Emergence of robotic assisted surgery in gynecologic oncology: American perspective
, Robert W. Holloway
, John F. Boggess
University of North Carolina, Chapel Hill, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, 101 Manning Drive, CB 7572, Chapel Hill,
NC 27599-7572. USA
Gynecologic Oncology Program, Florida Hospital Cancer Institute, 2501 N. Orange Avenue, Suite 689, Orlando, FL 32804, USA
Received 21 November 2008
Objectives. To discuss the emergence of robotic surgery in gynecologic oncology and describe the growth
of robotic surgery in a university medical center and a community based practice.
Methods. In addition to the historical evolution of the robotic assisted surgery medicine, a survey of
robotic cases was performed on two robotic programs since the inception of the programs. A review of the
current literature on the use of the da Vinci robot in gynecologic oncology was also performed.
Results. The robotic surgery programs at UNC Hospital and Florida Hospital are growing steadily since the
inception of the programs in 2005 and 2006, respectively. Since 2005 there have also been numerous
publications detailing the effectiveness, safety, and efﬁciency of the robot.
Conclusions. Robotic surgery is gaining acceptance and is rapidly growing as evidenced by an increased
number of publications on the topic; these publications demonstrate the safety, efﬁcacy, and improved
outcomes compared to open surgery and conventional laparoscopy.
© 2009 Published by Elsevier Inc.
Introduction ................................................................ S25
Evolution of surgical robotics ........................................................ S25
Historical perspectives.......................................................... S25
The da Vinci surgical system ......................................................... S26
Da Vinci surgical applications in gynecologic oncology ............................................ S26
Rationale and strategic approach to program building —a tale of two programs ................................ S27
Program initiation.............................................................. S27
Cost .................................................................. S27
Public institution experience ....................................................... S27
Private setting ............................................................. S27
Training ................................................................ S28
Teaching residents, fellows, and colleagues .................................................. S28
Surgical skill-set requirements and strategies for acquisition and development ................................. S29
Concept of a minimally invasive surgical team ................................................ S29
Institutional commitment ........................................................ S29
Strategies for building a robotic surgery team ................................................. S29
Establishing guidelines ........................................................... S29
Patient selection ............................................................ S29
Protocols, algorithms, clinical pathways.................................................. S30
Clinical outcomes ............................................................ S30
Summary .................................................................. S30
Conﬂict of interest statement ........................................................ S30
References ................................................................. S30
Gynecologic Oncology 114 (2009) S24–S31
⁎Corresponding author. Fax: +1 919 843 5387.
E-mail address: email@example.com (J.F. Boggess).
Fax: +1 919 843 5387.
Fax: +1 407 303 2435.
0090-8258/$ –see front matter © 2009 Published by Elsevier Inc.
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journal homepage: www.elsevier.com/locate/ygyno
Surgery is a controlled injury. In order to treat disease, surgeons
balance complications and invasiveness with clinical outcomes in
order to determine which techniques are best. Minimally invasive
surgery (MIS) is a method to reduce the morbidity of surgery and has
been shown in general to reduce blood loss, complications, post-
operative pain and length of hospital stay compared with traditional
laparotomy . While laparoscopic tools have evolved signiﬁcantly
over the last three decades, there has not been widespread adoption in
gynecology and gynecologic oncology [2,3]. The development and
introduction of robotic assisted MIS addresses many of the limitations
of traditional laparoscopy instruments by restoring dexterity and
intuitive instrument movement, 3-D vision, ergonomics and auton-
omy. Although robotic surgery in gynecology is in its infancy, the use of
the da Vinci surgical system is quickly becoming an integral tool for
treating gynecologic malignancies . Since 2005, robotic surgery has
emerged as an effective MIS tool in gynecologic oncology that in early
feasibility studies appears to decrease surgical morbidity beyond that
seen with traditional laparoscopy [5–12] . The following review will
outline the development of robotic surgical applications in gynecologic
oncology and will describe the development of two successful robotic
surgical programs –one university based and the other private practice
based –in order to illustrate the speciﬁc issues inherent to both
academic and private practice robotic surgery program development.
Evolution of surgical robotics
The ﬁrst surgical robots were utilized in the 1980s. The ﬁrst surgical
robots were industrial robots that were modiﬁed to assist with surgical
procedures. In 1984 the PUMA-560, a revamped industrial robot,
assisted with a stereotactic brain biopsy under CT guidance .After
the PUMA was used to assist with prostate surgery, further, specialized
surgical robots were developed . The PROBOT was developed in
England speciﬁcally to assist in transurethral prostate surgery. The
PROBOT had an ultrasonic tip, which allowed for reconstruction of the
prostate and adequate removal of the organ . Thus, prostatectomy
is considered the ﬁrst truly robotic operation. In the late 1980s, the
ROBODOC was developed by Integrated Surgical Supplies, Inc. to
speciﬁcally perform hip replacements (Fig. 1). ROBODOC was the ﬁrst
surgical robot approved by the FDA.
