Javascript is currently disabled in your browser. When javascript is disabled, some functions of this website will not work.

Open access for scientific and medical research

Open access to peer-reviewed scientific and medical journals.

Dove Medical Press is a member of OAI.

Batch reprints for the pharmaceutical industry.

We provide authors with real benefits, including fast processing of papers.

Register your specific details and specific drugs of interest, and we will match the information you provide with articles in our extensive database and send you a PDF copy via email in a timely manner.

Back to Journal »Robotic Surgery: Research and Review» Volume 4

Author Arian SE, Munoz JL, Kim S, Falcone T

Published on January 23, 2017 2017 Volume: 4 pages 7-18

DOI https://doi.org/10.2147/RSRR.S102743

Single anonymous peer review

Editor approved for publication: Dr. Masoud Azodi

Sara E Arian, Jessian L Munoz, Suejin Kim, Tommaso Falcone, Institute of Obstetrics and Gynecology and Women’s Health, Cleveland Clinic, Cleveland, Ohio, USA Abstract: Robot-assisted surgery has been rapidly developed and integrated in the field of gynecology. Since the approval of the use of robots for gynecological surgery Considering its several advantages compared with traditional laparoscopic surgery, it has been widely adopted, especially in the field of reproductive surgery. Uterine fibroids are the most common benign tumors of the female reproductive tract. Many women of childbearing age with this disease require uterine-preserving surgery to maintain fertility. Hysteromyomectomy is the surgical removal of uterine fibroids, and it is still the only surgical treatment option for uterine fibroids, which needs to preserve fertility. In this review, we focused on the role and status of robot-assisted laparoscopic myomectomy and its current status, compared with other alternative methods of myomectomy (including laparotomy, hysteroscopy and traditional laparoscopic techniques). For comparison. Robotic myomectomy has demonstrated several different surgical techniques. This review is dedicated to sharing and describing our experience in robotic-assisted hysteromyomectomy using standard laparoscopic equipment and the Da Vinci robotic system. For ideal surgical candidates, robot-assisted hysteromyomectomy is a safe and minimally invasive surgery that can be used as an alternative to open surgery. Compared with open myomectomy, the advantages of using a robotic system include shorter hospital stay, less postoperative pain and analgesics, faster return to normal activities, faster recovery of bowel function, and due to skin incisions. Smaller and improved cosmetic results. Some of the disadvantages of this technology include the high cost of robotic surgery systems and equipment, the steep learning curve of this new system, and extended surgery and anesthesia time. Robotic technology is a novel and innovative minimally invasive method, which is feasible in gynecological and reproductive surgery. This technology is expected to take a leading position in the field of gynecological surgery in the next ten years. Keywords: myomectomy, myomectomy, robotic surgery, robot-assisted laparoscopic myomectomy

In 2000, Falcone et al. first reported the use of robots in gynecological surgery. Such as sacral vaginal fixation and lymph node dissection. 2 Robotic surgery is easily accepted in the education of gynecological tumor surgery. A survey in 2010 showed that 95% of gynecological oncology scholarships plan to use robots for surgery, and 94% of graduates plan to perform robotic surgery in their future careers. 3 Compared with laparotomy, robot-assisted surgery provides many of the same postoperative advantages of traditional minimally invasive laparoscopic surgery. These advantages include smaller incisions, minimal blood loss, lower infection rates, less postoperative pain and shorter hospital stays. 4 The advantage of robotic surgery over traditional laparoscopic surgery lies in the engineering design of the robotic system, which allows greater wrist mobility, thereby allowing the surgeon to perform more complex tasks, such as delicate tissue anatomy and internal knotting. 5,6

The application of robots in benign gynecology

Hysterectomy is still the most common major gynecological surgery. Over time, various methods of hysterectomy have emerged, including open abdominal (TAH), vagina (TVH), laparoscopy (TLH), robot-assisted (RA-TLH) and hybrid laparoscopic assisted vaginal hysterectomy (LAVH). Over time, the trend is to avoid open surgery and shift the focus to minimally invasive methods. In a 2004 position statement, the American Association of Gynecological Laparoscopic Physicians (AAGL) stated that hysterectomy (for benign diseases) should be performed through vaginal or minimally invasive techniques whenever possible. 7

Despite the steep learning curve, the performance of robot-assisted laparoscopic hysterectomy (RA-TLH) has become very common in benign diseases. Wright and colleagues evaluated the trend of RA-TLH nationwide and noticed that the incidence of RA-TLH increased 19-fold over a 4-year period. 8 In addition, these authors pointed out that despite the shorter hospital stay and lower postoperative blood transfusion rate, the overall cost of RA-TLH is still higher than that of TLH. It is also noted that the operation time of RA-TLH is longer. The 2014 Cochrane evaluation also concluded that RA-TLH is comparable to TLH in terms of blood loss and safety, but the total cost of surgery has increased significantly. 9

Endometriosis resection is one of the most difficult laparoscopic procedures. This is mainly due to the inherent nature of the disease, leading to significant scars, distortion of anatomical structures, loss of surgical planes and immobility of pelvic organs. 10 Robot-assisted and better visualization are designed to improve the effectiveness of surgical resection of this complex. However, the current data does not support this claim. In a direct comparison between robot-assisted laparoscopy and traditional laparoscopy (especially for endometriosis), Nezhat et al. found no significant differences in blood loss, conversion rate, complications, and length of stay between the two techniques . The only difference noticed is that the average operation time associated with the robotic method is longer. 11 Since the overall results of robot-assisted and traditional laparoscopic surgery seem to be the same, the biggest advantage lies in the complexity of the robot-assisted cases. With the assistance of the robot system, deep infiltration involving the rectum, sigmoid colon and extensive ureteral dissolution can be achieved. Removal of endometriosis. 12 Studies have shown that with the assistance of robots, these operations can be performed safely and effectively. In addition, Neme et al. not only demonstrated the feasibility and safety of the robotic system, but also reported the subsequent fertility of 4 out of 10 patients in these series. 12

Permanent sterilization of women through fallopian tube ligation is still a common method of contraception. The fallopian tube re-anastomosis is traditionally performed by laparotomy, and the success rate in fertility and the risk of ectopic pregnancy vary. 13 In view of the overall advantages of postoperative care, the laparoscopic technique of tubal re-anastomosis has now developed into a viable option. The difficulty of laparoscopic surgery lies in the microsurgical technique and the need for precision and meticulousness, which leads to a steep learning curve.

