“The Giep needle pass: A simple technique for the passage of needles for vaginal cuff closure in robotically assisted laparoscopic hysterectomy.”
Giep, H. N. and B. N. Giep (2011).
Journal of Robotic Surgery 5(2): 99-100.
The passage of needles and suture to close the vaginal cuff during a robotically assisted laparoscopic hysterectomy typically necessitates the use of a 10-12 mm accessory port to allow for the passage of a CT-1 sized needle. This results in a relatively large incision, which may lead to increased patient discomfort and dissatisfaction with cosmetic results compared to a smaller incision. Our technique of passing the needle and suture through the vagina allows us to use a smaller caliber accessory port while maintaining our ability to use a larger CT-1 needle easily and safely, with a reduced risk of losing the needle within the patient’s abdomen. © 2010 Springer-Verlag London Ltd.
“Clinical and cost comparisons for hysterectomy via abdominal, standard laparoscopic, vaginal and robot-assisted approaches.”
Landeen, L. B., M. C. Bell, et al. (2011).
South Dakota Medicine 64(6): 197-199, 201, 203 passim.
INTRODUCTION: The goal of this study was to compare outcomes and costs of four methods of hysterectomy: abdominal, standard laparoscopic, vaginal and robot-assisted approaches. METHODS: We conducted a retrospective medical chart review of 1474 consecutive hysterectomy patients with benign indications. RESULTS: Implementation of a robotics program at our institution resulted in reductions in abdominal (33 percent to 8 percent) and laparoscopic (29 percent to 5 percent) hysterectomies. Robotic surgery demonstrated the least blood loss and shortest hospital stays (both p < 0.0001), despite greater case complexity. Overall complication rates were highest for abdominal procedures (14 percent) and similar across minimally invasive approaches (8 to 9 percent). Conversion rates were four times greater in laparoscopic than vaginal or robotic hysterectomy (p = 0.01). Vaginal hysterectomy, performed in the least complex cases, had the lowest major complication rate (1.5 percent) and lowest costs. Costs for robotic surgery were similar to abdominal and laparoscopic approaches when robots were not depreciated as direct surgical expenses. CONCLUSIONS: Vaginal hysterectomy was the least expensive surgical option. Robotic surgery reduced morbidity, conversions and hospital stays even in complex cases, without incurring additional costs beyond purchase of the robotic system.
“Robotic versus laparoscopic hysterectomy: A review of recent comparative studies.”
Sarlos, D. and L. A. Kots (2011).
Current Opinion in Obstetrics and Gynecology.
PURPOSE OF REVIEW: To illustrate the current stand on robotic versus conventional laparoscopic hysterectomy regarding operating times, clinical outcome and costs. RECENT FINDINGS: Only six studies were reviewed, as there are only few recent studies comparing robotic with laparoscopic hysterectomy and most are retrospective. Apart from one multicentre study with over 36 000 patients, 350 institutions and numerous surgeons, most studies were performed with few cases by one or two surgeons at one or two hospitals. Operating times for robotic hysterectomies generally were longer, ranging from 89.9 to 267 min. Surgery time for conventional laparoscopic hysterectomies was between 83 and 206 min. In all studies, clinical outcomes such as blood loss, complications or hospital stay of both the robotic and the conventional laparoscopic procedure were similar. Only two studies compared costs and both came up with very similar findings. Cost for a robot-assisted hysterectomy is approximately 2600 USD higher than that for conventional laparoscopic hysterectomy not including investment and amortization. SUMMARY: Robotic and conventional laparoscopic hysterectomy are essentially equivalent regarding surgical and clinical outcome. Operating times are slightly higher and costs are significantly higher for the robotic procedure.
“Preemptive multimodal analgesia facilitates same-day discharge following robot-assisted hysterectomy.”
Shultz, T. M. (2011).
Journal of Robotic Surgery: 1-9.
