Abstrakt Gynekologie Červen 2010

“Single-Incision Laparoscopic Myomectomy.”

Einarsson, J. I. (2010).

Journal of Minimally Invasive Gynecology 17(3): 371-373.


Single-incision laparoscopic myomectomy is a feasible operation even in the presence of a transmural uterine myoma. The most challenging step of the operation is greatly facilitated by using bidirectional barbed sutures because no knots are required and excellent tension is maintained throughout the hysterotomy closure site. Prospective studies are urgently needed to fully evaluate potential benefits of single-incision laparoscopic surgery. © 2010 AAGL.




“A novel method for training residents in robotic hysterectomy.”

Finan, M. A., M. E. Clark, et al. (2010).

Journal of Robotic Surgery 4(1): 33-39.


Standard surgeon training for robotic hysterectomy currently includes the use of a porcine lab to gain experience using the daVinci Surgical System. Residents in obstetrics/gynecology are taught using a novel dry lab which mimics the tasks specific to a robotic hysterectomy. This technique may ultimately aid in the credentialing of gynecologic surgeons, obviating the need for the porcine lab. A lab simulating the anatomy of key tasks in the hysterectomy with salpingo-oophorectomy has been developed using readily available materials. Residents perform simulated tasks under direct supervision. Time to complete, a subjective grading score, and any errors made are recorded and compared amongst the participants. From April 2007 through April 2008, 16 residents participated in the lab. Mean times (range, standard deviation) to perform simulated procedures were: 177.3 s (100-270, 48.2) for dexterity training, 71.9 s (32-171, 34.6) for identification of the ureter and sealing/dividing the infundibulopelvic ligament, 157.8 s (60-300, 76.8) for dissecting the bladder flap, 77 s (25-148, 34.8) for skeletonizing the uterine arteries, and 516 s (270-946, 237.8) for suturing the vaginal cuff. Since completing the lab, five residents have completed a total of 16 robotic hysterectomies on live patients, with no training-related patient complications. This lab closely mimics those segments of a hysterectomy on humans. Here, we describe a technique to train residents for robotic hysterectomy and bilateral salpingo-oophorectomy without the use of a porcine lab. © 2010 Springer-Verlag London Ltd.




“The early outcomes of the patients who were operated with Da Vinci for benign gynecologic conditions.”

Göçmen, A., F. Şanlikan, et al. (2010).

Da Vinci ile opere edilen benign jinekolojik nedenli hastalarda erken dönem sonuçlarimiz 20(1): 14-21.


Objective: The purpose of this study was to evaluate our early outcomes of robotic assisted surgery that we used first in Turkey in gynecology and to analyze the feasibility of this new minimally invasive surgery. Material and Methods: Between October 2008 and April 2009, 34 patients underwent robotic assisted surgery with da Vinci® Surgical System in our clinic. Four hysterectomy, 21 hysterectomy + bilateral salpingoophorectomy (in one case Burch Operation was performed additionally), 4 myomectomy, 2 sacrocolpopexy, 2 tubal reanostomosis and 1 salpingoophorectomy were performed for benign gynecological conditions. The age, body mass index, estimated blood loss, hospital stay, surgical times and complications were evaluated in all patients. Results: There were no conversions to laparotomy and no major complications were occurred. The complications were two vaginal lacerations, one subcutaneous emphysema, one subcutaneous needle loss and one paralytic ileus. All patients were discharged in post-operative 2 or 3 days. The mean estimated blood loss was calculated 29.1 cc. Conclusion: Surgical and set up times distinctly decreased with increasing number of cases. However, some surgical procedures were insufficient series and it is early to determine long-term surgical outcomes yet, we have successfully performed lots of kind surgery in benign gynecologic conditions. There were no serious problems in the patients even who were overweight, obese and a history of prior pelvic surgery. Robotic surgery will be fairly placed in the area of laparoscopy with increasing experiences and the benefits of this new technology will become clearer in the future. Copyright © 2010 by Türkiye Klinikleri.




