188 (4A, Suppl)52S-56S. Doi: 10.1016/j.amjsurg.2004.08.022
https://doi.org/10.1016/j.amjsurg.2004.0...
1010 Advincula AP, Song A, BurkeW, Reynolds RK. Preliminary experience with robot-assisted laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 2004;11(04):511-518. Doi: 10.1016/S1074-3804(05)60085-0
https://doi.org/10.1016/S1074-3804(05)60...
1111 Bush SH, Apte SM. Robotic-assisted surgery in gynecological oncology. Cancer Contr 2015;22(03):307-313. Doi: 10.1177/107327481502200308
https://doi.org/10.1177/1073274815022003...
1212 Manchana T, Puangsricharoen P, Sirisabya N, et al. Comparison of perioperative and oncologic outcomes with laparotomy, and laparoscopic or robotic surgery for women with endometrial cancer. Asian Pac J Cancer Prev 2015;16(13):5483-5488. Doi: 10.7314/APJCP.2015.16.13.5483
https://doi.org/10.7314/APJCP.2015.16.13...
1313 O'Malley DM, Smith B, Fowler JM. The role of robotic surgery in endometrial cancer. J Surg Oncol 2015;112(07):761-768. Doi: 10.1002/jso.23988
https://doi.org/10.1002/jso.23988...
However, technological implementation in a surgical environment, especially when it involves several or many teams, with different levels of training and skills, is a great challenge and responsibility because patient safety can never be put at risk, otherwise the use of those tools should be strongly discouraged. Proctors in our hospital are designated by a multidisciplinary surgical committee. They need to be experienced in laparoscopy and recognized as proficient in robotics, with a minimum of 20 robotics cases (usually more than that). Those proctors have the function of supporting other less experienced teams throughout the surgery and handling the robot, with the role of intervening and even performing some steps of the procedure, if necessary. At the end, they evaluate the surgeons' skills in the different tasks of operations. It is also the proctor who formally enables other surgeons to perform procedures on their own after proven proficiency, thus ensuring good surgical results while always prioritizing patient safety.

The objective of this study was to analyze the perioperative results and safety of performing gynecological surgeries using robot-assisted laparoscopy during implementation of the technique over a 6-year period, considering procedures performed with and without a proctor.

Methods

This retrospective, observational and cross-sectional study was approved by the Institutional Medical Ethics Committee, CAAE: 38045414.7.0000.0071. We analyzed the medical records of 274 patients who underwent gynecological surgeries for benign or malignant diseases at the Hospital Israelita Albert Einstein (HIAE), São Paulo, Brazil, from September 2008 to December 2014. Patients with surgical indication for the treatment of gynecological diseases were included, and patients with non-gynecological procedures were excluded, even if there was a gynecological procedure for them as well.

The study considered each patient age, BMI, ASA classification, and diagnosis. We evaluated the procedures performed, operative time, length of stay, perioperative complications, blood transfusion, conversions (laparoscopy or laparotomy), transfer to the intensive care unit, and mortality. The data were descriptively analyzed using absolute frequency and percentages for qualitative variables and averages, standard deviations, or medians and quartiles for quantitative variables. The median was selected in cases of asymmetric sample distribution. The analyses were performed using SPSS statistical program, version 17.0 (SPSS Inc., Chicago, USA) to compare complications, transfusion rate and surgical conversion between experienced robotic surgeons without proctor and beginner robotic surgeons with proctor assistance.

Results

The number of surgeries was found to have increased over the course of the study period, with 16 (5.8%) surgeries in 2009, 22 (8.0%) in 2010, 45 (16.4%) in 2011, 38 (13.9%) in 2012, 63 (23%) in 2013, and 87 (31.8%) in 2014. In 2008, three (1.1%) surgeries were performed from September to December. Three teams performed the procedures in 187 patients (68.2%), with a mean of 62.33 cases per surgeon (range: 27–126). Twenty teams still in their initial robotics learning curve were responsible for 87 cases (31.8%), with a mean of 4.35 cases per surgeon (range: 1–14), always with the participation of a proctor.

