Robot Assisted Laparoscopic Surgery in Gynaecology: An Evolving Assistive Technology

Abstract

Laparoscopic surgery is extensively utilized to treat a range of gynaecological conditions and pathologies. The advantages of laparoscopic surgery include the minimalization of blood loss and scarring, improved recovery times, and shorter hospital admissions. However, robotic technologies have had an increasing presence within gynaecological laparoscopic surgery in recent decades. This literature review therefore aims to discuss laparoscopy from 3 perspectives. First, the evolution of laparoscopy is reviewed with a focus on its origins, its transition from a diagnostic to an operative tool, and its role in present-day gynaecology. Second, interventions for benign gynaecological conditions (including excision of benign ovarian tumours, total laparoscopic hysterectomy, and laparoscopic myomectomy) are reviewed. The laparoscopic management of malignant gynaecology (including ovarian cancer, endometrial cancer, and cervical cancer) is also discussed. Finally, whilst robot-assisted laparoscopic surgery is experiencing rapid technological advancement, it is pertinent to consider the extent of its benefits when compared to open or conventional laparoscopic approaches in gynaecological surgery.

Introduction

Surgeons have long since attempted to minimize operative trauma in order to improve surgical outcomes, enhance recovery, minimize complications, and provide greater aesthetic results for their patients. ¹ Minimally invasive surgical approaches were subsequently developed to achieve these outcomes and have since undergone significant technological advancements over recent decades. Within gynecological surgery exclusively, Karl Fervers first described laparoscopic adhesiolysis using cauterization techniques in 1933. ² Between 1950 and 1970, advances in laparoscopic technology facilitated its transition from a purely diagnostic to an operative surgical tool. Advantages of the laparoscopic approach in gynaecology include its notable safety profile, the minimalization of blood loss and postoperative infection, reduced pain, faster recovery times, and high levels of patient satisfaction.^1,3-8

The surgical management of benign and malignant gynaecological conditions has transitioned through the open, conventional laparoscopic, and more recently, robot-assisted laparoscopic approaches. ⁸ Notable advantages of the robot-assisted approach when compared to conventional laparoscopy include ‘wristed’ instruments to enable greater loci of movement, incorporated tremor reduction for enhanced stability and precision, improved motion economy and tissue handling, and three-dimensional camera technology to increase the surgeon’s spatial awareness.^8-10 The first gynaecological procedure to utilize robotic assistance was a tubual anastomosis in 2000, before the first robot-assisted hysterectomy was undertaken in 2002.^11,12 The Da Vinci^® Surgical System (Intuitive Surgical Sunnyvale, California, USA) currently dominates the surgical robotics market and was approved for use in gynaecological surgery in 2005. However, concerns are being raised regarding its cost-effectiveness and lack of evidence to support its outcomes in comparison to conventional laparoscopy. The answers to these questions will likely provide valuable insights into the future role of robot-assisted surgery in gynaecology.^12-14

This review outlines the origins and development of laparoscopy, the utility of laparoscopy in gynaecology, and evaluates the status of robot-assisted laparoscopy in the surgical treatment of benign and malignant gynecological conditions.

Development of Laparoscopy

Laparoscopy has been used in surgical practice for over 2 centuries, but rapid advances within the field over the last 3 decades have enabled it to become a favoured operative modality. In the following paragraphs, the 4 stages of laparoscopy’s evolution are reviewed, including its origins, its application in surgical diagnostics, its application in operative surgery, and its application in modern gynaecological surgery.

Origins of Laparoscopic Surgery (1806-1901)

In 1806, German surgeon Philipp Bozzini invented a lighting device utilizing a tube, mirrors, and candlelight, thus providing a mechanism to observe the inside of the human body. ¹⁵ This constituted the earliest form of surgical endoscopy, but it wasn’t until the advent of the rigid cystoscope in 1879 that endoscopy was used clinically. ¹⁶ In Germany in 1901, Dr Georg Kelling pioneered the use of laparoscopy in veterinary surgery; by insufflating the abdominal cavity of dogs with filtered air, he was able to generate enough space to manipulate and visualize internal organs using the cystoscope invented by Dr Maximilian Carl-Friedrich Nitze. ¹⁷ This provided the platform upon which laparoscopy could enter its diagnostic era in human surgery.

