Abstrakt Gynekologie Červenec 2011

“Robotic single-incision total laparoscopic hysterectomy: A novel surgical technique.”

Farnam, R. W. (2011).

Journal of Gynecologic Surgery 27(2): 87-89.


Background: The primary goal of this study of 1 patient was to determine the feasibility of using the da Vinci® Surgical System to perform a single-incision total laparoscopic hysterectomy. Case: Careful patient selection and counseling was used to identify a patient with a benign indication for a laparoscopic hysterectomy. The surgery was performed at a major urban hospital with advanced laparoscopic and robotic technology and trained staff. The patient was appropriately counseled to undergo a robotic single-incision total laparoscopic hysterectomy. The outcome was compared to historical controls for total laparoscopic hysterectomy. Results: The patient’s blood loss, postoperative pain, recovery, and convalescence were similar to that of total laparoscopic hysterectomy. The number of incisions and scaring was reduced. However, operating room time was significantly longer. Prolongation was thought to result from difficulty with maintaining pneumoperitoneum and vaginal cuff closure. Conclusions: A robotic single-incision total laparoscopic hysterectomy can be done safely and effectively. These findings suggest that robotic single-incision total laparoscopic hysterectomy may be a safe alternative to traditional laparoscopic hysterectomy. However, increased operating room time may be a limiting factor. Improvement in pneumoperitoneum and vaginal cuff closure may enhance operative efficiency. Additional study is needed. © 2011, Mary Ann Liebert, Inc.



“Robotic surgery in the management of cervical carcinoma.”

Alazzam, M., A. Gillespie, et al. (2011).

Archives of Gynecology and Obstetrics: 1-7.


Objectives: To review the published literature concerning robotic surgery and its applications in the management of cervical carcinoma. Methods: We electronically searched the MEDLINE from January 1990 until June 2010. We cross-examined article references to identify relevant articles not detected by the electronic search. Results: The majority of the reported literature consisted of case series, case reports or retrospective comparisons. Twenty-one articles were included in this review covering the different surgical applications: (5) radical trachelectomy, (12) radical hysterectomy, (3) pelvic exenteration and one parametrectomy. Conclusion: Robotic surgery enabled more gynaecological oncologists to perform more complex procedures safely while maintaining the minimal access approach. © 2011 Springer-Verlag.




“Robotic-assisted total laparoscopic hysterectomy and staging for the treatment of endometrial cancer: a comparison with conventional laparoscopy and abdominal approaches.”

Estape, R., N. Lambrou, et al. (2011).

Journal of Robotic Surgery: 1-7.


The treatment of endometrial cancer using a minimally invasive approach provides benefits to the patient; however, there are currently few papers comparing robotic total laparoscopic hysterectomy with staging to conventional laparoscopic and abdominal approaches. Analyses of 102 consecutive patients undergoing robotic total hysterectomy were compared to historical cohorts of 104 patients undergoing laparoscopic total hysterectomy and 78 patients undergoing abdominal total hysterectomy (laparotomy). The majority of all patients were FIGO’88 stage IB. Patient characteristics were similar, except for lower age (P = 0.0236) and body mass index (P = 0.0134) in the laparoscopy group when compared to laparotomy. Operative time was longer for the robotic group at 108.7 min, compared to 79.4 min for laparoscopy (P = 0.0207) and 84.0 min for laparotomy (P < 0.0001). Lymph node yield was significantly higher in the robotic group (16.0 nodes) when compared to both laparoscopy (5.0 nodes, P < 0.0001) and laparotomy (11.4 nodes, P = 0.0006). The perioperative complication rates were significantly decreased in both the robotic (10.8%) and laparoscopy (6.7%) groups when compared to laparotomy at 25.6% (P = 0.0089; P = 0.0002). Hospital stay was significantly reduced in both the robotic (1.9 days, P < 0.0001) and laparoscopic (1.8 days, P < 0.0001) groups when compared to laparotomy (4.1 days). Both minimally invasive approaches reduced morbidity. Robotic assistance resulted in improved lymph node yield. Robotic surgery for endometrial cancer is at least equivalent to laparoscopic and open techniques and may be the preferred method for treatment of endometrial cancer. © 2011 Springer-Verlag London Ltd.




