Robotic surgery for gynecologic cancers: indications, techniques and controversies

Abstract

Minimally invasive surgery for gynecologic cancers is associated with fewer postoperative complications including less blood loss and quicker recovery time compared to traditional laparotomy. The robotic platform has allowed patients access to minimally invasive surgery due to its increased utilization by gynecologic oncologists. Many surgeons have embraced the robotic platform due to its technological advances over traditional laparoscopy including high-definition 3D optics, wristed instrumentation, camera stability and improved ergonomics. While robotic surgery continues as a mainstay in the management of gynecologic cancers, it remains controversial in regards to its cost effectiveness and more recently, its long-term impact on clinical and oncologic outcomes. A strong component of the justification of this surgical platform is based on extrapolated data from traditional laparoscopy despite limited prospective randomized trials for robotic-assisted surgery. In this review, we highlight the use of robotic surgery in the management of gynecologic cancers in special populations: fertility sparing patients, the morbidly obese, the elderly, and patients with a favorable response to neoadjuvant chemotherapy.

Keywords: gynecologic cancer; minimally invasive surgery; robotic surgery; sentinel lymph node.

Figure 1

Self-portrait of Leonardo da Vinci (1452–1519) and his detailed sketch of female anatomy.

Figure 2

Construction of Leonardo da Vinci’s mechanical drummer and mechanical knight, on display in Berlin. Designed around 1495 for a pageant in Milan, the Robotic Knight consisted of a life-size suite of armor filled with gears and wheels connected to an elaborate pulley and cable system allowing for independent motion (sitting down, standing up, moving its head, lifting its visor, and even playing the drums; rumors also suggested the Knight had the secret ability to write messages and draw pictures). This prototype was built by roboticist Mark Rosheim in 2002.

Figure 3

The DaVinci Xi Surgical Robot and DaVinci Robot Firefly™ technology demonstrating sentinel lymphatic mapping for endometrial cancer through which near-infrared light excites indocyanine green tracer to emit a fluorescent signal. Images from Dr. Tewari’s surgical practice.