{"paper_id":"9f25cf49-271d-4e1b-9979-28d74261967a","body_text":"Robot-Assisted Laparoscopy, Natural Orifice\nTransluminal Endoscopy, and Single-Site\nLaparoscopy in Reproductive Surgery\nAntonio R. Gargiulo, M.D., 1 and Ceana Nezhat, M.D. 2\nABSTRACT\nMinimally invasive gynecologic surgery is continuously pushing its limits by\nembracing ever more sophisticated technology. This is also true for reproductive surgery,\narguably the birthplace of gynecologic endoscopy, where minimally invasive treatment of\nuterine, tubal, ovarian, and peritoneal pathology has long become the gold standard. This\narticle describes in some detail three novel minimally invasive surgery approaches that have\nseen the light during the past decade: robot-assisted laparoscopic surgery, natural orifice\ntransluminal endoscopic surgery, and single-incision laparoscopic surgery. These fascinat-\ning technologies, far from being widely adopted, are sure to generate scientific controversy\nfor years to come. Nonetheless, they follow in the footsteps of the tradition of innovation\nthat is a defining aspect of our specialty and hold the promise to potentially revolutionize\nthe field of reproductive surgery.\nKEYWORDS: Robotic surgery, robotics, natural orifice transluminal endoscopic\nsurgery, NOTES, single-incision laparoscopic surgery, SILS, laparoscopic single-site\nsurgery, LESS, reproductive surgery\nJust when advanced laparoscopic technique has\nbecome more standardized and the laparoscopic ap-\nproach is finally being embraced even outside of the\nminimally invasive ‘‘sanctuary’’ of reproductive surgery,\nradically new techniques are being introduced that spark\nfamiliar controversies and shatter surgical dogmas all\nover again. Robot-assisted surgery brings stereoscopic\nvision and intuitive instrument control back to laparo-\nscopy, natural orifice transluminal endoscopy eliminates\nincisions of the skin and fascia, and single-incision\nlaparoscopy aims at limiting these points of entry. The\nfirst technique proposes to bridge the technical gap\nbetween open surgery and laparoscopy, and the other\ntwo push the limits of minimal invasiveness at the cost of\nfurther raising the bar of the technical skills required.\nTogether or separately, sooner or later, these techniques\nare likely to impact the way we will perform reproductive\nsurgery in the future.\nROBOT-ASSISTED REPRODUCTIVE\nSURGERY\nReproductive surgeons abide by the principles of micro-\nsurgery. Laparoscopy represents the natural evolution of\nclassic microsurgery: its closed approach limits peritoneal\ntrauma and promotes hemostasis. It also provides tissue\n1Center for Infertility and Reproductive Surgery, Brigham and\nWomen’s Hospital, and Department of Gynecology and Reproductive\nBiology, Harvard Medical School, at Boston, Massachusetts;\n2Depart-\nment of Obstetrics and Gynecology at Northside Hospital, Emory\nUniversity School of Medicine, and Stanford University School of\nMedicine, Atlanta, Georgia.\nAddress for correspondence and reprint requests: Antonio R.\nGargiulo, M.D., 75 Francis Street, Boston, MA 02115 (e-mail:\nagargiulo@partners.org).\nThe Role of Modern Reproductive Surgery for the Evaluation, Ther-\napy, and Preservation of Fertility; Guest Editor, Keith Isaacson, M.D.\nSemin Reprod Med 2011;29:155–168. Copyright # 2011 by\nThieme Medical Publishers, Inc., 333 Seventh Avenue, New York,\nNY 10001, USA. Tel: +1(212) 584-4662.\nDOI: http://dx.doi.org/10.1055/s-0031-1272478.\nISSN 1526-8004.\n155\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nmagnification and lighting conditions comparable with\nthose achieved in microsurgery. Thanks to improved\npatient acceptability and a lower rate of complications,\nlaparoscopy has replaced almost all open procedures in\nthe reproductive specialist’s armamentarium.\n1,2\nThis has come at a price. Laparoscopy has inher-\nent sensory and mechanical limitations compared with\nopen surgery. Sensory limitations include loss of stereo-\nscopic vision and partial loss of tactile sensation. Me-\nchanical limitations are caused by operating through a\nfulcrum (the anterior abdominal wall) with levers (the\nshafts of the laparoscopic instruments). In open surgery,\nthe surgeon’s upper limbs handle instruments with seven\ndegrees of freedom: the elbow provides yaw (left-right\nmovement about the transverse axis), pitch (up-down\nmovement about the vertical axis) and insertion (in-out\nmovement), the wrist provides another level of yaw and\npitch as well as providing roll (rotation around the\nlongitudinal axis); finally the hand provides grip (open-\nclose movement). In laparoscopy we lose yaw and pitch\nat the wrist. Lack of these movements is particularly\ntaxing during microsurgical procedures because we are\nused to performing our fine yaw and pitch movements\nwith our wrists, rather than our elbows.\nWorking through a fulcrum also establishes a\ncounterintuitive working environment where every yaw\nand pitch of an instrument in the pelvis must correspond\nto a diametrically opposed movement outside of the\nbody. Finally, operating through long instruments allows\nan amplification of natural muscle tremors that is not\nideal for microsurgical applications.\nMany excellent gynecologic surgeons who cannot\nafford the time and effort required to become proficient\nlaparoscopists are faced with a professional dilemma: to\npersevere in offering conventional surgery or to start a\npattern of referral to gynecologists trained in minimally\ninvasive surgery. What has happened to the field of\nreproductive surgery during the past 2 decades follows\nthe same practice-shift pattern, but the ramifications of\nsuch a shift are more complex. Gynecologic surgery in\nwomen facing reproductive challenges should be ap-\nproached with a comprehensive plan fostering their\nreproductive endeavor. In this perspective, reproductive\nsurgery encompasses virtually every conservative gyne-\ncologic operation during the reproductive years. At a\nvery minimum, it includes all those techniques aimed at\nthe restoration of reproductive structures (tubal, uterine,\nand ovarian surgery) and at the conservative manage-\nment of pelvic endometriosis.\nIt would seem that indications for reproductive\nsurgery abound. Yet a contraction of the field of proper\nreproductive surgery is more apparent than general\nstatistics seem to suggest.\n3 This is due to the fact that\nmany reproductive endocrinology and infertility (REI)\nsubspecialists refer their surgical patients to gynecolo-\ngists trained in minimally invasive surgery because the\noperations where they can best contribute their knowl-\nedge and understanding of the field have become too\ncomplex to be mastered within an already demanding\nassisted reproductive technology (ART) practice. This\npattern of referral represents, in our view, a concerning\ndisconnection from subspecialty care.