Arch Gynecol Obstet (2010) 282:163–171 DOI 10.1007/s00404-009-1250-6
GENERAL GYNECOLOGY
Turkey’s experience of robotic-assisted laparoscopic hysterectomy: a series of 25 consecutive cases Ahmet Go¨c¸men • Fatih S¸ anlıkan • Mustafa Gazi Uc¸ar
Received: 15 June 2009 / Accepted: 25 September 2009 / Published online: 17 October 2009 Ó Springer-Verlag 2009
Abstract Purpose To present the outcomes of the first 25 roboticassisted hysterectomies from Turkey. Method A total of 25 patients who underwent roboticassisted hysterectomy (RAH) for benign conditions were included in the study. Patients’ demographics, surgical procedures, operative and postoperative complications, hospital stay, conversion to laparotomy, time data including all operative times, uterus weight and estimated blood loss (EBL) were recorded. All hysterectomies were American Association of Gynecologic Laparoscopists type IVE. Results All hysterectomies were completed robotically with no conversion to laparotomy. The mean and range of the operating time were 104.1 and 47–176 min, respectively. The mean hysterectomy time was 40.5 min (range 14–77). The mean cuff incision time and cuff suturation time were 6.8 min (range 2–18) and 16.4 min (range 7–40), respectively. The mean set-up time was 30.4 min (range 17–41 min). The mean docking time was 4.3 min (range 2–9 min). The mean console time was 74.2 min (range 30–137). The mean and range of the anesthesia time were 133.8 min and 75–210 min, respectively. The averages of EBL and uterus weight were calculated as 38.2 cc and 221.9 g, respectively. Three complications occurred: one postoperative paralytic ileus and the others were peroperative vaginal cuff lacerations during the removal of the specimen through the vagina. Conclusion Robotic-assisted hysterectomy (RAH) is feasible and safe for women with benign uterine pathologies, A. Go¨c¸men (&) F. S¸ anlıkan M. G. Uc¸ar Departments of Obstetrics and Gynecology, ¨ mraniye Education and Research Hospital, Istanbul, Turkey U e-mail:
[email protected]
although it has limitations that may be overcome in the future. Keywords Robotic-assisted hysterectomy Da Vinci Surgical System
Introduction Hysterectomy is the most common major surgical procedure performed after cesarean section and other procedures inducing or assisting delivery among women aged between 18 and 44 years in the USA [1]. Recently, there are several surgical techniques for hysterectomy including abdominal, vaginal, laparoscopic and robotic-assisted. Harry Reich [2] reported the first laparoscopic hysterectomy in 1989. The aim of laparoscopic approach to hysterectomy is to provide a better magnification of the pelvis anatomy and pathology to the surgeon. The laparoscopic approach to hysterectomy is a new, minimally invasive technique, which offers the patient a short hospital stay, small incisions, less postoperative pain, earlier recovery and improved quality of life during the postoperative period compared with abdominal hysterectomy [3]. Although revolutionary in the aforementioned positive effects on patient trauma and recovery times, the laparoscopic approach has encountered significant technical drawbacks. Two-dimensional visualization, limited degrees of instrument motion within the body as well as ergonomic difficulty and tremor amplification are the limitations of laparoscopic surgery. In addition to these technical problems, long period of operating time, long learning curve for the surgeon, inability to perform surgery in some circumstances such as the presence of firm adhesions still remain as obstacles to surgeons. To overcome such technical difficulties, the application of robotics to
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surgical technology was introduced in the late 1990s. The first robot approved by the US Federal Drug Administration (FDA) for clinical use in the abdomen was the automated endoscope system for optimal positioning (AESOP) (Computer Motion, Santa Barbara, CA, USA) [4]. With the successful application of robotic technology to surgery, new generations of robotic surgical systems have been developed. The latest in this evolution is the da VinciÒ Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) which was approved in April 2005 by FDA. The da VinciÒ Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) has