The case for robotic-assisted hysterectomy

During my address as president of the Board of Trustees of the AAGL in 2008, I noted that essentially 95% of all cholecystectomies, 95% of all bariatric surgery, and 70% of all appendectomies in the United States were performed laparoscopically. Unfortunately, less than 20% of hysterectomies were performed via a minimally invasive route.

Subsequently, at the time of my 2012 presidential address for the International Society for Gynecologic Endoscopy (ISGE), I noted that the percentage of minimally invasive hysterectomies performed in the United States now reached 50%, while the percentage of laparoscopic and vaginal hysterectomies was still mired at 18% and 14%, respectively. The increase in a minimally invasive approach to hysterectomy appeared to be due to the newest method of hysterectomy; that is, robotic-assisted hysterectomy.

On March 14, 2013, Dr. James T. Breeden, president of the American College of Obstetricians and Gynecologists, released a statement regarding robotic surgery. In that, he noted, "While there may be some advantages to the use of robotics in complex hysterectomies ... studies have shown that adding this expensive technology for routine surgical care does not improve patient outcomes. Consequently, there is no good data proving that robotic hysterectomy is even as good as – let alone better than – existing, and far less costly, minimally invasive alternatives."

Dr. Breeden then went on to refer to a recent article in the Journal of the American Medical Association (JAMA 2013;309:689-98) to make the point that, in a study of 264,758 patients undergoing hysterectomy in 441 hospitals in the Premier hospital group, robotics added an average of $2,000/procedure without any demonstrable benefit.

Interestingly, however, the authors of the JAMA article acknowledge that while uptake of laparoscopic hysterectomy has been slow since its inception in the early 1990s, accounting for only 14% of hysterectomies in 2005, within 3 years of the introduction of the adoption of robotics for hysterectomy, nearly 10% of all cases were completed by this enabling technology. Furthermore, the authors comment that, "The introduction of robotic gynecologic surgery was associated with a decrease in the rate of abdominal hysterectomy and an increase in the use of minimally invasive surgery as a whole, including both laparoscopic and robotic hysterectomy." The authors acknowledge that robotic surgery may be easier to learn and that robotic assistance may allow for the completion of more technically demanding cases. In addition, they note that the increase in numbers of laparoscopic hysterectomy may have occurred because of competitive pressures or an increased awareness and appreciation of minimally invasive surgical options.

In comparison, the authors found that in hospitals at which robotic surgery was not performed as of the first quarter of 2010, nearly 50% of all hysterectomies were performed via an open abdominal route, while less than 40% of hysterectomies were performed with a laparotomy incision when robotic hysterectomy was performed at the hospital. With the future adoption of the robotics in gynecologic surgery, I am sure there will be a continued reduction in open abdominal hysterectomy. Benefit ... a resounding yes!

Another fascinating finding of the JAMA study was the fact that overall complication rates were similar for robotic-assisted and laparoscopic hysterectomy (5.5% vs. 5.3%; relative risk, 1.03; 95% confidence interval, 0.86-1.24). Moreover, patients who underwent a robotic-assisted hysterectomy were less likely to have a length of stay longer than 2 days (19.6% vs. 24.9%; RR, 0.78; 95% CI, 0.67-0.92).

Despite no differences in complications in the JAMA study, given the fact that robotics is an emerging technology, one can easily extrapolate that the percentage of cases performed in the study by relatively inexperienced robotic surgeons, as compared with laparoscopic surgeons, was higher. Therefore, with increased surgeon experience, as with any new technology, the rate of complications would be expected to be further decreased. To this end, one must remember that early in its inception, the New York Assembly voiced concerns with laparoscopic cholecystectomy secondary to complications. Now, virtually 95% of all cholecystectomies in the United States are performed via a laparoscopic route. Currently, what is the latest focus in cholecystectomy ... robotic assisted single site cholecystectomy that is being rapidly adopted throughout the country.

While one must acknowledge that, at present, robotic-assisted surgery would appear to be more expensive to perform than laparoscopic surgery is, it is difficult to ascertain what that cost differential is truly. Furthermore, one would anticipate with increased experience and efficiency that cost would, indeed, decrease. While in 1996, Dr. James H. Dorsey published an article on the higher costs associated with laparoscopic surgery (N. Engl. J. Med. 1996;335:476-82), more recent studies by Warren L., et al. (J. Minim. Invasive Gynecol. 2009;16:581-8), and Jonsdottir G.M., et al. (Obstet. Gynecol. 2011;117:1142-9) actually show that the laparoscopic route can be more cost effective.