Robotic surgery and tools for broader applications were further
developed in the 1990s. Abdominal robotic assisted procedures
became possible with the advent of Computer Motion's AESOP
(Automatic Endoscopic System for Optimal Positioning). In 1994, the
ﬁrst FDA approval of a robotic device for intra-abdominal surgery was
granted. AESOP was a robotic arm that allowed surgeons to control the
orientation of a traditional laparoscope via foot pedal and later voice
command (Fig. 2). AESOP was the ﬁrst voice-controlled robot to
receive FDA approval. Four years later, Computer Motion introduced
ZEUS, a second-generation robotic system. Zeus was the ﬁrst robotic
system to provide instrument control in addition to camera control.
Zeus was composed of three robotic arms —one for a 2-dimensional
laparoscope and two arms to control surgical instruments. The camera
was operated with voice commands similar to AESOP while the
surgeon controlled the instrument arms from a remote console. A
computer translated the surgeon's movements into the laparoscopic
instruments, which were scaled according to surgeon preference. The
Zeus system had a 2D video screen identical to laparoscopy (Fig. 3).
Fig. 1. ROBODOC developed by Integrated Surgical Supplies, Inc.
Fig. 2. Computer Motion's AESOP (Au tomatic Endoscopic System f or Optimal
Positioning) has allowed surgeons to control the orientation of the laparoscope via
foot pedal and later voice commands, freeing both hands for surgery.
Fig. 3. ZEUS robotic system; ﬁrst robotic system to combine instrument and camera
S25A. Mendivil et al. / Gynecologic Oncology 114 (2009) S24–S31
Using the ZEUS robotic system, a remote-site robotic surgery was ﬁrst
performed by a surgeon in New York who performed a cholecystect-
omy on a patient in Strasbourg, France. This surgery utilized a
dedicated ﬁber optic network and was performed after several similar
trans-Atlantic surgeries had been performed on pigs . Telesurgery
has been limited due to bandwidth restraints and cost limitations.
However, DARPA, the Defense Advanced Research Projects Agency,
and TATRC, the U.S. Army Telemedicine and Advanced Technology
Research center have led advancements in robotic telesurgery given
the Congressional mandate to transform the Army to one-third
unmanned vehicles by 2015. Around the time that ZEUS was being
developed, Intuitive Surgical introduced the da Vinci robotic surgical
system. The ﬁrst telesurgery using the da Vinci robotic system was
conducted via public-use internet between the University of Cincin-
nati and Intuitive Surgical in California in March 2006 . The da
Vinci surgical system is the only FDA approved robotic surgical system
on the market currently, and will be further described below.
The da Vinci surgical system
The da Vinci surgical system is the most sophisticated of the
surgical robotic systems. The da Vinci has three components: the
patient side surgical cart, the vision system and the surgical console
(Fig. 4). The patient side cart has three to four arms for controlling a
12 mm 3-dimensional camera and two or three robotic surgical
instruments. The vision cart processes the video signal from the
camera and the image displayed on the surgeon console and two
separate monitors for the surgical assistant. Each eyepiece on the
surgical console receives a different feed allowing reconstruction of
the internal 3-dimensional view of the operative ﬁeld. The surgeon
sits remotely from the patient at the surgical console. The robotic
instruments are controlled via the surgeon's ﬁngers in two hand
pieces or ‘masters’. The surgeon's movements are translated into the
robotic surgical instruments, decreasing tremor and enhancing
precision. Robotic instruments are uniquely wristed allowing seven
degrees of freedom as opposed to the four degrees of freedom offered
by traditional laparoscopic instruments. Foot controls allow the
console surgeon to adjust the camera independently and activate
monopolar and bipolar energy sources. A surgical assistant stands
patient side to assist via traditional laparoscopic instruments. There
are two da Vinci systems currently available; the standard and S-
systems. The standard system was developed ﬁrst and has 3 or an
optional 4th arm. The S-system was the next upgrade and has 3-
dimensional, high deﬁnition vision, a wider panoramic view, and a
digital zoom that was developed to prevent instrument interference.
An integrated touch screen LCD monitor is available with the S-system
that allows the bedside assistant to see what the surgeon sees. The
monitor has a telestration feature (ﬁnger writing feature viewable by
both the bedside assistant and the console surgeon) that allows for
better proctoring and communication between the bedside assistant
and the surgeon.
Da Vinci surgical applications in gynecologic oncology
In 1999, the cardiothoracic surgery team of Loulmet and colleagues
performed one of the ﬁrst procedures using the da Vinci surgical
system. They described the use of robotic assistance in performing
coronary artery bypass grafts and showed that patients who under-
went robotic assistance had shorter length of stays in the hospital, and
less time in the intensive case unit after surgery compared with
sternotomy . The use of the da Vinci robotic-assisted laparoscopic
radical prostatectomy (RALP) was pivotal in bringing about the
subsequent wide spread use of the tool in gynecology. In 2001, Binder
et al.  published their ﬁrst 10 cases of RALP. Since then, RALP has
quickly moved to an accepted method treatment for prostate cancer.
