Chan, W. S. W., K. K. Y. Kong, et al. (2012). “Vaginal vault dehiscence after laparoscopic hysterectomy over a nine-year period at Sydney West Advanced Pelvic Surgery Unit – Our experiences and current understanding of vaginal vault dehiscence.” Australian and New Zealand Journal of Obstetrics and Gynaecology 52(2): 121-127.

Background: A retrospective analysis of all women undergoing hysterectomy at Sydney West Advanced Pelvic Surgery Unit (SWAPS) was performed in the nine-year period from 2001 to 2009. Aims: To evaluate the incidence, timing and presenting symptoms of vaginal vault dehiscence after hysterectomy, especially via the laparoscopic approach to gain further understanding of patient risk factors and surgical factors that may predispose to this complication. Methods: Women who presented with vaginal vault dehiscence were identified and possible pre-operative, intra-operative and post-operative risk factors were assessed. A comprehensive literature search was performed to assess the current understanding and incidence of vault dehiscence after laparoscopic hysterectomy. Results: A total of 1224 hysterectomies were performed between 2001 and 2009. 989 (80.80%) were performed laparoscopically of which five women (0.42%) presented with vault dehiscence post-operatively. All had undergone total laparoscopic hysterectomy resulting in a vault dehiscence rate of 1.59% after total laparoscopic hysterectomy specifically. Baseline characteristics included a mean age of 42.8 years (37-51 years), mean BMI of 26.8 kg/m 2 (23.8-32.3 kg/m 2) and a mean parity of two deliveries (1-3 deliveries). The main presenting symptom of vaginal vault dehiscence was vaginal bleeding. Women with confirmed vaginal vault dehiscence readmitted to hospital at a mean of 18 days (11-28 days) post-operatively. Conclusion: Vaginal vault dehiscence is a rare complication after hysterectomy, but more common after a laparoscopic approach. A delayed presentation with vaginal bleeding was the main presenting symptom in this study – a literature review has shown common presenting symptoms to include abdominal pain, vaginal evisceration and vaginal bleeding. Techniques specific to total laparoscopic hysterectomy seem especially important in the increased risk of vaginal vault dehiscence seen after laparoscopic hysterectomy. © 2012 The Authors. ANZJOG © 2012 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Cohen, S. L. and J. I. Einarsson (2011). “Total and supracervical hysterectomy.” Obstetrics and Gynecology Clinics of North America 38(4): 651-661.

Despite a long history of success with laparoscopic approach to hysterectomy, the majority of hysterectomies in the United States are currently performed via laparotomy.48-51 Barriers to the integration of laparoscopic hysterectomy include technological difficulties, inadequate training, low levels of peer support, potential for decreased reimbursement and misconceptions about laparoscopic safety, cost, and technical feasibility.52-54 With the continual evolution of minimally invasive hysterectomy techniques, now including robotic, single-port, and natural-orifice surgery, it is vital to critically evaluate the literature in an effort to offer patients the most safe and effective treatments. This report aims to summarize the available data surrounding both the total and supracervical laparoscopic hysterectomy and to provide concrete suggestions for maximizing success with these procedures.

Tan, S. J., C. K. Lin, et al. (2012). “Robotic surgery in complicated gynecologic diseases: Experience of Tri-Service General Hospital in Taiwan.” Taiwanese Journal of Obstetrics and Gynecology 51(1): 18-25.

