Robotic Surgery: Practical Examples in Gynecology 9783110306576, 9783110306552

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Sami G. Kilic, Kubilay Ertan, M. Faruk Kose (Eds.) Robotic Surgery

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Innovative Neurosurgery Nikolai J. Hopf (Editor-in-Chief), Anne-Katrin Hickmann (Managing Editor) ISSN 2193-522X, e-ISSN 2193-5238

Biomedical Engineering / Biomedizinische Technik Olaf Dössel (Editor-in-Chief) ISSN 0013-5585, e-ISSN 1862-278X

Robotic Surgery

Practical Examples in Gynecology Edited by Sami G. Kilic, Kubilay Ertan, M. Faruk Kose

DE GRUYTER

Editors Sami G. Kilic The University of Texas Medical Branch School of Medicine Department of Obstetrics and Gynecology Minimally Invasive Gynecology 301 University Boulevard Galveston TX77555-0587 United States [email protected]

M. Faruk Kose Bahcesehir University School of Medicine Head of Obstetrics & Gynecology Liv Hospital Ulus Ahmet Adnan Saygun Cad Canan Sok 12 Ulus 34340 Istanbul Turkey [email protected]

Kubilay Ertan Klinikum Leverkusen gGmbH Klinik für Frauenheilkunde und Geburtsmedizin Am Gesundheitspark 11 51375 Leverkusen Germany [email protected]

ISBN 978-3-11-030655-2 e-ISBN 978-3-11-030657-6 Set-ISBN 978-3-11-030658-3 Library of Congress Cataloging-in-Publication data A CIP catalog record for this book has been applied for at the Library of Congress. Bibliographic information published by the Deutsche Nationalbibliothek The Deutsche Nationalbibliothek lists this publication in the Deutsche Nationalbibliografie; detailed bibliographic data are available in the Internet at http://dnb.dnb.de. © 2014 Walter de Gruyter GmbH, Berlin/Boston Typesetting: Compuscript Ltd, Shannon, Ireland Printing and binding: Hubert & Co. GmbH & Co. KG, Göttingen Cover image: Jupiterimages/Kollektion/Thinkstock ∞ Printed on acid-free paper Printed in Germany www.degruyter.com

Preface “One must examine what concerns it, not only on the basis of the conclusion and the premises on which the argument rests, but also on the basis of things said about it.” Aristotle’s Nicomachean Ethics

In this book, all the contributing authors agreed that this virtue must pertain to all aspects of this new technique in gynecologic surgery. Having said that we all also agreed that it was our obligation to share our experience with our colloquies the way it was pointed out by Johann Wolfgang von Goethe earlier; “Knowing is not enough, we must apply Willing is not enough, we must do”

The way we practice changes parallel to the changes in technology in faster speed more than ever. Our aim was to serve the latest, most updated developments in our field in the essence of: “Try not to resist the changes that come your way. Instead let life live through you. And do not worry that your life is turning upside down. How do you know that the side you are used to is better than the one to come?” Rumi

Sami G. Kilic, Kubilay Ertan and M. Faruk Kose October 2013

Acknowledgements Sami G. Kilic: I thank my wife, Banu, and sons, Emre and Burak, for allowing me to spend countless hours away from home working on this book. I also thank my parents, Mete and Nezihe Kilic, who encouraged me to always pursue excellence in life. I thank my mentors for nurturing me in my career by giving endless hours of their time: Dr. Turgay Atasu, Dr. Harrith M. Hasson, Dr. Ozay Oral, Dr. Hyung-Shik Kang, and Dr. Josef Blankstein. Finally, I thank the administrative and support staff in UTMB’s Department of Obstetrics & Gynecology for editorial and organizational assistance: Misty Byrd, LeAnne Garcia, Alan Sheffield, and Robert G. McConnell, who applied tireless and meticulous effort to this project. Kubilay Ertan: My thanks go first of all to my patients who gave me their full confidence and made this project possible. I am especially thankful for all the European contributions to this book. Many thanks go also to Dr. Alexander di Liberto for his steadfast support and diligent work as my colleague, a surgeon, and a scientist. I wish to thank my wife, Dr. Anke Ertan, my daughters, Lara and Samira, and my son, Tarkan, for their patience while I spent innumerable hours working on this book. I am grateful to have them at my side. Finally, thank you to the de Gruyter Verlag, especially Dr. Sven Fund and Dr. Alexander Grossmann for their friendly cooperation and support. M. Faruk Kose: I would like to thank my wife Gulsen who supported me during my medical and marriage life. In addition, thanks to my daughter, Pinar and my son, Orhun who has shown the inspiration and support. I would like to express the deepest appreciation to my excellent mentors’ team, especially starting with Firat Ortac, MD, Demir Ozbasar, MD, Rifat Gursoy, MD, Cihat Unlu, MD, and Esat Orhon, MD who have shown their tremendous desire to teach the residency of obstetrics and gynecology. I also wish to thank all prominent colleagues for taking time to put a state of art work in this book as an author.

Index of authors Silvia Agramunt Department of Obstetrics and Gynecology Gynecologic Oncology Unit Hospital del Mar Parc de Salut Mar Paseo Maritimo 25 08003 Barcelona Spain [email protected] [email protected] Chapter 16 Sarfraz Ahmad Florida Hospital Gynecologic Oncology Florida Hospital Cancer Institute 2501 N. Orange Avenue Orlando FL 32804 United States [email protected] Chapter 18 Ahmed Sekotory M. Ahmed Department of Gynaecology Oncology The Christie NHS Foundation Trust 550 Wilmslow Road Manchester M20 4BX United Kingdom [email protected] Chapter 10 Bahriye Aktas Department of Gynecology and Obstetrics University Clinic Essen West German Cancer Center University of Duisburg-Essen Hufelandstraße 55 45147 Essen Germany [email protected] Chapter 23

Ibrahim Alanbay Department of Obstetrics and Gynecology Gülhane Military Medical Academy School General Tevfik Sağlam Cad. 06010 Ankara Turkey [email protected] [email protected] Chapters 8, 21, 25 Omer Burak Argun Department of Urology Acibadem Maslak Hospital Büyükdere cad. No:40 34457 Maslak, Sariyer Istanbul Turkey [email protected] Chapter 24 Banu Arun Co-Director Clinical Cancer Genetics Breast Medical Oncology University of Texas MD Anderson Cancer Center 1155 Pressler Street Houston TX 77030 United States [email protected] Chapter 21 Masoud Azodi Department of Obstetrics, Gynecology, and Reproductive Sciences Gynecologic Oncology Section Yale University School of Medicine 333 Cedar Street, FMB 332 New Haven CT 06510 United States [email protected] Chapter 22

x 

 Index of authors

Eralp Başer Department of Gynecologic Oncology Zekai Tahir Burak Women’s Health Education and Research Hospital Talatpaşa bulvarı PK 06230, Altındağ Ankara Turkey [email protected] Chapter 3 Mostafa A. Borahay Department of Obstetrics & Gynecology The University of Texas Medical Branch at Galveston 301 Univeristy Boulevard Galveston TX 77555-0587 United States [email protected] Chapters 2, 5, 26 Kristina A. Butler Mayo Clinic Arizona 5779 E Mayo Boulevard Phoenix AZ 85054 United States [email protected] Chapter 17 Sai Daayana Department of Gynaecology Oncology The Christie NHS Foundation Trust 550 Wilmslow Road Manchester M20 4BX United Kingdom [email protected] Chapter 10 Murat Dede Department of Obstetrics and Gynecology Gulhane Military Medical Faculty School of Medicine Tevf ik Sağlam Cd. Etlik Keçiören 06018 Etlik Ankara Turkey [email protected] Chapter 19

Alexander di Liberto Department of Gynaecology and Obstetrics Leverkusen Municipal Hospital Am Gesundheitspark 11 51375 Leverkusen Germany [email protected] Chapters 6, 11 Gregory L. Eads Head of The Southwestern Robotic Surgery Epicenter 1120 Medical Plaza Dr, Suite 200 The Woodlands TX 77380 United States [email protected] Chapter 9

Cihangir Mutlu Ercan Gulhane Military Medical Faculty Department of Obstetrics and Gynecology School of Medicine Tevf ik Sağlam Cd. Etlik Keçiören 06018 Etlik Ankara Turkey [email protected] Chapter 19 Ilknur Erguner Department of General Surgery Acibadem University School of Medicine Büyükdere Cad. No:40 Maslak Sariyer 34457 Istanbul Turkey [email protected] Chapter 29 Kubilay Ertan Department of Gynaecology and Obstetrics Leverkusen Municipal Hospital Am Gesundheitspark 11 51375 Leverkusen Germany [email protected] Chapters 6, 11

Index of authors 

Jeffrey M. Fowler Department of Obstetrics and Gynecology The Ohio State University Wexner Medical Center 210m-SL 320 W. 10th Ave Columbus OH 43210 [email protected] Chapter 7

Ismail Hakki Hamzaoglu Department of General Surgery Maslak Acibadem Hospital Büyükdere Cad. No:40 Maslak Sariyer 34457 Istanbul Turkey [email protected] Chapter 29

Stefano Gidaro Clinical Validation Telelap-Alf-x-Project SOFAR S.p.A. Milan Italy [email protected] Chapter 31

Martin Heubner Department of Gynecology and Obstetrics University Clinic Essen West German Cancer Center University of Duisburg-Essen Hufelandstraße 55 45147 Essen Germany [email protected] Chapter 23

Ahmet Göçmen Department of Obstetrics and Gynecology Ümraniye Education and Research Hospital Adem Yavuz Cd. No.1 Ümraniye 34766 Istanbul Turkey [email protected] Chapters 13, 14 Murat Gültekin Cancer Control Department Turkish Ministry of Health İlkiz Sok.No: 4/2 Sıhhiye PK 06430 Cankaya Ankara Turkey [email protected] Chapter 3 Mete Gungor Department of Obstetrics and Gynecology School of Medicine Acibadem University Acibadem Maslak Hospital Buyukdere cad. 40, 34457, Sariyer Istanbul Turkey [email protected] Chapter 15

Robert W. Holloway Florida Hospital Gynecologic Oncology Florida Hospital Cancer Institute 2501 N. Orange Avenue Orlando FL 32804 United States [email protected] Chapter 18 Gustavo N. C. Inoue Medical School University of São Paulo Dr. Arnaldo Avenue, 455 01246-000 São Paulo Brazil [email protected] Chapter 27 James E. Kendrick IV Florida Hospital Gynecologic Oncology Florida Hospital Cancer Institute 2501 N. Orange Avenue Orlando FL 32804 United States [email protected] Chapter 18

 xi

xii 

 Index of authors

Sami G. Kilic Department of Obstetrics and Gynecology School of Medicine The University of Texas Medical Branch Minimally Invasive Gynecology 301 University Boulevard Galveston TX 77555-0587 United States [email protected] Chapters 2, 4, 8, 14, 25, 26 Rainer Kimmig Department of Gynecology and Obstetrics University Clinic Essen West German Cancer Center University of Duisburg-Essen Hufelandstraße 55 45147 Essen Germany [email protected] Chapter 23 M. Faruk Kose Head of Obstetrics & Gynecology School of Medicine Bahcesehir University Liv Hospital Ulus Ahmet Adnan Saygun Cad Canan Sok 12 Ulus 34340 Istanbul Turkey [email protected] Chapter 1 Ali Riza Kural Head of Robotic Surgery and Urology Department Maslak Hospital Acibadem University Büyükdere cad. No:40 34457 Maslak Saiyer Istanbul Turkey [email protected] Chapter 24

Eric Lambaudie Department of Surgery Paoli Calmettes Institute 232 Bd Sainte Marguerite 13009 Marseille France [email protected] Chapter 3 Yu Lee Medical Branch at Galveston The University of Texas 301 Univeristy Boulevard Galveston TX 77555 United States [email protected] [email protected] [email protected] [email protected] Chapter 4 Lyuba Levine Department of Obstetrics and Gynecology University of Texas Medical Branch at Galveston 301 Univeristy Boulevard Galveston TX 77555-0857 United States [email protected] Chapter 20 Javier F. Magrina Mayo Clinic Arizona 5779 E Mayo Boulevard Phoenix AZ 85054 United States [email protected] Chapter 17 Georgia Mccann Division of Gynecologic Oncology Department of Obstetrics and Gynecology The University of Texas Health Science Center at San Antonio 7703 Floyd Curl Dr. Mail code 7836 San Antonio TX 78229 United States [email protected] Chapter 7

Index of authors 

Camran Nezhat Center for Minimally Invasive and Robotic Surgery Stanford University Medical Center 900 Welch Road, Suite 403 Palo Alto CA 94304 United States [email protected] Chapter 12 Hiep T. Nguyen Department of Urology Boston Children’s Hospital 300 Longwood Avenue HU 353 Boston MA 02115 United States [email protected] Chapter 27

Can Obek Department of Urology Cerrahpasa School of Medicine Istanbul University Istanbul 34098 Turkey [email protected] Chapter 24 Fikret Fatih Önol Urology Clinic Ümraniye Training & Research Hospital Adem Yavuz Cd. No.1 Ümraniye 34766 Istanbul Turkey [email protected] Chapter 25 Chandhana Paka Center for Minimally Invasive and Robotic Surgery Stanford University Medical Center 900 Welch Road, Suite 403 Palo Alto CA 94304 United States [email protected] Chapter 12

 xiii

Pooja R. Patel Department of Obstetrics & Gynecology Medical Branch at Galveston The University of Texas 301 Univeristy Boulevard Galveston TX 77555 United States [email protected] Chapter 26

Thomas N. Payne Medical Director Texas Institute for Robotic Surgery 12221 Renfert Way Austin TX 78758 United States [email protected] Chapter 9 John Y. Phelps Medical Branch at Galveston The University of Texas 301 Univeristy Boulevard Galveston TX 77555 United States [email protected] Chapter 4 Pedro T. Ramirez Director of Minimally Invasive Surgical Research & Education Department of Gynecologic Oncology The University of Texas MD Anderson Cancer Center 1515 Holcombe Boulevard – Unit 1362 Houston TX 77030 United States [email protected] Chapter 16

xiv 

 Index of authors

Gwyn Richardson Medical Branch at Galveston The University of Texas 301 Univeristy Boulevard Galveston TX 77555 United States [email protected] Chapter 20 Emilio Ruiz Morales ALF-X Surgical Robotics Department SOFAR S.p.A. Via Firenze 40 2060 Trezzano Rosa (MI) Italy [email protected] Chapter 31 Fatih Şanlikan Department of Obstetrics and Gynecology Ümraniye Education and Research Hospital Adem Yavuz Cd. No.1 Ümraniye 34766, Istanbul Turkey [email protected] Chapters 13, 14 Fatih Sendag Chief of Minimally Invasive Gynecology Department of Obstetrics and Gynecology Ege University Cemal Gürsel Cad. N.436 Çolak Ap. 4/7 Karşıyaka İzmir Turkey [email protected] Chapter 21

Dan-Arin Silasi Division of Gynecologic Oncology Department of Obstetrics, Gynecology & Reproductive Sciences Yale University School of Medicine 333 Cedar Street New Haven CT 06520 United States [email protected] Chapter 22 Michael Stark The New European Surgical Academy (NESA) Unter den Linden 21 10117 Berlin Germany [email protected] Chapter 31 Giovanni Taibbi Department of Ophthalmology and Visual Sciences The University of Texas Medical Branch 301 Univeristy Boulevard Galveston TX 77555-1106 United States [email protected] Chapter 30 Omer Lutfi Tapisiz Department of Gynecologic Oncology Etlik Zubeyde Hanim Women’s Health Training and Research Hospital Yeni Etlik Caddesi, No:55 Etlik, 06680 Ankara Turkey [email protected] Chapter 8

Index of authors 

Courtney M. Townsend, Jr. Department of Surgery Medical Branch at Galveston The University of Texas 301 Univeristy Boulevard Galveston TX 77555 United States [email protected] Chapter 28 Gianmarco Vizzeri Department of Ophthalmology and Visual Sciences The University of Texas Medical Branch 301 Univeristy Boulevard Galveston TX 77555-1106 United States [email protected] Chapter 30

Müfit Cemal Yenen Gulhane Military Medical Faculty Department of Obstetrics and Gynecology School of Medicine Tevf ik Sağlam Cd. Etlik Keçiören 06018 Etlik Ankara Turkey [email protected] [email protected] Chapter 19 Müjdegül Zayıfoğlu Karaca Department of Cancer Control Turkish Ministry of Health İlkiz Sok.No: 4/2 Sıhhiye PK 06430 Cankaya Ankara Turkey [email protected] Chapter 3

 xv

Contents Preface   v Acknowledgements   vii Index of authors   ix Part I: Basics  1 1.1 1.2 1.3 1.4 1.5 1.6 1.7

2 2.1 2.2 2.2.1 2.2.2 2.2.3 2.3 2.3.1 2.3.2 2.4 2.5

3

3.1 3.2 3.3

 1

 3 Robotic gynecologic surgery – introduction  M. Faruk Kose History   3 Robotics systems   4 Endoscopic surgery in gynecology   7 The advantages of robotic surgery   9 Limitations of robotic surgery   9 Telemedicine and robotic surgery: future aspects  Final suggestions   10 References   10

 9

 13 Launching a successful robotic program  Mostafa A. Borahay and Sami G. Kilic Introduction   13 Phases of a successful robotic gynecologic program  Planning phase   13 Implementation phase (learning curve or initial robotic program)   18 Evolving program   18 Academic activities   20 Education   20 Research   21 Financial analysis   21 Conclusion   22 References   22  23 Financial analysis of robotic surgery in gynecology  Eralp Başer, Müjdegül Zayıfoğlu Karaca, Eric Lambaudie and Murat Gültekin Introduction   23 Cost of robotic surgery   23 Cost effectiveness of robotic surgery vs. laparoscopic and open approaches   24

 13

xviii 

3.4 3.5 3.6

4

4.1 4.2 4.2.1 4.2.2 4.3 4.3.1 4.3.2 4.3.3 4.4

5

5.1 5.2 5.3 5.3.1 5.4 5.4.1 5.4.2 5.5 5.6 5.6.1 5.7

6 6.1 6.2 6.2.1

 Contents

Coverage of robotic surgery by health systems   27 How to use robotics more cost efficiently?   28 Conclusion   28 References   28 Training and credentialing in robotic gynecologic surgery and legal issues   31 John Y. Phelps, Yu Lee and Sami G. Kilic Introduction   31 Training and credentialing   31 Training   31 Credentialing   32 Legal issues   33 Components of medical malpractice   33 Insufficient training and credentialing legal issues   33 Robotic proctors and legal issues   34 Conclusion   35 References   35 Patient positioning, trocar placement, and docking for robotic gynecologic procedures   37 Mostafa A. Borahay Introduction   37 Importance of proper patient positioning and trocar placement  Patient positioning   38 Principles of patient positioning   38 Trocar placement   41 Peritoneal access   41 Trocar placement   41 Initial survey   45 Docking   45 Docking types   46 Conclusion   46 References   47  49 Role of the robotic surgical assistant  Alexander di Liberto and Kubilay Ertan The surgeon in the area of conflict between autonomy and dependency   49 Tasks of the robotic surgical assistant   50 Tasks of the robotic surgical assistant previous to the beginning of the surgical intervention   50

 37

Contents  

6.2.2 6.2.3 6.2.4

6.3 6.4 6.4.1 6.4.2 6.5 6.6 6.7

7

7.1 7.2 7.3 7.4 7.4.1 7.4.2 7.4.3 7.5 7.5.1 7.5.2 7.6 7.6.1 7.6.2 7.7 7.8 7.9 7.10 7.11

Tasks of the robotic surgical assistant between beginning of the surgery and start of the console phase   52 Tasks of the robotic surgical assistant during the console phase   52 Tasks of the robotic surgical assistant after termination of the console phase until the skin closure   55 Selection criteria of the robotic surgical assistant   55 Training/education of the robotic surgical assistant   56 Practical and virtual simulation/simulator systems   57 Training programs – request and reality   58 Aspects of spatial arrangement and structures of communication   59 Available data relating to the role of the robotic surgical assistant/existing evidence   62 Conclusions   63 References   64 Strategies for avoiding complications from robotic gynecologic surgery   67 Georgia A. Mccann and Jeffrey M. Fowler Introduction   67 Patient positioning – prevention of neurologic injuries  Complications of pneumoperitoneum and steep Trendelenburg   70 Robotic equipment   71 Electrosurgical principles   71 Monopolar electrosurgery   71 Bipolar electrosurgery   73 Avoiding surgical complications   73 Avoiding port complications   74 Gastrointestinal complications   75 Genitourinary complications   76 Bladder   76 Ureter   77 Complications of pelvic and para-aortic lymph node dissection   78 Incisional hernia   79 Vascular injuries   80 Vaginal cuff dehiscence   81 Summary   81 References   82

 68

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 Contents

Part II: General gynecology  8 8.1 8.1.1 8.1.2 8.1.3 8.2 8.2.1 8.2.2 8.2.3 8.2.4 8.2.5 8.2.6 8.3

9 9.1 9.2 9.3 9.4 9.5 9.6 9.7

 87

 89 Robotically-assisted simple hysterectomy  Sami Gokhan Kilic, Omer L. Tapisiz and Ibrahim Alanbay Introduction   89 Background   89 Robotic hysterectomy vs. laparoscopy: surgical outcomes   91 Cost analysis   95 Robot-assisted simple hysterectomy procedure   95 Positioning the patient   95 Trocar placement   96 Docking   97 Instrument selection   99 Step-by-step approach to simple hysterectomy   99 New innovative techniques for robotic hysterectomy: robotic surgery to laparoendoscopic single-site surgery (R-LESS)   106 Comment   107 References   107 Approach to the big uterus for hysterectomy  Gregory L. Eads and Thomas N. Payne Introduction   111 How large is possible?   111 Technique   112 Creating the bladder flap   112 Approach to vessels   113 Making the colpotomy   113 Tissue removal   114 References   115

 111

 117 The difficult robotic hysterectomy  Sai Daayana and Ahmed Sekotory M. Ahmed 10.1 Introduction   117 10.2 The scenarios of difficult and complex hysterectomy   117 10.3 Patients selection for robotic hysterectomy   118 10.4 Pre-operative preparation for a difficult hysterectomy   119 10.5 Technical operative factors and considerations   119 10.5.1 Anesthesia considerations   119 10.5.2 Following induction of anesthesia   120 10.5.3 Patient positioning   120 10.5.4 Entry   121 10.5.5 Uterine manipulation   122 10

Contents  

10.5.6 10.5.7 10.5.8 10.6 10.6.1 10.6.2 10.6.3 10.6.4 10.6.5 10.6.6 10.6.7

Trocar placement   122 Docking   124 Steps of robotic hysterectomy   124 General considerations   126 Choice of instruments   127 How to avoid trocar site hernia?   127 How to avoid losing pneumo peritoneum?   128 How to avoid vaginal cuff infection/dehiscence?  Data collection   129 Learning curve   129 Continuing professional development   129 References   129

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 128

 131 Robot-assisted laparoscopic myomectomy (RALM)  Kubilay Ertan and Alexander di Liberto 11.1 Principles of surgical therapy of uterine myomas   131 11.2 Patient selection for robot-assisted laparoscopic myomectomy (RALM)   134 11.3 Technical and logistic aspects of robot-assisted myomectomies   134 11.3.1 Patient positioning   134 11.3.2 Equipment   135 11.3.3 Selection of robotic instruments (EndoWrist™ instruments)   136 11.3.4 Uterine manipulation   137 11.3.5 Trocar placement   138 11.3.6 Operation schedule for RALM   138 11.3.7 Camera work (0° vs. 30° endoscope)   140 11.3.8 Features and characteristics of robot-assisted myomectomy   140 11.3.9 Suturing techniques and suture material   141 11.3.10 Adhesion prophylaxis   141 11.3.11 Intraabdominal asservation/storage of removed myomas   142 11.4 Advantages of robotic assistance concerning myomectomies   142 11.5 Disadvantages and deficiencies of robotic assistance concerning myomectomy   143 11.6 Preoperative preparations/perioperative management   143 11.6.1 Indications for robot-assisted myomectomy   143 11.6.2 Organ-specific diagnostics   146 11.6.3 Medicamentous pretreatment   146 11.6.4 Preparation of the surgery   148 11.6.5 Patient information and informed consent   149 11.7 Recommendations for further diagnostics and treatment/time interval to pregnancy/mode of delivery   149 11

xxii 

11.8 11.9 11.10 11.11

12

12.1 12.2 12.3 12.4 12.5 12.6 12.7 12.8 12.9 12.10

 Contents

Case studies   150 Authors data of robot-assisted myomectomy   152 Available data from robot-assisted myomectomies/ existing evidence   155 Summary and conclusion   157 References   158 Endometriosis: robotic-assisted laparoscopic surgical approaches   161 Chandhana Paka and Camran Nezhat Introduction   161 Application to endometriosis   161 Surgical approach   162 Lysis of adhesions   163 Peritoneal and tubo-ovarian endometriosis   163 Intestinal endometriosis   164 Genitourinary endometriosis   166 Diaphragmatic and thoracic endometriosis   168 Hepatic endometriosis   169 Conclusion   169 References   170

 175 Robotic-assisted tubal reanastomosis  Ahmet Göçmen and Fatih Şanlıkan 13.1 Introduction   175 13.2 Surgical technique   176 13.2.1 Positioning of the robotic surgical system   176 13.2.2 Robotic-assisted tubal reversal procedure   177 13.3 The surgical outcomes of robotic-assisted tubal reversal  References   180 13

14 14.1 14.2 14.3

15 15.1 15.2

 181 Robotic-assisted abdominal cerclage  Ahmet Göçmen, Fatih Şanlıkan and Sami Gokhan Kilic Introduction   181 Operative technique   181 Outcomes   183 References   184  187 Single-port robotic surgery  Mete Gungor Introduction   187 Surgical technique   189

 178

Contents  

15.3 15.4

Discussion  Conclusion  References 

 191  193  193

Part III: Gynecologic onocology 

 195

16

Update on robotic surgery in the management of cervical cancer   197 Silvia Agramunt and Pedro T. Ramirez 16.1 Introduction   197 16.2 Early-stage disease   197 16.2.1 Radical hysterectomy   197 16.2.2 Radical trachelectomy   201 16.3 Locally advanced disease   203 16.4 Incidental invasive cervical cancer: robotic-radical parametrectomy   204 16.5 Conclusions   205 References   206 17

17.1 17.2 17.3 17.4 17.5 17.5.1 17.5.2 17.5.3 17.5.4 17.6 17.7

18

18.1 18.2 18.3 18.4

Robotic-infrarenal aortic lymphadenectomy: A step-by-step approach   209 Kristina A. Butler and Javier Magrina Introduction   209 Patient selection   209 Advantages   211 Approaches   211 Transperitoneal techniques   212 Midline approach, pelvic trocars, no table rotation   212 Midline approach, pelvic trocars, 180° table rotation   212 Midline approach, subcostal trocars   214 Left lateral approach   216 Extraperitoneal technique   216 Conclusion   217 References   217 Robotic-pelvic and aortic lymphadenectomy for gynecologic malignancies – one approach   221 James E. Kendrick IV, Sarfraz Ahmad and Robert W. Holloway Introduction   221 The rationale for lymphadenectomy   221 The minimally-invasive shift   222 Operating room set-up and patient preparation   223

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xxiv 

18.5 18.6 18.7 18.8 18.9 18.10

19

19.1 19.2 19.2.1 19.2.2 19.2.3 19.2.4 19.2.5 19.2.6 19.2.7 19.2.8 19.2.9 19.2.10 19.3

20 20.1 20.2 20.3 20.4 20.5 20.6

 Contents

Surgical technique for center-docked robotic-assisted aortic lymphadenectomy   226 Surgical technique for robotic-assisted pelvic lymphadenectomy   228 Comparative studies   230 Managing obese patients with endometrial cancer   230 Future directions   232 Conclusions   233 References   233 Robotic-extraperitoneal lymphadenectomy: A step-by-step approach   237 Murat Dede, Müfit Cemal Yenen and Cihangir Mutlu Ercan Introduction   237 Robotic-assisted retroperitoneal laparoscopic para-aortic lymphadenectomy: Technique   239 Informed consent   239 Examination under anesthesia and cystoscopy   239 Position of patient   240 Diagnostic laparoscopy   240 Entering the extraperitoneal space with intraperitoneal laparoscopic guidance   241 Placement of balloon trocar and the formation of the retroperitoneal space   241 Placement of surgical trocars into the retroperitoneal space   241 Formation of the surgical plan at the retroperitoneal space   242 Left aortic and paracaval nodal dissection   242 Marsupialization of the retroperitoneal space   243 Conclusion   243 References   245  249 Robotic surgery for ovarian cancer  Lyuba Levine and Gwyn Richardson Introduction   249 Benefits of minimally-invasive surgery   250 Low-malignant potential or borderline ovarian tumors  Early-stage invasive ovarian cancer   252 Advanced stage invasive ovarian cancer   254 Considerations   254 References   256

 250

Contents  

21

Risk-reducing bilateral salpingo-oopherectomy in BRCA mutations career   259 Ibraham Alanbay, Banu Arun and Fatih Sendag 21.1 BRCA1/2 mutations   259 21.2 Risk reducing strategies   259 21.3 Risk reducing salpingo-oopherectomy (RRSO)   260 21.4 Time of RRSO   262 21.5 Primary peritoneal carcinoma after RRSO   262 21.6 Occult cancer at the time of RRSO   263 21.7 Health proplems after RRSO   264 21.8 Technique of RRSO   264 21.9 RRSO with/without hysterectomy   264 21.10 Radical fimbriectomy: As a new temporary risk reducing surgery   265 21.10.1 Laparoendoscopic single port surgery (LEES) for RRSO  21.11 Pathologic examination of tuba   266 21.12 Complication of RRSO   267 21.13 Surveilance   267 21.14 Cost analysis   268 References   268 22 22.1 22.2 22.3 22.4 22.5 22.6 22.7 22.8 22.9 22.10 22.11 22.12 22.13

 273 Robotic surgery for uterine cancer  Dan-Arin Silasi and Masoud Azodi Epidemiology   273 Presentation   273 Surgical treatment   273 Preoperative evaluation   274 Surgical staging   274 Patient positioning   275 Pneumoperitoneum, port placement, and instruments   275 Anesthesia concerns   276 Pelvic lymphadenectomy   277 Para-aortic lymphadenectomy   279 Omentectomy   282 Extrafascial hysterectomy   284 Closure of the vaginal apex   285 References   285

 265

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23

23.1 23.2 23.3 23.4 23.5

 Contents

Compartment-based radical surgery: The TMMR, FMMR and PMMR family in uterine cancer   287 Rainer Kimmig, Bahriye Aktas and Martin Heubner Introduction   287 Therapeutic pelvic and periaortic lymphadenectomy (rtLNE)   288 Total mesometrial resection (rTMMR)   297 Fertility preserving mesometrial resection (rFMMR)  Peritoneal mesometrial resection (rPMMR)   307 Acknowledgements   316 References   316

Part IV: Urogynecology  24 24.1 24.2 24.3 24.4

25

25.1 25.2 25.3 25.3.1 25.3.2 25.3.3 25.3.4 25.3.5 25.3.6 25.3.7 25.3.8 25.3.9 25.4 25.4.1 25.4.2 25.4.3

 305

 319

 321 Robotic surgery for urogynecologic diseases  Omer Burak Argun, Can Obek and Ali Riza Kural Introduction   321 Robotic-vesicovaginal fistula repair   321 Robotic ureteral reconstructive surgery   322 Robot-assisted laparoscopic sacrocolpopexy (RALS)  References   325 Robotic sacrocolpopexy for the management of uterine and vaginal vault prolapse   327 Sami Gokhan Kilic, Ibrahim Alanbay and Fikret Fatih Onol Introduction   327 Evaluation and surgical indications   328 Technique and concomitant procedure   329 Preoperative preparation   329 Patient positioning and initial preparation   329 Access and port placement   330 Surgical technique   332 Sacral dissection   333 Anterior dissection   335 Posterior dissection   336 Mesh preparation   337 Follow-up   341 Outcomes and complications   342 Anatomical and functional outcomes of RASC   342 Complications   345 Disadvantages   345

 323

Contents  

25.5

26 26.1 26.2 26.3 26.4 26.4.1 26.4.2 26.4.3 26.4.4 26.4.5 26.4.6 26.4.7 26.4.8 26.4.9 26.4.10 26.4.11

Conclusion  References 

 349 Robotic-retropubic urethropexy  Sami Gokhan Kilic, Pooja R. Patel and Mostafa A. Borahay Introduction   349 Midurethral sling versus robotic retropubic urethropexy   349 Evolution of the robotic Burch colposuspension   350 Step-by-step description of the robotic-assisted Burch colposuspension   351 Preoperative planning   351 Positioning the patient and Foley insertion   351 Docking   351 Trocar insertion   352 Concomitant procedures   352 Repositioning the patient   352 Retrograde filling of the bladder   352 Dissection to create the retropubic space of Retzius   353 Identification of urethro-vesicular junction (UVJ) using hand in the vagina   353 Suturing   353 Cystoscopy   354 References   356

Part V: Specialties  27 27.1 27.2 27.2.1 27.3 27.3.1 27.4 27.4.1 27.5 27.5.1 27.6

 346  346

 359

 361 Pediatric gynecology for robotic surgery  Gustavo N. C. Inoue and Hiep T. Nguyen Introduction   361 Sling procedure for bladder outlet incompetence  Surgical technique   362 Vaginoplasty   365 Surgical technique   365 Hysterectomy   366 Surgical technique   367 Surgical management of endometriosis   367 Surgical technique   368 Conclusion   368 References   368

 361

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28

Robotic-assisted surgery advances benefit patients  Courtney M. Townsend, Jr.

29

Gynecology-related general surgery   373 Ilknur Erguner and Ismail Hakki Hamzaoglu How do gastrointestinal injuries occur?   373 Management of the gastrointestinal injuries   373 Bowel injuries   373 Small bowel injuries   374 Large bowel injuries   375 Rectal injury   376 Stomach Injury   376 Prevention of gastrointestinal injury   377 References   377

29.1 29.2 29.2.1 29.2.2 29.2.3 29.2.4 29.2.5 29.3

 379 Ophthalmology and steep Trendelenburg  Giovanni Taibbi and Gianmarco Vizzeri 30.1 Introduction   379 30.2 Posture-induced ocular changes   379 30.3 Post-operative ophthalmological complications  30.4 Ophthalmological patient management   381 30.4.1 Preoperative evaluation   381 30.4.2 Intraoperative period   382 30.4.3 Postoperative assessment   382 30.5 Conclusions   383 30.6 Acknowledgements   383 References   383

 371

30

31 31.1 31.2 31.3

Index 

 385 The future of telesurgery and new technology  Emilio Ruiz Morales, Stefano Gidaro and Michael Stark Introduction   385 Technical description   387 First preclinical studies   389 References   389  391

 380

Part I: Basics

1 Robotic gynecologic surgery – introduction M. Faruk Kose “There is no excuse today for the surgeon to learn on the patient.” William J. Mayo, 1927

1.1 History The word robot (from the Czech word robota meaning compulsory labor) was defined by the Robotic Institute of America (1979) as “A reprogrammable, multifunctional manipulator designed to move materials, parts, tools, or specialized devices through various programed motions for the performance of a variety of tasks” [1]. Leonardo di ser Piero da Vinci (1452–1519), is famous as an artist, but he was also a scientist, mathematician, engineer, inventor, anatomist, architect, botanist, musician and writer, and is recorded as being the creator of the first robot in human form (1495). The robot is a knight in appearance wearing the traditional outfit for the time, and is clad in Italian-German medieval armour (Fig. 1.1). The design is likely to be based on his anatomical research recorded in the Vitruvian Man (Fig. 1.2) [2, 3]. In 1738, Jacques de Vaucanson began building an automata in Grenoble, France and created a duck, called “moving anatomy’’. “The duck moved, quacked, flapped its wings and even ate and metabolized food” [4]. This was then followed by Joseph Marie Jacquard (1752–1834) in 1801; Jacquard built an automated loom that was controlled with punched cards. Punch cards were later used as an input method for some of the 20th century’s earliest computers [5, 6] (Fig. 1.3). The acclaimed Czech playwright Karel Capek (1890–1938) was the first to use the word “robot” in his play R.U.R. (Rossum’s Universal Robots) which opened in Prague in January 1921. In R.U.R., Capek creates a paradise, where the machines initially bring many benefits but in the end bring an equal amount of blight in the form of unemployment and social unrest [7]. Isaac Asimov used the word “robotics’’ initially in Runaround, a short story published in 1950. Asimov also proposed his three “Laws of Robotics’’, and he later added a “zeroth law’’ (Tab. 1.1) [8]. His laws refer to the protection of humanity above humans, that robots must obey humans unless it conflicts with a higher law. These principles of safety, initially raised by Asimov, are applicable for current robotic surgical systems. The use of robots in surgical approaches has grown exponentially within the past 20 years. The first implementation of the robot in surgery was in neurosurgery [9], known as the PUMA 560 (Staubli Corporation, Duncan, SC, USA). Meanwhile, at Imperial College in London in 1988, urologists were performing transurethral resection of the prostate with a robotic guidance system called PROBOT [10]. Subsequently in 1992, ROBODOC (Curexo Technology Corporation, Sacramento, CA, USA) was used in orthopedic surgery for

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  1 Robotic gynecologic surgery – introduction

Fig. 1.1: Model of Leonardo’s robot with inner workings, as displayed in Berlin. Photo by Erik Möller. Leonardo da Vinci. Mensch – Erfinder – Genie exhibit, Berlin 2005. (Leonardo‘s robot. From wikipedia, the free encyclopedia. Accessed November 1, 2013 at http://en.Wikipedia.org/wiki/Leonardo % 27_robot)

aiding in total hip replacements [11]. All these robotic applications were passive models with a preoperative plan or in a supervisory role and this would evolve into a more active one, known as robotic telepresence technology. The robotic telepresence technology was developed under the auspices of the military to allow surgeons to perform surgery on injured soldiers from a safe and remote location. Soon, research was also focused on robotic surgery to further improvements in laparoscopic and minimally-invasive surgery (MIS) for civilians. Although robotic telepresence surgery originated for cardiovascular surgery [12], it was widely used for urologic and gynecologic surgeries.

1.2 Robotics systems The first application of robotic surgery in the civilian operating room was to assist surgery in laparoscopic approaches with a voice-activated arm. This device was called AESOP (Automated Endoscopic Systems for Optimal Positioning; Computer Motion, Inc., Goleta, CA, USA). The second system was the ZEUS (Computer Motion, Inc., Goleta, CA, USA), which included three remotely controlled robotic arms that were attached to the surgical table. Two handles housed in a workstation called a robotic console control the arms that hold the surgical instruments. The robotic console can be

1.2 Robotics systems  

  5

Fig. 1.2: The Vitruvian Man is a world-renowned drawing created by Leonardo da Vinci circa 1487 [3]. (Vitruvian Man. From wikipedia, the free encyclopedia. Accessed November 1, 2013 at http:// en.wikipedia.org/wiki/Vitruvian_man)

positioned anywhere in the operating room and provides the instrument controls and three-dimensional (3D) vision with the aid of special glasses. The surgeon was moved

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  1 Robotic gynecologic surgery – introduction

Fig. 1.3: The most famous image in the early history of computing [6]. (Joseph Marie Jacquard. From wikipedia, the free encyclopedia. Accessed November 1, 2013 at http://en.wikipedia.org/wiki/ Joseph_Marie_Jacquard)

Tab. 1.1: Asimov’s Laws of Robotics [8] Law Zero: A robot may not injure humanity, or, through inaction, allow humanity to come to harm. Law One: A robot may not injure a human being, or, through inaction, allow a human being to come to harm, unless this would violate a higher order law. Law Two: A robot must obey orders given it by human beings, except where such orders would conflict with a higher order law. Law Three: A robot must protect its own existence as long as such protection does not conflict with a higher order law (k-4).

to a remote console for the first time with this system. In 1999, the first robotically assisted gynecologic surgery was performed and reported with the Zeus robotic system [13]. The third, most sophisticated of the surgical robotic systems is the “da Vinci® system’’ (Intuitive Surgical Inc, Sunnyvale, CA, USA), represents the most significant advancement in MIS of this decade. The U.S. Food and Drug Administration (FDA) approved this device for abdominal surgeries in 2000. Robotic assisted laparoscopic surgery (robotic surgery) was cleared in 2001 for urologic procedures in the USA, in 2002 for thorascopically-assisted cardiotomy, and in 2004 for coronary revascularization by the FDA. In April 2005, the da Vinci system was FDA-cleared for

1.3 Endoscopic surgery in gynecology   

  7

Fig. 1.4: The da Vinci robot system. Copyright Intuitive Surgical, Inc.

gynecologic procedures based on preliminary evidence of safety and efficacy from their early experience [14]. The standard three and four arm da Vinci units were upgraded with a high definition vision 4-arm “S” system in 2006. The da Vinci system utilization in gynecologic surgery has been rapidly improved in the last 5 years [15]. The da Vinci surgical system is composed of three parts: first, the surgeon’s console with two finger-controlled handles and foot pedals, allows control of the robotic wristed instruments inside the patient; second, the surgical cart, with four multi-joint robotic arms and EndoWrist® instruments allows for seven degrees of rotation; third, the vision cart (the camera) allows a 3D view of the surgical location (Fig. 1.4). After providing a pneumo-peritoneum, placing laparoscopic ports, and “docking” the robot, the surgeon sits at a console and views the pelvis with the 3D, high-definition vision system [16]. Robotic approaches in gynecologic surgery, and the technical and medical subjects will be mentioned in detail in the following chapters.

1.3 Endoscopic surgery in gynecology MIS often provides distinct, significant, consistently reproducible advantages compared to open approaches including smaller incisions, reduced intraoperative blood loss and postoperative pain, and shorter length of hospital stay [17–19]. The first gynecologic laparoscopy performed by Ott in Petrograd, evaluated the abdominal cavity with a head mirror and an abdominal wall speculum in 1901 [20]. The International Symposium of Gynecologic Endoscopy was original organized in 1964, and in the following years the laparoscopic tubal sterilization [21], intratubal gamete transfer [22], and the other gynecologic procedures were documented [23]. The first laparoscopic hysterectomy was reported by Harry Reich in 1989 [24] and the use of laparoscopy to treat a variety of benign gynecological conditions was reported over the following

8  

  1 Robotic gynecologic surgery – introduction

20 years. The introduction of robotic technology to assist these minimally-invasive procedures has been shown to significantly improve outcomes [25, 26]. Roboticassisted surgery, also known as surgical telemanipulation or computer-assisted surgery enables surgeons to overcome human limitations and eliminate handicaps associated with conventional surgery and interventions [25–29]. In the subspecialty of gynecologic surgery for both benign and malign conditions, performing surgical procedures with robotic systems has increased significantly in recent years. Many general gynecologists have changed their approaches and prefer robotic surgery for procedures such as hysterectomies, myomectomies, adnexal surgery, surgical treatment for endometriosis and tubal anastomosis [30–39]. Also, robots have been utilized for sacrocolpopexies and fistula repairs in urogynecologic surgeries [40–42]. Currently, robots have mostly been used in the field of gynecologic oncology, where hysterectomies and lymphadenectomies for endometrial cancer staging, radical hysterectomies and trachelectomies for cervical cancer, and even for the staging and debulking of early ovarian cancer are being increasingly performed with robotic systems [43–50] (Tab. 1.2).

Tab. 1.2: Gynecologic procedures performed with robotics A. Reproductive surgery – Simple hysterectomy – Myomectomy – USO, BSO – Tubal reanastomosis – Ovariopexy, ovarian transposition – Resection of endometriosis B. Reconstructive pelvic surgery – Burch procedure – Sacrocolpopexy – Bladder repair – Vesicovaginal fistule repair C. Gynecologic oncology – Radical hysterectomy – Pelvic and paraaortic lymphadenectomy – Radical parametrectomy – Radical vaginal trachelectomy – Radical cystectomy – Ovarian cystectomy – Sentinel lymph node biopsy – Appendectomy – Omentectomy – Laparoscopic assisted vaginal hysterectomy (LAVH) – Laparoscopic assisted robotic vaginal hysterectomy (LARVH)

1.4 The advantages of robotic surgery  

  9

1.4 The advantages of robotic surgery The advantages of robotic surgery compared to laparoscopy and open surgery included better visualization of the operating site with a 3D vision system, wristed instrumentation, improved dexterity, ergonomic positioning allows comfort for the surgeon with less hand fatigue and frustration, and eliminates hand tremors. The robot fingertip hand control mechanism is “intuitive”, which means that the robotic instruments move as the hands move. In addition, the robotic system eliminates the fulcrum effect observed in laparoscopy in which a surgeon must move his hand in the opposite direction to the intended location and provides intra-abdominal articulation with most instruments, which allows for difficult laparoscopic or microsurgical movements in seven different planes [51–53]. The MIS becomes more accessible without advanced laparoscopic training because of its short learning curve.

1.5 Limitations of robotic surgery The use of a robotic system has some limitations. The major disadvantage of robotic surgery is the high cost of purchase, maintenance and instruments of the robotic system. There is a significant difference in operative costs between open, laparoscopic, and robotic surgery due to the added expense of particular equipment. The other major limitation is the lack of tactile feedback or habits during the procedure, requiring the use of visual marks. While this is initially noted to be a limitation, most quickly adapt heightened visual feedback from the magnified 3D vision system. The bulky size of both the robotic unit and the console require a large operating room and limit the ability of surgical assistants to maneuver around the patient. As the system is attached to the patient, the system must be undocked with any changes in position of the surgical table resulting in increased operation time [52]. The need to train residents, attending surgeons and the operating room personnel in the use of this system is another disadvantage of this system. Finally, increased surgical operation time due to moving the robot to the operating table, docking or attaching the robotic arms to the trocars and prolonged console time is another major limitation of these systems. Some side effects including anesthetic complications can occur associated with increased operation time [53]. Further research and development may improve these undesirable disadvantages.