Most recently, a case series of 1500 patients of RALP they concluded
that the procedure was safe, feasible, and efﬁcacious .
Based upon the pioneering work of Advincula and Reynolds who
reported on the use of the robot for myomectomies followed by their
preliminary experience in staging gynecologic cancers the United
States Food and Drug Administration (FDA) approved the use of the da
Vinci in gynecologic procedures in April 2005 [21–24]. In February,
2006, Boggess performed the ﬁrst live telecast demonstrating a
technique for performing robotic assisted radical hysterectomy and
subsequently presented data for a series of 13 radical hysterectomies
at the Society of Gynecologic Oncologists annual meeting in March of
the same year . Since this initial demonstration of feasibility and
technique, the interest in robotic assisted gynecologic oncology
procedures has rapidly spread. Tables 1 and 2summarize the current
literature detailing experiences of robotic procedures for the
Fig. 4. Da Vinci Surgical System, Intuitive Surgical, Inc., Sunnyvale, CA.
Robotic-assisted radical hysterectomy cases; N/A = not available
Article Year # pts Median operative
Marchal, et al.  2005 7 N/A N/A N/A
Sert, et al.  2006 1 N/A N/A N/A
Sert, et al.  2007 15 241 71 N/A
Kim, et al.  2008 10 207 355 28
Magrina, et al.  2008 18 226 175 26
Fanning, et al.  2008 20 390 300 18
Boggess, et al.  2008 51 211 97 32
S26 A. Mendivil et al. / Gynecologic Oncology 114 (2009) S24–S31
treatment of cervical and endometrial cancer. While these series are
relatively small and non-randomized, they consistently demonstrate
safety and efﬁcacy with respect to complications, blood loss, operative
time and patient convalescence compared with laparotomy and
Rationale and strategic approach to program building —a tale of
Early adopters of robotic surgery have not only faced challenges in
procedure development, but also in program development. There are
inherent differences in program building based on the type of practice
involved. As more gynecology oncologists begin to adopt robotic
surgery, these early experiences can serve as a roadmap to establish-
ing a successful program.
Program initiation is based on two key players: surgeons and
administrators. Surgeon interest and commitment to a robotic
program is key in the successful implementation, whereas adminis-
trators are paid to protect the ﬁnancial interests of an institution and
thus must be convinced that robotics offers beneﬁts and is marketable.
The upfront capital investment for an institution is between
$1,000,000 and $1,500,000 per da Vinci
surgical system and requires
a 10% annual maintenance fee for repair and service as well as
software upgrades to the system. There are also costs associated for
each case that include robotic instrument use cost of $200 per use.
Second, additional costs include drapes for the actual system, robot
speciﬁc ports (depending on the type of system), and any other
accessories necessary for the particular case. Third, there is the cost of
training personnel to set up the system; initially there may be delays
due to the novel nature of the process and may lead to additional
operating room time and costs. Finally, there is the cost for proctoring
newly involved surgeons in a program . In the end, an institution
must view the system as an investment that requires continued
support by multiple services to ensure the program's success. The
ﬁxed cost of the system can be justiﬁed and distributed when utilized
to a maximum number of cases by multiple surgical services.
Public institution experience
At the publicly funded, University of North Carolina, surgeons
pursued a robotic surgery program based on extensive experience in
advanced laparoscopic surgery . The University administration was
interested in the ﬁnancial aspects of establishing a robotic program;
one key factor was use of the system by multiple surgical de-
partments. At UNC, Urology offered initial interest, followed by
pediatric and gynecologic oncology surgery. As a leading University-
based academic program questions regarding the advantages of
robotic assistance over laparoscopic techniques with regard to patient
outcomes and learner experience were considered. Ultimately,
surgeons and administration agreed that a robotic program would
be beneﬁcial and the initial system, a standard 3-arm robot was
installed in February 2005.
At the University of North Carolina, the Urology service was the
ﬁrst to use the robot. In 2005, the gynecologic oncology service
performed the institution's ﬁrst robotic hysterectomy and bilateral
salpingoophorectomy. Since then, the number of gynecologic proce-
dures performed has exceeded 700 cases. The initial success of the
program led to the purchase of a second system (S-system); both
systems are used virtually every day with access by ﬁve different
surgical services. Robotic surgical procedures by the gynecology and
gynecologic oncology services have grown progressively since the
inception of the program in 2005 (Figs. 5 and 6), and the majority of
staging for endometrial cancer and radical hysterectomy for cervical
cancer are currently performed via robotic assistance.