We aimed to determine whether early hospital discharge following minimally invasive surgery can be achieved through the use of preemptive multimodal analgesia without compromising patient safety or comfort. Data were retrospectively collected for 150 patients who underwent robotic-assisted laparoscopic hysterectomy for benign indications from 9 December 2009 to 6 October 2010 at Cox Health Systems (Springfield, MO, USA). One surgeon performed 100 consecutive cases with all patients receiving preemptive multimodal treatment with celecoxib and ropivacaine. These cases were compared with 50 patients treated with an opioid-based postoperative analgesia regimen by one of four other surgeons at the same center. Patient characteristics, perioperative outcomes, opioid requirement, and time to discharge were compared between groups. The patients in the multimodal group had significantly reduced opioid requirements intraoperatively (25.0 mg vs. 29.9 mg, P = 0.0077), postoperatively on the day of surgery (10.9 mg vs. 17.9 mg, P = 0.0030), and on the first postoperative day (3.1 mg vs. 15.3 mg, P = 0.0001). There were no differences in procedure time, transfusions, or readmission rates between groups. Time in the Post-Anesthesia Care Unit (PACU) was decreased in the multimodal group (72.0 min vs. 88.4 min, P < 0.0001), as was time to discharge from the hospital (8.5 h vs. 30.2 h, P < 0.0001). Age and body mass index were both significantly lower in the multimodal group; however, regression analyses demonstrated that analgesia regimen was the only parameter that predicted opioid requirement and time to discharge. Preemptive multimodal analgesia reduced the total dose of rescue opioids, facilitating same-day discharge without compromising patient comfort or safety. © 2011 Springer-Verlag London Ltd.
“Robotic-assisted gynecologic/oncologic surgery: experience of early cases in a Saudi Arabian tertiary care facility.”
Al-Badawi, I. A., M. Al-Aker, et al. (2011).
Journal of Robotic Surgery: 1-6.
We report early experience of a case-mix series of robotic-assisted (RA) gynecologic/oncologic surgery in an Arabian population from a tertiary care facility, and discuss the emergence/growth of robotic surgery in the Arab world (Middle East). From December 2005 to December 2010, 60 consecutive patients [benign with complex pathology (BN, n = 34) and 26 cases with various malignancies; i.e., endometrial cancer (EC, n = 13), ovarian cancer (OC, n = 4), cervical cancer (CC, n = 1), and other cancers (OTH, n = 8), underwent RA procedures for the diagnosis/treatment/management of gynecologic/oncologic diseases at a single institution using the da Vinci® Surgical System. Data were analyzed for demographics, clinico-pathologic and peri/post-operative factors using intent-to-treat analysis. Despite continuous growth in the number of cases performed each year, the establishment of the robotic surgery program at our institution has been rather challenging due to patient acceptance, public awareness, and administrative resistance. The mean age of the case-mix was 43 ± 15 years (distribution: BN 39 ± 14, EC 61 ± 6, OC 36 ± 15, CC 50, OTH 41 ± 12 years). The body mass index for the case-mix was 30.3 ± 6.9 kg/m2 (distribution: BN 29.7 ± 6.2, EC 34.0 ± 3.6, OC 20.0 ± 1.7, CC 48, OTH 30.2 ± 6.2 kg/m2). The histology of most EC cases was endometrioid adenocarcinoma. The mean operative time was case-mix 95 ± 43, BN 77 ± 26, EC 156 ± 30, OC 80 ± 35, CC 150, OTH 79 ± 23 min. Mean blood loss was case-mix 126, BN 129, EC 177, OC 67, CC 50, OTH 71 min. Two cases (3.3%) were converted to laparotomy (one each in EC and BN groups). Mean hospital length of stay was 2 days. Four cases (6.7%) experienced complications. Only 4/26 (15.4%) of cancer cases required adjuvant therapy. The data suggest that RA gynecologic/oncologic procedures are feasible and satisfactory to our Arabian patient population and comparable to the existing literature for Caucasian counterparts. We believe this report is the first (and perhaps largest) case-mix series on the early experience of RA surgery for gynecologic/oncologic cases from the Middle East. © 2011 Springer-Verlag London Ltd.