\nIt is in this environment that robotic surgical\nplatforms are coming of age, with a potential to induce\na paradigm shift in reproductive surgery.\nSURGICAL ROBOTS: A TECHNOLOGY IN\nRAPID DEVELOPMENT\nAt the time in which this article was written there is only\none robot being used in gynecologic surgery worldwide\nand approved for this specific use by the U.S. Food and\nDrug Administration (FDA): the da Vinci surgical\nsystem (Intuitive Surgical, Sunnyvale, CA).\nThe setup of the da Vinci surgical system is based\non the principle of robotic telepresence: The main\nsurgeon is physically removed from the operating table\nand guides the movements of a passive patient-side\nrobotic device while sitting at a master console. The da\nVinci Si model also supports an assistant surgeon’s\nconsole. The surgeon operates the master console\nthrough two hand controls and several foot pedals.\nEach of the hand controls is designed to accommodate\nthe surgeon’s thumb and opposing finger and allows\ncomplete freedom of upper limb movement in three\ndimensions. These movements are translated and down-\nscaled into movements of the robotic arms at the patient-\nside cart, and into fine movements of the interchange-\nable ‘‘wristed’’ robotic instruments that the surgeon elects\nto connect to the robotic arms during each step of any\ngiven case (Fig. 1).\nThe robotic three-dimensional (3D) endoscope\nenters the abdominal cavity through an 8.5- or 12-mm\ncannula placed at or above the umbilicus (a dedicated\ncamera port has been designed for the new-generation\n8.5-mm 3D endoscope). Robotic instruments enter\nthrough dedicated 5- or 8-mm steel cannulas. Although\n5-mm robotic instruments do exist, their use in gyneco-\nlogic surgery is limited at this time, mostly due to the\nlack of electrosurgical instrumentation.\nThe transposition of the elbows’ movements in\nthe transverse axis (yaw) and vertical axis (pitch) is\nautomatically inverted at the level of the robotic arms\nso the surgeon can perform intuitive movements at the\nconsole just as if he or she was operating in a conven-\ntional open case. Moreover, the accuracy of movement of\nthe robotic arms and instruments can be scaled down to\nthe surgeon’s preference. The surgeon’s hand move-\nments at the console occur in a fluid and unrestricted\nenvironment. This comes at the expense of tactile\nsensation (haptic feedback). Simulated haptic feedback\nis one of the expected improvements of future robotic\n156 SEMINARS IN REPRODUCTIVE MEDICINE/VOLUME 29, NUMBER 2 2011\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nsystems. For the time being, surgeons must learn to\ncompensate for the complete loss of tactile sensation\nwith the much improved visual clues allowed by a high-\ndefinition 3D binocular visor.\nLaparoscopic surgeons, who are accustomed to\ndepending on elusive foot pedals, quickly learn to appre-\nciate the ergonomics of the da Vinci console’s pedal\nplatform. The left side of the pedal platform contains all\nof the main operational pedals: clutch, instrument\nswitch, and camera motion. The right side of the pedal\nplatform is dedicated to powering the energy sources\nemployed by some of the robotic instruments. The\nclutch disengages the hand controls of the master con-\nsole from the robotic arms of the patient-side cart. This\nallows for continuous optimal positioning of the sur-\ngeon’s upper limbs during different stages of the oper-\nation. The other two left-sided foot pedals are the\ncamera motion pedal (allowing fine control of the\nrobotic arm holding the camera while disengaging all\nother arms) and the switch allowing alternate use of two\nof the three robotic instrument arms.\nA limitation of the da Vinci surgical system is its\nsize: The massive patient-side cart can make any\noperating room feel like a small space. This is espe-\ncially true because lateral docking of the patient-side\ncart has replaced docking between the patient’s legs to\nimprove vaginal access. Therefore miniaturization of\nsurgical robots is one of the first achievements to be\nexpected on the way to a more universal use of these\nmachines. Ideally, robots should be available as more\ncompact units that can be introduced as needed during\nthe flow of any operation, rather than defining the\noperation as ‘‘robotic’’ from the start. Such a scenario of\nuse ad hoc may sound futuristic because current robotic\nplatforms are quite expensive. In fact, cost seems to be\nthe biggest impediment to the diffusion of this prom-\nising technology.\nThere are several cost analyses in the literature,\nbut only one pertains to gynecologic surgery. This study\ncompared robot-assisted laparoscopic myomectomy with\nabdominal myomectomy.\n4 The authors matched cases by\nage, body mass index, and myoma weight. Patients with\nrobot-assisted laparoscopic myomectomy had signifi-\ncantly lower estimated blood loss, complication rate\nand length of stay when compared with the laparotomy\ngroup. Operative times and professional and hospital\ncharges were higher for the robotic group. Professional\nreimbursement was not significantly different between\ngroups, but hospital reimbursement rates were higher for\nthe robotic. The authors concluded that the costs of\nrobot-assisted myomectomy are higher than those for\nabdominal myomectomy, but the observed decreased\nestimated blood loss, complication rate, and length of\nstay may have a significant societal benefit that will\noutweigh the upfront financial impact.\nSeveral studies support the argument that robotic\nsurgical platforms are effective technical enablers. One\nstudy evaluated the improvement of skill testing before\nand after an intensive 5-day hands-on minimally invasive\nsurgery training course offered to surgeons. The robotic\nskill testing scores demonstrated greater improvement\nthan the laparoscopic skill testing scores, suggesting the\ntransfer of laparoscopic skills may be improved using the\nrobotic interface.\n5\nAnother study compared the quality of suture\nanastomosis of the ureteropelvic junction obtained\nwith open surgery, conventional laparoscopy and ro-\nbot-assisted laparoscopy, and it evaluated the surgeons’\nlearning curves. Sutures were performed in 57 pigs by\nthree inexperienced and one experienced surgeon using\nFigure 1 Current version of the da Vinci Si robotic surgical platform by Intuitive Surgical. (A) Surgeon’s console. (B) Optional\nsecond surgeon’s console. (C) Patient-side cart with four robotic arms and exchangeable instruments. (D) Laparoscopic tower\nwith main computer. (Copyright Intuitive Surgical, Inc. Reproduced with permission.)