“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 (2010).
Journal of Robotic Surgery: 1-2.
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.
“Histologic artifacts in abdominal, vaginal, laparoscopic, and robotic hysterectomy specimens: a blinded, retrospective review.”
Krizova, A., B. A. Clarke, et al. (2011).
American Journal of Surgical Pathology35(1): 115-126.
Total laparoscopic hysterectomy (LH) is a minimally invasive technique, which results in comparable morbidity and better cosmesis compared with total abdominal hysterectomy. The literature is discrepant as to whether it is associated with a higher incidence of positive peritoneal cytology compared with total abdominal hysterectomy and recently, associated artifacts, including vascular pseudoinvasion (VPI), have been described. A retrospective histopathologic review of 266 hysterectomy specimens from 2 centers was performed. The observers, blinded to the surgical technique, assessed for the presence of artifactual changes including disruption of the endometrial lining, nuclear crush artifact, VPI, endomyometrial cleft artifact with or without epithelial displacement, inflammatory debris within vessels, serosal carryover, and intratubal contaminants. In addition, the rates of positive peritoneal washings over a 5-year period, and the use of immunohistochemistry (IHC) to aid in cell typing over a 3-year period, were compared between hysterectomies in which a uterine manipulator (UM) device had and had not (nonmanipulated hysterectomies) been used. The hysterectomies were performed for malignant (n=160) and benign (n=102) uterine disease or for ovarian or cervical disease (n=4), and included total abdominal (n=108), vaginal (n=17), laparoscopy-assisted vaginal (n=24), laparoscopy converted to laparotomy (n=10), nonrobotic laparoscopic (n=51), and robot-assisted laparoscopic (n=56) hysterectomies. One hundred and two (38%) of these hysterectomies involved the use of a UM. Artifactual changes of disruption of the endometrial lining, endomyometrial clefts, intratubal contaminants, nuclear crush artifact, intravascular inflammatory debris, and VPI were significantly more common with LH and with the use of a UM, independent of whether the endometrial pathology was benign or malignant. IHC to aid in endometrial cancer subtyping was more likely to be used in manipulated hysterectomies (P=0.0166). Furthermore, peritoneal washings were significantly more likely to be positive in hysterectomies in which a UM had been used (P=0.0061). Histologic artifacts are significantly more common in LH and specifically in hysterectomies in which a UM is used. Such artifacts impair the pathologists’ interpretation of cell type requiring an increased use of IHC, and displaced epithelial fragments present within vessels or artifactual clefts may result in the misinterpretation of prognostic and staging parameters. Furthermore, there is a significantly higher rate of positive peritoneal cytology in cases that are subjected to uterine manipulation, suggesting dissemination of malignant cells into the abdominal cavity. The clinical significance of this finding needs to be determined.
“Lumbosacral osteomyelitis after robot-assisted total laparoscopic hysterectomy and sacral colpopexy.”Muffly, T. M., G. B. Diwadkar, et al. (2010).
International Urogynecology Journal and Pelvic Floor Dysfunction21(12): 1569-1571.
We report on the transabdominal resection of infected lumbosacral bone, synthetic mesh, and sinus tract following sacral colpopexy. A 45-year-old nulliparous patient who had undergone transvaginal mesh followed by robot-assisted sacral colpopexy presented with increasing back pain and foul-smelling vaginal drainage. An epidural abscess required surgical intervention, including diskectomy, sacral debridement, and mesh removal to drain the abscess and vaginal sinus tract. Recognized complications of open prolapse procedures also manifest following minimally invasive approaches. Osteomyelitis of the sacral promontory following sacral colpopexy may require gynecologic and neurosurgical management. © 2010 The International Urogynecological Association.
“Rate of vaginal cuff separation following laparoscopic or robotic hysterectomy.”
Nick, A. M., J. Lange, et al. (2011).
Gynecologic Oncology120(1): 47-51.
OBJECTIVE: Vaginal cuff separation is a rare but serious complication following hysterectomy. The goal of our study was to determine the rate of vaginal cuff separation and associated risk factors in patients undergoing laparoscopic or robotic hysterectomy. METHODS: We retrospectively identified patients who underwent a minimally invasive simple or radical hysterectomy at one institution between January 2000 and 2009. Fisher’s exact test, Wilcoxon rank sum test and multiple logistic regression were used to determine associations between variables and increased risk of separation. RESULTS: A total of 417 patients underwent laparoscopic (n=285) or robotic (n=132) hysterectomy during the study period. Three hundred and sixty-two underwent simple hysterectomy (249 laparoscopic, 113 robotic) and 57 underwent radical hysterectomy (36 laparoscopic, 19 robotic). Seven (1.7%) patients developed a cuff complication and all had a diagnosis of malignancy. Three (1.1%) patients in the laparoscopy group suffered a vaginal cuff evisceration (n=2) or separation (n=1). Four patients in the robotic group (3.0%) had a vaginal evisceration (n=1) or separation (n=3). There was no difference based on surgical approach (p=0.22). Vaginal cuff complications were 9.46-fold higher among patients who had a radical hysterectomy (p<0.01). Median time to presentation of vaginal cuff complication was 128 days (range, 58-175) in the laparoscopy group and 37 days (range, 32-44) in the robotic group. CONCLUSIONS: The overall risk of vaginal cuff complication was 1.7%. There appears to be no difference in cuff complication rates based on surgical approach. Radical hysterectomy, however, was associated with a 9-fold increase in vaginal cuff complications.