a widespread usage in many fields of surgery including gynecology [5], urology [6], cardiothoracic surgery [7], orthopedic surgery [8], general surgery [9] and more recently otolaryngology [10]. The limitations of traditional laparoscopy can be eliminated mostlyby this new technology. It offers the surgeon better visualization, dexterity, precision and control than with open surgery, while enabling operation through 1–2-cm incisions. Considering the anatomical structures of the pelvis, the da VinciÒ Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) can provide a better chance for careful dissection and homeostasis in gynecologic surgery. The complex gynecologic procedures such as staging for malignancies can be done by this minimally invasive surgery [11–13]. The components of the da VinciÒ Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) include surgeon console, patient-side cart, endowrist instruments and vision system. The console is the first part, which translates the surgeon’s hand, wrist and finger movements into precise, real-time movements of surgical instruments inside the patient. The console has a three-dimensional image of the surgical field and the master controls by foot pedals. The second part is the patient-side cart, which consists of robotic arms that execute the surgeon’s commands in real time. The third part is the endowrist instrument composed of units that mimic the surgeon’s hand and wrist motion at the operation site. Each instrument has a specific surgical function such as suturing, clamping, grasping, etc. The image-processing/insufflations stack contains the camera control units for the 3D imaging system, image-recording devices, a laparoscopic insufflators and a monitor allowing 2D vision for the assistants. Although the da VinciÒ Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) has many preferable advantages, the absence of tactile feedback, bulkiness of the system, lack of vaginal access and cost exist as the limitations for the robotic-assisted surgery [14]. In literature, there are only a few publications about the robotic-assisted hysterectomy (RAH) experience with the American Association of Gynecologic Laparoscopists (AAGL) type IVE hysterectomy. Type IVE hysterectomy is defined as total laparoscopic removal of the uterus and
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cervix including vaginal cuff closure [15]. Starting from October 2008, we performed robotic-assisted surgery including tubal reversal, myomectomy, sacrocolpopexy, hysterectomy, radical hysterectomy and pelvic lymph node dissection. We are the first team that has been performing robotic-assisted surgery in Turkey. The aim of the current study is the presentation of 25 RAH AAGL type-IVE outcomes from Turkey.
Materials and methods This study included 25 patients who underwent RAH between October 2008 and April 2009. All hysterectomies were AGLL type IVE. The first author performed all the surgeries. There were two assistants during the surgery: one assistant for manipulation of the uterus through the vagina and the other for changing the endowrist equipments, suction, suture preparation and counter traction. An educated operating staff recorded all data during the surgery including operating time, set-up time, console time, estimated blood loss (EBL), etc. All the patients had mechanical bowel preparation 1 day before surgery and prophylactic antibiotics 1 h before skin incision. Patients gave informed consent for the RAH, which when mandated could be converted to laparotomy. The following data were collected to review the outcomes: age, body mass index (BMI), operation type, set-up time (ST), console time (CT), docking time (DT), hysterectomy time (HT), cuff incision time (CIT), cuff suturation time (CST), operating time (OT), additional procedures time (APT), anesthesia time (AT), uterus weight, EBL and hospital stay. Set-up time was defined as the time comprising skin preparation, dressing, trocar incisions, CO2 insufflation, port placement, exploration, additional procedures if needed such as laparoscopic adhesiolysis and docking time. Docking time was defined as the patient side cart and trocar fixation time. Hysterectomy time was defined as the time including total RAH except vaginal cuff closure time. Cuff incision time was defined as