“Robotic assisted laparoscopic surgery in gynecology: Review.”

Göçmen, A., F. Şanlikan, et al. (2010).

Jinekolojide robotik asiste laparoskopik cerrahi 20(3): 176-187.


The laparoscopic surgery has taken a significant place in the concept of gynecological surgery for the last two decades. The thought including the application of the best surgical treatment modality to patients with minimal invasive procedure has been evolved new technological improvements and this idea has provided the application of robotics in the field of surgery. The robotics has integrated with virtual reality and the first step to the tele robotic surgery was started. The robotic as sisted surgery is one of the la test innovations in the field of minimally invasive surgery. The da Vinci surgical system has be en used in gynecological procedures including hysterectomy, myomec tomy, urogynecology and cancer surgery. The advantages of the robotic surgery versus laparoscopy are the presence of 3-D visualization, direct view with optimal eye-hand alignment, instruments capable of making 7 different direction movements (df), improved dexterity and coordination, easy suturing, easy tying of knots, no tremor, decreased fatigue of surgeon during operation, short learning process, less convertion to laparotomy, ability to perform complex procedures , shorter operation time. The disadvantages of robotic surgery include lack of tactile feedback, the cost of system, the cost of limited use and disposable instrument, annual service fees, monopoly of one company providing the system, bulkiness of system requiring a larger operating room, long time needed for preparation to surgery, additional training of surgeon and operating room personel and learning process. The robotic surgery is not a surgical system in which the operations were performed by robotics on its own with artificial intelligence. Therefore, surgery with robot is best described as computer-as-sisted laparoscopic surgery. The aim of this article is to introduce the robotic surgery and to assess the application fields in gynecology. Copyright © 2010 by Türkiye Klinikleri.




“Cost-Minimization Analysis of Robotic-Assisted, Laparoscopic, and Abdominal Sacrocolpopexy.”

Judd, J. P., N. Y. Siddiqui, et al. (2010).

Journal of Minimally Invasive Gynecology 17(4): 493-499.


Study Objective: To perform a cost-minimization analysis comparing robotic-assisted, laparoscopic, and abdominal sacrocolpopexy. Design: Cost-minimization analysis using a micro-costing approach (Canadian Task Force classification III). Measurements and Main Results: A decision model was developed to compare the costs (2008 US dollars) of robotic, laparoscopic, and abdominal sacrocolpopexy. Our model included operative time, risk of conversion, risk of transfusion, and length of stay (LOS) for each method. Respective baseline estimates for robotic, laparoscopic, and abdominal sacrocolpopexy procedures included operative time (328, 269, and 170 minutes), conversion (1.4%, 1.8%, and 0%), transfusion (1.4%, 1.8%, 3.8%), and LOS (1.0, 1.8, and 2.7 days). Two models were used, the Robot Existing model, that is, current hospital ownership of a robotic system, and the Robot Purchase model, that is, initial hospital purchase of a robotic system, with purchase and maintenance costs amortized and distributed across robotic procedures. Sensitivity analyses were performed to assess the effect of varying each parameter through its range. For the Robot Existing robot model, robotic sacrocolpopexy was the most expensive, $8508 per procedure compared with laparoscopic sacrocolpopexy at $7353 and abdominal sacrocolpopexy at $5792. Robotic and laparoscopic sacrocolpopexy became cost-equivalent only when robotic operative time was reduced to 149 minutes, robotic disposables costs were reduced to $2132, or laparoscopic disposable costs were increased to $3413. Laparoscopic and abdominal sacrocolpopexy became cost-equivalent only when laparoscopic disposable costs were reduced to $668, mean LOS for abdominal sacrocolpopexy was increased to 5.6 days, or surgeon reimbursement for abdominal sacrocolpopexy exceeded $2213. The addition of robotic purchase and maintenance costs resulted in an incremental increase of $581, $865, and $1724 per procedure when these costs were distributed over 60, 40, and 20 procedures per month, respectively. Conclusion: Robotic sacrocolpopexy was more expensive compared with the laparoscopic or abdominal routes under the baseline assumptions. © 2010 AAGL.




