Introduction

Gynecological surgery represents the gold standard approach for several benign [1,2,3,4] as well as malignant diseases [5,6,7].

The advantages of endoscopic procedures have been well investigated in the past. The benefits are mainly represented by the reduction of post-operative pain, enhanced recovery and, thus, a relevant improvement of quality of life [8,9,10]. In the last decade, a relevant technological progress was done, thanks to the presence of new laparoscopic appliances such as single port, mini-laparoscopic instruments and percutaneous devices [11,12,13,14,15,16,17,18].

Thanks to these developments, the role of endoscopy has become the gold standard for several benign gynecologic pathologies [19,20,21], gaining popularity even in oncology [22,23,24,25,26,27,28,29,30,31,32,33] mainly with fertility-sparing purpose [34, 35].

The most significant technological expansion was made by the introduction of robotic surgery that, thanks to the instruments articulation and the precision of movement, made possible to perform even the most complex procedures [36,37,38].

Recently, beside the Da Vinci platform, new robotic technology such as the Senhance (Senhance™—Transenterix USA) and the REVO-I Robotic Surgical System (Meere Company, South Korea) are actually available [39]. The Senhance robotic device provides a novel approach to endoscopy thanks to remote 3D vision with an eye-tracking camera control system, an incorporated haptic interaction feedback and high configuration versatility due to total robotic arms independency (Fig. 1) [40, 41].

Fig. 1
figure 1

Senhance robotic platform (cockpit and robotic arms)

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A recent study from Hutchins et al. demonstrated that this platform is intuitive, since surgeon’s learning and adaptation to the Senhance controls are rapid regardless of the experience level [42].

The present study has the purpose of displaying all characteristics and surgical performances of Senhance robotic platform in gynecologic surgery.

Materials and methods

The present review was conducted to incorporate population criteria, surgical interventions, and outcomes. The systematic search was modeled in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA) [43].

The terms “Alf-X” OR “Senhance” OR “robot” OR “robotic” were systematically used to search the PubMed and Scopus databases. A hand search of the references of both potentially relevant articles and articles qualifying for inclusion was also performed. Original reports in English language were identified, with the purpose of including all relevant papers regarding Alf-x (that was the old name of the platform) and Senhance in gynecologic surgery.

Exclusion criteria included duplicate publications, non-English language literature, video-articles and different fields of application other than gynecology and reviews to avoid repetition of studies results. The flow diagram of the detailed process of articles selection for inclusion in the review is reported in Fig. 2.

Fig. 2
figure 2

Flow diagram of the detailed process of selection of articles for inclusion in the review

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In each article, all the possible baseline demographic data and the surgical outcomes were extracted. In particular, the main findings considered in the present review were: the study design, the number of patients included in each study, operative time, estimated blood loss (EBL), conversion rate to standard laparoscopy (SLPS) or laparotomy (LPT), post-operative complications, post-operative hospital stay, and the possible advantages and disadvantages reported by the authors.

The studies were then rated according to the American College of Obstetricians and Gynecologists guidelines [44], which categorize the evidence underlying recommendations into three levels: level A (good and consistent evidence), level B (limited or inconsistent evidence), and level C (consensus and opinion).

Results

A total of eight studies were considered eligible for the present review, published between 2015 and 2018, consisting of six case series and two case–control. In all the selected articles, the strength of recommendation was level B and C and the level of evidence was low.

The most frequent procedures described were adnexal surgery, hysterectomy and pelvic lymphadenectomy (PL). The studies are very heterogeneous regarding the type of surgical procedures performed and the number of patients enrolled. The number of patients enrolled ranged between 4 and 203. All the articles were published by the same research group that investigates different subset of patients and pathologies, both benign and malignant. The first experience started in 2015 when Fanfani et al. [45] and Gueli Alletti et al. [46] reported case series of total hysterectomy ± bilateral salpingo-oophorectomy (TH ± BSO) and ovarian cyst enucleation (OCE), respectively. The oncological cases consisted of early stage endometrial cancer. The average operative time for TH reported was 97–140 min, whereas an average of 197 min was reported for PL. In a study by Fanfani et al. [47, 48], the operative time for hysterectomy performed for bening and oncologic indication was, respectively, a median of 133 and 160 min. Regarding adnexal surgery, mentioned in two studies [46, 48], an average operative time of 35–45 min was recorded. In two case–control studies, the operative time was significantly prolonged (P < 0.05) for robotic procedures when compared with SLPS [40, 47]. The EBL was ≤ 100 ml in all studies and in case reports [40, 47] no statistically significant differences were reported compared with SLPS. The conversion rate was divided into conversion to SLPS or conversion to LPT. All the studies selected are in accordance, reporting an average conversion rate of 3–4% and 2–3% to SLPS and LPT, respectively. In one article [45], the conversion rate to LPT occurred in 2/16 cases of PL (12.5%). No differences were reported in the two case–control studies [40, 47] in terms of conversion to LPT. All studies are in accordance with the hospital stay showing an average of 2 days for TH and 1 day for adnexal surgery. In a small case series by Gueli Alletti et al. [49] of TH ± BSO performed with 3 mm robotic instruments, the median hospital stay was 1 day. No statistically significant differences were demonstrated in case–control studies [40, 47]. Considering the robot characteristics that recreate the standard laparoscopic setting with the same number and size of the trocars, the data are coherent. The complication rate was superimposable in different studies, reporting only one case of major complication (grade 3), consisting of intra-operative bladder injury. The same complication was probably repeated in different studies, considering that the data originated from the same research group. No differences were reported in two case–control studies [40, 47].