The patients were aged 20 to 84 years, with a median age of 38 years, and the BMI range was 16 to 46.7 kg/m2, with a median of 23.3 kg/m2. In the surgical risk evaluation, only one patient had a preoperative ASA score of III (0.4%). The others were classified as ASA I or ASA II, indicating low clinical-surgical risk. The following preoperative diagnoses were found: endometriosis, uterine myoma, endometrial cancer, adenomyosis, and benign ovarian tumor. The following procedures were performed: ovarian cystectomy, treatment of intestinal endometriosis, hysterectomy, treatment of deep endometriosis (other than intestinal), myomectomy, oophorectomy, lymphadenectomy and sacrocolpopexy. The most frequent diagnosis was endometriosis, which occurred in 192 patients (70.1%). The most frequent procedures were ovarian cystectomy (22%) and treatment of intestinal endometriosis (20%) (Tables 1 and 2).

Table 1
Distribution of surgeries by the preoperative diagnosis (n= 338)

Table 2
Distribution of procedures performed (n= 501)

The diagnoses were included in the study as individual occurrences, given that each patient might have more than one diagnosis at the time of surgical decision. The same was considered for the procedures performed, as different procedures could be necessary during a single patient surgery. The operative time was 55 to 600 minutes, with a median time of 225 minutes (interquartile range [IQR]: 150–280 minute). The postoperative length of stay was 0.5 to 12 days, with a median time of 2 days (IQR: 2–3 days). Transfusions were required in 5.8% of the surgeries (1–3 red blood cell concentrates). There were complications in 2.6% of the surgeries and conversion to laparotomy or laparoscopy in 1.1% of the cases. There were no transfers to the ICU and no deaths (Table 3). There were no differences in complication rates between the group of surgeons with less experience in robotics (who were always assisted by a proctor) and the group of more experienced surgeons (Table 4).

Table 3
Distribution of surgeries by parameters analyzed in the case series (n= 274)
Table 4
Comparison of complication, conversion and transfusion rates between surgeries performed with and without proctor (n= 274)

Discussion

A 2010 review showed that robotic surgery has gradually become a frequent choice, and this modality has demonstrated good results in terms of reducing trauma and shortening the length of stay, with fewer complications, as evidenced by the extent to which it has been more present in several specialties every day.1414 Li CY, Wang JW, Jia JT, Zhang NW. [Review of the developmental history of robotic surgery]. Zhonghua Yi Shi Za Zhi 2010;40(04): 229-233. Doi: 10.3760/cma.j.issn.0255-7053.2010.04.008
https://doi.org/10.3760/cma.j.issn.0255-...
Although most gynecological procedures could be done by robotics, and this technology has been recently made available in more than 30 hospitals in Brazil, the number of procedures is still low even in those hospitals, demonstrating the difficulty in qualifying a good number of surgeons to use this technology safely and effectively.

In this study, we focused on safety-related outcomes, evaluating two distinct groups of surgeons: 20 with little experience in robotics (mean: 4.35 cases per surgeon; range: 1–14) and 3 experienced robotic surgeons (mean: 62.33 cases per surgeon; range: 27–126). The results demonstrated low rates of complications, transfusion and conversion, even when surgeons less experienced in robotics did the procedures, always assisted by an experienced proctor. However, we emphasize that our results have limitations related to study design, because it is retrospective and observational, with convenience sample, since we could not perform sample size analysis and may not have adequately identified confounding factors.

In a 2009 retrospective study that compared robotic surgery to laparoscopy for hysterectomy, the operative time was found to be like those reported in our casuistic. There were no statistically significant differences in operative time, blood loss or length of stay, and conversion to laparoscopy was not required.1515 Nezhat C, Lavie O, Lemyre M, Gemer O, Bhagan L, Nezhat C. Laparoscopic hysterectomy with and without a robot: Stanford experience. JSLS 2009;13(02):125-128 Reynolds and Advincula1616 Reynolds RK, Advincula AP. Robot-assisted laparoscopic hysterectomy: technique and initial experience. Am J Surg 2006;191 (04):555-560. Doi: 10.1016/j.amjsurg.2006.01.011
https://doi.org/10.1016/j.amjsurg.2006.0...
and Hanssens et al1717 Hanssens S, Nisolle M, Leguevaque P, et al. Place de la robotique dans l'endométriose pelvienne profonde : à propos du registre de la SERGS. Gynecol Obstet Fertil 2014;42(11):744-748. Doi: 10.1016/j.gyobfe.2014.09.005
https://doi.org/10.1016/j.gyobfe.2014.09...
have shown that the time required for robotic surgery exceeds that for laparoscopy, though these results vary according to the surgeons' experience.