Since robot assistance allows better control, visualization, and movement, research has been conducted to evaluate the feasibility and effectiveness of robotic methods for tubal reanastomosis. Rodgers et al. compared the robotic method with mini-laparotomy. 14 Again, it is noted that the operation time is longer and the cost of the robotic method is estimated to be higher, but the time to restore full function is much shorter than that of the mini laparotomy. 1 week in advance). In addition, Patel et al. compared the robotic fallopian tube reanastomosis with the laparotomy method in their study. 15 The conclusion of this study is that although the robotic surgery time is longer, the average hospital stay is significantly shorter (4 hours vs 35 hours), making the robotic approach feasible and comparable in terms of cost. The pregnancy rates of the two techniques are also similar (28% vs. 30%), and the average time from sterilization to reversal is 8.5 years (robot: 8.1 years, open: 7.8 years, P=0.23).

Uterine leiomyomas, also called uterine fibroids, are the most common benign gynecological tumors during the reproductive period, with prevalence ranging from 5.4% to 77%. 16 It is considered to be a benign overgrowth of the myometrium, which mainly includes smooth muscle cells and fibrous tissue, wrapped in a pseudo-capsule rich in collagen. Different types of uterine fibroids include intracavity, submucosal, intramural, subserosal, and pedicle fibroids. Although uterine fibroids may be asymptomatic, patients usually report pelvic pain, excessive menstrual blood loss, stress symptoms (including changes in urination and bowel habits), and infertility during or outside the menstrual cycle. Therefore, uterine fibroids are the most common indication for hysterectomy in the United States, which has a huge impact on health care costs and quality of life. 16,17

Treatment options for fibroids include drugs and surgical methods. Drug therapy includes non-hormonal therapies, such as non-steroidal anti-inflammatory drugs and tranexamic acid, and hormonal therapies, including oral contraceptives, gonadotropin (GnRH) analogs, progesterone intrauterine birth control system, and selective estrogen therapy. Body regulators, anti-progestin drugs, selective progesterone receptor modulators, androgens and aromatase inhibitors. 17,18 Non-hormonal therapies are mainly used to treat bleeding symptoms. Some hormonal therapies are designed to temporarily reduce the size of fibroids; however, these options can also be used as an adjunct to surgical treatment, as well as those who are about to enter menopause and wish to avoid surgical intervention People. 17-19 Surgical methods for the treatment of uterine fibroids include uterine artery embolization, uterine myomectomy and hysterectomy. Uterine artery embolism seems to be effective in relieving symptoms; however, there are complications with the procedure, including possible impaired ovarian blood supply and impaired fertility, as well as possible adverse obstetric results including premature birth. Approximately 15%–32% of these patients will require further surgical intervention within 2 years after surgery, and 35% will undergo hysterectomy within 10 years. 20,21 For patients trying to become pregnant, it is usually recommended to consider removing submucosal fibroids because they have a negative impact on fertility. Intramural fibroids that twist the uterine cavity or larger intramural fibroids larger than 4 cm may have a negative impact on fertility even if the uterine cavity is not twisted, so it should be considered to be removed. 22,23 Hysterectomy is the final surgical treatment for uterine fibroids; however, hysterectomy should be considered before hysterectomy to reduce postoperative morbidity and in cases where fertility needs to be preserved. 20

Abdominal myomectomy, also called open myomectomy, when the uterus is significantly enlarged, usually above the umbilical level, and/or multiple fibroids are present, abdominal myomectomy may be considered . However, the surgical method of hysteromyomectomy should be highly individualized, taking into account other factors, such as previous surgical history and patient comorbidities. 24 Some of the advantages of abdominal myomectomy include no limitation on the size and number of fibroids to be removed, the ability to palpate and completely remove all fibroids, and the ease of open surgery technique, depending on the surgeon’s experience And skills. 25 If feasible, abdominal myomectomy uses a suprapubic transverse incision; however, depending on the case and the size of the uterus, a vertical incision may be required for access. 25 The uterus was initially exposed with or without myoma screws. 25-27 The contents of the abdomen are equipped with sponges and retractors used for laparotomy. Several methods have been proposed to reduce intraoperative blood loss; among them, the use of tourniquets to physically block blood flow, uterine and ovarian artery ligation, and uterine artery embolization before uterine myomectomy may be helpful for some patients. 25 According to a study by Taylor et al., a tourniquet at the level of the cervix and bilateral pelvic funnel ligaments was used. This technology has been shown to be associated with a significant reduction in blood loss and blood transfusion rates. 28 Before performing the actual removal of fibroids to improve surgical blood loss, consider combining this technique with vasopressin injection. 29 After the tourniquet is fixed, vasopressin diluted in saline is injected into the myometrium around the fibroids to reduce intraoperative blood loss through vasoconstriction. 25-27 Make a small incision in the area that covers most of the fibroids, avoiding the corners and fallopian tube orifices to minimize uterine damage, and to avoid post-uterine incisions as much as possible to reduce the risk of adhesion formation. If possible, usually try to remove multiple fibroids through this single incision. 26,27 After the fibroids are identified, the fibroids should be removed using fibroids or single-tooth needle traction, and Metzenbaum scissors or electrocautery should be used as needed. 30 Excessive traction on the fibroids bed must be avoided, but the myometrium and endometrial fibroids are pushed down and away to prevent the endometrial cavity from rupturing. The blood vessels are usually located at the bottom of the fibroids and should be avoided if possible. The defect should be closed from the deepest layer to get hemostasis, and all muscle tissues should be included to achieve optimal tissue healing and remodeling. The myometrium can be re-sutured into multiple layers in a simple intermittent or continuous manner with the use of No. 0 or No. 1 absorbable polyglactin sutures. After the dead space is completely closed, the serosal layer can be closed subcutaneously with 3-0 or 4-0 delayed absorbable sutures or poliglecaprone sutures, and then the knot is buried. It is worth noting that excellent hemostasis must be performed throughout the operation and the serosal layer must be kept moist to ensure the formation of minimal adhesions. Free omentum grafts can also be used to help prevent adhesions.