In contrast, the development of the robotics program at Florida
Hospital in Orlando began in 2006 soon after seeing a live broadcast of
a robotic radical hysterectomy . As with many gynecology
practices, a da Vinci system was already in place at the medical center
being utilized by the Urology service. The evolution to robotics was
viewed as particularly challenging by the attending surgeons since the
gynecologic oncology program was not routinely performing mini-
mally invasive surgical techniques for treatment gynecologic malig-
nancies. Despite the ability to perform an open radical hysterectomy
in 97 min and an endometrial staging in 84 min on average , the
group decided to explore robotics in order to improve surgical
outcomes for their patients. It was postulated that the quicker patient
Robotic-assisted staging of endometrial cancer; N/A = not available
Article Year # pts Median operative
Mean total lymph
Reynolds, et al.  2005 2 N/A N/A 23
Marchal, et al.  2005 5 N/A N/A N/A
Bell, et al.  2008 40 184 166 17
Denardis, et al.  2008 56 177 105 19
Boggess, et al.  2008 103 191 75 33
Fig. 5. Growth of robotic assisted cases for the gynecology and gynecologic oncology
services at UNC since the inception of the program in 2005; 2008⁎represents data
compiled through October 2008.
Fig. 6. Cases performed by the gynecologic oncology service at UNC from 2005–2008;
data from 2008 is compiled up to 6/30/20 08.
S27A. Mendivil et al. / Gynecologic Oncology 114 (2009) S24–S31
recovery times combined with less pain and complications would
justify any anticipated increases in operative times. The purchase price
of a da Vinci
system is signiﬁcant to the budget of any hospital;
however, it was anticipated that conversion of complicated gyneco-
logic laparotomy cases to MIS would shorten length of stay, thus
freeing up inpatient bed-days to satisfy the admission needs of the
hospital. Ultimately, the potential improvement in patient outcomes
from MIS compared to the standard laparotomy justiﬁed the hospital
investment irrespective of the best and worst case economic
projections. Since the program's inception, the number of cases
performed robotically continues to grow each quarter, approaching
400 robotic procedures annually at present (Fig. 7).
Regardless of setting, training of multiple team members must
occur prior to procedure initiation. In both public and private
experiences, a dedicated team of nurses and operating room support
staff were trained on the operation of the system. Designated surgeons
were oriented to the system in a “dry lab”setting and then attended a
porcine lab for a one-day comprehensive training and certiﬁcation
In the academic setting, the ﬁrst case was a simple hysterectomy
and bilateral oophorectomy. The technique used was based upon a
modiﬁed KOH ring method for performing total laparoscopic
hysterectomy . Port placement strategy for this ﬁrst case was
derived from the robotic assisted prostatectomy literature. The
primary surgeon's perception was that the ergonomics and intuitive
movements of the instruments combined with the 3-dimensional
immersive vision were major improvements over traditional laparo-
scopy and that the system would be adequate for performing more
complex procedures. Based upon this initial success, a robotic assisted
endometrial cancer staging was performed the following week and a
radical hysterectomy performed as case number three. Since this
initial experience, the author has performed and/or instructed on over
600 robotic procedures with the emphasis being on hysterectomy,
simple or radical, and lymph node dissection.
Since the inception of the robotics program in gynecologic
oncology at Florida Hospital, there has been consistent growth in
the number of robotic cases performed each year (Fig. 8). Further-
more, there has been a shift in the trend of approach to endometrial
cancer staging cases with now more than half of the cases being
performed via robotic assistance (Fig. 9).
Teaching residents, fellows, and colleagues
Training of additional surgeons in robotic surgery has been crucial
to the success of both public and private gynecologic oncology
programs. The most successful training programs have utilized a
process involving progressive involvement. At the start of both
programs, a single surgeon developed procedures at the console
with assistants at the bedside. Cases were scheduled according to the
surgeon's level of comfort. With time, the involvement of assistants
(residents and fellows) on the console increased.
The observation of robotic cases by residents and fellows is
important to familiarize them to the instrument. At UNC, residents/
fellows begin by learning the placement of trocars necessary for the
particular case, followed by docking the robotic arms to the ports. It is
also a goal for learners to gain the ability to trouble shoot the device/
arms during the case as this can make a major difference in the ability
of the console surgeon to the effectively complete the case. Becoming
familiar with the robot as the bedside surgeon also serves to teach the
anatomy, surgical boundaries, and surgical procedures with vivid
visualization. After case observation, residents and fellows train in the
Fig. 7. Quarterly growth of robotic cases during the ﬁrst two-years of robotics program
at Florida Hospital—Orlando (6/30/06–6/30/08).
Fig. 8. Growth of gynecologic oncology robotic cases at Florida Hospital during the years
2006–2008 (⁎= 8-month data).
Fig. 9. Changes in the pattern of surgery for endometrial cancer during the ﬁrst two-
years of the program at Florida Hospital (2007–2008).
