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Evidence - Docking DaVinci step by step

gynecology
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Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Introduction

    Numerous systematic reviews, randomized studies, and guidelines address the evaluation of robot-assisted procedures compared to conventional laparoscopy, laparotomy, and vaginal surgery. The robot-assisted technique is predominantly used in hysterectomy, endometriosis surgery, and for oncological indications such as endometrial and cervical cancer. The evidence presents a nuanced picture, depending on indication, patient characteristics, and surgical complexity.

  2. Robot-Assisted Surgery vs. Laparoscopy vs. Laparotomy vs. Vaginal Approach

    Benign Indications:
    In benign conditions (e.g., fibroids, adenomyosis, prolapse, therapy-resistant bleeding disorders), robot-assisted surgery shows no significant advantage over conventional laparoscopy in terms of perioperative complications, blood loss, analgesic requirement, or recovery. However, it is associated with significantly higher costs and longer operation times [1,2]. The conversion rate to laparotomy is significantly lower in meta-analyses under robotics [3].

    Malignant Indications (Endometrial Cancer):
    For early endometrial cancer, randomized and retrospective studies show comparable oncological safety (OS, DFS) between robot-assisted, laparoscopic, and open hysterectomy with pelvic ± para-aortic LNE. At the same time, blood loss, hospital stay, and wound complications are significantly lower under robotics than under laparotomy [4,5].

    Malignant Indications (Cervical Cancer):
    The LACC study (2018) first showed significantly worse overall survival with minimally invasive (laparoscopic or robot-assisted) radical hysterectomy compared to open surgery in cervical cancer at FIGO stage IA2–IB1 [6]. These results led to a paradigm shift in the surgical treatment of cervical cancer. The use of robot-assisted procedures in this indication is currently justified only in study protocols.

    Operative Efficiency and Learning Curve

    Robot-assisted procedures are associated with prolonged operation time, especially in the initial learning phase. At the same time, data show that the learning curve for complex procedures (e.g., pelvic LNE, deep endometriosis) is shorter and more reproducible with robotics than with classical laparoscopy [7].

    Economic Evaluation

    The robotic technique is associated with higher procedure and system costs. A cost-benefit analysis shows no economic advantage over conventional laparoscopy in most benign indications [8]. However, in obese patients or complex oncological procedures, reduced complication rates can lead to a relative economic relief [9].

  3. Comparison of Surgical Approaches in Gynecology

    ParameterRobot-AssistedLaparoscopyLaparotomyVaginal Approach
    Visualization3D-HD, stable2D-HD, dependent on assistantDirectLimited
    Instrument Freedom7 degrees of freedomLimitedFreeLimited
    Operation Duration↑ (especially learning curve) [2]↔ to ↓ [2]↓ [2]↓ [1]
    Blood Loss↓ [3–5]↓ [3]↑ [5]↓ [1]
    Wound Complications↓ [4]↓ [3]↑ [5]↓ [1]
    Hospitalization Duration↓ [3–5]↓ [3]↑ [5]↓ [1]
    Oncological Safety↔ (except cervix) [4,6]↔ (except cervix) [4,6]Reference [6]Not established
    Costs↑↑ [8,9]↑ [8]↔↓ [1]
    Learning CurveFlat [7]Steep [7]FlatShort

  4. Conclusion

    Robot-assisted surgery is a safe and technically advanced procedure with advantages in visualization, ergonomics, and conversion rate. However, compared to conventional laparoscopy, there are no clinically relevant outcome advantages for benign indications, while costs are significantly higher. In complex procedures (obesity, endometriosis, oncological LNE), robotics can demonstrate its strengths. For cervical cancer, minimally invasive radical hysterectomy is currently not recommended due to the LACC study. The choice of approach should be made individually based on indication, patient, experience, and care structure.

  5. References

    1. Nieboer TE, Johnson N, et al. Surgical approach to hysterectomy for benign gynecological disease. Cochrane Database Syst Rev. 2009;(3):CD003677.
    2. Aarts JW et al. Surgical approach to hysterectomy for benign gynecological disease. Cochrane Database Syst Rev. 2015;2015(8):CD003677. DOI:10.1002/14651858.CD003677.pub5
    3. Scandola M et al. Robot-assisted laparoscopic hysterectomy vs traditional laparoscopic hysterectomy: five meta-analyses. J Minim Invasive Gynecol. 2011;18(6):705–715.
    4. Soliman PT et al. Systematic review of robotic surgery in gynecology. Am J Obstet Gynecol. 2014;211(6):583–593.
    5. Paley PJ et al. Comparison of robotic and open hysterectomy in endometrial cancer. J Minim Invasive Gynecol. 2016;23(4):544–551.
    6. Ramirez PT et al. Minimally Invasive versus Abdominal Radical Hysterectomy for Cervical Cancer. N Engl J Med. 2018;379(20):1895–1904. DOI:10.1056/NEJMoa1806395
    7. Lenihan JP Jr et al. The learning curve of robotic hysterectomy. Obstet Gynecol. 2008;112(6):1261–1267.
    8. Wright JD et al. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA. 2013;309(7):689–698.
    9. Seamon LG et al. Minimally invasive hysterectomy in obese women: decreased complications with robotic approach. Obstet Gynecol. 2009;114(1):16–21.

  6. literature search

    Literature search on the pages of pubmed.