Fastrez et al,1818 Fastrez M, Goffin F, Vergote I, et al. Multi-center experience of robot-assisted laparoscopic para-aortic lymphadenectomy for staging of locally advanced cervical carcinoma. Acta Obstet Gynecol Scand 2013;92(08):895-901. Doi: 10.1111/aogs.12150
https://doi.org/10.1111/aogs.12150...
in a multicenter study with a group of 37 robot-assisted pelvic lymphadenectomies, reported that one patient had an aortic injury requiring conversion to laparotomy and one patient had a ureteral lesion treated without conversion. In the nine lymphadenectomies performed at HIAE, none of these complications were observed, a result which reflects the safety of this kind of approach for this procedure.

At the hospital evaluated herein, 66 myomectomies were performed through minimally invasive robot-assisted approach between 2008 and 2014 and no conversions were required. This result is compatible with the data from Cheng et al,1919 Cheng HY, Chen YJ, Wang PH, et al. Robotic-assisted laparoscopic complex myomectomy: a single medical center's experience. Taiwan J Obstet Gynecol 2015;54(01):39-42. Doi: 10.1016/j.tjog.2014.11.004
https://doi.org/10.1016/j.tjog.2014.11.0...
in which 21 robotic myomectomies were performed between 2010 and 2012 with no conversions were required either.

In 2015, Corrado et al2020 Corrado G, Cutillo G, Pomati G, et al. Surgical and oncological outcome of robotic surgery compared to laparoscopic and abdominal surgery in the management of endometrial cancer. Eur J Surg Oncol 2015;41(08):1074-1081. Doi: 10.1016/j.ejso.2015.04.020
https://doi.org/10.1016/j.ejso.2015.04.0...
compared different surgical approaches for the treatment of endometrial cancer and showed that the group who underwent robotic surgery had a 1.4% rate of conversion to laparotomy and a 2.7% rate of conversion to laparoscopy, comparable to the rate observed at HIAE for all robotic gynecological surgeries between 2008 and 2014 (1.1%). The same authors reported a 1.4% blood transfusion rate, slightly lower than the 5.8% observed in the current study.2020 Corrado G, Cutillo G, Pomati G, et al. Surgical and oncological outcome of robotic surgery compared to laparoscopic and abdominal surgery in the management of endometrial cancer. Eur J Surg Oncol 2015;41(08):1074-1081. Doi: 10.1016/j.ejso.2015.04.020
https://doi.org/10.1016/j.ejso.2015.04.0...

Although we had only one case of sacrocolpopexy, a systematic review conducted in 2016 by Pan et al,2121 Pan K, Zhang Y, Wang Y, Wang Y, Xu H. A systematic review and meta-analysis of conventional laparoscopic sacrocolpopexy versus robot-assisted laparoscopic sacrocolpopexy. Int J Gynaecol Obstet 2016;132(03):284-291. Doi: 10.1016/j.ijgo.2015.08.008
https://doi.org/10.1016/j.ijgo.2015.08.0...
showed that the robotic approach is as safe as laparoscopy for performing the procedure, as there are no statistical differences between the two approaches in either complication rates or operative time. One of the biggest challenges of minimally invasive gynecological surgery is the difficulty in performing this type of approach on morbidly obese patients.2222 Kristensen SE, Mosgaard BJ, Rosendahl M, et al. Robot-assisted surgery in gynecological oncology: current status and controversies on patient benefits, cost and surgeon conditions - a systematic review. Acta Obstet Gynecol Scand 2017;96(03):274-285. Doi: 10.1111/aogs.13084
https://doi.org/10.1111/aogs.13084...
Being aware of this issue, minimally invasive surgeries must be introduced slowly and safely to those patients. Our casuistic had three patients with BMI > 40 kg/m2, with no complications at all.