Robotic surgical curriculum (adapted from Chitwood, et al. )
1. Didactic overview
Understanding robotic instrumentation
2. Inanimate lab
Master console (actuators/pedals)
3. Animal lab
Console surgeon—master suturing, tissue manipulation
Patient side surgeon—master instrument changes, trocar positioning
4. Cadaver lab
Master trocar placement
Apply acquired skills to cadaver
5. Operative observation
6. Performance live case
S28 A. Mendivil et al. / Gynecologic Oncology 114 (2009) S24–S31
(dry) laboratory and practice speciﬁctasksontherobot.The
completion of such pre-surgical preparation is followed by perfor-
mance of appropriate surgical procedures for patients under direct
supervision. The da Vinci
S system has an LCD with writing feature
allowing the bedside surgeon (attending) an opportunity to observe,
teach, and guide the resident/fellow at the same time. Table 3 outlines
a stepwise training strategy for robotic surgery.
Surgical skill-set requirements and strategies for acquisition and
The robotic surgical system is a tool set and, therefore, a successful
procedure is dependent upon the surgeon's abilities. The primary goal
when transitioning to robotics is to develop comfort and familiarity
with the tools in order to have safe and efﬁcient procedures. In our
experience, there are multiple ways to obtain the skills necessary to
become a successful robotic surgeon. One way is to participate in a dry
(inanimate) lab session practicing suturing, and performing simple
dexterity skills with the robotic surgical system. Furthermore, it is
useful to participate in a formal porcine training lab in order to practice
handling tissue, tissue dissection, cautery, and tissue resection to
become proﬁcient with the instrumentation. However, this has proven
ﬁnancially impractical for multiple residents. Finally, console experi-
ence with simple hysterectomies and salpingo-oophorectomy are the
necessary predecessors to more complicated procedures. Thus far, at
UNC, attending surgeons have logged over 400 h on the console since
2005 and fellows have logged almost 200 console hours.
Teaching other physicians the use of the da Vinci surgical system
can take several forms. Traditionally, educating other physician on
surgical techniques involves direct case observation in the operating
room. Direct case observation can prove very useful for surgeons who
have never seen robotic surgery performed in a live setting. Intuitive
Surgical has promotional material in DVD format of both an
endometrial cancer staging operation and a radical hysterectomy
with pelvic lymphadenectomy for cervical cancer that were developed
by the senior author. Surgical symposia are another way to educate
other physicians and ancillary personnel about robotic surgery. In
2007, UNC hosted the ﬁrst International Gynecologic Oncology
Robotic Symposium (IGORS). During this conference, attendees had
the opportunity to see two live cases, hear a series of lectures on
robotic surgery, experience and technique, and participate in discus-
sion forums on previous experiences in robotics (difﬁcult cases,
complications, trouble-shooting tips etc.).
Concept of a minimally invasive surgical team
There are currently over 600 da Vinci surgical systems installed in
the United States; and over 900 systems around the world .Since
most gynecology robotics programs will be implemented at an
institution already performing Urology or General Surgery cases,
surgical teams familiar with the system typically already exist. There
are, however, differences in gynecology that need to be taught. In this
situation, the ﬁxed cost of the system can be justiﬁed and distributed
throughout the difference services and is determined according to the
number of cases performed in total by all services using the robot. As
previously mentioned, there is an up from cost through a capital
investment between $1,000,000 and $1,500,000 per da Vinci surgical
system in addition to the 10% annual maintenance fee for repair and
service. There are also periodic software upgrades that are required to
maintain the ﬂuid function of the system. At $200 per use, the
instruments also add a signiﬁcant cost to the individual procedure and
to the program as a whole. Furthermore, additional costs include drapes
for the actual system, robot speciﬁc ports (depend on type of system),
and any other accessories necessary for the particular case. There is the
cost of training personnel to set up the system; initially there may be
delays due to the novel nature of the process and may lead to additional
operating room duration and costs. Finally, there is the cost for
proctoring newly involved surgeons in a program . In the end, an
institution must view the system as an investment that requires
continued support by multiple services to ensure the program's success.
Strategies for building a robotic surgery team
Building a professional sports team requires money, a good head
coach, and talented players. The same can be said about starting a
robotic surgery program. Once the institution has decided to make the
initial investment in a system, the next key step is to ﬁnd a physician
or small group of physicians within the institution who will take
charge in building the program: a surgical champion. This individual
should not only have the training necessary to operate the robot, but
also the support of their respective departments. Often the start of a
robotic program is met with resistance because initially the cases may
take longer to complete, there may be high rates of conversion from
robotic to open surgery, or there may be a lack of support from the
operating room staff. Regardless, it is important for the robot program
leader to assemble a team that will feel invested in the program and
feel that the success of the program depends upon them. The robot
team should consist of individuals that are open to change, are willing
to learn a whole new instrument, and don't mind enduring the
growing pains of implementing a new system.
Several considerations are involved when selecting the route of
surgical intervention in patients with gynecologic malignancies.
Factors to consider when choosing a robotic surgical approach may
include disease type, extent of disease, preoperative imaging, stage,
patient age, body mass index, parity, size of lesion(s), and equipment
availability. There are currently no published guidelines on patient
selection as it relates to robotic surgery in gynecology. In general, our
institution has developed some general considerations when deter-
mining the use of robotics for patients with uterine or cervical cancer.