The Diagnostic Era of Laparoscopy (1901-1933)

In 1910, Swedish doctor Hans Christian Jacobaeus performed the world’s first human laparoscopic diagnostic surgery in Stockholm. He successfully identified and diagnosed pathologies such as appendicitis, gallstones, and ovarian cysts, and was the first to propose the term “laparoscopy”. Following his pioneering surgery, laparoscopy advanced throughout Europe. ¹⁸ In 1911, Bertram M. Bernheim introduced laparoscopy to the United States. He inserted a proctoscope via a tiny incision in the abdominal wall and used an otolaryngoscope to diagnose a gastric ulcer, liver tumor, and diaphragmatic hernia. ¹⁹ In 1929, German scientist Heinz Kalk endorsed laparoscopy for diagnosing hepatic pathologies and later performed liver biopsies under laparoscopic guidance. ²⁰

The Operative Era of Laparoscopy (1933-1990)

The first operative laparoscopic surgery was performed in 1933; surgeon Carl Fervers carried out a laparoscopic release of intra-abdominal adhesions using cauterization. ²¹ Later, Hungarian doctor Jànos Veres invented the Veress needle; used to safely create a pneumothorax for the treatment of tuberculosis. ²² The Veress needle is still used extensively in laparoscopic gynaecological surgery today in order to provide entry into the peritoneal cavity and achieve pneumoperitoneum. ²³ Kurt Semm was a pioneer in minimally invasive surgery; he devised numerous minimally invasive techniques that could rival open laparotomy, earning him the title “Father of Modern Laparoscopy”. ²⁴ During the 1990s, additional electronic components such as video imaging systems, insufflators, electrosurgical units, and surgical stapling devices entered the operating room. ²⁵ This allowed the surgical field to be projected on monitors instead of individual laparoscopic eyepieces, and improved insufflation, haemostasis, and closure techniques.

Modern Laparoscopy (1990-Present Day)

Over the last 30 years, the advancement of laparoscopy has focused predominantly on 3 areas: enhanced visualization, innovative surgical techniques, and robot-assisted technology. In an era of increasingly specialized procedures, the question is no longer which surgeries can be performed laparoscopically, but which surgical approach is most appropriate given individual pathologies, comorbidities, and lifestyle considerations.

Laparoscopy and Gynaecology

In 1901, a Russian gynaecologist used a mirror and speculum to examine a pregnant abdomen internally, marking the first time that endoscopy was used in gynecology. ²⁶ Laparoscopy was formally incorporated within gynecology by Raoul Palmer in 1944. He detailed 250 intracavitary gynaecological examinations he performed and the tools he invented to develop and refine these techniques. ²⁷ Laparoscopy in gynaecological surgery gained popularity after the advent of the automatic insufflation machine, and by 1970, gynecologists had integrated laparoscopy into routine surgical practice.

Laparoscopy and Benign Ovarian Cysts

Benign gynecological cysts were traditionally treated via laparotomy if surgical intervention was required. However, laparoscopic surgery is now commonly used to treat benign gynaecological cysts due to its enhanced recovery, reduced blood loss, and more aesthetically pleasing scars. ²⁸ Presently, laparoscopic ovarian cystectomy is the main surgical intervention for benign ovarian cysts if their size, malignancy risk, and patient-specific factors support this. ²⁹ If an ovarian cyst is suspicious for malignancy, laparotomy may be the preferred approach to minimize the risk of cyst rupture and peritoneal seeding. ³⁰ Ovarian cysts are usually located within a layer of ovarian epithelium and hypothelium. Although the specific steps of laparoscopic ovarian cystectomy are surgeon-dependent, most gynaecologists choose to incise the skin 1-2 cm longitudinally from the lower edge of the umbilicus, manually lift the abdominal wall, insert the Veress needle and insufflate the peritoneal cavity, before inserting the camera port trocar. ³¹ The laparoscope is inserted and a diagnostic laparoscopy is performed. When the ovarian cyst is identified and confirmed, a site that has a thin film between the cortex and the cyst wall is identified. ³² The ovarian cyst is immobilized with grasping forceps, and the ovarian cortex is delicately incised with care being taken not to rupture the cyst capsule. Once the cyst has been successfully removed, the ovarian cortex is closed.