“Robot-assisted laparoscopic sacral colpopexy: Initial experience in a high-volume laparoscopic reference center.”
Xylinas, E., I. Ouzaid, et al. (2010).
Journal of Endourology24(12): 1985-1989.
Purpose: To describe the surgical technique of robot-assisted sacral colpopexy (RASCP) and to assess its feasibility and safety in a high-volume laparoscopic center. Patient and Methods: 12 women with symptomatic urogenital prolapse with or without concomitant urinary stress incontinence were treated with RASCP by one surgeon at our institution. The preoperative workup involved a detailed urologica and gynecologic history and physical examination to determine the type, the degree of the prolapse and the presence of concomitant stress urinary incontinence. Results: Mean operative time was 144 minutes (range 120-180min). No conversion to a laparoscopic or open procedure was necessary. The mean patient age was 57.1 years old (range 44-79). The mean estimated blood loss was 60mL (range 20-200mL). The mean catheterization time was 2 days, and the mean hospital stay was 3.4 days (range 3-4 d). At a mean follow-up of 19.1 months (range 8-28 mos), no recurrence of the prolapse occurred. Conclusion: RASCP for treatment of patients with urogenital prolapse is a feasible alternative to open and laparoscopic procedures. It procures an anatomic repositioning of the pelvic organs. The short-term results and the complication rates are similar with gold standard techniques. Copyright © 2010, Mary Ann Liebert, Inc.
“Robotic surgery, a variant of minimally invasive surgery for gynaecological malignancies.”
Anghel, R. (2010).
Memo – Magazine of European Medical Oncology3(3): 95-96.
“Histologic artifacts in abdominal, vaginal, laparoscopic, and robotic hysterectomy specimens: a blinded, retrospective review.”
Krizova, A., B. A. Clarke, et al. (2011).
American Journal of Surgical Pathology35(1): 115-126.
Total laparoscopic hysterectomy (LH) is a minimally invasive technique, which results in comparable morbidity and better cosmesis compared with total abdominal hysterectomy. The literature is discrepant as to whether it is associated with a higher incidence of positive peritoneal cytology compared with total abdominal hysterectomy and recently, associated artifacts, including vascular pseudoinvasion (VPI), have been described. A retrospective histopathologic review of 266 hysterectomy specimens from 2 centers was performed. The observers, blinded to the surgical technique, assessed for the presence of artifactual changes including disruption of the endometrial lining, nuclear crush artifact, VPI, endomyometrial cleft artifact with or without epithelial displacement, inflammatory debris within vessels, serosal carryover, and intratubal contaminants. In addition, the rates of positive peritoneal washings over a 5-year period, and the use of immunohistochemistry (IHC) to aid in cell typing over a 3-year period, were compared between hysterectomies in which a uterine manipulator (UM) device had and had not (nonmanipulated hysterectomies) been used. The hysterectomies were performed for malignant (n=160) and benign (n=102) uterine disease or for ovarian or cervical disease (n=4), and included total abdominal (n=108), vaginal (n=17), laparoscopy-assisted vaginal (n=24), laparoscopy converted to laparotomy (n=10), nonrobotic laparoscopic (n=51), and robot-assisted laparoscopic (n=56) hysterectomies. One hundred and two (38%) of these hysterectomies involved the use of a UM. Artifactual changes of disruption of the endometrial lining, endomyometrial clefts, intratubal contaminants, nuclear crush artifact, intravascular inflammatory debris, and VPI were significantly more common with LH and with the use of a UM, independent of whether the endometrial pathology was benign or malignant. IHC to aid in endometrial cancer subtyping was more likely to be used in manipulated hysterectomies (P=0.0166). Furthermore, peritoneal washings were significantly more likely to be positive in hysterectomies in which a UM had been used (P=0.0061). Histologic artifacts are significantly more common in LH and specifically in hysterectomies in which a UM is used. Such artifacts impair the pathologists’ interpretation of cell type requiring an increased use of IHC, and displaced epithelial fragments present within vessels or artifactual clefts may result in the misinterpretation of prognostic and staging parameters. Furthermore, there is a significantly higher rate of positive peritoneal cytology in cases that are subjected to uterine manipulation, suggesting dissemination of malignant cells into the abdominal cavity. The clinical significance of this finding needs to be determined.
