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Study Objective To assess whether a robotic simulation curriculum for novice surgeons can improve performance of a suturing task in a live porcine model. Design Randomized controlled trial (Canadian Task Force classification I). Setting Academic medical center. Patients Thirty-five medical students without robotic surgical experience. Interventions Participants were enrolled in an online session of training modules followed by an in-person orientation. Baseline performance testing on the Mimic Technologies da Vinci Surgical Simulator (dVSS) was also performed. Participants were then randomly assigned to the completion of 4 dVSS training tasks (camera clutching 1, suture sponge 1 and 2, and tubes) versus no further training. The intervention group performed each dVSS task until proficiency or up to 10 times. A final suturing task was performed on a live porcine model, which was video recorded and blindly assessed by experienced surgeons. The primary outcomes were Global Evaluative Assessment of Robotic Skills (GEARS) scores and task time. The study had 90% power to detect a mean difference of 3 points on the GEARS scale, assuming a standard deviation (SD) of 2.65, and 80% power to detect a mean difference of 3 minutes, assuming an SD of 3 minutes. Measurements and Main Results There were no differences in demographics and baseline skills between the 2 groups. No significant differences in task time in minutes or GEARS scores were seen for the final suturing task between the intervention and control groups, respectively (9.2 [2.65] vs 9.9 [2.07] minutes, p = .406; and 15.37 [2.51] vs 15.25 [3.38], p = .603). The 95% confidence interval for the difference in mean task times was –2.36 to .96 minutes and for mean GEARS scores −1.91 to 2.15 points. Conclusions Live suturing task performance was not improved with a proficiency-based virtual reality simulation suturing curriculum compared with standard orientation to the da Vinci robotic console in a group of novice surgeons.

Objective To compare the efficacy of simulation-based training between the Mimic dV- Trainer and traditional dry lab da Vinci robot training. Design A prospective randomized study analyzing the performance of 20 robotics-naive participants. Participants were enrolled in an online da Vinci Intuitive Surgical didactic training module, followed by training in use of the da Vinci standard surgical robot. Spatial ability tests were performed as well. Participants were randomly assigned to 1 of 2 training conditions: performance of 3 Fundamentals of Laparoscopic Surgery dry lab tasks using the da Vinci or performance of 4 dV-Trainer tasks. Participants in both groups performed all tasks to empirically establish proficiency criterion. Participants then performed the transfer task, a cystotomy closure using the daVinci robot on a live animal (swine) model. The performance of robotic tasks was blindly assessed by a panel of experienced surgeons using objective tracking data and using the validated Global Evaluative Assessment of Robotic Surgery (GEARS), a structured assessment tool. Results No statistically significant difference in surgeon performance was found between the 2 training conditions, dV-Trainer and da Vinci robot. Analysis of a 95% confidence interval for the difference in means (−0.803 to 0.543) indicated that the 2 methods are unlikely to differ to an extent that would be clinically meaningful. Conclusion Based on the results of this study, a curriculum on the dV- Trainer was shown to be comparable to traditional da Vinci robot training. Therefore, we have identified that training on a virtual reality system may be an alternative to live animal training for future robotic surgeons.

Study Objective To analyze the learning curve of intracorporeal cuff suturing during robotic single-site total hysterectomy. Design Retrospective study (Canadian Task Force classification II-1). Setting University hospital. Patients Twenty-four patients with benign indications for hysterectomy. Interventions Twenty-four patients who underwent robotic single-site total hysterectomy to treat benign indications were included in the study. Surgical procedures were performed by a single surgeon with extensive experience in laparoscopy, using the single-site platform of the da Vinci Surgical System. All vaginal cuffs were closed intracorporeally using semi-rigid single-site instruments. Measurements and Main Results An exponential learning curve technique was used to analyze the learning curve. The overall mean (SD) vaginal cuff closure time was 23.2 (7) minutes. Learning curve analysis revealed a decrease in vaginal closure time after 14 procedures. Conclusions An experienced robotic surgeon requires approximately 14 procedures to achieve proficiency in intracorporeal cuff suturing during robotic single-site total hysterectomy. Novel instruments that create perfect triangulation are needed to overcome the current challenges of suturing and to shorten operative time.