Total Laparoscopic Hysterectomy

Laparoscopic hysterectomy was first described by Reich and Wotzlaw in 1992, but the first total laparoscopic hysterectomy (TLH) was reported in 1994 by Donnez and Nisolle in Belgium.^33,34 TLH involves placing a uterine lifter in the vagina before the standard laparoscopic entry technique as described above is performed. ³⁵ The surgical steps involve reflecting the bladder, securing the uterine blood vessels and supporting ligaments, and separating the uterus and cervix from the vaginal apex, before removing the uterus vaginally. ³⁵ Whilst closing the vaginal vault, a swab may be left within the vagina to maintain the pneumoperitoneum. Once haemostasis is confirmed the surgery is complete, and the laparoscopy is concluded with the removal of the trocars and closure of the port sites. As is always the case when choosing the optimal surgical approach, it must be remembered that the laparoscopic approach for hysterectomy is not always appropriate. In the event of patient obesity or a large multi-fibroid uterus, hysterectomy performed via a laparotomy may be preferred.

Laparoscopic Myomectomy

Uterine fibroids affect 70%-80% of women, contributing to infertility, pelvic pain, and abnormal uterine bleeding. ³⁶ Not all fibroids are amenable to laparoscopic removal; many require removal via open myomectomy due to their size and risk of bleeding. However, laparoscopic myomectomy remains an option if individual cases are considered appropriate for the laparoscopic approach. ³⁷ This technique was first performed by Kurt Semm in 1979. ³⁸

Laparoscopy and Malignant Gynaecology

In 1989, Querleu pioneered the use of laparoscopy in gynaecological malignancies with his laparoscopic pelvic lymph node dissection. ³⁹ With the introduction of this technique, more advanced gynaecological malignancies could be treated laparoscopically. The following section describes the application of laparoscopy in the treatment of endometrial cancer, cervical cancer, and ovarian cancer.

Laparoscopy and Endometrial Cancer

Endometrial cancer is the most common gynaecological malignancy worldwide. Fortunately, most women are diagnosed at an early stage, resulting in cure rates as high as 90%. ⁴⁰ For women with endometrial cancer, the most effective treatment is a hysterectomy and bilateral salpingo-oophrectomy. ⁴¹ Patients with stage IIIB and below, once identified, can be treated laparoscopically. ⁴²

Laparoscopy and Cervical Cancer

Cervical cancer has one of the highest cancer mortality rates amongst women. ⁴³ The main treatment for early cervical cancer is a hysterectomy. Compared with traditional laparotomy, the laparoscopic approach has substantial benefits. Laparoscopic surgery for cervical cancer is growing in popularity, mostly through its reductions in urinary tract infections, vascular injuries, and bladder injuries.

Laparoscopy and Ovarian Cancer

Ovarian cancers generally have high mortality rates; the insidious onset of vague symptoms often means that advanced disease is present by the time of diagnosis. ⁴⁴ The role of laparoscopic surgery in early-stage ovarian cancer surgery is well documented; total laparoscopic hysterectomy and bilateral salpingo-oophorectomy are the current laparoscopic surgical treatment options. ⁴⁵ Decisions regarding patient suitability for laparoscopy or laparotomy need to be discussed by the Multidisciplinary Team, with consideration for the stage and extent of the disease.