“Rate of vaginal cuff separation following laparoscopic or robotic hysterectomy.”
Nick, A. M., J. Lange, et al. (2011).
Gynecologic Oncology120(1): 47-51.
OBJECTIVE: Vaginal cuff separation is a rare but serious complication following hysterectomy. The goal of our study was to determine the rate of vaginal cuff separation and associated risk factors in patients undergoing laparoscopic or robotic hysterectomy. METHODS: We retrospectively identified patients who underwent a minimally invasive simple or radical hysterectomy at one institution between January 2000 and 2009. Fisher’s exact test, Wilcoxon rank sum test and multiple logistic regression were used to determine associations between variables and increased risk of separation. RESULTS: A total of 417 patients underwent laparoscopic (n=285) or robotic (n=132) hysterectomy during the study period. Three hundred and sixty-two underwent simple hysterectomy (249 laparoscopic, 113 robotic) and 57 underwent radical hysterectomy (36 laparoscopic, 19 robotic). Seven (1.7%) patients developed a cuff complication and all had a diagnosis of malignancy. Three (1.1%) patients in the laparoscopy group suffered a vaginal cuff evisceration (n=2) or separation (n=1). Four patients in the robotic group (3.0%) had a vaginal evisceration (n=1) or separation (n=3). There was no difference based on surgical approach (p=0.22). Vaginal cuff complications were 9.46-fold higher among patients who had a radical hysterectomy (p<0.01). Median time to presentation of vaginal cuff complication was 128 days (range, 58-175) in the laparoscopy group and 37 days (range, 32-44) in the robotic group. CONCLUSIONS: The overall risk of vaginal cuff complication was 1.7%. There appears to be no difference in cuff complication rates based on surgical approach. Radical hysterectomy, however, was associated with a 9-fold increase in vaginal cuff complications.
“The role of robotic surgery in gynaecological oncology.”
Vasilescu, C. and R. Anghel (2010).
Memo – Magazine of European Medical Oncology3(3): 119-122.
PURPOSE: Laparoscopic surgery has been shown to be safe and feasible whilst treating patients with the same efficacy as traditional open procedures representing an acceptable approach in treating gynaecologic malignancies. However, the laparoscopic approach encountered some limitations: counterintuitive hand movements, two-dimensional visualization and limited degrees of instrument motion within the body. Robotic surgery overcomes many of the difficulties associated with conventional laparoscopy and allows surgeons to perform more complex procedures, whilst providing patients the benefits of minimally invasive surgery: radical hysterectomy with pelvic lymphadenectomy, trachelectomy and pelvic exenteration. MATERIAL AND METHODS: From March 2008 to April 2009, in our institution 19 patients underwent robotic radical hysterectomy with pelvic lymphadenectomy. Twelve patients were diagnosed with advanced cervical cancer, the rest of them with endometrial cancer. RESULTS: The mean operative time was 180 ± 23.45 min., the oral intake was started the next day after the operation and the patients were discharged 3.5 (±1.2) days postoperatively. CONCLUSION: As with any new procedure, careful patient selection is critical during the initial learning phase in order to progress through the learning curve with low morbidity and good outcomes. Robotic surgery is a viable option for many patients diagnosed with gynaecological cancers. © 2010 Springer.
“Role of robot-assisted surgery in cervical cancer.”
Yim, G. W., S. W. Kim, et al. (2011).
International Journal of Gynecological Cancer21(1): 173-181.
BACKGROUND: : The development of robotic technology has facilitated the application of minimally invasive techniques for complex operations in gynecologic oncology. OBJECTIVES: : The objective of the study was to assess and summarize the current literature on the role of robot-assisted surgery in cervical cancer in terms of its utility and outcome. METHODS: : Literature review concerning the use of robot-assisted technology in the management of cervical cancer, including radical hysterectomy, trachelectomy, parametrectomy, pelvic and aortic lymphadenectomy, and pelvic exenteration, was performed. RESULTS: : To date, 12 articles addressing radical hysterectomy, 5 articles of radical trachelectomy, and 6 articles of surgical procedure in advanced or recurrent cervical cancer, all performed robotically, are published in the literature. The advantages of the robotic system include 3-dimensional vision, tremor reduction, motion downscaling, improved ergonomics, and greater dexterity with instrument articulation. Because of these benefits, the robotic technology seems to facilitate the surgical approach for technically challenging operations performed to treat primary, early or advanced, and recurrent cervical cancer as evidenced by the current literature. CONCLUSIONS: : Surgical management of cervical cancer may be one of the gynecologic oncology surgeries that can take full advantage of robotic assistance in a minimally invasive manner. Continued research and clinical trials are needed to further elucidate the equivalence or superiority of robot-assisted surgery to conventional methods in terms of oncological outcome and patient’s quality of life.