“Venous injury during lymphadenectomy: management without laparotomy.”

Hoffman, M. S. and M. M. Humphrey (2011).

Journal of Robotic Surgery: 1-2.


During robotically-assisted pelvic lymphadenectomy, four venous injuries occurred that did not resolve with pressure. After the application of tightly woven, oxidized regenerated cellulose and a fibrin sealant, all four venotomies were hemostatic. There were no sequelae. © 2011 Springer-Verlag London Ltd.




“Robotic Transperitoneal Infrarenal Aortic Lymphadenectomy for Gynecologic Malignancy: A Left Lateral Approach.”

Jacob, K. A., V. Zanagnolo, et al. (2011).

Journal of Laparoendoscopic and Advanced Surgical Techniques. Part A.


Abstract Objective: To describe the technique and report patient outcomes of a left lateral approach for robotic transperitoneal infrarenal aortic lymphadenectomy with subsequent pelvic surgery in patients with gynecologic malignancy. Methods: Outcome data were collected retrospectively from March 2009 to September 2010 for all patients undergoing a left lateral approach for robotic transperitoneal aortic lymphadenectomy using a right lateral decubitus position by a single surgeon. Outcomes were analyzed and compared. Results: The median total operating time was 213 minutes (range, 186-265). The median body mass index was 25.2 kg/m(2) (range, 22.5-32.1). The median estimated blood loss was 150 mL (range, 50-550). The median length of hospital stay was 1 day (range, 1-2). The mean number of para-aortic lymph nodes was 8.2 (range 4-17). There were no conversions or perioperative complications in this 5-patient series. The mean follow-up was 12.8 months (range, 8-20). All patients underwent concomitant robotic hysterectomy and pelvic lymphadenectomy. Conclusions: A left lateral approach for robotic transperitoneal infrarenal aortic lymphadenectomy using a right lateral decubitus position is safe and feasible. Minimal patient repositioning provides access for pelvic surgery using the same abdominal trocar placement.



“Early evaluation of the feasibility of robot-assisted laparoscopy in the surgical treatment of deep infiltrating endometriosis.”

Bot-Robin, V., C. Rubod, et al. (2011).

Étude de faisabilité du traitement laparoscopique robot-assisté de lésions d’endométriose pelvienne profonde.


Background: Preliminary study of the feasibility of robot-assisted laparoscopy for deep pelvic endometriosis nodule resection. Patients and methods: Between May 2009 and February 2010, we collected medical and surgical data about deep infiltrating endometriosis resections performed in our institution, using robot-assisted laparoscopy (DA VINCI Intuitive Surgical System®). Results: Six patients were included: four partial bladder and two uterosacral ligament resections. The median age was 29.5 years (24-48). All patients reported chronic pelvic pain, associated with urinary tract symptoms in case of bladder endometriosis. Before surgery, lesion mapping was performed using magnetic resonance imaging for all, and mechanical bowel preparation or double-j stenting were prescribed, depending on the endometriosis location. Surgical procedures median time was 173 minutes (156-244), and median length of stay was 3 days (2-5). Complete resection was possible in all cases. There was no conversion in classical laparoscopy or laparotomy, and no intraoperative complication. Pathology diagnosis of surgical pieces concluded to endometriosis lesion in all cases. Conclusion: This study shows the feasibility of the robot-assisted laparoscopy in the resection of deep pelvic endometriosis, without increasing of surgical timing, blood loss or intraoperative complications. © 2011 Elsevier Masson SAS. All rights reserved.




“Robotics in reproductive surgery: Strengths and limitations.”

Catenacci, M., R. L. Flyckt, et al. (2011).



Minimally invasive surgical techniques are becoming increasingly common in gynecologic surgery. However, traditional laparoscopy can be challenging. A robotic surgical system gives several advantages over traditional laparoscopy and has been incorporated into reproductive gynecological surgeries. The objective of this article is to review recent publications on robotically-assisted laparoscopy for reproductive surgery. Recent clinical research supports robotic surgery as resulting in less post-operative pain, shorter hospital stays, faster return to normal activities, and decreased blood loss. Reproductive outcomes appear similar to alternative approaches. Drawbacks of robotic surgery include longer operating room times, the need for specialized training, and increased cost. Larger prospective studies comparing robotic approaches with laparoscopy and conventional open surgery have been initiated and information regarding long-term outcomes after robotic surgery will be important in determining the ultimate utility of these procedures.