“Robot-Assisted Laparoscopic Presacral Neurectomy: Feasibility, Techniques, and Operative Outcomes.”

Nezhat, C. and V. Morozov (2010).

Journal of Minimally Invasive Gynecology 17(4): 508-512.


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. © 2010 AAGL.




“Robotically assisted hysterectomy: 100 cases after the learning curve.”

Payne, T. N. and F. R. Dauterive (2010).

Journal of Robotic Surgery 4(1): 11-17.


To report on perioperative outcomes of robotic hysterectomy after the learning curve, we performed a retrospective review of our second 100 consecutive robotic hysterectomies performed by two surgeons between January 2007 and February 2008. Operative time following our learning curve was 79.3 ± 36.1 min. Patient age was 44.2 ± 9.6 years, body mass index (BMI) was 30.9 ± 8.3 kg/m<sup>2</sup>, and uterine weight was 223.7 ± 195.8 g. Indications for surgery included fibroids, menstrual disorders, and endometriosis. We performed total robotic-assisted laparoscopic hysterectomy type IVE. There were no conversions, no blood transfusions, and one cystotomy, repaired intraoperatively. Blood loss was 68.8 ± 105.8 cc, and average length of stay was 1.1 ± 0.3 days. There were no postoperative complications. Perioperative outcomes demonstrate low average operative times with a high level of safety on a broadened patient population, suggesting a potential advantage to using the robotic platform. © 2010 Springer-Verlag London Ltd.




“Robot-assisted laparoscopic surgery for a rudimentary uterine horn with two non-communicating cavities.”

Persson, J., T. Bossmar, et al. (2010).

Journal of Robotic Surgery: 1-4.


Due to severe dysmenorrhoea a 29-year-old woman, gravida 2 para 2, was diagnosed with a unicornuate uterus and a rare variety of a rudimentary uterine horn associated with two separate non-communicating cavities. Increasingly intense dysmenorrhoea, refractory to medical treatment, motivated fertility-sparing surgical treatment. A da Vinci S-HD robot was side-docked to facilitate simultaneous vaginal access during surgery. After sacrificing the left uterine artery for hemostatic reasons, the rudimentary horn with one cavity was resected. Guided by vaginal ultrasonography we then completely resected the second cavity located deep in the myometrium without entering the cavity of the functioning hemiuterus. Finally the uterine defect was sutured in two layers. Surgery and postoperative course were uneventful. At 4-month follow-up, dysmenorrhoea was alleviated, and 3 months later the patient had an early intrauterine pregnancy. We believe the precise dissection capabilities of the robot facilitated in particular resection of the second, deeply located cavity and its multilayer reapproximation by sutures. A video of the procedure is provided. © 2010 Springer-Verlag London Ltd.




“Histopathology indicates lymphatic spread of a pelvic retroperitoneal ectopic pregnancy removed by robot-assisted laparoscopy with temporary occlusion of the blood supply.”

Persson, J., P. Reynisson, et al. (2010).

Acta Obstetricia et Gynecologica Scandinavica 89(6): 835-839.


Retroperitoneal ectopic pregnancies are extremely rare and a diagnostic and therapeutic challenge as an early diagnosis is difficult and all treatments entail a risk for severe bleeding. We present a case of a live completely retroperitoneal ectopic pregnancy in the right obturator fossa. Following 3D color Doppler vaginal ultrasonography to evaluate the relation to larger blood vessels the pregnancy was completely removed by robot-assisted laparoscopic surgery. The hypogastric artery was temporarily occluded by removable vessel clips. Time for surgery was 126 minutes, no bleeding occurred. The postoperative course was uneventful and s-βhCG normalized in five weeks. Histopathology of the intact specimen showed trophoblast surrounded by lymphatic tissue. We believe robot-assisted laparoscopic surgery is a feasible and safe technique for surgery of retroperitoneal ectopic pregnancies with similar or other locations allowing occlusion of the main supplying artery. Lymphatic spread may explain retroperitoneal ectopic pregnancies. © 2010 Informa UK Ltd.