“Magnetic resonance or computerized tomography imaging to predict difficulty of robotic surgery for endometrial cancer.”
Finan, M. A., J. A. Harris, et al. (2011).
Journal of Robotic Surgery: 1-7.
To determine if the difficulty of a robotic hysterectomy for endometrial cancer can be predicted by MRI, CT or other methods. All robotic cases from 1 August 2006 through 30 July 2009 were identified. Data collected prospectively included co-morbidities, body mass index, surgical times, estimated blood loss (EBL), uterine weight, and pre- and postoperative complications. Those patients who received an MRI or CT scan prior to robotic hysterectomy had additional data gathered from imaging, including uterine volume, pelvic measurements and abdominal wall thickness. Cases were labeled difficult for the following reasons: outliers greater than 2 SD from the mean EBL, hysterectomy time and total console time. Additional factors identifying difficult cases included the need to undock to remove the specimen or conversion to laparotomy. Data were analyzed for their possible role in causing difficulty in a robotic hysterectomy. Comparative statistics utilized included chi-square and t-test, ANOVA and logistic regression analysis. From 2 August 2006 through 30 July 2009, 119 patients underwent robotic surgery for endometrial cancer and are included in this study. Of these patients, 25/119 (20.0%) were identified as difficult cases. Difficulty was found in those patients with greater than 2 SD from the mean for hysterectomy time, >90.9 min (n = 3, 2.5%), total console time of >178.1 min (n = 6, 5.0%), EBL >232 cc (n = 7, 5.9%) and undocking to remove the uterine specimen in 8 (6.7%) cases; 1/119 (0.8%) was converted to laparotomy. Lymphadenectomy (P = 0.005) was associated with case difficulty. In a logistic regression analysis CT/MRI measurements of uterine volume greater than 793 cm3 and CT/MRI pelvimetry, as well as abdominal wall thickness were independent predictors of a difficult case (P = 0.0116). MRI and CT scans can detect the probability that a robotic surgery will be difficult by determining uterine volume and pelvimetry; however, these were not the strongest predictors in our study. A narrow pelvic outlet as measured on CT/MRI and uterine volume of greater than 793 cc should raise a flag of caution when planning robotic hysterectomy for endometrial cancer. © 2011 Springer-Verlag London Ltd.
“Robot-assisted radical hysterectomy-perioperative and survival outcomes in patients with cervical cancer compared to laparoscopic and open radical surgery.”
Gortchev, G., S. Tomov, et al. (2011).
Gynecological Surgery: 1-8.
In this study, perioperative outcomes and survival data in patients with early cervical cancer operated with three surgical methods: robot-assisted, laparoscopic and open, are to be analyzed. From January 2006 to May 2010, 294 patients with T1v{cyrillic}1 cervical cancer were studied retrospectively. Robot-assisted radical hysterectomy (RARH) was performed in 73 (24.8%) of them, laparoscopic-assisted radical vaginal hysterectomy (LARVH) in 46 (15.6%) and, in 175, (59.5%), abdominal radical hysterectomy (ARH). Mean hospital stay of patients with RARH and LARVH was 4.1 ± 0.7 and 4.8 ± 0.5, respectively, and of those with ARH, 9.6 ± 1.0 days (p = 0.001). Mean operative time was 152.2 ± 26.5 min for the robotic group as it was significantly shorter in comparison with the laparoscopic group (232.1 ± 61.7 min) and laparotomy group (168.2 ± 31.1 min) (p = 0.001). The application of Cox regression analysis found that the regional lymph node metastases were of significant value for disease-free survival (DSF), and the nodal status and recurrence presence-for overall survival (OS). Type of surgical procedure did not influence DSF, as well as OS. RARH has been established to be a safe procedure with proven advantages in regard to operative time and hospital stay. The absence of significant differences in DSF and OS is a substantial reason to continue, from an oncologic point of view, the application of this method on patients with T1v{cyrillic}1 cervical cancer. © 2011 Springer-Verlag.