When a single intramural or serosal fibroids are ≤15 cm in size or ≤3 fibroids are less than 5 cm in diameter, laparoscopic myomectomy can be considered. However, this surgical approach depends on the expertise of the surgeon and may also be suitable for patients with fibroids greater than 20 cm in diameter. 31 According to a study by Sinha et al., for experienced surgeons, the number does not seem to limit the size, size, and location of fibroids for laparoscopic myomectomy. 32

The first step is to place the uterine manipulator 33. Then a trocar was inserted according to the size and location of the fibroids found in the imaging studies and physical examination before the actual operation. A supraumbilical skin incision can be made between the xiphoid process and the belly button, also known as the Lee-Huang point, or at the Palmer point, to suit the entry site. The auxiliary trocar can be placed on the suprapubic position outside the blood vessels of the lower abdominal wall. Like an abdominal myomectomy, vasopressin can be injected into the myometrium surrounding the myoma using a laparoscopic needle. Then a monopolar hook is used to create a vertical uterine incision to the pseudocapsule under high cutting current to help suture. Depending on the location and size of the fibroids, it can be an oval or lateral incision. The exposed fibroids are then removed by pulling and grasping the fibroids with grasping forceps or by using a drill and placing a reverse traction on the uterine manipulator and/or pulling the edges of the hysterectomy incision. The unipolar hook can be used to dissect the attachment of the pseudocapsule. After the fibroids are removed, the uterine cavity must be inspected for any damage to its integrity. If it has entered the cavity, a 3-0 polyglactin suture should be used to re-approach the endometrium. 31 Then start stitching or continuous stitching from the deepest myometrium, just like the abdominal method. Here, the use of barbed sutures may have a great advantage, by eliminating the need for laparoscopic sutures to properly distribute the tension and possibly shorten the operation time. The specimen can be placed in a bag for in-bag crushing, or it can be removed through a small incision, usually less than 4 cm. 34 It is worth noting that these incisions may be associated with more postoperative pain, and compared with laparoscopic methods without similar skin incisions, the blood loss is increased and the hospital stay is longer.

Comparison of Open and Minimally Invasive Hysteromyomectomy

Multiple studies have compared the surgical results of different uterine myomectomy procedures. Holzer et al. investigated postoperative pain within 72 hours after surgery in a double-blind prospective trial comparing laparoscopic and abdominal myomectomy, and the results favored the laparoscopic group. 35 Cicinelli et al. conducted a prospective randomized study comparing laparoscopic myomectomy with microlaparotomy for the removal of 1 to 3 fibroids <7 cm, and laparoscopic myomectomy The myomectomy group showed better results in terms of length of stay, blood loss, and postoperative intestinal obstruction, without increasing the operation time. 36 In a meta-analysis comparing laparoscopic and open myomectomy, it was noted that laparoscopic methods were associated with less blood loss, less blood transfusion requirements, less postoperative pain, and shorter hospital stay. However, some people have noticed that laparoscopic surgery takes longer operation time, which is thought to be due to the learning curve that surgeons must go through with this method. 37 A recent retrospective study of open myomectomy and laparoscopic myomectomy from Taiwan showed that blood loss was reduced, and the blood transfusion rate and operation time were shorter in the laparoscopic myomectomy group; however, the cost of surgery Slightly higher. 38,39 In a Cochrane review by Bhave et al., comparing open and minimally invasive hysteromyomectomy, it was noted that the two groups had inconsistent postoperative pain results at 48 hours and 72 hours after surgery. According to reports, this may be due to the inclusion of micro-laparotomy incisions in some laparoscopic surgery studies. 40 Compared with open surgery, the incidence of postoperative fever and blood loss during laparoscopic surgery are less common. 40

Open myomectomy can be compared not only with laparoscopy, but also with robotic myomectomy. Bakarat et al. retrospectively compared abdominal myomectomy with laparoscopic and robotic myomectomy. 41 In this study, it was noted that compared with the laparoscopic group, the fibroids in the open group and the robotic group were significantly larger. According to reports, compared with the open group, the operation time of the robot group was longer, and no difference was observed between the robot group and the laparoscopic group or between the laparoscopic group and the open group. Note that the blood loss in the open group was more significant, and no differences were found between the robotic and laparoscopic methods. Compared with the open approach, the robot group had a shorter hospital stay, which made up for the longer operation time. In a recent meta-analysis of robotic and laparoscopic and open hysteromyomectomy, compared with minimally invasive methods, open surgery has a shorter operation time (95% confidence interval [CI]: 60.41-109.29) ), there is no difference between the two methods. The minimally invasive method has less blood loss, and there is no difference between robotic and laparoscopic techniques (42.10 ml/time; 95% CI: 1.28-85.48). The open group had a higher blood transfusion rate (981 patients, odds ratio [OR], 0.20; 95% CI: 0.09-0.43), and longer hospital stays (95% CI: 1.40-2.29). Differences were observed in the other two groups ( 870 patients, OR: 1.13; 95% CI: 0.42-3.07 blood transfusion, 0.04 days/patient; 95% CI: 0.09-0.18 length of stay). Finally, there is no difference in postoperative pain levels between robotic surgery and open surgery. 42 In another study of approximately 40 cases in each group, robotic surgery and laparoscopic surgery were compared, and no differences were observed in short-term surgical results (including surgical time) 43 A small study by Nezhat et al. 15 cases of robotic surgery and 35 cases of laparoscopic surgery were also compared, and the results showed that the surgery time of the robotic group was longer; however, there were no differences between the two methods in terms of blood loss, length of hospital stay, and postoperative complications. 44 These results should be considered when choosing the best route for hysteromyomectomy, and the final decision should be based on individual circumstances. Every patient.

Indications, patient selection and preoperative preparation

Robot-assisted hysteromyomectomy is a common reproductive surgery. As mentioned earlier, in order to be able to determine the most appropriate surgical treatment of uterine fibroids, it is essential to master the principles of anatomical factors. Some of the key factors include fibroids size, extent, number, location, and distance from the uterine cavity. 45 The selection of ideal surgical candidates for robotic hysteromyomectomy is an important initial step in uterine fibroids surgery planning. Therefore, as mentioned earlier, the choice of robotic methods and other surgical paths for hysteromyomectomy should vary from person to person and based on the appropriate patient selection. Personal medical and surgical history are also factors that should be considered. Other principles that must be considered before choosing a surgical method for hysterectomy include the surgeon’s level of training and experience, as well as the availability and cost of surgical equipment. Generally speaking, the most suitable candidates for robotic surgery are subserosal, intramural, fundus or pedicle fibroids. 45 Some women may not be considered suitable candidates for robotic myomectomy. These include patients with uterine enlargement> 16 weeks, patients with more than 5 fibroids in the uterus, and uterine fibroids in anatomically challenging locations, such as the broad ligament, cervix, uterine horn, or Uterine blood vessels. When a single uterine fibroids are present, robotic uterine fibroids may not be suitable, and their size is >15 cm. 40,46 In addition, fibroids in the immediate vicinity of the endometrial cavity or fibroids with submucosal components may not be suitable for robotic surgery. Removal of these fibroids can be more challenging and is associated with a higher rate of entry into the endometrial cavity. Due to the lack of tactile feedback, the use of robots to close the cavity defects may be more complicated. 47 It is important to note that robotic hysterectomy can be attempted in these situations, as long as the patient is made aware that switching to open can expect a higher surgical rate. The general conversion rate from robot-assisted hysterectomy to open surgery is approximately 11.3%. 48 This ratio is similar to the conversion rate of laparoscopic myomectomy. The conversion rate may also vary based on the surgeon’s experience and patient choices. Therefore, the maximum size and number of uterine fibroids suitable for robot-assisted laparoscopic myomectomy must be personalized according to the professional knowledge, training and comfort of each surgeon.