1.6 Telemedicine and robotic surgery: future aspects Telemedicine is the use of telecommunication and information technologies in order to provide clinical health care from a distance. In other words it “is the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or healthcare provider and for the purpose of

10  

  1 Robotic gynecologic surgery – introduction

improving patient care” [54]. Telemedicine, specifically applied to surgical subspecialties such as telesurgery, is the ability for a doctor to perform surgery on a patient from a distance [55]. The first telerobotic remote surgical services were performed by Anvari and colleagues in Canada in 2003. They designed a program by which the Zeus TS microjoint system (Computer Motion Inc.®, Goleta, CA, USA) was set up 400 km away from patient. Twenty-one laparoscopic surgeries were completed and surgeons operated on the patients simultaneously with little time delay for communication and signal reception [56]. Research and development on this subject continues. The possibility of long-distance operations depends on the patient’s access to a robotic system and personnel being available to put the ports. The da Vinci surgical system can theoretically be used to operate over long distances. Overall, developing telesurgical technology that allows surgery remotely from a patient, may further improve patient outcomes while presenting new options for the minimally-invasive management of gynecologic pathology in the future.

1.7 Final suggestions Over the past three decades the field of gynecologic MIS has advanced rapidly. However, the most substantial improvements have come with the presence of robotic surgery. Currently, there is a lack of published knowledge about robotic gynecologic surgery. Thus, we decided to design a book on robotic gynecologic surgery which illustrates the information for the utilization of all professionals, especially general gynecologists, urogynecologists, and gynecologic oncologists. Here readers can find detailed information regarding robotic gynecologic surgery. We would like to thank all the contributing authors and to all those involved in aiding the publication of this book.

References [1] http://www.robotics.utexas.edu./rrg/learn_more/history. Accessed on 06/04/12. Robotics Research Group, The University of Texas at Austin. [2] Rosheim; Mark Elling. Leonardo’s Lost Robots. Germany, Springer-Verlag Berlin Heidelberg, 2006, p. 69. [3] Stemp, Richard. The Secret Language of the Renaissance. London, Duncan Baird Publishers, 2012. [4] http://robotics.megagiant.com/history.html. Accessed on 06/04/12. Robotics Lab., James Isom, 2002–2005. [5] Huchard, Jean. “Entre la légende et la réalité: Les tribulations de la mécanique de Joseph Marie Jacquard” [Between legend and reality: The problems of the Joseph Marie Jacquard mechanism], Bulletin Municipal de la Ville de Lyon, No. 5219–20, 3 May 1998. [6] Jeremy Norman’s Chronological and Thematic Studies on the History of Information and Media. “The Most Famous Image in the Early History of Computing”. (Accessed November 1, 2013 at http://www.historyofinformation.com/expanded.php?id=2245). [7] Capek K, Capek J. The Inspect Play. Oxford, New York, Oxford University Press, 1963.

References  

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[8] Asimov I. Robots, Machine in Man’s Image. New York, Harmony Books, 1985. [9] Kwoh YS, Hou J, Jonckheere EA, et al. A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery. IEEE Trans Biomed Eng 1988, 35, 153–60. [10] Davies BL, Hibberd RD, Coptcoat MJ, et al. A surgeon robot prostatectomy—a laboratory evaluation. J Med Eng Technol 1989, 13, 273–7. [11] Mantwill F, Schulz AP, Faber A, et al. Robotic systems in total hip arthroplasty—is the time ripe for a new approach? Int J Med Robot 2005, 1, 8–19. [12] Diodato MD Jr, Damiano RJ Jr. Robotic cardiac surgery: overview. Surg Clin North Am 2003, 83, 1351–67, ix. [13] Falcone T, Goldberg J, Garcia-Ruiz A, et al. Full robotic assistance for laparoscopic tubal anastomosis: a case report. J Laproendoscopic Adv Surg Tech Part A 1999, 9, 107–13. [14] Reynolds RK, Advincula AP. Robot-assisted laparoscopic hysterectomy. Technique and initial experience. Am J Surg 2006, 191, 555–60. [15] Holloway RW, Patel SD, Ahmad S. Robotic surgery in gynecology. Scand J Surg 2009, 98, 6–109. [16] http://www.davincisurgery.com/. The website of the da Vinci Surgical System. Accessed on 06/04/12. [17] Menon M, Tewari A, Baize B, et al. Prospective comparison of radical retropubic prostatectomy and robot-assisted anatomic prostatectomy: the Vattikuti Urology Institute experience. Urology 2002, 60, 864–8. [18] Smith JA Jr, Herrell SD. Robotic-assisted laparoscopic prostatectomy: do minimally invasive approaches offer significant advantages? J Clin Oncol 2005, 23, 8170–5. [19] Rudich SM, Marcovich R, Magee JC, et al. Hand-assisted laparoscopic donor nephrectomy: comparable donor/recipient outcomes, costs, and decreased convalescence as compared to open donor nephrectomy. Transplant Proc 2001, 33, 1106–7. [20] Gunning JE. The history of laparoscopy. J Reprod Med 1974, 12, 222–6. [21] Siegler AM, Berenyi KJ. Laparoscopy in gynecology. Obstet Gynecol 1969, 34, 572–7. [22] Steptoe PC. Laparoscopy in Gynecology. Edinburg and London: E & S Livingston Ltd., 1967, 1–3. [23] Peterson EP, Behrman SJ. Laparoscopy of the infertile patient. Obstet Gynecol 1970, 36, 363–7. [24] Reich H, Decaprio J, McGlynn F. Laparoscopic hysterectomy. J Gynecol Surg 1989, 5, 213–6. [25] Howe RD, Matsuoka Y. Robotics for surgery. Annu Rev Biomed Eng 1999, 1, 211–40. [26] Lanfranco AR, Castellanos AE, Desai JP, et al. Robotic surgery: a current perstective. Ann Surg 2004, 239, 14–21. [27] Camarillo DB, Krummel TM, Salisbury JK Jr. Robotic technology in surgery: past, present, and future. Am J Surg 2004, 188(4A Suppl), 2S–15S. [28] Ruurda JP, Vroonhoven TJ, Broeders IA. Robot-assisted surgical systems: a new era in laparoscopic surgery. Ann R Coll Surg 2002, 84, 223–6. [29] Hanly EJ, Talamini MA. Robotic abdominal surgery. Am J Surg 2004, 188(4A Suppl), 195–265. [30] Bedaiwy MA, Barakat EM, Falcone T. Robotic tubal anastomosis: technical aspects. J Soc Laparoendoscopic Surgeons 2011, 15, 10–5. [31] Dharia Patel SP, Steinkampf MP, Whitten SJ, et al. Robotic tubal anastomosis: surgical technique and cost effectiveness. Fertil Steril 2008, 90, 1175–9. [32] Bocca S, Stadtmauer L, Oehninger S. Uncomplicated full term pregnancy after da Vinci-assisted laparoscopic myomectomy. Reprod Biomed Online 2007, 14, 246–9. [33] Nezhat C, Lavie O, Hsu S, et al. Robotic-assisted laparoscopic myomectomy compared with standard laparoscopic myomectomy—a retrospective matched control study. Fertil Steril 2009, 91, 556–9. [34] Bedient CE, Magrina JF, Noble BN, et al. Comparison of robotic and laparoscopic myomectomy. Am J Obstet Gynecol 2009, 201, 566.e1–5. [35] Barakat EE, Bedaiwy MA, Zimberg S, et al. Robotic-assisted, laparoscopic, and abdominal myomectomy: a comparison of surgical outcomes. Obstet Gynecol 2011, 117, 256–65.

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[36] Nezhat C, Lewis M, Kotikela S, et al. Robotic versus standard laparoscopy for the treatment of endometriosis. Fertil Steril 2010, 94, 2758–60. [37] Bot-Robin V, Rubod C, Zini L, et al. Early evaluation of the feasibility of robot-assisted laparoscopy in the surgical treatment of deep infiltrating endometriosis. Gynecol Obstet Fertil 2011, 39, 407–11. [38] Kilic GS, Moore G, Elbatanony A, et al. Comparison of perioperative outcomes of total laparoscopic and robotically assisted hysterectomy for benign pathology during introduction of a robotic program. Obstet Gynecol Int 2011, 2011, 683703. [39] Weinberg L, Rao S, Escobar PF. Robotic surgery in gynecology: An updated systematic review. Obstet Gynecol Int 2011, 2011, 852061 (doi: 10.1155/2011/852061). [40] Bedaiwy MA, Abdelrahman M, Deter S, et al. The impact of training residents and fellow’s on the outcome of robotic-assisted sacrocolpopexy. Annual Society of Gynecologic Surgeons (SGS) Meeting, San Antonio, TX, USA, April 10–13, 2011. [41] Elliott DS, Frank I, Dimarco DS, et al. Gynecologic use of robotically assisted laparoscopy: Sacrocolpopexy for the treatment of high-grade vaginal vault prolapse. Am J Surg 2004, 188 (4A Suppl), 52S–6S. [42] Laungani R, Patil N, Krane LS et al. Robotic-assisted ureterovaginal fistula repair: report of efficacy and feasiblity. J Laparoendoscopic Advan Surgical Techniques—Part A, 2008, 18, 731–4. [43] Boggess JF, Gehrig PA, Cantrell L, et al. A comparative study of 3 surgical methods for hysterectomy with staging for endometrial cancer: robotic assistance, laparoscopy, laparotomy. Am J Obstet Gynecol 2008, 199, 360.e1–9. [44] Mabrouk M, Frumovitz M, Greer M, et al. Trends in laparoscopic and robotic surgery among gynecologic oncologists: A survey update. Gynecol Oncol 2009, 112, 501–5. [45] Yim GW, Kim SW, Nam EJ, et al. Role of robot-assisted surgery in cervical cancer. Int J Gynecol Cancer 2011, 21, 173–81. [46] Magrina JF, Kho RM, Weaver AL, et al. Robotic radical hysterectomy: comparison with laparoscopy and laparotomy. Gynecol Oncol 2008, 109, 86–91. [47] Ramirez PT, Slomovitz BM, Soliman PT, et al. Total laparoscopic radical hysterectomy and lymphadenectomy: the M.D. Anderson Cancer Center experience. Gynecol Oncol 2006, 102, 252–5. [48] Vitobello D, Siesto G, Bulletti C, et al. Robotic radical parametrectomy with pelvic lymphadenectomy: Our experience and review of the literature. Eur J Surg Oncol 2012, 38, 548–54. [49] Ramirez PT, Adams S, Boggess JF, et al. Robotic-assisted surgery in gynecologic oncology: a Society of Gynecologic Oncology consensus statement. Developed by the Society of Gynecologic Oncology’s Clinical Practice Robotics Task Force. Gynecol Oncol 2012, 124, 180–4. [50] Mendivil A, Holloway RW, Boggess JF. Emergence of robotic assisted surgery in gynecologic oncology: American perspective. Gynecol Oncol 2009, 114, S24–S32. [51] Dharia SP, Falcone T. Robotics in reproductive medicine. Fertil Steril 2005, 84, 1–11. [52] Bedaiwy MA, Volsky J, Sandadi S, et al. The expanding spectrum of robotic gynecologic surgery: A review. Middle East Fertil Soc J 2012, 17, 70–78. [53] Visco AG, Advincula AP. Robotic gynecologic surgery. Obstet Gynecol 2008, 112, 1369–84. [54] Rafig A, Merrell RC. Telemedicine for Access to quality care on medical practice and continuing medical education in a global arena. J Contin Educ Health Prof 2005, 25, 34–42. [55] Pande RU, Patel Y, Powers CJ, et al. The telecommunication revolution in the medical field: present applications and future perspective. Curr Surg 2003, 60, 636–40. [56] Anvari M, McKinley C, Stein H. Establishment of the world’s first telerobotic remote surgical suite. Ann Surg 2005, 241, 460–4.

2 Launching a successful robotic program Mostafa A. Borahay and Sami G. Kilic 2.1 Introduction Over the last decade, robotic surgery has become an integral part of minimallyinvasive gynecologic programs in many parts of the world. Since FDA approval of the da Vinci® Surgical System (Intuitive Surgical Inc, Sunnyvale, CA, USA) for clinical use in 2000 and, subsequently for hysterectomy in 2005, the new technology has been rapidly adopted, with 2,462 da Vinci surgical systems (1,789 in the USA, 400 in Europe, and 273 in the rest of world) installed as of September 30, 2012 [1]. However, the simple purchase and installation of the robotic system do not necessarily lead to a successful robotic surgery program. Rather a successful program with a maximized return on investment (ROI) is more likely to be the outcome of a comprehensive approach including surgeons, hospital administration, and other stakeholders. It is the aim of this chapter to describe such a comprehensive program.

2.2 Phases of a successful robotic gynecologic program A successful robotic gynecologic program advances through three phases: the planning phase, the implementation phase, and the evolving program (Fig. 2.1, Tab. 2.1). The planning phase starts with an initial business analysis, recruitment and/or training of staff, and other preparatory steps, ending with performing the first robotic case. The implementation phase (also known as the learning curve) describes the initial robotic program experience before reaching proficiency and full capacity. The goal should be a short, seamless, and trouble-free implementation phase. Once proficiency is reached, the established program enters the evolving program phase, where the focus should be on maintenance and, equally important, expansion. Some programs stay in a protracted implementation phase and do not reach proficiency. This is a warning sign that the program may not become cost effective, which if not swiftly addressed, may lead to its stagnation. It is the goal of this discussion to build efficient and thriving programs.

2.2.1 Planning phase Planning is probably the most critical phase and sets the tone for the whole program’s future. It includes all preparatory steps to make sure the program is feasible, the launch is smooth, and the program will thrive. Planning may last from a few months to more than a year. Hospital leadership and lead surgeons (first robotic surgeons in each specialty at a certain hospital, discussed in details in section 2.2.14) should work closely during this phase.

  2 Launching a successful robotic program

Number of Cases

14  

Planning Phase

Implementation Phase (Learning Curve)

Evolving Program Phase

Fig. 2.1: Phases of a successful robotic program

Tab. 2.1: Phases of a successful robotic gynecologic program I. Planning phase Business plan Forming an interdisciplinary robotic steering committee Hiring a robotic coordinator Lead surgeon Establishing institutional physician credentialing guidelines Building a robotic team OR optimization Marketing Database building Acquisition of a robotic system II. Implementation phase (learning curve) III. Evolving program Improving OR efficiency Growth Ongoing evaluation of financial position and cost effectiveness Further marketing Continuous education and in-service training Peer review of cases for case selection, operative time, morbidity and mortality Participation in quality control programs and designation as excellence center

2.2.1.1 Business plan For hospitals, the acquisition of the da Vinci surgical system represents a substantial investment. With a price tag of $1–2.3 million for the system alone, in addition to $100,000–$170,000 in annual maintenance costs [1], the system requires a welldesigned business plan to recapture these costs and maintain a satisfactory return on investment (ROI) for the hospital, especially in the current healthcare funding climate.

2.2 Phases of a successful robotic gynecologic program 

 15

Therefore, adequate cost effectiveness studies, along with sound financial analysis, should be completed beforehand. Costs include 1) the purchase of the robotic system, 2) system maintenance and instrument costs, 3) team member hiring and/or training (surgeon, coordinator, and other staff), and 4) administrative and marketing costs. Revenues include cases reimbursements and possibly research and/or training grants. Revenue analysis should be based on projected robotic surgical volume, growth potential, and insurance reimbursements. The patient catchment area should be carefully assessed, including potential competitors with currently existing robotic programs as well as those planning to acquire it in the near future. One possible outcome of a business analysis is the finding that the institution’s best course is to postpone the launch. In certain situations, it may be better to wait than to prematurely launch a program. Finally, financial analysis should include a projected date for the program to start having a positive operating margin (revenues exceeding costs).

2.2.1.2 Forming an interdisciplinary robotic steering committee Typically, institutional leadership makes the decision to proceed with establishing a robotic program after initial financial analysis demonstrates that it will be financially feasible, sustainable, and possibly profitable. At this point, it is advisable to form a robotic program steering committee. This committee includes 1) representative(s) from hospital administration; 2) surgeon champions from each specialty, including anesthesiology; 3) a robotic program coordinator; 4) the OR director; 5) a nurse as a representative of the robotic OR team; and 6) the institution’s marketing vice president (VP). The committee’s duties include, among others [2], 1) defining institutional physician credentialing guidelines; 2) deciding on OR robotic block time; 3) overseeing instrument purchases and maintenance; 4) observing physician and services OR utilization and quality of care; 5) setting, monitoring, and modifying marketing efforts; 6) writing and modifying clinical pathways; 7) developing, maintaining, and improving the database; 8) setting and monitoring program expansion plans; 9) setting plans, organizing, and monitoring research activities; and 10) developing and overseeing robotic surgery education [2]. The committee should meet as frequently as is needed during the planning phase and quarterly thereafter. Committee meetings constitute excellent opportunities for communication between surgeons and hospital administration as well as interspecialty discussions.

2.2.1.3 Hiring a robotics coordinator The robotics coordinator is one of the key people in the robotic program. He/she is the first contact for the da Vinci system and is responsible for system maintenance, purchases, case scheduling, database development and updating, staff training, coordinating with hospital administration as well as across specialties.

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  2 Launching a successful robotic program

2.2.1.4 Lead surgeon The lead surgeon is a crucial member of the robotic team and has a significant impact on the success of the whole program. He/she takes a leadership role and communicates with other team members as well as those outside the robotic team, e.g., hospital leadership, patients, referring physicians, and the community. Two approaches for appointing the lead surgeon include hiring a surgeon already trained in robotics or training one of the institution’s own surgeons [3]. The advantage of hiring a previously trained surgeon is avoiding the learning curve, or at least shortening it, while a disadvantage is the higher expense associated with hiring. Once the lead surgeon reaches the proficiency stage, he/she will be expected to train other surgeons and encourage them to adopt robotic technology.

2.2.1.5 Establishing institutional physician credentialing guidelines While there are no nationwide or board-approved certification criteria for robotic surgery, many hospitals have adopted institutional credentialing guidelines. This process is typically handled by the credentialing section in a hospital’s medical staff office in collaboration with the robotic steering committee. Intuitive Surgical has a certification process [4] that many institutions adopt (or a modification of it). We propose the following modification of Intuitive Surgical’s scheme: 1) online modules and didactic content addressing basic robotic knowledge as well as trouble-shooting tutorials; 2) simulation exercises and dry drives; 3) wet drives using an animal lab to become familiar with basic robotic surgical skills; 4) observation of actual cases (typically 5) performed by other surgeons, preferably with the opportunity to assist; 5) performance of “proctored” cases where candidates perform a certain number of cases (typically 5) under supervision of another experienced surgeon; and 6) subsequent performance of independent cases. After a surgeon completes a certain number of cases (typically 20), Intuitive Surgical adds the surgeon’s name to its online list of “certified” da Vinci surgeons. Over the last few years, robotic surgery has become part of routine obstetrics and gynecology residency training in US hospitals that have robotic programs with adequate surgical volume. Although the residency review committee (RRC) currently does not set minimum targets for robotic training during residency, many obstetrics and gynecology residency graduates in the US are robotically trained and ready to practice at the time of graduation.

2.2.1.6 Building a robotic team Begin by training a complete robotic team, including a surgical technician and circulating nurse in addition to the lead surgeon and a robotic-oriented anesthesiologist. Orienting one or more hospital coders about reimbursement in robotic cases is also important. It is advisable that team members meet at least once before the first case to make sure everyone is familiar with the robot and procedures and understands his/her individual responsibilities. Finally, once the program is established, it is important to add new team members later on only one new member at a time.

2.2 Phases of a successful robotic gynecologic program 

 17

2.2.1.7 OR optimization Preparing a state-of-the-art operating room theater for the robotic system is of paramount importance. We strongly recommend having one dedicated OR for robotic surgery to avoid moving the robot between operating rooms. In addition to saving time, this protects the system from possible transportation-related damage. The robotic operating room design should include adequate setup room for the operating table (with full Trendelenburg control capabilities), towers, and surgeon console (as well as assistant console if dual consoles are used). Also, storing the robotic instruments either inside the room or nearby is advisable for obtaining replacements and troubleshooting during cases [3]. We strongly recommend having these OR accommodations addressed early before purchasing the robotic system.

2.2.1.8 Marketing Cost analysis studies for robotic programs (discussed in more detail later in this chapter) demonstrate that a certain minimal surgical volume is required for a program to break even or become profitable due to both the high initial capital investment and maintenance costs. To reach these surgical volume targets, comprehensive marketing plans should be adopted. Marketing should be directed to patients as well as referring physicians. For patients, the first step is usually building a user-friendly website with information about the institution’s surgeons, procedures performed, contact information, patient testimonials, and educational material. In addition to online advertisement, local media (TV, radio, newspaper, magazines, billboards) can be used. Finally, program surgeons can host community lectures and outreach campaigns. To reach out to potential referring physicians, robotic surgeons should visit local community hospitals and give lectures at regional Continuing Medical Education (CME) programs. If the program’s institution has a residency or fellowship training program, then robotic surgery should be an integral part of its advertisement directed toward potential candidates. Finally, all of these marketing efforts should be organized through the robotic steering committee and focused on the catchment area. At our institution, the University of Texas Medical Branch, we established a marketing subcommittee comprising two surgeons and a representative of the university’s marketing VP.

2.2.1.9 Database building Starting database building early is critical for both short- and long-term success. A well-designed database allows the robotic team to 1) obtain regular statistics about surgical volume for monitoring the program progress and accomplished targets, 2) compare outcomes to national averages, 3) provide material for research purposes, and 4) find areas for potential improvement and expansion. The database should include clinical information, such as relevant history, operative data, hospitalization course, pathologic findings, post-operative course and complications, and

18  

  2 Launching a successful robotic program

financial aspects. Database building can be simplified by utilizing an electronic medical records system, if available. Database compliance with patient privacy protection regulations is critical. Finally, the database can be designed for an institutional level or can be part of a national database, e.g., the one run by the American Association of Gynecologic Laparoscopists (AAGL) Centers of Excellence in Minimally Invasive Gynecology (COEMIG) program [5].

2.2.1.10 Acquisition of robotic system This is perhaps the biggest price tag item. Currently, Intuitive Surgical is the only vendor of an FDA-approved robotic system, and the currently available system costs $1–2.3 million. Purchase contracts typically include maintenance, which costs $100,000–$170,000 annually [1]. These costs, in addition to costs associated with OR design changes, hiring and/or training of surgeons/coordinator/staff, as well as administrative and marketing costs, should be included in the cost analysis as will be discussed later in this chapter.

2.2.2 Implementation phase (learning curve or initial robotic program) This phase starts when the robotic team performs their first case and ends when they reach proficiency. Therefore, it represents those cases done while team members are going through the “learning curve.” There is no agreed-upon number of cases performed to reach proficiency, but many authors consider 20 cases performed over about 150 days a reasonable target [4]. During this phase, we advise 1) starting with uncomplicated cases, avoiding patients with large uteri, multiple previous surgeries, morbid obesity, or other medical problems; 2) meeting as a team before the first case to discuss each member’s tasks and make sure that appropriate resources and instruments are available; 3) documenting any comments after each case (debriefing session) from all team members so the process can be improved in the future; 4) holding regular meetings to discuss progress and goal achievement; and 5) having the appropriate case frequency. To having one case weekly during this stage is advisable to make sure surgeons and other team members are gaining the necessary skills.

2.2.3 Evolving program 2.2.3.1 Improving OR efficiency Established programs should have a mechanism in place to monitor and improve its efficiency, and therefore, competitiveness and sustainability. This task is the responsibility of the robotic steering committee and can be accomplished through

2.2 Phases of a successful robotic gynecologic program 

 19

adopting, and sometimes inventing, new approaches. At the University of Texas Medical Branch, we created a robotic OR efficiency subcommittee to find ways to improve efficiency. The subcommittee was able to slash surgical time by multiple measures, including multitasking activities in the OR, where team members perform their assigned tasks simultaneously rather than serially. In addition, we began discharging cases the same day, which resulted in a significant savings without compromising the quality of care.

2.2.3.2 Growth Successful robotic programs tend to spontaneously grow through patients “word of mouth.” The robotic steering committee, along with hospital administration, should also work to expand surgical volume through ongoing marketing. Additional surgical cases can be accommodated through 1) improving OR efficiency and use of current resources, 2) increasing robotic OR dedicated time, and 3) hiring and/or training more robotic surgeons and staff. These steps can be undertaken after careful review of current volumes and reasonable projections for future expansion.

2.2.3.3 Ongoing evaluation of financial position and cost effectiveness Closely monitoring the financial balance of the program is imperative to prevent unanticipated funding difficulties that may prevent necessary maintenance or replacement. The program’s financial status should be reviewed as a permanent item in the quarterly meetings of the robotic steering committee. Committee members should look at ways for 1) cost cutting through minimizing hospital stays, decreasing replaceable usage in the OR, decreasing OR time to increase case volume, and 2) growing revenue through marketing, staff hiring if necessary, and assuring appropriate coding and reimbursement of cases.

2.2.3.4 Further marketing Marketing should be an ongoing process through the same approaches as previously discussed. It should be continuously reviewed and adapted to changes in the catchment area and achievement of targeted goals.

2.2.3.5 Continuous education and in-service training Program surgeons should participate in conferences, workshops, and other academic and educational activities to keep up with state-of-the-art technology. In addition, OR staff members should participate in regular quality assurance and in-service programs, especially when major upgrades are introduced, e.g., switching from the da Vinci S to the da Vinci Si system.

20  

  2 Launching a successful robotic program

2.2.3.6 Peer review of quality of care Regular peer review of surgical cases is critical, including preoperative case selection and preparation, operative technique and time, intraoperative and postoperative complications, and postoperative care. Reviews can be accomplished as part of the obstetrics and gynecology department morbidity and mortality (M&M) meetings or as a separate robotic cases peer review. This review is important to assure that outcomes are close to or above national averages. In addition, patients’ questionnaires and online feedback are great tools for finding potential areas for improvement.

2.2.3.7 Participation in quality control programs and designation as excellence center Participating in third-party quality assurance programs at local, state, and/or national levels is recommended for robotic gynecologic programs. These programs help maintain quality of care and can be used as marketing tools as well. An example of such a program in the USA is the Center of Excellence in Minimally Invasive Gynecology (COEMIG) program [5]. Surgical Review Corporation (SRC), an independent healthcare quality organization, was contracted by the American Association of Gynecologic Laparoscopists (AAGL) to run the COEMIG program. The COEMIG program designates surgeons and healthcare facilities as centers of excellence, running sites through a preliminary phase to assure multiple prerequisites are in place before giving a provisional approval status. Full designation is granted after a site inspection. In addition to ensuring minimal standards, COEMIG builds a national database with participating minimally-invasive gynecologic centers in accordance with The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules [5].

2.3 Academic activities Some robotic programs focus only on patient care, while others (both in academic institutes and private practice) incorporate education and research as well. Advantages for programs include maintaining state-of-the-art technology, promoting communication and collaboration with other programs, and capitalizing on the robotics program as a recruiting and marketing tool. These endeavors should be tackled with clear vision and well-defined targets and action plans.

2.3.1 Education Programs in academic centers are typically expected to participate in training of residents and fellows as well as education of medical students. In fact, robotic training is becoming part of residency training in many US centers.

2.4 Financial analysis 

 21

In these programs, developing a structured robotic training program is important. Residents are asked to complete a didactic or online module to learn about basic concepts about robotics, followed by simulation training. After reaching a minimal skill level, residents can participate in surgery. At the University of Texas Medical Branch, we established a simulation lab where we combine a structured program for simulation training including robotic, laparoscopic, and hysteroscopic simulation modules. Dual console systems are helpful so that surgeons can switch control to and from the learning resident sitting on a second console. Finally, education can bring funding to institutions through educational grants, especially those tailored to educational research.

2.3.2 Research Robotic programs represent an excellent research opportunity which can be accomplished in collaboration with other institutions. Advantages gained through research include 1) improved quality of care, 2) increased cost effectiveness and competitiveness, 3) new opportunities for marketing, and 4) funding through grants. Successful research requires a strong database and protected research time for surgeons [2].

2.4 Financial analysis Keeping an eye on the financial health of the robotic program is important to ensure its sustainability and expansion. Analysis should be based on a sound understanding of the underlying economics of robotic programs. Costs include system acquisition, hiring and/or training of surgeons and staff, OR modifications, marketing, and administrative costs. Revenues include reimbursement for surgical cases and possibly research and education grants. Costs are subdivided into fixed and variable categories. Fixed costs include purchasing the system (US $1–2.3 millions) and annual maintenance (US $100,000–$170,000) [1]. Variable costs include 1) the cost of instruments used, e.g., shears, needle drivers, and graspers, which are replaced every 10 surgeries at a cost of approximately $2,200 each; 2) hospital stays; and 3) marketing. Because of longer OR time and costs of robotic instruments used in addition to capital investment, OR costs associated with robotic surgery are higher than conventional surgery. On the other hand, shorter hospital stays in robotic cases drive down the overall cost per case. Jonsdottir et al [6] showed that while operative costs for robotic hysterectomy were higher than that for open hysterectomy ($10,528 ± 2,968 vs. $6,214 ± 2,030), total costs were lower ($11,004 ± 4,208 vs. $12,678 ± $7,471). Therefore, it is important that hospital stays in robotic cases are minimized to 1 day or less. Leddy et al [7] demonstrated that because of high fixed costs associated with robotic surgery, robotic surgical volume should be high enough to drive down the average

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cost per case. In conclusion, to drive down costs associated with robotic surgery, it is advisable to 1) minimize routine hospital stays in uncomplicated low-risk cases; 2) avoid unnecessary use of robotic instruments during surgery; 3) avoid long operating hours, especially in programs with residents in training, by adopting simulation training; and 4) increase surgical volume through marketing and outreach programs to decrease the per-case share of capital investment and other fixed expenses.

2.5 Conclusion Given the significant investment, genuine commitment is necessary from hospital administration for the development of a robotic surgery program’s eventual success. Adequate planning and preparation are keys for seamless introduction, while monitoring and adjustment of the program are essential for sustainability, growth, and profitability. Robotic steering committees have become nearly universal in robotic centers in the US and are probably needed everywhere. As with any program, welldefined, realistic goals based on facts, along with clear vision and the ability to adjust to the environment, are indicators of ultimate success.

References [1] [2]

[3] [4] [5] [6] [7]

Investor FAQ. Intuitive Surgical. http://investor.intuitivesurgical.com/phoenix.zhtml?c=122359& p=irol-faq#22324. Updated 2012. Accessed on 7/6/2012. Kilic GS, Borahay M, Phelps JY. Introduction of Robotic Surgery: Pitfalls and Future. In: Textbook of Gynaecological Oncology. 2nd ed. Ankara, Turkey, Gunes Publishing, 2011, 606–14. Palmer KJ, Orvieto MA, Rocco BM, et al. Launching a Successful Robotic Program. In: Patel VR, ed. Robotic Urologic Surgery. London, Springer-Verlag, 2012. Recommendations for Building a da Vinci Surgery Program. 871455 Rev. A. Intuitive Surgical, 2006. COEMIG Program. Surgical Review Corporation. http://www.surgicalreview.org/coemig/. Updated 2013. Accessed on 19/12/2012. Jonsdottir GM, Jorgensen S, Cohen SL, et al. Increasing minimally invasive hysterectomy: effect on cost and complications. Obstet Gynecol 2011, 117, 1142–9. Leddy LS, Lendvay TS, Satava RM. Robotic surgery: applications and cost effectiveness. Open Access Surgery [Online] 2012, 2010, 99–107.

3 Financial analysis of robotic surgery in gynecology Eralp Başer, Müjdegül Zayıfoğlu Karaca, Eric Lambaudie and Murat Gültekin

3.1 Introduction Robotic surgery (RS) enables surgeons to perform complex operations with a minimally-invasive approach, due to its enhanced technology that provides improved visualization of the operative field and instrument flexibility. The term “robot” is actually a misnomer, as the device by itself does not perform any tasks except in a few orthopedic and neurosurgical procedures. Although “computer assisted tele-manipulator” term is more appropriate to define the purpose of the device, “robotic surgery” is now the universally accepted name. Many surgical procedures that would previously require open surgery are today carried out through 1–2 cm incisions with the help of these systems. Since their introduction in 1988, surgical robots have gained increasing acceptance among surgeons from various disciplines such as gynecology, gynecologic oncology, urology, cardiovascular, head and neck, general, colorectal and thoracic surgery [1, 2]. Kim et al reported that by the year of 2008, there were more than 645 da Vinci® systems in use worldwide, and by the year of 2013 it was more than 2000 [3]. Following the U.S. Food and Drug Administration (FDA) approval for use in gynecologic procedures, adoption of robotic systems for use in daily practice acquired significant popularity [4]. Advantages of minimally-invasive surgery (MIS) (e.g., laparoscopic and robotic) are well appreciated. Main advantages of these techniques over open surgery are decreased blood loss, less postoperative pain, shorter hospital stay, improved cosmetic results and earlier return to regular daily activity or work [5]. Robotic surgery further adds to these advantages (Tab. 3.1) [5–8]. The difference concerning morbidity between conventional laparoscopy and robot-assisted laparoscopy is being evaluated in a French randomized multi-centric trial for oncological indications. The results of this study will be available in 2015. In this chapter, financial aspects of using robotic surgery systems are discussed.

3.2 Cost of robotic surgery Despite its many advantages, robotic systems are expensive for institutions in both purchasing and maintenance. Thus, the financial burden of robotic surgery on healthcare systems and patients is an important issue. Currently, a da Vinci robotic surgery system costs more than $1.75 million and another $140,000–340,000 is required for

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  3 Financial analysis of robotic surgery in gynecology

Tab. 3.1: Advantages of robotic surgery vs. laparoscopic (L/S) and open (L/T) surgeries Advantages of robotic surgery compared to open (L/T) and laparoscopic (L/S) surgery Lower blood loss (compared to L/T) Lower intraoperative complications (compared to L/T) Lower postoperative complications (compared to L/T) Lower wound infections (compared to L/T) Shorter hospital stay (compared to L/T) Earlier return to daily activities (compared to L/T) Shorter learning curve (compared to L/S) Permits micromanipulations in regards to tremor filtration (compared to L/T) 3-D visualization (compared to L/S) Less conversions to open surgery (compared to L/S)

yearly maintenance [9]. Training cost of surgeons also adds to this expense. Each robotic instrument arm costs about $2,000–3,000 and is limited to 10 uses. Many institutions worldwide have started using robotic systems at the time of its initial presentation, although there were inadequate evidence-based data regarding its cost effectiveness. Rapid adoption of robotic procedures in gynecology was in contrast with laparoscopy. In a previous study by Wu et al, it was reported that 11.8% of gynecologic procedures were performed by laparoscopy, despite proven benefits supporting this technique [10]. However, robotic surgery gained significant popularity even among surgeons who did not have prior experience in laparoscopy. This difference may be due to a shorter learning curve in robotic surgery compared to conventional laparoscopy. Although the robotic approach provides significant technical advantages over conventional laparoscopy, high costs associated with the adoption of this technology necessitate a cost effectiveness determination.

3.3 Cost effectiveness of robotic surgery vs. laparoscopic and open approaches A number of studies that address the cost effectiveness of robotic systems in gynecology have been published recently. Nevertheless, well-designed randomized controlled trials (RCT) are currently lacking. A review of cost effectiveness analysis of robotic surgery compared with laparoscopy or open procedures utilized in the most common application fields of MIS such as general surgery, urology and gynecology has been published [11]. In this review, although it was shown that the robotic surgery generally cost the most, some exceptional situations for this have also been mentioned. The authors suggested that when the initial expense for the robotic system setup was ignored, robotic surgery was the more cost effective and feasible method for general surgical or urological

3.3 Cost effectiveness of robotic surgery vs. laparoscopic and open approaches   

  25

procedures [11]. Considering the shorter hospitalizations and shorter learning curve that robotic surgery offered, it had significant advantages over open surgery and conventional laparoscopy. In order to investigate the feasibility of robotic surgery for institutions that are planning to purchase a robotic system, a break-even analysis has been done [11]. The authors created two examples of clinical scenarios based on the number of procedures performed within a year. In the given examples, two hypothetical hospitals that performed 126 (Example A) and 330 (Example B) robotic cases a year were compared (Tab. 3.2). They made cost effectiveness assumptions based on studies by Bolenz et al [9] and Anderberg et al [12]. They pointed out that, institutions performing robotic surgery would primarily benefit from short hospital stays associated with these procedures. They also emphasized that, the higher number of cases performed within a given amount of time would ultimately result in a higher number of available beds that would give the opportunity for more procedures. Sarlos et al compared robotic vs. conventional laparoscopic surgery for hysterectomy in benign gynecologic cases [13]. In this prospective study, they compared outcome and cost of 40 consecutive total robot-assisted hysterectomies (RAH) with matched controls that had total laparoscopic hysterectomy (TLH). On average, RAH and TLH cost their institution €4,067 and €2,151, respectively. Although the robotic approach provided better ergonomic features for the surgeons, RAH had similar Tab. 3.2: Two examples of financial impact on hospital economics due to usage of robotic surgical systems (adapted, with permission, from Dove Medical Press Ltd.; Leddy L, Lendvay T, Satava R. Robotic surgery: applications and cost effectiveness. Dovepress J 2010, 99–107). [11]

Robotic cases (per year) Hospital days saved (per case) Hospital days saved (additional over-night capacity available) Nights stay after procedure Number of procedures made possible by freed up beds Average contribution margin per procedure (including stay) Annual value (CM) created from increased bed capacity Maintenance Disposable/limited use instruments Net annual benefit (capacity value minus incremental cost) Upfront investment to acquire and install robot Years to pay off acquisition Return on investment (ROI)

Example A

Example B

126 1.0 126

330 4.0 1,320

1.0 126

1.0 1,320

$3,500

$3,500

$441,000

$4,620,000

($340,000) ($60,000) $41,000

($340,000) ($60,000) $4,220,000

$1,500,000 36.6 2.7%

$1,500,000 0.4 281.3%

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  3 Financial analysis of robotic surgery in gynecology

operative outcome with higher costs [13]. The authors concluded that further assessment in terms of cost effectiveness was warranted. In another study that compared the cost of robotic, laparoscopic and open approaches for sacrocolpopexy, the robotic approach was significantly more expensive than others, even when the price of the robotic system was excluded from the calculation model [14]. The costs for robotic, laparoscopic and open sacrocolpopexy were $8,508, $7,353, and $5,792, respectively. A randomized study comparing laparoscopic and robotic sacrocolpopexy also demonstrated that a robotic approach was associated with higher costs [15]. A recent study by Wright et al compared robotic surgery (RS) vs. laparoscopic (L/S) approach performed for endometrial cancer treatment [16]. In this study, 1,027 women (41.7%) underwent L/S, whereas 1,437 women (58.3%) underwent RS. Overall surgery related morbidities were similar between the groups; however, mean costs of RS and L/S were $10,618 vs. $8,996, being significantly higher in the RS group. In a multivariable model, RS was significantly more expensive ($1,291; 95% CI $985–$1,597). The authors advocated that, taking into account the similar outcome between these two approaches, comparative long-term efficacy assessment was needed to justify the preference of a robotic system over traditional laparoscopy. Holtz et al also compared RS and L/S in endometrial cancer treatment [17]. The authors found that RS was significantly more expensive than L/S in terms of hospital ($5,084 vs. $3,615, P = 0.002) and operative costs ($3,323 vs. $2,029, P < 0.001). In another study by Barnett et al, three calculation models were used to compare robotic, laparoscopic and open hysterectomy in patients with endometrial cancer [18]. In the first model (societal perspective), they included inpatient hospital costs, robotic expenses, lost wages and caregiver costs. In the second model (hospital perspective plus robot costs), they excluded lost wages and caregiver costs from the societal perspective model. In the third model, they also excluded the initial cost of the robotic system. In the societal perspective model, L/S ($10,128) was the least expensive approach, followed by robotic ($11,476) and open surgery ($12,847). However, if the cost of robotic disposable equipment could be lowered below $1,046 per case (baseline cost $2,394), robotic surgery would cost less than L/S. In conclusion, authors stated that currently L/S was the least expensive approach for endometrial cancer treatment. They also found that robotic hysterectomy was less costly than open surgery, due to the shorter recovery associated with this approach. They also suggested that expenses in robotic surgery could further decrease, if disposable equipment costs are minimized. Lau et al also compared 143 patients that underwent robotic surgery for endometrial cancer, with 160 historic controls who were operated before the introduction of the robotic system [19]. Interestingly, overall hospital costs were significantly lower in the robotic surgery group (Can $7,644 [Canadian dollars] vs. Can $10,368; P < 0.001) even when the costs of robotic system and maintenance were included in analysis (Can $8,370 vs. Can $10,368; P = 0.001).

3.4 Coverage of robotic surgery by healthcare systems  

  27

A very recent article by Coronado et al also included costs resulting from conversion to other surgical approaches, complications, transfusions, need for intensive unit care stay in the calculation model when comparing the robotic, L/S and open approaches in endometrial cancer treatment [20]. Although surgical costs were highest with the robotic approach, global costs were similar between the three groups. This result was attributable to the fact that, robotic surgery cost least in terms of hospitalization expenses [20]. In a recent review by the Cochrane group, two trials involving 158 participants that underwent operative procedures for benign gynecologic disease were analyzed [21]. With the available data, the authors concluded that robotic surgery for benign gynecologic disease did not have an additional benefit in terms of effectiveness or safety. They also stated that future well-designed RCTs were required before making a final decision. The Society of Gynecologic Oncology (SGO) has recently published a consensus statement on robotic-assisted surgery in gynecologic oncology [22]. They suggested that, an ideal model for cost comparison between robotic and other approaches has to include both direct and indirect costs. In this model, fixed costs of the approach, costs of all operating room supplies and disposable equipment are considered; operating and recovery room time, physicians’ fees, laboratory, radiology, and pharmacy costs, and hospital room and board. They also stated that it was important to account for costs due to complications, care-giving, and lost productivity associated with the recovery period. It was concluded that, gaining efficiency in the operating room was the most important point to maximize utilization and minimize hospital costs associated with robotic surgery. The authors also stated that they anticipated decreased costs in time, as a result of increasing physician experience, the growing market and industry competition [22]. In Europe, the results of the COELCO Study are being awaited, which is a medicoeconomic evaluation of laparoscopy in oncological indications, including robotic procedures.

3.4 Coverage of robotic surgery by healthcare systems Robotic surgery is actually “robot-assisted laparoscopic surgery.” Thus, costs associated with this approach are generally covered by health insurance systems that cover laparoscopic operations. However, coverage may vary between government and private healthcare systems, as well as insurance companies and individual coverage plans. In some countries in which the healthcare system is dependent on tax payments, robotic surgery may be covered partly, and the patient may have to make extra payments in order to be treated with this approach. It may be anticipated that, as robotic surgery systems become more readily available and accepted by healthcare professionals, coverage rates will also increase.

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  3 Financial analysis of robotic surgery in gynecology

3.5 How to use robotics more cost efficiently? In order to use the robotics technology in a cost efficient way, several solutions may be suggested such as; – Renting a used version of a robot rather than buying a new one. – Collection of robots centrally so that many doctors in different institutions will have the opportunity for learning robotics, and for performing operations. In this way, the patient load may be high enough to make the robotics cost efficient. Instead of paying for the machine, with high patient loads, departments may invest on a predefined patient number per year. – Robotics should be strictly planned according to the population demographics and disease burdens. – Oncological tourism may be encouraged in order to increase patient volume.

3.6 Conclusion The introduction of robotic surgery has resulted in the beginning of a new era in minimally-invasive treatment of gynecologic as well as gynecologic oncological diseases. Nearly all of the previously conducted studies reported comparable – if not superior – medical outcomes for operations performed with robotic surgery. However, considering the importance of individual and healthcare system costs, high quality evidence acquired from randomized controlled trials will be necessary to reach a final conclusion.

References [1]

Kwoh YS, Hou J, Jonckheere EA, et al. A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery. IEEE Trans Biomed Eng 1988, 35(2), 153–60. [2] Mettler L, Ibrahim M, Jonat W. One year of experience working with the aid of a robotic assistant (the voice-controlled optic holder AESOP) in gynaecological endoscopic surgery. Hum Reprod 1998, 13(10), 2748–50. [3] Kim YT, Kim SW, Jung YW. Robotic surgery in gynecologic field. Yonsei Med J 2008, 49(6), 886–90. [4] Advincula AP, Song A. The role of robotic surgery in gynecology. Curr Opin Obstet Gynecol 2007, 19(4), 331–6. [5] ElSahwi KS, Hooper C, De Leon MC, et al. Comparison between 155 cases of robotic vs. 150 cases of open surgical staging for endometrial cancer. Gynecol Oncol 2012, 124(2), 260–4. [6] Bell MC, Torgerson J, Seshadri-Kreaden U, et al. Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques. Gynecol Oncol 2008, 111(3), 407–11. [7] Payne TN, Dauterive FR. A comparison of total laparoscopic hysterectomy to robotically assisted hysterectomy: surgical outcomes in a community practice. J Minim Invasive Gynecol 2008, 15(3), 286–91.

References  

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[8] Lim PC, Kang E, Park do H. A comparative detail analysis of the learning curve and surgical outcome for robotic hysterectomy with lymphadenectomy versus laparoscopic hysterectomy with lymphadenectomy in treatment of endometrial cancer: a case-matched controlled study of the first one hundred twenty two patients. Gynecol Oncol 2011, 120(3), 413–8. [9] Bolenz C, Gupta A, Hotze T, et al. Cost comparison of robotic, laparoscopic, and open radical prostatectomy for prostate cancer. Eur Urol 2010, 57(3), 453–8. [10] Wu JM, Wechter ME, Geller EJ, et al. Hysterectomy rates in the United States, 2003. Obstet Gynecol 2007, 110(5), 1091–5. [11] Leddy L, Lendvay T, Satava R. Robotic surgery: applications and cost effectiveness. Dovepress J 2010, 3, 99–107 . [12] Anderberg M, Kockum CC, Arnbjornsson E. Paediatric robotic surgery in clinical practice: a cost analysis. Eur J Pediatr Surg 2009, 19(5), 311–5. [13] Sarlos D, Kots L, Stevanovic N, et al. Robotic hysterectomy versus conventional laparoscopic hysterectomy: outcome and cost analyses of a matched case-control study. Eur J Obstet Gynecol Reprod Biol 2010, 150(1), 92–6. [14] Judd JP, Siddiqui NY, Barnett JC, et al. Cost-minimization analysis of robotic-assisted, laparoscopic, and abdominal sacrocolpopexy. J Minim Invasive Gynecol 2010, 17(4), 493–9. [15] Paraiso MF, Jelovsek JE, Frick A, et al. Laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse: a randomized controlled trial. Obstet Gynecol 2011, 118(5), 1005–13. [16] Wright JD, Burke WM, Wilde ET, et al. Comparative effectiveness of robotic versus laparoscopic hysterectomy for endometrial cancer. J Clin Oncol 2012, 10, 30(8), 783–91. [17] Holtz DO, Miroshnichenko G, Finnegan MO, et al. Endometrial cancer surgery costs: robot vs laparoscopy. J Minim Invasive Gynecol 2010, 17(4), 500–3. [18] Barnett JC, Judd JP, Wu JM, et al. Cost comparison among robotic, laparoscopic, and open hysterectomy for endometrial cancer. Obstet Gynecol 2010, 116(3), 685–93. [19] Lau S, Vaknin Z, Ramana-Kumar AV, et al. Outcomes and cost comparisons after introducing a robotics program for endometrial cancer surgery. Obstet Gynecol 2012, 119(4), 717–24. [20] Coronado PJ, Herraiz MA, Magrina JF, et al. Comparison of perioperative outcomes and cost of robotic-assisted laparoscopy, laparoscopy and laparotomy for endometrial cancer. Eur J Obstet Gynecol Reprod Biol 2012, 165(2), 289–94. [21] Liu H, Lu D, Wang L, et al. Robotic surgery for benign gynaecological disease. Cochrane Database Syst Rev 2012, 2:CD008978. [22] Ramirez PT, Adams S, Boggess JF, et al. Robotic-assisted surgery in gynecologic oncology: a Society of Gynecologic Oncology consensus statement. Developed by the Society of Gynecologic Oncology’s Clinical Practice Robotics Task Force. Gynecol Oncol 2012, 124(2), 180–4.