In the preoperative period, patients receive imaging studies such as
CT scans to assess for metastatic disease (as in the case of grade III or
atypical uterine cancer), or MRI (to assess for parametrial involve-
ment in the case of cervical cancer with large lesions). The size and
weight of the patient often plays a limited role in the decision to
proceed with robotic surgery. The main factor is the ability of the
patient to tolerate steep Trendelenberg, which is necessary to
complete the surgery. Patients with multiple (non-pulmonary) co-
morbidities need not be excluded from a robotic surgical approach if
anesthesia clears them.
Abbreviated clinical pathway for robotic surgery in gynecologic oncology
Endometrial cancer Cervical cancer
Bowel preparation Golytely
Preoperative Cefoxitin 2gm IV, no anticoagulant Same
Post operative laboratory Hemoglobin/hematocrit on POD 1 Same
Post-op diet Clear liquid when fully awake,
regular diet after 8 h
Analgesia Oral narcotics preferred PRN,
no standing order for IV narcotics
Ambulation Within 4 h Same
Catheter removal When able to ambulate if no
Can substitute magnesium citrate (POD= post operative day, PACU= post
anesthesia care unit).
S29A. Mendivil et al. / Gynecologic Oncology 114 (2009) S24–S31
Protocols, algorithms, clinical pathways
Clinical pathways are used to streamline and standardize post-
operative care. These pathways are prevalent in the general surgery
literature for MIS operations such as appendectomy, cholecystectomy,
and increasingly gastric bypass [31–33]. At UNC, our clinical pathway
since 2005 allows patients to quickly recover after anesthesia,
ambulate, eat, and be discharged from the hospital within 24 h
(Table 4). The clinical pathway was duplicated at Florida Hospital
with similar success. In both institutions this has led to more efﬁcient
utilization of hospital resources without compromising patient care.
Patients do not have a standing order for intravenous narcotics once
they leave the post anesthesia care unit (PACU). Patients requesting
intravenous pain medication are assessed by a physician then given
the appropriate medication to provide the appropriate analgesia. We
ﬁnd this is important since excessive and inappropriate pain after
minimally invasive surgery may potentially be a sign of an acute
Since 2005 there has been an increase in the published literature
describing outcomes for robotic surgery in gynecologic oncology.
Marchal et al. in 2005 ﬁrst described their experience with
hysterectomy, endometrial cancer staging, and radical hysterectomy
Piver type II for cervical cancer. They reported only one conversion to
laparotomy out of 30 cases; 17% post-operative complication rate, less
intra-operative bleeding, less pain, and a shorter hospital stay.
Reynolds has since echoed these outcomes as they reported on their
initial 7 cases. Post operative results demonstrated excellent lymph
node retrieval (average 15 lymph nodes), a blood loss of 50 mL, and a
median length of stay of 2 days and no conversions to laparotomy .
Sert and Abeler published the results on a series of 15 patients relating
to outcomes from robotic assisted radical hysterectomy compared to
laparoscopy. In their cohort, the robotic assisted group has less
operative times, less bleeding, and a shorter hospital stay compared to
traditional laparoscopy . Another paper dealing with outcomes
was from Kim et al. where they reported on 10 patients who
underwent robotic radical hysterectomy. The average estimated
blood loss for the 10 cases was 355 mL and their complication rate
was low . Magrina  and Fanning  have also reported their
outcomes with robotic radical hysterectomy. In both studies the
median case blood loss was less than 300 mL and the median lymph
count was 26 and 18 total pelvic lymph nodes, respectively. In the
current largest series by Boggess et al. , 51 patients underwent
robotic assisted radical hysterectomy with pelvic lymphadenectomy.
This cohort of patients had low median blood loss (97 mL), operative
time, and a high lymph node count. One of the most distinguishing
ﬁndings was that the median length of stay was 1 day in robotic cohort
compared to 3 days for the comparable open cohort.
Staging for endometrial cancer via robotic assistance is also gaining
acceptance. Laparoscopic surgical staging has generally led to lower
blood loss, less post-operative pain, and shorter length of stay. There
has been a single prospective randomized trial assessing the feasibility
of laparoscopy for endometrial cancer staging (Gynecologic Oncology
Group Lap-2). In this study of over 2000 women, the results showed
the procedure was feasible with an average hospital stay of 3 days and a
conversion rate of 23% . Since 2005 there have been reports
detailing the use of the robot for the staging of endometrial cancer. All
reports described shorter operative times, shorter length of stays, and
lower estimated blood loss [6,36]. To date, Boggess and colleagues have
reported on the largest cohort of patients undergoing robotic
endometrial cancer staging (see Table 2). The reported median
lymph node retrieval of 33 nodes was also the largest count achieved
to date. In their ﬁrst year's experience, the Florida Hospital group
reported a signiﬁcant reduction in peri-operative morbidity with the
initiation of robotic surgery compared to laparotomy . These studies
point the reproducibility and feasibility of the procedure.