Once the surgical technique is selected as robot-assisted hysterectomy, the same pre-operative preparations as open, laparoscopic and hysteroscopic surgery will be implemented. If the candidate for surgery is anemia, consider using a GnRH releasing hormone agonist for pretreatment to resolve the anemia and help reduce the size of the uterus or fibroids. 49 In our practice, we also consider preoperative magnetic resonance imaging (MRI) hysterectomy candidates for all patients to describe the size of the uterus and the number, size and exact location of uterine fibroids. MRI also helps to distinguish between uterine fibroids and adenomyosis, and is highly specific for the diagnosis of adenomyosis. 50 The preoperative diagnosis of adenomyosis is extremely important because it affects the entire surgical method. Therefore, in our practice, MRI is also performed when adenomyosis is suspected or the diagnosis is unclear.

Surgical techniques of robotic hysteromyomectomy

Various changes in the surgical technique of robotic hysteromyomectomy have been described. In this section, we will discuss the techniques commonly used in our institution for robotic-assisted hysteromyomectomy.

We use standard laparoscopic equipment for our robot-assisted hysterectomy, as well as the da Vinci Robot system and patient-side robots, vision carts, and robotic operator consoles. The patient's position is similar to the dorsal lithotomy position of traditional laparoscopic surgery, with the arms clamped on both sides in a neutral position. Although some people recommend using the maximum Trendelenburg position routinely in robotic surgery, we usually only use as many Trendelenburg positions as needed, and the patient can tolerate the surgery. Once the patient is prepared and lined up like a traditional gynecological laparoscopy, the uterine manipulator is inserted into the uterus. The manipulator is placed to optimize the exposure of the myomectomy and to provide a method of dripping the dye into the uterus to identify and avoid the rupture of the endometrial cavity during the operation. Chromopertubation using a uterine manipulator can also confirm that the fallopian tube is unobstructed. We usually use RUMI (CooperSurgical) as the uterine manipulator. Once the manipulator is firmly inserted into the uterus, a urinary catheter is placed to drain the bladder. We usually start with traditional laparoscopy to confirm that there are no contraindications to the use of robots. In view of the recent controversy regarding the use of electric pulverizers, we initially started with the placement of GelPoint on the pubic bone. About 2 cm above the pubic symphysis, a small lateral skin incision 3-4 cm low will be made and proceed down to the subfascia. Then cut the fascia at the midline and extend it bilaterally. After separating the fascia from the rectus muscle, enter the abdominal cavity in the usual way, insert the GelPoint and inflate the abdomen. This suprapubic incision is not large and will not interfere with the patient's beauty, because it is made within the natural hairline. As with any minimally invasive technique, the placement of the trocar is important in order to avoid contact between the robotic arms. Then place the laparoscopic trocar as follows:

Before inserting each trocar, 0.25% bupivacaine was injected subcutaneously. Initially, a small 5 mm incision was made in the subumbilical skin with a scalpel, and then an umbilical cord trocar was placed. This 5 mm trocar was originally used for laparoscopy and to ensure that the operation can be performed by a robot. Then use an optical trocar to enter the abdominal cavity. After a thorough investigation of the abdominal and pelvic cavities and confirmation that the robotic method is appropriate, we then enlarged the 5mm trocar to 12mm, which can be used to place the robotic camera. Next, two 8mm robotic trocars are placed at an angle of about 15° with the umbilical cord port and 8-12 cm laterally to accommodate the robotic arm without difficulty. In the case of large uterine fibroids, the port can be placed closer to the head. Then, we usually place a 5mm accessory port in the upper left quadrant of the Palmer point. Through this port, 5 mm laparoscopic hook clamp can be used to help remove leiomyomas. All these ports are placed under direct visualization. GelPoint is used both to pass through the needle and to extract tissue at the end of the case. If the patient does not want a suprapubic incision, the left upper abdominal accessory port can be used to pass and handle the needle, and at the end of the case, the GelPoint can be placed in the larger umbilical cord incision for tissue extraction. After placing the trocar, we “docked over” the Da Vinci robot to provide the assistant with more space for uterine operations. As mentioned earlier, the patient will be placed in Trendelenburg and performed under tolerable conditions. The robot can be placed between each stirrup, between the patient's legs, or on the patient's side. According to our experience, a third robotic arm is rarely needed, so we chose not to use it. Once all the mechanical arms are docked, the mechanical cameras and instruments will be inserted into the corresponding trocars. Our preferred instruments include hand-held forceps, Harmonic device, Maryland bipolar forceps connected to the cautery, and two needle drivers. Then, we proceed to the actual surgery as described below.