“Robotic uterine artery preservation and nerve-Sparing radical trachelectomy with bilateral pelvic lymphadenectomy in early-Stage cervical cancer.”
Hong, D. G., Y. S. Lee, et al. (2011).
International Journal of Gynecological Cancer 21(2): 391-396.
Objective: The aim of the study was to evaluate the safety and feasibility of robotic uterine artery preservation and nerve-sparing radical trachelectomy with pelvic lymphadenectomy using the da Vinci surgical system. Methods: Three patients who were diagnosed with early-stage cervical cancer underwent robotic uterine artery preservation and nerve-sparing radical trachelectomy with bilateral lymphadenectomy from January 2010 to March 2010. The data were compared with those of 4 cases of total laparoscopic nerve-sparing radical trachelectomy that were performed from July 2004 to May 2005 and were previously reported. Results: In the robotic group, the mean console time was 275 minutes (range, 240-305 minutes). The mean postoperative hemoglobin change was 0.4 g/dL (range, 0.2-0.6 g/dL). The mean estimated blood loss was 23 mL (range, 15-40 mL), which is less than that of the laparoscopic group. There were no metastases detected in any of the cases, and the resection margins were negative in both groups. Conclusions: The robotic uterine artery preservation and nerve-sparing radical trachelectomy with pelvic lymphadenectomy were efficient in reducing blood loss and feasible methods such as other approaches. © 2011 by IGCS and ESGO.
“Rate of port-site metastasis is uncommon in patients undergoing robotic surgery for gynecological malignancies.”
Ndofor, B. T., P. T. Soliman, et al. (2011).
International Journal of Gynecological Cancer 21(5): 936-940.
OBJECTIVE: : To describe the rate of port-site metastasis in patients who underwent robotic surgery for suspected gynecological malignancy. METHODS: : Using a prospective database, we identified all patients who underwent robotic surgery performed by the Gynecologic Oncology service at 1 institution between December 2006 and March 2010. Records of patients with confirmed malignancy were reviewed for clinicopathological data and information about port-site metastasis. RESULTS: : One hundred eighty-one patients met the inclusion criteria. The median age was 55.4 years (range, 19-82 years), and the median body mass index was 29.6 kg/m (range, 17.9-70.7 kg/m). Port-site metastases were detected in 2 patients (1.1%) at 3 weeks (patient 1) and 11 months (patient 2) after surgery. Patient 1 underwent surgery for an adnexal mass, and pathological examination revealed gallbladder adenocarcinoma metastatic to the ovary. She had a recurrence in the right lateral abdominal wall robotic trocar site with concurrent metastases in the gallbladder fossa and liver. Patient 2 was diagnosed with adenocarcinoma of unclear (cervical vs endometrial) origin. Imaging showed metastases in pelvic and para-aortic lymph nodes. She underwent laparoscopy and was found intraoperatively to have gross disease on the right ovary. The patient underwent right salpingo-oophorectomy and chemoradiation. She had residual disease in the cervix and subsequently underwent robotic hysterectomy and left salpingo-oophorectomy. Pathological examination revealed endometrial cancer. She had a recurrence at the transumbilical trocar site concurrent with retroperitoneal lymphadenopathy and carcinomatosis. There were no cases of isolated port-site metastasis. CONCLUSIONS: : The rate of port-site metastasis after robotic surgery in women with gynecological cancer is low and similar to the rate for laparoscopic procedures.
“Gynaecologic Robot-Assisted Cancer and Endoscopic Surgery (GRACES) in a Tertiary Referral Centre.” Ng, J. S., Y. F. Fong, et al. (2011).
Annals of the Academy of Medicine, Singapore 40(5): 208-205.