4 Training and credentialing in robotic gynecologic surgery and legal issues John Y. Phelps, Yu Lee and Sami G. Kilic 4.1 Introduction Since the 2005 U.S. FDA (Food and Drug Administration) approval for use of the da Vinci® robot in gynecology, there has been a rapid rise in not only the utilization of roboticsassisted gynecologic cases but interest among the general public. Inevitably, with any new technologic advances in medicine, several facets will need to be addressed. Among these, most importantly, are in regards to physician licensing, credentialing, and training. Also, closely intertwined, liability issues such as medical negligence, informed consent and the physician-patient relationship will need to be reexamined to adapt to the changing paradigm robotics presents to gynecologic surgery.

4.2 Training and credentialing 4.2.1 Training Appropriate training is a crucial aspect in developing competent surgical skills in the novice surgeon. As is seen in prior medical technology advances, a lag tends to exist between the emergence of the novel technique and in establishing the necessary standards and requirements needed for a surgeon’s skill to be deemed competent. The advances of robotic-assisted gynecologic surgery evolved after the majority of practicing gynecologists had already completed their residency training. Furthermore, postgraduate training opportunities available for gynecologists are limited. To date, there is not yet a universal standard in training or regulating credentialing among robotic gynecologic surgeons. The minimum U.S. FDA certification standard is a 1–2 day training practicum in the use of the da Vinci surgical platform. Currently, there are 17 active Intuitive Surgical training centers in the United States [1]. The Intuitive Surgical product training involves an introduction to the surgical platform and system training typically employed within a dry laboratory environment. Familiarity with the “functions of the robot, the attachment of the robotic arms to the robotic trocars and the overall functions of the robotic console,” as well as simple techniques involving grasping, intracorporeal knot tying and cutting are reviewed [2]. Additional training experience after this mandatory certification course is recommended. While there are no current universally established training guidelines, most hospital committee panels still require further experience to gauge adequate robotic surgical competence. As robotic gynecologic surgery continues to expand, two

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distinct classes of gynecologic surgeons will emerge—newly graduating physician residents with integrated robotic training from residency programs and a group of postgraduate surgeons with no prior robotic residency training. Ultimately it will be up to the hospitals and credentialing committees to determine the appropriate guidelines.

4.2.2 Credentialing Several multidisciplinary panels and forums have recommendations for gynecologic robotic credentialing. Intuitive Surgical provides recommendations for further robotic training. Included in their recommendations are 8 h (depending on type of case and number of cases) of case observation, 4–8 h of video case observation, 4 h of onsite da Vinci training, 2 h of two suturing sessions, 20–40 h of simulation exercises, and lastly two to five proctored cases. Case observation allows the novice robotic gynecologic surgeon to observe a da Vinci trained gynecologist performing robotic cases at an Intuitive EpiCenter. The video case observations provide additional opportunity for gynecologic surgeons to watch two to four videos of a trained robotic surgeon complete an intended procedure. Other informal recommendations detail a different approach. In a previous publication in the Journal of Minimally Invasive Gynecology by the authors of this chapter we outlined an informal guideline that first includes the mandatory completion of the robotic certification course and then a progressive approach involving a series of cases to be performed with the novice robotic surgeon assisting the more experienced robotic surgeon and then a switch in roles with the experienced robotic surgeon assisting the novice surgeon. Because learning curves vary among physicians, a set number of cases were intentionally not specified. In addition, establishing such parameters would be difficult and would not account for the variance in surgical skills among gynecologists. Also from a legal perspective once an institution sets their own internal written standard for a precise number of cases needed for credentialing, plaintiff attorneys may use the institution’s own written declared number of required cases in an attempt to prove a breach in the standard of care in the event an injury occurs by the novice robotic surgeon who has not reached the precise number of cases. Other authors have also provided recommendations for credentialing. Visco and Advincula recommend the gynecologic surgeon to have at least “8 hours of hands on training in use of the robotic surgical system,” or proof “of a minimum of 10 robotic surgical procedures of the same type [2].” In addition, they recommend a minimum of two proctored robotic surgical cases demonstrating competence for that particular procedure. The field of urology has been implementing the use of the robotics technology since the beginning of the 21st century. Therefore, it would be pertinent to not only examine but also highlight some of the recommendations set forth by the Society of Urologic Robotic Surgeons. First, to establish a centralized certification authority which would institute and regulate standards. This centralized authority would identify proctors and develop standardized reports for the proctors to complete.

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Second, to establish regional centers to assist novice robotic surgeons with preceptoring. Such endeavors would essentially help to develop and uniformly assess competency among gynecologic surgeons while mitigating liability issues [4].

4.3 Legal issues As the integral role of robotics assisted surgery in gynecology continues to grow, novel legal implications and questions began to surface. Such legal issues demand physicians and the medical arena to confront and adapt to these new changes. Many current robotic gynecologic surgeons completed their residency trainings prior to the integration of robotics technology in the residency curriculum. In addition, credentialing and surgical privilege standards are typically determined by individual hospitals. Because a universal standard in regulating credentialing among robotic gynecologic surgeons has yet to be set, these discrepancies in requirements could potentially pose additional liability risks among robotic gynecologic surgeons. Furthermore, robotic surgical instructors or proctors, a vital asset in the field of robotic surgery, may also face unforeseen legal issues.

4.3.1 Components of medical malpractice In order for a plaintiff attorney to claim medical malpractice, four components must be demonstrated. First, it must be established the physician had a duty of care to patient. Second, there must be evidence that this duty was breached, and third, an alleged injury must be present, and last, a causal connection must be shown that this breach in duty led to the proximate alleged injury. A plaintiff attorney can potentially have cause of action against gynecologists performing robotic surgery for breach in the standard of care from insufficient training and failure to obtain informed consent.

4.3.2 Insufficient training and credentialing legal issues A breach in the standard of care for negligence in obtaining proper informed consent was highlighted in the 2010 robotic case of Long v. Wentworth-Douglass Community Hospital [5]. The plaintiff filed malpractice following a known surgical complication despite full disclosure of risks prior to case. Typically, known inherent surgical maloccurrences and complications are not grounds for malpractice, however, the plaintiff attorney alleged ― improper informed consent, not because the patient was unaware of the known intrinsic complications that arose, but because prior knowledge of the gynecologist’s insufficient training and experience with robotics might have influenced the patient’s decision to undergo the da Vinci-assisted procedure [5].

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Plaintiff attorneys are also using insufficient training and credentialing in the field of robotic surgery to seek negligent litigation claims. For example, in the pending case of Mohler v. St. Luke’s Medical Center, a complaint of negligent credentialing in robotic surgery was filed [6]. During the robotic-assisted procedure, the plaintiff alleged the defendant caused injury to his bowels from improper use of the robotic equipment. The plaintiff filed a suit to hold the hospital liable for negligence in properly credentialing [the surgeon] to use robotic equipment. This case emphasizes the importance in recognizing the partnership between gynecologic surgeons and healthcare facilities. Because the robotics field in minimally-invasive surgery (MIS) is still evolving, hospitals have different guidelines and standards. At its 38th Global Congress, the American Association of Gynecologic Laparoscopists (AAGL) established its own robotics special interest group to undertake establishing uniform credentialing guidelines as its initial goal [7].

4.3.3 Robotic proctors and legal issues Robotics surgical proctors provide additional assistance after robotics training for novice robotic gynecologic surgeons. Traditionally, proctors serve only to observe and evaluate a physician’s competence, however, the scope of the current robotic proctor may expand to include the additional responsibility of providing instruction. The landmark 1985 Clark v. Hoek ruling found that proctors, as observers, do not constitute a physician-patient relationship. The court ruled, individual proctors do not owe a duty of care to the patient, and therefore are not held up to a standard of care or obligation to the patient in the event of a mis-occurrence [8]. However, this ruling was formed from a variety of facts, one of which implicitly stated that the proctor only observed and did not undertake to intervene in, supervise, or control the operation. If the roles of robotics proctors are expected to expand beyond pure observation to incorporate an active role in teaching or intervention, these instructors may be undertaking a duty of care by establishing a special physician-patient relationship and may not be afforded legal protection. To date there is no existing case law that provides a context on determining whether robotics instructors do assume this duty of care or physician-patient relationship. Typically, the court will consider several factors when determining if a physician-patient relationship exists. Some of these factors include whether the physician and patient met, whether the physician examined the patient, if the physician reviewed the patient’s record, and if there was a fee for the services rendered [8]. Legal cases such as the Walters v. Rinker and Peterson v. St. Cloud Hospital, in which pathologists were found to hold a physician-patient relationship, can argue that a special physician-patient relationship can be established despite direct contact between the two parties [9, 10]. Another legal issue that could arise for the robotic proctor is the potential to be joined in a malpractice lawsuit by the primary surgeon. The primary operating surgeon may join the proctor as a responsible party in the lawsuit by filing a cross

4.4 Conclusion 

 35

claim. However, the primary surgeon must claim the proctor provided improper instruction that was relied upon and that the improper instruction was the proximate cause of the patient’s injury.

4.4 Conclusion As robotics-assisted technology continues to expand in the field of gynecology, establishing a universal guideline in training and credentialing is important. Crucial in this process is identifying and recognizing the partnership between surgeons and healthcare facilities. Not only will healthcare facilities and committees ultimately decide appropriate guidelines for credentialing, but they will also play an integral role in facilitating the role and legal protection of robotic proctors. As standardized training and curriculum in robotics technology becomes further integrated in residency training, a more uniform front can be taken in regards to training requirements. It will require a collaborative effort from all involved parties. Such measures will also likely mitigate many of the legal issues discussed above.

References [1] Training Approach. Intuitive Surgical. N.d. Website. http://www.intuitivesurgical.com/training/ training_approach.html. Updated September 2010. Accessed on 19/3/2012. [2] Visco AG, Advincula AP. Robotic gynecologic surgery. Obstet Gynecol 2008, 112(6), 1369–82. [3] Lee Y, Phelps JY. Medicolegal review of liability risks for gynecologists stemming form lack of training in robot-assisted surgery. J Minim Invas Surg 2011, 18(4), 512–5. [4] Zorn KC. Training, credentialing, proctoring and medical legal risks of robotic urological surgery: Recommendations of the Society of Urological Robotic Surgeons. J Urol 2009, 182(3), 1126–32. [5] Carreyrou J. Botched operation using da Vinci robot spurs lawsuit. The Wall Street Journal May 25, 2010. Available at: http://online.wsj.com/article/SB10001424052748703341904575266952 674277806.html. Accessed on 10/3/2012. [6] Mohler v. St. Luke’s Medical Center, LP, No. C 08-0078, slip op. (Arizona. August 2010). Public documents accessed at: http://www.superiorcourt.maricopa.gov/docket/CivilCourtCases/ caseInfo.asp. [7] Advincula AP. Roadmap to robotics. AAGL News Scope 2010, 24, 9. [8] Clark v. Hoek. 174 Cal App 3d 208 (1985). [9] Walters v. Rinker. 520 Ind App 2d 468 (1988). [10] Peterson v. St. Cloud Hospital. 460 Minn App 2d 635 (1990).

5 Patient positioning, trocar placement, and docking for robotic gynecologic procedures Mostafa A. Borahay 5.1 Introduction The da Vinci® surgical system (Intuitive Surgical Inc, Sunnyvale, CA, USA), currently the only FDA-approved robotic surgical system, is composed of three components: surgeon’s console, patient cart, and video cart. After the patient is properly positioned and trocars are placed, the patient cart is moved toward the patient and “docked.” One of the critical differences between robotic and conventional surgery (both open and laparoscopic) is the difficulty in changing patient position during a procedure. In fact, such attempts typically necessitate robot undocking and redocking. This behavior wastes a great deal of valuable operating room time and should be avoided as much as possible. Correct patient positioning, appropriate trocar placement, and docking are critical skills for safe and successful robotic surgery. Currently, most surgeons learning robotic techniques have some degree of prior laparoscopic experience. Although this implies some knowledge of laparoscopic operative principles, it often leads to missing critical differences between conventional laparoscopic and robot-assisted approaches. As we will see, certain differences should be taken into consideration when switching to a robotic platform. Although knowledge of laparoscopic principles is expected for many readers, this text is intended to be appropriate for novice learners as well, e.g., those in residency training programs. The overall goals of this chapter are to maximize operative field exposure, minimize robotic arm collisions and other technical difficulties, improve the surgical team’s efficiency, improve ergonomics for the staff, and ensure patient safety.

5.2 Importance of proper patient positioning and trocar placement Inappropriate positioning and/or trocar placement can cause several technical difficulties, wasting valuable operating time and potentially introducing serious patient complications. For example, inappropriate positioning can lead to nerve injuries (e.g., brachial plexus, femoral, and common peroneal nerve palsies). Improper trocar placement can lead to potentially serious complications, such as vascular (major vessels and abdominal wall vessels) or bowel injuries, hernias, and infections. Furthermore, improper trocar placement may cause a novice surgeon to struggle during procedure. Examples include placing trocars too close together causing robotic

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arms to collide during surgery, or placing trocars too close to target anatomy (e.g., with a significantly enlarged uterus) limiting operating space and causing technical difficulties. In contrast, placing them too far from target organs can be problematic, also, if, for example, the instruments do not reach far enough for cuff closure after removal of a massively enlarged uterus.

5.3 Patient positioning 5.3.1 Principles of patient positioning Goals for appropriate positioning are maximizing efficiency of surgical technique while minimizing surgery-associated risks. Advanced and complex robotic cases can be lengthy, and improper positioning can be associated with serious complications. Except for procedures done through a retroperitoneal approach, almost all robotic gynecologic procedures are performed in the Trendelenburg position. Basically, the patient is placed in a modified dorsal lithotomy position. Legs are separated and positioned using adjustable boot Allen stirrups (Allen Medical Systems, Acton, MA, USA). Hips and knees are flexed, and legs (Fig. 5.1) are abducted. Typically, thighs are placed almost horizontal at table level with hips slightly flexed not more than 15°. Knees should be flexed less than 60° to prevent femoral nerve compression [1]. Extra care should be paid to ensure that the legs’ weight rests on the heels of the feet and not on the calves. This positioning is important to avoid nerve palsies and avoid compromising venous blood flow with possible vascular thrombosis. It is a common practice to tuck the arms during robotic surgery. Typically, this is accomplished by wrapping the under-patient sheet around the arms while hands, forearms, and elbows are padded by egg-crate sponge (Fig. 5.1). The team should be careful about protecting fingers and securing IV lines and the blood pressure cuff without undue pressure. In our experience, this seems to be a practice inherited from laparoscopic surgery with no clear benefit for robotic surgery. The benefits of not tucking the arms include more accurate blood pressure measurement by placing an unrestricted blood pressure cuff and easier access for anesthesiologists in case another IV is needed intra-operatively. Untucked arms do not seem to interfere with the flow of the procedure. Importantly, arms need to be well supported and restrained by adhesive tape. Prolonged procedures with patients in a steep Trendelenburg position can lead to patient sliding, and many approaches have been applied to prevent such sliding (Fig. 5.1). Some surgeons recommend using shoulder blocks. While blocks prevent skidding, they have been associated with cases of brachial plexus injuries and postoperative pain and nerve palsies. Other methods include using gel pads (if used, be careful when moving the patient to avoid skin scratches) or vacuum bean bags. In our experience, using adhesive gel pads along with gently wrapping adhesive

5.3 Patient positioning  

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Fig. 5.1: Modified lithotomy position used in most robotic gynecologic procedures. Please note: a) tray mounted to a bar to protect patient’s face, b) Bair Hugger to prevent hypothermia, c) tape on mid-thorax to help prevent sliding, d) arm is tucked in, e) hip is at 170° angle, f) knee is flexed at 90° and lower extremity is resting on knee, g) lower extremities resting on heel

tape around the patient’s chest has been enough to adequately and safely prevent skidding. It is imperative to adequately pad all pressure points. Some robotic procedures may last for many hours, especially early in the learning curve. Unprotected pressure points can predispose patients to deep venous thrombosis (DVT) and/or nerve palsies. An accumulating body of evidence associates hypothermia during surgery with poor perioperative outcomes, including increased infections. Therefore, patient core temperature should be maintained, and body warming techniques should be employed as necessary and as available in each institution. At the University of Texas Medical Branch, we use Bair Huggers® (Arizant Healthcare Inc., a 3M company, Eden Prairie, MN, USA) along with a Foley catheter with a temperature sensor that tracks core body temperature throughout the procedure. Prophylaxis against DVT is of critical importance. We follow published guidelines by the American College of Obstetricians and Gynecologists (ACOG) for prophylaxis [2]. Most cases occupy the moderate- or high-risk groups where a mechanical or pharmacologic prophylactic method is indicated. Since mechanical and pharmacologic methods give similar results, we prefer to use mechanical methods to avoid associated

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costs, side effects, increased bleeding, and hematoma formation. In most cases, we use a combination of TED hose and sequential compression devices. Both are placed in the preoperative holding area. Cases with highest risk, e.g., malignancy in patients over 60 years of age, prior DVT/PE, etc., are managed by combined pharmacologic and mechanical prophylaxis as indicated. Many institutions have protocols for DVT prophylaxis, and robotic surgeons are encouraged to follow these protocols. In robotic cases, the head should be adequately protected (Fig. 5.1). We use a metal tray mounted to a metal bar and attached to a table to protect the patient’s head from any injuries from instruments moved by the surgeon or assistant. Also, this ensures adequate visualization and access to the patient’s face and endotracheal tube for the anesthesiologist throughout the procedure. As with other surgical procedures, it is important to close the patient’s eyes and use eye ointment to prevent corneal ulceration. It is also advisable to insert a nasogastric or orogastric tube to decompress the stomach, which helps prevent potential stomach injuries in cases using the left hypochondrial area for peritoneal access. Patients with previous gastric bypass surgeries may require additional care. An orogastric tube is considered less invasive compared to a nasogastric tube. Before robot docking, position the patient in the maximum tolerable Trendelenburg position by lowering the head 15–30° [1]. Factors that might affect the degree of tilt include obesity, ophthalmologic problems with elevated intraocular pressure, pulmonary or cardiovascular conditions, and cerebrovascular diseases. After completing the patient’s positioning and prior to prepping, we typically perform a tilt test, where we position the patient in the maximum tolerated Trendelenburg and check for sliding as well as cardiopulmonary parameters. However, recent evidence suggests the maximum Trendelenburg position might not be necessary. For example, Ghomi et al [3] showed that 20 robotic gynecologic procedures were successfully performed with a median Trendelenburg of 16.4°. After a successful tilt test, level the patient back to a horizontal position and perform a routine examination under anesthesia. This step is critical, as it gives an idea about uterine size and can affect the plan for port placement. Adequately prep the vagina and perineum by povidone-iodine antiseptic (unless allergic to iodine), followed by prep of the abdomen and upper thigh by DuraPrep® (3M™, St. Paul, MN, USA) or other commercially available antiseptic preparations. Follow this step by patient draping. We prefer to place a 16-Fr Foley catheter after draping the patient and prior to placing the uterine manipulator. In many cases of robotic gynecologic surgery, a uterine manipulator needs to be placed. Different types of uterine manipulators are commercially available [e.g., RUMI®, RUMI II®, ZUMI® (CooperSurgical Inc, Trumbull, CT, USA), VCare® (ConMed Endosurgery, Utica, NY, USA), Advincula Arch™ Handle (CooperSurgical Inc, Trumbull, CT, USA), and others]. Regardless of the brand used, these systems typically include a uterine manipulating tip, colpotomy ring, and vaginal occluding balloon. The surgeon and team should familiarize themselves with the manipulator brand

5.4 Trocar placement  

  41

they plan to use and pay attention to properly sounding the uterus. Placing a manipulator tip that is too short or too long may cause inadequate uterine control during the procedure. Manipulators are usually used for two purposes: moving the uterus during surgery and providing an edge to perform a colpotomy. Although some surgeons do not use uterine manipulators during surgery, the vast majority do.

5.4 Trocar placement Robotic gynecologic surgeons and team members are expected to complete adequate training including trocar placement prior to their first case. This includes didactic education, relevant anatomic principles, and animal labs. Proper port placement maximizes exposure of the operative field, minimizes arms/instruments collision and assures patient safety and adequate and comfortable access to bedside assistant.

5.4.1 Peritoneal access Peritoneal access can be obtained using various approaches, including a Veress needle followed by camera trocar placement, camera trocar insertion prior to pneumoperitoneum, and open (Hasson) technique. Many surgeons still use a Veress needle at the umbilicus (or left hypochondrium if adhesions are suspected underneath the umbilicus) to create a pneumoperitoneum, followed by insertion of the first trocar under visualization using an Endopath Optiview® trocar (Ethicon Endo-Surgery, Inc., Cincinnati, OH, USA). Surgeons commonly use a 5–10 mm laparoscopic camera for initial entry and survey, reserving the robotic camera until after docking. Most surgeons use an initial pressure less than 10 mm Hg as suggestive of proper intraperitoneal insufflation. Once a camera is inside the abdomen, an immediate check for entryassociated injuries is critical before tilting the patient or manipulating the bowel.

5.4.2 Trocar placement The total number of ports used in most robotic gynecologic surgeries ranges from three to six. Most surgeons use a 3-arm configuration where one port is used for a camera and two ports for robotic instrument arms. In a 4-arm configuration, an additional port is placed for a third robotic instrument arm. The majority of surgeons routinely place an additional assistant port. A single-port robotic surgery platform is currently under trial and is expected to be available for clinical gynecologic practice in 2013. Many factors affect the number and location of port placement. These factors include patient factors (e.g., obesity, prior surgeries, anticipation of adhesive disease), procedure type (e.g., if para-aortic lymphadenectomy is planned), target anatomy

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factors (e.g., large uterus), the available system (e.g., robotic standard and S system arms are larger and require wider spacing to avoid collisions), and surgeon expertise and preference. Also, surgeons should bear in mind while determining port locations that the maximum working length of da Vinci standard instruments is 25 cm, while the length for da Vinci S instruments is 30 cm [4]. Placing instruments at longer distances may lead to a surgeon’s inability to reach the pelvis during surgery. The following trocar placements apply to most gynecologic robotic surgeries (e.g., hysterectomy and myomectomy). Special considerations for certain procedures will be discussed later.

5.4.2.1 Primary (robotic camera) port Examination under anesthesia prior to patient prepping is a critical step. Determine the uterine size and place the robotic camera (available in 8.5- and 12-mm sizes) trocar 8–10 cm cephalad to the upper limit of the elevated uterine fundus. This placement will help create the necessary space for visualizing the operative field and moving instruments while minimizing instrument collisions. Determine camera port placement prior to the pneumoperitoneum , but measure for the locations of the other trocars afterwards. Alternatively, especially in cases of prior surgeries and suspected adhesions, a 5–10 mm regular laparoscopic camera can be inserted in the left hypochondrial area to survey the abdomen and pelvis before safely placing the robotic camera trocar under direct visualization.

5.4.2.2 Port placement for a 3-arm configuration Place right and left robotic arm instrument ports (8 mm diameter) 8–10 cm lateral and 2–3 cm caudal to the robotic camera port. Alternatively, many surgeons place robotic instrument ports slightly caudal to the camera port and along an arc centered at the symphysis pubis and about 2–3 cm medial to the anterior superior iliac spine. Place an assistant port in the patient’s left or right side about 2–3 cm cephalad to the camera port and 8–10 cm from the camera and robotic instrument arm ports. See Fig. 5.2.

5.4.2.3 Port placement for a 4-arm configuration While some surgeons use a 4-arm configuration as their default, many reserve this approach for when more extensive manipulation is anticipated, e.g., sacrocolpopexy and lymph node dissection. An important principle for 4-arm use is to make sure that one of the two ipsilateral ports (typically the most lateral/fourth arm) is cephalad (or caudal) to the other to maximize interarm space and minimize arm collisions. In this configuration (Fig. 5.3), the first and second robotic instrument ports are typically placed 8–10 cm lateral and cephalad (or caudal) to the camera port on both

5.4 Trocar placement  

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Fig. 5.2: Port placements for 3-arm configuration. Please note use of bariatric trocar for camera, even in nonobese patients, to allow for easier accessibility and maneuverability. a) Camera port, b) and c) robotic instrument ports, d) assistant port

sides. Place a third robotic instrument port 8 cm lateral and caudal to the second trocar site. In all situations, maintaining at least 8 cm between all ports is recommended to minimize instrument collisions. Using a long needle to infiltrate local anesthetic at the instrument port sites may be helpful for locating and confirming port sites internally under vision. Confirming that the trocar remote center (marked by a broad black band – see Chapter 8) lies at the level of the peritoneum is critical. Misplacing the remote center leads to excessive fascial stretching and significant postoperative pain. Many surgeons prefer to attach an insufflation line to the assistant (or one of the robotic instrument) port during surgery and use the camera port for smoke evacuation. This arrangement helps minimize camera fogging and improve visualization. Finally, using bariatric trocar cannulas is important for obese patients. In fact, at the University of Texas Medical Branch, we made it the rule to use bariatric trocar cannulas for all cases to avoid errors and opening more than one instrument set.

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  5 Patient positioning, trocar placement, and docking

Fig. 5.3: Port placements for 4-Arm configuration: a) camera port, b), c), and d) robotic instrument ports, e) assistant port

5.4.2.4 Special considerations for port placement for specific procedures Procedures including lymph node dissection (especially para-aortic LN) Insert the camera port cephalad to the umbilicus, about 24–28 cm from the symphysis pubis. Most surgeons use 4 robotic arms (see Chapter 23). Sacrocolpopexy Place a camera port at or superior to the umbilicus. If a 4-arm approach is adopted, locate the patient-side assistant in the patient’s right side. Place the first and second robotic instruments arms 10 cm lateral and 30° inferior to the umbilicus at both sides. Place the third robotic arm as laterally as possible (about 3 cm from the iliac crest) and just inferior to the level of the camera port (see Chapter 25). Retroperitoneal robotic approach Magrina et al [5] described a robotic retroperitoneal approach (Fig. 5.4). In this approach, insert an 8 mm robotic trocar through a 10–12 mm Spacemaker™ Plus Dissector System placed 3 cm medial to the left anterior superior iliac spine. Introduce the 12 mm camera trocar through the patient’s left flank along the posterior axillary line, 10 cm cranial and lateral from the caudal robotic trocar. Insert a second 8 mm robotic

5.5 Initial survey 

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Fig. 5.4: Port placements for retroperitoneal robotic approach. Anatomic landmarks: a) camera port, b) costal margin, c) and d) trocar sites, e) anterior superior iliac spine

trocar 10 cm cranial and medial to the laparoscope, immediately below the left costal margin and in line with the caudal robotic trocar. Place the assistant trocar immediately adjacent to the anterosuperior iliac spine, equidistant between the laparoscope and the caudal robotic trocar.

5.5 Initial survey After port placement is complete, place the patient in a steep Trendelenburg position. Perform an initial survey of the abdomen and pelvis, comprising inspection of the pelvis (including uterus and adnexa) and upper abdomen (including liver, gall bladder, spleen, and stomach), followed by moving the bowel to the upper abdomen to improve pelvic visualization.

5.6  Docking It may be helpful, especially during the learning curve, to place marks on floor to help with proper robot docking. When three robotic instrument arms are used, placing

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  5 Patient positioning, trocar placement, and docking

the camera arm setup joint to the side opposite the third robotic arm is advisable to minimize arm collisions. First, determine the “sweet spot” by making sure the blue arrow lies within the blue marker line on the second joint. The marked sweet spot on the patient cart applies only to straight docking, not to side docking. The second step is to align the camera arm, the camera arm setup joint, the column, and the target operative field. Prior to moving the patient cart toward the patient, clear the path of overhead lights to maintain sterility and position the robotic arms high to avoid hitting the patient’s legs (patient legs can be lowered temporarily). Push the robotic patient cart until reaching target anatomy. Dock the camera arm first, taking care to maneuver the robotic arm (using the arm clutch) rather than the patient port. Next, dock the robotic instruments arms, keeping the farthest possible distance between the robotic arms. Finally, relieve any tension at the robotic trocars.

5.6.1 Docking types 5.6.1.2 Straight docking In the straight docking approach (Fig. 5.5a), position the robotic patient cart between the patient’s legs while facing the patient directly. The main disadvantage is the tight space available for assistance manipulating the uterus, especially in cases needing uterine morcellation.

5.6.1.3 Side docking For side docking (Fig. 5.5b), introduce the robotic patient cart while embracing one of patient legs with an arm positioned in between patient legs with the other arm coming from the patient’s side. The main advantage is leaving space for assistance in manipulating the uterus. Side docking is typically adapted for the retroperitoneal approach.

5.7 Conclusion Proper patient positioning, trocar placement, and docking are critical steps for a successful and safe robotic procedure since attempts to change the patient’s position or trocars during the procedure are costly in terms of procedure time and frequently necessitate patient cart undocking and redocking. Robotic surgeons should have a clear understanding of the general principles of patient positioning, port placement, and docking. In addition, adequate preprocedure planning takes into consideration the specifics of each case. These specifics include patient characteristics (e.g., obesity and prior surgery), procedure type (e.g., simple hysterectomy vs. sacrocolpopexy vs. para-aortic lymphadenectomy), and characteristics of targeted anatomy (e.g., uterine

References 

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a

b Fig. 5.5: Robot docking: a) straight docking, b) side docking

size and anticipated adhesions). Finally, a team approach should be adopted, and each team should clearly understand and anticipate an efficient and seamless flow of activities in the OR.

References [1] Boggess JF. da Vinci Hysterectomy for Early Stage Endometrial Cancer Procedure Guide. 871402 Rev F. Sunnyvale, CA: Intuitive Surgical, 2010. [2] ACOG Practice Bulletin No. 84. Prevention of deep vein thrombosis and pulmonary embolism. Obstet Gynecol 2007, 110, 429–40. [3] Ghomi A, Kramer C, Askari R, et al. Trendelenburg position in gynecologic robotic-assisted surgery. J Minim Invasive Gynecol 2012, 19, 485–9. [4] Visco AG. da Vinci Sacrocolpopexy Procedure Guide. 871619 Rev B. Sunnyvale, CA: Intuitive Surgical, 2007. [5] Magrina JF, Kho R, Montero RP, et al. Robotic extraperitoneal aortic lymphadenectomy: Development of a technique. Gynecol Oncol 2009, 113, 32–5.

6 Role of the robotic surgical assistant Alexander di Liberto and Kubilay Ertan 6.1 The surgeon in the area of conflict between autonomy and dependency The possibility for the robotic surgeon to dispose of three or four laparoscopic accesses simultaneously or consecutively (camera arm and two to three robotic surgical arms) is an important characteristic and a significant advantage of robot-assisted surgery with the da Vinci® system (Intuitive Surgical Inc, Sunnyvale, CA, USA). It makes it easier for the surgeon in contrast to traditional laparoscopic surgery, where only two laparoscopic accesses can be used at the same time, and provides a high degree of autonomy with regard to the core area of the surgical intervention, that is the actual therapeutical procedure. On the other hand, the work at the console in a non-sterile area results in a loss of control over the required accessory and logistic tasks of the surgical environment which are associated with the surgical access; the acquirement (passing instruments to, from or across the operating table from the circulating nurse), the change or the removal of the equipment (for instance, interference of the trocar positions, instrument exchange, taking over of additional instruments, etc.), the optimization of the visibility conditions (by suction and irrigation, cleaning of the camera, etc.), and the retrieval of the surgical specimen and tissues. In consequence of the work at the console the surgeon is quasi segregated from the sterile field of the operating table and the operating area and can focus on the virtual surgical work (dissection, suturing, etc.). The loss of control of particular activities such as direct engagement at the operating table leads the robotic surgeon to rely more on the robotic surgical assistant and the scrub nurse as in traditional laparoscopic interventions. This restriction of the operating range in favor of the manifold advantages resulting from the technique of the da Vinci system has to be counterbalanced by the robotic surgical assistant. As regards haptics and tactile feedback it comports similarly. Indeed, the surgeon can compensate for the absence of haptics partially by means of the tridimensional spatial view, but the surgical assistant can give more reliable feedback concerning the consistency of tissues and stiffness of anatomic structures. In addition to this, the use of the fourth arm can be relinquished for economic reasons or in order to minimize the amount of surgical accesses through the abdominal wall – in an effort to limit the surgical trauma as a basic principle of all laparoscopic, minimally-invasive surgical (MIS) techniques. Subsequently, the robotic surgical assistant has to take over further tasks. Due to specific selection criteria for robot-assisted operations the increase of complexity of minimally-invasive interventions imposes auxiliary requirements and challenges on the surgical assistant, which frequently exceed the measure of tasks in traditional laparoscopic interventions. For this reason, the criteria of

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choice, competence, skills and experience of the robotic surgical assistant have to be defined. This is illustrated in the following.

6.2 Tasks of the robotic surgical assistant The robotic surgical assistant has many tasks and responsibilities in the preoperative prearrangement of the operation theatre (patient positioning, disinfection, draping of the patient, other preparations at the operating table such as securing the camera position, wiring, etc.), the performance of or assistance in the traditional laparoscopic part of the operation prior to the docking of the patient side cart (depending on the specific allocation of tasks of a particular gynecologic department, respectively, depending on the level of training and experience of the particular surgical assistant, but in most cases in collaboration with the console surgeon), the proper robotic surgical assistance during the therapeutic part of the operation (console phase), the closing section after termination of the console phase and undocking of the patient side cart, and the postoperative care and post-processing procedures (neutralization of the intraoperative patient position, review and wrap-up of the intervention, documentation, etc.). Preoperative and postoperative patient care in the operating theatre hardly differs from traditional laparoscopic operations, and are described elsewhere (as regards specifics of patient positioning in robot-assisted interventions). The duties, tasks and functions of the robotic surgical assistant in the particular operation phase (between incision and cutaneous suture) are given below. In principle, it can be asserted that the robotic surgical assistant besides the handling of the robotic arms and their instrumentation accomplishes activities which are essentially the same as were used in traditional laparoscopic surgery, this means that he or she must be skilled and trained in conventional laparoscopy (Fig. 6.1).

6.2.1 Tasks of the robotic surgical assistant prior to beginning the surgical intervention The responsibility for the correct and safe positioning of the patient relies generally on the medical team, the anesthesiologist is in charge of those body regions which are used for the anesthesiological instrumentation (mostly the head and arms), the other parts of the body are the responsibility of the surgical team. For this reason the surgeon and/or the surgical assistant are involved in the positioning of the patient and in ensuring that the patient is protected from intraoperative positioning injury and damage (peripheral nerve injury, lesion of the plexus brachialis, compartment syndrome, etc.) in every case, predominantly in close collaboration with the OR nursing staff. However, the surgical team have dominion over and the

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Fig. 6.1: a) Docking maneuvre; the robotic surgical assistants are positioned at the operating table and act independently, the console surgeon is not scrubbed in; b) console phase; the robotic surgical assistant acts independantly at the patient’s side

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main responsibility for the correctness of the positioning measures and procedures. The importance of the robotic surgical assistant consists in performing the required tasks routinely and efficiently and in the knowledge of the specific demands of the respective robot-assisted interventions and types of surgery. Moreover, the robotic surgical assistant is constantly involved in the prearrangement of the surgical table (the laying down of the endoscope on the surgical table for later use before the placement of the trocars, fixing and protection of the da Vinci endoscope, arrangement of the cables, installation of suction/irrigation, placing of instrument pockets, etc.). A detailed knowledge of the layout of the accessory material for each robotassisted intervention is required as regards the docking position of the patient side cart (“between legs” docking, side docking, etc.). Optimal training and adequate experience are required.

6.2.2 Tasks of the robotic surgical assistant between beginning the surgery and starting the console phase The surgical steps required between beginning surgery and taking over the surgical console are: the attachment of the uterine manipulator (if used), the establishing of the capnoperitoneum, the insertion and placement of the da Vinci trocars and of the assistant ports (1–2), the performance of adhesiolysis, where required (provided that the insertion of the trocars and the placement of the robotic instruments are encumbered by adhesions), and the docking of the patient side cart to the da Vinci trocars as well as the insertion of the EndoWrist™ instruments and their correct placement in the abdominal cavity. Notably, the adhesiolysis can prove to be extremely complicated and sometimes requires a high degree of experience in traditional laparoscopic surgery. According to the allocation of tasks the robotic surgical assistant can perform this preliminary surgical steps alone, i.e., independently and being primarily responsible, or the surgical assistant supports the main surgeon in his activities. Usually these acitivities and tasks are done in equitable collaboration between the surgeon and surgical assistant, all movements and maneuvers have to be coordinated in order to ensure an uninterrupted trocar placement and a short docking time. Importantly, the time between beginning the surgery and the docking maneuver can be shortened by the experience of the robotic surgical assistance.

6.2.3 Tasks of the robotic surgical assistant during the console phase Besides the function of surgical assistance (this means the support of the console surgeon) the robotic surgical assistant is the responsible scrubbed physician and surgeon at the operating table during the console phase, so that he fulfils a dual

6.2 Tasks of the robotic surgical assistant  

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assignment: on the one hand, he assists and on the other hand, he assumes responsible tasks, where necessary. This clearly exceeds the common function of the surgical assistant in traditional surgical interventions in which the surgeon stands at the operating table; the robotic surgical assistant guards the patient safety at the operating table. The specific assisting tasks for robotic interventions after docking of the patient side cart are (usually in collaboration with the operation nurse) the instrument exchange, which have to be carried out as quickly and with as little disturbance as possible, the cleaning of the da Vinci camera and, as the case may be, of the EndoWrist™ instruments (depending on the established division of work between surgical assistances and nursing staff in the particular department), which also have to be performed without unnecessary delay, the surveillance, monitoring and adjustment of the capnoperitoneum, the correction of the robotic arms and the position of the trocars (modulation of penetration depth and stretching of the abdominal wall, primarily the camera arm in case of gas loss or requested low gas pressure), depending on the desired range of motion and expansion of the operating field (e.g., from the rectouterine excavation up to the renal veins in endometrial cancer staging), and troubleshooting at the patient side cart (e.g., in case of collision of the robotic arms, repositioning of the robotic arms in the event of dislocation due to unexpected movements). All these activities call for a fundamental and broad understanding of the robot system, and of the EndoWrist™ instruments and the patient side cart, notably the functionality, the mode of operation and the dimension of movements of the robotic arms including their manipulation, and an adequate experience in whose handling. At this juncture, the surgical assistant has to operate and act in a selfdirecting manner because the virtual surgeon at the console cannot engage directly at the operating table. The experienced handling of the da Vinci system is indispensable in case surgical intervention is required with the minimum of hesitation. The surgeon at the console is dependent on the competence of the surgical assistant during the activities at the operating table; the surgeon can direct the assistant verbally. The tasks of the surgical assistant which are not specific for the robotic device act are most often in accordance with the type of intervention required, mostly they concern holding functions (retraction, presentation of structures which have to be removed, or protection of tissues and organs which are near the surgical field, e.g., the ureter), optimization of the view in the surgical area by suction and irrigation, if necessary inserting of pads, and the placement of further surgical materials (endobags, suture material, hemostatic agents and material, vessel loops, staplers, etc.), and their removal, including the secure removal of tissues, organs and other surgical specimens (in case of hysterectomy, the vaginal retrieval can be a particular challenge if there is a unfavorable relation between the uterine size and the width of the vagina, especially if a contamination in case of malignant diseases has to be avoided. A dilatation and widening of the vagina to the point of an episiotomy can become necessary.

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Frequently, instruments have to be placed transvaginally in order to grasp specimens intraabdominally; this can be hindered due to a deficient accessibility to the vagina and reversed movements). Here, the selection of adequate laparoscopic instruments (traumatic and non-traumatic grasping forcipes, tenacula, bowel retractors, spoon forcipes, etc.) and their optimal placement is crucial. Even more requirements are called for by the surgical assistant in case of the use of transabdominal applications (e.g., injection of epinephrinehydrochloride prior to myomectomy), employment of sealing instruments (e.g., LigaSure™, HarmonicD, etc.), or staplers, or, for instance, performance of clip applications and of insertion of ureteral stents, etc. The basic principle in all these activities is the anticipation of each action, as well as in other surgical interventions (this applies both to abdominal and traditional laparoscopic interventions); but in robot-assisted surgery the anticipation of assistant activities seems to be more relevant because of the direct communication (quasi “face to face”) between the surgeon and the surgical assistant is interrupted or complicated due to the spatial distance (see the paragraph below about structures of communication). Additionally, the docked patient side cart provokes a restriction in the accessibility to the assistant ports, posing further requirements to the accuracy of the robotic surgical assistant. The optimal accomplishment of the mentioned activities and tasks require a detailed acknowledgement of the particular course of each surgical intervention. Most of the assistant activities that occur are not camera-guided, therefore they must be carried out unerringly and precisely as much as possible on the edge of the surgical field; furthermore, these movements should happen without collision with the robotic instruments or restricting the surgeon’s view. Where the fourth robotic arm is used robotic assistant’s tasks are transmitted to the surgeon. Sometimes, due to an increasing complexity of the robot-assisted operation, the placement of two assistant ports can be required; the manipulation of two assistant ports escalates the demands for the robotic surgical assistant. The intraoperative insertion of an additional assistant port in case of unexpected intraoperative conditions (due to a restricted surgical view or anatomic proportions) or complications (e.g., major bleeds) – given the docking situation of the patient side cart – is a task of the robotic surgical assistant and belongs to his field of expertise. Depending on departmental and personal specific conditions the robotic surgical assistant could take over the task of uterine manipulation, which increases the complexity of his function even more. In consequence of the at least temporary autonomic work of the console surgeon as a specification of robot-assisted operations there are periods of nonactivity for the robotic surgical assistant on the other side, when he has no tasks at all. These can result in a lack of attention of which the robotic surgical assistant has to be conscious at any time. Therefore, the function of the surgical assistant during these periods can be labeled as “attentive passiveness”. In critical situations during the surgery (e.g., in case of an unexpected and major bleed) the robotic surgical assistant has to perform self-determined responsible

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activities, such as applying clip application, utilization of several materials for hemostasis which may be applied in a complex way (e.g., Gelitacel™, Tachosil™, Floseal™, etc.), up to the emergency undocking procedure of the patient side cart, which requires appropriate training, and the urgent performance of laparotomy (longitudinal and transverse incision), the last one up to the time when the console surgeon is scrubbed and can take over the surgery at the operating table (Tab. 6.1).

6.2.4 Tasks of the robotic surgical assistant after termination of the console phase until the skin closure The tasks of the robotic surgical assistant between termination of the console phase and the end of the operation which are performed, depending on departmental division of labor, with or without the console surgeon, include the undocking of the patient side cart from the trocars (after removal of the robotic instruments), the insertion and placement of drainages [including a suprapubic catheter in case of radical hysterectomies (mainly type C hysterectomy according to the classification of Querleu-Morrow)], the removal of a temporarily stored specimen outside of the peritoneal cavity (including endobags), if necessary after restricted widening of the incisions or via natural orifices, where required (i.e., in myomectomies, supracervical hysterectomies and hysterectomies with large uteri not extractable through the vagina) the application of morcellation techniques, the peritoneal lavage, and the closure of the incisions (particularly the fascia closure). These activities require an adequate expertise of the robotic surgical assistat as well, especially with regard to the traditional laparoscopic experiences, skills and capabilities.

6.3 Selection criteria of the robotic surgical assistant Due to the fact that the robotic surgical assistant has to show both sufficient capabilities and experiences in complex traditional laparoscopic interventions and a comprehensive knowledge of the robotic system and whose functionality and Tab. 6.1: Tasks of the robotic surgical assistant during the console phase Central tasks of the robotic OR assistant concerning robot specific tasks

concerning laparoscopic, assistant tasks

instrument change and positioning troubleshooting correction of the position of the robotic arms and position of the trocars cleaning of the camera (and instruments)

retraction of tissues and organs suction/irrigation providing of material (sutures, endobags, etc.) specimen extraction uterus manipulation (if applicable)

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characteristics – as demonstrated in the preceeding chapters – the surgical assistant will usually be an experienced fellow or resident. Furthermore, selection criteria are a sufficient and practical training in the robotic system, interest, and enthusiasm for robot-assisted interventions. Commonly, the da Vinci surgeons alternate their work at the console and as surgical assistants from case to case. This no doubt shows an optimal combination concerning the efficient course of the intervention because the surgical assistant knows through their experience as a surgeon the outcome of the intervention, and therefore he is capable of performing all the assistant activities effectively and expeditiously. However, this reduces possibility and potential for educating and training residents and fellows. The latter also concerns the number of cases performed in the particular gynecologic department and the degree of complexity of robot-assisted interventions, the employee turnover, and the level of the particular department as university or teaching hospital. Due to the importance of the formation of a robotic team resulting from the complexitiy of the preparations and postprocessing procedures and the specific components of the da Vinci system, whose correct handling is essential for the unobstructed advancement of the intervention, the existence of a core team is indispensable. Adding a resident or fellow for training and education in robotic assistance to the core team may provoke a delicate disturbance of the operation sequence, especially in complex cases. The education and training of a robotic surgical assistant requires a minimum number of robot-assisted cases per year which is approximately 50 cases per year for an effective assistant training. The additional training at the surgeon console depends on the spectrum of the robot-assisted interventions of each gynecologic department. The higher the complexity of the robotic interventions, the stricter the selection criteria for using the robotic assistance, the more problematic is the realization of an additional console training. The basic principle for the selection of a qualified robotic surgical assistant is the existence of satisfactory experience and expertise in traditional laparoscopic surgery because robotic assistance essentially contains components of conventional laparoscopic activities and exercises.

