The limitations of conventional laparoscopy have catapulted robots into the OR. The da Vinci Surgical System was designed
to overcome these limitations by providing the surgeon with better dexterity, precision, and three-dimensional imaging. Introduced
in 1999, the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) gained FDA approval for gynecologic procedures
in March 2005.
A decade later, growing numbers of health-care institutions are purchasing the robotic system. Urologists are still considered
the system's number one user, but robotic applications in gynecologic surgery have been expanding—and that expansion is reflected
in literature reports on robotic applications for general gynecology, urogynecology/pelvic reconstructive surgery, gynecologic
oncology, and reproductive endocrinology.
Advantages of robotic technology
Several studies done in the dry laboratory have linked robotic technology with faster performance, better accuracy, faster
suturing, and fewer errors when compared to conventional laparoscopic instrumentation.1-4 Advantages include: 
Figure 1: The dexterity of the robotic instruments replicates the full range of motion of the surgeon's hand. (©2009 INTUITIVE
SURGICAL, INC.)
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Figure 2: This robotic laparoscope with two cameras allows three-dimensional vision at the console. (©2009 INTUITIVE SURGICAL,
INC.)
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- Dexterity: The robotic instrument has "seven degrees of freedom," replicating the full range of motion of a surgeon's hand. In this
way, it efficiently facilitates suturing, knot tying and dissection, and helps overcome the fulcrum effect (i.e., the tip
of the conventional laparoscopic instrument moves in a direction opposite to the surgeon's hand) that surgeons encounter with
conventional laparoscopy (Figure 1).
- Precision: Robotic technology is able to increase accuracy and precision by downscaling the surgeon's movements in a ratio that the
surgeon can select (e.g., in a 3:1 ratio: when the surgeon's hand moves 3 cm, the tip of the instrument moves only 1 cm).
A computer interface eliminates physiologic hand tremors, increasing precision.
- Three-dimensional imaging: The robotic laparoscope has two cameras, one for each eye, which give the surgeon a three-dimensional image at the console
(Figure 2).
- Reduced surgeon's fatigue: Having the surgeon and the assistant seated during robotic procedures lessens their physical fatigue, especially during longer
and more complex procedures (e.g., radical hysterectomy, lymphadenectomy, sacrocolpopexy).
What are its limitations?
- Lack of tactile feedback is one limitation of robotics. However, the depth of perception through the three-dimensional vision may compensate for this
limitation.
- Increased cost is considered another downside of robotic surgery. When comparing the costs of robotics, laparotomy, and laparoscopy, however,
a more complex cost-benefit analysis model should be used including hospital stay, time to return to work, and productivity,
and not only costs related to the operating room. Additional studies are needed to further investigate this issue.
- A bulky system and limited vaginal access also limit robotic surgery. For example, it's more difficult to use a uterine maniupulator during robotic surgery as compared
to conventional laparoscopy. As technology becomes more sophisticated in the future, however, these limitations are expected
to resolve
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