Before the hysterectomy, we used a diluted vasopressin solution (20 units of vasopressin in 200 ml of normal saline) for serous injections. This solution is injected into the serosal membrane and the myometrium surrounding the fibroids. The laparoscopic needle tip device is connected to a syringe containing dilute vasopressin for injection. If the injection is in the correct plane, the uterus will start to turn white. Vasopressin is rarely associated with serious cardiopulmonary complications, including bradycardia, hypertension, and cardiac arrest, and should be used with caution even in healthy individuals. 51-54 Therefore, the use of vasopressin pressure in individuals with coronary artery disease or high blood pressure must be avoided to prevent potentially fatal complications. Some other drugs that have been successfully described in the literature to reduce blood loss during myomectomy include preoperative misoprostol, bupivacaine and epinephrine, tranexamic acid, and the use of uterine tourniquets. 55 According to reports, other technical losses that can help reduce blood loss include temporary or permanent ligation of the uterine artery before myomectomy. Temporary occlusion of the uterine artery can be achieved by using a catheter, an elastic tourniquet or a rubber clip wrapped around the uterine artery. After the injection of vasopressin, the Harmonic device can be used to perform a hysterectomy through the serosa and myometrium until the fibroids are reached and opened. Compared with the use of electrosurgery and epinephrine, the use of a harmonic scalpel in a randomized controlled trial showed a reduction in operation time and blood loss. 56 If possible, we prefer to perform the hysterectomy horizontally to facilitate sutures. With the robot's advantage in providing easier operation of instruments than traditional laparoscopy, hysterectomy and suture can also be performed in a vertical manner (Figure 1). Before performing a hysterectomy, pay attention to the exact positions of the fallopian tubes, ovaries, uterine horns, and uterine blood vessels to stay away from these important anatomical landmarks. Throughout the hysterectomy, a Maryland bipolar electrocautery can be used to maintain hemostasis (Figure 2). However, excessive coagulation may compromise the integrity of the myometrium and make the closure of the hysterectomy more difficult. Some hemostatic agents commonly used in our practice are Surgiflo (Ethicon Inc.) and Floseal (Baxter, Deerfield IL, USA). These are gelatin products infused with thrombin and can be directly applied to the bleeding area. 57 After entering the fibroids envelope and exposing the fibroids, the robotic tentacles are placed on the fibroids and blunt dissection is used to remove the nucleus. Use harmonic energy as needed (Figures 3 and 4). Care should be taken to avoid applying additional traction to the fibroids, because avulsion fibroids may cause the endometrial cavity to rupture, which ultimately affects fertility. Preserving the endometrial cavity is extremely important for reproductive surgeons, especially when the end point of fibroids surgery is to preserve fertility. Chromopertubation with diluted methylene blue can be used to confirm the integrity of the endometrial cavity throughout the procedure. Pedicled fibroids are removed in a similar manner. However, vasopressin is injected directly into the stem of the fibroids. The LigaSure device (Covidien) is then preferably used to transect the myoma stem. Deep intramural fibroids and fibroids located in the broad ligament are difficult to perform robotic surgery and require meticulous laparoscopic suture techniques. Advanced knowledge of pelvic anatomy is required when performing operations on these fibroids, because the uterine blood vessels and ureters can run around them. After removing all fibroids, the surgical team should record the total to avoid leaving any specimens in the abdomen after the case is over. Small fibroids sometimes move toward the head or roll behind the liver or under the loops of the intestine, so their number must be tracked. The next step is to close the hysterectomy. The advantages of robotic surgery are simple suture and fast speed, which is very important for limiting blood loss during surgery. We usually prefer to use barbed sutures, such as Covidien's V-Loc™ or Angiotech's Quill™ SRS, which is the same as traditional laparoscopy. The advantage of this kind of suture is that there is no need for the surgeon to tie the knot with this kind of suture, so the uterine incision can be closed faster. The barbs also help distribute tension along the entire length of the suture without applying constant tension during the suture, thus helping to maintain hemostasis. Previous studies have shown that the use of barbed sutures during laparoscopic myomectomy can shorten the suture time and reduce intraoperative bleeding. 58 Another study by Einarsson et al. reported that compared with laparoscopic myomectomy, the use of barbed sutures for laparoscopic myomectomy can significantly shorten the operation time and shorten the length of hospital stay. Traditional suture. 59 In view of all the advantages of the barbed suture in the literature, we considered using this suture to close the uterine defect. The robotic closed hysterectomy is similar to an open myomectomy and must be performed in multiple layers. When transforming open surgery technology into robotic surgery, adequate myometrial closure is an important issue that needs to be considered. Perform a deep closure to close the dead space, and then place an additional suture layer to re-approach the myometrial tissue and provide additional strength and hemostasis. After re-approaching the myometrium, 2-0 or 3-0 absorbable monofilament polydioxanone sutures are then used to close the serosal layer in a continuous manner. All these sutures can be introduced and passed using GelPoint. As mentioned earlier, hemostatic agents can be used in the exudative area.

Figure 1 Hysterectomy using the Harmonic device horizontally through the serosa and myometrium.

Note: Photo courtesy of Dr. Tommaso Falcone from the Institute of Obstetrics and Gynecology and Women's Health, Cleveland Clinic, Cleveland, Ohio, USA.

Figure 2 The Maryland bipolar electrocautery device can be used to achieve hemostasis while performing a hysterectomy.

Note: Photo courtesy of Dr. Tommaso Falcone from the Institute of Obstetrics and Gynecology and Women's Health, Cleveland Clinic, Cleveland, Ohio, USA.

Figure 3 Place robotic tentacles on fibroids to help remove fibroids.

Note: Photo courtesy of Dr. Tommaso Falcone from the Institute of Obstetrics and Gynecology and Women's Health, Cleveland Clinic, Cleveland, Ohio, USA.

Figure 4 Using blunt anatomy with the help of robotic tentacles combined with harmonic energy for fibroidectomy.

Note: Photo courtesy of Dr. Tommaso Falcone from the Institute of Obstetrics and Gynecology and Women's Health, Cleveland Clinic, Cleveland, Ohio, USA.

In the past, electric pulverizers were often used for tissue removal at the end of myomectomy. However, the U.S. Food and Drug Administration has suspended power or electromechanical smashing for hysterectomy and myomectomy. This is mainly due to the potential risk of spreading malignant tumors in the case of occult uterine cancer. Leiomyosarcoma is the most aggressive undiagnosed malignant tumor of the uterus with a poor prognosis, with approximately 1 in 1,000 women suffering from presumed benign uterine fibroids. Due to this risk, we completely avoided any power comminution by using the suprapubic GelPoint device instead of tissue extraction. However, it is important to note that AAGL emphasizes that there are currently insufficient data to advise against aggressive smashing in correctly selected patients with low risk of uterine or cervical malignancies or precancerous lesions. Therefore, it is necessary to properly evaluate surgical candidates before surgery to determine whether they can choose to use dynamic comminuted surgery. 60,61

After all uterine fibroids are completely removed, they are brought to the level of the suprapubic incision in the GelPoint, and they are completely extracted or crushed outside the body using a scalpel. 60,61 There is no evidence to support the use of these techniques to affect the prognosis of leiomyosarcoma. After removing and extracting all fibroids, the robot can be disengaged from the docking. After unlocking each arm from each trocar, the robot can be pulled away from the patient. The trocar was then removed under direct vision, and the Carter-Thomason device (CooperSurgical) was used to close the fascia below the umbilical cord port. Then the skin is closed and the procedure ends.

The principles of postoperative management after robotic myomectomy are similar to those of laparoscopic myomectomy. Early activity and pain control are basic goals. Patients can be discharged from the hospital on the day of surgery or later the next day. Depending on the extent of the surgical procedure, the destruction of the myometrium, and access to the endometrial cavity, the surgeon should talk to the patient about obstetric recommendations and the potential needs of future cesarean sections. These recommendations should also be recorded in the surgeon’s surgical report for future review by the obstetrician. The potential increased risk of uterine rupture should also be discussed.