6.4 Training/education of the robotic surgical assistant The question how to accomplish and to optimize the training of the robotic surgical assistant is mostly associated with the issue how to educate and to train robotic surgeons in general. In this respect, the sequence is mostly – assumed that there exists a structured program and schedule in the particular department – the admission of a medical assistant to the robotic team, training at the device in terms of a dry run, the change over to robot-assisted interventions, instructed assistance, and finally independent robotic surgical assistance. As the robotic surgical assistance is

6.4 Training/education of the robotic surgical assistant   

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in essence a traditional laparoscopic exercise (direct guidance of the instruments in a two-dimensional view including the fulcrum effect, with physiological tremor and loss of the natural eye-hand alignment, etc.) sufficient training in traditional laparoscopic surgery and techniques is a mandatory prerequisite for assisting robotic surgery (because in existing and experienced robotic programs preferably complex cases are robot-assisted, thus the basics has to be acquired elsewhere). In this context, the spectrum of performed robot-assisted interventions is important. In the case of the (economic) possibility of a gynecologic department to do easier robot-assisted interventions (such as simple hysterectomy in benign diseases or non-complex myomectomies) the education and training at the da Vinci system is considerably easier. Moreover, the type and intensity of the training and its organization depends on the number of the performed robot-assisted cases of a gynecologic department and coincidentally is associated with the economic and the personal situation of the department and the whole hospital. There exist no international accredited standards for education and training both concerning the robotic surgeon and the robotic surgical assistant (including credentialing). However, professional societies (e.g., SERGS, SGO Clinical Practice Robotics Task Force [1]) are making efforts to establish standardized programs for the education of robotic surgeons and assistants; at this juncture both positions, surgeon and assistant, are associated and are simply components or different levels of a single field of work, namely robot-assisted surgery.

6.4.1 Practical and virtual simulation/simulator systems Diverse alternatives of simulation exist, both for traditional laparoscopic and for training in robotic surgery. These range from simple arrangements in a laboratory (e.g., the Pelvitrainer™) to large animal models (mainly porcine models) or even to experimental models with human cadavers. The elaborate and expensive practical simulation models should be centralized in the surgical department where robotic surgery will be carried out. For the virtual training there are – apart from numerous online tools for education – diverse laparoscopic and robotic surgical digital simulation programs available (e.g., the da Vinci Skills Simulator™ [for the da Vinci SI™ system], or SimSurgery™, LapSim™, LAP Mentor™, ProMIS™ Hybrid Surgical Simulator, etc., Fig. 6.2). All of these systems are focused on surgical operating activites and less on the surgical assistance, but this demonstrates the close association and relationship between surgical and assisting functions. For the robotic surgical assistance intensive 1–2 day-training sessions on the da Vinci system in specialized training centers and laboratories are most effective, but

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Fig. 6.2: da Vinci Skills Simulator™ (source: Intuitive Surgical Inc, Sunnyvale, CA, USA); examples for simulation tasks

are expensive and have long waiting lists, especially for whole robotic teams (surgeons, surgical assistants and surgical nurses).

6.4.2 Training programs – request and reality The ideal sequence for adaptation of robot-assisted interventions into the clinical routine is a bespoke training centre from which instruction in and operating from can be done. An alternating work pattern between operating and assisting function is ideal because only then can the surgical team amass the required experience. This applies to both open abdominal and traditional laparoscopic as well as robot-assisted surgery. There exist numerous structured conditions for training with the da Vinci system (examples are depicted in the Fig. 6.3), mostly from American robotic surgical teams because in the USA there is a large amount of da Vinci systems in use and subsequently a high number of cases. In Europe, the availability of da Vinci systems is lower (counted as number of da Vinci systems relating to the population), the scepticism towards robot-assisted surgery is larger and the economic constraints are higher, so that selection criteria for robot-assisted interventions are stricter. All this results in a lower number of performed robotic cases (this causes a lower turnover, less efficiency and longer operating times), this again aggravates the initiation and implementation of structured training programs and the admission of residents and training fellows into the robotic programs.

6.5 Aspects of spatial arrangement and structures of communication   

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(b)

(a)

Docking practicum Stage I: camera arm positioning - camera arm set-up - camera arm sweet spot - camera arm alignment

Stage II: instrument arm positioning and port placement - instrument arm positioning - patient cart positioning - port placement philosophy

Stage III: docking - docking camera arm - arm positioning during docking - docking instrument arms

Stage IV: checking system set-up - camera arm set-up - instrument arm set-up - instrument arm postioning

Stage V: instrument insertion and removal - instrument insertion - instrument removal - guided tool change

Education and training sequence I. didactic overview - understand robotic vision, electronics, and instrumentation - understand robotic ergonomics, and robotic limitations II. inanimate laboratory - master operative console, and robotic operative cart - master instrument and camera control III. animal laboratory - console surgeon - master suturing, tissue cutting, suture tying - patient-side assistant - master: • instrument exchanges, camera cleaning • cauterization, clip application • retraction, trocar positioning

IV. cadaver laboratory - master trocar positioning - apply I-III to human anatomy and to variable body habitus

V. operative observation - determine differences from I-IV - observe interaction with adjunctive surgical technology

Fig. 6.3: a) example of a structured training program (modified from Geller et al [2]); b) example for a educational and training program; robotic surgical training curriculum levels (modified from Chitwood et al [3])

6.5 Aspects of spatial arrangement and structures of communication The spatial and functional position of the robotic surgical assistant in the operation theatre should be considered as a central or a key position. The surgical assistant has direct contact with the scrub nurse, the circulating nurse and to the anesthesiologist and he should be in easy communication with the console surgeon (Fig. 6.4), thus the surgical assistant is important for the coordination the whole OR team. For this

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reason the spatial positioning of the robotic surgical assistant has to be chosen wisely in relation to the da Vinci system and with respect to the particular docking situation of the patient side cart, even if there are frequently constraints and limitations due to the spatial limitation of the OR. The following basic principles concerning the position of the surgical assistant have to be considered (Fig. 6.5): – in case of the “between legs docking” the surgical assistant should be placed visà-vis the scrub nurse and both should have uninterrupted visibility, likewise he should have a direct line of sight to the surgeon at the a Vinci console; this means that the robotic surgical assistant, the console surgeon and the scrub nurse are arranged in a triangular alignment – in the case of a side docking position (valid for both from upper and lower patient side, and both for the docking from the right and the left side) the surgical assistant should be placed opposite to the patient side cart, vis-à-vis to the scrub nurse (then rather diagonal) and as well as the console surgeon. Due to the spatial distance of the surgeon to the operating table and for this reason to the surgical assistant and the scrub nurse in robot-assisted operations in contrast to traditional laparoscopic interventions, where communication routes are shorter or non-verbal communication can take place easily by gestures and eye-contacts, special features and an increased intensity and difficulty of communication arise, or rather particular principles of communication in the operation theatre attain a major impact in robot-assisted operations. Basic rules of communication are the expression of explicit instructions and commands (mainly from the surgeon at the console), clear verbal confirmations and feedbacks (mainly from the surgical assistent, the scrub nurse and the anesthesiologist – “explicit communication”), the mutual respect of the particular tasks, as well as the reduction of conversation foci and ambient noises in the operating theatre in order to ensure an undisturbed and optimal flow of work

Anesthesiologist

Anesthesia nursing

Surgeon

OR assistant

2nd OR assistant

OR nurse

Circulating nurse

Fig. 6.4: Lines and structures of communication in robot-assisted interventions

6.5 Aspects of spatial arrangement and structures of communication   

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Fig. 6.5: a) position of the robotic surgical assistant in relation to the console surgeon, the scrub nurse and the anaesthesiologist, fourth arm on left patient side; triangular alignment of the surgical team (source: modification of an Intuitive Surgical Inc. image); b) position of the robotic surgical assistant in relation to the console surgeon, the scrub nurse and the anaesthesiologist, fourth arm on right patient side; triangular alignment of the surgical team (source: modification of an Intuitive Surgical Inc. image)

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and to minimize the “sense of physical and psychological isolation” of the surgeon at the console [4]. The application of a microphone/speaker system can simplify the communication between the console surgeon and the staff at the operating table. The communication between the console surgeon and the robotic surgical assistant has been shown in operation analyses as the predominant communication channel [5]; this emphasizes the outstanding importance and position of the surgical assistant.

6.6 Available data relating to the role of the robotic surgical assistant/existing evidence Hardly one study or trial deals explicitly with the role of the robotic surgical assistant. To date there are only two publications which investigate the function and the importance of the surgical assistant, namely one analysis of a Romanian study group from a department of general surgery [20]. This study assigns to the robotic surgical assistant a key role in the robotic surgical workflow (“the decisive role of the patient-side surgeon in robotic surgery”), and an urologic working group concerning the subject of training in robot-assisted prostatectomies [6]. These studies will be described in detail. Some studies and statements from non-gynecologic and gynecologic departments [7–12] even suggest that by the use of the fourth arm and an optimallytrained scrub nurse the robotic surgical assistant could be partially replaced. Publications with the explicit topic of demonstration and description of the role of the robotic surgical assistant in gynecologic robot-assisted operations are not available. A series of papers presents structured programs and schedules showing how to lead surgeons and training fellows and residents gradually in robot-assisted interventions, with respect to how to design and optimize the training and education to attain best possible learning curves and results by using simulation systems as well [3, 13–19, 2], or the importance and the interaction of the robotic surgical team as a whole are analyzed [22]; for the most part there is no decided discrimination between the functions and tasks of the surgeon and surgical assistant, but rather the robotic surgical assistance is specified as a certain stage or component of the robotic education and training [2]. This reveals that the role and position of the surgical assistant is not fixed or could be considered separately, but rather that the formation at the robotic system commonly combines both the assistant and the surgical function, or rather shows that the surgical assistance merely can be performed if a minimum of surgical experience at the surgical console has been acquired (comprehension and appreciation of the requirements to the surgical assistance from the own practical experience as surgeon). In the study of Sgarbura and Vasilescu [20] several different activities of the robotic surgical assistant are analyzed and quantified (trocar placement, docking and undocking of the patient side cart, insertion and change of robotic instruments, and

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maneuvers for hemostatis). The survey of these activities took place in the context of 280 robot-assisted interventions in digestive, thoracic, and gynecologic surgery, whereupon three trained robotic teams with three console surgeons and four certified robotic surgical assistants (here indicated as “patient-side surgeons”) have been grouped. Four more patient-side assistants were trained at the reporting center. The results revealed that assistants which are intensely trained and educated in training centers (e.g., with the help of animal models) are more comfortable in handling the robotic instruments and with docking and undocking of the patient side cart compared to those who are trained locally. Furthermore, the authors demonstrated that experienced surgical assistants (“who finalized their residency or attended in their final year”) are more accurate and precise with the insertion of laparoscopic instruments and performing haemostatic activities (e.g., clip applications, LigaSure™ handling). In interventions with a need of a high degree of participation and attendance of the surgical assistant a significantly shorter assistant-dependent time interval was demonstrated at the end of the learning curve compared to at its beginning. The authors concluded that besides the importance of the complete team in robotassisted surgery, the robotic surgical assistant accounts in the effective accomplishment of the intervention to a great extent, in addition, there are clear detectable differences between structured (e.g., by means of animal models in surgical laboratories) and locally (mainly by instruction and tutorial during robotic interventions) trained surgical assistants (Tab. 6.2). That a structured education and formation with respect to a periodical training can improve the course of robot-assisted operations has also been demonstrated on the basis of a three-phase hands-on RARP (robotassisted radical prostatectomy) bedside assistant training [6].

6.7 Conclusions In the opinion of the authors, the robotic surgical assistant in robot-assisted interventions with the da Vinci system has a greater higher importance compared to non-robot-assisted operations (abdominal and traditional laparoscopic). On the one hand, this results from the fact that the surgical assistant not only has to have experience in traditional laparoscopic surgery but also the differentiated knowledge and skills in the handling of the robotic system, and on the other hand, the surgical assistant has to take over or have the ability to take over tasks and activities (partially in cooperation with the entire robotic team) which cannot be accomplished by the console surgeon because of his work at a remote place. The console surgeon has a higher level of autonomy for the specific surgical work (dissection, etc.), but he is more dependent on the reliability of the patient-side assistant concerning accessory surgical activities. In this respect, it is permissible to characterize the relationship between the console surgeon and the patient-side assistant as the complementary work of two surgeons, namely the console surgeon and the patient-side surgeon

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Tab. 6.2: Differences between formal and local trained robotic surgical assistants; (according to Sgarbura [20]) “n” concerns number of assistants and not the number of measurements Differences between the assistants formally trained/experienced in laparoscopy and the assistants locally trained/less experienced in laparoscopy

Docking time (min) Instrument exchange time (s)

Time for insertion of the instruments in the operative filed (s) LigaSure/clip application time (s) Rate of unsuccessful applications

Formal training (n = 4)

Local training (n = 4)

P value

10.67 ± 2.4 5.9 ± 2.7 experienced in laparoscopy (n = 5) 4.6 ± 1.3

16.3 ± 4.5 7.7 ± 3.7 less experienced in laparoscopy (n = 3) 8.2 ± 3.5

0.05 0.0004 P value 0.0001

4 ± 1.7 4%

7.8 ± 2.6 15%

0.0001 0.007

(the “scrubbed surgeon”, [21]). The education and training of robotic surgical assistants are essential; it has been demonstrated that a formal training (i.e., in a training center) is beneficial related to the effectiveness of the assistance compared to a local, unstructured training. Furthermore, novel and unresolved problems concerning team coordinating strategies, characterization of interactions between the team members, and their choreography in the performance of the particular tasks arise for each department performing robot-assisted interventions.

References [1] Ramirez PT, Adams S, Boggess JF, et al. Robotic-assisted surgery in gynecologic oncology: a society of gynecologic oncology consensus statement. Developed by the society of gynecologic oncology’s clinical practice robotics task force. Gynecol Oncol 2012, 124(2), 180–4. [2] Geller EJ, Schuler KM, Boggess JF. Robotic surgical training program in gynecology: how to train residents and fellows. J Minim Invas Gynecol 2011, 18, 224–9. [3] Chitwood WR, Nifong LW, Chapman W, et al. Robotic Surgical Training in an Academic Institution. Ann Surg 2001, 234(4), 475–86. [4] Lai F, Entin E. Robotic surgery and the operating room team. Proceedings of the Human Factors and Ergonomics Society, 49th Annual Meeting 2005, Orlando Florida, 1070–3. [5] Degueldre M. Communicating in the robot OR. Society of European robotc gynaecological surgery (SERGS), 2nd annual meeting Lund (Sweden) 2010, oral presentation. [6] Thiel DD, Lannen A, Richie E, et al. Simulation-Based Training for Bedside Assistants Can Benefit Experienced Robotic Prostatectomy Teams. J Endourol 2012, 26, 1–8. [7] Rogers CG, Laungani R, Bhandari A, et al. Maximizing console surgeon independence during robot-assisted renal surgery by using the Fourth Arm and TilePro. J Endourol 2009, 23, 115–21. [8] Lee DI, Eichel L, Skarecky DW, et al. Robotic laparoscopic radical prostatectomy with a single assistant. Urology 2004, 63, 1172–5. [9] Sundaram CP, Koch MO, Gardner T, et al. Utility of the fourth arm to facilitate robot-assisted laparoscopic radical prostatectomy. Br J Urol Int 2005, 95, 183–6.

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[10] Esposito MP, Ilbeigi P, Ahmed M, et al. Use of fourth arm in da Vinci robot-assisted extraperitoneal laparoscopic pro-statectomy: novel technique. Urology 2005, 66, 649–52. [11] Van Appledorn S, Bouchier-Hayes D, Agarwal D, et al. Robotic laparoscopic radical prostatectomy: setup and procedural techniques after 150 cases. Urology 2006, 67, 364–7. [12] Kimmig R. Robotic Surgery in der Gynäkologie – Chirurgie der Zukunft oder teurer PR-Gag? Eine persönliche Betrachtung. Gynäkologe 2011, 44, 401–4. [13] Ali MR, Rasmussen J, BhaskerRao B. Teaching robotic surgery: a stepwise approach. Surg Endosc 2007, 21, 912–5. [14] Dulan G, Rege RV, Hogg DC, et al. Developing a comprehensive, proficiency-based training program for robotic surgery. Surgery 2012, 152, 477–88. [15] Gobern JM, Novak CM, Lockrow EG. Survey of robotic surgery training in obstetrics and gynecology residency. J Minim Invas Gynecol 2011, 18, 755–60. [16] Hashimoto DA, Gomez ED, Danzer E, et al. Intraoperative resident education for robotic laparoscopic gastric banding surgery: A pilot study on the safety of stepwise education. J Am Coll Surg 2012, 214, 990–6. [17] Hoekstra AV, Morgan JM, Lurain JR, et al. Robotic surgery in gynecologic oncology: Impact on fellowship training. Gynecol Oncol 2009, 114, 168–72. [18] Kilic GS, Walsh TM, Borahay M, et al. Effect of Residents’ Previous Laparoscopic Surgery Experience on Initial Robotic Suturing Experience. Internat Scholarly Res Netw ISRN Obstet Gynecol 2012, Article ID 569456: 1–4. [19] Menager NE, Coulomb MA, Lambaudie E, et al. Interest of robot-assisted laparoscopy in the initial surgical training: Resident survey. Gynécologie Obstétrique Fertilité 2011, 39, 603–8. [20] Sgarbura O, Vasilescu C. The decisive role of the patient-side surgeon in robotic surgery. Surg Endosc 2010, 24, 3149–55. [21] Kumar R, Hemal AK. The ‘scrubbed surgeon’ in robotic surgery. World J Urol 2006, 24, 144–7. [22] Mendivil A, Holloway RW, Boggess JF. Emergence of robotic assisted surgery in gynecologic oncology: American perspective. Gynecol Oncol 2009, 114, S24–S31.

Further reading ACOG Technology Assessment in Obstetrics and Gynecology No. 6. Robot-assisted surgery. Obstet Gynecol 2009, 114, 1153–5. Chandra V, Nehra D, Parent R, et al. A comparison of laparoscopic and robotic assisted suturing performance by experts and novices. Surgery 2010, 147, 830–9. Drasin T, Dutson E, Gracia C. Use of a robotic system as surgical first assistant in advanced laparoscopic surgery. J Am Coll Surg 2004, 199, 368–73. Einarsson JI, Hibner M, Advincula AP. Side docking: An alternative docking method for gynecologic robotic surgery. Rev Obstet Gynecol 2011, 4(3/4), 123–5. Sfakianos GP, Frederick PJ, Kendrick JE, et al. Robotic surgery in gynecologic oncology fellowship programs in the USA: a survey of fellows and fellowship directors. Int J Med Robotics Comput Assist Surg 2010, 6, 405–12.

7 Strategies for avoiding complications from robotic gynecologic surgery Georgia A. Mccann and Jeffrey M. Fowler 7.1 Introduction Minimally-invasive surgery (MIS) has progressed from being limited to diagnostic procedures and tubal sterilization to more advanced laparoscopic (LS) and now robotic surgeries. Over the past two decades, improvements in instrumentation, accumulated surgical experience and specialized surgical training have all contributed to advances in the ability to perform a wide range of major surgical procedures via MIS for complex benign and malignant conditions. Many postoperative complications associated with laparotomy are comparatively less when the same procedure is performed via MIS. However, incorporating LS into the comprehensive management of general gynecology and gynecologic oncology patients has been only moderately successful secondary to technologic limitations, a difficult and long learning curve, variability in surgeon experience, longer operative times and patient factors such as surgical history and obesity. The robotic platform overcomes many of the technologic limitations of LS. The surgical goal of MIS is for equivalent or improved disease-related outcomes but with the expectation of a decrease in perioperative morbidity, disability, and improved quality of life. Therefore, patient and physician expectations are very high with MIS procedures and any complication is likely to be perceived as more unacceptable under these conditions. Advantages to a MIS include smaller incisions, less tissue manipulation and damage, and decreased adhesion formation. The operator of the robotic platform not only has improved vision but also controls the direction and distance of the camera from the operative field without relying on the assistant. In addition, the surgeon has up to three other port sites to use for a dissector, cutting instrument and another retracting instrument. The marked technological improvements provided by robotic surgery has allowed experienced surgeons to offer more patients, requiring complex procedures, the advantage of a MIS approach. Nevertheless, these are still major surgical procedures performed via minimized access and therefore major surgical complications are possible, some which are unique to MIS. MIS introduces additional layers of technological, human and procedural complexity for any given surgical procedure traditionally performed via laparotomy. Prevention of complications begins long before the actual operative procedure with appropriate treatment selection and preoperative counseling. Selection of a surgical route will often be based on a surgeon’s formal training and experience. It is recommended that surgeons develop a careful accumulated experience of increasingly complex robotic procedures. It is important for the surgeon to develop a consistent,

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step-wise approach to major MIS procedures. Preoperative planning in regards to setting one’s surgical strategy is extremely helpful. Anesthesia consultation and/or preoperative medical clearance may be necessary regarding pulmonary and ocular sequelae unique to MIS. Once in the OR, proper patient position is critical to facilitate the procedure and minimize extremity-related complications. Skilled surgical assistance must be arranged and the operating room set-up properly orchestrated. A team approach with excellent communication between all members in the OR is critical. OR staff experienced with the robotic platform such as the circulating nurse, scrub technologists and biomedical support are necessary for efficiency and safety.

7.2 Patient positioning – prevention of neurologic injuries In addition to optimizing visualization and surgical conditions, the most important function of patient positioning is minimizing the risk of neurologic injuries. Nerve injury is ultimately the result of ischemia, hemorrhage, tissue necrosis, and endoneural edema. There are two major mechanisms in which improper patient positioning can result in neurologic injury: stretch and compression. Lithotomy is the position most commonly associated with lower extremity nerve injury and is the position in which all gynecologic robotic procedures are performed. The risk of sensory and motor deficits in patients placed in lithotomy position is 1.5% and 0.03%, respectively [1, 2]. Prolonged hip flexion, abduction and external rotation can result in obturator nerve stretch as well as compression of the femoral and lateral femoral cutaneous nerves as they course under the inguinal ligament. The common peroneal nerve courses around the lateral fibula and can be injured as a result of lateral compression or can suffer stretch injury during extended flexion of the knee with external hip rotation [3]. Although rare, stretch injury to the sciatic nerve can result from prolonged hyperflexion and external rotation of the hips with the knees extended [1, 4]. The genito-femoral and obturator nerves are at risk of direct injury during gynecologic oncology procedures [5]. The genito-femoral nerve can easily be transected during dissection of external iliac lymph nodes, resection of pelvic sidewall mass or adhesiolysis of the sigmoid colon to the pelvic sidewall and often results in temporary sensory neuralgia. Likewise, the obturator nerve can be transected during pelvic lymphadenectomy and, unlike the genito-femoral nerve, usually should be repaired [6, 7]. Endometrial cancer is the most common indication for robotic surgery performed by gynecologic oncologists [8–10]. There is no prospective data on the rate of neurologic injury in robotic gynecologic surgery. Retrospective data suggests that the rate of neurologic injury is approximately 5% with the great majority resulting in sensory neuralgia resulting from injury to the genito-femoral nerve [11]. Prevention of nerve complications related to patient positioning starts with understanding the mechanism of lower extremity nerve injury. The ideal lithotomy position is a trunk-to-thigh angle between 60–170°. The knees should be flexed, never

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extended, such that the thigh to calf angle is between 90–120°. Positioning should also minimize external hip rotation so that the angle of hip adduction results in no more than 90° between inner thighs. The use of Allen stirrups helps to minimize neurologic injury both by making the correct lithotomy position easily obtainable and by minimizing compression injury with the additional padding it provides [12]. Upper extremity neurologic injury is rare with an incidence in MIS of 0.16% and is usually the result of compression injury to the brachial plexus [13]. There are two main palsy’s associated with brachial plexus injury. When the superior aspect of the nerve plexus (C5–7) is injured the result is an Erb’s palsy: the arm is straight and wrist fully bent (waiter’s tip); this is usually a stretch injury. Klumpke’s palsy results from a stretch injury to the inferior aspect of the plexus (C8–T1) causing weakness or paralysis of the intrinsic hand muscles and finger flexors. A retrospective review by Romanowski et al found that steep Trendelenburg position, use of shoulder braces, and extension of the arms at 90° or more were all associated with brachial plexus injuries [12, 13]. In their study of surgical positioning in cadavers, Jackson et al identified five positions that increased the risk of brachial plexus injury [14]: 1. Dorsal extension of the head with lateral flexion to the contralateral side 2. Abduction of the arm greater than 90° (especially if externally rotated and extended) 3. Compression over acromion or 2–3 inches medially by shoulder braces 4. Lateral pressure by shoulder braces 5. Use of wristlets to prevent sliding Knowledge of the mechanisms by which neurologic injury occurs during patient positioning allows for the establishment of general guidelines. EKG leads and IV tubing should be placed on top of the arms as opposed to under the arms, over the acromion or along the lateral shoulder. Yellowfin stirrups should be used to position the patient in low lithotomy. In general, the ankle, knee and hip should be aligned to the opposite shoulder and the legs should be placed as low as possible. Lowering the legs prevents repositioning once the robot is docked and thus limits maneuvers that could increase the risk of lower extremity injury. One of the difficulties with steep Trendelenburg is maintaining that position/preventing the patient from sliding down the bed. A gel mattress has a high friction coefficient and thus having the patient lay directly on it can help prevent slippage. This in addition to a beanbag helps stabilize the patient in the correct position. Additional padding along the patient’s wrist, elbows, and shoulder also helps further minimize risk of nerve injury. The chest is also padded to prevent injury from the robotic arms. For further support the patient is secured to the table by taping around the beanbag and stirrups [15]. It is important to have the anesthesiologist be an active participant of patient positioning. Often, they assist with padding and protection of the shoulders and correct placement of EKG wires and IV tubing. It is also imperative to repeatedly assess the patient’s positioning throughout the surgery, especially when adjustments in patient position are made. The surgeon

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must also be cognizant of the operating time. In their large retrospective analysis, Romanowski et al found that duration of operation was significantly correlated with nerve injury such that each additional hour increased the risk of lower extremity neuropathy 100-fold [13]. Having a team that is trained in robotic surgery is of the utmost importance. Patient safety in the operating room is dependent on everyone [16].

7.3 Complications of pneumoperitoneum and steep Trendelenburg While the requirement of pneumoperitoneum is not unique to robotic surgery, patient positioning in steep or maximal Trendelenburg position is vital to obtaining adequate exposure to perform most complex robotic pelvic surgical procedures. These conditions are usually well tolerated but may offer a challenge in the obese population as well as those with compromised respiratory function [17, 18]. While the anesthesiologist manages the majority of these physiologic changes intraoperatively, it is incumbent on the surgeon to be aware of the associated risks as well as avoidance/management of these potential problems. Pneumoperitoneum is usually achieved with insufflation of CO2 gas to obtain a pressure of 15 mmHg, which can require anywhere from 2.5–5.0 L of gas within the abdomen. This has physiological effects on multiple organ systems. It can result in decreased renal cortical perfusion and an increase in the secretion of anti-diuretic hormone and ultimately in decreased GFR and urine output by approximately 50%. The cardiovascular system is also affected [19, 20]. Pneumoperitoneum can result in increased systemic and pulmonary vascular resistance with resultant hypertension. At pressures greater than 15 mmHg, the IVC can be compressed with consequent venous stasis, decreased preload and decreased cardiac output and hypotension [21, 22]. Furthermore, increased abdominal pressure restricts diaphragmatic excursion and lung expansion that results in increased peak inspiratory pressure and mean airway pressure resulting in decreased pulmonary compliance and functional residual capacity [23]. The ventilation-perfusion mismatch and intrapulmonary shunting that results manifests as hypercapnea and hypoxemia [18, 24]. This is exacerbated by the intravascular absorption of CO2. In order to compensate for these changes, the anesthesiologist must make adjustments to minute ventilation (respiratory rate × tidal volume) to prevent the development of acidosis [25]. Both pneumoperitoneum and steep Trendelenburg increase the risk of aspiration of gastric contents. This can be reduced with the use of cuffed endotracheal tubes, having the patient be NPO for at least 8 h prior to the procedure. Orogastric tube placement and decompression of the stomach may not decrease the rate of aspiration due to its overall low incidence. However, it is good practice and can help improve exposure and decrease the risk of stomach injury.

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There is limited data on the ocular changes associated with robotic or laparoscopic surgery, however there are reports of complications including retinal detachment and post-operative vision loss, thought to result at least in part from the steep Trendelenburg position. In a study by Awad et al, patients undergoing robotic prostatectomy were found to have a mean increase in intraocular pressure 13 mmHg higher after being placed in steep Trendelenburg position as compared to pre-induction anesthesia. In addition, length of procedure and end-tidal CO2 were the only significant predictors of increased intraocular pressure [26]. The exact mechanism by which steep Trendelenburg may result in increased intra-ocular pressure and post-operative vision loss in some is mostly theorized and likely multi-factorial. While current research will help identify any modifiable factors, it is the current practice of the authors to not offer robotic procedures to patients with underlying ocular disease especially those with glaucoma or retinopathy.

7.4 Robotic equipment 7.4.1 Electrosurgical principles In order to understand and be able to prevent electrosurgical injuries, one must first have a fundamental understanding of basic electrosurgical principles. Unlike household current, electrosurgical current uses high frequency (300–600 kHz) alternating current. This range of frequency is so high that it flows through the patient’s body without being detected and thus does not result in electrocution, nerve depolarization, or muscular twitching as with household current. There are three main tissue effects of electrosurgery: cutting, fulguration, and desiccation. Both cutting and fulguration are non-contact phenomena. Cutting uses unmodulated current (i.e., current flows 100% of the duty cycle) and results in tissue vaporization due to the rapid heating. Fulguration involves modulated current in which current is only flowing for a small percentage of time, resulting in short bursts of high voltage, which is important since electrosurgical complications are directly related to the amount of voltage. Nonetheless, the electrical sparks created by fulguration denature proteins resulting in superficial tissue effects over a large surface area. Desiccation is a contact phenomenon in which current passes through tissue resulting in dehydration and coagulation through heating.

7.4.2 Monopolar electrosurgery Monopolar electrosurgery (ES) involves an active electrode at the surgical site (i.e., the electrosurgical instrument) and a return electrode somewhere on the patient’s body.

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In general, monopolar ES (as compared to bipolar) is more effective at hemostasis and provides deeper tissue penetration, which can be both an advantage and disadvantage. There are three main complications associated with the active electrode in monopolar ES: insulation failure, direct coupling, and capacitive coupling. There are four major zones in which insulation failure can result in injury [27]. Zone 1 includes the distal end of the laparoscopic instrument that is in the surgical view. It is the most common location for insulation failure and is usually secondary to wear and tear of the instrument through the protective sheath [28, 29]. However, insulation failure can also result from high voltage associated with open circuit activation. For example, resistance develops if the monopolar instrument is activated while not in close tissue proximity. In order to overcome the resistance, higher voltage is generated and can essentially blow through the insulation. Zone 2 incudes the shaft of the instrument and is the area along the active electrode from just outside the laparoscopic view. Thus a defect in insulation can result in tissue injury that is outside of the surgical view and can go unrecognized. Zone 3 is the portion of the instrument that is within the cannula; the potential for injury is dependent on the type of cannula that is used. If a plastic, non-conductive cannula is used then insulation failures are usually not detectable. However, a metal cannula can conduct low frequency currents that usually manifest as muscular twitching or interference with the monitors. Zone 4 complications are rare and involve exposed metal in the handle of the instrument. This can result in injury to the handler of the instrument [27]. Direct coupling occurs when the active electrode is in direct contact with another metal instrument and can be intentional or inadvertent. As long as the instruments are passed through a metal cannula the currents will be dispersed through the anterior abdominal wall without issue. However, if the cannula is plastic the current may be directed to surrounding tissue including the bowel [27, 30]. To prevent this complication, all conducting instruments should be passed through metal cannulas. Capacitive coupling occurs when current is passed from the active electrode through a non-conductive material (instrument insulation) to another conductor. Higher voltage increases capacitive coupling and thus is more likely to happen with the coag mode as well as in open circuit activation. While it is best to avoid high voltage generators and not use the coagulation mode, both of these are usually necessary to produce the desired tissue effect. Thus the surgeon must be cognizant of the potential complications and use surgical technique to avoid them [27, 30]. Problems with the active electrode are the second leading cause of electrosurgical injuries. Prevention includes inspecting the insulation on all instruments and using the lowest power setting necessary to achieve the desired effect. If there is a change in the tissue effect, it is important to not increase the power without first checking the circuit as a sudden change in effect can be a sign that there is a short in the circuit. Use of a low-voltage cut waveform will also minimize risk of injury, remembering not to activate in an open circuit. It is also important to keep the instruments clean from tissue eschar and when intentionally performing direct coupling it is important to touch the desired instrument prior to activation of the monopolar energy [31, 32].

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The importance of the return electrode is commonly over-looked as 70% of electrosurgical injuries in fact involve the return electrode [33]. To avoid these injuries, it is important to ensure that the site is clean, shaved and dry and the electrode is applied in a location that minimizes the amount of resistance (i.e., a place without a significant amount of adipose, hair, scar tissue, or along bony prominences). It is also important to use the largest pad possible with a full-surface adhesive. Throughout the surgery, the electrode should be continually examined, especially after patient re-positioning.

7.4.3 Bipolar electrosurgery In bipolar electrosurgery the instrument has two arms, one of which acts as the active electrode and one that serves as the return electrode. There is a small space between the two arms in which tissue is grasped and thus the circuit consists of the active electrode, the tissue being grasped, and the return electrode. Unlike monopolar electrosurgery, current does not flow through the patient. Furthermore, there is a preset level of resistance at which the circuit automatically becomes deactivated and an ammeter (instrument used to measure current) that notifies the surgeon when electrical activity has ceased. While one of the advantages of bipolar energy is localized tissue effect, thermal spread is possible and is usually the result of steam bubbles that spread to surrounding tissue. Ways to minimize the amount of thermal spread include ending current flow when the tissue blanches and steam is no longer seen. While ammeters can be beneficial, they usually result in over-desiccation of tissue. In addition bipolar electrosurgery has the ability to occlude sizeable vessels. However, it is important to remember that more heat is generated with larger pedicles, resulting in greater degree of thermal spread. When dealing with bulkier tissue it may be beneficial to have the jaws slightly open and use them to directly tamponade and then desiccate the tissue [30]. Other advantages of bipolar energy include the ability to use lower currents, the lack of the capacitance effects, and the ability to use it while submersed in fluid.

7.5 Avoiding surgical complications The overall incidence of MIS complications is difficult to quantitatively define as it is primarily based on retrospective reports and very likely underreported. The data on LS complications is mostly anecdotal, based on single institutional experience and even less commonly based on meta-analysis and rarely prospective and/or randomized studies. This is not unique to MIS as most data on surgical complications is retrospective and therefore biased and imprecise. Various series on LS in gynecology and gynecologic oncology report the incidence to be 10% [34–37]. Data from relatively large series of robotic procedures in gynecology and gynecologic oncology are rapidly emerging. The overall complication rates are below that of equivalent

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  7 Strategies for avoiding complications from robotic gynecologic surgery

procedures performed via laparotomy and even less than LS is some series [38]. The actual rate of surgical complications that occur in MIS will depend on institutional/ surgeon experience, types and mix of surgical procedures, and associated patient co-morbidities. The improved visualization, precision and control over the operative field that the robotic platform offers is likely to improve the surgeon’s ability to dissect surgical planes, minimize blood loss and perform complicated adhesiolysis all giving the potential for decreased complications. However, with the availability of robotic technology, surgeons may attempt more difficult cases via MIS than they would have tried with LS. Loss of haptic feedback with the robotic platform is a potential disadvantage however the experienced surgeon is able to overcome loss of this sense with heightened visual feedback and meticulous surgical technique. Many complications related to the specific robotic surgical procedures will occur at least at a minimum rate and can vary with complexity of the procedure and surgeon experience. Gastrointestinal and urologic injuries are more common than major vascular injuries. Potential complications unique to MIS can be minimized by an expert knowledge of anatomy, smooth movement of the surgical instruments, learning visual cues that replace haptic feedback, always keeping instruments in the visual field, careful use of electrosurgical instruments and meticulous surgical dissection technique. Vigilance and focus throughout the procedure is critical.

7.5.1 Avoiding port complications Access to the peritoneal cavity is different than the traditional laparotomy approach and most critical to the success of MIS procedures. The most hazardous portion of the procedure is the primary trochar placement and location of secondary ports is critical in actually facilitating the planned procedure. There is not an accepted “standard” approach among the three most common primary port entry techniques, however, approximately 50% of major injuries and most deaths resulting from MIS are from insufflation and trocar injuries [35]. Consensus opinion reports do not agree on the preferred or optimal approach to placement of the primary port [39]. The technique for placement of the primary port will vary according to surgeon experience and preference and also with the patient’s body habitus, previous surgical history and goals of the surgical procedure. Safe placement is optimized with excellent control of insertion force and a minimum of subcutaneous tunneling facilitates the effectiveness of robotic instrument use during the operative procedure. All secondary ports must be placed under direct visualization. Port site locations are chosen based on the instrument needs for the specific procedure. While there is an emphasis to not only minimize the size of surgical incisions but also reduce the number of sites such as “single site” access MIS, it is imperative that the surgeon use as many ports as necessary to eliminate any potential surgical compromise.

7.5 Avoiding surgical complications 

 75

7.5.2 Gastrointestinal complications There are a variety of mechanisms by which gastrointestinal injuries occur during laparoscopic surgery. In a large review by van der Voort et al, the overall incidence of bowel injury or perforation during laparoscopy was approximately 0.13% and 0.22%, respectively, and is higher in patients with prior abdominal surgery or previous intraabdominal infection [40]. The small intestine is the most commonly injured (55.8% of cases), followed by the large intestine (38.5%) and stomach (3.9%). The majority of injuries are the result of Veress needle or trocar placement (41.8%) followed by thermal injuries (25.6%), grasping forceps (1.1%) and scissors (0.7%). To date it is not clear if one method of entry (open – Hasson vs. closed – Veress/trocar) is superior to the other. Merlin et al performed a meta-analysis to answer this question. The openentry group had a higher rate of bowel injury but lower rate of vascular injury however the incidence is low enough that at this point it remains inconclusive. Gastric injury may also be prevented with placement of an orogastric or nasogastric tube to allow for decompression of the stomach, especially following difficult intubation where the stomach can potentially be distended with air [41]. The most clinically significant intervention after bowel injury is early recognition as mortality associated with bowel injury is approximately 3.6% and is time dependent. If small bowel injury is suspected at the time of laparoscopy, the surgeon should run the intestines in their entirety with bowel graspers. Also, the surgeon should consider the possibility of other injuries caused to other organs. A leak test can be performed at the time of laparoscopy to evaluate for possible injury to the recto-sigmoid colon; the pelvis is filled with saline and air is injected through the anus. The presence of bubbles in the pelvis suggests that a leak or injury is present. After MIS patients should be counseled to expect continuous improvement. Increasing pain, tachycardia, or fever should raise concern. Due to the high bacterial load, large bowel injuries generally have higher rates of infectious and febrile morbidity. In addition, unlike laparotomy, ileus is not common after laparoscopy and must be thoroughly evaluated. An upright abdominal film to demonstrate free intra-abdominal air may not be as reliable after laparoscopic surgery as patients can have up to 2 cm of free air 24 h after laparoscopy that can persist for up to a week. If the amount of free air is increasing or not improving, the clinician should suspect a bowel injury. Small intestinal injury can be repaired via robotic instrumentation or laparotomy, depending on the size, location and physician comfort level. Non-thermal injuries can be repaired in two layers with care not to increase the risk of stricture formation by placement of sutures perpendicular to the long axis of the bowel. Small injuries (35 years, this is in line of the authors’ patient cohort – no delay of the surgical treatment (if indicated) by trials of medicamentous pretreatments with questionable benefit should occur, because, effectively, the time for planning a pregnancy could pass; against this background it is important that these patients frequently suffer from coexistent factors which diminish fertility A detailed discussion with the patient and her partner should is most important to impart all the relevant information to them. Due to the more precise dissection of uterine myomas in robot-assisted myomectomies and the potentially more selective hemostasis during myoma dissection and myoma removal a medicamentous pretreatment seems to have a secondary relevance. At present, however, there are no available data, neither prospective nor retrospective.

11.6.4 Preparation of the surgery There exists no essential differences in preoperative preparations of patients designated for robot-assisted myomectomy compared to those who are planned for traditional laparoscopic myomectomy. Beside the routine laboratory diagnostics and the obligatory pregnancy test the provision of blood should be considered in the case of multiple myomas. The surgical sequence and operation scheduling should be clarified if additional diagnostic and interventional hysteroscopy is planned, anesthesiological and nursing staff should be instructed. The preoperative imaging should also be reconsidered. In the case of a medicamentous pretreatment a pelvic MRI is necessary before and after treatment. Within the scope of the anesthesiological preparation contraindications for a prolonged and extended Trendelenburg position with respect to a long-lasting capnoperitoneum should be excluded (e.g., severe cardiac insufficiency, chronic heart failure, high-grade pulmonary emphysema, significant increase of intracranial pressure, etc.). Cases of contraindications are very uncommon in the usual patient cohort who are considered for myomectomy.

11.7 Recommendations for further diagnostics and treatment   

  149

Informed consent before robot-assisted myomectomy should include the extended intraoperative monitoring with respect to the additional instrumentation [arterial catheterization (improvement of blood pressure surveillance concerning hypovolemia due to hemorrhage and in case of accidental intravascular application of vasoconstrictive agents during myomectomy), central venous catheter]. The sufficient and anticipatory patient monitoring is very important in robot-assisted myomectomy (as well as in all robot-assisted interventions) due to the reduced accessibility to the patient after docking the patient side cart.

11.6.5 Patient information and informed consent The characteristics of patient information for robot-assisted myomectomies contain information about the technique of robotic assistance, the indication for the number of incisions and their position, especially in case of a large uterus which requires supraumbilical placement of the camera trocar, and the allusion to the possibility of conversion to traditional laparoscopy [e.g., in case of device defect (mechanical failure, etc.)] and conversion to laparotomy (in case of minimally-invasive unforeseen complications, mainly major bleeding). Regarding other complications adverse effects concerning the intraoperative positioning should be emphasized (lengthended skinto-skin time implies a lengthened Trendelenburg position; e.g., risk of brachial plexopathy). Other points of patient information depend on the other complications of surgical treatment. There is no difference in postoperative treatment and observation between traditional laparoscopic and robot-assisted myomectomy. Elements of postoperative treatment and surveillance such as hospital stay, iron supplementation, wound drainage, other diagnostics (transvaginal ultrasound, etc.) depend on duration and complexitiy of surgery and hospital-specific algorithms.

11.7 Recommendations for further diagnostics and treatment/ time interval to pregnancy/mode of delivery Recommendation for further diagnostics and therapy after robot-assisted myomectomy are dependent on the extent of the myomectomy, the course of the surgery, localization of the removed myomas, or additional factors such as coexistent endometriosis. Due to the expected cumulation of complexity of myomectomy by robotassisted surgery (as a result of selecting complex cases) the amount of associated treatments could increase (postoperative implantation of an IUD in the case of extensive intracavitary surgery, control hysteroscopies and laparoscopies including tubal patency testing or evaluation of the tubal patency by means of contrast-enhanced ultrasound). Published data on this topic are not available. Also

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  11 Robot-assisted laparoscopic myomectomy (RALM)

recommendations for further treatments [e.g., treatment of endometriosis, assisted reproductive techniques (ART), etc.] depends on the extent and complexity of the myomectomy performed. Based on the patient selection criteria for robot-assisted myomectomy, a higher incidence of associated treatments has also to be anticipated. The recommendation for the interval between myomectomy and the attempt to become pregnant lies between 3 and 6 months; but this is not based upon valid data. Apart from the possible need for an after-treatment the dimension of myomectomy plays a major role; this has to be decided individually, i.e., for every specific case. The recommended mode of delivery behaves similarly, however, the advice to an elective cesarean section will be given in the majority of cases in consequence of the fact that in robot-assisted myomectomy frequently several, deep intramural myomas have been removed and thus a considerable myometrial scarring is present. Indeed, the robotassisted suturing has to be considered as more effective but no prospective data are available, concerning the question as to whether this has a significant impact on the firmness and rigidity of the uterine wall during contractions and labor, or if a reduction of antepartual and intrapartual risk of uterine rupture results. Because of a high number of cases needed to test the hypothesis that after robot-assisted myomectomy the risk of uterine rupture will be significantly decreased valid data for this topic are not expectable for the present. At the very least, case series could identify preventive factors for a uterine rupture after myomectomy (avoidance of excessive uterine scarring, multilayer uterine suturing, limited application of HF surgery; Parker 2010 [1] and others). Furthermore, due to the fact that in the cohort of patients receiving a complex robot-assisted myomectomy there is a high percentage of older primiparous women no one would take no risks, particularly the rate of cesarean section is high in this cohort for several reasons. In summary, significant differences between robot-assisted and traditional laparoscopic myomectomy concerning pregnancy rate (also a high number of cases needed), reduction of miscarriages, the mode of delivery, with respect to recommendation for spontaneous delivery and the risk reduction of uterine ruptures have not as yet been elucidated. The evidence-based clarification of these questions become increasingly difficult the more surgeons adopt robotic assistance for complex myomectomy.

11.8 Case studies Case 1 A 43-year-old patient with hypermenorrhoea and menorrhagia, presented with the desire to become pregnant; she had a 5-cm partially intramural, partially intracavitary myoma in a transvaginal ultrasound (type II according to the classification of submucosal myomas of the European Society of Hysteroscopy, ESH); an underwent an external interventional hysteroscopy without success. The decision was made for a robot-assisted myomectomy. The were no intraoperative or postoperative complications and there has been no pregnancy to date (follow-up: 15 months) (Fig. 11.6).