The development of surgical robots is revolutionizing surgery in
gynecologic oncology just as it has done for urology and cardiothoracic
surgery. With improvements in operative times, decreased blood loss,
and decrease in length of stay after surgery, the robot has allowed
surgeons to perform more and more complex procedures, while
providing patients the beneﬁts of minimally invasive surgery. Endo-
metrial cancer staging and radical hysterectomy have emerged as the
most common gynecologic oncology procedures performed using
robotic assistance. Over 1000 systems have been installed worldwide
and the use of the robot continues to increase. Community based
practices and university based institutions are increasingly adopting the
use of the robot and its use continues to expand. In this review, we have
outlined templates for the successful initiation of a robotic surgery
program in both an academic and private setting, and have discussed
many facets of program development and surgeon training. Today,
robotic surgery has introduced precision, autonomy, ergonomics and
efﬁciency to minimally invasive surgery. Tomorrow, with development,
computers and robots will enhance our abilities beyond what can be
achieved or imagined today. It will be our responsibility as surgeons to
critically evaluate these new developmentsin the context of ourpatients
to ensure the best clinical outcomes.
Conﬂict of interest statement
Alberto Mendivil, MD has no conﬂict of interest to declare.
Robert W. Holloway, MD is a consultant for Intuitive Surgical.
John F. Boggess, MD is a consultant for Intuitive Surgical.
 Abaid LN, Boggess JF. Current applications of laparoscopy in gynecologic oncology:
a literature review. Women's Oncol Rev [Review] 2005;5(4):193–201.
 Naumann RW, Coleman RL. The use of adjuvant radiation therapy in early
endometrial cancer by members of the Society of Gynecologic Oncologists in 2005.
Gynecol Oncol 2007 Apr;105(1):7–12.
 Visco AG, Barber MD, Myers ER. Early physician experience with laparoscopically
assisted vaginal hysterectomy and rates of surgical complications and conversion
to laparotomy. Am J Obstet Gynecol 2002 Oct;187(4):1008–12.
 Boggess JF. Robotic surgery in gynecologic oncology: evolution of a new surgical
paradigm. J Robot Surg [review article] 2007 2/28/2007;1(1):31–7.
 Boggess JF, Gehrig PA, Cantrell L, Shafer A, Ridgway M, Skinner EN, et al. A
comparative study of 3 surgical methods for hysterectomy with staging for
endometrial cancer: robotic assistance, laparoscopy, laparotomy. Am J Obstet
Gynecol 2008 Oct;199(4):360 e1–9.
 Boggess JF, Gehrig PA, Cantrell L, Shafer A, Ridgway M, Skinner EN, et al. A case-
control study of robot-assisted type III radical hysterectomy with pelvic lymph
node dissection compared with open radical hysterectomy. Am J Obstet Gynecol.
2008 Oct;199(4):357 e1–7.
 Denardis SA, HollowayRW, Bigsby GEt, Pikaart DP, Ahmad S, Finkler NJ. Robotically
assisted laparoscopic hysterectomy versus total abdominal hysterectomy and
lymphadenectomy for endometrial cancer. Gynecol Oncol 2008 Dec 1.
 Kim Y T, Kim SW, Hyung WJ, Lee SJ, Nam EJ, Lee WJ. Robotic radical hysterectomy
with pelvic lymphadenectomy for cervical carcinoma: a pilot study. Gynecol Oncol
 Magrina JF, Kho RM, Weaver AL, Montero RP, Magtibay PM. Robotic radical
hysterectomy: comparison with laparoscopy and laparotomy. Gynecol Oncol 2008
 Payne TN, Dauterive FR. A comparison of total laparoscopic hysterectomy to
robotically assisted hysterectomy: surgical outcomes in a community practice. J
Minim Invasive Gynecol 2008 May–Jun;15(3):286–91.
 Shafer A, Boggess JF. Robotic-assisted endometrial cancer staging and radical
hysterectomy with the da Vinci surgical system. Gynecol Oncol 2008 Nov;111
 Veljovich DS, Paley PJ, Drescher CW, Everett EN, Shah C, Peters WA 3rd. Robotic
surgery in gynecologic oncology: program initiation and outcomes after the ﬁrst
year with comparison with laparotomy for endometrial cancer staging. Am J
Obstet Gynecol 2008 Jun;198(6):679 e1–9; discussion e9–10.
 Kwoh YS, Hou J, Jonckheere EA, Hayati S. A robot with improved absolute
positioning accuracy for CT guided stereotactic brain surgery. IEEE Trans Biomed
Eng 1988 Feb;35(2):153–60.
 Davies BL, Hibberd RD, Ng WS, Timoney AG, Wickham JE. The development of a
surgeon robot for prostatectomies. Proc Inst Mech Eng [H] 1991;205(1):35–8.