Robotic myomectomy is considered to be a safe, minimally invasive alternative to open myomectomy for appropriately selected surgical candidates. Compared with abdominal myomectomy, it is associated with a shorter hospital stay. The beauty has also been improved due to smaller skin incisions, less use of analgesics, faster return to normal activities and faster recovery of intestinal function. 62 However, considering all equipment costs, the cost of using this surgical technique is higher. Due to its minimally invasive nature, robotic myomectomy has very few complications. According to our experience, compared with traditional laparoscopic myomectomy and abdominal myomectomy, robotic myomectomy involves less blood loss. 41 One advantage of robotic hysteromyomectomy is that it can be safely performed in patients with different body mass indexes, and obesity does not necessarily affect the outcome of the surgery. 63 In addition, robotic surgery can be performed without the steep Trendelenburg position, which may not be ideal in some patients. 64

Compared with other types of myomectomy, especially abdominal myomectomy, robotic myomectomy is generally associated with many desirable results. A significant advantage of robotics is the opportunity to perform minimally invasive surgery on patients who would otherwise require traditional laparotomy for hysterectomy. 47 This advantage is due to the fact that robots provide surgeons with the ability to open up surgical techniques in a minimally invasive manner. As mentioned earlier, and from the experience of our center, compared with other surgical techniques, robotic hysteromyomectomy can reduce blood loss and hospital stay, although it increases surgical time and surgical costs. 41

From a reproductive perspective, studies have shown that patients undergoing robotic hysteromyomectomy have favorable reproductive outcomes and high pregnancy rates. The 65-68 robot can provide surgeons with dexterity to achieve gentler tissue dissection and processing, which is conducive to reproductive results.

Some other benefits of using surgical robots in gynecological surgery include the 3D image of the surgical area provided by the surgical console, ease of suture, improved and precise suture processing, and the ability of robotic endoscopic instruments to mimic the dexterity of human hands and provide a larger range Motion and depth perception to improve surgical accuracy, as well as motion zoom to eliminate tremor. Compared with complicated cases of laparoscopic and laparotomy, the autonomous control of cameras and instruments reduces surgical fatigue, which may require the surgeon to twist his or her body in different positions over a long period of time. 69 Robotic hysteromyomectomy also provides better cosmetic results and is related to the aforementioned improvement in postoperative pain results.

The long-term endpoints of robotic myomectomy, including myoma recurrence, quality of life results, and obstetric results are still lacking, and additional data are needed. These data are very important for determining the ultimate value and efficacy of robotic surgery.

The Da Vinci system is not without its own limitations. Some of the major constraints include the cost of surgical systems and specialized equipment, the need for personnel training, the learning curve associated with learning new surgical techniques, and the extended operating time. There is also a lack of tactile feedback during the operation, which may cause the suture to break or exert excessive traction on the fibroids, leading to rupture and damage to the endometrial cavity, which is a negative consequence. Port placement in robotic surgery is another limitation because the ports are larger than typical traditional laparoscopic ports and they are placed higher in the abdomen. If needed, this higher port placement will make the conversion of the robot to laparoscopic myomectomy more challenging. The use of robotic systems is also limited due to their size. Any position change requires the robot to be detached and re-docked, which will result in more operation time. 62 These aspects will have a major impact on the cost-effectiveness of robotic surgery.

The field of robotic surgery has made significant progress in the past decade, and its application in gynecological surgery is becoming more and more common. According to reports, gynecological surgeries accounted for approximately 60% of the total number of robotic surgeries in 2013. 70 With the continuous development of robotics technology, it is expected that additional revisions, technological advancements and rapid expansion of the system will be made. Some of these potential future directions include the use of smaller robotic equipment, measures to reduce the setup and operation time required for robots, including assisted docking, the introduction of single-incision surgery, and the ability to use robotic systems for remote surgery. These potential directions can provide a series of clinical research opportunities in the field of robotic surgery. Additional prospective studies are needed to provide further information about the long-term endpoints after robotic surgery and the cost-effectiveness of this surgical technique.

The authors report no conflicts of interest in this article.

Falcone T, Goldberg JM, Margossian H, Stevens L. Robot-assisted laparoscopic microtubal anastomosis: a human experimental study. Fertilize. 2000;73(5):1040–1042.

Tan SJ, Lin CK, Fu PT, etc. Robotic Surgery for Complex Gynecological Diseases: Experiences from the General Hospital of Taiwan’s Armed Forces. Taiwan J Obstet Gynecol. 2012;51(1):18-25.

Sfakianos GP, Frederick PJ, Kendrick JE, Straughn JM, Kilgore LC, Huh WK. Robotic surgery in the American Gynecological Oncology Scholarship Program: A survey of researchers and scholarship leaders. Int J Med robot. 2010;6(4):405–412.

Chiu LH, Chen CH, Tu PC, Chang CW, Yen YK, Liu WM. Comparison of robotic surgery and laparoscopic surgery for pelvic adhesions or total hysterectomy. J Minimal access surgery. 2015;11(1):87–93.

Palep JH. [Not available]. J Minimal access surgery. 2009;5(1):1-7.

Nguan C, Girvan A, Luke PP. Robotic surgery and laparoscopic surgery; comparison between two robotic systems and laparoscopy. J Robot Surgery. 2008;1(4):263–268.

Sinha R, Sanjay M, Rupa B, Kumari S. Gynecological robotic surgery. J Minimal access surgery. 2015;11(1):50–59.

Wright JD, Herzog TJ, Tsui J, Ananth CV, Lewin SN, Lu YS, Neugut AI, Hershman DL. National trends in inpatient hysterectomy in the United States. Obstetrics and Gynecology. 2013;122(2 Pt 1):233-241.

Liu H, Lawrie TA, Lu D, Song H, Wang L, Shi G. Robot-assisted surgery in gynecology. Cochrane database system revision 2014; (12): CD011422.

Bloski T, Pierson R. Endometriosis and chronic pelvic pain: uncovering the mystery behind this complex disease. Nurse women's health. 2008;12(5):382–395.

Nezhat C, Lewis M, Kotikela S, etc. Robot and standard laparoscopic surgery to treat endometriosis. Fertilize. 2010;94(7):2758-2760.

Neme RM, Schraibman V, Okazaki S, etc. Robot-assisted rectosigmoid colectomy for the treatment of deep invasive colorectal endometriosis. JSLS. 2013;17(2):227–234.

Sotrel G. Is the surgical repair of the fallopian tube appropriate? Rev Obstet Gynecol. 2009; 2(3): 176–185.