\nMINIMALLY INVASIVE REPRODUCTIVE SURGERY /GARGIULO, NEZHAT 157\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\neach of the techniques. Operating times were measured.\nThe quality of the anastomoses was evaluated with\nurodynamic measurements and histology. Data analysis\nindicated that, among inexperienced surgeons, the effi-\nciency of performing suturing using robot-assisted lap-\naroscopy is operator independent and requires less time\nto learn compared with conventional laparoscopy.\n6\nFinally, in a more recent study, medical students\nwere shown an instructional video and then were tested\nin intracorporeal suturing on two identical porcine\nNissen fundoplication models.\n7 The students were asked\nto place sutures using conventional laparoscopic instru-\nments in one model and using robotic assistance in the\nother, in random order. Workload was assessed using the\nvalidated National Aeronautics and Space Administra-\ntion task load index questionnaire, which measures the\nsubjects’ self-reported performance, effort, frustration,\nand the mental, physical, and temporal demands of the\ntask. The study showed that, compared with standard\nlaparoscopy, robotic assistance significantly improved\nintracorporeal suturing performance and the safety of\nnovices in the operating room while decreasing their\nworkload. Moreover, the robot significantly shortened\nthe learning curve.\nNo similar studies exist at this time to compare the\nlearning curve of actual laparoscopic and robot-assisted\nprocedures. Studies have been published on the learning\ncurve of certain robot-assisted gynecologic operations.\nThese have arbitrarily defined surgical speed as the main\noutcome variable. It is expected that a great variability\nwill exist in the learning curve of different types of\nsurgery. The curve is also likely to depend on the baseline\nlaparoscopic and surgical skills of the team, as well as on\nits surgical volume. Even with these limitations, these\nstudies give us an idea of what is required to master\ncertain robot-assisted techniques. For example, operative\ntimes for hysterectomies performed at a general gynecol-\nogy practice stabilized at /C2495 minutes after 50 cases.\n8 A\nmore recent study performed by a gynecologic oncology\nteam to define the learning curve for robotic hysterec-\ntomy and pelvic-aortic lymphadenectomy for endome-\ntrial carcinoma yielded somewhat different results.\n9\nSeventy-nine consecutive patient outcomes were com-\npared between quartiles (cases 1 to 20, 21 to 40, 41 to 60,\nand 61 to 79), and proficiency was defined as the point at\nwhich the slope of the curve becomes less steep for\noperative times. Operative time decreased from the first\n20 cases to the next 20 but did not significantly change\nover the next three quartiles. The authors concluded that\nproficiency for robotic hysterectomy with pelvic-aortic\nlymphadenectomy for endometrial cancer is achieved\nafter 20 cases. However, the number of procedures to\ngain efficiency (i.e., the time when the slope of the curve\nequals zero) varies for each portion of the case. Finally, in\na series of 80 robot-assisted sacrocolpopexies, the mean\noperative time decreased by 25.4% after only 10 cases,\ninducing the authors to conclude that the operation has a\nshort learning curve.\n10\nIn conclusion, robotic surgical platforms over-\ncome the limitations of conventional laparoscopy, and\nlearning curves for gynecologic operations appear to\nflatten within the first 50 cases. The high cost of this\ntechnology is holding back a more widespread use.\nExpected market competition should induce an accel-\neration in the diffusion and advancement of robotic\nsurgery. Future technical improvements, aside from the\npreviously mentioned miniaturization, are likely to in-\nclude simulated haptic feedback, gaze-based cameras\nwith eye tracker and autofocus, ultra-miniaturization\nfor ‘‘wristed’’ single-port applications, image fusion,\nand, eventually, active robotic features (such as autono-\nmous knot tying).\nROBOTIC APPLICATIONS IN\nREPRODUCTIVE SURGERY\nRobot-Assisted Laparoscopic Tubal\nReanastomosis\nThe evidence for the effectiveness of tubal surgery in the\nmanagement of infertility is limited,\n11 and robotic sur-\ngery is unlikely to make an impact in this field in the era\nof ART. However, surgery has an important role in the\nmanagement of regret of tubal sterilization. The first\nfeasibility study for tubal reanastomosis on the da Vinci\nsurgical system was published by Degueldre et al.\n12 Two\ncase series compared robot-assisted tubal reanastomosis\nperformed with the da Vinci surgical system with con-\nventional microsurgical reanastomosis through minila-\nparotomy. The case-control study by Rodgers et al\ncompared 26 robot-assisted tubal reanastomosis cases\nwith 41 reanastomoses performed by outpatient mini-\nlaparotomy.\n13 Surgical times were significantly longer\nfor the robot compared with open surgery. Robotic\nreanastomosis was also more costly, with a median cost\ndifferential of $1446 (cost analysis did not include the\nbase cost of the surgical system and the annual main-\ntenance fee). Hospitalization times, pregnancy (61%\nrobotic versus 79% minilaparotomy), and ectopic preg-\nnancy rates were not significantly different. Complica-\ntions occurred less frequently in the robotic group. and\nthe return to normal activity was shorter in this group by\n/C241 week. The prospective cohort study by Dharia Patel\net al compares 18 robot-assisted tubal reanastomosis\ncases and 10 open microsurgical tubal reanastomosis\ncases with hospital admission.\n14 Surgical times were\nsignificantly longer for the robot compared with open\nsurgery This group did not perform outpatient mini-\nlaparotomy, whereas all patients undergoing robot-as-\nsisted surgery were discharged home on the day of\nsurgery. Hence hospitalization times were shorter in\nthe robot-assisted than in the open surgery. Time to\n158 SEMINARS IN REPRODUCTIVE MEDICINE/VOLUME 29, NUMBER 2 2011\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nrecovery was significantly less for the robot-assisted\nreanastomosis group compared with the open surgery\ngroup (11.1 days; range: 2 to 28 days, and 28.1 days;\nrange: 21 to 42 days, respectively). Pregnancy (62.5%\nrobotic versus 50% open) and ectopic pregnancy rates\nwere not significantly different. The hospital cost for\nrobot-assisted reanastomosis was $13,773 (versus\n$11,742 for the open procedure). However, the cost\nper delivery was similar between the two procedures.