Robotic surgery; into the era of common place

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Since the past few decades, robot-assisted laparoscopy becomes an advancement of traditional laparoscopy and allows more complex procedures in many fields of surgery through main advantages including improved visualization by three-dimensional view, better ergonomics, no tremor, and shorter learning curves. Although the evidence from large-scaled randomized controlled trials in gynecology are lacking, gynecologic robot-assisted laparoscopy has shown exponential growth and has been progressively implemented as the standard procedure in various gynecologic field [1]. Recently, the US Food and Drug Administration cautioned against the use of robotic surgery in cancer operations, stating that “survival benefits to patients when compared to traditional surgery have not been established” after phase III Laparoscopic Approach to Cervical Cancer (LACC) trial. This phase III trial was designed for the definitive comparison of survival outcomes of radical hysterectomy in patients with early stage cervical cancer between minimally invasive surgery (MIS) and open procedure. This trial demonstrated that MIS is associated with lower rates of disease-free survival and overall survival than open procedure [2]. The findings of this LACC trial are consistent with those of a retrospective study based on the data from the Surveillance, Epidemiology, and End Results (SEER) program database of National Cancer Database (NCDB) for the year of 2000–2010 period [3]. Even though underlying mechanism that causes the poorer outcome of MIS in cervical cancer has yet to be identified, the collective findings have largely halted MIS for cervical cancer. Therefore, several societies announced position statement for MIS in cervical cancer. Korean Society of Gynecologic Oncology (KSGO), one of representative society in Korea, stated that all cervical cancer patients scheduled to undergo radical hysterectomy should be informed about the results of the LACC trial together with institutional data before choosing MIS. Furthermore, KSGO emphasized that establishment of optimal indication for MIS based on the tumor size and surgical methods to minimize tumor destruction or intraperitoneal spillage during colpotomy is required to ensure the oncologic safety of MIS in cervical cancer [4]. On the other hand, a recent systematic review showed that robotic hysterectomy may be a generally safer and better option than open or laparoscopic hysterectomy for patients with endometrial cancer [5]. Another meta-analysis compared robotic and laparoscopic hysterectomy concluded that there was no significant difference in the duration of surgery and the blood loss, the total complication rate and conversions to laparotomy were less in the robotic hysterectomy [6]. Unfortunately, however, very limited data are available regarding oncologic outcomes. One retrospecRobotic surgery; into the era of common place