Rodgers AK, Goldberg JM, Hammel JP, Falcone T. Comparison of robotic tubal anastomosis and outpatient mini-laparotomy. Obstetrics and Gynecology. 2007;109(6):1375–1380.

Dharia Patel SP, Steinkampf MP, Whitten SJ, Malizia BA. Robotic tubal anastomosis: surgical technique and cost-effectiveness. Fertilize. 2008;90(4):1175–1179.

Sparic R, Mirkovic L, Malvasi A, Tinelli A. The epidemiology of uterine fibroids: a review. Int J Fertil Steril. 2016; 9(4): 424–435.

Drayer SM, Catherino WH. The prevalence, incidence and current medical management of uterine fibroids. Int J Gynaecol Obstet. 2015;131(2):117-122.

Kashani BN, Centini G, Morelli SS, Weiss G, Petraglia F. The effect of medical management on uterine leiomyomas. Best Pract Res Clin Obstet Gynaecol. 2016;34:85-103.

Gurusamy KS, Vaughan J, Fraser IS, Best LM, Richards T. Drug treatment of uterine fibroids-a systematic review of randomized controlled trials and a network meta-analysis. Public Science Library One. 2016;11(2):e0149631.

Donnez J, Dolmans MM. Uterine fibroids management: from now to the future. The hum reappears and updates. 2016;22(6):665–686.

de Bruijn AM, Ankum WM, Reekers JA, etc. Uterine artery embolization and hysterectomy for symptomatic uterine fibroids: 10-year results of the randomized EMMY trial. I’m J Obstet Gynecol. 2016;215(6):745e1–745e12.

Zepiridis LI, Grimbizis GF, Tarlatzis BC. Infertility and uterine fibroids. Best Pract Res Clin Obstet Gynaecol. 2016;34:66-73.

The American Society of Reproductive Medicine Practice Committee cooperates with the Society of Reproductive Surgeons. Fibroids and reproductive function. Fertilize. 2008; 90 (5 supplements): S125–S130.

Ciavattini A, Tsiroglou D, Litta P, Frizzo H, Tranquilli AL. Ultra-mini open hysterectomy: a minimally invasive surgical method for the treatment of large uterine fibroids. Gynecol Obstet investment. 2009;68(2):127–133.

Mukhopadhaya N, De Silva C, Manyonda IT. Routine hysteromyomectomy. Best Pract Res Clin Obstet Gynaecol. 2008;22(4):677–705.

McElvin M, Lee TC. Hysteromyomectomy: an overview of surgical techniques. Hum Fertil (Camb). 2005;8(1):27–33.

Wong LF, Gleeson N. Hysteromyomectomy: The suture technique of open surgery. J Obstet Gynaecol. 2013;33(2):197-198.

Taylor A, Sharma M, Tsirkas P, Di Spiezio Sardo A, Setchell M, Magos A. The use of triple tourniquets to reduce blood loss during open myomectomy: a randomized controlled trial. Beijing Olympics. 2005;112(3):340–345.

Conforti A, Mollo A, Alviggi C, etc. Techniques for reducing blood loss during open myomectomy: a qualitative review of the literature. Eur J Obstet Gynecol Reprod Biol. 2015; 192: 90-95.

Guarnaccia MM, Rein MS. Traditional surgical methods for uterine fibroids: abdominal uterine fibroids resection and hysterectomy. Clinical Obstetrics and Gynecology. 2001;44(2):385–400.

Sammy Walid M, Heaton RL. The role of laparoscopic myomectomy in the treatment of uterine fibroids. Curr Opin Obstet Gynecol. 2011;23(4):273–277.

Sinha R, Hegde A, Mahajan C, Dubey N, Sundaram M. Laparoscopic myomectomy: Does the size, number and location of myoma constitute the limiting factors of laparoscopic myomectomy? J minimally invasive gynecology. 2008;15(3):292–300.

Mattei A, Cioni R, Bargelli G, Scarselli G. Techniques of laparoscopic myomectomy. Reprod Biomed Online. 2011;23(1):34-39.

Chitawa PB, Ms. Camas. Review of non-surgical/minimally invasive treatment of uterine fibroids and open uterine fibroids resection. Curr Opin Obstet Gynecol. 2015;27(6):391–397.

Holzer A, Jirecek ST, Illievich UM, Huber J, Wenzl RJ. Laparoscopic and open myomectomy: a double-blind study to assess postoperative pain. Anesthesia analysis. 2006;102(5):1480–1484.

Cicinelli E, Tinelli R, Colabiglio G, Saliani N. Laparoscopy and minimally invasive surgery in women with symptomatic uterine fibroids: a prospective randomized study. J minimally invasive gynecology. 2009;16(4):422–426.

Jin C, Hu Y, Chen XC, et al. Laparoscopic and open myomectomy—a meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol. 2009;145(1):14-21.

Chang CC, Chen W. Comparison of surgical results of laparoscopic and open hysteromyomectomy in southern Taiwan. Int J Gynaecol Obstet. 2012;119(2):189-193.

Zhang CC. Cost comparison of laparoscopic myomectomy and open myomectomy in a teaching hospital in southern Taiwan. Taiwan J Obstet Gynecol. 2013;52(2):227-232.

Bhave Chittawar P, Franik S, Pouwer AW, Farquhar C. Comparison of minimally invasive surgical techniques and open myomectomy for uterine fibroids. Cochrane database system revision 2014; (10): CD004638.

Iavazzo C, Mamais I, Gkegkes ID. Robot-assisted and laparoscopic and/or open myomectomy: a systematic review and meta-analysis of clinical evidence. Arch Gynecol Obstet. 2016;294(1):5-17.

Bedient CE, Magrina JF, Noble BN, Kho RM. Comparison of robotic and laparoscopic myomectomy. I’m J Obstet Gynecol. 2009;201(6):566.e1-e5.

Nezhat C, Lavie O, Hsu S, Watson J, Barnett O, Lemyre M. Robot-assisted laparoscopic myomectomy compared with standard laparoscopic myomectomy—a retrospective matched controlled study. Fertilize. 2009;91(2):556–559.

Soto E, Flyckt R, Falcone T. Endoscopic treatment of uterine fibroids: update. Minerva Ginecol. 2012; 64(6): 507-520.

Seracchioli R, Rossi S, Govoni F, etc. Fertility and obstetric results after laparoscopic large myomectomy: a random comparison with abdominal myomectomy. Hum reappeared. 2000;15(12):2663-2668.

Soto E, Flyckt R, Falcone T. Minimally invasive hysteromyomectomy using unidirectional knotless barbed sutures. J minimally invasive gynecology. 2014;21(1):27.