Introduction: Robotic-assisted gynaecologic surgery is gaining popularity and it offers the advantages of laparoscopic surgery whilst overcoming the limitations of operative dexterity. We describe our experience with the fi rst 40 cases operated under the GRACES (Gynaecologic Robot- Assisted Cancer and Endoscopic Surgery) programme at the Department of Obstetrics & Gynecology, National University Hospital, Singapore. Materials and Methods: A review was performed for the fi rst 40 women who had undergone robotic surgery, analysing patient characteristics, surgical timings and surgery-related complications. All cases were performed utilising the da Vinci(R) surgical system (Intuitive Surgical, Sunnyvale, CA) with 3 arms and 4 ports. Standardised instrumentation and similar cuff closure techniques were used. Results: Seventeen (56%) were for endometrial cancer and the rest, for benign gynaecological disease. The mean age of the patients was 52.3 years. The average docking time was 11 minutes (SD 0.08). The docking and operative times were analysed in tertiles. Data for patients with endometrial cancer and benign cases were analysed separately. There were 3 cases of complications- cuff dehiscence, bleeding from vaginal cuff and tumour recurrence at vaginal vault. Conclusion: Our caseload has enabled us to replicate the learning curve reported by other centres. We advocate the use of a standard instrument set for the fi rst 20 cases. We propose the following sequence for successful introduction of robot-assisted gynaecologic surgery – basic systems training, followed shortly with a clinical case, and progressive development of clinical competence through a proctoring programme.
“Surgical outcomes in gynecologic oncology in the era of robotics: Analysis of first 1000 cases.”
Paley, P. J., D. S. Veljovich, et al. (2011).
American Journal of Obstetrics and Gynecology 204(6): 551.e551-551.e559.
Objective: We sought to examine outcomes in an expanding robotic surgery (RS) program. Study Design: In all, 1000 women underwent RS from May 2006 through December 2009. We analyzed patient characteristics and outcomes. A total of 377 women undergoing RS for endometrial cancer staging (ECS) were compared with the historical data of 131 undergoing open ECS. Results: For the entire RS cohort of 1000, the conversion rate was 2.9%. Body mass index increased over 3 time intervals: T1 = 26.2, T2 = 29.5, T3 = 30.1 (T1:T2, P = .01; T1:T3, P = .0001; T2:T3, P = .037). Increasing body mass index was not associated with increased major complications: T1 = 8.7%, T2 = 4.3%, T3 = 5.7%. In the ECS cohort, as compared with open ECS, women undergoing RS had lower blood loss (46.9 vs 197.6 mL, P < .0001), shorter hospitalization (1.4 vs 5.3 days, P < .0001), fewer major complications (6.4% vs 20.6%, P < .0001), with higher lymph node counts (15.5 vs 13.1, P = .007). Conclusion: RS is associated with favorable morbidity and conversion rates in an unselected cohort. Compared to laparotomy, robotic ECS results in improved outcomes. © 2011 Mosby, Inc.
“Robot-assisted laparoscopic radical hysterectomy: Comparison with total laparoscopic hysterectomy and abdominal radical hysterectomy; One surgeon’s experience at the Norwegian Radium Hospital.”
Sert, M. B. and V. Abeler (2011).
Gynecologic Oncology 121(3): 600-604.