“The technique of robotic assisted laparoscopic surgery in gynaecology, its introduction into the clinical routine of a gynaecological department and the analysis of the perioperative courses – a german experience.”

Kubilay Ertan, A., M. Ulbricht, et al. (2011).

Uterus hastali{dotless}klari{dotless}nda robot yardi{dotless}mli{dotless} laparoskopik jinekolojik cerrahi tekniǧi; bir jinekoloji departmani{dotless}ni{dotless}n klinik rutinine girişi ve perioperatif sürecin analizi – bir alman deneyimi 12(2): 97-103.


Objective: Robotic assisted surgery is an advancement on conventional laparoscopy. The first and single FDA-approved device is the da- VinciTM system, which provides means to overcome the limitations of conventional laparoscopy. In Germany the use of the robotic system in gynaecology is at the threshold of a promising development. There is a wide spectrum of indications, such as simple and radical hysterectomies, including pelvic and paraaortic lymph node dissection. The introduction of the robotic system into the clinical routine is demonstrated. Material and Methods: Robotic assisted laparoscopic interventions have been performed in the reporting hospital since April 2008. In the course of treatment of 172 cases, an increasing rise of complexity of surgical procedure has been achieved. The daVinciTM system is well adaptable in clinical routine. Hitherto, the clinical outcome has been favourable, higher-grade specific complications occurred very rarely. The short time advantages are a decrease of postoperative length of stay, a reduction of postinterventional need of analgetics and an overall accelerated period of recovery has been demonstrated compared to conventional abdominal procedures. It also shows that a drastic decrease of open conventional abdominal procedures concerning uterine pathologies appeared in the reporting department. Results: Perioperative advantages of robotic assisted laparoscopic interventions are, above all, the decrease of morbidity (concerning blood loss, need of analgetics, length of stay, etc.). Surgical advantages are the more complex applicability, improved precision, dexterity and vision (3D), a greater autonomy of the surgeon, a smaller learning curve and an increase of preparation consistent with the anatomical structures. In contrast, disadvantages concern an initial greater time investment, the potentially different management of complications, the limited applicability in multiquadrant surgery and the difficulty regarding cost coverage respective to recovery. Conclusions: In conclusion, robotic assisted minimal invasive surgery has an enormous potential in gynaecology; by simplifying the essential surgical procedure. The advantages of this technique will be approachability for a majority of gynaecological patients. The feasibility of a multitude of gynaecological surgical interventions has already been approved partially in a small number of cases. The upcoming challenge now is to verify the short and long term advantages of robotic surgery in prospective trials, especially concerning gynaecological oncology.




“Medicolegal review of liability risks for gynecologists stemming from lack of training in robot-assisted surgery.”

Lee, Y. L., G. S. Kilic, et al. (2011).

Journal of Minimally Invasive Gynecology 18(4): 512-515.


The advances in robot-assisted surgery in gynecology evolved after most practicing gynecologists had already completed residency training. Postgraduate training in new technology for gynecologists in practice is limited. Therefore, gynecologists with insufficient training who perform robot-assisted surgery may potentially be at risk for liability. In addition to the traditional medical negligence claims, plaintiff attorneys are seeking causes of actions for lack of informed consent and negligent credentialing. Thus, it is essential that gynecologists be aware of these potential liability claims that arise in a robot-assisted malpractice suit. This commentary provides an overview of the current medicolegal liability risks originating from lack of training in robotic surgery and seeks to raise awareness of the implications involved in these claims. A better understanding of the doctrine of informed consent and seeking assistance of proctors or experienced co-surgeons early in robotics training are likely to reduce the liability risks for gynecologic surgeons.




“Learning experience using the double-console da Vinci surgical system in gynecology: a prospective cohort study in a University hospital.”

Marengo, F., D. Larrain, et al. (2011).

Archives of Gynecology and Obstetrics.


