“Re: Kim et al.: Robotic Sigmoid Vaginoplasty: A Novel Technique. (Urology 2008;72:847-849).” Joshi, D. C. and V. Vasudevan (2009).
Urology 73(3): 682.
“Robotic extraperitoneal aortic lymphadenectomy: Development of a technique.”
Magrina, J. F., R. Kho, et al. (2009).
Gynecol Oncol 113(1): 32-5.
OBJECTIVES: To develop a robotic technique for extraperitoneal aortic lymphadenectomy in cadavers followed by application in a patient with advanced cervical cancer. METHODS: Two fresh frozen female torso cadavers were used to develop the correct placement of the robotic column and trocars, respectively, to allow for a safe and adequate performance of aortic lymphadenectomy using the da Vinci S system. The resulting technique was applied to a patient with cervical cancer Stage IB2 presenting with enlarged aortic nodes. RESULTS: Appropriate sites for trocar and robotic column placement were identified in the female cadavers. In the patient, the operating, docking, and console times were 103, 3.5, and 49 minutes, respectively. The blood loss was 30 ml. Selective removal of 5 enlarged aortic nodes revealed no evidence of metastases. CONCLUSION: Robotic extraperitoneal aortic lymphadenectomy is feasible provided there is proper robotic trocar and column placement. The operating time and number of aortic nodes selectively removed by robotics in this patient are within the range of those reported with an extraperitoneal systematic aortic lymphadenectomy by laparoscopy.
“Surgical techniques: robot-assisted laparoscopic colposacropexy with the da Vinci® surgical system.”
Matthews, C. A. (2009).
Journal of Robotic Surgery: 1-5.
Colposacropexy is the gold-standard operation for repair of apical vaginal support defects. While it is feasible to perform this operation using conventional laparoscopic techniques, a limited number of surgeons have mastered the advanced minimally invasive skills that are required. Introduction of the da Vinci® robotic system with instruments that have improved dexterity and precision and a camera system with three-dimensional imaging presents an opportunity for more surgeons treating women with pelvic organ prolapse to perform the procedure laparoscopically. This paper will outline a technique that is exactly modeled after the open procedure for completion of a robotic-assisted colposacropexy using the da Vinci® surgical system. © 2009 Springer-Verlag London Ltd.
“The use of minimally invasive surgery for endometrial cancer.”
Humphrey, M. M. and S. M. Apte (2009).
Cancer control : journal of the Moffitt Cancer Center 16(1): 30-37.
BACKGROUND: Endometrial cancer is the most common gynecologic malignancy in the United States. Surgical staging is an integral component in the treatment of this disease. Minimally invasive surgical techniques have been utilized with increasing frequency in its management. METHODS: This article reviews the use of minimally invasive surgery for the treatment of endometrial cancer. RESULTS: Prospective trials and retrospective analyses have demonstrated the safety and feasibility of laparoscopy in performing hysterectomy, bilateral salpingo-oophorectomy, and pelvic and periaortic lymphadenectomy for surgical staging in endometrial cancer. The use of minimally invasive techniques does not appear to have an adverse impact on survival, and it improves quality of life in the postoperative period. Robotic surgery has been used in the management of this disease with promising preliminary results. CONCLUSIONS: Laparoscopy is a safe and effective approach for surgical staging of selected patients with endometrial cancer. Further studies and cost-benefit analyses are required to determine if the use of robotics improves outcomes over standard laparoscopy and can extend the benefits of minimally invasive surgery to a larger proportion of patients with this common gynecologic malignancy.
“A comparison of robot-assisted and traditional radical hysterectomy for early-stage cervical cancer.”
Lowe, M. P., A. V. Hoekstra, et al. (2009).
Journal of Robotic Surgery: 1-5.
A robotics surgery program was introduced into the division of gynecologic oncology at Northwestern University Feinberg School of Medicine in June 2007. A prospective database of all patients undergoing a type III radical hysterectomy for stage IB1 cervical cancer between July 2007 and June 2008 was collected and analyzed. Demographic data and perioperative outcomes were analyzed between a traditional and robot-assisted approach. A total of 14 patients were identified who underwent a type III radical hysterectomy for stage IB1 cervical cancer. Seven patients underwent robotic surgery and seven patients underwent traditional surgery. There were no significant differences in median age or body mass index between the two groups. A significant difference in blood loss between robotic (75 cc) and traditional (700 cc) surgery was detected (P = 0.002). A significant difference in hospital stay between robotic (1 day) and traditional (5 days) surgery was observed (P = 0.0007). No significant difference in operative time (260 vs. 264 min) or lymph node yield (19 and 14) was identified between the robotic and traditional approaches. No major operative complications occurred with robotic radical hysterectomy. Robot-assisted radical hysterectomy was associated with a significant reduction in blood loss and hospital stay. Improved nodal yields, fewer operative complications, and less pain was observed with the robotic approach. Robot-assisted radical hysterectomy appears safe and feasible and further investigation is warranted in a prospective fashion. © 2009 Springer-Verlag London Ltd.