the time including robotic-assisted colpotomy. Cuff suturation time was defined as the time including intracorporeal robotic cuff closure. Console time was termed as the total time on the console. Operation time was calculated as the sum of ST and CT. Anesthesia time was defined as the time between intubation and extubation. Additional procedure time was defined as the time taken for procedures including adhesiolysis, technical problems such as port displacement, equipment failure, procedures for huge size uterus, etc. All patients were operated under general anesthesia. The first skin incision for the 12-mm trocar was made at the umbilicus or 3–4 cm above the umbilicus according the size of the uterus. CO2 was used to establish enough
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pneumoperitoneum. Abdominal exploration was first made with a 3D optic camera through a 12-mm port. The left robotic instrument port was inserted 10 cm lateral to the camera port at the mid-clavicular line and 2–3 cm below the umbilicus. The right robotic instrument port point was symmetrically on the contralateral side of the left robotic port. The last port, assistant port, was introduced between the left robotic port and the camera port, approximately 2–3 cm above the umbilicus. The sizes of trocars for endowrist equipments and assistant port were 8 and 10 mm, respectively. The third robotic instrument port was not routinely used. V-care (Conmed, USA) was used as the uterine manipulator. Each patient underwent insertion of an indwelling Foley catheter. A grasping forceps, inserted through the left robotic port, was used to take the small intestines to the right paracolic region to visualize the pelvic anatomy more clearly. The patient was positioned in the dorsal lithotomy and steep Trendelenburg position. After the docking procedure, that is the fastening the patient side cart to the trocars, the camera and endowrist instruments were introduced through trocars. EndoWrist (Intuitive Surgical, Sunnyvale, CA) bipolar grasper through the left robotic trocar and EndoWrist (Intuitive Surgical, Sunnyvale, CA) monopolar scissors through the right robotic trocar were used at the beginning of all the operations. The first author, the operator, began the surgery on the console after effecting the set-up. All hysterectomies were performed according to AAGL type-IVE classification, defined as the total removal of the cervix and closure of the vaginal cuff laparoscopically. The hysterectomy was started by using bipolar forceps for cauterizing the right round ligament. After cutting the round ligament by using the monopolar hot shears, an incision was made on the anterior and posterior broad ligament. The right ureter was visualized and the uterine artery was skeletonized. The infundibulopelvic ligament was first cauterized by bipolar forceps and incised with monopolar hot shears. The same procedure was followed on the left side. Dissection of the bladder peritoneum from its cervical attachments down to the external os was done. The uterine artery skeletonized at the level of the internal cervical os was cauterized with bipolar forceps and incised with monopolar hot shears. A uterine manipulator was pushed at midline to provide the surgeon an appropriate border for colpotomy. Anterior and posterior colpotomy was made across the borderline of the uterine manipulator edge that covers the cervix. After complete colpotomy, the specimen was taken out of the abdomen with a tenaculum through the vagina. The uterus was left in the vagina to prevent CO2 leakage. For the suturing of the vaginal cuff, monopolar hot shears was taken out and EndoWrist (Intuitive Surgical, Sunnyvale, CA) suture cut instrument was introduced from the right
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Fig. 1 The port placement sites for trocars are shown
robotic port. According to the size of the vaginal cuff, we either preferred continuous suture technique or separate figure-of-eight suture technique for closure of the cuff; 30 mm rounded 0 polyglycolic suture was used for closure. All sutures were tied intracorporeally. After adequate hemostasis control, the robotic system was undocked. The port placement sites for the trocars are shown in Fig. 1. The operative technique of the RAH that we used is shown in Fig. 2.