Objective: Minimally invasive surgery has been the trend in various specialties and continues to evolve as new technology develops. The development of robotic surgery in gynecology remains in its infancy. The present study reports the first descriptive series of robotic surgery in complicated gynecologic diseases in Taiwan. Materials and Methods: From March 2009 to February 2011, the records of patients undergoing robotic surgery using the da Vinci Surgical System were reviewed for patient demographics, indications, operative time, hospital stay, conversion to laparotomy, and complications. Results: Sixty cases were reviewed in the present study. Forty-nine patients had benign gynecologic diseases, and 11 patients had malignancies. These robot-assisted laparoscopic procedures include nine hysterectomy, 15 subtotal hysterectomy, 13 myomectomy, eight staging operation, two radical hysterectomy, five ovarian cystectomy, one bilateral salpingo-oophorectomy and myomectomy, two resections of deep pelvic endometriosis, one pelvic adhesiolysis, three sacrocolpopexy and one tuboplasty. Thirty-three patients had prior pelvic surgery, and one had a history of pelvic radiotherapy. Adhesiolysis was necessary in 38 patients to complete the whole operation. Robotic myomectomy was easily accomplished in patients with huge uterus or multiple myomas. The suturing of myometrium or cervical stump after ligation of the uterine arteries minimized the blood loss. In addition, it was much easier to dissect severe pelvic adhesions. The dissection of para-aortic lymph nodes can be easily accomplished. All these surgeries were performed smoothly without ureteral, bladder or bowel injury. Conclusion: The present analyses include various complicated gynecologic conditions, which make the estimation of the effectiveness of robotic surgery in each situation individually not appropriate. However, our experiences do show that robotic surgery is feasible and safe for patients with complicated gynecologic diseases. © 2012 .

GYN_Benign|GYN_Cancer|GYN_General (1)

GYN_Cancer (5)

Bolles, O. and M. Borowsky (2012). “Port-site metastasis following robotic-assisted radical hysterectomy for squamous cell cervical cancer.” Gynecologic Oncology Case Reports 2(2): 32-34.

Capmas, P., A. S. Bats, et al. (2012). “Robotic surgery in endometrial cancer: A review.” Place de la chirurgie robotisée dans la prise en charge des cancers de l’endomètre : revue de la littérature.

Robotic surgery had spread for a few years. This access is now important in urologic surgery, especially for prostatic procedures. Development of robotic surgery in gynecology is more recent. Gynecologic oncology is probably one of the most interesting fields of development of this access. Robotic surgery is frequently used in endometrial cancer. As no randomized study is available, it seems to be interesting to make a review of retrospective studies. Feasibility seems to be high and the learning curve is short (around 20 cases). Operative lengths are longer when compared to laparotomy, but are similar or shorter than laparoscopy. Robot setting increases the global length of the procedure, but decreases with experience. Operative blood loss, as well as transfusion rate are decreased when compared to laparotomy, but are similar to those of laparoscopy. The overall morbidity rate seems lower than with other approaches. Postoperative pain, hospital stay and time to recovery are decreased when compared to laparotomy as well as to laparoscopy for some authors. The main limit to the diffusion of robotic surgery is accessibility because of its important cost. Other limits are pointed out by the most trained teams. © 2012.

Gil-Moreno, A., J. F. Magrina, et al. (2012). “Location of aortic node metastases in locally advanced cervical cancer.” Gynecologic Oncology 125(2): 312-314.

Background: To assess the location of aortic node metastasis in patients with locally advanced cervical cancer undergoing extraperitoneal aortic lymphadenectomy to define the extent of the aortic lymphadenectomy. Material and methods: Between August 2001 and December 2010, 100 consecutive patients with primary locally advanced cervical cancer underwent extraperitoneal laparoscopic aortic and common iliac lymphadenectomy. The location of aortic node metastases, inframesenteric or infrarenal was noted. Results: The mean number ± standard deviation (SD) of aortic nodes removed was 15.9 ± 7.8 (range 4-62). The mean number ± SD of inframesenteric (including common iliac) nodes removed was 8.8 ± 4.5 (range 2-41) and the mean number ± SD of infrarenal nodes removed was 7.8 ± 4.1 (range 2-21). Positive aortic nodes were observed in 16 patients, and in 5 (31.2%) of them the infrarenal nodes were the only nodes involved, with negative inframesenteric nodes. Conclusion: Inframesenteric aortic nodes are negative in the presence of positive infrarenal nodes in about one third of patients with locally advanced cervical cancer and aortic metastases. © 2012 Elsevier B.V. All rights reserved.

