Dr Walker’s comments are representative of some of the important features of the more global conversation among surgeons and administrators of robotics programs (proponents and naysayers alike).

Surgical trials are often plagued by the issue that participating surgeons have different experience levels for different techniques. Thus, Dr Walker’s critique of the available randomized controlled trials in robotic gynecologic surgery is valid, in that the surgeons’ experience with laparoscopy was overall more extensive than with robotic surgery. However, the methodological quality of a well-designed randomized controlled trial is generally better at controlling confounders than retrospective cohort designs using historical controls.

The conversation around the extent of the learning curve for robotics has been a difficult one. Why robotic surgery should demonstrate a more prolonged learning curve than many other procedures in gynecology, especially when many surgeons are coming to robotic surgery as experienced endoscopic surgeons, has not been well studied. Certainly part of the answer lies in the fact that the entire surgical team must learn a new set of tasks with robotic surgery; the operating room team, not just the expertise of the surgeon, will contribute to the efficiency of the case. Still, the acknowledgment of the extent of the robotic learning curve poses a challenge to surgeons and systems alike; should surgeons inform each of their first 70-100 patients that they are “on the learning curve” and, therefore, may have longer operative times and potentially adverse events associated with this? It is my hope that educational efforts, notably simulation programs for skills acquisition and maintenance, can shorten the learning curve. A growing number of published trials have provided support to the role that simulation might play in new technologies such as robotic surgery, where an extended learning curve has been observed.

The intent of my message was not to malign robotic surgery, but rather to support all forms of minimally invasive surgery, and to promote efforts to define a set of circumstances in which a robotic approach might be better suited to positive outcomes than others. These assessments should be carried out at local as well as academic levels. I would echo the following statement by the Society of Gynecologic Surgeons’ Systematic Review Group, which concluded, “Conflicting data are obtained when comparing robotics vs laparoscopic techniques. Therefore, the specific method of minimally invasive surgery, whether conventional laparoscopy or robotic surgery, should be tailored to patient selection, surgeon ability, and equipment availability.”