In this era of cost containment, it is imperative that surgical innovation thrive. Where would all specialties involved in minimally invasive surgery be if surgical pioneer and visionary Professor Kurt Semm were not allowed to perform early operative laparoscopic cases in Kiel, Germany? As chronicled by his associate, Professor Lisolette Mettler, in the July-September 2003 NewsScope of the AAGL, "Kurt endured much resistance, including a request for him to undergo a brain scan to rule out brain damage when attempting to introduce operative laparoscopy; the laughter of general surgeons when he recommended laparoscopic cholecystectomy in the late 1970s; a call for suspension by the president of the German Surgical Society after a 1981 lecture on laparoscopic appendectomy; and rejection of a paper on laparoscopic appendectomy to the American Journal of Obstetrics & Gynecology as unethical." Where would the cholecystectomy market be if general surgeons headed the randomized controlled trial of open vs. laparoscopic cholecystectomy published in Lancet in 1996 (Lancet 1996;347:989-94)? The study concluded that the open procedure was superior because there was no difference in hospital stay or recovery, compared with the laparoscopic route. Where would minimally invasive gynecologic surgery be if our specialty fell in line behind Dr. Roy Pitkin, then president of ACOG, who in 1992 entitled an editorial in Obstetrics & Gynecology "Operative Laparoscopy: Surgical Advance or Technical Gimmick?" (Obstet. Gynecol. 1992;79:441-2). In this editorial he questioned operative laparoscopy on the following:

• How does one separate technical feasibility from therapeutic appropriateness?

• What is the nature of "quality assurance"?

• How can appropriate credentialing criteria be established for procedures not taught in residency and for which no present member of the medical staff can claim experience?

• To what extent are these procedures "experimental," requiring review by an institutional body charged with protection of human subjects, and how should truly informed consent be obtained?

• What about fees? When the procedure is not part of established clinical care, is it ethical to charge for professional services?

Dr. Pitkin concluded by commenting, "Our approach to evaluation of these newer surgical techniques is not something of which we can be proud." Many of these same concerns are currently being voiced by those who do not see the brilliant potential of robotics in gynecologic surgery.

Eighteen years later, in a subsequent editorial (Obstet. Gynecol. 2010;115:890-1), Dr. Pitkin acknowledged that "A substantial body of evidence has accumulated in the recent years to support the laparoscopic approach to various gynecologic operations. ... From this extensive literature, it is now clear that many, if not most gynecologic operations traditionally done by laparotomy are amenable to a laparoscopic approach. Further, the studies are consistent in indicating that operative laparoscopy confers unequivocal advantages over older surgical approaches."

Dr. Pitkin and his coauthor, Dr. William Parker, then go on to discuss the issue of cost, "All health care financial studies are complicated by inconsistencies and uncertainties regarding the meaning of cost. ... Increase in operating time with laparoscopic surgery and disposable instruments are offset, by decreased charges reflecting shortened postoperative hospital stays. If a societal cost that included financial results from early return to work or full home activity were calculated, the advantage of endoscopic surgery would be even greater."

Just as it is imperative that our surgical specialty must remain innovative, we must remember, as can be learned with Dr. Pitkin’s two editorials, that scientific evidence behind the innovation takes time. The fact that, in its infancy, robotic assisted surgery has enabled more gynecologic surgeons to perform minimally invasive surgery for more patients cannot be denied. As seen by the JAMA article, even early on, it can be performed safely and effectively. Data collected in the final decade of the 20th century and the first decade of the 21st have enabled operative laparoscopy to enter mainstream surgical care. One can foresee, with the accumulation of knowledge and experience, that robotics will have a similar – if not even greater – role within our specialty. We must learn from William Shakespeare, who provided Marc Anthony the words, "I have come to bury Caesar, not to praise him." We must not come here to bury robotic assisted surgery, but to praise it!

Dr. Miller is clinical associate professor at the University of Illinois at Chicago, immediate past president of the International Society for Gynecologic Endoscopy, and a past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville, Ill., and Schaumburg, Ill.; the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill; and the medical editor of this column. Dr. Miller has received grants from Intuitive Surgical Inc. He also has served as a consultant for and served on the speakers bureau for Intuitive.