Dubuisson JB, Fauconnier A, Fourchotte V, Babaki-Fard K, Coste J, Chapron C. Laparoscopic myomectomy: predict the risk of switching to open surgery. Hum reappeared. 2001;16(8):1726-1731.

Crosignani PG, Vercellini P, Meschìa M, Oldani S, Bramante T. GnRH agonist before uterine leiomyoma surgery. review. J Reprod Med. 1996;41(6):415-421.

Moghadam R, Lathi RB, Shahmohamady B, etc. The predictive value of magnetic resonance imaging in distinguishing leiomyoma from adenomyosis. JSLS. 2006;10(2):216-219.

Tulandi T, Béique F, Kimia M. Pulmonary edema: a complication of laparoscopic local injection of vasopressin. Fertilize. 1996;66(3):478-480.

Hobo R, Netsu S, Koyasu Y, Ttsutsumi O. Bradycardia and cardiac arrest caused by intramuscular injection of vasopressin during laparoscopic-assisted hysterectomy. Obstetrics and Gynecology. 2009;113(2 Pt 2):484–486.

Hung MH, Wang YM, Chia YY, Chou YM, Liu K. Intramuscular injection of vasopressin caused bradycardia and cardiac arrest—a report of two cases. Taiwan Journal of Anesthesiology. 2006;44(4):243-247.

Nezhat F, Admon D, Nezhat CH, Dicorpo JE, Nezhat C. Life-threatening hypotension after injecting vasopressin during laparoscopic surgery, followed by smooth repetition of laparoscopy. J Am Assoc Gynecol Laparosc. 1994;2(1):83-86.

Kongnyuy EJ, Wiysonge CS. Interventions to reduce bleeding during myomectomy. Cochrane database system revision 2014; (8): CD005355.

Litta P, Fantinato S, Calonaci F, etc. A randomized controlled study comparing harmonics and electrosurgery in laparoscopic myomectomy. Fertilize. 2010;94(5):1882–1886.

Raga F, Sanz-Cortes M, Bonilla F, Casañ EM, Bonilla-Musoles F. Use gelatin-thrombin matrix hemostatic sealant to reduce blood loss during myomectomy. Fertilize. 2009;92(1):356–360.

Alessandri F, Remorgida V, Venturini PL, Ferrero S. One-way barbed suture and continuous suture with internal knots in laparoscopic myomectomy: a randomized study. J minimally invasive gynecology. 2010;17(6):725-729.

Einarsson JI, Chavan NR, Suzuki Y, Jonsdottir G, Vellinga TT, Greenberg JA. The use of bidirectional barbed sutures in laparoscopic myomectomy: evaluation of perioperative outcome, safety and effectiveness. J minimally invasive gynecology. 2011;18(1):92-95.

Brown J. AAGL promotes minimally invasive gynecology globally: a statement to the FDA on power crushing. J minimally invasive gynecology. 2014;21(6):970–971.

AAGL promotes minimally invasive gynecology globally. AAGL Practice Report: Fragmentation in the extraction process of uterine tissue. J minimally invasive gynecology. 2014;21(4):517–530.

Catenacci M, Flyckt RL, Falcone T. Reproductive surgery robots: advantages and limitations. placenta. 2011; 32 (Supplement 3): S232–S237.

Barakat EE, Bedaiwy MA, Zimberg S, Nutter B, Nosseir M, Falcone T. Robot-assisted, laparoscopic and abdominal myomectomy: comparison of surgical results. Obstetrics and Gynecology. 2011;117(2 Pt 1):256-265.

George A, Eisenstein D, Wegienka G. Analyze the influence of body mass index on the surgical results after robot-assisted laparoscopic myomectomy. J minimally invasive gynecology. 2009;16(6):730–733.

Ghomi A, Kramer C, Askari R, Chavan NR, Einarsson JI. Trendelenburg's position in gynecological robot-assisted surgery. J minimally invasive gynecology. 2012;19(4):485–489.

Lönnerfors C, Persson J. Robot-assisted laparoscopic myomectomy: a feasible technique to remove unfavorable local myomas. Acta Obstet Gynecol Scand. 2009;88(9):994–999.

Bocca S, Stadtmauer L, Oehninger S. Da Vinci assisted uncomplicated term pregnancy after laparoscopic myomectomy. Reprod Biomed Online. 2007;14(2):246-249.

Cela V, Freschi L, Simi G, etc. Fertility and endocrine results after robot-assisted laparoscopic myomectomy (RALM). Gynecological endocrinology. 2013;29(1):79-82.

Lönnerfors C, Persson J. Robot-assisted laparoscopic myomectomy for pregnancy in women with deep intramural fibroids. Acta Obstet Gynecol Scand. 2011;90(9):972-977.

Hickman LC, Kotlyar A, Luu TH, Falcone T. Do we need robots in endometriosis surgery? Minerva Ginecol. 2016;68(3):380–387.

Xie Y. Cost-effectiveness of robotic surgery for gynecological tumors. Curr Opin Obstet Gynecol. 2015;27(1):73-76.

This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and include the Creative Commons Attribution-Non-commercial (unported, v3.0) license. By accessing the work, you hereby accept the terms. The use of the work for non-commercial purposes is permitted without any further permission from Dove Medical Press Limited, provided that the work has an appropriate attribution. For permission to use this work for commercial purposes, please refer to paragraphs 4.2 and 5 of our terms.

Contact Us• Privacy Policy• Associations and Partners• Testimonials• Terms and Conditions• Recommend this site• Top

Contact Us• Privacy Policy

© Copyright 2021 • Dove Press Ltd • Software development of maffey.com • Web design of Adhesion

The views expressed in all articles published here are those of specific authors and do not necessarily reflect the views of Dove Medical Press Ltd or any of its employees.

Dove Medical Press is part of Taylor & Francis Group, the academic publishing department of Informa PLC. Copyright 2017 Informa PLC. all rights reserved. This website is owned and operated by Informa PLC ("Informa"), and its registered office address is 5 Howick Place, London SW1P 1WG. Registered in England and Wales. Number 3099067. UK VAT group: GB 365 4626 36

In order to provide our website visitors and registered users with services that suit their personal preferences, we use cookies to analyze visitor traffic and personalize content. You can understand our use of cookies by reading our privacy policy. We also retain data about visitors and registered users for internal purposes and to share information with our business partners. By reading our privacy policy, you can understand what data we retain, how we process it, who we share it with, and your right to delete data.

If you agree to our use of cookies and the content of our privacy policy, please click "Accept".