Robot-Assisted Laparoscopic Gynaecological Surgery

Since the 1980s, 3 robotic surgical systems have been used in gynaecological surgery. The first gynaecological procedure to utilize robotic assistance was a tubual anastomosis in 2000, before the first robot-assisted hysterectomy was performed by Diaz-Arrasti in 2002.^11,12,46 In modern surgical practice, the Da Vinci^® Surgical System (Intuitive Surgical Sunnyvale, California, USA) is the most widely used robotic surgical system, including in gynaecological robot-assisted surgery. ¹¹ The Da Vinci^® Surgical System functions in a ‘master/slave’ configuration, with the surgeon controlling the mechanical robotic arms from a peripherally located console. ⁴⁷ Presently, robot-assisted surgery has a range of applications within gynaecological surgery, with utility in both benign and malignant conditions. ¹¹ Gynaecological surgeries that can be performed via the robot-assisted laparoscopic approach include hysterectomy, myomectomy, fallopian tubual anastamosis, and pelvic floor surgery. In 2006, Sert and Abeler reported the world’s first robotic-assisted total laparoscopic hysterectomy and pelvic lymph node dissection in Norway. ⁴⁸ In 2006, Elliott reported the first robot-assisted sacral colpopexy, and the first robot-assisted myomectomy was reported by Bocca in 2007.^49,50 With present-day dual-console capabilities, complex surgeries can be performed with a multi-specialty approach. This means that in advanced malignancies involving multiple anatomical structures or in deep infiltrating endometriosis, robot-assisted laparoscopic surgery can be performed simultaneously with other relevant specialties, with other surgeons taking control when required. ¹²

Discussion

Gynaecological surgery has evolved significantly over the past two hundred years, with a gradual transition through open, laparoscopic, and robot-assisted techniques. ⁸ When choosing the optimal surgical approach, the Multidisciplinary Team (MDT) plays a vital role in deciding whether or not the patient, their condition, and their relative comorbidities are best suited to an open, laparoscopic, or robot-assisted approach. As new technologies continue to establish themselves within the operating theatre, these considerations will become ever more important.

Laparoscopic surgery has significant and established advantages over open surgery for conditions and pathologies amenable to either approach. For example, in patients undergoing hysterectomy for endometrial cancer, the laparoscopic approach ensures a lower risk of infection, shorter inpatient stays, improved aesthetic results, improved quality of life indices, and earlier resumption of activities of daily living than would otherwise be achieved with laparotomy. ⁸ Whilst robot-assisted laparoscopic surgery gains momentum in gynaecology and is utilized more extensively, it is important to consider whether robot-assisted surgery provides any measurable benefit in comparison to conventional laparoscopy alone. Indeed, this is an area of intense scrutiny. Across all surgical specialties, the robot-assisted surgery with the greatest benefit in comparison to its laparoscopic counterpart is a radical prostatectomy undertaken for prostate cancer.^8,51 The robot-assisted laparoscopic prostatectomy results in reduced intraoperative blood loss, whilst providing greater long-term sexual function and improved urinary continence in comparison to that achieved with the conventional laparoscopic approach.^8,51 However, outcomes in gynaecological robot-assisted surgery are less clear, with studies overall reporting inconclusive results and providing no overall consensus. This is compounded further by differences in the reported outcomes of different individual procedures. For instance, the first robot-assisted laparoscopic surgery for ovarian malignancy was performed at the Mayo Medical Center in the United States in 2006, but the outcomes of this approach in comparison to others are inconclusive. ⁵² Although the operative duration with robot-assisted sacral colpopexy is longer, its reported advantages in comparison to the conventional laparoscopic approach include reduced postoperative blood loss and shorter inpatient stays. ⁵³ Robot-assisted laparoscopic myomectomy has been considered more effective than open myomectomy in terms of morbidity and overall recovery, with fertility outcomes comparable to both the open and conventional laparoscopic approach.^11,54,55 Chan et. al. also reported no differences in blood loss or complication rates between robot-assisted and conventional laparoscopic surgery for advanced-stage endometriosis in their meta-analysis.^11,56