Results This study presents the outcomes of 25 consecutive robotic-assisted AAGL type IVE hysterectomy. All hysterectomies were completed robotically with no conversion to laparotomy. The mean age of the patients was 51.4 years (ranging from 43 to 72) and mean BMI was 28.1 kg/m2 (range 18.4–37.4) (Table 1). As much as 20 RAH and bilateral salpingoophorectomy (RAH ? BSO), four RAH and one RAH and bilateral salpingoophorectomy and Burch operation were performed. A history of abdominal surgery for different reasons was present in 24% of the patients (n = 6). The operating time was calculated as the sum of ST and CT. The mean and range of the OT were 104.2 and 47–176 min. Hysterectomy time was defined as the time taken for the total removal of the uterus except cuff suturation time. Mean HT was 40.5 min. The time parameters of the HT, CIT and CST obtained from 25 consecutive cases are shown in Fig. 3. Docking time was
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Fig. 2 The operative technique of the RAH used is shown
Table 1 The patient demographic properties and surgical operations in the study are shown
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Case
Age (years)
BMI (kg/m2)
Surgical operation
Past abdominal surgical history
1
53
29.47
RAH ? BSO
–
2
51
30.38
RAH ? BSO
–
3
50
28.04
RAH ? BSO
Left inguinal hernia anterior mesh repair
4
52
27.41
RAH ? BSO
–
5
43
27.11
RAH
–
6
44
20.81
RAH
C/S
7
72
28.40
RAH ? BSO
–
8
53
34.10
RAH ? BSO
Appendectomy
9 10
46 55
26.80 36.50
RAH RAH ? BSO
Myomectomy –
11
49
27.77
RAH ? BSO
–
12
40
32.10
RAH
13
54
28.10
RAH ? BSO
–
14
55
32.01
RAH ? BSO ? Burch
Nephropyelolithotomy
15
52
30.01
RAH ? BSO
–
16
56
37.40
RAH ? BSO
–
17
50
18.40
RAH ? BSO
–
18
50
25.10
RAH ? BSO
–
19
49
31.10
RAH ? BSO
C/S
20
60
35.40
RAH ? BSO
–
21
44
32.50
RAH ? BSO
–
22
45
26.70
RAH ? BSO
–
23
60
30.10
RAH ? BSO
–
24
51
32.10
RAH ? BSO
–
25 Average
51 51.4
28.60 28.09
RAH ? BSO
–
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Fig. 3 The time parameters of the HT, CIT and CST obtained from 25 consecutive cases are shown
counted from the beginning of the approach to the patient side cart to the operating table, until the complete docking of the robotic arms to the trocars. Mean docking time was 4.3 min (ranging from 2 to 9 min). Set-up time includes surgical site dressing, skin disinfection, skin incision, port insertion, CO2 insufflation, first abdominal inspection and if necessary laparoscopic interventions such as dissection of adhesions and docking time, as well as additional procedures before console time. Mean ST was 30.4 min (ranging from 17 to 41 min). In the case of number nine, the patient had firm omental and peritoneal adhesions throughout the uterus. The cul-de-sac was almost totally obliterated. Laparoscopic dissection of adhesions was done in 51 min of ST (Table 2). The average EBL was calculated to be 38.2 cc. After the removal of the hysterectomy specimens, they were weighed and the average was calculated to be 221.9 g (Table 3). Three complications occurred: one was postoperative paralytic ileus, and the others were peroperative vaginal cuff lacerations during the removal of the specimen through the vagina. The patient status with paralytic ileus recovered in 2 days without any postoperative intervention. The possible reason for the lacerations was the large size of the hysterectomy specimens that were 417 and 734 g. There was no remarkable complication after the postoperative time. All patients who underwent robotic-assisted surgery were discharged from hospital disease-free after surgery at 2.8 days on average. There was no need of blood transfusion of the patients at the postoperative time.
Discussion The past two decades have witnessed a revolutionary transition in surgical technique and technology. The new developments in the field of laparoscopic instruments and
