The current study compares the outcomes of total laparoscopic to robotic approach for hysterectomy and all indicated procedures after controlling for surgeon and other possible confounding factors. In our study, total laparoscopic hysterectomies were performed for benign or malignant indications an average 39 minutes faster than robotic hysterectomies. Exclusion of the subset of patients that had multiple procedures and/or conversion to laparotomy did not affect these results. The finding of reduced operative time associated with total laparoscopic hysterectomy is consistent with the majority of the studies in the literature that compare this type of hysterectomy with a robotic approach. In the study by Payne and Dauterive [9
], 2008, the robotic cases took an average 27 minutes longer to complete. The authors state however that the last 25 robotic cases (of 100) were done faster than the average total laparoscopic hysterectomy (92.4 minutes vs. 78.7 minutes). Other studies that had longer operative times for the robotic cohort, include the studies from Shashoua et al. [10
], 2009 and Nezhat et al. [11
], 2009 where there was an increased operative time of 20, and 70 minutes respectively.
The available studies in the literature that analyze specifically the use of a robotic versus a laparoscopic approach for surgical staging of endometrial carcinoma have shown conflicting results in regards to operative time. The studies by Seamon et al. [12
], 2009 and Boggess et al. [13
], 2008, found that the robotic cohort had less operative time than the laparoscopic by approximately 45 minutes, and 22 minutes respectively. Other studies by Jung et al. [14
], 2009 and Bell et al. [15
], 2008 found that the laparoscopic cohort was an average 27 minutes, and 13 minutes faster than the robotic cohort respectively. In the study by Bartos et al. [16
], 2007, the implementation of the robot to their gynecologic oncology cases increased the overall cost and operative time by 59% in comparison to identical laparoscopic procedures in the same institution.
Variability in the skill of the surgeon likely accounts for some of the inconsistencies seen in the literature. However, it is also possible that hospital dependent factors like anesthesia time, operating room staff efficiency and level of training of assistants may play a role in these conflicting results.
Our study confirmed the finding that the estimated blood loss is lower in robotic hysterectomies in comparison to total laparoscopic hysterectomies. Other authors that found similar results include Payne and Dauterive [9
], 2008, where there was a 52 mL difference favoring robotic hysterectomies. Studies that further prove this difference by having fewer blood transfusions in the total laparoscopic hysterectomy group include the studies from Boggess et al. [13
], 2008, Jung et al. [14
], 2009, and Bell et al. [15
], 2008. In our study, the 76 mL blood loss difference in the groups had no evident clinical significance given that none of our patients required a blood transfusion and there were no complications directly related to blood loss. The etiology behind the difference in blood loss between these two techniques is yet to be determined.
The data for complications for total laparoscopic vs. robotic hysterectomies have shown conflicting results. The study from Bell et al. [15
], 2008 showed a lower complication rate for the robotic in comparison to the laparoscopic group (7.5% vs. 20.0%), while our study shared findings with Nezhat et al. [11
], 2009 showing no statistically significant difference in both groups. The complication we encountered (cystotomy) was repaired laparoscopically.
With respect to rate of conversion to laparotomy, our study had similar results to Boggess et al. [13
], 2008, by finding no statistically significant difference between the total laparoscopic and robotic hysterectomy groups. The studies by Payne and Dauterive [9
], 2008 and Seamon et al. [12
], 2009 however, showed a decrease in the rate of conversion to laparotomy in the robotic hysterectomy group in comparison to the total laparoscopic approach (4% vs. 9%, and 12% vs. 26%, respectively). Additionally, there are two studies in the literature in which no conversions were reported (Nezhat et al. [11
], 2009 and Jung et al. [14
], 2009). Of note, the latter study was for staging of endometrial carcinoma and 83% of patients were stage I. Similarly, we included patients with endometrial carcinoma and our institutional practice is to perform a laparoscopic assessment for the cases with suspicion or with a known malignancy in order to determine resectability. This is performed whenever felt reasonable preoperatively with the purpose of avoiding unnecessary laparotomy in the cases where the intended outcome can be achieved laparoscopically. There is a definite need for larger studies to assess the expanding role of laparoscopy in gynecologic oncology.
Typical indications for robotic hysterectomy include patient and/or physician preference. Patient preference may be driven by patient-to-patient or by corporate direct-to-consumer marketing channels. Physician preference is based on the physician's training and experience with each modality including traditional laparoscopic, open, and robotic methods. The features of 3D visualization, play a role not only in visual field acquity/resolution, but also in camera control and image stability. Regarding the matter of the surgical assistance and console management, it is important to underline the paradox that exists. Many surgeons state that the console provides increasing personal control of the surgery and therefore a decreased dependence on the assistant. However at the same time, the presence of the primary surgeon remote and unscrubbed from the primary operative site results in a greater dependence on the ability of the assistant to complete the necessary ancillary functions in a timely and efficient manner.
Our study demonstrates that a traditional laparoscopic hysterectomy can be performed in less time than a robotic hysterectomy, while achieving similar outcomes. Therefore we raise the question: Would the generalized use of the robot be justified for this procedure? Our data does not support this claim. Robotic surgery is however a brilliant technology which may aid some physicians in the transition to a more minimally invasive approach to gynecologic surgery.
Learning and incorporation of the robotic technique is certainly appropriate as all surgeons should be familiar with the full spectrum of available methods for treating patients. However, physicians should not relinquish their hard learned and mastered traditional laparoscopic techniques. Physicians should also be conscious of the costs. Our data demonstrate that for skilled laparoscopic surgeons, the robot rarely improves the outcome as compared to a total laparoscopic approach to hysterectomy.
The findings in our study suggest that total laparoscopic is an approach for hysterectomy that can be performed safely and in less operative time than using the robot when performed by trained surgeons at institutions that have the proper operative team and equipment. The decrease in operative time and lack of the costs associated with robotic surgery make total laparoscopic hysterectomy a likely better and more cost-effective approach to patients that require a hysterectomy for a benign or malignant indication.
Our study has the limitations associated with a retrospective study and the results derive from a single institution with two affiliated hospitals. Prospective multicenter randomized studies are needed to definitively delineate the role of robotic surgery in the field of operative gynecology. Ideally, each surgeon should be familiar with both the total laparoscopic and robotic techniques for hysterectomy and perform the procedure for which the surgeon has the most experience. The current data for robotic hysterectomies does not demonstrate any clear benefits over traditional laparoscopy. Instead, robotic technology adds time and cost to the procedure. We believe that whenever a case can be done without the robot, it should be.