11.8 Case studies  

  151

Fig. 11.6: a) Presentation of an intracavitary myoma; b) luxation of the myoma from the uterine cavity; c) demonstration of the opening of the uterine cavity; d) suturing of the uterine cavity

Case 2 A 35-year-old patient who wished to become pregnant presented with a 10-cm intraligamentary and intramural myoma on the right side as well as a 2-cm intramural myoma in the area of the uterine fundus (type II myoma according to EHS classification); she had bleeding disorders and chronic pelvic pain syndrome, and compression of pelvic vessels on the right side. Robot-assisted myomectomy with removal of both myomas, 330 g atypical myoma (without therapeutical implication) was prefermed with postoperative resolution of symptoms (Fig. 11.7). Case 3 A 35-year-old patient with no wish to become pregnant presented with bleeding disorders for the previous 15 years (hypermenorrhoea, menorrhagia), two miscarriages, two interventional hysteroscopies with several submucosal myomas; multiple submucosal myomas illustrated by pelvic MRI and a hardly indentifiable uterine cavity and further myoma of 5 cm at the junction of cervix and corpus uteri. Robot-assisted myomectomy was carried out with a large opening of the uterine cavitiy and removal of multiple (up to 10) nest-like arranged myomas; removal of the cervix myoma, postoperative implantation of an IUD (for 3 months); with postoperative resolution of symptoms; pregnancy after 15 months; delivery by elective cesarean section (36 weeks of gestation) with suspect of placenta increta (pelvic MRI), consecutive cesarean hysterectomy due to placenta increta (histopathologic proved) and diffuse myomas. The patient had an uncomplicated recovery (Fig. 11.8).

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  11 Robot-assisted laparoscopic myomectomy (RALM)

Fig. 11.7: a) The same patient as in Fig. 11.5b; presentation and removal of the submucosal myoma; b) the same patient as in Fig. 11.5b; dissection of the polylobated, partially intramural , partially intraligamentary myoma on the right side; c) the same patient as in Fig. 11.5b; closure of the uterine wound – first layer of suturing; d) the same patient as in Fig. 11.5b; closure of the uterine wound – second layer of suturing; e) the same patient as in Fig. 11.5b; closure of the uterine wound – superficial closure of the uterine incision

11.9 Authors data of robot-assisted myomectomy Between June 2008 and September 2012 the authors performed 65 robot-assisted myomectomies. The mean age of the patients was at the time of surgery was 36.5 years (23–48), only 21.5% of these women already has one to three children; 23.1%

11.9 Authors data of robot-assisted myomectomy  

  153

Fig. 11.8: a) Preoperative pelvic MRI shows a nearly completely filled uterine cavity; scattering of endometrial parts; b) intraoperative image with large-area opened uterine cavity (the tip of the Hulka tenaculum for uterine manipulation is protruding out of the uterine cavity); c) corpus uteri after completion of the uterine reconstruction; d) abdominal MRI with 30 weeks of gestation (there are still myomas in the lower corpus uteri and in the cervix; the arrow highlights the membraneous uterine scar)

had miscarriages in the patient history; on average 4.3 myomas had been removed (1–18), the mean weight of the removed myomas totalled 154.5 g (4–611), in nine cases (respectively, 13.8%) the uterine cavity was opened during myomectomy. The mean skin-to-skin time accounts for 219 min (82–484). In one case an intraoperative blood transfusion was done because of severe bleeding from the myoma bed (patient with multiple myomas). In another case a conversion to traditional laparoscopy was necessary due to a mechanical defect of the da Vinci system, where a conversion to laparotomy was carried out. The mean hemoglobin difference (preoperative vs. postoperative) was 1.5 g/dl (–0.7 to 6.6). About a quarter of the patients (23%) have delivered or are still pregnant in the observation period. The portion of cesarean sections was 83% [n = 10 (of 12)] given an nationwide rate of cesarean sections of ca. 35%. In more than 90% the existing myoma symptoms (bleeding disorders, pelvic pain, etc.) resolved (Fig. 11.9).

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  11 Robot-assisted laparoscopic myomectomy (RALM)

(a)

(b)

Patient characteristics and clinical data (I)

Patientin characteristics and clinical data (II)

Number of patients

n = 65 (06/2008–09/2012)

Postoperative hospital stay [days]

4.92 (2–9)

Mean age

36.5 years (23–48)

Conversion to traditional laparoscopy

1.5%

Patients with children

21.5%

Conversion to laparotomy

0

Patients with miscarriages

23.1%

Blood transfusion

1 (1.5%)

Pts with ≥2 miscarriages

6.6%

Other complications (brachial plexus lesion [temporary])

1 (1.5%)

Mean number of removed myomas

4.4

1 myoma

31.1%

≥2 myomas

68.9%

Opening of the uterine cavity

13.8%

Mean difference of hemoglobin

1.5 g/dl (–0.7 – 6.6)

Mean myoma weight

154.5 g (4–611)

(c)

25

(d)

22 19

12.4 10.9 Hemoglobine [g/dl]

20 15 10 5

1

5

≥5

2–4

2.5

(f)

2.2

350 306

skin-to-skin time [min] weight of myomas [g]

296.3

263 219

1.5

175

1.1

177.6

169 141

131

1.0

88 0.5

44 0

0

1–4

≥5

1–4

(g)

postop.

preop.

2.0 Hemoglobine [g/dl]

10

0

0

(e)

15

20

(h)

500 400

≥5

500 400

300

300 [min]

[min] 200

200

100

100

0

0 0

5

10 [n myomas]

15

20

0

175

350

525

700

[g]

Fig. 11.9: a) Authors’ data – clinical characteristics; b) authors’ data – clinical characteristics c) number of removed myomas (y-axis: number of patients); d) mean hemoglobine difference (preoperative vs. postoperative); e) mean hemoglobine difference preoperative vs. postoperative (as a function of number of removed myomas); f) skin-to-skin time and myoma weight (dependent on the number of the removed myomas); g) skin-to-skin time as a function of the number of removed myomas; h) skin-to-skin time as a function of the myoma weight [9]

11.10 Available data from robot-assisted myomectomies/existing evidence  

  155

11.10 Available data from robot-assisted myomectomies/ existing evidence Since 2007 there are only a few publications on robot-assisted laparoscopic myomectomy with a large number of cases. Before 2007 only feasibility studies were published. Thereafter, the most studies depict small case series, and show the feasibility of robot-assisted myomectomy or particular aspects of this kind of myoma treatment. Some important studies are indicated below. Advincula (2007) [2] analyses in a retrospective case-matched study 29 robotassisted myomectomies vs. 29 cases with traditional laparotomy. As expected, a significant reduction of the length of hospital stay (1.48 vs. 3.62 days) for robot-assisted interventions, and a significant decreased blood loss as well (228.55 vs. 364.66 ml) could be demonstrated. On the other hand, there has been a significant increase of operation time for the da Vinci myomectomies (231.38 vs. 154.41 min). In the cohort of traditional laparotomy a clear elevated incidence of postoperative complications occured. In one patient in the robotic group an intraoperative cardiogenic shock as a side effect of vasopressin application was seen. Advincula concludes that the advantages concerning blood loss, length of stay and complication rate and the subsequent societal benefits outweigh the upfront higher costs resulting from robot-assisted myomectomy. Barakt (2011) [3] arrives at the same results and conclusions with a higher number of cases. He suggests that the robotic technology may improve and increase the use of MIS in the treatment of symptomatic myomas. Nezhat (2009) [4] compares in a retrospective matched-control study robot-assisted laparoscopic myomectomies (n = 15, RALM) with a matched pair control-group of traditional laparoscopic myomectomy (n = 35). He shows that RALM compared to traditional laparoscopy has a significant longer operative time, whereas the amount of blood loss and length of hospital stay are not different in both groups. Subsequently, he concludes that RALM offers no relevant advantages for the trained and skilled laparoscopic surgeon, but the technology of robotic surgery would provide exciting potential applications while learning endoscopic surgery. Bedient (2009) [5] compares in a retrospective chart review robot-assisted (n = 40) and traditional laparoscopic (n = 41) myomectomies, as well. The study shows data from myoma characteristics (localization, number of myomas, weight, pathologic findings) plus operative time, blood loss, complications and lenght of hospital stay. In the group of traditional laparoscopy there are significantly larger uteruses, a significantly elevated myoma size in respective of the largest myoma and a higher number of removed myomas. When adjusted for uterine size and fibroid size and number, no significant differences were noted between robotic vs. laparoscopic groups (concerning mean operating time, mean blood loss, intraoperative or postoperative complications, hospital stay more of than 2 days, readmissions, and symptom resolution). Long-term results have not been analyzed. As such, no advantages for robot-assisted myomectomy could be identified. However, the primary selection criteria could be

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held responsible for these results. Moreover, the cases have been recruited over a very long time period from 2000 to 2008, this means partially in a period in which robotic surgery recently started and in which robotic myomectomy was in the learning stage. Thus, there may be a bias in this analysis. Nash (2012) [6] compares the clinical outcome and the effectiveness between robot-assisted laparoscopic myomectomy (n = 27) and abdominal myomectomy (n = 106). Here, he stratifies groups of different uterine size (16 weeks) and illustrates that patients with RALM have a significant decrease in postoperative need of analgesics (IV hydromorphone) and length of hospital stay. But no significant differences concerning blood loss can be demonstrated. Furthermore, he reveals for RALM that the bigger a uterus size with respect to the removed myomas the longer the operating time, and the lower the efficiency [represented as operating time (min) per gramme removed myoma tissue] (Fig. 11.10). Loennerfors (2011) [7] investigated in a prospective observational study the fertility after robot-assisted laparoscopic myomectomy of deep intramural myomas. The follow-up of 31 patients (14 with known infertility) is shown. The target criterion of the observation is the fertility and pregancy outcome after myomectomy. Fifteen of 22 (68%) of patients with an urgent desire to become pregnant became pregnant in a median time of 10 months after surgery. A total of 18 pregnancies occured, resulting in three miscarriages, two terminated pregnancies, 10 successful term deliveries (rate of cesarean section: 50%) and three ongoing pregnancies at the time of reporting.

500

Abdominal

Minutes of Operating Room Time

Robot Abdominal Robot

400

300

200

100

0 .0

500.0 1000.0 1500.0 2000.0 2500.0 3000.0 Grams of Specimen Removed

Fig. 11.10: Trends in minutes of operating room time per specimen for abdominal vs. robot-assisted laparoscopic myomectomy (Nash K, et al [6] Arch Gynecol Obstet 2012)

11.11 Summary and conclusion  

  157

The subgroup of 14 women with known but otherwise unexplained infertility had a pregnancy rate of 69% and of those, 55% conceived naturally. These results are comparable to these which have been reported from traditional laparoscopic myomectomies and abdominal myomectomies. In a multicenter (three center) retrospective analysis from Pitter (2013) [8] the pregnancy rate and pregnancy outcome are reported in 872 women who received a robot-assisted laparoscopic myomectomy (October 2005–November 2010). One hundred and twenty-seven pregnancies and 92 deliveries have been investigated. The mean age of patients at the time of surgery was 34.8 years, in 20.6% of cases the uterine cavity was opened. In this study the median time after surgery to conception was 12.9 months, in 39.4% an assisted reproduction technique has been effected. A multivariate regression analysis showed that a significantly higher preterm delivery rate was associated with a higher amount of removed myomas and the anterior localization of the largest uterine incision (P = 0.01). The rate of cesarean section was 95.7 in this study. A similar conclusion as in the mentionned study before has shown that pregnancy rate and pregnancy outcome are comparable to these after traditional laparoscopic. In summary, the conclusion that no prospective randomized trials to prove the superiority of robot-assisted myomectomy are available is needed. Furthermore there are only a small number of studies analyzing the resolution of symptoms intermediate-term or long-term after RALM. Two retrospective studies engage in the investigation of pregnancy and pregnancy outcome after RALM. They have shown at least that the results after RALM are equivalent to these after abdominal and traditional laparoscopic myomectomies.

11.11 Summary and conclusion The technique of robotic assistance is very suitable for complex myomectomy, especially in cases with unfavorable myoma localization, in patients with multiple myomas and with large and deep intramural myomas which require extensive and otherwise very exhaustive and fatiguing suturing of the uterine wall. The three-dimensional view and the enormous versatility of the robot-assisted instruments offer major advantages compared to traditional laparoscopy. Economic aspects and the question of the provable advantages over traditional laparoscopy concerning symptom reduction and resolution and pregnancy specific parameters (pregnancy rate, mode of delivery, etc.) are still unresolved. Due to the assumption that this questions could never be answered on the basis of prospective randomized trials, the improvement and advancement of endoscopic feasibility and perioperative outcomes and the simplification of the surgical intervention resulting in a maximum of minimal invasive conducted proportion of myomectomies are essential in judging the method of robot-assisted myomectomy.

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References [1] [2]

[3] [4]

[5] [6]

[7] [8] [9]

Parker WH, Einarsson J, Istre O, et al. Risk factors for uterine rupture after laparoscopic myomectomy. J Minim Invasive Gynecol 2010, 17, 551–4. Advincula AP, Xu X, Goudeau S, et al. Robot-assisted laparoscopic myomectomy versus abdominal myomectomy: A comparison of short-term surgical outcomes and immediate costs. J Minim Invasive Gynecol 2007, 14, 698–705. Barakat EE, Bedaiwy MA, Zimberg S, et al. Robotic-assisted, laparoscopic, and abdominal myomectomy: a comparison of surgical outcomes. Obstet Gynecol 2011, 117(2 Pt 1), 256–65. Nezhat C, Lavie O, Hsu S, et al. Robotic-assisted laparoscopic myomectomy compared with standard laparoscopic myomectomy – a retrospective matched control study. Fertil Steril 2009, 91, 556–9. Bedient CE, Magrina JF, Noble BN, et al. Comparison of robotic and laparoscopic myomectomy. Am J Obstet Gynecol 2009, 201, 566.e1–5. Nash K, Feinglass J, Zei C, et al. Robotic-assisted laparoscopic myomectomy versus abdominal myomectomy: a comparative analysis of surgical outcomes and costs. Arch Gynecol Obstet 2012, 285, 435–40. Loennerfors C, Persson J. Pregnancy following robot-assisted laparoscopic myomectomy in women with deep intramural myomas. Acta Obstet Gynecol Scan 2011, 90, 972–7. Pitter MC, Gargiulo AR, Bonaventura LM, et al. Pregnancy outcomes following robot-assisted myomectomy. Human Reproduction 2013, 28(1), 99–108. Di Liberto A, Ulbricht M, Dukic A, et al. Clinical features of robot-assisted laparoscopic complex myomectomy: techniques, indications and perioperative outcomes of 50 cases of single institute. 3rd European symposium on Robotic Gynecological Surgery, Leuven, Sep 2011.

Further reading ACOG Technology Assessment in Obstetrics and Gynecology No. 6. American College of Obstetricians and Gynecologists. Robot-assisted surgery. Obstet Gynecol 2009, 114, 1153–5. Advincula AP, Song A, Burke W, et al. Preliminary experience with robot-assisted laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 2004, 11, 511–8. Agdi M, Tulandi T. Minimally invasive approach for myomectomy. Sem Reprod Med 2010, 28(3), 228–34. Ascher-Walsh CJ, Capes TL. Robot-assisted laparoscopic myomectomy is an improvement over laparotomy in women with a limited number of myomas. J Minim Invasive Gynecol 2010, 17, 306–10. Behera MA, Likes CE, Judd JP, et al. Cost analysis of abdominal, laparoscopic, and robotic-assisted myomectomies. J Minim Invasive Gynecol 2012, 19, 52–7. Crosignani PG, Vercellini P, Meschia M, et al. GnRH agonists before surgery for uterine leiomyomas. A review. J Reprod Med 1996, 41(6), 415–21. Donnez J, Tatarchuk TF, Bouchard P, et al. Ulipristal acetate versus placebo for fibroid treatment before surgery. N Engl J Med 2012, 336, 409–20. Donnez J, Tomaszewski J, Vázquez F, et al. Ulipristal acetate for uterine fibroids. N Engl J Med 2012, 366, 421–32. Dubuisson JB, Fauconnier A, Deffarges JV, et al. Pregnancy outcome and deliveries following laparoscopic myomectomy. Hum Reprod 2000, 15, 869–73.

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Dubuisson JB, Lecuru F, Foulot H, et al. Gonadotropin-releasing hormone agonist and laparoscopic myomectomy. Clin Ther 1992, 14 Suppl A, 51–6. Ertan AK, Ulbricht M, Huebner K, et al. 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. J Turkish-German Gynecol Assoc 2011, 12, 97–103. George A, Eisenstein D, Wegienka G. Analysis of the impact of body mass index on the surgical outcomes after robot-assisted laparoscopic myomectomy. J Minim Invasive Gynecol 2009, 16, 730–3. Goecmen A, Sanlikan F, Ucar MG. Comparison of robotic-assisted laparoscopic myomectomy outcomes with laparoscopic myomectomy. Arch Gynecol Obstet. 2013 Jan, 287(1), 91–6. Holloway RW, Patel SD, Ahmad S. Robotic surgery in gynecology. Scand J Surg 2009, 98, 96–109. Jasonni VM, D’Anna R, Mancuso A, et al. Randomized double-blind study evaluating the efficac on uterine fibroids shrinkage and on intra-operative blood loss of different length of leuprolide acetate depot treatment before myomectomy. Acta Obstet Gynecol Scand 2001, 80, 956–8. Jin C, Hu Y, Chen XC, et al. Laparoscopic versus open myomectomy—a meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol 2009, 145, 14–21. Korell M. Methoden der adhäsionsprophylaxe – pro und kontra. J Gynaekol Endokrinol 2010, 20(2), 6–13. Kumakiri J, Tekeuchi H, Kitade M, et al. Pregnancy and delivery after laparoscopic myomectomy. J Minim Invasive Gynecol 2005, 12, 241–6. Kumakiri J, Kikuchi I, Kitade M, et al. Association between uterine repair at laparoscopic myomectomy and postoperative adhesions. Act Obstet Gynecol Scand 2012, 91, 331–7. Landi S, Fiaccavento A, Zaccoletti R, et al. Pregnancy outcomes and deliveries after laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 2003, 10, 177–81. Liu H, Lu D, Wang L, et al. Robotic surgery for benign gynaecological disease. Cochrane Database Syst Rev 2012 Feb 15;2:CD008978. Loennerfors C, Persson J. Robot-assisted laparoscopic myomectomy; a feasible technique for removal of unfavorably localized myomas. Acta Obstet Gynecol Scand 2009, 88, 994–9. Malzoni M, Tinelli R, Cosentino F, et al. Laparoscopic versus minilaparotomy in women with symptomatic uterine myomas: short-term and fertility results. Fertil Steril 2010, 93, 2368–73. Mansour FW, Kives S, Urbach DR, et al. Robotically assisted laparoscopic myomectomy: a Canadian experience. J Obstet Gynaecol Can 2012, 34(4), 353–8. Mao SP, Lai HC, Chang FW, et al. Laparoscopy-assisted robotic myomectomy using the da Vinci system. Taiwan J Obstet Gynecol 2007, 46(2), 174–6. Parker W. Uterine myomas: management. Fertil Steril 2007, 88, 255–71. Quaas AM, Einarsson JI, Srouji S, et al. Robotic myomectomy: a review of indications and techniques. Rev Obstet Gynecol 2010, 3(4), 185–91. Reza M, Maeso S, Blasco JA, et al. Meta-analysis of observational studies on the safety and effectiveness of robotic gynaecological surgery. Br J Surg 2010, 97, 1772–83. Senapati SS, Advincula AP. Surgical techniques: robot-assisted laparoscopic myomectomy with the da Vinciw surgical system. J Robotic Surg 2007, 1, 69–74. Sinha R, Hegde A, Mahajan C, et al. Laparoscopic myomectomy: do size, number, and location of the myomas form limiting factors for laparoscopic myomectomy? J Minim Invasive Gynecol 2008, 15, 292–300. Tan SJ, Lin CK, Fu PT, et al. Robotic surgery in complicated gynecologic diseases: Experience of Tri-Service General Hospital in Taiwan. Taiwanese J Obstet Gynecol 2012, 51, 18–25. Tinelli A, Malvasi A, Gustapane S, et al. Robotic Assisted Surgery in Gynecology: Current Insights and Future Perspectives. Recent Patents Biotechnol 2011, 5, 12–24.

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Visco AG, Advincula AP. Robotic gynecologic surgery. Obstet Gynecol 2008; 112:1369–84. Walid S, Heaton RL. The role of laparoscopic myomectomy in the management of uterine fibroids. Curr Opin Obstet Gynecol 2011, 23, 273–7. Walters L, Eley S. Robotic-assisted surgery and the need for standardized pathways and clinical guidelines. AORN J 2011, 93, 455–63. Zullo F, Pellicano M, De Stefano R, et al. A prospective randomized study to evaluate leuprolide acetate treatment before laparoscopic myomectomy: efficacy and ultrasonographic predictors. Am J Obstet Gynecol 1998, 178(1), 108–12.

12 Endometriosis: robotic-assisted laparoscopic surgical approaches Chandhana Paka and Camran Nezhat 12.1 Introduction The robotic platform entered the surgical playing field more than 20 years ago, and the introduction of the commercially available da Vinci® robotic system (Intuitive Surgical Inc, Sunnyvale, CA, USA) in the early 2000s was followed by a rapid application of this computer-assisted technology. Advocates of this platform revere the system’s ergonomic positioning, three-dimensional surgical view allowing for depth perception, wristed instrumentation, motion scaling and 7° of freedom mimicking open surgery [1, 2]. Furthermore, it boasts a shorter learning curve, thus enabling surgeons to complete complex surgical procedures formerly performed by laparotomy [3–7]. However, this technology is not without limitations, including lack of haptic feedback requiring the surgeon to utilize visual cues, limited instruments and higher costs [8]. Despite these limitations, robot-assisted laparoscopy has made surgeries, which are challenging via traditional laparoscopy, more easily performed in a minimally-invasive way [7, 9]. This platform is a reliable and durable way to be precise in surgical dissection and reconstruction, enabling surgeons to bridge the gap between laparotomy and laparoscopy [10, 11].

12.2 Application to endometriosis Endometriosis is an estrogen-dependent chronic inflammatory condition affecting 6 to 10% of reproductive-aged women [12, 13]. It is the leading cause of pain and infertility in women [14]. Endometriosis is characterized by the presence of endometriallike tissue outside the uterine cavity. Three clinically distinct forms exist: peritoneal endometriosis, ovarian endometriosis and extragenital endometriosis [13, 15]. Although endometriosis was described as early as 1690 by Shroen, a German physician, [16, 17] and a year later, Ruysch, a Dutch anatomist, proposed an early version of retrograde menstruation, [16, 17] its pathogenesis remains elusive. The progress of this clinical enigma can be moderated by the use of hormonal therapy. Medical management, used to suppress symptoms, includes non-steroidal anti-inflammatory drugs, oral contraceptives, antigestogens and GnRH agonists. However, this intervention is not desired in those seeking fertility, and the rate of recurrence is high after discontinuation [18–22]. Laparoscopy is the gold standard for definitive diagnosis and surgical treatment of endometriosis. Numerous studies support the use of laparoscopy in order to ameliorate pain and enhance fertility [23–27]. Laparoscopy offers many advantages over conventional laparotomy; namely a

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magnified view of the pelvis and greater exposure that allows for close examination and visualization of endometriotic implants. Larger implants or deep endometriotic nodules are best treated with resection. Surgical excision of all endometriosis has been proven to be the most effective method for symptom relief and prevention of recurrence [24, 28, 29]. Advanced laparoscopic techniques have replaced laparotomy as the mode of choice [24, 30, 31]. However, severe cases of endometriosis are difficult and can pose a surgical challenge, resulting in either incomplete treatment via laparoscopy or the need for conversion into a laparotomy. During a surgery for endometriosis, after initial evaluation of the abdomen and pelvis with a laparoscope, more complex and challenging cases may lend themselves to the robotic platform, facilitating the continued use of a minimally-invasive route of treatment without compromise.

12.3 Surgical approach Surgical intervention of endometriosis has evolved from indiscriminate use of hysterectomy and bilateral salpingo-oophorectomy to more precise and directed excision of all endometriotic implants and restoration of normal anatomy. For application of the robotic platform to the treatment of endometriosis steps are taken to maximize treatment potential with use of both laparoscopy and the robot to effectively address all aspects of endometriosis. Initially, the surgeon explores the pelvic cavity to assess the extent of disease and identify abnormalities or distortions of the pelvic organs. The location and boundaries of the bladder, ureter, colon, rectum, pelvic gutters, uterosacral ligaments and major blood vessels are noted. The upper abdominal organs, abdominal walls, liver and diaphragm should be evaluated for endometriosis or any other condition that may contribute to the patient’s symptoms. The omentum and the small bowel are evaluated for disease and to ensure that they were not injured during insertion of the Veress needle or trocar. A rectovaginal examination is performed to evaluate deep and retroperitoneal endometriosis found in the lower pelvis in the rectovaginal septum, uterosacral ligament, descending colon and pararectal area. Deep retroperitoneal endometriosis is rare without a connection to the surface peritoneum. In 15% of patients with endometriosis, the appendix is involved and thus should be examined [32]. With the forceps or probe, endometriotic implants are examined to gauge size, depth and proximity to normal pelvic structures. A surgical plan is constructed to optimally restore normal anatomy and excise all areas of endometriosis. The robot currently has limited instrumentation for surgical stapling or sealing and cutting. Additionally, many general laparoscopic procedures require movement in many quadrants around the abdomen, which can also be difficult for the robot. Once the initial survey is complete, the robot is docked using only three arms. The assist port, which is either suprapubic or left upper quadrant, allows the bedside assist to aid with retraction or with a suction-irrigator as needed. It is important to

12.4 Lysis of adhesions  

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remember that robotic surgeons need to evolve their procedures because a standard robotic approach does not yet exist [33]. Therefore traditional laparoscopic techniques are applied to robotic surgery. Limited instrumentation is available in the robotic platform that include; cautery hook, scissors and bipolar coagulation. All of which allow for cauterization and resection of endometriotic implants [8]. We tend to use an atraumatic grasping forceps in the left robotic arm and either a monopolar hook or cold scissors in the right robotic arm.

12.4 Lysis of adhesions Adhesions vary in bulk, vascularity and extent of resultant anatomic distortion. The methods used to restore normal anatomy and remove adhesions are determined by type of adhesions encountered. Filmy adhesions can be separated by blunt dissection. While more dense adhesions require electrosurgery at points of attachment to pelvic organs. This can be accomplished by use of the monopolar hook and the atraumatic grasping forceps. Structures requiring separation are teased apart via a cleavage plane. Hydrodissection is useful to help create such planes. A safe area is sought, a small incision is made with a scissors or electrocautery and the suction-irrigator is brought into the surgical field from the assist port. Care must be taken with electrosurgery near the bowel, bladder and vessels. If concern exists as to proximity to such organs or thermal spread, then the cold scissors is employed.

12.5 Peritoneal and tubo-ovarian endometriosis As mentioned previously, the main goal of surgical intervention in endometriosis is restoration of anatomy and removal of all endometriotic implants, with the hope of alleviating pain and in some cases improving fertility. Peritoneal implants can be ablated or excised, depending on surgeon preference. Evidence does not show superiority in pain relief when comparing excision versus ablation [34, 35]. When excision of implants is the technique employed, the atraumatic forceps is used to elevate and tent the peritoneum towards the midline. The monopolar hook or the cold scissors is then used to undermine and shave away the endometriotic implant. This is done in a progressive manner until the implant is excised with visually clear margins, and the underlying tissue appears healthy and not fibrotic. The decision of whether to use the energy is based on proximity to bowel, ureters and vessels. If the implant appears superficial and relatively small, the monopolar hook can be applied directly to the implant. For ovarian pathology, namely for endometriomas, it has been well established that recurrence is less likely with complete excision versus drainage and ablation [36–38]. Further caution is also taken with the use of energy on the ovary, as there is potential

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for damage to normal surrounding ovarian tissue, though this is also possible with excision alone [39]. Ideally, removal of an ovarian cyst involves removal of an intact cyst wall with limited trauma to normal ovarian tissue. However, endometriomas can be difficult to remove, and many cysts are ruptured even with delicate manipulation. If necessary, controlled drainage of the cyst can be performed with a small incision made into the ovary with a cold scissors or a puncture with the monopolar hook. This incision should be made large enough to then allow for the suctionirrigator to aspirate and irrigate the contents. The suction-irrigator is brought to the level of the cyst by the bedside assist via the assist port. Once the cyst is irrigated, the incision is made larger with the aid of scissors to allow for examination of the internal surface. The cyst wall and the ovarian cortex are then identified. If there is need for further delineation of planes, hydrodissection can occur with the assistance of the bedside assist. Once this is accomplished, the cyst wall is grasped with the nontraumatic forceps and the cortex is stabilized with the scissors. With the use of traction and countertraction, the cyst wall is stripped away from the ovarian cortex. If the cyst wall does not come away easily, the scissors can be used to dissect the cyst away from the ovary. Hemostasis is then obtained with the use of either monopolar or bipolar energy. Additionally, as the robotic platform makes suturing easier, bleeding can be controlled with suture. A needle driver is placed in the surgeon’s dominant hand, and the needle is brought into the operating field via the assist port.

12.6 Intestinal endometriosis The gastrointestinal tract is involved in endometriosis in up to 37% of patients with pelvic endometriosis [40, 41]. However, in specialized practices, this may be an underestimate. Endometriotic implants can be found anywhere between the small intestine to the anal canal, and the clinical manifestations can range from asymptomatic lesions to obstruction [42]. The most frequently involved site for endometriosis is the rectosigmoid, accounting for 70–88% of all cases. This is followed by the sigmoid colon, rectum, appendix and cecum [15, 32, 43, 44]. Surgical intervention of intestinal endometriosis remains debatable [45]. In the absence of bowel obstruction or other emergent presentation, the optimal timing of surgery and extent of intervention has not been determined. Various minimallyinvasive surgical (MIS) techniques are currently available for treatment. Determining which approach to use is based on the extent, location and expertise of the surgical team. Less invasive approaches, as long as there is complete excision and adequate margins, are often the preferable option [46]. The use of the robotic platform has allowed for difficult surgical procedures to be attempted in a minimally-invasive approach. As diathermy excision should be used with caution as thermal damage to the bowel may result in a delayed postoperative fistula or other complications, it is used sparingly [45].

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Use of hydrodissection can help delineate planes, thus allowing for less damage to underlying normal tissue. Superficial endometriotic implants can be shaved off the rectal wall, while maintaining the integrity of the mucosa [47]. The rectum is first mobilized by freeing the anterior and the lateral aspects of peritoneal attachments. This allows for access to the extraperitoneal rectovaginal septum. With the use of the atraumatic grasping forceps and the cold scissors, the implant is dissected off the anterior rectal wall, separating it from the posterior vaginal wall. Care is taken to maintain bowel integrity, and therefore the dissection is kept superficial. If the dissection requires deeper resection in order to remove the implant in its entirety, then the defect is reinforced with the use of sutures in order to prevent postoperative bowel perforation [48]. Upon completion, to ensure integrity, a proctoscopy should be performed [49–51]. For endometriotic implants that are deeper, a full thickness excision may be required. As before, the rectum must be mobilized. The excision can be performed using the electrocautery hook or an instrument like the PlasmaJet that is brought into the field via the bedside assist. The bowel is then repaired with suture. The repair is made in a transverse plane so as to prevent narrowing and potential stricture formation of the lumen [48, 51]. In a procedure performed for endometriosis the appendix must be carefully assessed. It can be involved up to 22% of cases. The appendix can be easily assessed and resected. The periappendiceal fat can be dessicated with thermal energy, ensuring that the appendiceal artery is ligated. The resection of the appendix can be easily performed then using endoloop device or by undocking the robot and using a endoscopic linear stapling device brought in from the umbilical port. Our practice has been to resect the appendix early in the surgical procedure so as to then be able to evaluate it again at the completion of the procedure [32, 52]. Because the sigmoid colon is the most commonly involved segment of the bowel, it is more likely to be extensively involved and thus require a resection. A laparoscopically assisted resection of the involved segment with primary colorectal anastomosis is the procedure of choice. However, due to technical difficulty, the application of the laparoscopic approach has been slow. With the aid of the robot, this technically challenging approach can be attempted. The patient must be positioned in steep Trendelenburg position with a right tilt to allow for optimal visualization of the attachments of the mesosigmoid colon to the retroperitoneum. The medial aspect of the peritoneum overlying the mesosigmoid is opened up from the sacral promontory up to the origin of the left colic artery. This dissection can be done more precisely with the use of the robotic platform. During this process, care should be taken to avoid injury to the ureter and gonadal vessels. The superior rectal artery is divided proximal to the sigmoidal artery. This is secured with hemostatic clips, a thermal energy device or a vascular stapler. These instruments are brought in via the accessory port as needed. For such cases, the accessory port must be in the upper quadrant to allow for appropriate triangulation. The descending colon is then mobilized up to the splenic flexure

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to provide a tension-free anastomosis. The robot is undocked because no commercially available stapling device is available. The mesorectum is divided at the desired level and the rectosigmoid junction is transected using a laparoscopic linear stapling device through a 12-mm port. A specimen is extracted via extension of an incision or via the vaginal cuff if a hysterectomy is being performed. The anvil of the circular stapling device is secured with a purse-string suture extracorporeally at the proximal open end of the bowel. Subsequently, a transanal circular stapling device is used to perform the anastomosis. An air leak test and sigmoidoscopy used to ensure an intact anastomosis. If there is any evidence of a leak, a reanastomosis versus additional sutures must be made. Additionally, it is vital to ensure that both ends of the bowel are vascularized, and the anastomosis is tension-free [51, 53]. The approach is similar for a low anterior resection as with a sigmoidectomy. However, this procedure requires that the pelvic peritoneum is opened, the lateral ligaments ligated and the anastomosis to occur below these. The rectum is thus mobilized far inferiorly as to allow for complete resection of diseased tissue. When mobilization occurs distal to the levator ani, dissection is carried out in the avascular planes of the rectum and mesorectum. This can be done easily with the aid of the robotic platform. Once the dissection is complete, the robot is undocked so that the rectum can be transected transversely with an articulating linear stapler [51, 54]. When the ascending colon or the small bowel is involved, mobilization of the small bowel mesentery and attachments of the right colon must be addressed. This mobilization occurs from a medial to lateral fashion retroperitoneally in both blunt and sharp fashion using the atraumatic grasping forceps and the cold scissors. With the use of the robot, the surgeon is enabled more precise dissection. The robot is once again undocked for creation of a side-to-side functional end-to-end stapled anastomosis with an endo-linear stapling device [51].

12.7 Genitourinary endometriosis Pelvic endometriosis can infrequently involve the urinary tract system in approximately 1% of cases [55]. The bladder is the most commonly involved and the urethra the least. Bladder endometriosis can be intrinsic or extrinsic. Intrinsic disease involves the detrusor muscle and is commonly associated with iatrogenic implantation [56, 57]. Extrinsic disease, which is more common, refers to disease involving the serosa or peritoneal surface [58]. Treatment of bladder endometriosis is aimed at symptomatic relief, as often it does not involve the ureteral openings. Medical management is effective, but often disease recurs with discontinuation of continuous oral contraceptive pills or GnRH agonists [59, 60]. The surgical intervention that appears to allow for complete removal of disease is a combination approach of cystoscopy and laparoscopy [61–64]. Intrinsic bladder disease is transmural and thus complete

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transurethral resection may lead to perforation of the bladder. Therefore the use of the laparoscope can aid in visualization, as well as repair. In this combined approach a partial bladder cystectomy should be considered the treatment of choice for bladder lesions and surrounding disease and inflammation [58]. The surgical technique for such cases all start with a cystoscopy at start of procedure, during which time bilateral ureteral stents are placed. This allows for easy recognition of the ureteral orifices, as well as easier identification in the pelvis. This also allows for a surgical plan to be mapped out. In some instances, a total transurethral approach can be performed. However, for intrinsic disease the risk of perforation during procedure or incomplete excision warrants simultaneous visualization from above [58, 65]. Once the examination from above is complete, the robot is brought in via side docking or parallel docking to allow for easier access to the perineal area. A atraumatic grasping forceps is placed in the left robotic arm and the monopolar scissors in the right. The bladder is identified and careful dissection is carried out to separate the uterus and cervix away [66]. Once this is accomplished, a cystoscopy is performed. In this way, the bladder cystotomy can be performed under visualization, allowing for visually clear margins and assurance of integrity of the ureteral orifices. The cystoscope is then withdrawn and the defect is repaired intracorporeally. A watertight seal is confirmed with the cystoscope. Ureteral endometriosis is a serious localization of disease burden. Asymmetric involvement of endometriosis, with the left pelvis more commonly involved than the right, is readily explained by anatomic differences of the pelvis [67]. The distal segment of the ureters and bladder are the more frequently involved locations, due to the proximity of the reproductive organs [68]. Additionally, ureteral endometriosis is more likely to be associated with rectosigmoid lesions as opposed to bladder involvement [69]. Two major pathological types exist: extrinsic and intrinsic ureteral endometriosis. In the extrinsic type, which is the most common, endometrial glandular and stromal tissue involve only the adventitia of the ureter or surrounding connective tissues. The intrinsic type involves the muscularis propria, lamina propria or ureteral lumen [70]. Surgical interventions for relief of obstructive uropathy include: ureterolysis, ureteroureterostomy, distal ureterectomy and ureteral reimplantation or interposition of ileal segment between the ureter and bladder [58, 60]. Nephroureterectomy is a successful treatment alternative in refractory cases. Additionally, this is performed if there are recurrent urinary tract infections or persistent flank pain. The robotic platform is ideal for the careful dissection and potential suturing that is required for ureteral manipulation and implantation. All surgical approaches begin with identification of the ureter. Ureterolysis is carried out starting proximal to diseased area, at a level of healthy tissue, unaffected by endometriosis. Careful dissection proceeds down to the level of damage. This is done using the atraumatic graspers and scissors. Care should be taken with use of thermal energy near the ureter. Techniques such as hydrodissection with the the suction-irrigator brought in from the assist port by the bedside assist greatly facilliates. Based on the extent and localization of disease, the decision is made whether ureterolysis will be adequate to relieve obstruction.

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Ureterolysis is often acceptable in cases of extrinsic, nonobstructive disease [58, 60, 71–73]. If stenosis is evident but limited to the ovarian fossa and distal ureter can be preserved, then ureteral resection and end-to-end anastomosis can be performed over a ureteral stent [58, 60, 64, 73–75]. Surgical approach is changed if the ureteral stenosis is close to the vesicoureteral junction and is extensive. The ureter is resected before the area of disease, and the proximal end is reimplanted into the bladder [58, 60, 71, 73, 76, 77].

12.8 Diaphragmatic and thoracic endometriosis Thoracic endometriosis is a rare disorder characterized by the presence of functioning endometrial tissue in pleura, lung parenchyma, airways, and/or diaphragm. The diagnosis of thoracic endometriosis syndrome (TES) has improved substantially over the past two decades because of advances in video endoscopic techniques as developed by Nezhat [78, 79] [video-assisted thoracoscopic surgery (VATS) as well as laparoscopy] a higher level of clinical suspicion. VATS is currently the gold standard for the surgical treatment of TES, especially catamenial pneumothorax. Laparoscopy aids in the surgical treatment of implants on the abdominal aspect of the diaphragm. VATS provides magnification and exposure of possible defects that are sometimes better than that provided by thoracotomy. Misdiagnosis may occur, especially if the patient is positioned for an axillary thoracotomy, as complete visualization of diaphragm is difficult. A better approach seems to be a VATS with the patient positioned for a postero-lateral thoracotomy. When endometriotic implants are the sole findings during VATS and are superficial, they can be carefully fulgurated using bipolar diathermy or CO2 laser, regardless of their location (i.e., parietal, visceral, or diaphragmatic pleura). Larger endometriotic implants of the visceral pleura may be excised using sharp dissection [80]. Nonetheless, large lesions or deep parenchymal endometriotic nodules are best treated with parenchymalsparing procedures such as wedge resection [81] or subsegmentectomy [82]. Occasionally, lobectomy may be required [83]. Diaphragmatic lesions (endometriotic implants or perforations) are probably best treated by resection using endoscopic stapler devices, provided that the resected surface is relatively small [81, 84]. Laparoscopic treatment of diagphragmatic endometriosis was first described Nezhat in 1992 [51]. Larger diaphragmatic perforations can be sutured, although significant recurrences have been reported with the use of sutures [85]. The use of mesh to replace large diaphragmatic excisions has been described in three women who at 45 months follow-up suffered no recurrences [86]. Although other authors have not confirmed these results [87]. Because the robot has limited mobility and movement in to the upper quadrants is limited, a thorough evaluation must be made at the initial survey of the abdomen prior to docking the robot.

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If the abdominal aspect of the diaphragm is involved with endometriotic implants, an experienced team of gynecologic and thoracic surgeons can fulgurate or excise small lesions. Hydrodissection, laser fulguration, or excision can be carried out successfully [88]. However, if larger implants or defects are present, they should be approached via VATS, as the liver bulk and limited subdiaphragmatic space may not allow complete resection [89]. A multidisciplinary approach of VATS and laparoscopy, optimally addressing pelvis, thoracic cavity and subdiaphragmatic region in a single operation and is gaining momentum [90]. Unfortunately, until the robotic platform is able to move freely in the upper abdomen, this aspect of endometrioisis surgery will remain with laparoscopy.

12.9 Hepatic endometriosis Hepatic endometriosis is exceedingly rare and poses a diagnostic challenge. It can present with right upper quadrant pain or be incidentally diagnosed. Nezhat et al published their experience with laparoscopic treatment of hepatic endometriosis in 2005 [91]. In a majority of cases that have been published, the patients had a history of pelvic endometriosis, but preoperative symptoms and clinical findings were inconsistent [92–102]. As preoperative diagnosis of hepatic endometriosis is if often difficult, laparoscopy offers an excellent opportunity to explore the upper abdomen compared to a laparotomy [103]. Regardless of indication for surgery, thorough inspection of the entire abdominal cavity should be undertaken. If an extra-hepatic lesion is noted, a biopsy is taken and sent for frozen section. If this confirms endometriosis, the cyst is stabilized with a grasping forceps and excised. Once it is removed entirely, the hemostasis is ensured with use of electrocautery or a hemostatic agent.

12.10 Conclusion The robotic platform has enabled and enhanced surgeons ability to perform MIS. Used appropriately, in trained hands, it may improves patient care. Areas of improvement presently being developed include systems with improved tactile feedback, multifunctioning instruments and robotic miniaturization. New instrumentation, such as robotically controlled stapling devices, will push the adoption even further. As with any new technology, time and experience will dictate how this platform will integrate into the surgical playing field.

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[23] Sutton CJ, Ewen SP, Whitelaw N, et al. Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertil Steril 1994, 62, 696–700. [24] Nezhat C, Crowgey SR, Garrison CP. Surgical treatment of endometriosis via laser laparoscopy. Fertil Steril 1986, 45, 778–83. [25] Abbott J, Hawe J, Hunter D, et al. Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. Fertil Steril 2004, 82, 878–84. [26] Jacobson TZ, Duffy JM, Barlow D, et al. Laparoscopic surgery for pelvic pain associated with endometriosis. Cochrane Database Syst Rev 2009, CD001300. [27] Marcoux S, Maheux R, Berube S. Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian Collaborative Group on Endometriosis. N Engl J Med 1997, 337, 217–22. [28] Nezhat C, Nezhat FR. Safe laser endoscopic excision or vaporization of peritoneal endometriosis. Fertil Steril 1989, 52, 149–51. [29] Sutton CJ, Pooley AS, Ewen SP, et al. Follow-up report on a randomized controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal to moderate endometriosis. Fertil Steril 1997, 68, 1070–4. [30] Kelley WE Jr. The evolution of laparoscopy and the revolution in surgery in the decade of the 1990s. Jsls 2008, 12, 351–7. [31] Nezhat C, Nezhat F. Operative laparoscopy (minimally invasive surgery): state of the art. J Gynecol Surg 1992, 8, 111–41. [32] Nezhat C, Nezhat F. Incidental appendectomy during videolaseroscopy. Am J Obstet Gynecol 1991, 165, 559–64. [33] Nezhat C, Saberi NS, Shahmohamady B, et al. Robotic-assisted laparoscopy in gynecological surgery. J Soc Laparendoscopic Surgeons 2006, 10, 317–20. [34] Healey M, Ang WC, Cheng C. Surgical treatment of endometriosis: a prospective randomized double-blinded trial comparing excision and ablation. Fertil Steril 2010, 94, 2536–40. [35] Wright J, Lotfallah H, Jones K, et al. A randomized trial of excision versus ablation for mild endometriosis. Fertil Steril 2005, 83, 1830–6. [36] Fayez JA, Vogel MF. Comparison of different treatment methods of endometriomas by laparoscopy. Obstet Gynecol 1991, 78, 660–5. [37] Beretta P, Franchi M, Ghezzi F, et al. Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation. Fertil Steril 1998, 70, 1176–80. [38] Saleh A, Tulandi T. Reoperation after laparoscopic treatment of ovarian endometriomas by excision and by fenestration. Fertil Steril 1999, 72, 322–4. [39] Busacca M, Vignali M. Endometrioma excision and ovarian reserve: a dangerous relation. J Minim Invasive Gynecol 2009, 16, 142–8. [40] Samper ER, Slagle GW, Hand AM. Colonic endometriosis: its clinical spectrum. South Med J 1984, 77, 912–4. [41] Williams TJ, Pratt JH. Endometriosis in 1,000 consecutive celiotomies: incidence and management. Am J Obstet Gynecol 1977, 129, 245–50. [42] Ponka JL, Brush BE, Hodgkinson CP. Colorectal endometriosis. Dis Colon Rectum 1973, 16, 490–9. [43] Yantiss RK, Clement PB, Young RH. Endometriosis of the intestinal tract: a study of 44 cases of a disease that may cause diverse challenges in clinical and pathologic evaluation. Am J Surg Pathol 2001, 25, 445–54. [44] Nezhat C, Datta MS, Defazio A, et al. Natural orifice-assisted laparoscopic appendectomy. Jsls 2009, 13, 14–8.