The robot-assisted laparoscopic hysterectomy is the most frequent robot-assisted surgery in gynaecology, and the second most common surgery overall in the United States. ⁵⁷ McCarthy et al compared multiple outcomes including operative duration, length of hospital stays, and quality of life in women undergoing conventional laparoscopic and robot-assisted laparoscopic hysterectomies for confirmed or suspected malignancy. ⁸ They demonstrated that the operative duration was shorter (albeit insignificantly) for the conventional laparoscopic hysterectomy cohort. ⁸ The total length of hospital stay was shorter for the robot-assisted laparoscopic hysterectomy cohort, but this was also insignificant. ⁸ This is supported by other studies, which also report reductions in wound infections and reductions in the length of hospital stay. The average hospital stay of patients after robot-assisted laparoscopic hysterectomy is 2 days, compared with up to 5 days after traditional laparoscopic hysterectomy.^58-60 Neither the conventional laparoscopic nor robot-assisted laparoscopic cohorts demonstrated any greater benefit in terms of quality of life or functional outcomes. ⁸ A systematic review by Alshowaikh et al. also examined the differences in outcomes between robot-assisted and conventional laparoscopic hysterectomies. ⁶¹ Their analyses outlined that there were no significant differences in blood loss, operative duration, length of hospitalization, complication rates, and long-term survival. ⁶¹

Bogani et al compared complications and perioperative morbidity between robot-assisted and open endometrial cancer staging surgeries. ¹⁰ They demonstrated that the robotic surgery cohort experienced significantly fewer complications within 30 days of surgery, had a smaller chance of readmission, and had a shorter inpatient stay. ¹⁰ Consistent with McCarthy et al.’s study, Bogani et al. demonstrated that the robot-assisted cohort had longer operative durations, although the 2 studies are not directly comparable as they did not compare the same surgery, nor the same surgical approaches.^8,10

As well as examining patient-specific outcomes, McCarthy et al. also examined the cost-effectiveness of conventional laparoscopic vs robot-assisted laparoscopic hysterectomies. ⁸ They reported that total costs incurred during the hospital admission (including the cost of the procedure itself) were higher for the robot-assisted group (£5462 ± 1472 vs £4592 ± 2,072, P = .002). ⁸ They concluded that when costs were compared to functional and quality of life outcomes, robot-assisted laparoscopic hysterectomy has evidence to support that it may be cost-effective. ⁸ However, Bogani et al. reported significantly lower median costs from the surgery itself to the end of the first month following robot-assisted surgery, when compared to the open endometrial cancer staging approach ($19,128 vs $20,369, P = .02). ¹⁰ They reported that the cost of the surgical intervention itself was lower for the open surgery cohort due to shorter operative durations, whilst the shorter inpatient stays and reduced complication rates in the robotic cohort meant that their overall hospitalization costs were smaller. ¹⁰ In contrast, Lundin et al. stated that robot-assisted laparoscopic hysterectomy in the early stages of endometrial cancer is 20% more expensive than an abdominal hysterectomy, citing the acquisition costs, instrument costs, and maintenance costs as the main reasons for this. ¹⁴ Alshowaikh et al.’s systematic review stated that robot-assisted laparoscopic hysterectomy was 1.43 times more expensive than conventional laparoscopic hysterectomy, yet was more profitable in complex surgeries, patients with large uterine weights, and with regards to obesity. ⁶¹ There is, therefore, no overall consensus regarding the cost-effectiveness of robot-assisted surgery when compared to other approaches for gynaecological procedures.^12,62,63 Cost-effectiveness analyses are complex and are severely limited due to variations in the surgeries compared, the techniques and instruments used, and the experience of the surgeon. ¹² Furthermore, global differences in health care economics and health care models used (public or private) mean that total costs, and therefore cost-effectiveness, will vary significantly between countries utilizing robot-assisted surgery.

Despite its presence for over 2 decades, the role of robot-assisted surgery remains an evolving technology within gynaecological surgery. Direct comparisons between its outcomes and cost-effectiveness in comparison to conventional laparoscopic or open approaches are complex, given differences in international health care systems and health economics. Further randomized controlled trials, systematic reviews, and meta-analyses are required to comprehensively determine the long-term patient outcomes and cost-effectiveness of robot-assisted laparoscopic surgery in comparison to its established counterparts. ⁶⁴

ORCID iDs

Siwen Xie https://orcid.org/0009-0007-5300-5672

Abdullatif Aydin https://orcid.org/0000-0002-5440-7741