“Robotic radical hysterectomy: Technical aspects.”
Magrina, J. F., R. Kho, et al. (2009).
Gynecol Oncol 113(1): 28-31.
OBJECTIVES: To describe the surgical technique of robotic radical hysterectomy. METHODS: Retrospective video review of the instrumentation and methodology employed in 21 robotic radical hysterectomies for cervical cancer Stages IB-IIA. RESULTS: All radical hysterectomies were performed with the use of three or four robotic arms, three or four robotic instruments and one assistant trocar. The mean operating time was 225.8 min; mean console time was 182.1 min; and mean docking time was 2.2 min. The mean blood loss was 174.6 ml, mean number of lymph nodes 26.2, and the mean length of hospital stay was 1.6 days. CONCLUSIONS: Robotic technology facilitates the performance of robotic radical hysterectomy.
“Robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy with short and long term morbidity data.”
Persson, J., P. Reynisson, et al.
Objective: To evaluate feasibility and morbidity of robot assisted laparoscopic radical hysterectomy. Methods: From December 2005 to September 2008 robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy was performed on 80 women. Using a prospective protocol, and an active investigation policy for defined adverse events, perioperative, short and long term data were obtained. Results: Time for surgery (skin to skin) reached 176 and 132 min after 9 and 34 procedures respectively. All tumours were radically removed. Median number of retrieved lymph nodes was 26 (range 15-55). All women had an early follow up (1-3 months) and 43 of eligible 46 women (93%) had a long term follow up (? 12 months). In 33 of 80 women (41%) the peri/postoperative period was uneventful. The remainder had one or more mainly mild adverse events, most commonly from the vaginal cuff (n = 17, 21%) or the lymphatic system (n = 16, 20%). The proportion of uneventful cases increased significantly over time. Five women were resutured for dehiscence of the vaginal cuff, two women were reoperated for trocar site hernias and one woman had a ureter stricture that resolved following stent treatment. Eight women (14%) needed 60 days or more to resume spontaneous voiding. One 72-year old woman with disseminated endometrial cancer on autopsy died of pulmonary embolism 31 days after surgery. Conclusions: Robot assisted laparoscopic radical hysterectomy is a feasible alternative to conventional laparoscopy and open surgery. Effort should be made to ensure proper closure of the vaginal cuff, trocar sites and to develop nerve sparing techniques. © 2009 Elsevier Inc. All rights reserved.
“Minimally invasive comprehensive surgical staging for endometrial cancer: Robotics or laparoscopy?”
Seamon, L. G., D. E. Cohn, et al. (2009).
Gynecol Oncol 113(1): 36-41.
OBJECTIVE: To compare outcomes between robotic versus laparoscopic hysterectomy and lymphadenectomy in patients with endometrial cancer. METHODS: A cohort study was performed by prospectively identifying all patients with clinical stage I or occult stage II endometrial cancer who underwent robotic hysterectomy and lymphadenectomy from 2006-2008 and retrospectively comparing data using the same surgeons’ laparoscopic hysterectomy and lymphadenectomy cases from 1998-2005, prior to our robotic experience. Patient demographics, operative times, complications, conversion rates, pathologic results, and length of stay were analyzed. RESULTS: 181 patients (105 robotic and 76 laparoscopic) met inclusion criteria. There was no significant difference between the two groups in median age, uterine weight, bilateral pelvic or aortic lymph node counts, or complication rates in patients whose surgeries were completed minimally invasively. Despite a higher BMI (34 vs. 29, P<0.001), the estimated blood loss (100 vs. 250 mL, P<0.001), transfusion rate (3% vs. 18%, RR 0.18, 95%CI 0.05-0.64, P=0.002), laparotomy conversion rate (12% vs. 26%, RR 0.47, 95%CI 0.25-0.89, P=0.017), and length of stay (median: 1 vs. 2 nights, P<0.001) were lower in the robotic patients compared to the laparoscopic cohort. The odds ratio of conversion to laparotomy based on BMI for robotics compared to laparoscopy is 0.20 (95% CI 0.08-0.56, P=0.002). The mean skin to skin time (242 vs. 287 min, P<0.001) and total room time (305 vs. 336 min, P<0.001) was shorter for the robotic cohort. CONCLUSION: Robotic hysterectomy and lymphadenectomy for endometrial carcinoma can be accomplished in heavier patients and results in shorter operating times and hospital length of stay, a lower transfusion rate, and less frequent conversion to laparotomy when compared to laparoscopic hysterectomy and lymphadenectomy.