During my address as president of the Board of Trustees of the AAGL in 2008, I noted that essentially 95% of all cholecystectomies, 95% of all bariatric surgery, and 70% of all appendectomies in the United States were performed laparoscopically. Unfortunately, less than 20% of hysterectomies were performed via a minimally invasive route.

Subsequently, at the time of my 2012 presidential address for the International Society for Gynecologic Endoscopy (ISGE), I noted that the percentage of minimally invasive hysterectomies performed in the United States now reached 50%, while the percentage of laparoscopic and vaginal hysterectomies was still mired at 18% and 14%, respectively. The increase in a minimally invasive approach to hysterectomy appeared to be due to the newest method of hysterectomy; that is, robotic-assisted hysterectomy.

On March 14, 2013, Dr. James T. Breeden, president of the American College of Obstetricians and Gynecologists, released a statement regarding robotic surgery. In that, he noted, "While there may be some advantages to the use of robotics in complex hysterectomies ... studies have shown that adding this expensive technology for routine surgical care does not improve patient outcomes. Consequently, there is no good data proving that robotic hysterectomy is even as good as – let alone better than – existing, and far less costly, minimally invasive alternatives."

Dr. Breeden then went on to refer to a recent article in the Journal of the American Medical Association (JAMA 2013;309:689-98) to make the point that, in a study of 264,758 patients undergoing hysterectomy in 441 hospitals in the Premier hospital group, robotics added an average of $2,000/procedure without any demonstrable benefit.

Interestingly, however, the authors of the JAMA article acknowledge that while uptake of laparoscopic hysterectomy has been slow since its inception in the early 1990s, accounting for only 14% of hysterectomies in 2005, within 3 years of the introduction of the adoption of robotics for hysterectomy, nearly 10% of all cases were completed by this enabling technology. Furthermore, the authors comment that, "The introduction of robotic gynecologic surgery was associated with a decrease in the rate of abdominal hysterectomy and an increase in the use of minimally invasive surgery as a whole, including both laparoscopic and robotic hysterectomy." The authors acknowledge that robotic surgery may be easier to learn and that robotic assistance may allow for the completion of more technically demanding cases. In addition, they note that the increase in numbers of laparoscopic hysterectomy may have occurred because of competitive pressures or an increased awareness and appreciation of minimally invasive surgical options.

In comparison, the authors found that in hospitals at which robotic surgery was not performed as of the first quarter of 2010, nearly 50% of all hysterectomies were performed via an open abdominal route, while less than 40% of hysterectomies were performed with a laparotomy incision when robotic hysterectomy was performed at the hospital. With the future adoption of the robotics in gynecologic surgery, I am sure there will be a continued reduction in open abdominal hysterectomy. Benefit ... a resounding yes!

Another fascinating finding of the JAMA study was the fact that overall complication rates were similar for robotic-assisted and laparoscopic hysterectomy (5.5% vs. 5.3%; relative risk, 1.03; 95% confidence interval, 0.86-1.24). Moreover, patients who underwent a robotic-assisted hysterectomy were less likely to have a length of stay longer than 2 days (19.6% vs. 24.9%; RR, 0.78; 95% CI, 0.67-0.92).

Despite no differences in complications in the JAMA study, given the fact that robotics is an emerging technology, one can easily extrapolate that the percentage of cases performed in the study by relatively inexperienced robotic surgeons, as compared with laparoscopic surgeons, was higher. Therefore, with increased surgeon experience, as with any new technology, the rate of complications would be expected to be further decreased. To this end, one must remember that early in its inception, the New York Assembly voiced concerns with laparoscopic cholecystectomy secondary to complications. Now, virtually 95% of all cholecystectomies in the United States are performed via a laparoscopic route. Currently, what is the latest focus in cholecystectomy ... robotic assisted single site cholecystectomy that is being rapidly adopted throughout the country.

While one must acknowledge that, at present, robotic-assisted surgery would appear to be more expensive to perform than laparoscopic surgery is, it is difficult to ascertain what that cost differential is truly. Furthermore, one would anticipate with increased experience and efficiency that cost would, indeed, decrease. While in 1996, Dr. James H. Dorsey published an article on the higher costs associated with laparoscopic surgery (N. Engl. J. Med. 1996;335:476-82), more recent studies by Warren L., et al. (J. Minim. Invasive Gynecol. 2009;16:581-8), and Jonsdottir G.M., et al. (Obstet. Gynecol. 2011;117:1142-9) actually show that the laparoscopic route can be more cost effective.