visual systems provide the chance of making minimally invasive surgery more comfortable and easy. The limitations of the conventional laparoscopy include twodimensional visualization, an unstable camera platform, limited degrees of instrument motion within the body, as well as ergonomic difficulty, tremor amplification and inability to perform complex surgical procedures in some circumstances such as endometriosis or dense adhesions in the abdomen. Indeed, the learning curve of the conventional laparoscopy has still been a problem for new surgeons. Wattiez et al. [16] reported a retrospective comparative study on the learning curve of total laparoscopic hysterectomy of 1,647 cases and concluded that the operating times and major complications significantly decreased after adequate training. The application of the robotics to surgery has been an important evolutionary stage of minimally invasive surgery. Most of the limitations of conventional laparoscopy can be solved with this new technology. The application of the robotic surgery includes cardiothoracic surgery [7], urology [6], gynecology [5], general surgery [9], otolaryngology [10] and, maybe, all fields of surgery in the future. The da VinciÒ Surgical System (Intuitive Surgical, Sunnyvale, CA, USA), which was approved by FDA in April 2005 for gynecologic procedures, is the forefront of the robotic surgery. The benefits and features of the da VinciÒ Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) include better visualization, dexterity, precision and control than with open surgery, natural depth of field, enhanced contrast and magnification, comfortable seated posture for surgeon, motion scaling and tremor reduction. The application fields of robotic surgery in gynecology include hysterectomy [17], myomectomy [18], pelvic reconstructive surgery [19], tubal surgery [20] and oncology [11–13]. The altitudes about hysterectomy technique have begun to change with the introduction of new technological developments. The
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Table 2 The time data of the surgical procedures Case
Operation
ST (min)a
DT (min)
HT (min)
CIT (min)
CST (min)
CT (min)
OT (min)
AT (min)
ADT (min)
1
RAH ? BSO
41
8
77
11
40
135
176
210
32
2
RAH ? BSO
25
6
53
10
25
104
129
145
15
3
RAH ? BSO
27
5
45
13
15
83
110
128
10
4
RAH ? BSO
27
6
51
6
18
88
115
145
–
5
RAH
30
3
45
9
11
65
95
112
–
6
RAH
38
9
47
6
26
82
120
165
–
7
RAH ? BSO
33
3
22
3
11
44
77
97
–
8
RAH ? BSO
31
5
42
4
20
67
98
120
8
9
RAH
85
7
37
5
14
65
150
180
51
10
RAH ? BSO
33
6
41
9
37
137
170
210
60
11 12
RAH ? BSO RAH
27 24
5 6
40 50
4 3
12 20
72 92
99 116
135 150
6 33
13
RAH ? BSO
23
2
14
2
9
30
53
75
–
14
RAH ? BSO ? Burch
35
3
35
4
11
95
130
165
40
15
RAH ? BSO
17
2
16
3
7
30
47
75
1
16
RAH ? BSO
27
4
38
8
13
60
87
110
–
17
RAH ? BSO
31
5
65
12
18
127
158
210
67
18
RAH ? BSO
27
4
50
6
33
90
117
134
7
19
RAH ? BSO
17
2
45
7
12
77
94
120
6
20
RAH ? BSO
25
4
42
2
11
59
84
115
38
21
RAH ? BSO
30
2
24
7
9
39
69
80
2
22
RAH ? BSO
32
2
28
4
11
49
81
140
29
23
RAH ? BSO
24
3
39
5
11
59
73
105
18
24
RAH ? BSO
21
3
26
10
8
36
55
85
3
25
RAH ? BSO
30
3
41
18
10
71
101
135
15
74.2
104.1
133.8
17.6
47 176
75 210
Average time (min)
30.4
4.3
40.5
Minimum time (min) Maximum time (min)
17 41
2 9
14 77
a
6.8 2 18
16.4 7 40
30 137
Min minutes
evolution of hysterectomy technique includes abdominal, vaginal, laparoscopic-assisted supracervical [21], total laparoscopic approach [22] and finally RAH [23]. In literature, there are few published reports on the experience of RAH type IVE according to the American Association of Gynecologist Laparoscopists (AAGL). We present our first experience with RAH type IVE from Turkey. Diaz-Arrastia et al. [23] reported the first experience with RAH in 2002. In their series, all hysterectomies were type IIB. The type IIB hysterectomy includes additional vaginal approach for posterior culdotomy and ligation of the cardinal and uterosacral ligament. The operating time and EBL were reported to be in the range of 4.5–10 h and 300 ml, respectively. In our series, all hysterectomies included AAGL type IVE, meaning total laparoscopic removal of the uterus and cervix including vaginal cuff closure. The average operating time of our patients was 104.2 min. The EBL was 38.2 cc.