Study Objective To present our initial experience with reduced-port robotic surgery (RPRS) for myomectomy using the Octo-Port system (DalimSurgNet, Seoul, Korea). Design Prospective and noncomparative study (Canadian Task Force classification II-3). Setting University hospital. Patients Nineteen consecutive patients with symptomatic uterine myomas desiring conservative minimally invasive robotic surgery from October 2015 to December 2016. Interventions An 8.5-mm or 12-mm robotic camera cannula was inserted through 1 of the Octo-Port channels and an 8-mm conventional robotic port was inserted into a 10-mm channel of the Octo-Port through a 3-cm transumbilical incision. An additional 8-mm conventional robotic port was inserted into a typical robotic port site in the patient's right abdomen. Measurements and Main Results Feasibility and operative outcomes of RPRS myomectomy. The median docking time and console time were 10 minutes (range, 4–22) and 90 minutes (range, 29–198). The largest myoma was located on the anterior uterine wall in 11 patients (57.9%). The median myoma size and weight were 7.2 cm (range, 4.1–10.5) and 141 g (range, 42–590), respectively. Median operative blood loss and change in hemoglobin were 100 mL (range, 30–700) and 2.6 mg/dL (range, .1–3.8), respectively. The procedure was successfully performed via RPRS in 89.5% of patients; 2 patients required placement of 1 to 2 additional robotic ports, resulting in a return to traditional multiport robotic surgery. There were no major postoperative complications or postoperative hernias. Conclusion Our experience demonstrated the feasibility of RPRS for myomectomy using the Octo-Port system in selected patients.

To compare gynecologic practice and perioperative outcomes of patients undergoing total laparoscopic hysterectomy and robotic hysterectomy before and after implementation of a robotics program.A retrospective chart review of the last 200 consecutive hysterectomy cases completed before and after implementation of a robotics program (Canadian Task Force classification III).Community hospital.All patients requiring hysterectomy for benign indications between November 2004 and January 2007.Patients were candidates for total laparoscopic, abdominal, or vaginal hysterectomy before February 2006 and were candidates for total laparoscopic, total abdominal, total vaginal, or robotic-assisted laparoscopic hysterectomy after February 2006. Perioperative characteristics and trends were studied.In all, 100 patients intended to be treated by laparoscopic hysterectomy before the implementation of a robotics program were compared with 100 patients treated by robotic hysterectomy after robot implementation. Overall the robotic cohort experienced longer operative times by an average of 27 minutes. The prerobotic cohort, however, when compared with the last 25 robotic cases had longer operative times (92.4 minutes [29.2], 95% CI 46.0-225.0 vs 78.7 minutes [29.5], 95% CI 66.0-91.2, p = .03). The mean blood loss in the prerobotic cohort was twice that of the robotic cohort (113 mL [85.9], 95% CI 95.9-130.1 vs 61.1 mL [60.9], 95% CI 48.9-73.2, p.0001) and the mean length of hospital stay was half a day longer in the prerobotic cohort than in the robotic cohort (1.6 days [1.4], 95% CI 1.3-1.9 vs 1.1 days [0.7], 95% CI 1.0-1.3, p.007). The incidence of adverse events was the same in both groups. The total number of exploratory laparotomies in the prerobotic cohort was significantly greater than in the robotic group (11% vs 0%). The rate of intraoperative conversions to total abdominal hysterectomy from laparoscopy was approximately 2-fold higher in the prerobotic cohort as compared with the robotic cohort (9% vs 4%).A higher likelihood of exploratory laparotomy for hysterectomy in the prerobotic cohort versus the robotic cohort and a higher likelihood of intraoperative conversion to laparotomy with the prerobotic cohort than with the robotic cohort existed. Reduced operative time, reduced blood loss, and shortened length of stay may be achieved in patients who are treated robotically versus a nonrobotic approach. Robotics may facilitate the minimally invasive treatment of patients while potentially reducing the rate of abdominal hysterectomies.