“Brachial Plexus Injury after Laparoscopic and Robotic Surgery.”

Shveiky, D., J. N. Aseff, et al. (2010).

Journal of Minimally Invasive Gynecology 17(4): 414-420.


The objective of this article was to review the literature regarding brachial plexus injury (BPI) in laparoscopic and robotic surgery. BPI complicates gynecologic laparoscopic surgery with an estimated incidence of 0.16%. Nevertheless, as the numbers of advanced laparoscopic and robotic procedures increase, the anticipated risk of this complication may rise as well. Robotic surgery often requires steeper Trendelenburg positioning and longer operative times when compared with traditional laparoscopic surgery. In this article we review the anatomy, pathophysiology, diagnosis, and treatment of position-related BPI in the context of laparoscopic and robotic gynecologic surgery. We suggest a multidisciplinary approach to the diagnosis and treatment of BPI. Recommendations for prevention of this complication are also provided. © 2010 AAGL.




“Past, Present, and Future of Hysterectomy.”

Sutton, C. (2010).

Journal of Minimally Invasive Gynecology 17(4): 421-435.


Until the late 1930s, the standard type of abdominal hysterectomy was subtotal, leaving the cervix behind to decrease the risk of peritonitis with its attendant high mortality. With the discovery of antibiotics, careful attention to antisepsis, and other medical and surgical advances, this method was gradually replaced by total abdominal hysterectomy in the United States and the United Kingdom, although the subtotal approach still remained popular, in particular in Scandinavian countries. With the advent of laparoscopic hysterectomy, many surgeons, wanting a simpler approach and for a variety of other reasons, have returned to performance of subtotal hysterectomy. The objectives of the present article is to review the development of the operation from a historical perspective, and to attempt to answer some of the dilemmas posed when choosing between a total and subtotal procedure, using results from evidence-based research when possible. © 2010 AAGL.




“Robotically assisted hysterectomy in patients with large uteri: outcomes in five community practices.”

Walter, A. (2010).

Obstetrics and Gynecology 116(1): 193-194; author reply 194.




“Robotic-assisted laparoscopic myomectomy.”

Wattiez, A. and J. Nassif (2010).

Gynecological Surgery 7(1): 90.




“Implementation of robotic surgery into a gynecologic and gynecologic oncology practice: zero to 75 in 16 months.”

Dudley, B. S. (2010).

Tennessee medicine : journal of the Tennessee Medical Association 103(2): 39-41.




“Comparison of outcomes between laparotomy and robotic technique for cervical cancer.”

Göçmen, A., F. Şanlikan, et al. (2010).

Journal of Robotic Surgery: 1-6.


We evaluated the results of patients who had undergone robotic-assisted radical hysterectomy or open radical hysterectomy for cervical cancer. The study included eight patients who had undergone robotic-assisted radical hysterectomy (group 1) and seven patients who had undergone radical hysterectomy (group 2). Demographic characteristics and operative results of all patients were compared. Body mass index, age, previous abdominal surgery, surgical procedure performed, total anesthesia duration, operation duration, intra- and postoperative complications, duration of hospital stay, and number of resected lymph nodes were recorded. Mean age of patients in the robotic surgery group was 47.8 years (38-56 years) and in the laparotomy group was 45.4 years (32-57 years). Body mass index was 33.2 kg/m<sup>2</sup> (24.8-40.2 kg/m<sup>2</sup>) in group 1 and 27.8 kg/m<sup>2</sup> (23.5-33.7 kg/m<sup>2</sup>) in group 2. Total duration of operation in group 1 and 2 was 233 min (185-321 min) and 210.8 min (134-310 min), respectively. Mean duration of hospital stay was 3.5 days (2-7 days) in group 1 and 9.5 days (6-11 days) in group 2. Mean number of resected lymph nodes was 23.6 (17-36) and 38.8 (22-59) in group 1 and 2, respectively. Robotic surgery was superior to laparotomy in terms of duration of hospital stay, estimated amount of blood loss, and number of complications. Operation duration was longer with robotic surgery compared with laparotomy, and rate of complications was higher with laparotomy. Although the number of patients in the present study is limited, the results are important since they represent the first data relating to robotic surgery in Turkey. © 2010 Springer-Verlag London Ltd.