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[45] Remorgida V, Ferrero S, Fulcheri E, et al. Bowel endometriosis: presentation, diagnosis, and treatment. Obstet Gynecol Surv 2007, 62, 461–70. [46] Mohr C, Nezhat FR, Nezhat CH, et al. Fertility considerations in laparoscopic treatment of infiltrative bowel endometriosis. Jsls 2005, 9, 16–24. [47] Nezhat C, Nezhat F, Pennington E. Laparoscopic treatment of infiltrative rectosigmoid colon and rectovaginal septum endometriosis by the technique of videolaparoscopy and the CO2 laser. Br J Obstet Gynaecol 1992, 99, 664–7. [48] Nezhat C, Nezhat F, Pennington E, et al. Laparoscopic disk excision and primary repair of the anterior rectal wall for the treatment of full-thickness bowel endometriosis. Surg Endosc 1994, 8, 682–5. [49] Nezhat C, de Fazio A, Nicholson T. Intraoperative sigmoidoscopy in gynecologic surgery. J Minim Invasive Gynecol 2005, 12, 391–5. [50] Nezhat C, Seidman D, Nezhat F. The role of intraoperative proctosigmoidoscopy in laparoscopic pelvic surgery. J Am Assoc Gynecol Laparosc 2004, 11, 47–9. [51] Kopelman D, King L, Nezhat C. Laparoscopic management of intestinal endometriosis. In: Wetter PA, ed. Prevention & Management. 3 ed; 2011. Miami, FL, Society of Laparoendoscopic Surgeons. [52] Berker B, Lashay N, Davarpanah R, et al. Laparoscopic appendectomy in patients with endometriosis. J Minim Invasive Gynecol 2005, 12, 206–9. [53] Nezhat F, Nezhat C, Pennington E, et al. Laparoscopic segmental resection for infiltrating endometriosis of the rectosigmoid colon: a preliminary report. Surg Laparosc Endosc 1992, 2, 212–6. [54] Nezhat C, Pennington E, Nezhat F, et al. Laparoscopically assisted anterior rectal wall resection and reanastomosis for deeply infiltrating endometriosis. Surg Laparosc Endosc 1991, 1, 106–8. [55] Abeshouse BS, Abeshouse G. Endometriosis of the urinary tract: a review of the literature and a report of four cases of vesical endometriosis. J Internat Coll Surgeons 1960, 34, 43–63. [56] Ball TL, Platt MA. Urologic complications of endometriosis. Am J Obstet Gynecol 1962, 84, 1516–21. [57] Manuel E, Meyersfield S, Seery W, et al. Combined vesical and abdominal endometriosis following hysterotomy: a case report. J Urol 1977, 118, 332–3. [58] Comiter CV. Endometriosis of the urinary tract. Urol Clin North Am 2002, 29, 625–35. [59] Fedele L, Bianchi S, Montefusco S, et al. A gonadotropin-releasing hormone agonist versus a continuous oral contraceptive pill in the treatment of bladder endometriosis. Fertil Steril 2008, 90, 183–4. [60] Berlanda N, Vercellini P, Carmignani L, et al. Ureteral and vesical endometriosis. Two different clinical entities sharing the same pathogenesis. Obstet Gynecol Surv 2009, 64, 830–42. [61] Nezhat CH, Malik S, Osias J, et al. Laparoscopic management of 15 patients with infiltrating endometriosis of the bladder and a case of primary intravesical endometrioid adenosarcoma. Fertil Steril 2002, 78, 872–5. [62] Nezhat CR, Nezhat FR. Laparoscopic segmental bladder resection for endometriosis: a report of two cases. Obstet Gynecol 1993, 81, 882–4. [63] Makar AP, Wauters HA, van Dijck HH, et al. Vesical endometriosis: value of laparoscopy. Br J Urol 1993, 72, 115. [64] Antonelli A, Simeone C, Zani D, et al. Clinical aspects and surgical treatment of urinary tract endometriosis: our experience with 31 cases. Eur Urol 2006, 49, 1093–7, discussion 7–8. [65] Foster RS, Rink RC, Mulcahy JJ. Vesical endometriosis: medical or surgical treatment. Urology 1987, 29, 64–5.

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[66] Liu C, Perisic D, Samadi D, et al. Robotic-assisted laparoscopic partial bladder resection for the treatment of infiltrating endometriosis. J Minim Invasive Gynecol 2008, 15, 745–8. [67] Vercellini P, Pisacreta A, Pesole A, et al. Is ureteral endometriosis an asymmetric disease? Br J Obstet Gynaecol 2000, 107, 559–61. [68] Yohannes P. Ureteral endometriosis. J Urol 2003, 170, 20–5. [69] Abrao MS, Podgaec S, Dias JA Jr., et al. Endometriosis lesions that compromise the rectum deeper than the inner muscularis layer have more than 40% of the circumference of the rectum affected by the disease. J Minim Invasive Gynecol 2008, 15, 280–5. [70] Gehr TW, Sica DA. Case report and review of the literature: ureteral endometriosis. Am J Med Sci 1987, 294, 346–52. [71] Nezhat C, Nezhat F, Nezhat CH, et al. Urinary tract endometriosis treated by laparoscopy. Fertil Steril 1996, 66, 920–4. [72] Donnez J, Nisolle M, Squifflet J. Ureteral endometriosis: a complication of rectovaginal endometriotic (adenomyotic) nodules. Fertil Steril 2002, 77, 32–7. [73] Bosev D, Nicoll LM, Bhagan L, et al. Laparoscopic management of ureteral endometriosis: the Stanford University hospital experience with 96 consecutive cases. J Urol 2009, 182, 2748–52. [74] Nezhat C, Nezhat F, Green B. Laparoscopic treatment of obstructed ureter due to endometriosis by resection and ureteroureterostomy: a case report. J Urol 1992, 148, 865–8. [75] Seracchioli R, Mabrouk M, Manuzzi L, et al. Importance of retroperitoneal ureteric evaluation in cases of deep infiltrating endometriosis. J Minim Invasive Gynecol 2008, 15, 435–9. [76] Gran JT, Gaarder PI, Husby G, et al. IgG heavy chain (Gm) allotypes in rheumatoid arthritis and in healthy individuals seropositive for IgM-rheumatoid factor. Scand J Rheumatol 1985, 14, 144–8. [77] Perez-Utrilla Perez M, Aguilera Bazan A, Alonso Dorrego JM, et al. Urinary tract endometriosis: clinical, diagnostic, and therapeutic aspects. Urology 2009, 73, 47–51. [78] Kelley WE Jr. The evolution of laparoscopy and the revolution in surgery in the decade of the 1990s. J Soc Laparendoscopic Surgeons 2008, 12, 351–7. [79] Nezhat C CS, Garrison CP. Surgical treatment of endometriosis via laser laparoscopy. Fertil Steril 1986, 45, 778–83. [80] Hilaris GE, Payne CK, Osias J, et al. Synchronous rectovaginal, urinary bladder, and pulmonary endometriosis. J Soc Laparendoscopic Surgeons 2005, 9, 78–82. [81] Alifano M, Roth T, Broet SC, et al. Catamenial pneumothorax: a prospective study. Chest 2003, 124, 1004–8. [82] Terada Y, Chen F, Shoji T, et al. A case of endobronchial endometriosis treated by subsegmentectomy. Chest 1999, 115, 1475–8. [83] Kristianen K, Fjeld NB. Pulmonary endometriosis causing haemoptysis. Report of a case treated with lobectomy. Scand J Thorac Cardiovasc Surg 1993, 27, 113–5. [84] Alifano M, Cancellieri A, Fornelli A, et al. Endometriosis-related pneumothorax: clinicopathologic observations from a newly diagnosed case. J Thorac Cardiovasc Surg 2004, 127, 1219–21. [85] Fonseca P. Catamenial pneumothorax: a multifactorial etiology. J Thorac Cardiovasc Surg 1998, 116, 872–3. [86] Bagan P, Le Pimpec Barthes F, Assouad J, et al. Catamenial pneumothorax: retrospective study of surgical treatment. Ann Thorac Surg 2003, 75, 378–81; discusssion 81. [87] Sakamoto K, Ohmori T, Takei H. Catamenial pneumothorax caused by endometriosis in the visceral pleura. Ann Thorac Surg 2003, 76, 290–1. [88] Nezhat C, Seidman DS, Nezhat F. Laparoscopic surgical management of diaphragmatic endometriosis. Fertil Steril 1998, 69, 1048–55.

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[89] Redwine DB. Diaphragmatic endometriosis: diagnosis, surgical management, and long-term results of treatment. Fertil Steril 2002, 77, 288–96. [90] Nezhat C, Nicoll LM, Bhagan L, et al. Endometriosis of the diaphragm: four cases treated with a combination of laparoscopy and thoracoscopy. J Minim Invasive Gynecol 2009, 16, 573–80. [91] Nezhat C, Kazerooni T, Berker B, et al. Laparoscopic management of hepatic endometriosis: report of two cases and review of the literature. J Minim Invasive Gynecol 2005, 12, 196–200. [92] Finkel L, Marchevsky A, Cohen B. Endometrial cyst of the liver. Am J Gastroenterol 1986, 81, 576–8. [93] Rovati V, Faleschini E, Vercellini P, et al. Endometrioma of the liver. Am J Obstet Gynecol 1990, 163, 1490–2. [94] Cravello L, D’Ercole C, Le Treut YP, et al. Hepatic endometriosis: a case report. Fertil Steril 1996, 66, 657–9. [95] Verbeke C, Harle M, Sturm J. Cystic endometriosis of the upper abdominal organs. Report on three cases and review of the literature. Pathol Res Pract 1996, 192, 300–4, discussion 5. [96] Chung CC, Liew CT, Hewitt PM, et al. Endometriosis of the liver. Surgery 1998, 123, 106–8. [97] Inal M, Bicakci K, Soyupak S, et al. Hepatic endometrioma: a case report and review of the literature. Eur Radiol 2000, 10, 431–4. [98] Bohra AK, Diamond T. Endometrioma of the liver. Int J Clin Pract 2001, 55, 286–7. [99] Huang WT, Chen WJ, Chen CL, et al. Endometrial cyst of the liver: a case report and review of the literature. J Clin Pathol 2002, 55, 715–7. [100] Goldsmith PJ, Ahmad N, Dasgupta D, et al. Case hepatic endometriosis: a continuing diagnostic dilemma. HPB Surg 2009, 2009, 407206. [101] Schuld J, Justinger C, Wagner M, et al. Bronchobiliary fistula: a rare complication of hepatic endometriosis. Fertil Steril 2011, 95, 804, e15–8. [102] Roesch-Dietlen F, Jimenez-Garcia A, Perez-Morales A, et al. Hepatic endometriosis. Ann Hepatol 2011, 10, 347–8. [103] Nezhat F, Nezhat C, Levy JS. Laparoscopic treatment of symptomatic diaphragmatic endometriosis: a case report. Fertil Steril 1992, 58, 614–6.

13 Robotic-assisted tubal reanastomosis  Ahmet Göçmen and Fatih Şanlıkan 13.1 Introduction The most widely used contraceptive method in the world is currently tubal ligation and more than 153 million women of reproductive age have chosen sterilization as their contraceptive method [1, 2]. As of June 2010, a recent decline of tubal ligation procedures in the United States after two decades of stable rates was observed due to an improved access to a wide range of highly effective reversible contraceptives [3]. A change in family circumstances such as the death of a child, improved economic situation, a change in marital status and desire of having more children are the reasons for request of fertility restoration and 1%–5% of the patients will request sterilization reversal [4]. The women who are sterilized at a younger age have a universal risk indicator for tubal reversal due to longer period in which women can become regretful. It has been estimated that women sterilized before age 25 years are 18 times more likely to request reversal over the course of follow-up than women older than 30 years at the time of sterilization [5]. Tubal reversal and in vitro fertilization (IVF) are the options for the patients who desire fertility after tubal ligation. Tubal reversal, also called tubal sterilization reversal or tubal ligation reversal, is a surgical procedure that attempts to restore fertility to women after a tubal ligation. The advantages of the successful surgical reanastomosis are the possibility of natural conception and chance of multiple singleton pregnancies. However, especially for older age women, the time to conception might be long. When considering the IVF option, a relatively short time to conception might be achieved, but the cost, risk of multiple pregnancies, ovarian hyperstimulation syndrome and the need for repeating the procedure for desired pregnancy are the disadvantages of IVF. Costs and reimbursement policies for each method may differ between countries. The results of tubal reversal were improved dramatically with the introduction of microsurgical techniques. With this technique, reported pregnancy rates vary between 57% and 84% with a risk for ectopic pregnancy of 2%–7% [6–8]. Microsurgical tubal reversal techniques include laparotomy, laparoscopy and recently roboticassisted reanastomosis. The well-established advantages of laparoscopy over laparotomy include reduced postoperative discomfort and morbidity, more rapid return to activity and improved cosmesis. Laparoscopic tubal reversal is a difficult procedure technically. Two-dimensional visualization, limited degrees of instrument motion within the body as well as ergonomic difficulty and tremor amplification are the limitations of laparoscopic surgery. In addition to these technical problems, long period of operating time, long learning curve for the surgeon, inability to perform surgery

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in some circumstances such as the presence of firm adhesions still remain as obstacles to surgeons. To overcome such technical difficulties, the application of robotics to surgical technology was introduced in the late 1990s. Robotic surgery is a step forward in the field of minimally-invasive surgery (MIS). The limitations of traditional laparoscopy can be eliminated mostly by this new technology. Advantages of robotic surgery over laparoscopy include obtaining three-dimensional (3D) images, enabling direct visualization by eye-hand axes, increased number of basic hand movements of laparoscopic devices, ease of left-hand usage, easier suturing, easier tying, elimination of hand tremor, being less exhausting for the surgeon, shorter learning time, less need for transition to laparotomy, enabling performance of more complex procedures, and shorter operation duration [9]. The world’s first robotically-assisted laparoscopic surgery was performed in June of 1998 by Falcone et al [10].

13.2 Surgical technique The surgical technique needs total excision of the occluded portions, proper alignment and precise apposition of each layer of the proximal and distal tubal segments. The type of anastomosis is usually described by its site and the diameter of the tube, i.e.: 1. Ampullary-ampullary (same size) 2. Ampullary-isthmic (different sizes) 3. Isthmic-isthmic (same size) 4. Isthmic-cornual

13.2.1 Positioning of the robotic surgical system The operation is performed under general anesthesia. Dorsal lithotomy position in the Trendelenburg position is usually used as the patient positioning. To provide the access the uterine cavity for manipulation of the uterus and for choromopertubation, a variety of manipulators can be used. For the robotic tubal reversal, a 4-trocar transperitoneal approach is used. The abdominal cavity is insufflated with carbon dioxide via a Verres needle or direct trocar entrance. A 12-mm blunt-tip disposable trocar is introduced to abdomen for the robotic camera. Before the docking procedure, examination of the status of the fallopian tubes is recommended to assess the feasibility of the anastomosis. In some circumstances, the patient may have previous total or partial salpingectomy for tubal ligation or the tubal damage may be irreversible for reversal procedure. If the status of the ligated tubes is feasible for the reversal, the 8-mm left robotic instrument port was inserted 8–10 cm lateral to camera port at midclavicular line and 2–3 cm below the umbilicus. The right robotic instrument port point is symmetrically contra lateral side of the left robotic port. A 5-mm trocar for assistance is

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positioned in the area between the camera and either the left or the right robotic arm port. Alternatively, the accessory trocar can be placed in the left or right lower quadrant. After port placement, the patient is placed in a steep Trendelenburg position to aid in visualization and bowel mobilization away from the surgical field. The da Vinci® surgical system (Intuitive Surgical Inc, Sunnyvale, CA, USA) is docked either at the foot of the patients in center or side. Side docking provides an easy access to the vagina and the manipulation or choromopertubation can be easily made than the central docking. EndoWrist instruments were introduced through trocars.

13.2.2 Robotic-assisted tubal reversal procedure Microsurgical techniques and principles of gentle tissue handling should be applied during surgery. Precise dissection and accurate approximation of the different layers of the proximal and distal tubal segments are crucial for the technique. The operative technique of the robotic-assisted tubal reversal was shown in Fig. 13.1. The subserosal injection of vasopressin diluted 20 U in 200 mL of normal saline in both proximal and distal ends and in the mesosalpinx may be used to facilitate subsequent

Fig. 13.1: Robot-assisted laparoscopic tubal reanastomosis. a) preparation of the proximal stump with flow of methylene blue, b) preparation of the distal stump, c) four interrupted 7/0 polypropylene sutures used for suturing at 12, 3, 6, and 9 o’clock and the closure of the serosa, d) checking the tubal patency with chromotubation. (Photos archive of Ahmet Göçmen, Ümraniye Education and Research Hospital, İstanbul, Turkey)

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dissection of both ends and hemostasis. The tubal patency of the proximal segment should be checked with chromopertubation. The ligated segment of the tube is resected proximally and distally using scissors. After checking the proximal passage of the methylene blue or indigo carmine solution from the incised part of the proximal tube, the distal patency may be checked by irrigation from the fimbrial end of the tube. A stent may be used between the proximal and distal portion of the tubes before reversal to make the suturing and alignment of the segments easy, but it is not mandatory for technique. The mesosalpinx is reapproximated with one interrupted 7/0 or 8/0 suture to prevent tension on the anastomosis site. The submucosal and muscular layers of the tube were sutured with four interrupted 7/0 or 8/0 polypropylene or polyglactin sutures at the 3, 6, 9 and 12 o’clock positions. It is recommended the first suture position should be at 6 o’clock. Attention to proper suturing will avoid misalignment or rotation of the distal tubal segment along its longitudinal axis. After checking the tubal patency with chromopertubation, the serosal part of the tube is also sutured. The same procedure is performed on the other fallopian tube.

13.3 The surgical outcomes of robotic-assisted tubal reversal Traditionally, tubal reanastomosis has been performed microscopically via laparotomy. With the emergence of advanced laparoscopy techniques in recent times, many centers have demonstrated good success through laparoscopy and this has been widely regarded as the alternative route to perform microsurgical reversal of a ligated tube [11]. The laparoscopic approach has revealed high pregnancy rates comparable with those obtained after microsurgery by laparotomy and yields important advantages such a less postoperative discomfort and fewer complications, no incisional scar, a shorter recovery time, and earlier resumption of normal activities [12]. The laparoscopic procedure for reversal of tubal sterilization is equally effective as the laparotomic approach [13]. Robotic surgery in tubal reversal has been advocated to bridge the learning gap between an open approach and laparoscopy. Microsurgical tubal reversal is the predominant procedure using robotic technology in reproductive surgery. There are a few previously published data using robotic-assisted surgery in tubal reversal. The first complete robotic assisted tubal reversal in six female pigs was performed in 1997 by Falcone et al [14]. The same authors performed successful reanastomosis in ten patients in a human pilot study with no complication in the following year [10]. The mean operative time was 159 ± 33.8 min. The patency rate 6 weeks after surgery with postoperative hysterosalpingogram was 89% (17/19 tubes anastomosed) with a pregnancy rate of 50% in 1 year. Goldberg et al compared the surgical results of tubal reversal with robotic (n = 10) and laparoscopic (n = 15) approach [15]. The operative times were 2 h longer with robotic

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assistance (P < 0.001). The increased estimated blood loss with the use of the robot (70 ± 68 mL vs. 20 ± 16 mL) was statistically but not clinically significant. Tubal patency and clinical pregnancy rates were not significantly different. The robotic system was used in the study was Zeus robotic system. However this study has many potential biases which were small number of subjects and noncomparability of groups (women in the laparoscopy group were significantly older and tended towards having larger BMI and prior surgeries) [16]. The first tubal reversal with the da Vinci robotic system was published by Degueldre et al [17]. Eight patients underwent robotic tubal reversal. The tubal patency was confirmed. The mean time was 140 min, and mean surgical time was 52 min per tube. Although follow-up was limited to 4 months, two of the eight patients achieved a pregnancy and 5/8 patients demonstrated at least unilateral patency. After their feasibility study, they reported the study included 28 patients underwent robotic tubal reversal and the operative time was 122 min [18]. Rodgers et al reported a case control study to compare tubal anastomosis by robotic system (n = 26) compared with outpatient minilaparotomy (n = 41) [19]. Surgical times for the robot and minilaparotomy were 229 (205–252) min and 181 (154–202) min, respectively (P = 0.001). Hospitalization times, pregnancy (61% robotic vs. 79% minilaparotomy) and ectopic pregnancy rates were not significantly different. The robotic technique was more costly. The median difference in costs of the procedures was $1,446 (P < 0.001). Complication rates in the robotic group were lower than the laparotomy group. Dharia et al reported a comparative study including tubal reanastomosis through either robotic approach (n = 18) or through a laparotomy (n = 10) [20]. The mean operative time for robotic group was 201 min and statistically greater than the laparotomy. The hospitals stay in robotic and laparotomy group were 4 h and 34.7 h, respectively. During the 8.9 months follow-up period, the pregnancy rates were comparable between two groups (62.5% for robotic vs. 50% for laparotomy group). The cost per delivery was similar between two groups. They concluded that robotic approach was feasible and cost effective. Caillet et al reported a recent study which included 97 patients with available follow-up who underwent the reversal of tubal ligation [21]. The follow-up of the patients was 2 years. The overall pregnancy and birth rates were 71% and 62%, respectively. Ninety-one percent of patients 50 kg/m2), we have open instruments available in order to avoid delay should conversion be necessary. Because the arms are tucked, we recommend patients undergoing lymphadenectomy have two peripheral IVs placed prior to tucking the arms in the event of major bleeding or IV malfunction, although we have had no need for intra-operative transfusion from acute blood loss in our 6-year experience with aortic lymphadenectomy. Robotic hysterectomy is greatly facilitated with the use of a uterine manipulator. Uterine manipulation improves safety, far outweighing the unlikely and theoretical risk of dislodging cancer cells from the uterus or cervix [22]. We prefer the V-CARE® disposable uterine manipulator (ConMed, Utica, NY, USA) for its ease of placement and single piece design. Many surgeons prefer their experience from laparoscopic hysterectomy using the ZUMI® manipulator, KOH® ring, and a separate pneumo-occluder balloon (Cooper Surgical, Turnbull, CT, USA). Still other surgeons use a metal endto-end anastomosis, EEA® (US Surgical Corp., Norwalk, CT, USA) rectal sizer as an obturator to distend the vaginal fornices for colpotomy while using the third da Vinci operating arm for uterine manipulation. Port sites are anesthetized with 0.5% bupivacaine with the camera port placed 25–28 cm above the symphysis pubis, depending on the individual patient’s height, torso length, uterine size, and need to perform infra-renal aortic lymphadenectomy. The S and Si da Vinci models have longer instrument shafts than the original standard model, allowing higher placement of ports and easier dissection of aortic nodes and hysterectomy from the same port set-up. It is also helpful to use bariatric-length laparoscopic instruments in order to reach the pelvis from upper abdominal accessory ports. Placement of the third operating arm cephalad to the second arm in the left flank at the level of the camera port, allows its optimal use as a retractor during aortic node dissection as well as obturator space dissection, and avoids collisions with arm no. 2 during aortic lymphadenectomy. A 12-mm accessory port is placed between the camera and right robotic ports near the mid-clavicular line, and a 5-mm port, if necessary, can be placed high in the right flank, lateral and slightly cephalad to arm no. 1 (Fig. 18.1). We have recognized no benefit from side docking, but have experienced some difficulties during infra-renal dissections due to limitations in the arm motion, and therefore recommend routine center docking for this procedure.

18.4 Operating room set-up and patient preparation  

  225

12mm assist camera 5mm assist Arm 3 Arm 1

Arm 2

Fig. 18.1: da Vinci port set-up for aortic lymphadenectomy. Camera port is midline 25–28 cm above the symphysis pubis

A zero degree scope is used for most cases; however, a 30° downward facing lens can afford better visualization of upper abdominal anatomy for infra-renal dissection and omentectomy in the event that the ports were inadvertently placed too low. Monopolar scissors are used in the right operative arm 1 with the energy set at 38 Watts on fulgarate mode, a fenestrated bipolar grasper is placed in the left arm 2 at 45 Watts, and a double-fenestrated grasper/retractor is preferred for the third operative arm primarily for use as a retractor. For controlling vascular pedicles, we prefer the da Vinci fenestrated bipolar grasper, which avoids the cost of an additional laparoscopic energy device, and is a more efficient grasper than the Maryland bipolar grasper. Performance of aortic lymphadenctomy to the left renal vein is usually possible with the da Vinci system, but can be compromised by difficult exposure in morbidly obese patients, especially those with short stature. A Ray-Tec® sponge is placed during port placement at the ligament of Treitz as the omentum and small bowel are gently folded into the left upper quadrant during port placements. The sponge retards peristalsis of small bowel into the field of view and can be useful for blotting during aortic dissection. Prior to docking, it may be necessary to first lyse omental adhesions using laparoscopic scissors in patients with prior surgeries, so that the omentum and transverse colon can be optimally displaced above the stomach and liver.

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18.5 Surgical technique for center-docked robotic-assisted aortic lymphadenectomy For patients determined preoperatively to require aortic lymphadenectomy based on their endometrial pathology, or if pelvic lymphadenopathy is encountered upon opening the spaces, it is recommended to proceed immediately with the aortic lymph node dissection prior to hysterectomy. Proceeding with the aortic dissection first avoids potential difficulties with blood and irrigation fluid that may track cephalad because of the patient’s Trendelenburg position, potentially obscuring dissection planes. Also, small bowel peristalsis into the mid-abdomen during hysterectomy may be more difficult to repeatedly displace while the robot is docked. To initiate lymphadenectomy, first open the peritoneum along the right common iliac artery in a caudal to cephalad direction up the aorta above the inferior mesenteric artery (IMA). The assistant surgeon grasps the leading peritoneal edge with an atraumatic laparoscopic grasper in the 12-mm port, while a suction cannula in the 5-mm flank port retracts the ureter and gonadal vessels laterally over the psoas muscle. The third operative arm is positioned over the aorta grasping the recently opened peritoneum and creating a peritoneal “tent” with the assistant surgeon’s grasper, which effectively creates retroperitoneal exposure. If a redundant sigmoid colon is encountered, it is useful to suture the tinea coli to the left colic gutter using a 3-0 silk, displacing it from the lower aorta. Common iliac (CI) lymph nodes are dissected free from the artery using robotic scissors and short bursts of monopolar cautery, taking care to avoid injury to the underlying iliac vein and genito-femoral nerve coursing below the artery along the psoas muscle. It is useful to begin the dissection first on the artery; then free the nodal bundle from the psoas muscle, lifting it up, and exposing the genito-femoral nerve and CI vein. Deviation of dissection away from the exposed artery into nodal fat pads without first exposing the CI vein increases the risk of vascular injury. Once the CI nodes are removed to the aortic bifurcation, maximum exposure to the renal veins is achieved by optimizing the assistant’s grasper and the third operative arm over the duodenum-peritoneal “tent,” and by using the suction cannula to gently retract the duodenum cephalad via the 5-mm right flank port. Dissection planes between precaval, intra-aortic-caval, and infra-renal lymph nodes are created with gentle separation of adventitia and lymphatics using monopolar cautery. Bipolar cautery is used on the most cephalad lymphatic borders of the dissection at the left renal vein to potentially limit lymphatic fluid spill during dissection, and the potential risks of symptomatic post-operative lymphoceles, and/or chylous ascites. It is prudent to avoid major lymphatic channels running between the aorta and vena cava for similar reasons, and use of laparoscopic clips is advised when they are encountered. The articulating da Vinci metal clip applicator can be very useful for small vessels occasionally encountered on the aorta between the IMA and renal vein. Dissect lymph nodes off the aorta and vena

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cava in a cranial to caudal direction from the duodenum and left renal vein, taking care to identify and avoid the insertion of the right gonadal artery and vein, as well as the origin of the IMA from the anterior aortic surface. The IMA is usually encountered approximately 4 to 5 cm above the aortic bifurcation, and the left renal vein is usually another 4 to 5 cm above the IMA (Figs. 18.2 and 18.3). Once the anterior lymph nodes are cleared from the aorta and cava, position the third arm in the left retroperitoneum retracting the left gonadal vein and ureter laterally to allow dissection of infra-renal lymph nodes lateral to the aorta and above the IMA. Minor bleeding is controlled with short bursts of mono- and bi-polar cautery, but great caution must be exercised to avoid collateral injuries from overzealous or blind use of cautery. Aortic nodes on the right, below the IMA, are then cleared off the vena cava to the CI vein. Care must be taken

Fig. 18.2: Exposing the left renal vein and infra-renal lymph nodes

Fig. 18.3: View of left renal vein, aorta, and vena cava following the removal of infra-renal lymph nodes

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to avoid lifting the nodal bundle off the vena cava. This can result in sheering of the anterior perforating (“fellow’s”) veins and resultant hemorrhage. Careful dissection and exposure around these veins using bipolar and monopolar cautery is paramount. Minor vena caval bleeding can be easily managed with pressure and Fibrillar®, and The Ray-Tec® sponge already in-situ can be most helpful. To this point in the dissection, all lymph nodes have been placed in visible, strategic locations in the pelvis and colic gutters, and are now retrieved with a reusable, laparoscopic retractable bag system through the 12-mm port. The left infra-mesenteric aortic and left CI lymphadenectomy are now completed by dissecting below the IMA, using the third-arm’s double fenestrated grasper to retract the left ureter laterally down to the external iliac artery. It is not necessary to routinely sacrifice the IMA during this dissection, and major lymphatic trunks are sealed with bipolar cautery or clipped when identified to minimize the risk of lymphoceles or chylous ascites. The left infra-IMA aortic and CI lymph nodes are removed separately in the re-usable laparoscopic endo-bag.

18.6 Surgical technique for robotic-assisted pelvic lymphadenectomy Once the aortic dissection is complete, hysterectomy with bilateral salpingo-oophorectomy is accomplished in the standard robotic-assisted fashion removing the entire broad-ligament with wide margins on the round and infundibulo-pelvic ligaments. A modified radical hysterectomy is performed when indicated for clinical suspicion of disease extension into the cervix. The formal pelvic lymphadenectomy is initiated on the right side of the pelvis by using the third operative arm to open the paravesical space and retract the superior vesical artery medially. The external iliac artery, vein, and obturator spaces are now exposed (Fig. 18.4). The dissection is best initiated at the right CI artery with the ureter retracted medially by the bed-side assistant. Lymphatic tissue is dissected free from the psoas muscle, taking care to separate the genito-femoral nerve and retract it laterally. Avoid cautery damage to the nerve bundle during dissection in order to minimize cutaneous anesthesia over the antero-medial thigh. The lymphatic bundle is dissected laterally to medially off the external iliac artery using traction, short bursts of monopolar cautery, and cold cutting. The dissection is carried caudally to the distal circumflex iliac artery and vein, then progresses medially sweeping tissue off the external iliac vein, in a cephalad direction, back to the right internal iliac artery. Taking full advantage of the instrument’s wristed capabilities allows the surgeon to avoid trauma to the vein with monopolar electrical arcing. Bipolar cautery is used on the most distal and medial lymphatic pedicles to create a lymphatic seal, minimizing lymphatic leakage or lymphocele formation. Avoid removing large fat pads distal to the circumflex vessels. These are rarely involved with tumor, and their removal

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Fig. 18.4: Left obturator space following lymphadenectomy revealing the external iliac vein (V) above the grasper, obturator nerve (N), and superior vesical artery (A) near endo-shears

significantly increases the incidence of lymphedema [23]. It is helpful during the right-sided pelvic dissection for the assistant to use a bariatric length suction cannula through the 12-mm port as a retractor, and use a laparoscopic grasper through the 5 mm port to displace the external iliac vein laterally during the obturator space dissection. Lymph nodes are placed in the posterior cul-de-sac for subsequent retrieval. The obturator nodal packet is next addressed by first bringing the camera closer into the pelvis and rotating it slightly to the right. With the superior vesical artery on medial stretch by the third arm, the obturator space is gently dissected, separating the nodal fat pad from the underlying obturator nerve. The nerve should be meticulously dissected and visualized to minimize risks of injury. Remain vigilant for the frequently encountered obturator vein entering the distal external iliac vein, and dissect the lymph nodes free from the dorsal (or underside) of the external iliac vein and obturator fascia. Sweep tissue from distal to proximal along the obturator nerve, avoiding monopolar cautery that may cause obturator muscle twitches. Bleeding in this area is better handled with bipolar energy, and lymphatic tissue below the nerve and above the deep branches of the internal iliac system can also be removed. Again, any bothersome capillary bleeding can be managed with Fibrillar® in these spaces, avoiding potential thermal damage with use of excessive cautery. The external and obturator lymph nodes are removed separately in the reusable laparoscopic bag retrieval system, while the left paravesical space is opened by the console surgeon. An identical nodal resection is carried out on the left side of the pelvis using the third operative arm to displace the ureter medially to inspect the CI dissection and remove any remaining nodes. Next, position the third arm’s double-fenestrated grasper to elevate the distal peritoneal edge at the lateral pelvic sidewall during external iliac dissection. The same instrument can then be re-positioned to serve as a vein hook

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during dissection of the left obturator nodal packet. The bedside assistant holds the paravesical space open with a grasper in the 5-mm port and uses the suction via the 12-mm port.

18.7 Comparative studies In the 7 years since the US FDA clearance of da Vinci for gynecologic surgery, several retrospective case-series and comparative studies (either laparoscopy or laparotomy) for endometrial cancer have been published. There have been no prospective randomized trials completed, but two meta-analyses of observational studies were published simultaneously in 2010 [24–25]. In an analysis of eight comparative studies [18–19, 26–31] that included at least 25 robotic cases, [24] identified a cumulative 1,591 patients with endometrial cancer (robotic 589, laparoscopic 396, laparotomy 606). Robotic and laparoscopic cases appeared similar with the exception of less blood loss for robotic cases (P = 0.001), but no difference in transfusion rates (OR 0.47, CI 0.10–2.19, P = 0.22). For the robotic versus laparotomy comparison, lower transfusion rates approached statistical significance in favor of robotic cases (OR 0.25, CI 0.05–1.16, P = 0.06). Operative times for robotic and laparoscopy cases were similar, but both were greater than laparotomy operative times (P < 0.005). Lymph node yields were not statistically different for any surgical method. Conversion to laparotomy was 9.9% for laparoscopy compared to 4.9% for robotic, also approaching statistical significance (P = 0.06). Reza et al in 2010 [25] also analyzed gynecologic surgery publications including those for endometrial cancer, and reported that robotic surgery was associated with reduced blood loss (76 mL, P = 0.03) and fewer transfusions (OR 0.24, CI 0.09 to 0.64) than conventional laparoscopy. In their analysis, conversion to laparotomy was less for robotic surgery (OR 0.43, CI 0.21–0.85) and the overall risk of complications was no different for robotic compared to laparoscopic surgery. Thus, two systematic reviews of comparative studies suggest that for the management of endometrial cancer, surgeons may expect less blood loss, fewer transfusions, fewer conversions to laparotomy, similar operative times, and similar overall complications for robotic compared to laparoscopic hysterectomy with lymphadenectomy. However, it is important to recognize the limitations of meta-analyses of retrospective observational studies, and that their conclusions are not nearly so robust as those from meta-analyses of prospective randomized trials due to inherent selection biases encountered in retrospective studies.

18.8 Managing obese patients with endometrial cancer Obesity is associated with a 10-fold increased risk for endometrial cancer, and is often mentioned as a “limiting factor” concerning patient selection for MIS procedures.

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Obese patients have an increased risk of conversion to laparotomy, and less complete lymph node dissection [16]. Establishment and maintenance of exposure during aortic lymph node dissection and adequate ventilation with requirements for steep Trendelenburg positioning can be challenging for both the surgeon and anesthesiologist. Gehrig et al in 2008 [18] reported that robotic surgery was preferable to laparoscopy for treatment of endometrial cancer in 36 obese and 13 morbidly obese patients because of shorter operative times, blood loss, hospital stay, and increased lymph node retrieval. Ninety-two percent of the robotic cases and 84% of the laparoscopic cases completed both a pelvic and aortic node dissection. While robotic lymph node yields were greater than those for laparoscopic cases, node counts for morbidly obese (BMI >40 kg/m2) patients were not greater than laparoscopy, indicating that robotic aortic lymphadenectomy may still have some limitations for this group of difficult patients. Seamon et al in 2009 [19] reported that of 105 patients with endometrial cancer, 13 (12.4%) with BMI’s ranging from 47 to 58 and Grade 1 cancer did not undergo a complete staging: six patients underwent pelvic lymphadenectomy without aortic dissection and seven had no lymphatic staging. There was a 12.4% rate of conversion to laparotomy. The mean BMI for those patients requiring conversion to laparotomy was 40 ± 7 kg/m2 compared to 34 ± 9 kg/m2 for those successfully completed robotically. The feasibility for completing robotic aortic lymphadenectomy was 67% and 35% for BMI 45 and 50 kg/m2, respectively. Most recently, Subramaniam et al [32] compared outcomes from a group of obese patients with endometrial cancer undergoing robotic (n = 73, BMI 39.8 kg/m2) and open hysterectomy (n = 104, BMI 41.9 kg/m2). Lymphadenectomy (total mean node count 8.0) was performed in 66% of robotic cases and the rate of conversion to laparotomy was 11%. Transfusions, hospital stay, and complications were all improved for robotic-assisted surgery. In our experience, height is also very important when considering patients with an elevated BMI. Short stature and the “apple” shaped body habitus, in contrast to a tall patient with “pear” shaped habitus, portends significant difficulty with aortic dissection for patients with BMI in excess of 40 kg/m2. Pelvic lymphadenectomy can almost always be accomplished for morbidly obese patients as long as Trendelenburg positioning is tolerated. James et al in 2012 [33] reported that 72% of 47 patients selected to undergo aortic lymphadenectomy based on pre-operative histology or intra-operative analysis of the uterine tumor had successful infra-renal dissections during the first year attempting this surgical technique (Figs. 18.2 and 18.3). The mean aortic and pelvic node counts for the 34 patients with infra-renal dissections were 13.1 and 21.9, respectively, mean BMI 31 kg/m2 (range 20–46), mean operative time 178 + 31 min, and there were no conversions to laparotomy. Three (8.8%) patients had isolated aortic metastases that were above and below the IMA in this study. In summary, our key recommendations for performing aortic lymphadenectomy in obese patients include securing the patient carefully to an operating table with

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gel pads under the buttocks and shoulders, then taping carefully across the humeri and chest just below the clavicles (over a thin towel to prevent skin damage). Avoid taping too low and limiting chest excursion, thus impeding ventilation and increasing diaphragm excursion (which hinders visibility). Place ports as high as possible, but at least 26 cm above the pubis if infra-renal node dissection is desired. During the case, the robotic arms can be adjusted externally as needed to improve access and facilitate easier dissection in difficult areas. Use a bed that will accommodate at least 32° of Trendelenburg. Place the third operative arm above and lateral to arm no. 2, at the level of the camera for ideal retraction in the left infra-renal space. Keep a clean sponge in this area to prevent small bowel intrusion, and use it for blotting when necessary. Avoid excessive trauma to the small bowel and descending colon mesentery to minimize chylous lymphatic leaking. Consider bipolar energy or metallic clips on major lymphatic trunks for the same purpose. Identify the left renal vein, the insertion of the right and left gonadal veins, and the IMA before dissecting and removing lymph nodes. A reusable endoscopic bag reduces equipment costs and allows for serial labeling of node specimens by anatomic location as they are removed.

18.9 Future directions Lymphatic mapping for assessment of sentinel lymph nodes (SLN) is an accepted practice for breast, melanoma, and vulvar cancers with the primary goal to reduce morbidity of a complete lymphadenectomy. A secondary goal is to improve detection of metastatic disease with pathology protocols that utilize ultra-sectioning of SLN and imunohistochemical (IHC) staining [34]. Bilateral detection of pelvic SLN is reported in 66 to 86% of cervix and endometrial cancer cases using isosulfan blue (ISB) with or without Tecnetium-99 (Tc-99) [35–38]. Roy et al in 2011 [38] reported a 7.8% increase in SLN detection utilizing both ISB and Tc-99 compared to ISB alone, achieving a 90.6% bilateral detection rate in patients with cervical cancer. Recently, other medical dyes that fluoresce in light at the near-infrared (NIR) spectrum (700–900 nm) using laparoscopic imaging systems have been reported for use in lymphatic mapping, of which indocyanine green (ICG) is considered the most clinically useful fluorescent dye [39]. The da Vinci NIR fluorescence imaging system is FDA cleared for vascular imaging and is useful for confirming patency of vascular anastamoses in cardiovascular surgery [40]. Rossi et al in 2012 [41] described preliminary results with NIR fluorescence imaging used with robotic-assisted surgery in patients with cervical and endometrial cancers, recommending that a 1 mg dose of ICG was most efficacious for lymphatic mapping. Fluorescence imaging with ICG was subsequently shown to identify more sentinel lymph nodes and identify more metastatic disease than colorimetric analysis of ISB in a pilot study of 35 patients [42], and all patients had bilateral SLN detected using combination ISB and ICG with NIR imaging.

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Intra-operative tumor assessment utilizing gross examination and frozen section can identify a population of patients with endometrial cancer who have a low risk for metastasis, also know as “Mayo criteria” [43]. It may be possible to eliminate complete lymphadenectomy for this group of patients in favor of SLN mapping. For high-risk tumors, SLN mapping will likely increase the detection of metastatic lymph nodes through the appropriate use of ultra-staging and IHC staining. Future multi-institutional prospective trials will be needed to better define the sensitivity for detection of disease and the negative predictive value of a normal SLN for lowrisk and high-risk populations.

18.10 Conclusions To date, robotic-assisted lymphadenectomy for endometrial cancer is widely accepted as the preferred surgical approach to this disease. Proven benefits of decreased blood loss, less post-operative pain, faster recovery, and equivalent efficacy regarding staging ability and lymph node yields serve to bolster this opinion. As technology increasingly evolves, staging procedures will become even more facile and efficient in the hands of well-trained minimally invasive surgeons. Compelling research in the field of sentinel node detection holds tremendous promise for future patients with early stage disease. Many patients may safely be identified as low risk for metastasis intra-operatively and may not require an extensive, time consuming, and potentially morbid complete lymphadenectomy. Staying abreast of the latest technologic advancements, surgical techniques, and provocative data in the field of robotic surgery and gynecologic cancer is vital to the success of the modern-day robotic surgeon.

References [1] Jemal A, Bray F, Center MM, et al. Global cancer statistics. CA Cancer J Clin 2011, 61, 69–90. [2] International Federation of Gynecology and Obstetrics. Annual report on the results of treatment in gynecologic cancer. Int J Gynecol Obstet 1989, 28, 189–93. [3] Creasman WT, Morrow CP, Bundy BN, et al. Surgical pathologic spread patterns of endometrial cancer: A gynecologic oncology group study. Cancer 1987, 60, 2035–41. [4] Neubauer NL, Lurain JR. The role of lymphadenectomy in surgical staging of endometrial cancer. Int J Surg Oncol 2011, 814649. [5] Kilgore LC, Patridge EE, Alvarez RD, et al. Adenocarcinoma of the endometrium: Survival comparisons of patients with and without pelvic lymph node sampling. Gynecol Oncol 1995, 56, 29–33. [6] Mariani A, Webb MJ, Galli L, et al. Potential therapeutic role of para-aortic lymphadenectomy in node-positive endometrial cancer. Gynecol Oncol 2000, 76, 348–56. [7] Benedetti Panici P, Basile S, Maneschi F, et al. Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: Randomized clinical trial. J Natl Cancer Inst 2008, 100, 1707–16.

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[8] The Writing Committee on Behalf of the ASTEC Study Group. Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): A randomized study. Lancet 2009, 373, 125–36. [9] Seamon LG, Fowler JM, Cohn DE. Lymphadenectomy for endometrial cancer: The controversy. Gynecol Oncol 2010, 117, 6–8. [10] Creasman WT, Mutch DE, Herzog TJ. ASTEC lymphadenectomy and radiation therapy studies: Are conclusions valid? Gynecol Oncol 2010, 116, 293–4. [11] Childers JM, Brzechffa PR, Hatch KD, et al. Laparoscopically assisted surgical staging (LASS) of t[12] Childers JM, Hatch KD, Tran AN, et al. Laparoscopic para-aortic lymphadenectomy in gynecologic malignancies. Obstet Gynecol 1993, 82, 741–7. [13] Thoma V, Salvatores M , Mereu L, et al. Laparoscopic hysterectomy; technique, indications. Ann Urol (Paris) 2007, 41, 80–90. [14] Leiserowitz GS, Xing GB, Parikh-Patel A, et al. Survival of endometrial cancer patients after laparoscopically assisted vaginal hysterectomy or total abdominal hysterectomy; analysis of risk factors. Gynecol Oncol 2007, 104 (Suppl 1), A7. [15] Naumann RW, Coleman RL. The use of adjuvant radiation therapy in early endometrial cancer by members of the Society of Gynecologic Oncologists in 2005. Gynecol Oncol 2007, 105, 7–12. [16] Walker JL, Piedmonte MR, Spirtos NM, et al. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic oncology group study LAP2. J Clin Oncol 2009, 27, 5331–6. [17] Walker JL, Piedmonte MR, Spirtos NM, et al. Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic oncology group LAP2 study. J Clin Oncol 2012, 30, 695–700. [18] Gehrig PA, Cantrell LA, Shafer A, et al. What is the optimal minimally invasive surgical procedure for endometrial cancer staging in the obese and morbidly obese woman? Gynecol Oncol 2008, 111, 41–5. [19] Seamon LG, Bryant SA, Rheaume PS, et al. Comprehensive surgical staging for endometrial cancer in obese patients: Comparing robotics and laparotomy. Obstet Gynecol 2009, 114, 16–21. [20] Magrina JF, Magtibey PM. The case of robotics and the infra-renal aortic nodes. Gynecol Oncol 2011, 123, 407–8. [21] Holloway RW, Ahmad S. Robotic-assisted surgery in the management of endometrial cancer. J Obstet Gynaecol Res 2012, 38, 1–8. [22] Rakowski JA, Tran TAN, Ahmad S, et al. Does a uterine manipulator affect cervical cancer pathology or identification of lymphovascular space involvement? Gynecol Oncol 2012, 127, 98–101. [23] Todo Y, Yamamoto R, Minobe S, et al. Risk factors for postoperative lower-extremity lymphedema in endometrial cancer survivors who had treatment including lymphadenectomy. Gynecol Oncol 2010, 119, 60–4. [24] Gaia G, Holloway RW, Santoro L, et al. Robotic-assisted hysterectomy for endometrial cancer compared with traditional laparoscopic and laparotomy approaches: A systematic review. Obstet Gynecol 2010, 116, 1422–31. [25] Reza M, Maeso S, Blasco JA, et al. Meta-analysis of observational studies on the safety and effectiveness of robotic gynaecological surgery. Br J Surg 2010, 97, 1772–83. [26] DeNardis SA, Holloway RW, Bigsby IV GE, et al. Robotically assisted laparoscopic hysterectomy versus total abdominal hysterectomy and lymphadenectomy for endometrial cancer. Gynecol Oncol 2008, 111, 412–7. [27] Bell MC, Torgeson J, Seshadri-Kreaden U, et al. Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques. Gynecol Oncol 2008, 111, 407–11.