Conclusion

Robot-assisted laparoscopy in gynecological surgeries has been shown to be safe, with the presence of a proctor being critical for a successful transition for less experienced teams. This study demonstrates the safety of the model here presented for the introduction of robotic gynecological surgery into the hospital practice, but the rapid development in robot-assisted surgery calls for long-term prospective randomized controlled trials.

Acknowledgments

The authors would like to thank for Edna Roter, Fernanda Assir and Elivane da Silva Victor for their technical assistance.

References

  • 1
    García OF, Olvera HR, Montoya JJ. [Telemedicine and robotic surgery in gynecology]. Ginecol Obst Mex 2008;76:161-166
  • 2
    Rafiq A, Merrell RC. Telemedicine for access to quality care on medical practice and continuing medical education in a global arena. J Contin Educ Health Prof 2005;25(01):34-42. Doi: 10.1002/chp.7
    » https://doi.org/10.1002/chp.7
  • 3
    Satava RM. Looking forward. Surg Endosc 2006;20(Suppl 2): S503-S504. Doi: 10.1007/s00464-006-0057-9
    » https://doi.org/10.1007/s00464-006-0057-9
  • 4
    Senapati S, Advincula AP. Telemedicine and robotics: paving the way to the globalization of surgery. Int J Gynaecol Obstet 2005;91 (03):210-216. Doi: 10.1016/j.ijgo.2005.08.016
    » https://doi.org/10.1016/j.ijgo.2005.08.016
  • 5
    Fanfani F, Restaino S, Ercoli A, et al. Robotic versus laparoscopic surgery in gynecology: which should we use? Minerva Ginecol 2016;68(04):423-430
  • 6
    Cohn DE, Castellon-Larios K, Huffman L, et al. A prospective, comparative study for the evaluation of postoperative pain and quality of recovery in patients undergoing robotic versus open hysterectomy for staging of endometrial cancer. J Minim Invasive Gynecol 2016;23(03):429-434. Doi: 10.1016/j.jmig.2016.01.002
    » https://doi.org/10.1016/j.jmig.2016.01.002
  • 7
    Berlinger NT. Robotic surgery-squeezing into tight places. NEngl J Med 2006;354(20):2099-2101
  • 8
    Dubin AK, Smith R, Julian D, Tanaka A, Mattingly P. A comparison of robotic simulation performance on basic virtual reality skills: simulator subjective versus objective assessment tools. J Minim Invasive Gynecol 2017;24(07):1184-1189. Doi: 10.1016/j.jmig.2017.07.019
    » https://doi.org/10.1016/j.jmig.2017.07.019
  • 9
    Elliott DS, Frank I, Dimarco DS, Chow GK. Gynecologic use of robotically assisted laparoscopy: Sacrocolpopexy for the treatment of high-grade vaginal vault prolapse. Am J Surg 2004;188 (4A, Suppl)52S-56S. Doi: 10.1016/j.amjsurg.2004.08.022
    » https://doi.org/10.1016/j.amjsurg.2004.08.022
  • 10
    Advincula AP, Song A, BurkeW, Reynolds RK. Preliminary experience with robot-assisted laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 2004;11(04):511-518. Doi: 10.1016/S1074-3804(05)60085-0
    » https://doi.org/10.1016/S1074-3804(05)60085-0
  • 11
    Bush SH, Apte SM. Robotic-assisted surgery in gynecological oncology. Cancer Contr 2015;22(03):307-313. Doi: 10.1177/107327481502200308
    » https://doi.org/10.1177/107327481502200308
  • 12