“Endometrial Cancer Surgery Costs: Robot vs Laparoscopy.”

Holtz, D. O., G. Miroshnichenko, et al. (2010).

Journal of Minimally Invasive Gynecology 17(4): 500-503.


Study Objective: To compare surgical costs for endometrial cancer staging between robotic-assisted and traditional laparoscopic methods. Design: Retrospective chart review from November 2005 to July 2006 (Canadian Task Force classification II-3). Setting: Non-university-affiliated teaching hospital. Patients: Thirty-three women with diagnosed endometrial cancer undergoing hysterectomy, bilateral salpingo-oophorectomy, and pelvic and paraaortic lymph node resection. Interventions: Patients underwent either robotic or traditional laparoscopic surgery without randomization. Measurements and Main Results: Hospital cost data were obtained for operating room time, instrument use, and disposable items from hospital billing records and provided by the finance department. Separate overall hospital stay costs were also obtained. Mean operative costs were higher for robotic procedures ($3323 vs $2029; p < .001), due in part to longer operating room time ($1549 vs $1335; p = .03). The more significant cost difference was due to disposable instrumentation ($1755 vs $672; p < .001). Total hospital costs were also higher for robotic-assisted procedures ($5084 vs $ 3615; p = .002). Conclusion: Robotic surgery costs were significantly higher than traditional laparoscopy costs for staging of endometrial cancer in this small cohort of patients. © 2010 AAGL.




“Robotic surgical management of endometrial cancer in octogenarians and nonagenarians: analysis of perioperative outcomes and review of the literature.”

Lowe, M. P., S. Kumar, et al. (2010).

Journal of Robotic Surgery: 1-7.


The primary aim of this article is to report the outcomes of octogenarians and nonagenarians who have undergone robotic surgery for endometrial cancer. A multi-institutional research consortium was created to evaluate the utility of robotics for gynecologic surgery (benign and malignant). IRB approval was obtained at each institution. A multi-institutional HIPPA compliant database was then created and analyzed for all patients that underwent robotic-assisted surgery with staging for endometrial cancer between the April 2003 and January 2009. In total, 395 patients were identified. A subset of patients between the ages of 80 and 95 years were then identified and analyzed for demographic data and perioperative outcomes. Twenty-seven patients in this age group were identified who underwent robotic-assisted hysterectomy and staging. The median age was 84, and median body mass index was 28. Comorbidities such as diabetes mellitus and hypertension were identified in 22 and 74% of patients, respectively. Over one-half (56%) of the patients reported a prior abdominal surgery. Final pathological analysis demonstrated that 88% of all patients had either Stage I or II disease. The median operative time was 192 min. The median estimated blood loss was 50 cc, and the median lymph node count was 16. The median hospital stay was 1.0 day. The overall intraoperative and postoperative complication rate was 7.4 and 33%, respectively. No patient received a blood transfusion. There was one conversion to laparotomy (3.7%). A comparison of the outcomes of the elderly cohort to those of all patients in the database (control group) revealed that there was no statistically significant difference between the groups in terms of operative time, blood loss, hospital stay, nodal yield, or conversion rate. Intraoperative complications were statistically similar between the groups; however, postoperative complications were significantly higher in the elderly cohort. We conclude that robotic surgery is safe, feasible, and expands surgical options for octogenarians and nonagenarians diagnosed with endometrial cancer. Age should not be considered a contraindication for robotic surgical management of patients with endometrial cancer. © 2010 Springer-Verlag London Ltd.