\nThe data seem to indicate that robot-assisted\ntubal reanastomosis is safe and its results are comparable\nwith those obtained by classic tubal microsurgery per-\nformed by trained REI subspecialists. Cost analysis is\ncontroversial, but it would appear that even at the\ncurrent high operating costs, open surgery is cost effec-\ntive only if patients are sent home within a few hours but\nnot if they stay overnight.\nRobotic tubal reanastomosis is performed with\neither a three- or a four-arm configuration with the\nassistant port in one of the lower quadrants (Fig. 2) so\nthe exceptionally small needles being passed in and out\nof the patient can always travel in front of the laparo-\nscope and away from the bowel. As in all robot-assisted\nreproductive surgery techniques, we prefer lateral dock-\ning of the patient-side cart, which allows ample space for\naccess to uterine positioning devices. Typical robotic\ninstrument configurations include a first stage employing\nProGrasp forceps, Potts Scissors, and Micro-Bipolar\nforceps (all Intuitive Surgical) for preparation of the\ntubal stumps and placing the stent, and a second stage\nemploying ProGrasp forceps and two Black Diamond\nMicro Forceps (Intuitive Surgical) for suturing. We\nemploy ultrafine (1:5) downscaling on the da Vinci S\nand fine (1:3) downscaling on the da Vinci Si. Fig. 3\nsummarizes the technique.\nMost reproductive surgeons only perform a lim-\nited number of tubal reanastomoses per year. A case\ncould be made that the enabling nature of robotic\ntechnology makes this a perfect example of an operation\nthat is more safely learned and performed robotically.\nRobot-Assisted Myomectomy\nThree prospective randomized trials showed the safety\nand reproductive benefits of laparoscopic myomectomy\nover abdominal myomectomy.\n13–17 Moreover, abundant\ndata have accumulated attesting to the extremely rare\noccurrence of the dreaded uterine rupture in pregnancies\nfollowing laparoscopic myomectomy. 18,19\nYet such good scientific evidence has not signifi-\ncantly impacted the 50-year trend of performing my-\nomectomy through an abdominal incision. The fact that\nabdominal myomectomy still represents the standard of\ncare in most developed countries is not surprising, given\nthe serious technical challenges of this operation.\n20 That\nis why the pioneering work by Advincula and his team,\nwho had the foresight of applying robotic technology to\nmyomectomy almost a decade ago, represents a true\nmilestone in our field. In 2004, this group published\nthe first feasibility study with data from 35 patients.\n21\nThese were not small cases: The mean myoma weight\nwas 223.2 /C6244.1 g and the mean diameter was\n7.9 /C63.5 cm. The median myoma number was 1.6\n(range: 1 to 5). The mean blood loss was 169 /C6198.7\nml; the mean operating time was 230.8 /C683 minutes.\nPatients went home within a day. This study helped pave\nthe way for FDA clearance of the use of the da Vinci\nsurgical system for this and other gynecologic indications\nin early 2005. Classically trained reproductive surgeons\nshould take much comfort in following the steps of a\nrobot-assisted myomectomy and see that this is an\noperation of uncompromised precision. Robot-assisted\nmyomectomy is performed with either a three- or four-\narm configuration with the assistant trocar in one of the\nlower quadrants so the many needles passed in and out of\nthe patient can always travel in front of the laparoscope\nand away from the bowel. There is another good reason\nto place the bedside assistant’s port in one of the lower\nquadrants. As you will notice in Fig. 2 the right lower\nquadrant assistant port and the right robotic port end up\npositioned on the same vertical line. This means that if\nconventional laparoscopy is needed for any part of the\noperation, there already is the ideal trocar placement for\nthat, the ‘‘ultra-lateral’’ port position described by Koh\nand Janik.\n22\nBriefly, (1) the myometrium is infiltrated with\ndilute vasopressin and a transverse incision is performed\nwith robotic Harmonic shears set at maximum power\n(which has less thermal spread and produces less smoke\nthan any electrical devices); (2) tenaculum forceps are\napplied and an ‘‘onionskin’’ technique,\n26 is applied with\nFigure 2 View of lower abdomen with our standard setup\nfor robot-assisted reproductive surgery. The 12-mm primary\ntrocar is placed through an umbilical incision, da Vinci 8-mm\ntrocars are placed 8 to 10 mm to either side of it with a 15 to\n30 degree caudal angle, and a patient-side assistant trocar is\nplaced in the right lower quadrant. (Photo courtesy of A.\nGargiulo and S. Srouji, Brigham and Women’s Hospital.)\nMINIMALLY INVASIVE REPRODUCTIVE SURGERY /GARGIULO, NEZHAT 159\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nrobotic Harmonic shears; (3) a Maryland fenestrated\ngrasper is used as a dynamic retractor and to cauterize\narteriolar bleeding; (4) the myoma is placed in the\nposterior cul-de-sac and a myoma count is initiated (if\nmultiple small myomata are removed, they can be kept\ntogether on a loop of suture until morcellation); (5)\nchromotubation is performed after enucleation to iden-\ntify possible occult endometrial entry; (6) uterine inci-\nsions are closed in one to five layers (depending on size\nand depth) right after each myoma enucleation occurs to\nminimize blood loss; (7) the endometrium (when en-\ntered) is reapproximated with running 3–0 polyglecap-\nrone 25; (8) the deep myometrial layer is closed with\ninterrupted figure-of-eight sutures of 0 polyglactin and\nthe outer myometrial layer(s) with running suture(s) of 0\npolyglactin; (9) the uterine serosa is closed with 2–0 or\n3–0 polyglecaprone 25 in a running baseball stitch; (10)\nextraction of the enucleated myomata from the abdomi-\nnal cavity is accomplished with an electric morcellator.\nThe technique is summarized in Fig. 4 and Fig. 5.\nThe recent development of self-anchoring barbed\nsutures offers a way to decrease operative time in large\nrobot-assisted myomectomies. Successful use of barbed\nsuture in conventional laparoscopic myomectomy has\nalready been described.\n23 We hope evidence of optimal\nperformance of uteri reconstructed with knot-free su-\ntures (in terms of low chance of rupture) will soon\nbecome available. As far as evidence of reproductive\nsafety of robot-assisted myomectomy performed with\nconventional sutures, it would seem redundant to ‘‘re-\ninvent the wheel’’ after > 50 years of overall safe obstetric\nreports following abdominal myomectomy and freehand\nlaparoscopic myomectomy. In any case, tens of women\nhave safely delivered following robot-assisted myomec-\ntomy at our institutions, and a large multicenter study\naddressing this question is currently being prepared for\npublication. No discussion on robot-assisted myomec-\ntomy can be complete without mention of the intense\npreoperative work to establish stringent indications for\nthe procedure and the most effective operative strategy.