Discussion

The present review provides a summary of the available studies regarding a different robotic platform other than Da Vinci that actually is the most widespread and, consequently, the most studied technology.

Considering the literature, only eight studies regarding gynecologic surgery are currently available. The main reason is probably related to the fact that only one research group principally studied this new technology. There are no randomized trials, but only case series and case–control studies. However, various surgical procedures (adnexal surgery, hysterectomy and lymphadenectomy) and different subset of patients (obese, oncologic patients) were deeply investigated.

During our analysis, we even reported in Table 1 the authors’ comments of each study.

Table 1 Selected studies of Senhance platform in gynecologic surgery
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In two different studies [45, 47], Fanfani et al. reported that Senhance platform could be considered an effective and safe option for both benign and malignant gynecologic pathology.

In a case–control study by Gueli Alletti et al. [40], the authors confirmed that the platform represents a feasible solution for patient affected by endometrial cancer, even if the operative time recorded was significantly longer in the robot group; however, the authors commented that the difference could be attributed to the fact that it was the first application of the Senhance system in the surgical management of patients with endometrial cancer.

In another interesting study by Rossitto et al. [50], a cost analysis was reported. The authors commented that thanks to the full re-usability of resterilizable robotic instruments, it is possible to achieve a significant reduction of costs.

In another case series [51], the platform was tested in obese patients demonstrating the feasibility even in this subset of patients. At last, in a small series of four patients reported as letter to the editor [49], the new 3 mm instruments were presented, reducing the cosmetic impact of endoscopic surgery.

Considering all studies available in the literature, Senhance platform represents a hybrid technology located in the middle between laparoscopic and robotic surgery. In fact, the Senhance system balances aspects of laparoscopic and robotic surgery, incorporating advantages of both approaches. In contrast to other robotic platforms, in the Senhance Robotic Platform the surgeon has haptic and tactile feedback, and each arm is independent from the others and can be positioned anywhere in the surgical field through a standard 5-mm trocar placed in the same position as used during SLPS. This last point seems relevant when a conversion from a robotic platform to SLPS or LPT is needed; it is also appreciated by patients because, mimicking the laparoscopic approach, it results in better cosmetic outcomes compared with those obtained with other robotic approaches [40]. Moreover, the cosmetic outcome was recently improved thanks to the availability of new 3 mm robotic instruments reducing the invasiveness. Considering that actually the aspect of quality of life has acquired more importance, even if other factors could be implicated in this aspect [52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68], the invasiveness reduction could represent an important point.

However, evaluating the Senhance in a Robotic environment, the lack of endo-wristed instruments represents the most important limitation: the availability of only one, disposable, 10 mm endo-wristed needle-holder does not represent a determining value.

The majority of the literature available about Senhance is focused on gynecologic surgery even if there are other studies regarding colorectal surgery and cholecystectomies [69, 70] confirming the feasibility of these procedures using this robotic platform.

If on a side, the presence of independent robotic arms represents an advantage in terms of variability in docking and, on the other side, requires large operative rooms and well-trained surgical staff to avoid waste of time in docking procedures; in fact, sometimes the difficulty in finding a correct balance between different instruments could take long time during the docking phase.

Conclusions

Considering all these factors Senhance platform could represent a standard care for gynecological surgery even if some aspects such as operative time and docking procedures should be deeper investigated. Moreover, almost all the studies are focused on pelvic surgery; more research is needed to show the real potential of this technology, especially in other surgical procedures, considering the lack of studies about other specialties as general surgery and urology. At the end in next future, more technological improvements with the aim of reducing the operative time such as incorporated multifunctional instruments will be available.