In this era of cost containment, it is imperative that surgical innovation thrive. Where would all specialties involved in minimally invasive surgery be if surgical pioneer and visionary Professor Kurt Semm were not allowed to perform early operative laparoscopic cases in Kiel, Germany? As chronicled by his associate, Professor Lisolette Mettler, in the July-September 2003 NewsScope of the AAGL, "Kurt endured much resistance, including a request for him to undergo a brain scan to rule out brain damage when attempting to introduce operative laparoscopy; the laughter of general surgeons when he recommended laparoscopic cholecystectomy in the late 1970s; a call for suspension by the president of the German Surgical Society after a 1981 lecture on laparoscopic appendectomy; and rejection of a paper on laparoscopic appendectomy to the American Journal of Obstetrics & Gynecology as unethical." Where would the cholecystectomy market be if general surgeons headed the randomized controlled trial of open vs. laparoscopic cholecystectomy published in Lancet in 1996 (Lancet 1996;347:989-94)? The study concluded that the open procedure was superior because there was no difference in hospital stay or recovery, compared with the laparoscopic route. Where would minimally invasive gynecologic surgery be if our specialty fell in line behind Dr. Roy Pitkin, then president of ACOG, who in 1992 entitled an editorial in Obstetrics & Gynecology "Operative Laparoscopy: Surgical Advance or Technical Gimmick?" (Obstet. Gynecol. 1992;79:441-2). In this editorial he questioned operative laparoscopy on the following:

• How does one separate technical feasibility from therapeutic appropriateness?

• What is the nature of "quality assurance"?

• How can appropriate credentialing criteria be established for procedures not taught in residency and for which no present member of the medical staff can claim experience?

• To what extent are these procedures "experimental," requiring review by an institutional body charged with protection of human subjects, and how should truly informed consent be obtained?

• What about fees? When the procedure is not part of established clinical care, is it ethical to charge for professional services?

Dr. Pitkin concluded by commenting, "Our approach to evaluation of these newer surgical techniques is not something of which we can be proud." Many of these same concerns are currently being voiced by those who do not see the brilliant potential of robotics in gynecologic surgery.

Eighteen years later, in a subsequent editorial (Obstet. Gynecol. 2010;115:890-1), Dr. Pitkin acknowledged that "A substantial body of evidence has accumulated in the recent years to support the laparoscopic approach to various gynecologic operations. ... From this extensive literature, it is now clear that many, if not most gynecologic operations traditionally done by laparotomy are amenable to a laparoscopic approach. Further, the studies are consistent in indicating that operative laparoscopy confers unequivocal advantages over older surgical approaches."

Dr. Pitkin and his coauthor, Dr. William Parker, then go on to discuss the issue of cost, "All health care financial studies are complicated by inconsistencies and uncertainties regarding the meaning of cost. ... Increase in operating time with laparoscopic surgery and disposable instruments are offset, by decreased charges reflecting shortened postoperative hospital stays. If a societal cost that included financial results from early return to work or full home activity were calculated, the advantage of endoscopic surgery would be even greater."

Just as it is imperative that our surgical specialty must remain innovative, we must remember, as can be learned with Dr. Pitkin’s two editorials, that scientific evidence behind the innovation takes time. The fact that, in its infancy, robotic assisted surgery has enabled more gynecologic surgeons to perform minimally invasive surgery for more patients cannot be denied. As seen by the JAMA article, even early on, it can be performed safely and effectively. Data collected in the final decade of the 20th century and the first decade of the 21st have enabled operative laparoscopy to enter mainstream surgical care. One can foresee, with the accumulation of knowledge and experience, that robotics will have a similar – if not even greater – role within our specialty. We must learn from William Shakespeare, who provided Marc Anthony the words, "I have come to bury Caesar, not to praise him." We must not come here to bury robotic assisted surgery, but to praise it!

Dr. Miller is clinical associate professor at the University of Illinois at Chicago, immediate past president of the International Society for Gynecologic Endoscopy, and a past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville, Ill., and Schaumburg, Ill.; the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill; and the medical editor of this column. Dr. Miller has received grants from Intuitive Surgical Inc. He also has served as a consultant for and served on the speakers bureau for Intuitive.