PURPOSE: To report our preliminary experience with robotic-assisted laparoscopy in a variety of gynecological surgeries in a teaching hospital. METHOD: A total of 33 patients who underwent robotic-assisted laparoscopic procedures for gynecological diseases were included in the study. All surgeries were performed using the double-console da Vinci surgical system. Patient’s demographics, surgical procedures, operative time, perioperative complications, conversion rate, hospital stay and estimated blood loss were prospectively collected. RESULTS: All procedures were completed robotically except three (9%): two cases were converted to laparotomy and one case was converted to vaginal surgery. The mean age was 47 +/- 11 and mean BMI was 23 kg/m(2). Mean time taken for docking the robot was 22 min. Mean operative time was 152 min. Mean anesthesia time was 196 min. Mean hemoglobin drop was 2 g/dL. Four complications occurred: one transitory ischemic attack, one port-site hernia managed through trocar incision, one periumbilical hematoma managed conservatively and one vaginal cuff hematoma who required laparoscopy. The mean hospital stay was 4 days. CONCLUSION: With the use of robotic technology, surgeons are able to offer minimally invasive surgery to a larger percentage of patients. Double console system seems a promising tool in surgical education, improving both resident training and participation in surgeries. A shorter adaption to robotics could be expected in teams with previous experience with standard laparoscopy, however, a stepwise start with simpler cases is the key to achieve a safe adaption to robotic surgery.




“Long-term outcomes after robotic sacrocolpopexy in pelvic organ prolapse: Prospective analysis.”

Moreno Sierra, J., E. Ortiz Oshiro, et al. (2011).

Urologia Internationalis 86(4): 414-418.


Objective: To evaluate the feasibility and long-term outcomes of our initial series of robot-assisted laparoscopic sacrocolpopexy. Methods: We conducted a prospective analysis of our series of robotic sacrocolpopexy. Inclusion criteria: patients with grades III and IV cystocele and or other symptomatic pelvic organ prolapse. We performed a transperitoneal four-trocar technique with the Da Vinci robotic system using two polypropylene meshes for fixation to the sacral promontory. The primary outcome was recurrence; secondary outcomes included operating room time, blood loss, conversion to open surgery, complications and length of stay. Results: 31 consecutive procedures were included. Mean patient age was 65.2 (50-81) years. Mean operating room time was 186 (150-230) min. We converted 1 case to laparoscopy (3.2%). There were two major complications (1 acute myocardial infarction and 1 reoperation for excess tension with syncopes), two minor complications (1 wound infection and 1 ileus) and no recurrences at a mean follow-up of 24.5 (16-33) months. Conclusions: Robotic sacrocolpopexy could possibly improve with experience after overcoming the learning curve. There is no doubt it is a reproducible technique, but its safety and efficacy still need to be proven. Our initial series demonstrated good outcomes and no recurrences at 24.5 months of follow-up. Copyright © 2011 S. Karger AG, Basel.




“Robotic-assisted laparoscopic myomectomy versus abdominal myomectomy: a comparative analysis of surgical outcomes and costs.”

Nash, K., J. Feinglass, et al. (2011).

Archives of Gynecology and Obstetrics.


OBJECTIVE: To compare clinical and effectiveness outcomes between robotic-assisted laparoscopic myomectomy (RALM) and abdominal myomectomy (AM). STUDY DESIGN: Records were reviewed for the first 27 RALM procedures at our institution. Age, BMI, insurance status, race, uterine size, and operative indication were used to select comparable patients who had undergone AM. Clinical and efficiency outcomes were compared stratifying for uterine size, specimen weight, and matched propensity scores. RESULTS: IV hydromorphone use was significantly lower for RALM (P < 0.01), with no significant differences in blood loss or complications. RALM patients had significantly shorter hospital stays; however, total hospital charges were higher (P < 0.0001). This likely reflects longer operating room time (P < 0.0001), which was magnified as specimen size increased (P < 0.0001). CONCLUSION: RALM patients require less IV hydromorphone, have shorter hospital stays, and have generally equivalent clinical outcomes compared with AM patients. Additionally, as specimen size increased, the operative efficiency of RALM decreased compared with AM.