Objectives: The purpose of this study was to investigate the 3 years follow-up results regarding the recurrence pattern of robot-assisted laparoscopic radical hysterectomies and pelvic lymphadenectomies in the early stage cervical carcinoma patients and compare the results with both total laparoscopic radical hysterectomy and abdominal radical hysterectomy groups. Methods: A total of 68 patients underwent radical hysterectomy and pelvic lymphadenectomy for early stage cervical carcinoma management. All cases (35 robot-assisted, 7 cases laparoscopy and 26 with laparotomy) were operated by the same surgeon at the Norwegian Radium Hospital. All cases were retrospectively reviewed to compare demographics, peri-operative variables such as mean operative time, estimated blood loss, lymph node counts, complications and follow-up results. Results: The mean operating times (skin-to-skin) for patients undergoing robot-assisted laparoscopic radical hysterectomy (RALRH), total laparoscopic radical hysterectomy (TLRH) or abdominal radical hysterectomy (ARH) were 263 ± 70, 364 ± 57 and 163 ± 26 min respectively. Patients receiving laparotomy had shortest operative time, followed by those undergoing RALRH and then laparoscopy (p < 0.0001 for both). Estimated blood loss was significantly reduced in robot-assisted surgeries compared to surgeries involving laparoscopy and laparotomy (82 ± 74 ml vs. 164 ± 131 ml (p < 0.0001) and 595 ± 284 ml (p = 0.023), respectively). The mean follow-up times were 36 ± 14.4, 56.4 ± 14 and 70 ± 21 months in patients who underwent RALRH, TLRH and ARH respectively. Until now there have been 5 recurrences and one cervical cancer related death in the robot-assisted group and no recurrences in both the laparoscopy and the laparotomy group. One patient died due to primary lung cancer in the laparoscopic group and other patient died due to primary pancreatic cancer in the laparotomy group. Conclusions: Robot-assisted laparoscopic radical hysterectomy and pelvic lymph node dissection is feasible and more precise because the instruments provide better flexibility and 3-D vision. We must proceed cautiously, however, if a new treatment modality appears to present an increased recurrence rate. Therefore, patients submitted to robot-assisted laparoscopic radical hysterectomy should be followed carefully and RALRH would be encouraged as protocol setting until the long-term oncological outcome data are available. © 2011 Elsevier Inc.
“A cohort study evaluating robotic versus laparotomy surgical outcomes of obese women with endometrial carcinoma.”
Subramaniam, A., K. H. Kim, et al. (2011).
Gynecologic Oncology.
OBJECTIVE: Minimally invasive surgery offers advantages for management of obese patients, but technical difficulty often deters its utilization. Compared to laparotomy, robotic surgery should allow comparable staging and improved surgical outcomes. Therefore, we evaluated outcomes in robotic and laparotomy cohorts of obese women with endometrial cancer at our institution. METHODS: Retrospective robotic and laparotomy cohorts of obese women (BMI>/=30kg/m(2)) undergoing surgical management of primary endometrial cancer from March 2006 to March 2009 were formulated utilizing a computerized database. Patient demographics, operative statistics, peri-operative complications, and pathologic details were collected in an intent to treat analysis. Chi-square or Fisher’s exact test and t-test were used for statistical analysis. RESULTS: 73 women underwent robotic surgical management, 11% converted to laparotomy. Mean BMI (39.8 vs. 41.9, p=0.152), number of co-morbidities (2.49 vs. 2.62, p=0.690), number of previous surgeries (0.97 vs. 0.94, p=0.841), and lymphadenectomies performed (65.8% vs. 56.7%, p=0.227) were similar between cohorts. Total lymph nodes obtained were not statistically different between cohorts (8.01 vs. 7.24, p=0.505). Total operative time and room time was significantly longer for robotic surgery; however, estimated blood loss, the percentage of patients receiving transfusion, hospital length of stay, wound complications (4.1% vs. 20.2%, p=0.002) and other complications (9.6% vs. 29.8%, p=0.001) were improved for the robotic cohort. CONCLUSIONS: Robotic management of obese women with endometrial cancer yields acceptable staging results and improved surgical outcomes. Although operating time is longer, hospital time is shorter. Robotic surgery may be an ideal approach for these patients.
“Supracervical robotic-assisted laparoscopic sacrocolpopexy for pelvic organ prolapse.”
Benson, A. D., B. A. Kramer, et al. (2011).
Journal of the Society of Laparoendoscopic Surgeons 14(4): 525-530.
