I read the outstanding article of Dr Rardin on robotics and the challenges facing minimally invasive surgery programs with interest. I have 2 comments regarding a statement in his abstract: “…the best currently available science suggests that, in the hands of experts, robotics offers little in surgical advantage over laparoscopy, at increased expense….” The 3 randomized controlled trials cited in support of this statement all found longer operative times, the largest driver of cost, with robotics. Since each study compared robotic and laparoscopic surgeries performed by expert laparoscopists who had relatively little robotic experience (10-30 robotic cases), all 3 authors, I believe, made the assumption that experienced laparoscopists can transition to robotics with a short learning curve. There is evidence that this assumption is incorrect. For example, Payne and Dauterive found that robotic operative times for 2 experienced laparoscopic surgeons continued to decrease through the first 75 robotic cases, and then plateaued at 16% shorter than laparoscopic procedures (79 vs 92 minutes). Woelk et al analyzed 566 robotic hysterectomies performed over a 36-month period at the Mayo Clinic, and estimated the learning curve to be 91 cases. Thus, the “best currently available science” on this subject may be flawed by invalid assumptions regarding the learning curve for robotic surgery, even “in the hands of experts.”

Second, intraoperative conversion rates to laparotomy appear to be lower with robotics. Payne and Dauterive compared their last 100 laparoscopic to their first 100 robotic hysterectomies, and found a significantly lower (4% vs 9%) intraoperative conversion rate for robotics. In particular, intraoperative conversion because of pelvic adhesive disease was less likely with robotics (0 vs 8 patients). Patzkowsky et al compared outcomes for 3 experienced laparoscopic surgeons performing laparoscopic and robotic hysterectomies for benign disease over a 9-year period at the University of Michigan (288 laparoscopic, 255 robotic), and found fewer conversions (1.7% vs 6.2%, P = .007) and reoperations (1.7% vs 5.1%, P = .03) in the robotics group, despite a higher incidence of previous laparotomies (78.4% vs 49.8%, P = .002), stage III/IV endometriosis (15.3% vs 4.7%, P = .001), and severe adhesions (23.3% vs 13.2%, P = .003) in that group.

Our patients care deeply about our ability to deliver the minimally invasive procedures we recommend to them. If robotics increases our probability of success, with a better ability to deal with complex pelvic pathology and a lower likelihood of intraoperative conversion to laparotomy, I believe this is the strongest argument for robotics over traditional laparoscopy in benign gynecology.