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[28] Boggess JF, Gehrig PA, Cantrell L, et al. A comparative study of 3 surgical methods for hysterectomy with staging for endometrial cancer: Robotic assistance, laparoscopy, laparotomy. Am J Obstet Gynecol 2008, 199, 360, e1–9. [29] Cardenas-Goicoechea J, Adams S, Bhat SB, et al. Surgical outcomes of robotic-assisted surgical staging for endometrial cancer are equivalent to traditional laparoscopic staging at minimally invasive surgical center. Gynecol Oncol 2010, 117, 224–8. [30] Seamon LG, Cohn DE, Henretta MS, et al. Minimally invasive comprehensive surgical staging for endometrial cancer: Robotics or laparoscopy? Gynecol Oncol 2009, 113, 36–41. [31] Veljiovich DS, Paley PJ, Drescher CW, et al. Robotic surgery in gynecologic oncology: Program initiation and outcomes after the first year with comparison with laparotomy for endometrial cancer staging. Am J Obstet Gynecol 2008, 198, 679, e1–9 (Discussion 679.e9–10). [32] Subramaniam A, Kim KH, Bryant SA, et al. A cohort study evaluating robotic versus laparotomy surgical outcomes of obese women with endometrial carcinoma. Gynecol Oncol 2011, 122, 604–7. [33] James JA, Rakowski RA, Jeppson CN, et al. An assessment of robotic transperitoneal infra-renal aortic lymphadenectomy in early endometrial cancer. Gynecol Oncol 2012, 125 (Suppl. 1): A386. [34] Yared MA, Middleton LP, Smith TL, et al. Recommendations for lymph node processing in breast cancer. Am J Surg Pathol 2002, 26, 377–82. [35] Khoury-Collado F, Murray MP, Hensley ML, et al. Sentinel node mapping for endometrial cancer improves the detection of metastatic disease to regional lymph nodes. Gynecol Oncol 2011, 122, 251–4. [36] Ballester M, Dubernard G, Lecuru F, et al. Detection rate and diagnostic accuracy of sentinelnode biopsy in early stage endometrial cancer: A prospective multicenter study (SENTI-ENDO). Lancet Oncol 2011, 12, 469–76. [37] Cormier B, Diaz JP, Shih K, et al. Establishing a sentinel lymph node mapping algorithm for the treatment of early cervical cancer. Gynecol Oncol 2011, 122, 275–80. [38] Roy M, Bouchard-Fortier G, Popa I, et al. Value of sentinel node mapping in cancer of the cervix. Gynecol Oncol 2011, 122, 269–74. [39] Gioux S, Choi HS, Franggioni JV. Image-guided surgery using invisible near-infrared light: Fundamentals of clinical translation. Mol Imaging 2010, 9, 237–55. [40] Balacumaraswami L, Abu-Omar Y, Anastasiadis K, et al. Does off-pump total arterial grafting increase the incidence of intraoperative graft failure? J Thorac Cardiovasc Surg 2004, 128, 238–44. [41] Rossi EC, Ivanova A, Boggess JF. Robotically assisted fluorescence-guided lymph node mapping with ICG for gynecologic malignancies. Gynecol Oncol 2012, 124, 78–82. [42] Holloway RW, Bravo RAM, Rakowski JA, et al. Detection of sentinel lymph nodes in patients with endometrial cancer undergoing robotic-assisted staging: A comparison of colorimetric and fluorescence imaging. Gynecol Oncol 2012, 126, 25–9. [43] Mariani A, Dowdy SC, Cliby WA, et al. Prospective assessment of lymphatic dissemination in endometrial cancer: A paradigm shift in surgical staging. Gynecol Oncol 2008, 109, 11–8.

19 Robotic-extraperitoneal lymphadenectomy: A step-by-step approach Murat Dede, Müfit Cemal Yenen and Cihangir Mutlu Ercan 19.1 Introduction Today, the incidence of cervical cancers has been decreasing due to effective screening protocols in developing countries, but it is still the second most common cancer among women and the most frequent cause of death from gynecological cancers worldwide [1]. Although most of the cervical cancer cases can be spotted at early stages through smear screening tests, nearly half of them are beyond the cervix at the time of diagnosis (locally advanced stage cervical cancer, LACC) [2]. The International Federation of Gynecology and Obstetrics (FIGO) classification is used to determine the anatomical extent of cervical cancer. FIGO staging for cervical cancer is an assessment of the size of the tumor and its spread to adjacent and distant sites; stage IA1 is the earliest and stage IVB the most advanced. Staging is based on clinical evaluation; the presence or absence of metastatic cancer in the lymph nodes within the pelvis and abdominal cavity do not contribute to the FIGO staging [3]. Although they do not form part of the assessment of the disease stage, additional investigations and surgical procedures may be useful in our treatment strategy [4]. The major prognostic factors of the disease are tumor stage and the presence of metastatic disease in the lymphatic nodes, particularly those at the para-aortic level [5]. It is known that women who present with metastatic para-aortic lymph nodes have a lower overall survival rate than those who are para-aortic node negative at presentation [6]. The 5-year survival rate for women with FIGO stage IB and IIA disease is 95% as long as the node is negative with only 78% with positive lymph nodes [7]. It is estimated that para-aortic lymph node metastasis is present in 21% of women with stage IIB disease, 31% of those with stage III, and 13% of those with stage IVA disease at presentation [8]. In locally advanced disease (stage IIB to IVA) the treatment of choice is the radiation of primary tumor and pelvic lymph nodes, with concurrent chemotherapy [9]. Accurate detection of involved para-aortic nodes does not alter staging, but it may result in the modification of treatment plans. Although the use of prophylactic extended field radiation including the para-aortic nodes in women with LACC is not proven to improve survival rates, it does increase morbidity due to side effects and complications of treatment [10]. On the other hand, on local control or survival in cases with positive para-aortic lymph nodes, extended field radiotherapy does have a positive effect. In a large, controlled, randomized study of advanced stage cervical cancer cases, pelvic radiotherapy and pelvic plus para-aortic radiotherapy was compared and survival at 10 years was found to be higher in the group with additive para-aortic radiotherapy (44% vs. 55%, respectively) [11]. Thus, accurate knowledge pertaining to

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para-aortic nodal status is an important step to enable treatment planning such that only those women with confirmed involved para-aortic nodes are given extended field radiotherapy, with its individualized benefits but concurrent risks [12]. A number of techniques have been used to examine pelvic and para-aortic lymph nodes. Computed tomography and magnetic resonance imaging have low sensitivity and specificity in diagnosing lymph node metastasis; these techniques are restricted to assessing the lymph node size [13]. Even though the reported sensitivities range from as low as 38% to 86%, positron emission tomography, a form of functional imaging, seems to be more effective in detecting involved para-aortic nodes [12]. Therefore, for patients with LACC many physicians support the surgical assessment of lymph nodes via performing a para-aortic lymphadenectomy before concomitant radiochemotherapy [5, 12]. Surgical staging provides better treatment individualization, leading to a better clinical outcome. Surgical evaluation of para-aortic nodal involvement is more reliable than radiological imaging, and it also contributes to treatment by the removal of large, positive lymph nodes [5, 14]. Surgicopathologic results impact treatment planning in up to 43% of cases [15, 16]. The surgical evaluation procedure can be performed via laparotomy or laparoscopy through a transperitoneal or extraperitoneal approach [17–20]. Initially, open transperitoneal surgical staging was used [21]. This involves operating to remove the lymph nodes by opening up the abdominal cavity. However, when followed by radiotherapy, this approach results in a significant increase in morbidity with up to 30% of women requiring a second surgical procedure for small bowel complications [22]. More recently, laparoscopic staging has been proposed [23]. This technique was intended to combine the benefits of laparoscopic access with those of the extraperitoneal approach, avoiding laparotomy-associated trauma, preventing blood loss and intestinal adherences, and reducing the recovery time and the occurrence of radiation enteritis [24, 25]. Finally, lymph node dissection via the transperitoneal or extraperitoneal laparoscopic approach was developed due to improvements in endoscopic methods [26, 27]. More recently, robotic surgery with da Vinci® surgical system (Intuitive Surgical Inc, Sunnyvale, CA, USA) that provides a steady three-dimensional visualization started to be used in LACC patients. Since 2000, the da Vinci surgical system has enabled the development of a new, minimally-invasive surgical (MIS) procedure in cardiac, urological, general, and gynecological surgery. Currently, the increasing availability of da Vinci surgical system opens up new indications and opportunities for the treatment of gynecological malignancies. The extraperitoneal approach in advanced cervical cancer staging is one such new indication. According to initial reports, lower para-aortic lymphadenectomy is feasible in patients with LACC, but the procedure’s safety and effectiveness must be demonstrated to be equivalent or better than that of conventional laparoscopy [5, 26, 28–31]. In this session, we tried to share our experience with the robotic extraperitoneal lymphadenectomy procedure in patients with stage IB2-IVA cervical cancers.

19.2 Robotic-assisted retroperitoneal laparoscopic para-aortic lymphadenectomy  

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19.2 Robotic-assisted retroperitoneal laparoscopic para-aortic lymphadenectomy: Technique Despite improvements in endoscopic surgery, robotic-assisted laparoscopic retroperitoneal para-aortic lymphadenectomy remains a technically challenging operation. The procedure has been reported in one case with testicular cancer [32] and five patients with cervical cancer [28]. More recently, a preliminary report with six cervical cancer cases was published by Narducci et al [31]. Briefly, para-aortic node dissection consists of the resection of nodal tissue over the distal vena cava from the level of the inferior mesenteric artery to the mid right common iliac artery and between the aorta and the left ureter from the inferior mesenteric artery to the left mid common iliac artery [33]. Some experts extend the para-aortic lymph node dissection superiorly to the level of the renal veins [34]. For a robotic-assisted laparoscopic extraperitoneal para-aortic lymphadenectomy procedure, these steps must be included: a) inform the patient about the aims and complications of the procedure and obtain an informed consent; b) examine the patient under general anesthesia and perform a cystoscopy; c) position the patient; d) perform a diagnostic laparoscopy; e) enter the extraperitoneal space with intraperitoneal laparoscopic guidance; f) place the balloon trocar and form the retroperitoneal space; g) place the surgical trocars into the retroperitoneal space; h) form the retroperitoneal spaces surgically; i) dissect the left aortic and paracaval nodes; and j) marsupialize the retroperitoneal space.

19.2.1 Informed consent The initial and most crucial step is informing the patient about the aim, complications, and expectations of the procedure. The given informed consent form must be clearly understandable and, according to us, must be given in her own handwriting. Then the patient may be scheduled for a robotic retroperitoneal lower para-aortic lymphadenectomy.

19.2.2 Examination under anesthesia and cystoscopy Prior to surgery, the patient will receive a bowel preparation and be injected with a single dose of 40 mg enoxaparin (BMI >25 kg/m2) the morning of surgery. First, examination under general anesthesia for parametrial involvement and then cystoscopy to exclude any bladder invasion will be performed in a dorsolithotomy position. These steps are important for the staging and prediction of advancement of the tumor.

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  19 Robotic-extraperitoneal lymphadenectomy: A step-by-step approach

19.2.3 Position of patient A Foley catheter will be inserted and the patient will be placed in a naturally supine position [28]. The patient will be positioned with the right arm at 90°, left arm tucked to her side, and her body in a moderate Trendelenburg position with right tilt to avoid collision between the robotic arms and left arm of the patient. The da Vinci surgical system will be positioned at the right shoulder of the patient (Fig. 19.1). The nurse and the assistant will stand at the patient’s left side [31].

19.2.4 Diagnostic laparoscopy The operation will start with a transperitoneal laparoscopy through an umbilical 10-mm Hassan trocar. An orogastric/nasogastric tube placement will be appropriate for decompression at the beginning of this step. A transperitoneal port is needed to evacuate leakage of CO2 through the intraperitoneal cavity. Next the abdominal

Fig. 19.1: a) Marked port sites, after diagnostic laparoscopy, before port placement. There must be 8–10 cm distance between robotic camera and two robotic arms. b) Guidence of a spinal needle for the placement of trocars. c) Da Vinci S surgical system is positioned at the right shoulder of the patient in the left extraperitoneal technique. d) Closed port sites with adhesive wound dressing peds at the end of the procedure

19.2 Robotic-assisted retroperitoneal laparoscopic para-aortic lymphadenectomy  

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cavity will be inspected to evaluate any evidence of intraperitoneal involvement with metastatic disease [3]. If there is evidence of peritoneal carcinomatosis, performing extraperitoneal approach is not required [31, 35]. Diagnostic laparoscopy will also allow us to guide a proper entry to the retroperitoneal space by avoiding the disruption of the peritoneum during the finger dissection and in positioning the balloon trocar.

19.2.5 Entering the extraperitoneal space with intraperitoneal laparoscopic guidance The robotic retroperitoneal para-aortic lymphadenectomy will start at this step. While the video screen will be set on the right side at the level of the patient’s head [28], the port placement will be performed with the surgeon on the left side of the patient at the left hip and the assistant on the left side at the upper leg. The extraperitoneal access will be performed at the level of the left McBurney point through a 15-mm incision. Skin, subcutaneous fat, and fascia will be opened sharply along the same access. The large muscles will be opened bluntly with the opening of the parietal fascia but not of the peritoneal fascia. The surgeon’s right forefinger will be introduced into the incision and the extraperitoneal space will be separated from the overlying muscles of the abdominal wall under laparoscopic monitoring, as described by Querleu et al [29, 36]. The extraperitoneal space may also be developed using a balloon trocar. Digital finger dissection will be continued until the anterior surface of the left psoas muscle and the common iliac artery on the left side are identified. Being very meticulous is vital as the formation of the retroperitoneal space will be prevented if peritoneal rupture occurs.

19.2.6 Placement of balloon trocar and the formation of the retroperitoneal space After the introduction of a 12-mm blunt-tip balloon trocar (Tyco HealthCare, Princeton, NJ, USA) along the access created by finger dissection, the extraperitoneal space will be insufflated with a CO2 pressure of 14 mmHg. The zero angle da Vinci laparoscope and camera will be introduced through this port [28]. Following the insertion of the camera into the retroperitoneal space, the psoas muscle, iliac vessels, and ureter must be identified. At this time, the intraperitoneal pneumoperitoneum will be emptied.

19.2.7 Placement of surgical trocars into the retroperitoneal space We usually mark the port sites and then perform sufficient incisions for surgical ports. A spinal needle may be used for guidance under direct vision before placement of the

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  19 Robotic-extraperitoneal lymphadenectomy: A step-by-step approach

trocars (Fig. 19.1). In this step, two additional robotic trocars will be introduced, one 8–10 cm distal and medial to the scope trocar and one under the left lowest rib on the same line as the laparoscopic trocar at a distance of 8–10 cm of the endoscopic port. An assistant port with an 11-mm trocar (Applied Medical Rancho, Santa Margarita, CA, USA) will be inserted at about 1 cm above the right corner of the pubic hair in order to lift the peritoneum with the ureters and ovarian vessels and to remove the lymph nodes. As it is described by Vergote et al, the optimum docking of the da Vinci S robotic system is from the patient’s right side with the robotic arms reaching over the patient [28]. Using the third robotic surgical arm is unnecessary due to the limited space to place the ports. We commonly use Gyrus bipolar forceps (SP Generator, Gyrus, Maple Grove, MN, USA) through the right port and monopolar scissors through the left port. Although the 30° scope might be opted for the dissection of the lateral part of the caval vein to provide a better view on the paracaval area, the 0° Surgical Intuitive endoscope will be used for the dissection of the para-aortic and pre-aortic region.

19.2.8 Formation of the surgical plan at the retroperitoneal space The steps described by Querleu et al will be followed by the development of the extraperitoneal surgical space and the margins of the para-aortic lymphadenectomy [29, 36]. The left psoas muscle will be freed cephalad up to the fascia of the left kidney and the left ureter will be made visible by retracting the peritoneal sac above the psoas muscle. The dissection plan will include the area between the common iliac artery and renal vein. The space will be created in the midst of the iliac vessels, aorta, and ureter by gripping and dissecting with the robotic arms. The final view of the dissected aortic area will include the common iliac arteries, the aorta, the inferior mesenteric artery, and the left renal vein [25]. Care must be taken to identify, isolate, and preserve the inferior mesenteric artery.

19.2.9 Left aortic and paracaval nodal dissection At this point, the left common iliac and aortic lymph nodes will be dissected from the bifurcation of the common iliac artery caudally to the renal vessels cephalad. Following this step, we will continue to elevate the peritoneal sac over the sacral promontory, bifurcation of the aorta, and inferior aspect of the vena cava. The right common iliac artery will be identified and followed caudally to its bifurcation. Then, the right ureter will be identified and lifted up together with the overlying peritoneal sac, thus, separating it from the underlying iliac vessels and psoas muscle. At this stage, the right lateral common iliac nodes, precaval nodes, and presacral nodes will

19.3 Conclusion  

  243

Fig. 19.2: Robotic assisted laparoscopic-extraperitoneal lymphadenectomy procedure. a) Para-aortic lymph node dissection and b) paracaval lymph node dissection

be dissected off (Fig. 19.2). This will complete the high para-aortic nodal dissection; however, some experts prefer a lower retroperitoneal para-aortic lymphadenectomy as metastases above this level are rare in cases with negative infra-mesenteric lymph nodes [28, 37]. Hemostasis will be ensured under low pressure. The upper and bottom limits of the lymph node dissection will be labeled using a 5-mm laparoscopic vascular clip to guide further radiotherapy. The dissected lymph nodes may be retrieved by using a laparoscopic extractor (Coelio-extractor) or an endo-bag.

19.2.10 Marsupialization of the retroperitoneal space At the end of the procedure, a hole in the peritoneum will be created anteriorly of the left ureter to the intra-peritoneal cavity to avoid lymphoceles. Preventive marsupialization must be performed to avoid the formation of a postoperative symptomatic retroperitoneal lymphocyst by inserting a retroperitoneal drainage via the 10-mm port above the symphysis. At the end of the procedure, the fascia of the laparoscopic ports will be closed with interrupted sutures of Polyglactin 2/0 (Doğsan, Turkey) and the skin will be closed with monofilament polyglycolide 4/0 (Doğsan, Turkey) sutures. Then the port sites will be closed with adhesive wound dressing materials (Fig. 19.1).

19.3 Conclusion Advances in radiochemotherapy has allowed for improved control of the disease by adjusting radiation fields in accordance with the extent of the disease.

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  19 Robotic-extraperitoneal lymphadenectomy: A step-by-step approach

The presence of lymph node metastasis is a major prognosis factor influencing survival of LACC patients [5, 38–40]. Therefore, assessing lymph node involvement at the para-aortic level seems appropriate to adjust radiation fields and to tailor individualized treatment for every patient. Although imaging modalities are improving, the gold standard for determining lymph node status is currently surgical sampling. Retroperitoneal lymphadenectomy via laparotomy is associated with perioperative morbidity and it delays initiating radiation therapy. In the extraperitoneal approach, fewer adhesions are observed and the complication risk due to postoperative radiation is very low. Furthermore many adverse effects could be prevented by not entering into the peritoneal cavity particularly postoperative ileus, intraperitoneal adhesion, and intestinal obstruction. Other advantages of the extraperitoneal approach include faster access to the nodal areas and no need for adhesiolysis and intestinal mobilization. Moreover, this approach could decrease the risk of inferior epigastric artery injury and rectum hematoma, and the risks of electrosurgical intestine injury and undetected enterotomy due to dissection and traction could completely be eliminated [29]. Dargent et al reported success rates of transperitoneal, bilateral extraperitoneal, and left extraperitoneal para-aortic lymphadenectomy as 78%, 93%, and 95%, respectively. The authors reported that converting to the transperitoneal approach rates as 24% for the bilateral extraperitoneal and 14% for the left extraperitoneal approach. The average removed aortic lymph node count was 15, and the mean operation time was 119 minutes for the extraperitoneal approach. They concluded that operation time could be decreased by using the left extraperitoneal technique [26]. Although laparoscopy has proven to be feasible, it is still a technically challenging operation. As the robotic da Vinci surgical system provides a steady, threedimensional view, instruments with articulating tips, and less reliance on the surgeon’s movements (increasing accuracy and precision), it could facilitate the retroperitoneal para-aortic lymphadenectomy procedure [41]. Vergote and coworkers reported on the technique and operative results of robotic retroperitoneal para-aortic lymphadenectomy in five patients with IIB or IIIB disease [28]. From the authors’ preliminary experience, robotic para-aortic lymphadenectomy might be more advantageous than standard laparoscopy. Our early experience on LACC patients suggests that para-aortic lymphadenectomy up to the left renal vein is feasible by robotic-assisted laparoscopy. Our experience is limited in its scope due to the relative newness of the technique. Further studies with extended follow up periods are needed to confirm that the robotic extraperitoneal approach is as safe as laparoscopy [42]. Moreover, roboticassisted laparoscopy is currently more expensive than the laparoscopic approach. Therefore, the oncological outcomes and cost effectiveness of this new, MIS approach needs to be verified through prospectively larger series before reaching any definitive conclusions.

References  

  245

References [1] Ferlay J, Bray F, Pisani P, et al. GLOBOCAN 2002. Cancer Incidence, Mortality and Prevalence Worldwide. IARC Cancer Base No. 5, version 2.0. IARC Press, Lyon 2004. [2] Lu KH, BurkeTW. Early cervical cancer. Curr Treat Options Oncol 2000, 1 (2), 147–55. [3] Benedet JL, Bender H, Jones H 3rd, et al. FIGO staging classifications and clinical practice guidelines in the management of gynecologic cancers. FIGO committee on gynecologic oncology. Int J Gynecol Obstet 2000, 70(2), 209–62. [4] Benedet JL. Progress in gynecologic cancer detection and treatment. Int J Gynecol Obstet 2000, 70(1), 135–47. [5] Leblanc E, Narducci F, Frumovitz M, et al. Therapeutic value of pretherapeutic extraperitoneal laparoscopic staging of locally advanced cervical carcinoma. Gynecol Oncol 2007, 105(2), 304–11. [6] Carl UM, Bahnsen J, Wiegel T. Radiation therapy of paraaortic lymph nodes in cancer of the uterine cervix. Acta Oncologica 1993, 32, 63–7. [7] Kim SM, Choi HS, Byun JS. Overall 5-year survival rate and prognostic factors in patients with stage IB and IIA cervical cancer treated by radical hysterectomy and pelvic lymph node dissection. Int J Gynecol Cancer 2000, 10(4), 305–12. [8] Heller PB, Maletano JH, Bundy BN, et al. Clinical-pathologic study of stage IIB, III, and IVA carcinoma of the cervix: extended diagnostic evaluation for paraaortic node metastasis—a gynecologic oncology group study. Gynecol Cancer 1990, 38(3), 425–30. [9] Moore DH. Surgical staging and cervical cancer After 30 years, have we reached a conclusion? Cancer 2008, 112, 1874–86. [10] Haie C, George M, Pejovic MH, et al. Feasibility study of an alternating Schedule of radiotherapy and chemotherapy in advanced uterine cervical carcinoma. Radiother Oncol 1988, 12(2), 121–7. [11] Rotman M, Pajak TF, Choi K, et al. Prophylactic extended-field irradiation of paraaortic lymph nodes in stages 2B and bulky 1B and 2A cervical carcinomas. Ten-year treatment results of RTOG. J Am Med Assoc 1995, 274(5), 387–5. [12] Gold MA, Tian C, Whitney CW, et al. Surgical versus radiographic determination of para-aortic lymphnode metastases before chemoradiation for locally advanced cervical carcinoma: a Gynecologic Oncology Group Study. Cancer 2008, 112, 1954–63. [13] Leblanc E, Gauthier H, Querleu D, et al. Accuracy of 18-fluoro-2-deoxy-D-glucose positron emission tomography in the pretherapeutic detection of occult para-aortic node involvement in patients with a locally advanced cervical carcinoma. Ann Surg Oncol 2011, 18(8), 2302–9. [14] M. Patricklowe, Todd Tillmans. Outpatient laparoscopic extraperitoneal aortic nodal dissection for locally advanced cervical carcinoma. Gynecol Oncol 2008, 111, S24–28. [15] Cosin JA, Fowler JM, Chen MD, et al. Pretreatment surgical staging of patients with cervical carcinoma: the case for lymph node debulking. Cancer 1998, 82(11), 2241–8. [16] Goff BA, Muntz HG, Paley PJ, et al. Impact of surgical staging in women with locally advanced cervical cancer. Gynecol Oncol 1999, 74(3), 436–42. [17] Zanvettor PH, Filho DF, Neves AR, et al. Laparoscopic surgical staging of locally advanced cervix cancer (IB2 to IVA): initial experience. Gynecol Oncol 2011, 120(3), 358–61. [18] Moore KN, Gold MA, McMeekin DS, et al. Extraperitoneal para-aortic lymph node evaluation for cervical cancer via pfannenstiel incision: technique and peri-operative outcomes. Gynecol Oncol 2008, 108(3), 466–71. [19] Sonoda Y, Leblanc E, Querleu D, et al. Prospective evaluation of surgical staging of advanced cervical cancer via a laparoscopic extraperitoneal approach. Gynecol Oncol 2003, 91(2), 326–31.

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20 Robotic surgery for ovarian cancer Lyuba Levine and Gwyn Richardson 20.1 Introduction Approximately 22,000 women will be diagnosed with ovarian cancer and more than 15,500 women will die from their disease in 2012 in the USA [1]. Women have a 1 in 72 lifetime risk of developing ovarian cancer. The 5-year survival rate of women diagnosed with ovarian cancer in the USA was 43.7% from 2002 to 2008 [1]. A patient’s survival rate is directly correlated to the stage at diagnosis. About 15% of patients will have early-stage disease confined to the ovary at the time of diagnosis [2]. Such patients have a much better outcome, with a 5-year survival rate greater than 90% [2]. Patients with advanced disease have a 5-year survival rate close to 25%. Most often, early-stage ovarian cancer is identified at the time of oophorectomy for a presumed benign adnexal mass [3]. The adnexal mass may have been incidentally identified in an asymptomatic patient or discovered in the evaluation of a symptomatic patient. Prior to surgery, most patients will have undergone a thorough history, physical examination and evaluation with radiologic imaging and possibly serum markers such as CA125 [4]. Risk factors for ovarian cancer such as a family history of cancer, increasing age, nulliparity, endometriosis and infertility, will also have been evaluated [4]. Particular findings on radiologic imaging such as papillary projections, solid components or excrescences may raise the index of suspicion for a malignant process [4]. Similarly, a significantly elevated CA125 in a postmenopausal patient may also raise concerns. Most benign-appearing adnexal masses are removed by benign gynecologist and thus patients may have incomplete staging and suboptimal debulking. When presumed early-stage ovarian cancer patients undergo comprehensive surgical staging, almost one-third are upstaged [5]. The International Federation of Obstetrics and Gynecology (FIGO) surgical staging for ovarian cancer includes hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvic and para-aortic lymph node sampling, peritoneal biopsies and peritoneal cytologic washings. Comprehensive surgical staging provides important information to guide treatment planning and patient counseling. Optimal cytoreduction confers a significant survival advantage in patients with advanced ovarian cancer. Traditionally, a vertical midline abdominal incision is used to stage ovarian cancer patients. Such an incision affords excellent exposure to the peritoneal cavity and allows exploration of both the pelvis and upper abdomen. Thorough evaluation of the peritoneum, diaphragm, bowel and its mesentery in addition to the pelvic and upper abdominal structures is required to complete surgical staging. Bowel resection

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and reanastomosis, diaphragmatic stripping and extensive surgery involving upper abdominal structures including the spleen, pancreas or liver may be required to optimally debulk patients with ovarian cancer. Because minimally-invasive surgery (MIS) typically has fewer complications including less blood loss, decreased postoperative pain and quicker recovery, there has been interest in using minimally-invasive techniques to stage patients with ovarian cancer, particularly if they have a low-malignant potential tumor or are earlystage. In patients with diffuse wide-spread metastasis, MIS has not generally been recommended due to the decreased chance of optimal cytoreduction and increased risk of vascular and bowel complications intraoperatively [6]. There are no large randomized-controlled trials comparing traditional laparotomy to MIS in patients with ovarian cancer. The available literature is limited to retrospective reviews, case-control studies and case series. The majority of these studies evaluate traditional laparoscopy [7]. The robotic surgery literature is limited to case reports, retrospective reviews and case series [8]. This chapter reviews the potential use of robotic surgery in staging low-malignant potential (LMP) ovarian tumors, early-stage invasive ovarian cancer and a potential utility for patients with advanced ovarian cancer. The chapter also reviews several pitfalls of MIS in ovarian cancer including inadequacy of staging, risk of cyst rupture, port-site metastasis and tumor cell dissemination with carbon dioxide pneumoperitoneum. The vast majority of the studies available that involve MIS are laparoscopic studies. Results from case series, retrospective reviews and case-control studies indicate that ovarian cancer staging for low-malignant potential tumors and early-stage cancers is both safe and effective.

20.2 Benefits of minimally-invasive surgery When compared to laparotomy, MIS for borderline and early ovarian cancer offers a number of benefits. Previous randomized and retrospective studies in endometrial cancer suggest that laparoscopic staging offers shorter hospital stay, less blood loss and fewer postoperative complications including earlier return of bowel function when compared to laparotomy [9–10]. Although no randomized data exists for patients with early-stage or low-malignant potential ovarian cancer, the bulk of retrospective data suggests these benefits can be extrapolated to include patients undergoing comprehensive staging for early ovarian cancer.

20.3 Low-malignant potential or borderline ovarian tumors Low-malignant potential tumors comprise up to 15% of early-stage ovarian cancers. Most of these tumors are confined to the ovary and patients have a greater than

20.3 Low-malignant potential or borderline ovarian tumors  

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95% 5-year survival rate [11]. Low-malignant potential tumors frequently occur in premenopausal women aged 30 to 50 years with up to 85% of patients diagnosed with stage I cancers [12]. A prior study of over 300 patients of varying histologic subtypes found up to 30% of patients diagnosed with low-malignant potential tumors at the time of frozen section were subsequently found to have invasive ovarian cancer on final pathology [13]. Low-malignant potential tumors are most commonly serous and mucinous histologic subtypes. Up to 30% of serous tumors are bilateral with concurrent peritoneal involvement in 35% of cases [14]. Almost 42% of patients with serous tumors had nodal involvement in one study [15]. In contrast, very few mucinous low-malignant potential tumors have lymph node involvement [16]. Frequently appendiceal primaries are identified in patients with mucinous low-malignant potential ovarian tumors, so appendectomy is recommended [11]. Because many patients with low-malignant potential tumors desire future fertility, efforts have been made to use minimally-invasive techniques to decrease adhesion formation and theoretically improve fertility [17]. The literature involving staging of patients with low-malignant potential tumors using minimally-invasive techniques shows promising results but is limited to case series and retrospective analysis. Several case series have been published analyzing the clinical outcome of patients undergoing laparoscopic staging of low-malignant potential ovarian tumors. The largest retrospective cases series to date suggested that laparoscopy had a higher rate of incomplete staging and cyst rupture [18]. In this study, Fauvet et al analyzed data from 358 women who underwent surgery for low-malignant potential tumors at multiple institutions in France. One hundred and forty-nine (41%) of women underwent laparoscopy were compared to 209 women who underwent laparotomy. Forty-two women underwent conversion from laparoscopy to laparotomy because of suspected ovarian cancer or large tumor volume. Women who underwent laparoscopy were more likely to have undergone conservative surgery (unilateral cystectomy, bilateral cystectomy and unilateral salpingoophorectomy) than the laparotomy group (68.9% vs. 31.6%, respectively), which likely explains the lower rate of complete surgical staging. Mean followup was 27.5 months with 100% survival and only four patients with evidence of disease. A later retrospective study compared 61 patients who underwent laparotomy vs. 52 patients who underwent laparoscopy and did not find a difference in progression-free survival with a mean follow-up of 44 months [19]. Additional studies support laparoscopic surgical staging of low-malignant potential tumors (Tab. 20.1). Lenhard et al reported on their long-term followup of patients who underwent staging via laparotomy (n = 95) or laparoscopy (n = 18) [20]. The mean follow-up was 9.6 years and the recurrence rate was similar in women who underwent conservative surgery (10.5%) and those who underwent traditional surgical staging (10%), which is in contrast to the study by Fauvet.

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  20 Robotic surgery for ovarian cancer

Tab. 20.1: Laparoscopic management of borderline ovarian tumors Author

Darai et al 1998 [21] Querleu et al 2003 [22] Camatte et al 2004 [23] Fauvet et al 2005 [18] Romagnolo et al 2006 [19] Lenhard et al 2009 [20]

No. of Conversions Complications Mean Recurrences Survival n patients to laparotomy (n) follow-up n (%) (%) n (%) (months) 25

7 (28)

0

41

 3 (12)

23 (92)

30

0

3

29.1

 1 (3.2)

30 (100)

34

0

0

45

 6 (17.7)

34 (100)

0

27.5

149

42 (28.2)

52

0

–

44

18

0

–

115.2

13 (12.1)  107 (100)  7 (13.5)  51 (98.1)  1 (5.5)

 18 (100)

The overall survival rate of patients undergoing laparoscopic staging for borderline tumors of the ovary approaches 98%. Continued evaluation of long-term outcome should occur but initial studies show promise for minimally-invasive techniques to stage low-malignant potential tumors.

20.4 Early-stage invasive ovarian cancer Approximately 15% of women will have early-stage ovarian cancer at diagnosis. The diagnosis of early ovarian cancer is frequently made incidentally at the time of surgery for another indication. In such cases, complete surgical staging provides important prognostic information, avoids understaging patients and guides treatment recommendations. Traditionally, patients undergo total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, peritoneal biopsies, pelvic and paraaortic lymph node dissection and peritoneal washings. If complete staging is not performed at the time of initial surgery, a restaging procedure via laparaoscopy or laparotomy is recommended. As MIS has become more prevalent, recent studies have sought to address its appropriateness for patients with early ovarian cancer. Staging for early ovarian cancer requires careful inspection of the peritoneum, pelvic and abdominal structures and lymph node dissection. To determine whether MIS is feasible to stage early ovarian cancers several issues must be addressed: the frequency of complications, the frequency of conversion to laparotomy and the recurrence rate after minimallyinvasive staging [6]. Due to the rarity of early-stage ovarian cancer and difficulty in early diagnosis, a randomized controlled trial has not been possible. However, several case reports and series have been published.

20.4 Early-stage invasive ovarian cancer  

  253

The first case report of laparoscopic restaging in early-stage invasive ovarian cancer was published in 1994. The retrospective report included complete pelvic and paraaortic lymph node dissection in a case series of nine patients undergoing restaging procedures for either fallopian tube or ovarian cancer [24]. Patients in this study had a mean blood loss of 300 mL and a hospital stay of 2.8 days. A prospective study published in 1995 of 14 patients undergoing primary or restaging early ovarian cancer confirmed a shorter hospital stay and suggested similar accuracy rates between laparoscopy and laparotomy based on an upstaging rate of 57% (8/14), which was slightly greater than the published laparotomy rate at the time [25]. In particular, the authors found that the magnification of the hemidiaphragm using laparoscopy might yield a higher detection rate than palpation used at laparotomy. Studies published since then have sought to address potential complications, conversion to laparotomy and survival data. Three case control series were published by 2008 that compared laparotomy and laparoscopy. Chi et al reported 20 laparoscopic patients with 30 laparotomy patients who underwent primary surgery or restaging procedures [26]. Nodal counts, rate of upstaging, complication rate and omental specimen size were similar between the two groups. Hospital stay and blood loss were less in patients undergoing laparoscopy but the mean surgery time was 321 min compared to 276 min in the laparotomy group. Ghezzi et al compared 17 patients undergoing laparoscopy with 17 patients undergoing laparotomy and found no difference in nodal count, complication rate or likelihood of metastatic disease [27]. Park et al reported on a more rapid return of bowel function with less postoperative complications in patients undergoing laparoscopic procedures [28]. The Gynecologic Oncology Group evaluated the feasibility of laparoscopic completion of surgical staging in patients with incompletely staged ovarian, fallopian tube, endometrial and primary peritoneal cancer in Protocols 9,302 and 9,402 [29]. Seventy-four of 84 eligible patients had ovarian, fallopian tube or primary peritoneal cancers. Fifty-eight patients underwent complete laparoscopic staging, confirmed with photographic documentation. Nine patients were incompletely staged laparoscopically secondary to lack of bilateral lymph nodes, cytology or peritoneal biopsies. Seventeen patients underwent laparotomy: 13 because of extensive adhesive disease, three because of complications and one because of macroscopic metastatic disease. Among patients treated laparoscopically, five patients had a bowel injury, one had a cystotomy, one developed a small bowel obstruction, one had a venotomy and two required a blood transfusion. Compared to patients undergoing laparotomy, patients who underwent laparoscopic staging had a significantly shorter hospital stay, less blood loss and comparable nodal counts. Most recently, Ghezzi et al published the results of a multi-institutional cohort evaluating laparoscopic staging of early ovarian cancer [30]. No patients were converted intraoperatively to laparotomy. Only one patient had an intraoperative hemorrhage requiring transfusion. One patient did require a reoperation that included a laparotomy

254  

  20 Robotic surgery for ovarian cancer

for a retroperitoneal hematoma identified 7 hours after her initial surgery. Thirty-four of 82 women had reached or exceeded 3-year follow-up with a 97% 3-year survival rate and 91.2% disease free survival rate. Table 20.2 summarizes the laparoscopic literature for early ovarian cancer staging.

20.5 Advanced-stage invasive ovarian cancer Given the multiple complicated surgeries typically involved in cases of advanced ovarian cancer, MIS has not generally not been recommended [6]. Magrina et al recently reported a retrospective case-control study of 25 patients who underwent primary surgical debulking via robotic approach, 27 patients who underwent debulking via laparoscopic approach and 119 patients who were surgically debulked via laparotomy [31]. Sixty and 75 percent of patients had stage III or IV disease in the robotic and laparoscopy groups, respectively, and 87 percent of the laparotomy group patients were stages III and IV. The rest of the patients had stage I and II disease. Patients were categorized based on the extent of surgery and number of procedures required to achieve optimal cytoreduction. Complete cytoreduction was defined as no remaining visible disease at the end of the procedure. The robotics group took significantly longer (315 min) compared to the laparoscopy (254 min) or laparotomy (261 min) groups. However, the robotics group had less blood loss and a shorter hospital stay than either the laparoscopy or laparotomy group. Optimal debulking was achieved in 84% of patients in the robotic group, 93% of patients in the laparoscopic group and 56% of the laparotomy group (P < 0.001). After 3 years, there was no difference in the overall survival among the three groups. Among patients requiring one major additional surgical procedure, the authors recommend robotic or laparoscopic approach for primary tumor debulking. If patients require more than two or major surgical procedures, then the authors recommend an open procedure. Because of the inherent patient selection bias in choosing patients for each surgical method and the retrospective nature of the data, the results must be interpreted and used with caution.

20.6 Considerations The use of robotic surgery in ovarian cancer has been primarily recommended for borderline tumors and an early-stage ovarian cancer. MIS has not been recommended for advanced ovarian cancer with gross metastatic disease due to low likelihood of optimal tumor debulking and increased risk of surgical complications especially with liver involvement [32]. Port-site metastasis are still of concern as well as effect of CO2 pneumoperitoneum on tumor growth, tumor rupture and associated peritoneal seeding. The risk of port-site metastasis has been evaluated in several retrospective series and reported to be 1 to 2%.

Ghezzi et al 2012 [30] 82

36: 9 restaging

Nezhat et al 2009 [33]

263

229

303.8

17: 6 restaging

Park et al 2007 [28]

100

195

231.2

n/a

377

n/s

n/a 235

50% of circumference Transection of colon (a) Transection of the colon with segmental tissue lost (b) Devascularized segment

Primary repair

II III IV

Primary repair Resection + anastomosis Resection + anastomosis (resection should be continued until the well-perfused edge are obtained)

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  29 Gynecology-related general surgery

Resection and anastomosis In grade III and IV (destructive) injuries, resection to normal and well-perfused edges should be performed, and the anastomosis should be tension free. One or two layer anastomosis can be done with continuous or interrupted 3/0 or 4/0 silk or absorbable suture. Also GIA and Endo-GIA staples can be used. Colostomy Until recently, several guidelines suggest that patients who have had blood transfusions >6 units, delays of operations >6 h, shock at admission and destructive colon injury (scale 3–4) resection and colostomy occurs [11, 12, 18, 19]. The American Society of Colon and Rectal Surgeons (ASCRS) suggest, however, that the only indications for colostomy are the presence of severe colon edema or a questionable blood supply of the colon [15].

29.2.4 Rectal injury Rectal injury is more common during vaginal surgeries. The rate of the iatrogenic rectal injury during gynecologic operation is reported between 1.4% and 2.1% [11].

29.2.5 Stomach Injury Stomach injuries are relatively lower than bowel injuries. It is reported 1 in 3,000 cases [5, 20]. Prior to upper abdominal surgery, a distended stomach may increase the risk of injury. An orogastric or nasogastric tube should be placed before Veress or trocar insertion. The defect can be over sewn with a interrupted or continuous delayed absorbable suture by robotic arms or laparoscopically or laparotomy. The abdominal cavity should be irrigated and antibiotherapy should be given. The nasogastric tube usually stays in place until bowel movements begin [21]. Management of undiagnosed injury In the postoperative period if the patient has signs of sepsis, gastrointestinal injuries should be always suspected. On the postoperative third or fourth day the patient generally presents with abdominal pain, high temperature, nausea, and anorexia (Tab. 29.3). Usually, the patient’s bowel movements decrease. White blood cell count increases or decreases. Radiograms reveal multiple air and fluid levels or air under the diaphragm. Further radiologic examinations may be needed, e.g., ultrasonography or abdominopelvic computerize tomography (CT) with a contrast agent. If rectal injury is suspected, a water soluble contrast enema with CT should be used. The patient should be hydrated well and antibiotic therapy should be started promptly.

29.3 Prevention of gastrointestinal injury  

  377

Tab. 29.3: Symptoms of undiagnosed injury Abdominal pain Abdominal distention Trocar pain Leukopenia/Leucytosis Diarrhea Ileus Fever Nausea Vomiting

The patient should be operated upon immediately [5, 10, 13, 14, 17]. Exploration can be done laparoscopically or by laparotomy. The injured bowel should be excised with or without diversion. All necrotic tissues should be resected. The abdomen should be irrigated with copious saline [9, 12, 22]. Oral regimen should not be started until the bowel movements begin.

29.3 Prevention of gastrointestinal injury There are some precautions that can prevent injuries [10, 17, 22]. 1. If the patient has abdominal surgery history, the first port should be placed with an open-entry technique. 2. Inspection of the bowel under the entry site can prevent undiagnosed injury. 3. Gentle and careful tissue dissection is very important. 4. Using atramatic instruments for bowel handling decreases bowel injury. 5. If bowel injury is suspected, exploration of all the bowel beginning from the treizt ligaman should be done. 6. Electrothermal devices should be used carefully.

References [1] Smith AL, Krivak TC, Scott EM, et al. Dual-console robotic surgery compared to laparoscopic surgery with respect to surgical outcomes in a gynecologic oncology fellowship program. Gynecol Oncol 2012, 126(3), 432–6. [2] Weinberg L, Rao S, Escobar PF. Robotic surgery in gynecology: an updated systematic review. Obstet and Gynecol Int 2011, 852061. [3] Backes FJ, Brudie LA, Farrell MR, et al. Short- and long-term morbidity and outcomes after robotic surgery for comprehensive endometrial cancer staging. Gynecol Oncol 2012, 125(3), 546–51. [4] Cho JE, Shamshirsaz AH, Nezhat C, et al. New technologies for reproductive medicine: laparoscopy, endoscopy, robotic surgery and gynecology. A review of the literature. Minerva Gynecol 2010, 62(2), 137–67.

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  29 Gynecology-related general surgery

[5] Sharp HT, Swenson C. Hollow viscus injury during surgery. Obstet Gynecol Clin North Am 2010, 37(3), 461–7. [6] van der Voort M, Heijnsdijk EA, Gouma DJ. Bowel injury as a complication of laparoscopy. Br J Surg 2004, 91(10), 1253–8. [7] Chapron C, Pierre F, Harchaoui Y, et al. Gastrointestinal injuries during gynaecological laparoscopy. Hum Reprod 1999, 14(2), 333–7. [8] Brosens I, Gordon A, Campo R, et al. Bowel injury in gynecologic laparoscopy. J Am Assoc Gynecol Laparosc 2003, 10(1), 9–13. [9] Lam A, Kaufman Y, Khong SY, et al. Dealing with complications in laparoscopy. Best pract Res Clin Obstet Gynaecol 2009, 23(5), 631–46. [10] Nezhat CR, Nezhat FR, Nezhat C, et al. Complications. In: Operative Gynecologic Laparoscopy Principles and Techniques. Second Edition edn. Edited by CR N. New York: McGraw Hill Medical Publishing Division, 2000, 365–386. [11] Mendez LE. Iatrogenic injuries in gynecologic cancer surgery. Surg Clin North Am 2001, 81(4), 897–923. [12] Sweeney KJ JM, Geraghty JG. Management of intra-operative bowel injuries. CME J Gynecol Oncol 2002, 7, 178–82. [13] Bishoff JT, Allaf ME, Kirkels W, et al. Laparoscopic bowel injury: incidence and clinical presentation. J Urol 1999, 161(3), 887–90. [14] Winter WE, Cosin JA. Management of intraoperative injuries to the gastrointestinal tract in radical gynecologic surgery. CME J Gynecol Oncol 2002, 7, 187–93. [15] Hoyt DB LM. Trauma of the colon and rectum. In: The ASCRS Textbook of Colon and Rectal Surgery. Second Edition edn. Edited by Beck DE, Roberts PL, Saclarides TJ, Senagore AJ, Stamos MJ, Wexner SD. New York: Springer, 2011. [16] LN D. Stomach and small bowel. In: Trauma. 6th Edition. edn. Edited by Feliciano DV MK, Moore EE. New York: McGraw-Hill, 2008, 682–700. [17] Li TC, Saravelos H, Richmond M, et al. Complications of laparoscopic pelvic surgery: recognition, management and prevention. Hum Reprod Update 1997, 3(5), 505–15. [18] Pasquale M, Fabian TC. Practice management guidelines for trauma from the eastern association for the surgery of trauma. J Trauma 1998, 44(6), 941–56, discussion 956–47. [19] Chappuis CW, Frey DJ, Dietzen CD, et al. Management of penetrating colon injuries. A prospective randomized trial. Ann Surg 1991, 213(5), 492–7, discussion 497–8. [20] Taylor R, Weakley FL, Sullivan BH, Jr. Non-operative management of colonoscopic perforation with pneumoperitoneum. Gastrointest Endosc 1978, 24(3), 124–5. [21] Sharp HT, Dodson MK, Draper ML, et al. Complications associated with optical-access laparoscopic trocars. Obstet Gynecol 2002, 99(4), 553–5. [22] Nezhat F, Nezhat CH, Admon D, et al. Complications and results of 361 hysterectomies performed at laparoscopy. J Am Coll Surg 1995, 180(3), 307–16.