Göçmen, A., F. Şanlikan, et al. (2012). “Robotic-assisted infrarenal aortic lymphadenectomy and pelvic lymphadenectomy for endometrial staging using a single docking procedure.” Gynecologic Oncology Case Reports2(2): 44-46.

Holloway, R. W., R. A. Bravo, et al. (2012). “Detection of sentinel lymph nodes in patients with endometrial cancer undergoing robotic-assisted staging: A comparison of colorimetric and fluorescence imaging.” Gynecologic Oncology.

OBJECTIVE: To retrospectively compare results from lymphatic mapping of pelvic sentinel lymph nodes (SLN) using fluorescence near-infrared (NIR) imaging of indocyanine green (ICG) and colorimetric imaging of isosulfan blue (ISB) dyes in women with endometrial cancer (EC) undergoing robotic-assisted lymphadenectomy (RAL). A secondary aim was to investigate the ability of SLN biopsies to increase the detection of metastatic disease. METHODS: Thirty-five patients underwent RAL with hysterectomy. One mL ISB was injected submucosally in four quadrants of the cervix, followed by 0.5mL ICG [1.25mg/mL] immediately prior to placement of a uterine manipulator. Retroperitoneal spaces were dissected for colorimetric detection of lymphatic pathways. The da Vinci(R) camera was switched to fluorescence imaging and results recorded. SLN were removed for permanent analysis with ultra-sectioning, H&E, and IHC staining. Hysterectomy with RAL was completed. RESULTS: Twenty-seven (77%) and 34 (97%) of patients had bilateral pelvic or aortic SLN detected by colorimetric and fluorescence, respectively (p=0.03). Considering each hemi-pelvis separately, 15/70 (21.4%) had “weak” uptake of ISB in SLN confirmed positive with fluorescence imaging. Using both methods, bilateral detection was 100%. Ten (28.6%) patients had lymph node (LN) metastasis, and 9 of these had SLN metastasis (90% sensitivity, one false negative SLN biopsy). Seven of nine (78%) SLN metastases were ISB positive and 100% were ICG positive. Twenty-five had normal LN, all with negative SLN biopsies (100% specificity). Four (40%) with LN metastasis were detected only by IHC and ultra-sectioning of SLN. CONCLUSIONS: Fluorescence imaging with ICG detected bilateral SLN and SLN metastasis more often than ISB, and the combination resulted in 100% bilateral detection of SLN. Ultra-sectioning/IHC of SLN increased the detection of lymph node metastasis.

GYN_General (14)

Barbalat, Y. and H. S. G. R. Tunuguntla (2012). “Surgery for Pelvic Organ Prolapse: A Historical Perspective.”Current Urology Reports: 1-6.

Surgical treatment of pelvic organ prolapse has evolved from the use of pomegranates as pessary devices to contemporary robot-assisted laparoscopic sacral colpopexy. Symptomatic pelvic organ prolapse requires correction of all the defects to achieve optimal outcomes. Factors to consider in selecting the appropriate repair include patient’s age; stage of prolapse; vaginal length; hormonal status; desire for uterine preservation and coitus; symptoms of sexual, urinary, or bowel dysfunction; and any comorbidities that influence her eligibility for anesthesia or chronically increase intra-abdominal pressure. There is currently no consensus as to the best surgical approach for advanced pelvic organ prolapse. Reconstructive surgery for pelvic organ prolapse is currently performed by vaginal or abdominal (open, laparoscopic, and robotic approaches) approaches or a combination. It is important to maintain skills in proven procedures such as abdominal sacrocolpopexy and sacrospinous ligament suspension. This paper discusses the historical evolution of surgery for pelvic organ prolapse from antiquity to date. © 2012 Springer Science+Business Media, LLC.