    Manchana T, Puangsricharoen P, Sirisabya N, et al. Comparison of perioperative and oncologic outcomes with laparotomy, and laparoscopic or robotic surgery for women with endometrial cancer. Asian Pac J Cancer Prev 2015;16(13):5483-5488. Doi: 10.7314/APJCP.2015.16.13.5483
    » https://doi.org/10.7314/APJCP.2015.16.13.5483
  • 13
    O'Malley DM, Smith B, Fowler JM. The role of robotic surgery in endometrial cancer. J Surg Oncol 2015;112(07):761-768. Doi: 10.1002/jso.23988
    » https://doi.org/10.1002/jso.23988
  • 14
    Li CY, Wang JW, Jia JT, Zhang NW. [Review of the developmental history of robotic surgery]. Zhonghua Yi Shi Za Zhi 2010;40(04): 229-233. Doi: 10.3760/cma.j.issn.0255-7053.2010.04.008
    » https://doi.org/10.3760/cma.j.issn.0255-7053.2010.04.008
  • 15
    Nezhat C, Lavie O, Lemyre M, Gemer O, Bhagan L, Nezhat C. Laparoscopic hysterectomy with and without a robot: Stanford experience. JSLS 2009;13(02):125-128
  • 16
    Reynolds RK, Advincula AP. Robot-assisted laparoscopic hysterectomy: technique and initial experience. Am J Surg 2006;191 (04):555-560. Doi: 10.1016/j.amjsurg.2006.01.011
    » https://doi.org/10.1016/j.amjsurg.2006.01.011
  • 17
    Hanssens S, Nisolle M, Leguevaque P, et al. Place de la robotique dans l'endométriose pelvienne profonde : à propos du registre de la SERGS. Gynecol Obstet Fertil 2014;42(11):744-748. Doi: 10.1016/j.gyobfe.2014.09.005
    » https://doi.org/10.1016/j.gyobfe.2014.09.005
  • 18
    Fastrez M, Goffin F, Vergote I, et al. Multi-center experience of robot-assisted laparoscopic para-aortic lymphadenectomy for staging of locally advanced cervical carcinoma. Acta Obstet Gynecol Scand 2013;92(08):895-901. Doi: 10.1111/aogs.12150
    » https://doi.org/10.1111/aogs.12150
  • 19
    Cheng HY, Chen YJ, Wang PH, et al. Robotic-assisted laparoscopic complex myomectomy: a single medical center's experience. Taiwan J Obstet Gynecol 2015;54(01):39-42. Doi: 10.1016/j.tjog.2014.11.004
    » https://doi.org/10.1016/j.tjog.2014.11.004
  • 20
    Corrado G, Cutillo G, Pomati G, et al. Surgical and oncological outcome of robotic surgery compared to laparoscopic and abdominal surgery in the management of endometrial cancer. Eur J Surg Oncol 2015;41(08):1074-1081. Doi: 10.1016/j.ejso.2015.04.020
    » https://doi.org/10.1016/j.ejso.2015.04.020
  • 21
    Pan K, Zhang Y, Wang Y, Wang Y, Xu H. A systematic review and meta-analysis of conventional laparoscopic sacrocolpopexy versus robot-assisted laparoscopic sacrocolpopexy. Int J Gynaecol Obstet 2016;132(03):284-291. Doi: 10.1016/j.ijgo.2015.08.008
    » https://doi.org/10.1016/j.ijgo.2015.08.008
  • 22
    Kristensen SE, Mosgaard BJ, Rosendahl M, et al. Robot-assisted surgery in gynecological oncology: current status and controversies on patient benefits, cost and surgeon conditions - a systematic review. Acta Obstet Gynecol Scand 2017;96(03):274-285. Doi: 10.1111/aogs.13084
    » https://doi.org/10.1111/aogs.13084

Publication Dates

  • Publication in this collection
    July 2018

History

  • Received
    30 Oct 2017
  • Accepted
    09 Apr 2018
Federação Brasileira das Sociedades de Ginecologia e Obstetrícia Av. Brigadeiro Luís Antônio, 3421, sala 903 - Jardim Paulista, 01401-001 São Paulo SP - Brasil, Tel. (55 11) 5573-4919 - Rio de Janeiro - RJ - Brazil
E-mail: editorial.office@febrasgo.org.br