\nThe importance of the input of the REI subspecialist on\nthe indications for myomectomy in women facing re-\nproductive challenges cannot be overemphasized. The\ntopic of myomectomy in infertile women is rife with\nconflicting scientific literature, and important decisions\nwill still have to be made based on extensive professional\nexperience.\n24\nConsidering that tactile sensation is lost with\ncurrent robotic platforms, detailed preoperative imaging\nstudies become a fundamental prerequisite for robot-\nassisted laparoscopic myomectomy. Preoperative map-\nping has several goals: (1) assess the number, size, and\nFigure 3 Robot-assisted laparoscopic tubal reanastomosis. (A) Preparation of the proximal stump with flow of dye from the\ntransected tubal lumen. (B) Placement of graduated endoscopic retrograde cholangiopancreatography catheter as stent.\n(C) Placement of 8–0 polypropylene sutures at 12, 3, 6, and 9 o’clock. (D) Final result with copious bilateral spill at\nchromotubation. (Photos courtesy of A. Gargiulo and S. Srouji, Brigham and Women’s Hospital, Boston, MA.)\n160 SEMINARS IN REPRODUCTIVE MEDICINE/VOLUME 29, NUMBER 2 2011\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nlocation of all myomata in reference to the endometrial\ncavity; (2) rule out adenomyosis; and (3) provide addi-\ntional reassurance as to the benign nature of large uterine\nmasses. Magnetic resonance imaging (MRI) has a high\nsensitivity and a low specificity for diagnosing leio-\nmyoma and a high specificity and a low sensitivity for\ndiagnosing adenomyosis,\n25 hence a good transvaginal\nultrasound is just as useful as MRI in the mapping of\nsmaller uterine tumors.\n26 In the case of large uterine\nmasses, ultrasound cannot show the type of detailed\nrelationships between the tumor and the uterine cavity\nthat are needed for a safe laparoscopic myomectomy, and\nMRI with gadolinium enhancement is preferable. An-\nother good reason to prefer MRI in the case of larger\nuterine masses is that this technique has a better chance\nof identifying tumors suspected of malignant degener-\nation. The study by Goto et al showed that the combined\nuse of MRI and serum measurement of lactate dehydro-\ngenase is useful in making a differentiated diagnosis of\nleiomyosarcoma from nonmalignant degenerated leio-\nmyoma before surgical treatment.\n27 Defining a mass at\nrisk of being a sarcoma is a fundamental step when\nmorcellation is required for tumor extraction. Preoper-\native identification of diffuse adenomyosis precludes\neffective surgical treatment of any kind. Adenomyomas\ninstead are discrete uterine masses that resemble myo-\nmata but have a poorly demarcated plane that typically\ninvolves the endometrium. Even so, in our experience\nthese tumors are amenable to satisfactory enucleation\nwith robot assistance.\nTwo recent studies have compared robot-assisted\nmyomectomy with freehand laparoscopic myomec-\ntomy.\n28,29 Both studies were relatively small and, more\nimportantly, compared the proficiency of very advanced\nconventional laparoscopic teams with robotic teams\nwithin the initial learning curve (i.e., < 50 cases). Not\nsurprisingly, operative times were significantly lower for\nthe conventional laparoscopy cases. However, the entire\ndebate of freehand laparoscopic versus robot-assisted\nlaparoscopic has limited clinical significance in our\nview. Robot-assisted surgery is just another way to do\nlaparoscopic surgery. Some of us will argue that the\nquality of the microsurgical and reconstructive work\nperformed robotically is more in keeping with the\nprinciples of our specialty, but that has to be demon-\nstrated on a case-by-case basis. The bottom line is that\nFigure 4 Robot-assisted myomectomy. (A) Incision of the myometrium with robotic harmonic shears. (B) Enucleation of\nintramural myoma. (C) Reapproximation of the endometrium with 3–0 polyglecaprone 25. (D) Closure of deep myometrial layer\nwith interrupted figure-of-eight sutures of 0 polyglactin. (Photos courtesy of A. Gargiulo and S. Srouji, Brigham and Women’s\nHospital.)\nMINIMALLY INVASIVE REPRODUCTIVE SURGERY /GARGIULO, NEZHAT 161\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\ncurrent robotic surgical platforms can enable good lap-\naroscopic surgeons to expand their field of action to\nmatch that of advanced laparoscopic surgeons. In con-\nclusion, robot-assisted laparoscopic myomectomy allows\ntransposition of the classic abdominal myomectomy\ntechnique to the laparoscopic arena. It is safe and\nreproducible and—with the expected advancements of\nsurgical robotics—has the potential to be adopted by\nmore infertility specialists as part of their armamenta-\nrium for comprehensive reproductive care.\nRobot-Assisted Debulking of Pelvic\nEndometriosis\nEndometriosis is yet another clinical scenario in which\nthe decision of how, when, and to what extent to proceed\nwith debulking of the disease should not lie outside of a\nconcerted treatment strategy formulated by an REI\nsubspecialist.\n30,31 However, endometriosis can present\nsome of the most challenging and intimidating surgical\nscenarios that a gynecologist will ever encounter. Hence\nthe temptation for the reproductive specialist to refer\nthese patients to minimally invasive gynecologic sur-\ngeons can be strong. Can the robot come to the rescue in\nthis case and become the enabler it has shown to be for\ntubal and uterine surgery? Recently, Nezhat et al\n32\nreported on the safe use of the 5-mm da Vinci system\nto treat endometriosis (Fig. 6). The full report is in\nprocess, but while we await publication of case series on\nrobot-assisted debulking of endometriosis, we are glad to\nshare some thoughts derived from our own robotic\npractices. There is no question that the lack of tactile\nfeedback does pose limitations to the application of\ncurrent robotic technology to endometriosis. However,\nexceptional visual feedback and the ability to operate\neffortlessly in the posterior cul-de-sac provide a rational\nbasis to consider robotic assistance in some case of severe\nendometriosis. This is, in our view, the most challenging\nof robot-assisted reproductive surgeries and should be\napproached only when compensatory visual feedback is\nwell developed and use of the machine has become\nsecond nature. These cases are usually long and not\nparticularly hemostatic, and anatomical planes are elu-\nsive at best; therefore unhindered concentration is fun-\ndamental. In situations like these, another improvement\noffered by robot-assisted surgery is its advanced ergo-\nnomics.