Carbonnel, M., A. Roulot, et al. (2012). “[Robot-assisted coelioscopic proximal tubal reanastomosis.].” Gynecologie, Obstetrique et Fertilite.

We report two cases of robot-assisted coelioscopic proximal tubal reanastomosis after proximal tubal ligature. Patients were aged 43 and 34 years respectively and had previously undergone proximal tubal ligation by coagulation section at 37 years of age for the first patient, and by Filshie clip at 24 years for the second one. Both had regular menstrual cycles and their ovarian reserve was good. Their partners were presenting with normal sperm criteria. Proximal tubal reanastomosis was carried out in September 2010 by robotic coelioscopy with five extramucous vicryl 5-0 stitches on each tube and positive blue testing. Total durations of the interventions were 200 and 220minutes respectively. Postoperative outcomes were simple and patients had spontaneous pregnancy at 4 and 2.5 months respectively. Both pregnancies show normal progress currently. This is a contribution to literature data meant to determine the role of robotics in proximal tubal reanastomosis.

Chon, H. S., W. D. Bush, et al. (2012). “Robotic-assisted resection of isolated paraaortic lymph node recurrence with right lateral decubitus position.” Journal of Robotic Surgery: 1-3.

In this report we describe transperitoneal robotic-assisted paraaortic lymphadenectomy via the right lateral decubitus position to treat solitary recurrence in a patient with cervical carcinoma. This is, to our knowledge, the first report utilizing the right lateral decubitus position rather than the traditional approach with the Trendelenberg position. This approach adds another option for surgical approaches to the paraaortic lymph nodes, particularly in subgroups of patients who have significant cardiopulmonary cormobidities and are unable to tolerate the steep Trendelenburg position. © 2012 Springer-Verlag London Ltd.

Hampel, C., C. Thomas, et al. (2012). “Sacropolpopexy – pro robotic.” Sakrokolpopexie – pro robotisch: 1-5.

Abdominal sacrocolpopexy is a standard procedure for the correction of pelvic organ prolapse of all three compartments and can also be performed minimally invasively without compromising efficacy as by open techniques. In comparison to conventional laparoscopy robotic-assisted laparoscopic sacrocolpopexy benefits from several technical stand-alone features, such as three-dimensional view, increased degrees of freedom through angulated instruments, tremor filter and up and down scaling of instrument movements. These advantages facilitate preparation of the vesicovaginal and rectovaginal spaces as well as suturing and reperitonealization, which should lead to decreased operation time and anesthesia time in extreme Trendelenburg position. Surgeon also benefit from the much more ergonomic working conditions of the da Vinci® system: however, comparative studies are rare and conclusions are preliminary. The German reimbursement system (DRG) does not adequately cover da Vinci expenses which, despite the obvious advantages represents the most significant obstacle in the propagation of this technique. © 2012 Springer-Verlag.

Kolbl, H. (2012). “[Comments on sacrocolpoplexy - laparoscopic versus robotic.].” Urologe. Ausgabe A.

Levy, B. (2012). “Experience counts.” Obstetrics and Gynecology 119(4): 693-694.

Mansour, F. W., S. Kives, et al. (2012). “Robotically assisted laparoscopic myomectomy: a canadian experience.”Journal of Obstetrics and Gynaecology Canada 34(4): 353-358.