“Placental site trophoblastic tumor presenting as an intramural mass with negative markers: An opportunity for novel diagnosis and treatment with robotic hysterectomy.”

Namaky, D., J. Basil, et al. (2010).

Journal of Robotic Surgery 4(1): 57-59.


A patient presented with persistent levels of quantitative human chorionic gonadotropin despite therapy with methotrexate. A dilation and curettage procedure did not provide a pathologic diagnosis. Gestational trophoblastic disease was suspected, but serum biomarkers were unable to provide a pre-operative diagnosis. A mass was found in the uterus by ultrasound and subsequent computed tomography scans. There was no evidence of extrauterine disease, but the uterine mass was continuous with the endometrial cavity, evoking the suspicion of an invasive endometrial mass. The patient underwent robotic hysterectomy for both therapy and diagnosis of suspected gestational trophoblastic disease (GTD). The final pathologic diagnosis was placental site trophoblastic tumor. The robotic approach allows for a minimally invasive surgical procedure with thorough examination of the pelvic cavity and adnexae and does not require a uterine manipulator which may be contra-indicated in the setting of uterine GTD. For patients with suspected persistent uterine GTD who are otherwise candidates for minimally invasive surgery, a robotic procedure offers advantages when compared to traditional laparoscopy or vaginal hysterectomy. © 2010 Springer-Verlag London Ltd.




“Robotic radical hysterectomy using a side-docking approach.”

Tam, K. F. and H. Y. S. Ngan (2010).

Journal of Gynecologic Surgery 26(2): 99-104.


Objective: The objective of this study was to describe the use of a robotic surgical system for radical hysterectomy in a side-docking approach. Methods: We report a series of laparoscopic radical hysterectomies performed using the da Vinci Robotic Surgical System in a side-docking approach. The patient’s record and operative findings were reviewed. Results: A series of eight laparoscopic radical hysterectomies using the da Vinci Robotic Surgical System in a side-docking approach were performed from July 2009 to November 2009. Vaginal access was readily available to surgeons. The working space for the first assistant was improved comparing to the central-docking approach. The median operative time was 257 minutes and median blood loss was 200 mL. There was no major complication from the operations. All patients recovered from the operation without significant sequelae. Conclusions: A series of laparoscopic radical hysterectomies using the da Vinci Robotic Surgical System in a side-docking approach was reported. This approach provides better vaginal access and improved the working spaces for the assistants. © Mary Ann Liebert, Inc. 2010.




“Recent advances of robotic surgery and single port laparoscopy in gynecologic oncology.”

Yong, W. J., W. K. Sang, et al. (2009).

Journal of Gynecologic Oncology 20(3): 137-144.


Two innovative approaches in minimally invasive surgery that have been introduced recently are the da Vinci robotic platform and single port laparoscopic surgery (SPLS). Robotic surgery has many advantages such as 3-dimensional view, the wrist like motion of the robotic arm and ergonomically comfortable position for the surgeon. Numerous literatures have demonstrated the feasibility of robotic surgery in gynecologic oncology. However, further research should be performed to demonstrate the superiority of robotic surgery compared to conventional laparoscopy. Additionally, cost reduction of robotic surgery is needed to adopt robotic surgery into gynecologic oncology worldwide. SPLS has several possible benefits including reduced operative complications, reduced postoperative pain, and better cosmetic results compared to conventional laparoscopy. Although several authors have indicated that SPLS is a feasible approach for gynecologic surgery, there have been few reports demonstrating the potential advantages over conventional laparoscopy. Moreover, technical difficulties of SPLS still exist. Therefore, the advantages of a single port approach compared to conventional laparoscope should be evaluated with comparative study, and further technologic development for SPLS is also needed. These two progressive technologies take the lead in the development of MIS and further studies should be performed to evaluate the benefits of robot surgery and SPLS.