S30 A. Mendivil et al. / Gynecologic Oncology 114 (2009) S24–S31
 Harris SJ, Arambula-Cosio F, Mei Q, Hibberd RD, Davies BL, Wickham JE, et al. The
Probot–an active robot for prostate resection. Proc Inst Mech Eng [H] 1997;211
 Marescaux J, Leroy J, Gagner M, Rubino F, Mutter D, Vix M, et al. Transatlantic
robot-assisted telesurgery. Nature 2001 Sep 27;413(6854):379–80.
 Romano Jr JA, Lam DM, Moses GR, Gilbert GR, Marchessault Jr R. The future of
military medicine has not arrived yet, but we can see it from here. Telemed J E
Health 2006 Aug;12(4):417–25.
 Loulmet D, Carpentier A, d'Attellis N, Berrebi A, Cardon C, Ponzio O, et al.
Endoscopic coronary artery bypass grafting with the aid of robotic assisted
instruments. J Thorac Cardiovasc Surg 1999 Jul;118(1):4–10.
 Binder J, Kramer W. Robotically-assisted laparoscopic radical prostatectomy. BJU
Int 2001 Mar;87(4):408–10.
 Patel VR, Palmer KJ, Coughlin G, Samavedi S. Robot-assisted laparoscopic radical
prostatectomy: perioperative outcomes of 1500 cases. J Endourol 2008 Oct;22
 Advincula AP, Reynolds RK. The use of robot-assisted laparoscopic hysterectomy in
the patient with a scarred or obliterated anterior cul-de-sac. JSLS 2005 Jul–Sep;9
 Advincula AP, SongA, BurkeW, ReynoldsRK. Preliminary experience withrobot-assisted
laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 2004 Nov;11(4):511–8.
 Reynolds RK, Advincula AP. Robot-assisted laparoscopic hysterectomy: technique
and initial experience. Am J Surg 2006 Apr;191(4):555–60.
 Reynolds RK, BurkeWM, AdvinculaAP. Preliminary experience with robot-assisted
laparoscopic staging of gynecologic malignancies. JSLS 2005 Apr–Jun;9(2):149–58.
 Boggess JF. Robotic-assisted radical hysterectomy for cervical cancer: National
Library of Medicine Archives. 2006 [updated 20 06; cited 2008 11/08/2008];
Available from: http://www.nlm.nih.gov/medlineplus/surgeryvideos.html.
 Fanning J, Fenton B, Purohit M. Robotic radical hysterectomy. Am J Obstet Gynecol
2008 Jun;198(6):649 e1–4.
 Sert B, Abeler V. Robotic radical hysterectomy in early-stage cervical carcinoma
patients, comparing results with total laparoscopic radicalhysterectomy cases. The
future is now? Int J Med Robot 2007 Sep;3(3):224–8.
 Sert BM, Abeler VM. Robotic-assisted laparoscopic radical hysterectomy (Piver
type III) with pelvic node dissection—case report. Eur J Gynaecol Oncol 2006;27
 Koh CH. A new te chnique and system for simplif ying tot al laparoscopic
hysterectomy. J Am Assoc Gynecol Laparosc 1998 May;5(2):187–92.
 IntuitiveSurgical. Intuitive Surgical company proﬁle. Sunnyvale, CA; 2008 [updated
2008; cited 2008 September 29, 2008]; Available from: http://www.intuitivesurgi-
 Soria V, Pellicer E, Flores B, Carrasco M, Candel Maria F, Aguayo JL. Evaluation of
the clinical pathway for laparoscopic cholecystectomy. Am Surg 2005 Jan;71
 Almond SL, Roberts M, Joesbury V, Mon S, Smith J, Ledwidge N, et al. It is not what
you do, it is the way that you do it: impact of a care pathway for appendicitis. J
Pediatr Surg 2008 Feb;43(2):315–9.
 Campillo-Soto A, Martin-Lorenzo JG, Liron-Ruiz R, Torralba-Martinez JA, Bento-
Gerard M, Flores-Pastor B, et al. Evaluation of the clinical pathway for laparoscopic
bariatric surgery. Obes Surg 2008 Apr;18(4):395–400.
 Marchal F, Rauch P, Vandromme J, Laurent I, Lobontiu A, Ahcel B, et al.
Telerobotic-assisted laparoscopic hysterectomy for b enign and on cologic
pathologies: initial clinical experience with 30 patients. Surg Endosc 2005
 Walker J. Phase III trial of laparoscopy (scope) vs TAH (open) for surgical resection
and comprehensive surgical staging of uterine cancer: a Gynecologic Oncology
Group (GOG) study funded by NCI. Gynecol Oncol 20 06;101(1):S2–S11.
 Pikaart DP, Holloway RW, Ahmad S, Finkler NJ, Bigsby GEt, Ortiz BH, et al. Clinical-
pathologic and morbidity analyses of Types 2 and 3 abdominal radical
hysterectomy for cervical cancer. Gynecol Oncol 2007 Nov;107(2):205–10.
S31A. Mendivil et al. / Gynecologic Oncology 114 (2009) S24–S31