Objective: To compare operative and immediate postoperative outcomes of robotically assisted laparoscopic myomectomy (RALM) and open myomectomy. Methods: We conducted a retrospective review of 38 cases of RALM performed in women of reproductive age with symptomatic uterine fibroids between October 2008 and February 2011. Twenty-one cases of open myomectomy were used as historical controls. Operative and immediate postoperative outcomes were compared. Data analysis was performed using Student t test, chi-square test, and analysis of covariance where appropriate. Results: The two groups were comparable in age, body mass index, parity, and symptoms. Up to 12 fibroids were resected robotically with a mean diameter of 9.1 +/- 2.0 cm and a mean weight of 389 +/- 170 g (range 73 to 900 g). RALM was associated with less blood loss (decrease in hemoglobin concentration 25.6 +/- 12.0g/L) than open myomectomy (37.7 +/- 20.1 g/L) (P = 0.018). Adjusting for baseline levels, postoperative hemoglobin levels were 99 g/L and 88 g/L in the robotic and open groups, respectively (P = 0.005). RALM was associated with shorter hospitalization (1.2 +/- 0.5 vs. 2.5 +/- 0.6 days, P < 0.001) and longer operating times (189.7 +/- 71.5 vs. 92.5 +/- 33.0 minutes, P < 0.001). Three patients in the open myomectomy group and one in the robotic group required blood transfusion. One patient in the robotic group developed lumbar plexopathy postoperatively. Conclusion: Robotically assisted laparoscopic myomectomy is associated with less blood loss and shorter hospital stay than myomectomy by laparotomy. Accumulating evidence of the risks and benefits of RALM will contribute to enhancing access to this technology on the part of women and their surgeons.

McNanley, A., M. Perevich, et al. (2012). “Bowel function after minimally invasive urogynecologic surgery: a prospective randomized controlled trial.” Female Pelvic Med Reconstr Surg 18(2): 82-85.

OBJECTIVES: The goals of this study were to assess the effect of a standardized postoperative bowel regimen of over-the-counter medications on (1) time to first bowel movement (BM) and (2) pain level associated with first BM in subjects undergoing minimally invasive urogynecologic surgery. METHODS: Eligible patients scheduled to undergo minimally invasive urogynecologic surgery were offered participation. Enrolled subjects were randomized by computerized schedule. Demographic and perioperative data were collected. Subjects completed a validated questionnaire preoperatively and postoperatively assessing preexisting constipation, frequency and consistency of bowel movements, use of pain medications, mean daily pain level (using visual analog scale), stool consistency, and pain associated with first postoperative bowel movement. The control group was instructed to take docusate sodium twice daily postoperatively. The treatment group took docusate sodium plus Miralax, fiber wafers, and bisacodyl suppositories as directed by protocol. Wilcoxon or t testing was used to compare continuous variables; chi testing was used for categorical relationships, and backward-elimination multiple regression was used to assess independent effects. RESULTS: Seventy-two subjects were enrolled and randomized. Twelve subjects withdrew, leaving 60 (30 per group) completing the study. There were no statistically significant differences between groups in baseline characteristics. Mean (SD) age was 63 (9) years for the control group and 58 (10) for the study group (P = 0.06). Mean pelvic organ prolapse stage was III in each group. The mean (SD) operating room time was 198 (65) minutes for the controls and 216 (74) for the study subjects. Sixty-five percent underwent robot-assisted surgery (50% hysterectomy and 63% sacrocolpopexy). Ninety-eight percent of surgeries were performed under general anesthesia.Before adjustment, the mean (SD) time to first BM was 77 (24) hours in controls versus 64 (21) in the study patients (P = 0.03). Using multiple regression, baseline frequency of defecation (1-2 BMs/wk) was directly associated with the time to first BM (added 25.2 hours; P = 0.009) and being in the study group was inversely associated (first BM, 11.7 hours sooner; P = 0.04). No other variables were retained.There was no difference in pain associated with first postoperative BM (visual analog scale, 3.6 (3.2) vs 3.7 (2.8); P = 0.98), but those with prior complaints of vaginal or rectal splinting had higher pain scores (1.9 and 2.8 points higher, respectively; P = 0.04 for both). There was a trend toward higher pain scores with higher postoperative daily narcotic intake (P = 0.06). No other variables were retained.There was a significant difference in recorded compliance between control versus study regimens (94% vs 81%, respectively; P = 0.002). CONCLUSIONS: Mean time to first postoperative BM after minimally invasive urogynecologic surgery is more than 3.5 days with use of docusate sodium alone and is only slightly shorter when combination therapy is used. First BM after surgery is considered to be painful despite the use of medications. Future studies targeting postoperative discomfort/pain with defecation could target preoperative bowel regimens or more aggressive postoperative interventions. Regimens should remain simple to increase compliance.