Background: Supracervical robotic-assisted laparoscopic sacrocolpopexy (SRALS) is a new surgical treatment for pelvic organ prolapse that secures the cervical remnant to the sacral promontory. We present our initial experience with SRALS in the same setting as supracervical roboticassisted hysterectomy (SRAH). Methods: Women with vaginal vault prolapse and significant apical defects as defined by a Baden-Walker score of ≥3 who had not undergone hysterectomy were offered SRALS in combination with SRAH. A chart review was performed to analyze operative and perioperative data. Outcome data also included patients who underwent robotic- assisted laparoscopic sacrocolpopexy (RALS) without any other procedure. Results: Thirty-three patients underwent RALS, including 12 patients who underwent SRALS. All SRALS were performed following SRAH in the same setting. The mean follow-up for the RALS and SRALS patients was 38.4 months and 20.7 months, respectively. One patient in the RALS group had an apical recurrence. There were no recurrences in the SRALS group. Conclusions: SRALS is effective for repair of apical vaginal defects in patients with significant pelvic organ prolapse who have not undergone previous hysterectomy. Complications are few and recurrences rare in short- and medium-term follow-up. Greater follow-up and numbers are needed to further establish the role of this procedure. © 2010 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.
“Robotic surgery in gynecology – Surgery of the future or expensive PR gimmick? A personal opinion.”
Kimmig, R. (2011).
Robotic surgery in der gynäkologie – Chirurgie der zukunft oder teurer PR-Gag? Eine persönliche betrachtung44(5): 401-404.
“Pregnancy following robot-assisted laparoscopic myomectomy in women with deep intramural myomas.”
Lonnerfors, C. and J. Persson (2011).
Acta Obstetricia et Gynecologica Scandinavica.
Objective. To describe fecundity after robot-assisted laparoscopic myomectomy for deep intramural myomas. Design. Prospective observational study. Setting. University Hospital. Population. Women undergoing robot-assisted laparoscopic myomectomy. Methods. Expanding on a previous prospective feasibility study 31 consecutive women in whom a robot-assisted laparoscopic myomectomy was performed between April 2006 and July 2010 were included. The women, of which 14 had known infertility, were selected for having symptomatic, deep intramural myomas with a possible impact on fertility. Using a prospective protocol, relevant peri-operative and follow-up data were retrieved. Main Outcome Measures. Fertility and pregnancy outcome. Results. The 31 women included had a median age of 35 years (range 28-42 years) and median Body Mass Index of 22.0 kg/m(2) (range 20.1-24.7 kg/m(2) ). Fifteen of the 22 (68%) women with an active wish of conceiving have become pregnant at a median time of 10 months after surgery. A total of 18 pregnancies occurred resulting in three miscarriages, two terminated pregnancies, 10 successful term deliveries and three ongoing pregnancies. The subgroup of 14 women with a known but otherwise unexplained infertility had a similar pregnancy rate (69%) and of those, (55%) conceived naturally. The women who conceived naturally were on average eight years younger than the women becoming pregnant after IVF and all miscarriages occurred in an IVF pregnancy. Conclusions. In women with symptomatic, deep intramural myomas and either otherwise unexplained infertility or myomas with possible effect on conception the pregnancy rate following robot-assisted laparoscopic myomectomy was 68%.
“Robotics in gynaecology: a very brief history.”
Ng, J. S. (2011).
Annals of the Academy of Medicine, Singapore 40(5): 207-201.
“Robotic rectovaginal fistula repair.”
Puntambekar, S., N. Rayate, et al. (2011).
Journal of Robotic Surgery: 1-3.
Minimally invasive surgery for diseases in the pelvic region is gaining popularity due to advances in technology and increased benefit to the patient. As indications for such surgeries increase, the known boundaries for minimal access are being extended by a few teams. We report a patient who underwent robotic-assisted transabdominal repair of a high rectovaginal fistula which developed following a vaginal hysterectomy. Vaginography revealed a communication between the vaginal vault and the upper rectum. After evaluation of the colon and the vagina, the patient was planned for a robotic-assisted rectovaginal fistula repair. The three-arm daVinci® surgical robot was used. A total of five ports were used to complete the entire procedure, which included adhesiolysis, re-creation of the vaginal vault, repair of the fistula and omental interposition. This is the first robotic-assisted rectovaginal fistula repair reported to date. Besides the advantages of minimally invasive surgery for the patient, the surgeon benefits from the ease of suturing deep in the pelvis afforded by the articulated robotic arms. © 2011 Springer-Verlag London Ltd.