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Fiorentino et al. [24] published a pilot study assessing robotic laparoscopic hysterectomy and patient outcomes including 18 type IVE hysterectomies in 2006. Due to poor visualization, two cases were converted to laparotomy. The EBL was 81 ml and uterine weight average was 98 g. According to our data, the uterine weight was 221.9 g. In two patients, vaginal cuff laceration occurred due to the huge size of the uterus during removal of the uterus through the vagina. We preferred to divide the uterus, which was 734 g into two pieces intracorporeally by monopolar hot shears, but we could not prevent the vaginal cuff laceration. Electromechanical morcellation can be performed in patients with large uterus to prevent vaginal lacerations. Therefore, during the removal of the huge sized uterus, additional attention is needed at this stage of the operation. We experienced three complications: two vaginal cuff lacerations and one paralytic ileus. On comparing the hospital stay of our cases with literature, it appeared to be longer by 2.8 days. However, beginning
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Table 3 The data included EBL, uterus weight, complications and additional procedures of each case Case
EBL (cc)
Uterus weight (g)
Complication
Hospital stay (Day)
Additional procedures
1
55
192
–
3
22 mina technical problem ? 5 min drainage ? 5 min adhesiolysis
2
60
205
–
3
12 min port dislocation ? 3 min drainage
3
50
417
Vaginal laceration
3
10 min port dislocation
4
40
178
–
2
–
5
10
125
–
3
–
6
125
203
–
3
–
7 8
5 60
98 104
– –
3 3
– 5 min port dislocation ? 3 min vaginal cuff suturation
9
25
190
–
3
51 min laparoscopic adhesiolysis
10
30
734
Vaginal laceration
3
45 min uterus dividing ? 3 min adhesiolysis ? 8 min port dislocation ? 4 min vaginal cuff repair
11
15
212
–
2
5 min ureter dissection ? 1 min adhesiolysis
12
40
184
–
6
5 min technical problem ? 3 min manipulator failure ? 25 min ureter iliac dissection
13
5
144
–
3
–
14 15
15 10
177 164
– –
3 4
40 min Burch operation 1 min adhesiolysis
16
50
110
–
3
–
17
80
265
–
4
37 min double J catheterization ? 30 min adhesiolysis
18
35
170
–
1
3 min aspirator failure ? 4 min cyst aspiration
19
90
315
–
2
6 min adhesiolysis
20
10
134
–
1
23 min waiting for frozen section ? 2 min adhesiolysis ? 13 min bilateral pelvic dissection
21
30
156
–
1
2 min adhesiolysis
22
50
267
–
2
29 min anesthesia problem (re-intubation)
23
30
143
Paralytic ileus
5
11 min technical problem ? 5 min uterus removal ? 2 min adhesiolysis
24
15
164
–
2
3 min adhesiolysis
25 Average
25 38.2
640 221.9
– 12%
2 2.8
10 min uterus removal ? 5 min technical problem
a
Min minutes
from the 18th case, we have started to discharge patients on the postoperative second day. Reynolds et al. [25] reported a study including 16 robotic-assisted laparoscopic hysterectomy cases outcomes. In the study, 12 AAGL type IVE and 4 AAGL type LSH III were presented. The median operating time was reported to be 242 min (ranging from 170 to 432). The average of the EBL was 96 ml (ranging from 50 to 300 ml). They experienced four complications including thermal bowel injury, postoperative infection and vaginal cuff hematoma. The hospital stay in the study was reported to be 1.5 days. The learning curve of robotic surgery seems to be shorter than conventional laparoscopy when considering the limitations of conventional laparoscopy, which can be eliminated in robotic surgery. However, conventional laparoscopy is more accessible, cheaper and nearly all gynecologic procedures may be performed by this modality.
