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Page 6 of 9 Kiss et al. Mini-invasive Surg 2021;5:55 https://dx.doi.org/10.20517/2574-1225.2021.70

reperfusion intervals every 20 min.

One of the technical disadvantages of the robotic system is the lack of haptic feedback of the instruments. In
myomectomy especially, the absence of tactile feedback can lead to longer operation time due to the
necessary identification of intramural myomas with ultrasound and less accurate and destructive
myometrial incisions above the myoma . Giannini et al. presented a device (wearable fabric yielding
[46]
[13]
display) that can reproduce the stiffness of myomas ex vivo. When integrated into commercially available
robotic systems, this device could lead to a better intraoperative identification of myomas with more precise
surgery.

LEARNING CURVE AND ECONOMICS
Acquisition of a new robotic system and its maintenance cost are considered as the biggest drawback of
faster expansion of robotic surgery worldwide. Despite the obligatory cost of purchasing the robotic system
with its disposable instruments, implementation of correct strategies can reduce the costs of robotic surgery
while maximizing its benefits. The most influential modifying factors which lead to the cost-effectiveness of
robotic assisted surgeries are intraoperative and postoperative complications, length of surgery, and length
[47]
of hospital stay, which are all related to surgeons’ experience .
Even though there are no recent data on cost comparison of robotic vs. standard laparoscopic
myomectomy, information could be related from benign hysterectomy surgeries. Interestingly, after
adjusting patient-level covariates such as uterine weight, age, BMI, and previous abdominal or pelvic
surgery, the cost of robotic surgery vs. laparoscopy was not significantly different in two separate hospitals.
It is important to point out that the surgeries were performed by experienced surgeons past their learning
[48]
curve . Similar results were presented in a randomized trial , where comparable cost could be attained
[49]
between the two modalities if a robot is already a pre-existing investment.
Data from single-center experience with robotic single-site myomectomy show a very rapid learning
[50]
curve . After 10 cases, port placement time and docking time significantly reduced, in addition to a higher
number of retrieved myomas and lower hemoglobin decrease after surgery. When comparing with
conventional laparoscopy, docking time needs to be assessed separately as it is an element that does not
exist in laparoscopy. When looking at cases of robotic hysterectomies, console time has the most rapid
learning curve followed by docking time. Even in the case of a well-experienced laparoscopic surgeon
transferring to robotic surgery, suturing requires the greatest number of attempts to achieve stability .
[51]

Given that suturing is a major part of myomectomy, the surgeon’s experience is a crucial variable in
operation time resulting in cost effectiveness, as stated in previous studies.

Many resident and young surgeons struggle to keep up with the rapid advances in surgical techniques,
mainly due to a lack of time spent in the operating room. Surgical simulators have an important role in
helping to master these techniques outside the operation theatre. While computer simulators are often
expensive and not realistic enough, live simulations are often very basic and life-like models cannot
reproduce complex cases. Towner et al. constructed a model of myomatosus uterus with artificial blood
[52]
perfusion and secured it in a training box. In the post-simulation survey, residents stated higher confidence
and comfort performing minimal invasive myomectomy which could have a positive impact on the learning
curve in real-life surgeries.