unfortunately this demand is more than the supply in terms of surgeons performing these surgeries .
robotic surgery fills the gap between having skills and not having one . a surgeon with limited skills
this leads to added advantage both to the patient as well as the surgeon . notwithstanding the cost , robot helps to duplicate the laparoscopic surgeries which otherwise would be beyond the reach of surgeon with limitation of skills . in april 2005 ,
davinci robot was food and drug administration cleared for gynaecologic procedures based on preliminary evidence of safety and efficacy from their early experience with myomectomy and hysterectomy at the university of michigan .
robotics is best for single quadrant surgery and for fixed structures and hence is especially useful in gynaecological surgery .
it has added advantages of 3d perception , wristed instrumentation , intuitive movements and dexterity .
since november 2009 until date , we have performed 80 robotic gynaecological cases in galaxy care laparoscopy institute , pune .
we standardized the port positions as 
 a 12 mm camera port was placed 2 cm above the umbilicus.an 8 mm robotic port on the either side was placed 10 cm lateral and 12 cm caudal to the camera port.the right sided robotic port was a mirror image of the left robotic port.two assistant 10 mm ports were placed pararectally at the level of the camera port . 
 
an 8 mm robotic port on the either side was placed 10 cm lateral and 12 cm caudal to the camera port .
two assistant 10 mm ports were placed pararectally at the level of the camera port .
the robotic cart was docked from in between the legs a zero degree scope was used for the procedure . for all the surgeries ,
robotic docking time.console time surgical time.blood loss.complications.conversion to either lap or open 
  robotic docking time .
conversion to either lap or open for the oncological surgeries , other parameters such as paracervical clearance , nodal yield and vaginal margins were also recorded .
of the total of 80 gynecological cases performed robotically in our institute , 29 were benign and 51 were malignant cases .
of the benign cases , 24 were hysterectomies for various complex benign pathologies like big fibroids , previous abdominal surgeries .
2 tubotuboplasties , 1 endometriotic cyst excision , 1 metroplasty , 1 rectovaginal fistula repair were also performed with good results at our institute . of the total of 51 oncological cases performed robotically ,
27 were robotic radical hysterectomies for cancer cervix , 10 total robotic hysterectomies with bilateral salpingo - opherectomy with ilioobturator node dissection for cancer endometrium , 2 were total robotic hysterectomy with bilateral salpingo- opherectomy and omentectomy for cancer ovary , 7 were exenterations , 5 were parametrectomy .
total robotic hysterectomy : we compared our outcomes with those of previously done standard studies as shown in the table 1 .
comparison of our data of total robotic hysterectomy with previously reported series our operative time , estimated blood loss was considerably lower when compared with other standard international studies .
there was no conversion to open surgery ; furthermore no major intraoperative or postoperative complications were noted .
robotic radical hysterectomy : we have compared the results of our radical hysterectomies with those of other standard reported cases in literature . as shown in table 2 our operative time , effective blood loss was less than that of others . two cases of ureteric fistulas reported were during initial phase after acquiring the robot . as we got acquainted with these procedures
comparison of our data of radical robotic hysterectomy with previously reported series table 3 below provides comparison of parameters between our laparoscopic cases with the robotic cases .
total robotic hysterectomy : we compared our outcomes with those of previously done standard studies as shown in the table 1 .
comparison of our data of total robotic hysterectomy with previously reported series our operative time , estimated blood loss was considerably lower when compared with other standard international studies .
there was no conversion to open surgery ; furthermore no major intraoperative or postoperative complications were noted .
robotic radical hysterectomy : we have compared the results of our radical hysterectomies with those of other standard reported cases in literature . as shown in table 2 our operative time , effective blood loss was less than that of others .
two cases of ureteric fistulas reported were during initial phase after acquiring the robot . as we got acquainted with these procedures
comparison of our data of radical robotic hysterectomy with previously reported series table 3 below provides comparison of parameters between our laparoscopic cases with the robotic cases .
the advantages of robotic assistance include enhanced dexterity , improved 3-d vision , and more intuitive instrument manipulation .
it thus helps to bridge the skill gap for a laparoscopic surgeon helping to overcome skill limitations .
this may make a complex surgical task more accessible to surgeons without much laparoscopic experience .
placement of robotic trocars has to be in such a way to prevent collision of robotic working arms and accessory ports .
the accessory ports are used for retraction , for energy sources like ligasure or for applying clips .
the preoperative planning helps in performing a smooth procedure as well as reducing the docking time .
