Perioperative outcomes and anesthetic challenges of robotic-assisted gynecologic surgery: a systematic review

Background Robotic-assisted gynecologic (RAS) surgery offers enhanced precision, ergonomics, and visualization compared with open (OP) and laparoscopic (LAP) approaches. However, it introduces distinct anesthetic challenges related to patient positioning, airway access, and postoperative recovery and analgesia. This review aims to evaluate perioperative outcomes across four domains: intraoperative anesthetic management, postoperative recovery, pain control strategies, and surgical performance. Methods We performed a systematic review of the current literature on adult women undergoing robotic-assisted gynecologic surgery under general anesthesia. Data on perioperative outcomes across the aforementioned domains were extracted via standardized selection, extraction, and bias assessment methods. Results A total of 479 papers were included in the study following screening of over 10,000 citations. Intraoperatively, airway complications were infrequently reported; however, a few cases of increased pulmonary pressures and hypercapnia emerged. Postoperatively, RAS was associated with shorter hospital stay (mean 2.52 days RAS vs. 1.85 LAP vs. 5.11 OP) and faster return to daily activities (mean 11.4 days RAS vs. 13.6 LAP vs. 13.2 OP), but evidence for validated quality of recovery scores was lacking. Pain intensity and analgesic requirements were found to be lower after RAS than after OP and sometimes LAP, with inconsistent findings across studies. Surgical outcomes favored RAS, showing reduced blood loss (mean 154 mL RAS vs. 149 LAP vs. 358 OP), lower conversion and major complications rates than other approaches. Oncologic metrics—including lymph node yield and R0 resection—were comparable across approaches. Overall study quality was limited by a moderate to serious risk of bias across most outcomes. Conclusion Robotic-assisted gynecologic surgery is a feasible and safe alternative to laparoscopic and open approaches, with advantages in selected surgical outcomes and potential benefits in postoperative pain and recovery. However, further high-quality randomized studies are needed to confirm these benefits. Systematic review registration PROSPERO CRD420251105240