Robotic surgery: Still competing with laparoscopic surgery?

One of the most important improvements in minimally invasive gynecological surgery has been the introduction of robotic surgery.

Since robotic hysterectomy was first reported in 2002 [1]. Robotic surgery has a large share in most areas of gynecological surgery due to its many advantages such as learning curve and precision, and its use is accelerating [2,3]. There are many studies showing that robot is more advantageous than laparoscopic surgery in obese patients and patients with high surgical difficulty [4-6].

Robotic surgery also has some disadvantages. The biggest problems are longer surgical times and higher costs. [7-9] Of course, docking time can be reduced with a lot of experience, but the increase in cost has still not been resolved in many countries. For hysterectomy, the average cost of robotic surgery is 1.5 to 3 times higher than the average cost of laparoscopic surgery [10]. The purchase cost of robotic devices, maintenance costs, and consumable costs per case are the three main reasons for the increase in the cost of robotic procedures. However, it is believed that an increase in frequency of use and a decrease in equipment production costs may reduce the average cost in the long run.

There have been two debates related to robotic gynecologic surgery in Korea.

First, in many papers to date, most of the conclusions are that robotic surgery is better than laparoscopy when looking at surgical indicators, but that there is no significant difference. The conclusion of most papers was like “surgical outcomes of robotic and laparoscopic hysterectomy were comparable in terms of EBL, first gas discharge and hospital stay. Operation time was longer for robotic hysterectomy.” If so, some gynecological surgeons could wonder whether, considering the cost, they should recommend laparoscopic rather than robotic surgery to the patients, especially for very simple gynecological surgeries such as BSO. Even some patients are complaining that hospitals recommend robotic surgery to make money.

Second, it is a hybrid surgery that involves both robotic and laparoscopic surgery. For example, in the case of uterine myomectomy, the myoma is removed through laparoscopic surgery, and the uterine suture is performed by a robot. There are some desirable aspects of both surgeries in terms of taking advantage of both and minimizing their disadvantages. However, because the cost difference between the two surgeries is very large, there may be a tendency to prefer hybrid surgery even though laparoscopic surgery is possible. In particular, operators with little experience in robotic surgery tend to perform most surgeries laparoscopically and use robots to a minimum.

These debates come usually from unexperienced robotic surgeon. As experience with robotic surgery increases, surgeons’ eyes open to the many advantages of robots, and they confidently recommend robotic surgery to patients.

To solve these problems, the Korean Society of Robotic Gynecology Surgery (SKRGS) has developed and is implementing a proctoring system that matches the beginners and experts in robotic surgery and plans to introduce a robot certificate. Also, we plan to actively promote the benefits of robotic surgery to patients.

I hope all gynecologists who love robotic surgery can perform happy surgeries.