“[How I do... to define circumstances of an immediate conversion into a laparotomy, during a laparoscopic or a robotically-assisted laparoscopic surgery.].”
Leblanc, E., F. Narducci, et al. (2009).
Gynecol Obstet Fertil.
“Robot-assisted laparoscopic surgery of a 12-week scar pregnancy with temporary occlusion of the uterine blood supply.”
Persson, J., G. Gunnarson, et al. (2009).
Journal of Robotic Surgery: 1-3.
A Cesarean section scar pregnancy is a serious obstetric complication. For all treatment modalities there are risks of heavy bleeding and emergency hysterectomy. Here we report the use of the da Vinci robot for removal of the pregnancy with adequate bleeding control. A 36-year-old para-3 was diagnosed having a 11 + 3 week live cesarean scar pregnancy and a complete placenta previa. S-hCG was 52 726 IU/l. One week after methotrexate treatment the pregnancy was uneventfully and completely removed by robot-assisted laparoscopy with minimal blood loss. The uterine defect was repaired. Bleeding was controlled by temporary application of metal clips to the distal internal iliac arteries and the propria ligaments. Postoperative color Doppler ultrasonography revealed normal uterine blood flow, a repaired uterine defect, and no remaining pregnancy tissue. S-hCG was normalized (<3 IU/l) 38 days after surgery. Robot-assisted laparoscopic surgery with temporary occlusion of the main uterine blood supply is a feasible and safe technique for surgery of a Cesarean scar pregnancy. © 2009 Springer-Verlag London Ltd.
“Robot-assisted gynecological surgery in a community setting.”
Piquion-Joseph, J. M., A. Nayar, et al. (2009).
Journal of Robotic Surgery: 1-4.
The objective of this study is to review our experience using the da Vinci robotic system to perform various gynecological surgeries for benign indications. Between July 2005 and April 2008, 110 patients underwent robot-assisted gynecological surgeries in Rochester General Hospital, NY. The records of these patients were retrospectively reviewed by an independent data collector to analyze the safety, effectiveness, and outcome of the surgeries done using the robotic system. The parameters reviewed include indication for surgery, type of procedure, operative time, blood loss, hospital stay, and intraoperative and post operative complications. The procedures completed include 74 hysterectomies including hysterectomies with bilateral salpingoophorectomy, 15 hysterectomies with sacrocolpopexy and other concomitant procedures, 18 myomectomies, and 3 oophorectomies. All procedures were completed robotically without the need for conversion to an open approach. The mean operation time was 2.15 h. Average estimated blood loss was 160 cc. Complications encountered include one cystotomy which was identified immediately and repaired in addition to one vault dehiscence and two post operative infections. The mean hospital stay was 1 day, with more than half of the patients being discharged within 24 h after the surgery. Post operative pain level was in the range of 0-6 in a scale of 0-10 (0: no pain, 10: worst pain in their life) and relieved by non-steroidal anti-inflammatory drugs. Robot-assisted laparoscopic benign surgical procedures are feasible techniques in a community setting. Robot-assisted laparoscopy has a promising future in minimally invasive surgery as it proved beneficial for our patients who experienced low complication rate and overall fast recovery compared to other approaches. © 2009 Springer-Verlag London Ltd.
“Smaller pieces of the hysterectomy pie: current challenges in resident surgical education.”
Pulliam, S. J. and L. R. Berkowitz (2009).
Obstetrics and gynecology 113(2 Pt 1): 395-398.
Residents in obstetrics and gynecology are increasingly confronted with a wider range of techniques that must be mastered to perform hysterectomy, including abdominal, vaginal, laparoscopic, and robotic approaches. This is accompanied by a decrease in the number of hysterectomies performed annually. Possible solutions to the dilemma created for surgical teaching includes a comprehensive program evaluating surgical competency by establishing numbers needed to achieve competency for specific major procedures.