Osmundsen, B. C., A. Clark, et al. (2012). “Mesh erosion in robotic sacrocolpopexy.” Female Pelvic Med Reconstr Surg 18(2): 86-88.

OBJECTIVE: This study aimed to compare the incidence of mesh erosion after robotic sacrocolpopexy between women undergoing total and those undergoing supracervical hysterectomy (SH). METHODS: This is a retrospective cohort study of women who underwent sacrocolpopexy and concomitant hysterectomy using the DaVinci surgical robot between May 2007 and December 2010 at 2 sites. Baseline data were gathered before surgery. The primary outcome was mesh erosion identified during 3 months of follow-up. RESULTS: A total of 102 women underwent sacrocolpopexy, of whom 45 were with concomitant SH and 57 were with total hysterectomy (TH). Their mean age was 58 years, mean body mass index was 26.8 kg/m, 98% were white, 6% smoked, and 25% were on systemic hormone replacement therapy. Mean preoperative Ba = +1.4, C = -2.2. These were not different between the 2 groups or by site. Within 3 months of surgery, mesh erosion was diagnosed in 8 women, all of whom had TH. No mesh erosions occurred in the SH group (14% vs 0%). Total hysterectomy mesh erosion rate at site 1 was 3% compared with 37% at site 2. Mesh type was the only identifiable difference between sites: self-cut polypropylene at site 1, precut polypropylene at site 2. Two women in the SH had abnormal uterine pathology: 1 endometrial adenocarcinoma and 1 focus of hyperplasia with atypia. CONCLUSIONS: No mesh erosions were associated with SH within the first 3 months. In TH, the graft material used may be a modifiable factor needing further investigation. Unexpected abnormal uterine pathologic diagnosis remains a possibility with SH. Longer-term follow-up and a randomized trial are warranted to answer these questions.

Pilka, R. (2011). “Robotic surgery in gynecology.” Robotická chirurgie v gynekologii 20(2): 46-50.

Objective: The objective of this article is to review the recent adoption, experience, and applications of robot-assisted laparoscopy in gynecologic surgery. Methods: Review of literature with robotic surgery. Results: Robotic-assisted laparoscopic surgeries in gynecology include benign hysterectomy, myomectomy, tubal reanastomoses, radical hysterectomy, lymph node dissections, and sacrocolpopexies. Robot-assisted gynecologic surgery is often associated with longer operating room time but generally similar clinical outcomes, decreased blood loss, and shorter hospital stay when compared to open or laparoscopic surgery. Conclusions: Well-designed, prospective studies with well-defined clinical, long-term outcomes, including complications, cost, pain, return to normal activity, and quality of life, are needed to fully assess the value of this new technology.

Pulliam, S. J., M. M. Weinstein, et al. (2012). “Minimally invasive apical sacropexy: a retrospective review of laparoscopic and robotic operating room experiences.” Female Pelvic Med Reconstr Surg 18(2): 122-126.