\nSurgical ergonomics has evolved as a scientific\nfield in parallel with the introduction of complex tech-\nnology in the operating room.\n33 Its underlying principle\nFigure 5 Robot-assisted myomectomy. (A) Completed closure of deep layers. (B) Running suture of 0 polyglactin to close\nouter layer of myometrium. (C) use of Telestration (USAOPOLY Inc., Carlsbad, CA) to instruct a training robotic surgeon.\n(D) Closure of the uterine serosa with running baseball stitch of 2–0 polyglecaprone 25. (Photos courtesy of A. Gargiulo and S.\nSrouji, Brigham and Women’s Hospital, Boston, MA.)\n162 SEMINARS IN REPRODUCTIVE MEDICINE/VOLUME 29, NUMBER 2 2011\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nis that disruptions to the surgical workflow have been\ncorrelated with an increase in surgical errors and sub-\noptimal outcomes in patient safety measures\n34 and there-\nfore must be avoided. Conventional laparoscopic surgery\noccurs in an operating room environment where dis-\nruptions to the workflow abound. For example, we are\nwell aware that gaze disruptions (the surgeon looking\naway from the laparoscopic screen) occur frequently due\nto instrument exchange, extracorporeal work, equipment\ntroubleshooting, and communication. Still, how fre-\nquently gaze disruptions actually occur may be a little\nsurprising: On average, 40 breaks occurred in the main\noperating surgeon’s attention per 15 minutes of operat-\ning time during routine laparoscopic cholecystectomy.\n35\nBecause robotic surgeons work in an immersive environ-\nment, one could safely extrapolate that the amount of\ngaze disruption in robotic surgery approaches zero. And\nwhat about surgeon’s generalized fatigue? The data on\nthe negative effects of laparoscopic surgery on the\nmusculoskeletal system of surgeons are nothing short\nof alarming. Park and colleagues polled > 300 general\nsurgery laparoscopic specialists in North America and\npresented evidence that 87% of them suffer from mus-\nculoskeletal occupational injury.\n36 Surgical assistants are\nnot immune to this type of occupational hazard either, as\ndemonstrated by a separate study from the same group. 37\nBecause they eliminate the standing and unbal-\nanced posture of surgeons and assistants, as well as the\nneck strain and the heavy work normally performed by\nthe shoulders, robotic plat forms appear to be an effec-\ntive way to improve the ergonomics of our operating\nrooms.\nIn conclusion, recently published data describe\nthe safe use of robot-assisted laparoscopic surgery in\nendometriosis. Improved visual feedback, instrumenta-\ntion, and ergonomics seem to compensate for the current\nabsence of haptic feedback and may represent significant\nadvantages over conventional laparoscopy when ap-\nproaching complex pelvic dissection.\nNATURAL ORIFICE TRANSLUMINAL\nENDOSCOPIC SURGERY AND SINGLE-SITE\nLAPAROSCOPIC SURGERY\nFor centuries, surgeons have been searching for ways to\nimprove operative outcomes with minimal intervention.\nThe recent advances in laparoscopic techniques have\nresulted in shorter recovery times, less morbidity, and\nbetter cosmetic outcomes. Although we have achieved\nenormous success in the field of minimally invasive\nsurgery, the quest for perfection and minimal interven-\ntion remains as compelling as before. Two of the newest\nconcepts in minimally invasive surgery, natural orifice\ntransluminal endoscopic surgery (NOTES) and single-\nincision laparoscopic surgery (SILS), also known as\nlaparoendoscopic single-site surgery (LESS), have been\non the frontline of innovation and are showing promis-\ning results.\nFigure 6 Robotic excision of infiltrating bladder endometriosis. (Photo courtesy of C. Nezhat, Atlanta Center for Minimally\nInvasive Surgery and Reproductive Medicine.)\nMINIMALLY INVASIVE REPRODUCTIVE SURGERY /GARGIULO, NEZHAT 163\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nNatural Orifice Transluminal Endoscopic\nSurgery\nIn the field of gynecology, vaginal approaches to surgery\nhave always been a very popular and preferred method.\nVaginal hysterectomies are rapidly increasing in popular-\nity due to improved postoperative pain, shorter hospital\nstays and surgery times, better cosmetic results, and\nsimilar outcomes. As part of ART, transvaginal oocyte\nretrieval under ultrasound guidance has been the stand-\nard of care for quite some time for in vitro fertilization.\nSurgeons naturally began to investigate other procedures\nthat could be done through the vagina and other natural\norifices.\nNOTES was first proposed in the early 1990s. It\nis a new form of minimally invasive surgery that is\nquickly moving from feasibility studies to actual practice.\nThe intent of this approach is to perform surgery\nthrough the body’s natural orifices (i.e., mouth, vagina,\nanus) to minimize incisions and disruption of the ab-\ndominal or pelvic muscles and fascia. Multiple attempts\nhave been documented, including transcolonic, trans-\ngastric, transurethral, and transvaginal approaches. The\nhope is that this will decrease recovery time and surgical\nsite complications such as infections and hernias, and it\nwill ultimately provide an added cosmetic benefit of no\nvisible incisional scars.\n38\nMultiple pilot studies have been published in the\nlast decade addressing the feasibility of this novel tech-\nnique. The first reports of surgical outcomes were in the\nearly 2000s by Kalloo and colleagues. 37 Transgastric\nperitoneoscopy was successfully performed on 17 50-kg\npigs, demonstrating the technique was technically pos-\nsible and worth further investigation. All of the pigs\nrecovered from the procedure and were able to tolerate\noral intake without adverse events.\n39\nIn response to this and other successful studies, a\ncommittee was formed by the American Society for\nGastrointestinal Surgery and the Society of American\nGastrointestinal and Endoscopic Surgeons to review the\ncurrent literature and future possibilities of NOTES.\nTheir conclusion was that animal models had shown\npromise and human studies were warranted.\n40\nA pilot study compared diagnostic laparoscopy\nwith transgastric peritoneoscopy in human subjects with\npancreatic masses. In 9 of the 10 patients, the findings\ncorrelated between the two techniques. No operative\ncomplications were encountered. The conclusion was\nmade that NOTES was feasible and could eventually\nbe at least comparable with traditional laparoscopy.\n41\nSteele and colleagues reported a feasibility study\nthat included three patients undergoing laparoscopic\ngastric bypass surgery. During the surgery, a liver biopsy\nwas performed using a flexible endoscope that was passed\nthrough the existing gastrotomy. The biopsies were\neasily obtained, and the abdomen was explored without\nany reported difficulty.