During my address as president of the Board of Trustees of the AAGL in 2008, I noted that essentially 95% of all cholecystectomies, 95% of all bariatric surgery, and 70% of all appendectomies in the United States were performed laparoscopically. Unfortunately, less than 20% of hysterectomies were performed via a minimally invasive route.

Subsequently, at the time of my 2012 presidential address for the International Society for Gynecologic Endoscopy (ISGE), I noted that the percentage of minimally invasive hysterectomies performed in the United States now reached 50%, while the percentage of laparoscopic and vaginal hysterectomies was still mired at 18% and 14%, respectively. The increase in a minimally invasive approach to hysterectomy appeared to be due to the newest method of hysterectomy; that is, robotic-assisted hysterectomy.

On March 14, 2013, Dr. James T. Breeden, president of the American College of Obstetricians and Gynecologists, released a statement regarding robotic surgery. In that, he noted, "While there may be some advantages to the use of robotics in complex hysterectomies ... studies have shown that adding this expensive technology for routine surgical care does not improve patient outcomes. Consequently, there is no good data proving that robotic hysterectomy is even as good as – let alone better than – existing, and far less costly, minimally invasive alternatives."

Dr. Breeden then went on to refer to a recent article in the Journal of the American Medical Association (JAMA 2013;309:689-98) to make the point that, in a study of 264,758 patients undergoing hysterectomy in 441 hospitals in the Premier hospital group, robotics added an average of $2,000/procedure without any demonstrable benefit.

Interestingly, however, the authors of the JAMA article acknowledge that while uptake of laparoscopic hysterectomy has been slow since its inception in the early 1990s, accounting for only 14% of hysterectomies in 2005, within 3 years of the introduction of the adoption of robotics for hysterectomy, nearly 10% of all cases were completed by this enabling technology. Furthermore, the authors comment that, "The introduction of robotic gynecologic surgery was associated with a decrease in the rate of abdominal hysterectomy and an increase in the use of minimally invasive surgery as a whole, including both laparoscopic and robotic hysterectomy." The authors acknowledge that robotic surgery may be easier to learn and that robotic assistance may allow for the completion of more technically demanding cases. In addition, they note that the increase in numbers of laparoscopic hysterectomy may have occurred because of competitive pressures or an increased awareness and appreciation of minimally invasive surgical options.

In comparison, the authors found that in hospitals at which robotic surgery was not performed as of the first quarter of 2010, nearly 50% of all hysterectomies were performed via an open abdominal route, while less than 40% of hysterectomies were performed with a laparotomy incision when robotic hysterectomy was performed at the hospital. With the future adoption of the robotics in gynecologic surgery, I am sure there will be a continued reduction in open abdominal hysterectomy. Benefit ... a resounding yes!

Another fascinating finding of the JAMA study was the fact that overall complication rates were similar for robotic-assisted and laparoscopic hysterectomy (5.5% vs. 5.3%; relative risk, 1.03; 95% confidence interval, 0.86-1.24). Moreover, patients who underwent a robotic-assisted hysterectomy were less likely to have a length of stay longer than 2 days (19.6% vs. 24.9%; RR, 0.78; 95% CI, 0.67-0.92).

Despite no differences in complications in the JAMA study, given the fact that robotics is an emerging technology, one can easily extrapolate that the percentage of cases performed in the study by relatively inexperienced robotic surgeons, as compared with laparoscopic surgeons, was higher. Therefore, with increased surgeon experience, as with any new technology, the rate of complications would be expected to be further decreased. To this end, one must remember that early in its inception, the New York Assembly voiced concerns with laparoscopic cholecystectomy secondary to complications. Now, virtually 95% of all cholecystectomies in the United States are performed via a laparoscopic route. Currently, what is the latest focus in cholecystectomy ... robotic assisted single site cholecystectomy that is being rapidly adopted throughout the country.

While one must acknowledge that, at present, robotic-assisted surgery would appear to be more expensive to perform than laparoscopic surgery is, it is difficult to ascertain what that cost differential is truly. Furthermore, one would anticipate with increased experience and efficiency that cost would, indeed, decrease. While in 1996, Dr. James H. Dorsey published an article on the higher costs associated with laparoscopic surgery (N. Engl. J. Med. 1996;335:476-82), more recent studies by Warren L., et al. (J. Minim. Invasive Gynecol. 2009;16:581-8), and Jonsdottir G.M., et al. (Obstet. Gynecol. 2011;117:1142-9) actually show that the laparoscopic route can be more cost effective.