OBJECTIVES: Minimally invasive apical sacropexies (MI-APSC) can be performed using robotics or laparoscopy. We hypothesized that operative characteristics of MI-APSC, laparoscopic (LSC) and robotic (RSC), were similar. The objective of our study was to compare operative characteristics, objective prolapse outcomes, and robotic learning curve. METHODS: Ninety-two women planning MI-APSC for treatment of apical pelvic organ prolapse from 2006 to 2010 were included in the study. The primary outcome was operative time. The secondary outcomes included estimated blood loss, rate of conversion, intraoperative complications, hospital stay, and objective prolapse outcome. We also analyzed the robotic learning curve. Statistical analysis included independent samples t test, Wilcoxon rank sum test, chi, and multiple logistic regressions; significance was set at P < 0.05. Learning curve was graphed with moving average and analyzed with moving block technique. RESULTS: Forty-eight RSCs and 43 LSCs were analyzed. Mean operative times were LSC, 238 +/- 59 minutes; and RSC, 242 +/- 54 minutes. Robotic MI-APSC setup was longer (P = 0.02). Complications, conversions, estimated blood loss and hospital stay were low and similar between groups. Patients’ characteristics were similar. Concomitant procedures produced longer operative times. CONCLUSIONS: Operating room experiences with laparoscopic- and robotic-assisted approaches to MI-APSC were similar, but setup time is longer for the robotic-assisted approach. The robotic learning curve is short for surgeons who have experience with LSC.

Sotelo, R., V. Moros, et al. (2012). “Robotic repair of vesicovaginal fistula (VVF).” BJU International 109(9): 1416-1434.

Stark, M., S. Gidaro, et al. (2011). “The future of gynaecological surgery – Telesugery with haptic sensation.”Gineco.ro 7(4): 210-213.

The 19 th century will be remembered as the era of open surgery. The history of gynaecological surgery started in 1807 in Kentucky, Missoury, when Ephraim McDowell performed the first successful cystectomy using a longitudinal abdominal incision. Throughout the 19 th century, longitudinal incisions were routinely used in all gynaecological operations. In 1897, however, Johannes Pfannenstiel introduced the transverse incision, which showed to have benefits over the longitudinal one, such as less wound dehiscence (1). At the beginning of the 20 th century, experimental endoscopy was introduced by Georg Kelling in Germany (2). Due to the development of light sources, insufflators, and endotracheal intubation, more and more gynaecological operations, such as the laparoscopyassisted vaginal hysterectomy, were done endoscopically (3). At the beginning of the 21 st century, telesurgical systems are emerging for gynaecological procedures, both for benign and malignant indications. It seems that in the course of this century this new technology will replace many of the conventional endoscopic techniques.

bjective: Minimally invasive surgery has been the trend in various specialties and continues to evolve as new technology develops. The development of robotic surgery in gynecology remains in its infancy. The present study reports the first descriptive series of robotic surgery in complicated gynecologic diseases in Taiwan. Materials and Methods: From March 2009 to February 2011, the records of patients undergoing robotic surgery using the da Vinci Surgical System were reviewed for patient demographics, indications, operative time, hospital stay, conversion to laparotomy, and complications. Results: Sixty cases were reviewed in the present study. Forty-nine patients had benign gynecologic diseases, and 11 patients had malignancies. These robot-assisted laparoscopic procedures include nine hysterectomy, 15 subtotal hysterectomy, 13 myomectomy, eight staging operation, two radical hysterectomy, five ovarian cystectomy, one bilateral salpingo-oophorectomy and myomectomy, two resections of deep pelvic endometriosis, one pelvic adhesiolysis, three sacrocolpopexy and one tuboplasty. Thirty-three patients had prior pelvic surgery, and one had a history of pelvic radiotherapy. Adhesiolysis was necessary in 38 patients to complete the whole operation. Robotic myomectomy was easily accomplished in patients with huge uterus or multiple myomas. The suturing of myometrium or cervical stump after ligation of the uterine arteries minimized the blood loss. In addition, it was much easier to dissect severe pelvic adhesions. The dissection of para-aortic lymph nodes can be easily accomplished. All these surgeries were performed smoothly without ureteral, bladder or bowel injury. Conclusion: The present analyses include various complicated gynecologic conditions, which make the estimation of the effectiveness of robotic surgery in each situation individually not appropriate. However, our experiences do show that robotic surgery is feasible and safe for patients with complicated gynecologic diseases. © 2012 .