Evaluation of the learning curve and safety outcomes in robotic assisted vaginal natural orifice transluminal endoscopic hysterectomy: A case series of 84 patients

The idea of reproducing himself with the use of a mechanical robot structure has been in man's imagination in the last 3000 years. However, the use of robots in medicine has only 30 years of history. The application of robots in surgery originates from the need of modern man to achieve two goals: the telepresence and the performance of repetitive and accurate tasks. The first "robot surgeon" used on a human patient was the PUMA 200 in 1985. In the 1990s, scientists developed the concept of "master-slave" robot, which consisted of a robot with remote manipulators controlled by a surgeon at a surgical workstation. Despite the lack of force and tactile feedback, technical advantages of robotic surgery, such as 3D vision, stable and magnified image, EndoWrist instruments, physiologic tremor filtering, and motion scaling, have been considered fundamental to overcome many of the limitations of the laparoscopic surgery. Since the approval of the da Vinci(®) robot by international agencies, American, European, and Asian surgeons have proved its factibility and safety for the performance of many different robot-assisted surgeries. Comparative studies of robotic and laparoscopic surgical procedures in general surgery have shown similar results with regard to perioperative, oncological, and functional outcomes. However, higher costs and lack of haptic feedback represent the major limitations of current robotic technology to become the standard technique of minimally invasive surgery worldwide. Therefore, the future of robotic surgery involves cost reduction, development of new platforms and technologies, creation and validation of curriculum and virtual simulators, and conduction of randomized clinical trials to determine the best applications of robotics.

The purpose of this study was to estimate the learning curve when using the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) in benign gynecologic cases by a team of 2 gynecologic laparoscopists. Retrospective case series (Canadian Task Force classification II-1). A private practice obstetrics/gynecology clinic. Patients requiring major benign gynecologic surgery who were candidates for a laparoscopic approach. All patients who would have otherwise been offered a transabdominal or conventional laparoscopic procedure were offered the option of having their procedure performed laparoscopically with robotic assistance. Data that were collected included robot set-up times by the operative room staff, operative times for use of robot, total operative times, and perioperative outcome. We analyzed the learning curve defined as the number of cases required to stabilize operative time to perform the various procedures. One hundred thirteen patients were treated over a 22-month period with the da Vinci Surgical System. Most procedures were hysterectomies, whereas other gynecologic procedures included supracervical hysterectomy, laparoscopic vaginal assisted hysterectomy, myomectomy, sacrocolpopexy, and oophorectomy. Total operative times for hysterectomies studied sequentially stabilized at approximately 95 minutes after 50 cases. The decrease in robotic time did not depend on uterine size. The mean length of hospital stay was 24 hours, and return to normal activities averaged 2.8 weeks. Robotic assisted surgery is an enabling technology that allows gynecologic surgeons the ability to offer laparoscopic procedures to most of their patients. In the hands of surgeons with advanced laparoscopic skills, the learning curve to stabilize operative times for the various surgical procedures in women requiring benign gynecolologic interventions is 50 cases.