\n42\nOne of the first published human series of\nNOTES involved nine transvaginal cholecystectomies,\none transvaginal appendectomy, and one transgastric\nappendectomy. These were not ‘‘pure’’ NOTES proce-\ndures: Eight of the eleven trials were aided by a\ntransumbilical cannula, two had two transabdominal\ncannulas, and the transgastric appendectomy was aided\nby two 2-mm abdominal ports. There were no reported\npostoperative or intraoperative complications in any of\nthe procedures, all patients were sent home by post-\noperative day 2, and postope rative pain was reported as\nminimal, confirming the feasibility of this approach.\nThree additional patients were enrolled in this study,\nbut NOTES was not performed after visualization of\nthe peritoneal cavity revealed adhesions and inflamma-\ntion, thus pointing to the po tential limitations of such\nan approach.\n38 In 2009, Nezhat et al 43 reported their\nstudy of 42 patients who underwent natural orifice-\nassisted laparoscopic appendectomy at the time of\nlaparoscopic hysterectomy. They reported no intrao-\nperative or major postoperative complications (Fig. 7).\nAs with any new technique, there are limitations to\nthese procedures. The main technical issue reported by\nsurgeons is the limited mobility of available instru-\nments. This is likely due to the fact that the instruments\nbeing used are not designed specifically for these\nprocedures. The surgeons performing these trials be-\nlieved this issue could be alleviated with some instru-\nment modifications.\n38,40,41 There is also a theoretical\nrisk that an increased rate of postoperative wound\ninfections may occur due to the use of nonsterile\nentry.\n40,41 There have been no reported incidents of\npostoperative infection in t h e s ep r o c e d u r e st h u sf a r ,\nalthough data are limited. The ideal way to close entry\nsites, particularly at the level of the stomach, also\nremains unclear.\nAnother significant limitation is the inability to\nmeasure and maintain intra-abdominal pressure accu-\nrately during these procedures. Bergstro¨m et al reported\nintra-abdominal pressures in a series of transgastric\ncholecystectomies and tubal resections in a porcine\nmodel. A standard Veress needle technique was used\nto calculate pressure, and surgeons were asked to report\nwhen signs or symptoms of high intra-abdominal pres-\nsure were noted. Unacceptably high pressures were noted\nin all of the procedures, and physicians were unaware of\nthe pressures > 50% of the time. To address this prob-\nlem, the same group reported a modified feedback\ncontrol valve that aided in the monitoring and control\nof intra-abdominal pressure.\n44\nA surgical robot system recently was developed\nwith telecontrol function. This system was successfully\nused in endoscopic procedure with two hands for tele-\nNOTES.45 The advent of robotic surgery, combined\nwith a NOTES approach, can change the concept of\nlimiting factors in this newly developing field.\n164 SEMINARS IN REPRODUCTIVE MEDICINE/VOLUME 29, NUMBER 2 2011\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nAlthough a promising technique, NOTES is still\nin its infancy. It has shown a great deal of promise with\nsome identifiable limitations that can be modified in\nfuture trials. Those limitations and surgeons’ perception\nof the new approach will need to be addressed before the\nnext leap forward of NOTES. Recent survey of practic-\ning gynecologists has demonstrated that although close\nto 70% of surgeons think positively about NOTES,\n< 30% of physicians would recommend NOTES to their\npatients. Positive thoughts regarding scarless surgery and\nquicker recovery times were counterbalanced by concerns\nfor postoperative infection, visceral lesions, infertility,\nand adhesions. Potential problems such as dyspareunia,\ninfertility, and the spread of preexisting endometriosis\nwere also named as factors in long-term follow up.\n46\nSingle-Site Laparoscopy\nAn additional proposed method of entry for minimally\ninvasive surgery is SILS (or LESS) This technique uses a\nsingle, usually umbilical, incision for all instruments\nrather than multiple port sites as usually used in laparo-\nscopic surgery. The terms are often used interchangeably\nin the literature, although some authors describe them as\ntwo separate techniques. Both techniques are discussed\nand referred to collectively here as single-site laparo-\nscopy.\nReports of various laparoscopic abdominal sur-\ngeries through a single incision first surfaced in the\ngeneral surgery literature. The most commonly reported\nprocedures are cholecystectomy and gastric banding.\nHernandez et al\n47 published their experience with 100\nsingle-site cholecystectomies that showed promising\nresults. The operating times were similar when com-\npared with conventional laparoscopy controls as were\nmost of the measured outcomes. The authors concluded\nthat single-site laparoscopy is a safe and feasible proce-\ndure.\n45 Additionally, a case series in the pediatric pop-\nulation reported similar outcomes between single-site\nlaparoscopy and traditional laparoscopy for splenectomy,\ncholecystectomy, and appendectomy in all measured end\npoints including postoperative pain.\n48\nTo address some of the identified problems with\nloss of pneumoperitoneum and increased stress on fascia,\nvarious multiaccess ports have been created, such as the\nX-Cone (Karl Storz Endoscopy, Tuttlingen, Germany),\nASC-Triport (Advanced Surgical Concepts, Bray, Ire-\nland), GelPOINT (Applied Medical, Rancho Santa\nMargarita, CA), and the SILS Port (Covidien, Mans-\nfield, MA). Each of the devices represents a single port\nthat has three to four canula access sites through which\nstandard laparoscopic instruments are placed.\n49\nOne small case series of three patients undergoing\nsingle-site laparoscopy with a multiaccess port for gastric\nbanding showed improved outcomes and was reported to\nbe technically more feasible and successful in comparison\nwith the same procedure without the multiaccess port.\n49\nAnother series of 20 single-site laparoscopic cholecys-\ntectomies with a single port (R-port, Advanced Surgical\nConcepts) showed promising results with similar out-\ncomes to laparoscopy. Seventeen of 20 cases were able to\nbe performed through a single site, and postoperative\npain was reported as less than with traditional laparo-\nscopy. However, the authors did report a significant\namount of difficulty with instrumentation through the\nsingle port.