Nezhat et al. [26] reported that the time for mastering endoscopic surgery and suturing by using robotic technology might be shorter for those who have a less skilled laparoscopic experience. If the surgeon has previous sufficient experience with laparoscopic surgery, it will be easier to adopt the new robotic surgical system. In the study of Nezhat et al. [26], 137 robotic-assisted surgeries were reported including 10 hysterectomies, 17 hysterectomies and oophorectomy and other operations. The operating times of 10 hysterectomies and 17 hysterectomy and oophorectomy were reported to be 192 min (60–420) and 236 min (122–355), respectively. The technique of RAH was not mentioned according to AAGL classification. When comparing the operating time of hysterectomy, we experienced shorter operating and console time of 104.2 min (47–176) and 74.2 min (30–137) than the reported study of Nezhat et al. They reported the disadvantages of the robotic-assisted surgery including the
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lack of tactile feedback to the surgeon, bulkiness of the system, improper ergonomics of the assistance port due to limited range of motion, large incisions with increased risk of herniation and the longer time needed for the preparation of the system including draping, calibration, etc. We reported a set-up time of 30.4 min, which includes skin preparation, dressing, trocar incisions, CO2 insufflation, port placement, exploration as well as additional procedures if needed, such as laparoscopic adhesiolysis, docking time and skin closure. Although the system is bulky, evolution and technology will bring us robots that are of more suitable in size in the future. We did not experienced any port herniation. The usage of nonbladed trocars or radially expanding type trocars, slow release of carbon dioxide through the port valve and closure of all the fascial defects greater than 8 mm are the strategies that can be employed to reduce trocar site hernias [27]. Pitter et al. [28] reported a retrospective analysis of 40 consecutive cases over a 1-year period using the da VinciÒ Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). They performed 14 hysterectomies, AAGL LSH III and 3 AAGL type IVE, and the operating times were 110– 225 min and 130–160 min, respectively. The EBL was between 50 and 150 cc. The other operations were 23 myomectomy in the study. The cases in the study were separated into two groups, group I (1–20 cases) and group II (21–40 cases). The statistical analysis in the study showed a significant decrease in the overall operative time for all procedures when comparing two groups, which were 211.8 min for group I and 151 min for group II (p \ 0.05). They concluded that after 20 cases for a single surgeon, a statistical improvement in operative time can be established. Payne et al. [29] reported a retrospective chart review of 200 consecutive hysterectomy cases completed before and after implementation of robotic program. They performed 100 laparoscopic AAGL type IV hysterectomies and 100 robotic-assisted AAGL type IV hysterectomies. Overall, the robotic cohort experienced longer operative times by an average of 27 min. The prerobotic cohort, however, when compared with the last 25 robotic cases had longer operative times (92.4 min, 95% CI 46.0–225.0 vs. 78.7 min, 95% CI 66.0–91.2, p = 0.03). Seamon et al. [30] published a cohort study that included the comparison of outcomes between robotic versus laparoscopic hysterectomy and lymphadenectomy in patients with endometrial cancer in 2009. The study included 181 patients (105 robotic and 76 laparoscopic). There was no significant difference between the two groups in median age, uterine weight, bilateral pelvic or aortic lymph node counts, or complication rates in patients. The only remarkable difference between the two groups was the BMI (34 in robotic arm versus 29 in the laparoscopic arm,
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p \ 0.001) The authors concluded that robotic hysterectomy and lymphadenectomy outcomes for endometrial carcinoma (operating time, hospital length of stay, transfusion rate, conversion to laparotomy) were better than in laparoscopic approach even in heavy patients. Even in patients with high BMI, robotic surgery was more comfortable to the surgeon. Our hospital purchased the da Vinci system (Intuitive Surgical, Sunnyvale, CA, USA) at about $1.7 million and the annual maintenance cost of the system is approximately $100,000. The average cost of robotic endowrist equipments per case is around $1,400 in our patients. Therefore, robotic-assisted surgery seems to be an expensive technology. Murphy et al. [31] mentions the cost of the da Vinci system (Intuitive Surgical, Sunnyvale, CA, USA). The capital expenditure is $2.5– 3.5 million with an annual running cost approximating 5–10% of the purchase cost. However, the proliferation of these machines in the private health-care system suggests that there is a health economic case in favor of this outlay [31]. In future, this state may be changed by decreasing the cost of the equipments. In conclusion, we have reported the outcomes of the first RAH type IVE performed in Turkey. RAH is feasible and safe for women with benign uterine pathologies, although it has limitations that may be overwhelmed in the future. Further randomized prospective trials are necessary to determine long-term outcomes and benefits of this new technology. Conflict of interest statement There was no financial interest or financial support that we received for any aspect of the work.
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