https://orcid.org/0000-0003-2428-3992
With great deal of interest we read the published article entitled “Intraoperative complications and conversion to laparotomy in gynecologic robotic surgery” [Citation1]. The authors analyzed their single center single surgeon 2-year experience in robotic gynecologic procedures that were underwent from July of 2016 to July of 2018. They focused on their complication and conversion rates. Regarding the mentioned complications, they were defined and recorded as: failure in entry, vascular, nerve, visceral or solid organ injury, tumor fragmentation or anesthetic complication. Interestingly the only complication that lead in conversion to open was anesthesiologically related. All the others were managed. Moreover, 1 out of 83 procedures and 4 out of 83 were converted in either laparoscopy or laparotomy, respectively. Only 1 procedure was converted due to robotic platform related complication (robotic arm malfunction). The overall conversion rate was calculated at 6.02%.
As the authors mentioned in the discussion, the conversion rates vary in the current literature. In a recently published retrospective analysis of robotic gynecological surgeries in the UK the conversion to laparotomy rate was found to be 0.3% in about 4,400 robotic surgeries over 12 years [Citation2]. This rate is much lower compared to aforementioned one of 6.02%. A possible reason is the learning curve and the small population of study.
Robotic procedures may be extremely beneficial for the patients regarding hospital stay, postoperative pain and cosmetic outcome. Robotic surgery in severely obese women can be challenging regarding trocar entry and creation of pneumoperitoneum. This statement was studied by two recently published metalanyses. Both of them mentioned that robotic procedures in such patients are not only feasible but also complication and conversion rates are lower than laparotomy and laparoscopy groups [Citation3,Citation4]. Furthermore, patients’ Trendelenburg position and pneumoperitoneum are problems that must be managed by anesthesiology team especially in elderly patients. A metanalysis of published articles studying the utility of robotic procedures in elderly women with endometrial cancer showed that the risk of overall and peri-operative complications was lower in robotic group compared to laparotomy group. Interestingly, this decrease is greater with increasing patient age [Citation5]. We would like to ask the authors whether they can present statistics of a possible subanalysis in their obese or elderly patients.
The authors concluded that most of the complications faced during robotic procedures were managed uneventfully without conversion. Interestingly, most of them concerned vascular injuries during lymphadenectomy that were managed by suturing, coagulation or surgical clip placement. Same statement was published in a large prospective randomized trial [Citation6]. Bebia et al concluded that robotic assisted lymphadenectomy is associated with fewer complications compared to laparoscopic, due to better visualization, surgeon’s ergonomy and hemostatic precision [Citation6]. Based on their findings, do the authors have a similar experience?
Regarding the learning curve and safety of initial robotic procedures, the presence of an experienced proctor that can lead and interfere especially during first operation attempts is crucial [Citation7]. In this way, surgeon can achieve the required number of cases in order to carry out a safe and uneventful robotic procedure. This number varies, but most of published articles conclude that a number of 25 procedures are satisfactory[Citation8]. Can the authors perform a subanalysis of their first 25 cases regarding complications and conversion rates? Is there any difference between them and overall rates?
Once again, we would like to thank the authors for sharing their experience with robotic surgery.
Disclosure statement
No potential conflict of interest was reported by the author(s).
References
- Gokmen Karasu AF, Kıran G, Sanlikan F. Intraoperative complications and convertion to laparotomy in gynecologic robotic surgery. Journal of Investigative Surgery. (In press)
- El-Hamamsy D, Geary RS, Gurol-Urganci I, et al. Uptake and outcomes of robotic gynaecological surgery in England (2006-2018): an account of Hospital Episodes Statistics (HES). J Robot Surg. 2021. doi:https://doi.org/10.1007/s11701-021-01197-5. (online ahead of print).
- Brunes M, Johannesson U, Häbel H, et al. Effects of obesity on peri- and postoperative outcomes in patients undergoing robotic versus conventional hysterectomy. J Minim Invasive Gynecol. 2021;28(2):228–236. doi:https://doi.org/10.1016/j.jmig.2020.04.038.
- Cusimano MC, Simpson AN, Dossa F, et al. Laparoscopic and robotic hysterectomy in endometrial cancer patients with obesity: A systematic review and meta-analysis of conversions and complications. Am J Obstet Gynecol. 2019; 221(5) :410–428.e19. doi:https://doi.org/10.1016/j.ajog.2019.05.004.
- Raffone A, Travaglino A, Raimondo D, et al. Laparotomic versus robotic surgery in elderly patients with endometrial cancer: A systematic review and meta-analysis. Int J Gynaecol Obstet. 2021.doi:https://doi.org/10.1002/ijgo.13766. (online ahead of print).
- Bebia V, Gil-Moreno A, Hernández A, et al. Robot-assisted extraperitoneal para-aortic lymphadenectomy is associated with fewer surgical complications: a post hoc analysis of the STELLA-2 randomized trial. J Minim Invasive Gynecol. 2021;S1553-4650(21)00231-4. doi:https://doi.org/10.1016/j.jmig.2021.05.009. (online ahead of print).
- Gomes MTV, de Costa Porto BT, Parise Filho JP, et al. Safety model for the introduction of robotic surgery in gynecology. Rev Bras Ginecol Obstet. 2018;40(7):397–402. doi:https://doi.org/10.1055/s-0038-1655746.
- Tang FH, Tsai EM. Learning curve analysis of different stages of robotic-assisted laparoscopic hysterectomy. Biomed Res Int. 2017;2017:1827913. doi:https://doi.org/10.1155/2017/1827913.