\n50\nThe field of gynecologic surgery was not an\nexception to this innovative technique. One of the ear-\nliest reports of single-site laparoscopy was for treatment\nof ectopic pregnancy and involved the placement of one\nFigure 7 Transvaginal appendectomy. The glove maintains pneumoperitoneum as the stapler and specimen are removed\nthrough the colpotomy. (Photo courtesy of C. Nezhat, Atlanta Center for Minimally Invasive Surgery and Reproductive\nMedicine.)\nMINIMALLY INVASIVE REPRODUCTIVE SURGERY /GARGIULO, NEZHAT 165\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\n10-mm and two 5-mm ports through a single 2.5-cm\numbilical skin and 12-mm fascial incision. The authors\nreport that this method can be performed successfully\nwith standard laparoscopic instruments and is therefore\nattractive and feasible. The patient experienced a sig-\nnificant amount of postoperative pain, which was attrib-\nuted to pelvic inflammatory disease.\n51\nYoon reported on a series of 20 patients under-\ngoing salpingectomy for the treatment of ectopic preg-\nnancy. All procedures were performed through a single\n2-cm vertical umbilical incision without use of any\nadditional ports, including five patients with ruptured\nectopic pregnancies, seven with hemoperitoneum, and\nsix with pelvic adhesions. The mean operating time\nreported was 55 minutes and was showed to decrease\nwith experience.\n52\nA series of nine laparoscopic single-site and four\nrobotic single-site gynecologic oncology procedures were\nreported by Nickles and Escobar. These cases were\nperformed using a multiaccess port (SILS Port Multiple\nAccess Port), which allowed for three laparoscopic in-\nstruments to be placed. The port was placed through a 3-\ncm vertical skin incision made through the umbilicus.\nThere were no reported postoperative complications,\nsurgery and recovery time were at least comparable\nwith laparoscopy if not better, and there was a definite\nimprovement in cosmesis.\n53\nAs with NOTES and other surgical innovations,\nimplementation of robot-assisted surgery into minimally\ninvasive surgical treatment led to the combination of\nSILS and robotic technology. Several reports addressed\nthe feasibility of this ‘‘hybrid’’ procedure, including\nhemicolectomy\n53 and radical prostatectomy, dismem-\nbered pyeloplasty, and radical nephrectomy. 54 Out of\nthe experimentations with single-site laparoscopy and\nobservation of limiting factors, several authors proposed\nwhat is known as the ‘‘cross-hand technique’’; designed\nto simulate the ipsilateral surgical orientation, it has\nshown promising results in several trials.\n55,56\nAlthough fascinating and promising, single-site\nlaparoscopy in its current form is far from being adapted\ninto general surgical practice. Several studies reported on\nincidences of increased postoperative pain, intraopera-\ntive complications due to poor visualization, and diffi-\nculty maintaining pneumoperitoneum compared with\ncontrols.\n47,57–59 Despite these occasional complications,\nthe authors of each series believed that single-site\nlaparoscopic surgery is a technique that warrants further\nexploration.\nAs with any evolving technique, some clinical\nquestions have yet to be answered. Long-term data on\nincisional hernias are not available as of yet. It is possible\nthat with the theoretically increased stress placed on the\nfascia by multiple instruments, hernia risk may actually\nbe increased. Surgeons report difficulty with visualiza-\ntion using standard laparoscopic instruments, which has\nled to occasional intraoperative complications. In addi-\ntion, improved postoperative pain compared with con-\nventional laparoscopy has not been proven, and no\nreported data on cost effectiveness exist thus far.\n47,59\nAs with any new procedure, there is a learning curve\ninvolved, and many believe the outcomes will improve\nover time.\nIn conclusion, both NOTES and single-site lap-\naroscopy are exciting new techniques that have the\npotential to add to the realm of minimally invasive\nsurgery. However, randomized clinical trials, long-term\noutcome data, and cost analysis would be necessary\nbefore either technique could be adopted into standard\nclinical practice.\nROBOTIC, NATURAL ORIFICE, AND\nSINGLE-SITE SURGERY: THE FUTURE\nOF REPRODUCTIVE SURGERY?\nSurgical robotics are a significant technical enabler that\ncould persuade more REI subspecialists to maintain\nownership of their patients’ reproductive surgery needs.\nIts safety and efficacy in tubal and uterine surgery is now\nwell established, and even its role in the surgical manage-\nment of endometriosis appears promising. Indeed, REI\nspecialists (arguably, the pioneers of modern laparoscopy)\nhave strong fundamentals of endoscopy and therefore\nrepresent the ideal substrate for a robotic ‘‘revolution.’’\nBut robotic surgery must first survive what appears to be a\nturbulent infancy where this technology may be destined\nto succumb in a radically cost-conscious health-care\nenvironment. It appears that the true coming of age of\nsurgical robotics can only happen when the cost of this\ntechnology drops significantly.\nOn the other end of the spectrum are the new\ntechnologies of natural orifice transluminal surgery and\nsingle-site laparoscopy. Both offer options of ultra-\nminimal invasiveness but at the cost of more technical\nchallenges and limitations than conventional laparo-\nscopy. In a surgical environment that still struggles to\nembrace traditional laparoscopy, this may seem like a\ncountercurrent move. It does not take much imagination\nto conclude the future may well lie in a fusion of all of the\npreviously described techniques. Robotic NOTES and\nrobot-assisted single-site laparoscopy just make sense,\nand early prototypes of this technology are already in use.\nUpsetting as it may sound to surgeons of our generation,\nconventional laparoscopy in all of its forms may never\nhave a chance of becoming standard of care. Indeed,\nthere is a chance it may take its place in the history of\nmedicine as an inspiring but anti-ergonomic (and po-\ntentially surgeon-crippling) exercise that bridged the\nspan of half a century between the era of open surgery\nand that of robotic surgery. Time will tell. The dawn of\nrobotics is still an exciting time to be a reproductive\nsurgeon.\n166 SEMINARS IN REPRODUCTIVE MEDICINE/VOLUME 29, NUMBER 2 2011\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nREFERENCES\n1. Isaacson KB. Complications of Gynecologic Endoscopic\nSurgery. Philadelphia, PA: WB Saunders; 2006\n2. Nezhat C, Nezhat F, Nezhat C. Nezhat’s Operative\nGynecologic Laparoscopy and Hysteroscopy. 3rd ed. New\nYork: Cambridge University Press; 2008\n3. Ketefian A, Hu J, Bartolucci AA, Azziz R; Society of\nReproductive Surgeons, Inc. Fifteen-year trend in the use of\nreproductive surgery in women in the United States. 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