Journal of Surgical Oncology 2012;105:481–487 Robotic Surgery Applications in the Management of Gynecologic Malignancies WILLIAM J. LOWERY, MD, 1,3,4 CHARLES A. LEATH, MD, 1,3,4 AND RANDAL D. ROBINSON, MD 2,3,4 * 1 Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, San Antonio Military Medical Center, San Antonio, Texas 2 Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, San Antonio Military Medical Center, San Antonio, Texas 3 Brooke Army Medical Center, Fort Sam Houston, Texas 4 Wilford Hall Air Force Medical Center, Lackland AFB, Texas This review evaluates the use of robotic-assisted laparoscopic surgery in the treatment of gynecologic malignancies and objectively evaluates the use of these systems in performing radical hysterectomies and surgical staging of gynecologic malignancies. The review focuses on surgical length, blood loss, complications, recovery time, and adequacy of surgical staging of robotic-assisted surgery compared to abdominal and non-robotically assisted laparoscopic surgery for malignancies. J. Surg. Oncol. 2012;105:481–487. Published 2012. This article is a U.S. Government work and is in the public domain in the USA. KEY WORDS: gynecologic cancer; robotic surgery; laparoscopy; surgical techniques BACKGROUND A surgical robot is a computer-controlled system that can be pro- grammed to assist the surgeon in the utilization and manipulation of surgical instruments. The desire to perform procedures laparoscopi- cally, which were historically performed via laparotomy, led to the development of a robotic system specifically designed to facilitate a minimally invasive approach to surgical procedures. This system was initially planned for implementation by the military to provide im- mediate surgical capability on the battlefield for a surgeon located at a site remote from the injured service member (telesurgery) [1]. Over time the emphasis on robotic surgery progressed to the operat- ing room where a robotic system was designed to facilitate laparo- scopic surgical procedures. The first robotic-assisted gynecologic surgery was performed in 1998 [2]. Immersive, telerobotic technolo- gy became commercially available in 2000 and was marketed as the daVinci surgical system (Intuitive Surgical, Sunnyvale, CA). This system permits the surgeon to operate from a console that is remote from the operative table. The surgeon views the operative field with a binocular device with images electronically transmitted to the sur- geon’s console from the laparoscope inserted into the patient. A three-dimensional view of the operative field is provided with the stereoscopic, binocular viewer. The surgeon controls the movement of the robotic arms and laparoscopic ports and instruments from the console using movements of the hand controls and foot pedals locat- ed within the console. The surgeon is able to perform traditional laparoscopic procedures to include: grasping, cutting, manipulating tissues, dissecting, cutting, suturing, and coagulating. Because of the seven degrees of freedom permitted with the wristed instruments with the robotic system, surgical procedures are performed similar to the way they are accomplished during laparotomy. The robotic instruments provide improved dexterity and eliminate hand tremor permitting finer, delicate procedures to be accomplished compared to traditional laparoscopy [1]. Urologic surgeons rapidly implemented the use of the daVinci robotic system to perform prostatectomy. Food and Drug Administration approval for the use of daVinci system in gynecolog- ic surgery was granted in 2005. The primary advantages of robot assisted gynecologic, laparoscopic surgery are improvements in visu- alization, improved functional capability of the robotic instruments and improved ergonomics for the surgeon. There are limitations to telerobotic-assisted surgery. Among these are increased cost and operating time, lack of tactile feedback to the surgeon, additional surgical training required to become proficient on the system, large operating room size (secondary to the size of the robotic system), instrumentation limitations, and risk of mechanical failure intraoper- atively [3]. Recently robotic assistance for laparoscopic surgery has been utilized for the treatment of gynecologic malignancies [4]. Currently only minimal outcome data examining the use of robotic surgery in the treatment of gynecologic malignancies is available. The purpose of this review is to evaluate the use of robotic- assisted laparoscopic surgery in the treatment of gynecologic malig- nancies. This review presents the current status of this new technolo- gy in the treatment of gynecologic cancers and future directions for robotic systems in the treatment of these malignancies. A MEDLINE literature search of papers written in English from January 1976 to April 2010, using the keywords ‘‘gynecologic cancer,’’ ‘‘robotic sur- gery’’, ‘‘laparoscopy,’’ and ‘‘surgical techniques’’ formed the basis for the literature review. We objectively evaluate the use of these systems in performing radical hysterectomies and surgical staging of gynecologic malignan- cies. This review specifically focuses on surgical length, blood loss, *Correspondence to: Randal D. Robinson, MD, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Texas Health Science Center-San Antonio, 7703 Floyd Curl Drive, MSC 7836, San Antonio, TX 78229-3901. Fax No.: 210-567- 4958. E-mail: robinsonr3@uthscsa.edu Received 23 May 2011; Accepted 3 August 2011 DOI 10.1002/jso.22080 Published online in Wiley Online Library (wileyonlinelibrary.com). Published 2012 Wiley Periodicals, Inc.