Study Objective To measure and compare levels of extremely-low-frequency magnetic field (ELF-MF) exposure to surgeons during laparoscopic and robotic gynecologic surgeries. Design Prospective case-control study. Design Classification Canadian Task Force I. Setting Gynecologic surgeries at the Yonsei University Health System in Seoul, Korea from July to October in 2014. Patients Ten laparoscopic gynecologic surgeries and 10 robotic gynecologic surgeries. Intervention The intensity of ELF-MF exposure to surgeons was measured every 4 seconds during 10 laparoscopic gynecologic surgeries and 10 robotic gynecologic surgeries using portable ELF-MF measuring devices with logging capability. Measurement and Main Results The mean ELF-MF exposures were .1 ± .1 mG for laparoscopic gynecologic surgeries and .3 ± .1 mG for robotic gynecologic surgeries. ELF-MF exposure levels to surgeons during robotic gynecologic surgery were significantly higher than those during laparoscopic gynecologic surgery (p Conclusion The present study demonstrated low levels of ELF-MF exposure to surgeons during robotic gynecologic surgery and conventional laparoscopic surgery, hoping to alleviate concerns regarding the hazards of MF exposure posed to surgeons and hospital staff.

To evaluate the adverse events encountered during robotic gynecologic surgery, as reported to the FDA MAUDE database from January 2006 to December 2012.Database search (Canadian Task Force classification III).A search of the FDA MAUDE database was performed by brand name "da Vinci" and manufacturer "Intuitive Surgical." Reports reflecting gynecologic procedures either by description or procedure name were included. A record of reports was kept to ensure that no duplicates were added. The date and type of event (operator-related error, technical system failure, or surgical injuries attributed to use of the robot) and the clinical outcome were recorded.Twenty-six percent of reported events (n = 73) resulted in injury, and 8.5% (n = 24) resulted in death. Of note, although adnexal procedures were performed in3% of the cohort, they accounted for 20% of the fatalities. Twenty-one percent of injuries were attributed to operator-related error, and 14% to technical system failure; 65% were not directly related to use of the robot. Fifteen deaths were reported during planned hysterectomy. Four of those were due to injury to a major blood vessel (iliac artery in 3, and aorta in 1), although a detailed description of how the injury occurred was absent from the event description.It is important to continue to evaluate the occurrence of injuries during robot-assisted surgery in an effort to identify unique challenges associated with this advanced technology.

A protocol was established to standardize surgical training using the da Vinci Surgical System. Third- and fourth-year residents and first-year fellows in obstetrics and gynecology participated. The protocol includes online instruction and 2 hands-on modules: platform set-up and surgical skills. Platform set-up provides orientation to the console, visual platform, surgical cart ("robot"), camera set-up, port placement, and instrument insertion and removal. Surgical skills includes specific drills using rubber models that simulate human tissue: manipulation, dissection, and simple and advanced suturing. Performance times were recorded for each trainee, as well as previous robotic experience. Times were compared with goals established by Intuitive Surgical, Inc., to assess feasibility of this protocol and baseline robotic surgical aptitude. All trainees (n = 17) completed the training protocol. Performance times met goals for docking and dissection. These times also varied according to level of training. Performance times for manipulation and simple and advanced suturing were prolonged across all groups. Overall pass rates were 100% for docking, 90% for dissection, 11.8% for manipulation, and 0% for simple and advanced suturing. Dissection pass rates varied according to level of training. Performance times and pass rates were not improved with higher level of training or previous robotic experience. Resident and fellow instruction in new surgical technology is an important part of training in obstetrics and gynecology. Herein is reported a method to accomplish robotic training that standardizes instruction and assessment of skills.