In this era of cost containment, it is imperative that surgical innovation thrive. Where would all specialties involved in minimally invasive surgery be if surgical pioneer and visionary Professor Kurt Semm were not allowed to perform early operative laparoscopic cases in Kiel, Germany? As chronicled by his associate, Professor Lisolette Mettler, in the July-September 2003 NewsScope of the AAGL, "Kurt endured much resistance, including a request for him to undergo a brain scan to rule out brain damage when attempting to introduce operative laparoscopy; the laughter of general surgeons when he recommended laparoscopic cholecystectomy in the late 1970s; a call for suspension by the president of the German Surgical Society after a 1981 lecture on laparoscopic appendectomy; and rejection of a paper on laparoscopic appendectomy to the American Journal of Obstetrics & Gynecology as unethical." Where would the cholecystectomy market be if general surgeons headed the randomized controlled trial of open vs. laparoscopic cholecystectomy published in Lancet in 1996 (Lancet 1996;347:989-94)? The study concluded that the open procedure was superior because there was no difference in hospital stay or recovery, compared with the laparoscopic route. Where would minimally invasive gynecologic surgery be if our specialty fell in line behind Dr. Roy Pitkin, then president of ACOG, who in 1992 entitled an editorial in Obstetrics & Gynecology "Operative Laparoscopy: Surgical Advance or Technical Gimmick?" (Obstet. Gynecol. 1992;79:441-2). In this editorial he questioned operative laparoscopy on the following:

• How does one separate technical feasibility from therapeutic appropriateness?

• What is the nature of "quality assurance"?

• How can appropriate credentialing criteria be established for procedures not taught in residency and for which no present member of the medical staff can claim experience?

• To what extent are these procedures "experimental," requiring review by an institutional body charged with protection of human subjects, and how should truly informed consent be obtained?

• What about fees? When the procedure is not part of established clinical care, is it ethical to charge for professional services?

Dr. Pitkin concluded by commenting, "Our approach to evaluation of these newer surgical techniques is not something of which we can be proud." Many of these same concerns are currently being voiced by those who do not see the brilliant potential of robotics in gynecologic surgery.

Eighteen years later, in a subsequent editorial (Obstet. Gynecol. 2010;115:890-1), Dr. Pitkin acknowledged that "A substantial body of evidence has accumulated in the recent years to support the laparoscopic approach to various gynecologic operations. ... From this extensive literature, it is now clear that many, if not most gynecologic operations traditionally done by laparotomy are amenable to a laparoscopic approach. Further, the studies are consistent in indicating that operative laparoscopy confers unequivocal advantages over older surgical approaches."

Dr. Pitkin and his coauthor, Dr. William Parker, then go on to discuss the issue of cost, "All health care financial studies are complicated by inconsistencies and uncertainties regarding the meaning of cost. ... Increase in operating time with laparoscopic surgery and disposable instruments are offset, by decreased charges reflecting shortened postoperative hospital stays. If a societal cost that included financial results from early return to work or full home activity were calculated, the advantage of endoscopic surgery would be even greater."

Just as it is imperative that our surgical specialty must remain innovative, we must remember, as can be learned with Dr. Pitkin’s two editorials, that scientific evidence behind the innovation takes time. The fact that, in its infancy, robotic assisted surgery has enabled more gynecologic surgeons to perform minimally invasive surgery for more patients cannot be denied. As seen by the JAMA article, even early on, it can be performed safely and effectively. Data collected in the final decade of the 20th century and the first decade of the 21st have enabled operative laparoscopy to enter mainstream surgical care. One can foresee, with the accumulation of knowledge and experience, that robotics will have a similar – if not even greater – role within our specialty. We must learn from William Shakespeare, who provided Marc Anthony the words, "I have come to bury Caesar, not to praise him." We must not come here to bury robotic assisted surgery, but to praise it!

Dr. Miller is clinical associate professor at the University of Illinois at Chicago, immediate past president of the International Society for Gynecologic Endoscopy, and a past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville, Ill., and Schaumburg, Ill.; the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill; and the medical editor of this column. Dr. Miller has received grants from Intuitive Surgical Inc. He also has served as a consultant for and served on the speakers bureau for Intuitive.