“The role of laparoscopic myomectomy in the management of uterine fibroids.”
Sami Walid, M. and R. L. Heaton (2011).
Current Opinion in Obstetrics and Gynecology.
PURPOSE OF REVIEW: Laparoscopic myomectomy has been described as comparable to open myomectomy in terms of fertility and obstetrical outcome with decreased intraoperative bleeding and postoperative disability. Despite this, laparoscopic myomectomy is not widely used reportedly due to lack of experience. This article presents our technique for laparoscopic myomectomy and assesses the current evidence-based literature for the use of this minimally invasive procedure in benign gynecological practice. RECENT FINDINGS: Literature continues to support the safety and feasibility of laparoscopic myomectomy for symptomatic women desiring to preserve their fertility. Alternatively, laparoscopically assisted myomectomy has been suggested when wider access is needed to perform the procedure. This variant of the technique allows palpating the uterus and does not require laparoscopic suturing skills. Robotic-assisted laparoscopic myomectomy currently has limited advantage over conventional laparoscopy due to longer operative time, loss of tactile sensation necessary to detect intramural myomas and high cost. Single-port surgery is a new promising approach, but still requires extensive investigation to determine whether it has significant benefits over conventional techniques. SUMMARY: Laparoscopic myomectomy cases are mostly doable, but may become difficult if bleeding problems occur. Extended operative times may be required for morcellation and extensive laparoscopic suturing. Gynecologists need to improve their laparoscopic skills, as minimally invasive surgery is becoming the sine qua non of a modern surgeon.
“Leiomyomas in adolescents.”
Wright, K. N. and M. R. Laufer (2011).
Fertility and Sterility 95(7): 2434.e2415-2434.e2417.
Objective: To describe a rare finding of a large leiomyoma and recurrence in an adolescent. Design: Case report. Setting: Major academic medical center. Patient(s): A 14-year-old gravida 0 presented with a 16-cm pelvic mass that was found to be an anterior uterine leiomyoma. Intervention(s): Exploratory laparotomy with resection of leiomyoma followed by robotic myomectomy when the mass recurred. Main Outcome Measure(s): The incidence, pathogenesis, fertility implications, and treatment options for leiomyomas in adolescents. Result(s): Leiomyomas are rare in adolescents. The mass was resected and recurred within 1 year. There are no prior cases of recurrence in an adolescent. Conclusion(s): Benign leiomyomas should be considered in adolescents presenting with uterine masses, as malignancies are even less common. Myomectomy is the procedure of choice to preserve fertility in this population. © 2011 by American Society for Reproductive Medicine.
“Robotic-assisted laparoscopic repair of symptomatic cesarean scar defect: a report of two cases.”
Yalcinkaya, T. M., M. E. Akar, et al. (2011).
Journal of Reproductive Medicine 56(5-6): 265-270.
BACKGROUND: Symptomatic cesarean scar defect is one of the commonly reported long-term complications of cesarean section. CASES: We present two cases of symptomatic cesarean scar defect treated conservatively by robotic-assisted laparoscopy at our institution. Both patients presented with hematocele, pelvic discomfort and secondary infertility. Transvaginal ultrasound revealed hematocele measuring 3.7 x 1.9 x 3.8 cm and 3.0 x 2.0 x 1.6 cm in the lower uterine segments, respectively. After surgery normal menses resumed in both patients, and their childbearing potential was preserved. The patients conceived 3 and 11 months after surgery, respectively. CONCLUSION: Recognition of cesarean scar defect is important in the explanation of certain menstrual disorders since surgical intervention can result in improvement of symptoms and prevent the related secondary obstetric and gynecologic complications. Robotic-assisted laparoscopic approach is a good minimally invasive alternative for the repair of cesarean scar defect.