Study Objectives To report the feasibility and description of robot-assisted presacral neurectomy (RPSN) and to compare outcomes with laparoscopic presacral neurectomy (LPSN). Design Prospective case series (Canadian Task Force classification III). Setting Tertiary care center. Patients Eighteen patients with central pelvic pain who underwent RPSN and 12 patients with central pelvic pain who underwent conventional LPSN in a metropolitan hospital between July 1, 2006, and April 30, 2008. Interventions The da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) was used for the robotic portion of the procedure. Availability of the robot was the sole determining factor for the procedure chosen. Bipolar, monopolar, and ultrasonic instruments were used for conventional laparoscopy. All patients underwent several additional procedures performed laparoscopically including adhesiolysis, treatment of endometriosis, appendectomy, enterolysis, and salpingo-ovariolysis. Measurements and Main Results All presacral neurectomies in both groups were successfully completed by excising the hypogastric nervous plexus within the interiliac triangle. Presence of nerve ganglion and fibers was confirmed at pathologic analysis in all cases. Mean duration of presacral neurectomy, from incision of the posterior peritoneum at the sacral promontory to complete excision of the superior hypogastric nerve plexus at the interiliac triangle (Cotte triangle) was less than 10 minutes in both groups. Mean estimated blood loss was less than 30 mL for the entire surgical procedure (29.4 mL for RPSN, and 28.8 mL for LPSN). Median (range) patient age was 25 (19–44) years in the RPSN group, and 26 (18–36) years in the LPSN group; gravidity was 0, and parity was 0. All patients had central pelvic pain, the primary indication for presacral neurectomy. Concomitant indications for surgery included ovarian cysts, endometriosis, and adhesions. There were no intraoperative or postoperative complications. At analysis, follow-up ranged from 13 to 36 months. No short- or long-term complications related to the surgical procedure were reported. All patients reported subjective improvement of pelvic pain. Conclusion Robot-assisted laparoscopic presacral neurectomy is feasible and safe, without added risk of short- or long-term complications. It compares favorably to the conventional laparoscopic approach of presacral neurectomy. The surgical robot provides a better angle and 3-dimensional visualization of the operating field, similar to laparotomy, and supplemented with magnification. This combined with elimination of hand tremor enables better surgeon control.

Study Objective The purpose of this study was to estimate the learning curve when using the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) in benign gynecologic cases by a team of 2 gynecologic laparoscopists. Design Retrospective case series (Canadian Task Force classification II-1). Setting A private practice obstetrics/gynecology clinic. Patients Patients requiring major benign gynecologic surgery who were candidates for a laparoscopic approach. Intervention All patients who would have otherwise been offered a transabdominal or conventional laparoscopic procedure were offered the option of having their procedure performed laparoscopically with robotic assistance. Data that were collected included robot set-up times by the operative room staff, operative times for use of robot, total operative times, and perioperative outcome. We analyzed the learning curve defined as the number of cases required to stabilize operative time to perform the various procedures. Measurements and Main Results One hundred thirteen patients were treated over a 22-month period with the da Vinci Surgical System. Most procedures were hysterectomies, whereas other gynecologic procedures included supracervical hysterectomy, laparoscopic vaginal assisted hysterectomy, myomectomy, sacrocolpopexy, and oophorectomy. Total operative times for hysterectomies studied sequentially stabilized at approximately 95 minutes after 50 cases. The decrease in robotic time did not depend on uterine size. The mean length of hospital stay was 24 hours, and return to normal activities averaged 2.8 weeks. Conclusions Robotic assisted surgery is an enabling technology that allows gynecologic surgeons the ability to offer laparoscopic procedures to most of their patients. In the hands of surgeons with advanced laparoscopic skills, the learning curve to stabilize operative times for the various surgical procedures in women requiring benign gynecolologic interventions is 50 cases.