the docking time was previously 30 min which later reduced to 10 min because of standardization of ports , team gaining experience and getting acquainted with the system . in 1989 , laparoscopy was first used to perform a hysterectomy . in 2002 , the use of the davinci robot for hysterectomies was first reported .
payne and dauterive concluded that robotic hysterectomy was quicker and with less risk for abdominal conversion than standard laparoscopy .
we have an extensive experience in laparoscopic hysterectomies with which we have started doing robotic hysterectomies .
the patients with high body mass index and patients with narrow pelvis were preferred for robotic procedure . the time taken and blood loss was the same as in laparoscopy .
standardization of procedure and proper training of the technique was necessary to prevent complications and for safe outcome .
the salient steps of our technique 
 use of combined anaesthesia , ergonomic port positioning , use of myoma screw for traction , use of bipolar forceps medial to uterine stump , colpotomy at the level of uterosacral ligaments . 
 
use of combined anaesthesia , ergonomic port positioning , use of myoma screw for traction , use of bipolar forceps medial to uterine stump , colpotomy at the level of uterosacral ligaments .
all our patients had stage iv endometriosis and the rectum and ureter could be separated well due to the high magnification and the intuitive movements of the robot .
robotic - assisted laparoscopic surgery promises to provide advantages in the management of women with severe endometriosis secondary to 3-dimensional visualization , decreasing surgeon 's fatigue and hand tremors and improving surgical precision . with the davinci system
, the challenges of visibility with laparoscopy can be overcome as well as many other limitations of laparoscopy .
hence , the field of gynaecologic oncology has begun adopting the davinci system in performing oncological surgeries due to its shorter learning curve and ease of use .
studies , suggest that robotic radical hysterectomy ( rrh ) is preferable over laparoscopic radical hysterectomy ( lrh ) due to its decrease in blood loss , hospital stay , recovery time , and complications
. however , rrh appears to be equivalent to lrh in the hands of experienced surgeons . in patients predicted to have a high chance for conversion to open from laparoscopy , davinci system may prevent conversion .
the international federation of gynaecology and obstertrics staging requires lymphadenectomy for assignment of stage , and morbid obesity is usually cited as the most common limiting factor for completing a satisfactory lymphadenectomy .
the multi - centre gynecologic oncology group lap-2 trial with 1,696 laparoscopic cases reported a 23% conversion rate and a mean operative time of 3.3 hrs , indicating difficulty with a significant proportion of cases .
reasons for not adopting laparoscopic surgery often cited by surgeons are prolonged operating times , surgeon fatigue , a difficult and prolonged learning curve , and lack of formal training in advanced laparoscopic technique .
we have reported our experience of laparoscopic gynaec oncology procedures such as radical hysterectomy , anterior exenteration and total pelvic exenteration .
the use of hybrid technique and using bipolar energy near the ureters have prevented any further fistulas in subsequent patients .
the two larger series from boggess et al . , and lowe et al . ,
show that there were no transfusions , length of stay was one day , and total complications were less than that usually associated with either open or laparoscopic approaches .
the results are comparable to those of laparoscopy , robot helps to duplicate many procedures with exceptional laparoscopic skills .
 aims : to study the role of robotics in various gynaecological cases , benign and malignant.materials and methods : a total number of 80 cases have been analyzed . 
 operative time , estimated blood loss , hospital stay , complications , conversion rates have been retrospectively studied in all cases . 
 nodal yield , vaginal margin and paracervical clearance have been studied in all malignant cases . 
 this investigation was conducted at a single minimal access surgery institute.results:of total 80 cases , 29 were benign and 51 were malignant cases . in benign cases , total robotic hysterectomies were 24 , 2 cases of tubotuboplasty , 1 case of endometriotic cyst excision , 1 case of metroplasty and 1 case of rectovaginal fistula . in 51 cases , 
 37 of radical hysterectomy , 9 exenterations and 6 were parametrectomy . 
 in benign cases , mean operative time was 80 min , estimated blood loss was 20 ml , mean hospital stay was for 1 day , no major complications and no conversions . in malignant cases , 
 mean operative time was 122 min , estimated blood loss was 50 - 100ml , 2 cases of ureteric fistulas and no conversions , nodal yield was 30 , vaginal margin was 2.5 - 3.8 cm and para cervical clearance was 3 - 3.5 cm.conclusions:ours is the largest series of robotic surgery in gynecological procedures in india . 
 benign and malignant cases were addressed robotically showing the feasibility . 