30 Ophthalmology and steep Trendelenburg position Giovanni Taibbi and Gianmarco Vizzeri 30.1 Introduction Robotic-assisted gynecological surgery is conducted in a steep Trendelenburg position for several hours. As head-down tilt is not a physiological posture, questions related to the safety of this surgical approach on the visual system may arise. In fact, data from bed-rest studies and reports from different surgical specialties indicate that ophthalmological changes may occur when the body is placed in a recumbent position. In this chapter, we describe the effects of head-down tilt on the ocular structures and the possible complications that may arise when surgery is performed in a steep Trendelenburg position.

30.2 Posture-induced ocular changes Posture-induced ocular changes are largely described for different angles of tilt and time lengths. The majority of data derive from bed-rest studies designed to investigate the relationship between body position and intraocular pressure (IOP). For example, short-duration (from 2 min to 48 h) bed-rest studies indicate that IOP immediately increases when the body is placed in a recumbent position, with a rise in IOP that ranged from 2 to 5 mmHg for body angles between 0° and –50° [1–6]. In general, the amount of IOP elevation correlates with the angle of tilt. In addition, posture-induced IOP changes may be more pronounced in patients with glaucoma [7]. Although the underlying mechanisms need to be fully elucidated, cephalad shifts of body fluids in response to tilt may increase episcleral venous pressure, causing an increased resistance to aqueous humor outflow [8]. Moreover, headdown tilt causes choroidal vascular engorgement. This expansion against the rigid sclera (the outermost ocular layer), leads to ocular compression and subsequent IOP elevation [5, 9, 10]. Quick Hit: Elevated IOP may be harmful in predisposed individuals. There is consensus that the risk of developing glaucoma increases substantially with the degree of IOP elevation [11]. However, there is conflicting evidence with regard to the effects of “short-term” IOP fluctuations (i.e., IOP changes occurring within the same day), and glaucoma development or progression [12]. Bed-rest studies suggest that increased IOP may be associated with a drop in heart rate and a significant gradual reduction in blood pressure [3, 4, 6]. A limited number of experiments have been conducted to evaluate the effect of postural changes on ocular perfusion pressure (OPP, defined as mean blood pressure minus IOP) and choroidal blood flow (ChBF) [3, 4, 6]. Although there is no direct

380  

  30 Ophthalmology and steep Trendelenburg position

evidence, it is conceivable that, after a possible initial increase, both OPP and ChBF may subsequently decrease in response to head-down tilt with the presence of limited or no autoregulatory mechanisms. OPP increased in response to 2, 21 and 30 min of body tilt at –8° [3], –15° [4], and 0° [6], respectively. In one study, there was an 11% increase in ChBF after 2 min at –8° head-down tilt [3]. However, in another study, Kaeser et al reported a 12% decrease in ChBF after 30 min in a supine position; ChBF plotted against OPP demonstrated that both variables decreased uniformly [6]. The disparate findings can be partially explained by differences in study design and data collection at various time points and by difficulties in obtaining accurate and reproducible measurements. Further studies are required to better characterize posture-related changes in ocular blood flow. In summary, head-down tilt position may cause an increase in IOP associated with a reduction in blood pressure. This finding may be particularly relevant for patients with cardiovascular risk factors undergoing robotic-assisted surgical procedures, since their optic nerves may suffer an acute ischemic insult, likely due to insufficient blood supply coupled with elevated IOP. As discussed below, ischemic optic neuropathy is a cause of permanent perioperative vision loss (POVL) after nonocular surgeries [13].

30.3 Postoperative ophthalmological complications To our knowledge, there are no available reports of ophthalmological complications after robotic-assisted gynecological surgery. This may be due to the fact that gynecological robotic surgery is a relatively novel surgical approach and such reports are not yet available. It is possible that this surgical approach may be safe and well tolerated with little or no ophthalmological complications. However, to date no studies have been performed to test the safety of surgery conducted in steep Trendelenburg positions on ocular structures and visual function. A case of unilateral anterior ischemic optic neuropathy possibly associated with gynecological surgery has been recently described [14]. The patient complained of monocular vision loss upon awakening from a laparotomy performed 36 h apart from a previous hysterectomy that was complicated by substantial abdominal hemorrhage. The hysterectomy was conducted in the Trendelenburg position for an unspecified period of time. Of note, on ophthalmological exam the patient was found to have small optic discs, an anatomical feature possibly associated with an increase in the incidence of ischemic optic neuropathy. At 3-year follow-up, visual acuity in the affected eye had further decreased from 20/25 to 20/32, there was a superior altitudinal visual field defect and the optic disc appeared diffusely pale on ophthalmoscopic examination. Quick Hit: Anterior ischemic optic neuropathy (AION) is classified in nonarteritic (NA-AION) AND arteritic (A-AION). NA-AION is caused by transient ischemia or, in rare cases, by an embolism to the arterial vessels feeding the anterior segment of the optic nerve. The degree of visual impairment depends on the extent and duration

30.4 Ophthalmological patient management  

  381

of the ischemic event. There is no established treatment for postoperative NA-AION and prognosis varies, with mild improvement in visual function over time still possible in some cases. A-AION is primarily caused by giant cell arteritis. It left untreated, it rapidly leads to blindness. High doses of systemic corticosteroid therapy must be immediately established when there is a reasonable index of suspicion of A-AION. Robotic-assisted surgery is not limited to gynecology. It is being increasingly used in other surgical specialties, such as urology. Weber et al described two cases of posterior ischemic optic neuropathy after minimally-invasive prostatectomy, one of which was robotic-assisted [15]. Both surgeries were performed in the steep Trendelenburg position for a prolonged time (>6.5 h). Given the similarities between gynecology and urology with regard to the use of robotic technology and patient positioning, it is possible that similar complications may occur after gynecological procedures. Ocular complications following non-ophthalmic conventional surgery are well described. As discussed below, the cornea is most commonly involved, usually without permanent visual impairment [16]. However, in rare cases, permanent POVL resulted from ischemic optic neuropathy (anterior or posterior), retinal vascular occlusion (central artery or vein), pituitary apoplexy, or cortical infarction [13, 17–19]. Several factors, including prone head-down positioning, operative time, direct external compression of the eye, substantial blood loss, anemia, decreased blood pressure, systemic vascular risk factors, ocular/cerebral microemboli, or small optic disc size, have been suggested to explain the occurrence of POVL. Given the rare incidence of POVL (from 0.002% among all nonocular surgeries to 0.2% of cardiac and spine surgeries) [13], prospective controlled studies aimed at evaluating specific risk factors for POVL are not available, and current knowledge mainly derives from retrospective chart reviews or case reports. For the interested reader, more detailed discussions pertaining to POVL after nonocular surgery are referenced at the end of this chapter.

30.4 Ophthalmological patient management Based on currently available evidence, following are recommendations that might help prevent ocular complications in patients undergoing robotic-assisted gynecological surgery.

30.4.1 Preoperative evaluation A pre-operative ophthalmological evaluation should be performed to assess the risk of POVL and to evaluate the presence of glaucoma or ocular hypertension. Attention should be paid to history of ocular ischemic events and potential risk factors for POVL such as a small optic disc size and small cup to disc ratio [18]. Surgeons should adequately inform patients with regard to possible ophthalmological

382  

  30 Ophthalmology and steep Trendelenburg position

changes, including vision loss, along with other complications associated with steep Trendelenburg positions. This is particularly important in cases in which a longer operation is expected or when significant blood loss is anticipated. Patients should be informed that IOP will likely increase intraoperatively as a result of the steep Trendelenburg position. The amount of change in IOP is dependent on multiple factors, such as the angle of tilt or the time spent in the recumbent position, and cannot be accurately predicted. Although at present the relationship between “short-term” IOP fluctuations and glaucoma onset or disease progression has not yet been fully characterized, there is strong evidence in support of elevated IOP as a risk factor for the development and progression of glaucoma [11]. Therefore, in patients with a diagnosis of glaucoma or ocular hypertension, the risk of glaucoma progression associated with robotic-assisted surgery should not be ignored, although it is not quantifiable at this time.

30.4.2 Intraoperative period During a surgical procedure, the eyes should be periodically evaluated to ensure that corneas are adequately protected. Corneal abrasions are the most common ocular complication of non-ophthalmic surgery [16]. The American Society of Anesthesiologists’ Closed Claim Project reports that the corneal abrasions account for 35% of general anesthesia ocular injuries [20]. Damage to the ocular surface is generally caused by incomplete eyelid closure leading to tear film evaporation and corneal drying, though accidental trauma caused by the operating room staff and the surgical instrumentation has also been implicated. General anesthesia predisposes patients to corneal injury. Under general anesthesia, tear production is significantly decreased and the eyelids usually are not completely closed, particularly in the steep Trendelenburg position. Applying paraffin-based or methylcellulose ointments on the cornea and taping the eyelid closed for the duration of the operation are preventive measures used to minimize the likelihood of corneal abrasion postoperatively. Monitoring the systemic arterial pressure may be a useful measure to minimize the intraoperative risk of ocular hypoperfusion and optic nerve ischemia. The Task Force on Perioperative Vision Loss established by the American Society of Anesthesiologists emphasizes the importance of continuous blood pressure monitoring in high-risk patients undergoing spine surgery, which is frequently performed in a prone position under some degree of head-down tilt [21].

30.4.3 Postoperative assessment Patients’ complaints of vision loss postoperatively should never be underestimated or ignored. Vision should be first evaluated upon awakening from anesthesia (e.g., in the recovery room or intensive care unit). Particular attention should be

30.5 Conclusions  

  383

given to those patients who lost a significant amount of blood and/or underwent prolonged procedures. Prompt ophthalmological consult is warranted when ocular changes (e.g., decreased vision, altered color perception, red eyes) are noticed by the patient and/or the medical staff. Finally, clinicians should be aware that ocular signs/symptoms may be delayed up to 7–10 days postoperatively [19, 22]. Therefore, patients need to be advised to seek additional care should they experience decreased vision or other ocular symptoms upon discharge.

30.5 Conclusions –

– –

–

There is evidence that IOP increases when the body is placed in a recumbent position. It is unclear whether head-down tilt may produce other ocular structural and functional changes. At present, there are no studies that have evaluated the ocular safety of surgery performed in steep Trendelenburg positions. POVL is a rare, vision-threatening complication of general non-ophthalmological surgery. Although there are no reports of POVL after robotic-assisted gynecological surgery, some cases of POVL after procedures conducted in the steep Trendelenburg position have been described. It is advised that a pre-operative ophthalmological evaluation be performed to assess the risk of POVL and evaluate the presence of glaucoma or ocular hypertension.

30.6 Acknowledgements The authors wish to thank Thomas Jennings, MD for his thoughtful suggestions during the preparation of this chapter.

References [1] Carlson KH, McLaren JW, Topper JE, et al. Effect of body position on intraocular pressure and aqueous flow. Invest Ophthalmol Vis Sci 1987, 28(8), 1346–52. [2] Frey MA, Mader TH, Bagian JP, et al. Cerebral blood velocity and other cardiovascular responses to 2 days of head-down tilt. J Appl Physiol 1993, 74(1), 319–25. [3] Longo A, Geiser MH, Riva CE. Posture changes and subfoveal choroidal blood flow. Invest Ophthalmol Vis Sci 2004, 45(2), 546–51. [4] Xu X, Cao R, Tao Y, et al. Intraocular pressure and ocular perfusion pressure in myopes during 21 min head-down rest. Aviat Space Eviron Med 2010, 81(4), 418–22. [5] Mader TH, Taylor GR, Hunter N, et al. Intraocular pressure, retinal vascular and visual acuity changes during 48 hours of 10 degrees head-down tilt. Aviat Space Eviron Med 1990, 61(9), 810–3.

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[6] Kaeser P, Orgül S, Zawinka C, et al. Influence of change in body position on choroidal blood flow in normal subjects. Br J Ophthalmol 2005, 89(10), 1302–5. [7] Prata TS, De Moraes CG, Kanadani FN, et al. Posture-induced intraocular pressure changes: considerations regarding body position in glaucoma patients. Surv Ophthalmol 2010, 55(5), 445–53. [8] Friberg TR, Sanborn G, Weinreb RN. Intraocular and episcleral venous pressure increase during inverted posture. Am J Ophthalmol 1987, 103(4), 523–6. [9] Kergoat H, Lovasik JV. Seven-degree head-down tilt reduces choroidal pulsatile ocular blood flow. Aviat Space Environ Med 2005, 76(10), 930–4. [10] Weinreb RN, Cook J, Friberg TR. Effect of inverted body position on intraocular pressure. Am J Ophthalmol 1984, 98(6), 784–7. [11] Weinreb RN, Khaw PT. Primary open-angle glaucoma. Lancet 2004, 363(9422), 1711–20. [12] Bagga H, Liu JH, Weinreb RN. Intraocular pressure measurements throughout the 24 h. Curr Opin Ophthalmol 2009, 20(2), 79–83. [13] Newman NJ. Perioperative visual loss after nonocular surgeries. Am J Ophthalmol 2008, 145(4), 604–10. [14] Stoffelns BM. Anterior ischemic optic neuropathy due to abdominal hemorrhage after laparotomy for uterine myoma. Arch Gynecol Obstet 2010, 281(1), 157–60. [15] Weber ED, Colyer MH, Lesser RL, et al. Posterior ischemic optic neuropathy after minimally invasive prostatectomy. J Neuroophthalmol 2007, 27(4), 285–7. [16] White E, Crosse MM. The aetiology and prevention of peri-operative corneal abrasions. Anaesthesia 1998, 53(2), 157–61. [17] Berg KT, Harrison AR, Lee MS. Perioperative visual loss in ocular and nonocular surgery. Clin Ophthalmol 2010, 4, 531–46. [18] Roth S. Perioperative visual loss: what do we know, what can we do? Br J Anaesth 2009, 103 Suppl 1, i31–40. [19] Williams EL. Postoperative blindness. Anesthesiol Clin North Am 2002, 20(3), 605–622, viii. [20] Gild WM, Posner KL, Caplan RA, et al. Eye injuries associated with anesthesia. A closed claims analysis. Anesthesiology 1992, 76(2), 204–8. [21] American Society of Anesthesiologists Task Force on Perioperative Visual Loss. Practice advisory for perioperative visual loss associated with spine surgery: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Visual Loss. Anesthesiology 2012, 116(2), 274–85. [22] Buono LM, Foroozan R. Perioperative posterior ischemic optic neuropathy: review of the literature. Surv Ophthalmol 2005, 50(1), 15–26.

31 The future of telesurgery and new technology Emilio Ruiz Morales, Stefano Gidaro and Michael Stark 31.1 Introduction Ephraim McDowell in Kentucky was the first to perform a successful laparotomy at the beginning of the 19th century [1]. Just before the beginning of the 20th century Johannes Pfannenstiel described the transverse abdominal incision which improved the surgical outcome [2]. As tradition prevails, the first known comparison of the two methods was done not before 1971 [3]. At the beginning of the 20th century Georg Kelling in Germany [4] introduced the experimental endoscopy which was developed throughout the century along with the introduction of endotracheal intubation [5], and the development of other instruments, the insufflators and light sources [6]. At the end of the 20th century it looked as if most the abdominal operations had endoscopic alternatives [7], such as nephrectomies [8], cholecystectomies [9], appendicectomies [10] and splenectomies [11]. It was shown that patients undergoing endoscopic procedures present decreased morbidity with shorter hospital stay and need less postoperative analgesics [12]. Two new developments emerged during the last years with the intention to improve surgical outcomes, namely natural orifice surgery and telesurgery. Gastroenterologists started to perforate the stomach as an entry into the abdominal cavity and had already performed experimentally various procedures such as partial hysterectomy [13], oophorectomy [14] and tubal ligation [15]. This approach however implies technical difficulties such as the small given size of the possible instruments used due to the limited diameter of the esophagus as well as pharmacological problems due to the acidity of the stomach, as well as technical problems concerning the closure of the perforated stomach. The use of the pouch of Douglas as an entry to the abdominal cavity is another potential approach [16]. Due to the lack of abdominal scars these developments seem promising, and prospective comparative studies will prove if these methods will improve surgical outcome. The development of telesurgery is supported by the fast progress in mechanics and electronics in the last years. The term “robotic” used by many to refer to these systems is questionable. These systems are not equipped with artificial intelligence, although it is probable it will be added in the future, and therefore in this chapter the more preferred descriptive term is “telesurgery”. In 1988 the PUMA system was used for the first time in a neurosurgical biopsy guided by computer tomography [17].

386  

  31 The future of telesurgery and new technology

Other systems in use today or in the past are the PROBOT [18], ROBODOC [19], ZEUS [20] and the da Vinci® system (Intutitive Surgical Inc, Sunnyvale, CA, USA) [21]. The usage of today’s telesurgical systems proved beneficial in certain procedures, and questions are raised as to the added value of using these systems in certain operations like radical hysterectomy or sacrocolpopexy. It seems that the outcome is equivalent to endoscopy and laparotomy, but it shows that the procedures increase the operation time and costs [22]. The advantages of the existing telesurgical systems are 3D stereo-vision with augmented reality, accuracy, filtration of the surgeons hands tremor, improved ergonomics, and the potential of operating from remote sites. The main disadvantages of the existing systems are lack of haptic feedback, restriction to specific indications next to long docking time and high initial investments and maintenance costs. In some systems the access to the patient is limited, and the trans Douglas access is not possible. Haptic sensation is an integral part of any surgical procedure, including laparotomy. The surgeon can use the tips of his/her fingers to palpate anatomical or pathological findings, looking for lymph glands, and control the traction force exerted on the suture material. Haptic sensation during surgery should be part of an optimal telesurgical system, despite claimed similarities between visual force feedback and haptic feedback [23]. Physiologically, fingertips are one of the most sensitive areas in the human body, making palpation a useful characteristics in surgery. Musicians use their fingertips to produce sounds and when playing strings can feel the vibrations through their fingers. Most of the delicate craftsmanship’s professions activities are performed through the fingertips. In surgery it was the same until the introduction of endoscopy, when the fingertips were abandoned in favor of the fists, and indeed, most of today’s endoscopic tools are controlled with the fists or the proximal part of the fingers. Today’s telesurgical systems proved beneficial in a limited number of procedures. In a recent review article, the question was raised what was the added value of use of telesurgical systems in certain gynaecological operations (radical hysterectomy and sacrocolpopexy). It was shown that the outcome is equivalent to endoscopy and laparotomy. It was stressed that the procedures increase the time of the operation as well as the costs [22]. Longer operation times and higher costs were shown also in hysterectomies [24]. In ophthalmological operations, a telesurgical system proved to be less sufficient for standard operations compared to an ophthalmic microscope [25]. Telesurgical systems were found however to be optimal for procedures like bariatric operations in extremely obese patients [26]. Obviously, the next telesurgical systems should provide benefits in a wide range of procedures, as there is no sense in high investments in procedures where there is no added value to traditional systems.

31.2 Technical description  

  387

31.2 Technical description To meet these demands, the Joint Research Centre (JRC) of the European Commission in collaboration with SOFAR S.p.A. in Milan, Italy under the scientific supervision of the New European Surgical Academy (NESA) in Berlin, initiated a novel telesurgical system, the Telelap Alf-x, based on a new concept, integrating haptic sensation into a system combining today’s technical and software know-how with a system which offers the advantages both of laparotomy (concerning the tactile feedback) and endoscopy (concerning precision, lack of big abdominal scars and better outcome) (Fig. 31.1). The system is characterized by the following features: 1. Modular system consisting of three or four manipulator arms and one or two consoles, according to the needs; each extendable manipulator arm is an independent movable unit. This system enables free access to the patient throughout the operation; 2. Introducing the arms from any given angle. The system enables direct access to the abdominal cavity through the abdominal wall or, in women, through the pouch of Douglas; 3. Quick docking of instruments to access ports: the system detects within seconds the optimal pivot point of each inserted instrument. This point becomes the axis of the arm movement, preventing extension of the incision in the fascia; 4. Immediate exchange of instruments. The instruments are attached to the arms through magnets; 5. Uninhibited view and easy access to the surgical area when working through auxiliary surgical ports (Fig. 31.2); 6. A console with an unobstructed view onto the screen with 3D vision and an ergonomic seat enabling a comfortable position (Fig. 31.3); 7. One or two surgeon’s consoles for cooperative work or training purposes;

Fig. 31.1: The Telelap Alf-x system

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  31 The future of telesurgery and new technology

Fig. 31.2: The assistant during a procedure using the Telelap Alf-x system

Fig. 31.3: The eye-tracking system

8. Haptic (1:1) sensation and newly designed handles enabling manipulation of the instruments with the fingertips. Sensed forces can be amplified when necessary; 9. Avoidance of tremor, advanced control and limitation of applied forces, thus avoiding the risk of breaking suture threads during knot tying; 10. The console features an eye-tracking system that is adjusted to any surgeon within a short time by him/herself following instructive icons on the screen. The camera is controlled by the movements of the surgeon’s eyes, and any point looked at on the screen will automatically move to the centre of the screen. By approaching or retracting his/her head to or from the screen, the zoom function is activated. The Telelap Alf-x system can be applied to any surgical discipline where an anatomical cavity exists or can be produced.

31.3 First preclinical studies  

  389

31.3 First preclinical studies Despite extensive work, telesurgery is probably still in its infancy. The main reason for the long operative time is the lack of haptic sensation and the reliance on visual force feedback. In order to find whether the Telelap Alf-x brings added value to existing systems or traditional endoscopy, an experimental operation room was installed at the University of Lodi, Italy. In experimental surgeries the average time for cholecystectomy using the Telelap Alf-x was 31.75 min as compared to 91 min using a conventional telesurgical system [27]. Haptic sensation probably contributed to the self-confidence of the surgeon, who was not dependent on visual force feedback only. With the combination of haptic sensation, 3D vision, and universality, the Telelap Alf-x provides all the advantages of laparotomy along with those of endoscopy.

References [1] Ellis H. Ephraim McDowell and the first successful elective laparotomy. Br J Hosp Med (Lond) 2009, 70(2), 107. [2] Pfannestiel J (1897) Über die Vorteile des suprasymphysären Faszienquerschnitt für die gynäkologischen Koliotomien, zugleich ein Beitrag zu der Indikationsstellung der Operationswege. Samml Klin Vortr Gynäkol 68–98 (Klin Vortr NF Gynäk 1900, 97, 268). [3] Mowat J, Bonnar J (1971) Abdominal wound dehiscence after caesarean section. Br Med J 2(756), 256–7. [4] Schollmeyer T, Soyinka AS, Schollmeyer M, et al. Georg Kelling (1866–1945): the root of modern day minimal invasive surgery. A forgotten legend? Arch Gynecol Obstet 2007, 276(5), 505–9. [5] Baggot MG. The endotracheal tube in situ as a foreign body: the master key to general anesthesia, its mechanism and inherent (though not peculiar) complications and to effective ‘life support’. Med Hypotheses 2002, 59, 742–50. [6] Dukanović S, Canić T. The value of hysteroscopy in perimenopausal women. Acta Med Croatica 2007, 61(2), 185–90. [7] Nezhat C. Operative endoscopy will replace almost all open procedures. J Soc Laparoendoscopic Surgeons 2004, 8(2), 101–2. [8] Rashid P, Goad J, Aron M, et al. Laparoscopic partial nephrectomy: integration of an advanced laparoscopic technique. ANZ J Surg 2008, 78(6), 471–5. [9] Reynolds W. Jr. The first laparoscopic cholecystectomy. J Soc Laparoendoscopic Surgeons 2001, 5, 89–94. [10] Yong JL, Law WL, Lo CY, et al. A comparative study of routine laparoscopic versus open appendectomy. JSLS 2006, 10(2), 188–92. [11] Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 2004, 60, 114–7. [12] Ng SS, Li JC, Lee JF, et al. Laparoscopic total colectomy for colorectal cancers: a comparative study. Surg Endosc 2006, 20, 1193–6.

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[13] Wagh MS, et al. Endoscopic transgastric abdominal exploration and organ resection: Initial experience in a porcine model. Clin Gastroenterol Hepatol 2005, 3(9), 892–6. [14] Moscucci O, Clarke A. Prophylactic oophorectomy: a historical perspective. J Epidemiol Community Health 2007, 61(3), 182–4. [15] Katsarelias D, Polydorou A, Tsaroucha A, et al. Endoloop application as an alternative method for gastrotomy closure in experimental transgastric surgery. Surg Endosc 2007, 21, 1862–65. [16] Stark M, Benhidjeb T. Natural Orifice Surgery: Transdouglas surgery – a new concept. J Soc Laparoendoscopic Surgeons 2008, 12(3), 295–8. [17] Kwoh YS, Hou J, Jonckheere EA, et al. A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery. IEEE Trans Biomed Eng 1988, 35(2), 153–60. [18] Harris SJ, Arambula-Cosio F, Mei Q, et al. The Probot--an active robot for prostate resection. Proc Inst Mech Eng H 1997, 211(4), 317–25. [19] Hananouchi T, Nakamura N, Kakimoto A, et al. CT-based planning of a single-radius femoral component in total knee arthroplasty using the ROBODOC system. Comput Aided Surg 2008, 13(1), 23–9. [20] Zhou HX, Guo YH, Yu XF, et al. Zeus robot-assisted laparoscopic cholecystectomy in comparison with conventional laparoscopic cholecystectomy. Hepatobiliary Pancreat Dis Int 2006, 5(1), 115–8. [21] Kang CM, Kim DH, Lee WJ, et al. Conventional laparoscopic and robot-assisted spleen-preserving pancreatectomy: does da Vinci have clinical advantages? Surg Endosc 2011, 25(6), 2004–9. [22] Swan K, Advincula AP. Role of robotic surgery in urogynecologic surgery and radical hysterectomy: how far can we go? Curr Opin Urol 2011, 21(1), 78–83. [23] Reiley CE, Akinbiyi T, Burschka D, et al. Effects of visual force feedback on robot-assisted surgical task performance. J Thorac Cardiovasc Surg 2008, 135(1), 196–202. [24] Sarlos D, Kots LA. Robotic versus laparoscopic hysterectomy: a review of recent comparative studies. Curr Opin Obstet Gynecol 2011, 23(4), 283–8. [25] Bourla DH, Hubschman JP, Culjat M, et al. Feasibility study of intraocular robotic surgery with the da Vinci surgical system. Retina 2008, 28(1), 154–8. [26] Markar SR, Karthikesalingam AP, Venkat-Ramen V, et al. Robotic vs. laparoscopic Roux-en-Y gastric bypass in morbidly obese patients: systematic review and pooled analysis. Int J Med Robot 2011, 7(4), 393–400. [27] Jayaraman S, Davies W, Schlachta CM. Getting started with robotics in general surgery with cholecystectomy: the Canadian experience. Can J Surg 2009, 52, 374–8.

Index absorbable polyglyconate 104 adhesion prophylaxis 138, 141, 142 Advincula Arch™ 40, 137 Allen stirrup 38, 69, 95, 120, 135 American Association for the Surgery of Trauma (AAST) 375 American Association of Gynecologic Laparoscopists (AAGL) 18, 20, 34, 89, 111, 117 anastomotic leak 274 anesthesia 40, 42, 68, 71, 83, 95, 118, 119, 176, 182, 189, 224, 228, 239, 275–277, 329, 344, 382, 384, 389 antibiotic 117, 120, 189, 329, 376 anticipation 41, 54, 262 aorta 80, 112, 204, 214, 226, 227, 239, 242, 279, 280, 281, 288, 290, 295, 296, 310 appendix 162, 164, 165 artery – common iliac 204, 212, 214, 215, 226, 239, 241, 242, 277, 279, 284, 290, 310, 311 – hypogastric 277, 278 – inferior mesenteric 210–212, 214, 215, 226, 239, 242, 280, 294, 295 – superior rectal 165 ASC 323, 324, 327, 342, 343, 344 assistant 9, 17, 28, 40–45, 49–65, 67, 95, 96, 98, 99, 105, 112, 113, 123, 124, 139, 182–184, 188, 190, 192, 199, 204, 212, 214–216, 226, 228–230, 240–242, 275–277, 280, 281, 288, 330–333, 341, 352, 353, 368, 388 – robotic surgical 49–57, 59–64 attentive passiveness 54 audible feedback 113 bag – Anchor 115 – laparoscopic 115, 229, 274, 279 basin – paravisceral 292–294 – pelvic and periaortic lymph 315 – periaortic lymph 294, 295, 315 – periaortic lymphatic 296 bifurcation, aortic 121, 130, 204, 212, 214, 226, 227, 242, 280, 291, 292, 333, 334

big uterus 111 bladder 8, 45, 76, 77, 101, 102, 112, 113, 117, 118, 120, 123, 125, 126, 128, 162, 163, 166–168, 170, 172, 173, 182, 192, 200–203, 205, 239, 284, 285, 299, 301–303, 324, 327, 330, 335, 336, 338, 340–342, 345, 352–357, 361–363, 367, 373 – neck 327, 361–365 – neck sling 362 – neurogenic 361 blood loss 7, 23, 24, 74, 90, 91, 93, 94, 107, 108, 111, 124, 133, 143, 146, 147, 155, 156, 159, 179, 183, 184, 192, 198, 202, 203, 205, 213, 223, 224, 230, 231, 233, 238, 250, 253–255, 265, 322, 323, 342, 343, 345, 346, 351, 366, 381, 382 body mass index (BMI) 93, 106, 118, 121, 127, 179, 213, 215, 224, 231, 239, 341 bowel preparation 119, 239, 274, 365 bulldog clamp 281 Burch 8, 350, 351, 352, 355–357 business plan 14 camera 41, 42, 96, 97, 105, 176, 190, 191, 216, 240, 330 – computer chip television 371 cancer – cervical 8, 12, 78, 79, 106, 126, 197–199, 201, 203–207, 210, 212, 216, 218, 221, 232, 234, 235, 237–239, 245–247, 265, 287–290, 293, 295, 297, 298, 305, 309, 313, 316, 317, 368 – endometrial 8, 12, 26–29, 47, 53, 68, 78–80, 83–85, 130, 210, 214, 217–219, 221–223, 230–235, 246, 250, 256, 265, 266, 271, 273, 285, 288, 290, 294, 309, 310, 311, 313, 314, 369, 377 – extraperitoneal approach 238 – hereditary ovarian 269, 271 – high risk endometrial 79, 290, 314, 316 – locally advanced stage cervical (LACC) 237 – ovarian 8, 85, 210, 211, 218, 221, 249–257, 259–261, 262, 264, 267–271, 295 – uterine 85, 219, 221, 222, 234, 273, 278, 282, 285–288, 315, 316, 328 Carter Thomason 333, 341

392  

  Index

Centers of Excellence in Minimally Invasive Gynecology (COEMIG) 18, 20 cerclage 181–185, 203, 306, 308 – abdominal 181–184 – robotic-assisted laparoscopic 181, 184 cervical insufficiency 181, 183 chromopertubation 178 chyloperitoneum 79 collision 37, 42, 43, 46, 187, 191, 224 colostomy 75, 375, 376 colposuspension 350–352, 357 – laparoscopic 350, 356 communication 9, 10, 12, 15, 20, 54, 59, 60, 62, 68, 82 compartment – mesonephric 309, 310 – Müllerian 289, 298, 301, 303, 304, 309, 310, 314 – ontogenetic 287, 314, 316 – ontogenetically permissive 287 complication 9, 17, 20, 22, 24, 27, 33, 37, 38, 54, 67, 68, 70–76, 78, 81, 82, 84, 85, 91, 92, 94, 107, 109, 124, 131, 132, 142, 149, 150, 155, 164, 172, 178, 183, 191, 198, 203, 205, 213, 215–217, 230, 231, 237–239, 250, 252–255, 266, 268, 273, 274, 283, 321, 328, 342–345, 351, 357, 361, 365, 367, 373, 378–382, 389 – gastrointestinal 75 configuration – 3-arm 41–43 – 4-arm 41, 42, 44 – M 112 – W 112 console training 56 corneal abrasion 382, 384 cost 9, 11, 13–15, 17–19, 21–29, 40, 45, 46, 90, 91, 95, 108, 122, 133, 136, 143, 155, 158, 161, 175, 179, 184, 199, 217, 219, 225, 232, 234, 268, 317, 324, 343, 345–347, 361, 368, 386 – caregiver 26 – effectiveness 11, 14, 15, 19, 21, 22, 24–26, 29, 180, 199, 244, 271 – fixed 21, 27 – inpatient hospital 26 – of robotic surgery 23, 345 – robotic 26 – variable 21

credentialing 14–16, 31–35, 57, 129 C-section 335 cuff 38, 70, 81, 86, 92, 93, 96, 103–105, 114, 126, 128, 166, 201, 205, 215, 303, 306, 330, 332, 335–341 – dehiscence 81, 85, 86, 93, 105, 114, 126 cystoscopy 76, 77, 84, 118, 166, 167, 239, 322, 340, 341, 354, 363, 364 database 14, 15, 17, 18, 20, 21, 29, 80, 84, 108, 130, 159, 170, 171, 193, 217, 356 da Vinci surgical system 7, 10, 11, 13, 14, 130, 189, 238, 240, 244, 276, 361, 368, 371, 390 diaphragm 70, 162, 168, 169, 173, 174, 214, 218, 223, 232, 249, 250, 253, 276, 283, 357, 376 diaphragmatic lesions 168 diathermy 126, 128, 164, 168 dissection – posterior 336–338 – sacral 333–335 docking 7, 9, 37, 40, 41, 45–47, 50–54, 59, 60, 62–65, 91, 95, 97, 98, 106, 109, 121, 123, 124, 135, 138, 140, 143, 149, 167, 168, 176, 177, 189, 211, 212, 215–218, 223–225, 242, 282, 283, 288, 324, 332, 351, 386, 387 – side 46, 47, 52, 60, 65, 98, 124, 135, 138, 167, 177, 212, 224, 283, 288 – straight 46, 47 drive – dry 16 – wet 16 dual console 17, 21, 129, 372 duodenum 215, 226, 227, 279, 282, 295, 373 economics 21, 25 education – in robotic assistance 56 – structured 63 efficiency 14, 18, 19, 27, 37, 38, 58, 68, 156 electrosurgery (ES) – bipolar 73 – monopular 71 endometriosis 8, 12, 77, 90, 111, 113, 118–120, 124–126, 134, 149, 150, 161–174, 249, 367–369 – hepatic 169, 174 – thoracic syndrome (TES) 168 – ureteral 167, 170, 173 endoscopy 7, 377, 385–387, 389

Index  

end-to-end anastomosis 168, 336 enterocele 328, 351 epiploica 281 estrogen 133, 161, 324, 329, 341 evolving program phase 13 exposure 37, 41, 70, 95, 126, 140, 141, 143, 145, 162, 168, 187, 211, 214, 216, 223–226, 228, 231, 249, 274–281, 283, 333, 336, 337, 363, 365 extraperitoneal 47, 65, 80, 85, 123, 165, 203, 204, 207, 211–213, 216, 218, 219, 237–246, 367 femoral 37, 38, 68, 278, 292, 293, 390 fibrin 279 financial analysis 15, 21, 23 fistula 8, 12, 164, 174, 321–323, 325 – vesicovaginal 76, 205, 321, 322, 325 fistulization 77 fleet enema 274 Foley catheter 39, 40, 76, 77, 203, 240, 329, 341, 362, 364, 368 genito-femoral 68, 290, 292 glaucoma 71, 379, 381–384 gonadotropin-releasing hormone (GnRH) 119, 130, 170 – agonists 131–133, 146, 147, 158, 161, 166 Gore-tex 339 grasper – alligator 99, 353 – Cadiere 99, 188, 333, 353 gynecologic malignancy 83, 85, 197, 211, 221, 234, 235 gynecologic operation 373 gynecology 7, 11, 12, 16, 18, 20, 23, 24, 28, 31–33, 35, 64, 65, 67, 73, 87, 90, 109, 158, 159, 170, 180, 193, 197, 209, 222, 233, 237, 249, 269, 273, 316, 319, 321, 325, 326, 349, 356, 361, 368, 369, 373, 377, 381 haemostatic activity 63 Halban 340 haptic sensation 386, 387, 389 hematoma 40, 80, 81, 191, 213, 217, 244, 254, 255, 265, 341, 345, 374, 375 hemostasis 55, 72, 133, 136, 140, 141, 143, 148, 164, 169, 178, 190, 209, 243, 279, 281, 283, 284, 285, 341

  393

heparin 329 hydrodissection 163–165, 167, 169, 335 hypothermia 39 hysterectomy 7, 8, 11–13, 21, 22, 25, 26, 28, 29, 42, 46, 47, 53, 55, 57, 76, 81, 84, 85, 89–96, 99, 106–109, 111, 115, 117, 119, 124, 125, 129–131, 138, 151, 162, 166, 187, 191, 192, 193, 204, 207, 211, 213, 215, 216, 218, 222–224, 226, 228, 230, 231, 234, 235, 249, 252, 256, 259, 264–266, 269, 271, 274, 277, 279, 281, 283, 306, 327, 329, 330, 332, 335–337, 342, 344, 352, 356, 357, 361, 366, 369, 372, 380, 385, 390 – complex 117 – difficult 118–120, 122–124 – extrafascial 284 – laparoscopic (LH) 89, 91–94 – radical 8, 12, 78, 81, 93, 106, 126, 134, 135, 197–199, 202, 203, 205, 206–228, 245, 287, 309, 313, 316, 317, 368, 386, 390 – robot-assisted 92–94, 97 – robot-assisted laparoscopic (RALH) 11, 94, 109, 130, 368 – robotic 21, 26, 29, 77, 80, 81, 83, 86, 91, 94, 97, 106, 108, 111, 117, 118, 120, 122–124, 127, 129, 224, 247, 351 – single-port total (R-SPH) 106, 107 – supracervical 109, 112, 131, 170, 335, 336 – total laparoscopic 25, 28, 84, 108, 193, 256, 351, 357, 369 – vaginal (VH) 81, 89, 90, 93, 107, 109, 234 ileus 75, 244, 324, 343, 345, 377 iliac crest 44, 184, 331 implant 162–165, 168, 169, 367, 368 implementation phase 13, 14, 18 incision 7, 23, 50, 55, 67, 74, 77, 79, 80, 82, 85, 103, 106, 114, 115, 117, 121, 125, 127, 128, 130, 136, 138, 140, 145, 149, 152, 157, 163, 164, 166, 178, 187–193, 199, 202, 204, 205, 214, 216, 241, 245, 249, 266, 277–280, 284, 288, 290, 291, 298, 312, 314, 334, 335, 337, 345, 349, 352, 364, 367, 371, 385, 387 incontinence 328, 329, 347, 349, 350, 351, 356, 357 – urinary 325, 328, 349, 351, 356, 357 indigo carmine 76, 77, 178, 335, 340, 341, 354, 355

394  

  Index

infertility 156, 157, 161, 170, 249, 367 informed consent 31, 33, 149, 239 infundibulopelvic (IP) 101, 367 injury – bowel 37, 75, 80, 84, 213, 215, 253, 324, 337, 345, 373–378 – electrosurgical 71–73, 84, 373 – gastrointestinal 75, 373, 374, 376–378 – nerve 37, 82 – prevention of gastrointestinal 377 – rectal 376 – small bowel 374 – stomach 70, 376 – thermal 75–77, 285, 373, 374 – undiagnosed 376, 377 – ureteral 76, 77, 84, 345 – vascular 74, 80 instrument 4, 7, 9, 17, 18, 21, 22, 25, 38, 40–42, 44, 46, 49, 52–55, 57, 62–64, 72, 74, 79, 84, 89, 95–97, 104, 106, 111, 113, 115, 117, 119, 123, 127, 135, 136, 141–143, 145, 157, 161, 165, 169, 177, 182, 187–189, 191, 224, 244, 275, 276, 281, 321, 342, 345, 349, 351, 362, 366, 368, 371, 372, 377, 385, 387, 388 interdisciplinary 14, 15, 372 intraocular pressure 40, 71, 84, 276, 277, 345, 379, 383, 384 ischemic optic neuropathy 380, 381, 384 – anterior (AION) 380 Jackson-Pratt 77 junction – cervico-uterine 285 – urethro-vesicular (UVJ) 101, 353, 354 landmark 45, 123, 124, 277, 333 large fibroid 120, 123, 125 lateral femoral 68 lead surgeon 13, 14, 16, 62 leak test 75, 166 learning curve 9, 13, 14, 16, 18, 24, 25, 29, 32, 39, 45, 62, 63, 67, 89–91, 93, 106, 108, 117, 129, 130, 132, 161, 170, 175, 179, 187, 191, 214, 222, 223, 266, 271, 326, 327, 330, 342, 345, 347, 349 legal issue 31, 33–35 Lehey 114 length of stay (LOS) 155, 255, 322–324, 343, 346

lesser omental sac 283 ligament – anterior longitudinal 327, 334 – Cooper’s 350, 353, 354 – gastro-colic 283, 284 – lieno-diaphragmatic 283 – longitudinal 334, 339 – phrenico-colic 283 – round 99–101, 124, 199, 202, 205, 278, 279, 284, 285, 298, 306, 312, 367 – utero-ovarian 101, 201 – uterosacral 112, 162, 201, 202, 205, 285, 367 linear stapling 165, 166 lithotomy 39, 68, 69, 82, 135, 199, 216, 239, 266, 275, 365 – dorsal 38, 95, 176, 202, 205, 329, 362, 368 lobectomy 168, 173 lower uterine segment 77, 101, 203, 284, 335 lumbosacral trunk 290, 291, 293 lung 70, 168, 372, 389 lymphadenectomy 12, 29, 68, 78, 79, 83, 85, 127, 197, 198, 201, 203, 206, 207, 209–213, 215–219, 221–224, 226, 228–234, 237, 238, 243, 244, 246, 274, 277, 278, 285, 286, 290, 292, 295, 307, 310 – aortic 8, 47, 78, 83, 203, 207, 209–219, 221–226, 231, 235, 246 – inframesenteric periaortic 295 – infrarenal aortic 209, 210, 212, 217–219 – para-aortic 41, 46, 85, 203, 204, 207, 218, 219, 233, 234, 238, 239, 241–244, 246, 275–277, 279 – pelvic and periaortic 287, 288, 290, 310, 316 – periaortic 287, 288, 290, 294, 295, 297, 310, 316 – robotic-assisted retroperitoneal laparoscopic para-aortic 239 – therapeutic pelvic 287, 290, 294, 305, 311 – therapeutic pelvic and periaortic (rtLNE) 287, 288, 290, 297, 306, 310, 311, 314–316 – therapeutic periaortic 294, 297 lymphedema 78, 79, 215, 229, 255, 278, 279 lymphadenopathy 226, 274, 275, 278 lymphocyst formation 78, 79 magnesium citrate 274 malpractice 33, 34

Index  

mapping of the pelvic anatomy 146 marketing 14, 15, 17–22, 356 Marshall-Marchetti-Krantz (MMK) 350 May-Thurner syndrome 279 mescolpia 298 mesh 168, 324, 327, 332, 336–347, 349, 350 – polypropylene 327, 337 mesocolpium 303 mesometria – fibrofatty (ligamentous) 288, 298 – ligamentous (fibrofatty) 298, 299, 304–306, 309, 310, 314 – ligamentous 298–300, 309 – vascular 288, 290, 294, 295, 297–304, 309, 310, 312–314 mesureter 298, 299, 301, 303, 304, 310, 312 metastatic disease 199, 204, 232, 235, 237, 241, 253, 254, 273, 274 microsurgical 9, 117, 175, 177–180 midurethral sling 349, 350, 356, 368 Monopolar EndoWrist 99 monopolar hook 163, 164 monopolar scissor 99–104, 136, 167, 182, 201, 225, 242, 332 morbidity 14, 20, 23, 67, 75, 78, 83, 84, 95, 108, 111, 175, 181, 199, 210, 217, 223, 232, 237, 238, 244, 255, 260, 265, 305, 316, 321, 323, 327, 343, 373, 377, 385 Moschcowitz 340 myoma – localization of 134 – multiple 131, 137, 145–148, 153, 157 – uterine 131–134, 148, 159 myomectomy 8, 11, 42, 54, 112, 113, 118, 130–138, 140–143, 145, 146, 148–153, 155–160, 170, 187, 193, 361 – robot-assisted (RALM) 131–143, 148–152, 155–158 narcotic use 344 Navratile Brzezinski 336, 338 negligent 34 nephroureterectomy 167, 322, 325 nerve 68, 290, 380 – cutaneous 68 – genito-femoral 226, 228, 278 – hypogastric vesical 302 – obturator 68, 83, 229, 277–279, 290–293 – peroneal 37, 68

  395

node – infra-renal periaortic 311 – intercalated 290, 300, 310 – intercalated mesometrial 297, 310 – preischiadic 309, 310 novice surgeon 31, 32, 37 obese 43, 70, 80, 83, 90, 93, 108, 109, 118–123, 126, 127, 130, 142, 222–225, 230, 231, 234, 235, 276, 277, 279, 282, 328, 345, 386, 390 obesity 18, 40, 41, 46, 67, 83, 91, 122, 123, 130, 222, 230, 277, 281, 328 octreotide 79 ocular hypertension 381–383 ocular perfusion 379, 383 omentectomy 8, 211, 214, 225, 249, 252, 274, 275, 282, 283, 286 – infracolic 282, 283 – total 282, 283 omentum 142, 162, 169, 225, 281–284, 350 oncological tourism 28 onion peel 115 open-entry 121, 377 operating – table 9, 17, 49, 50–53, 55, 60, 62, 120, 122, 211, 212, 214, 216, 223, 231, 275 – time 37, 58, 70, 91, 94, 155, 156, 175, 222, 327, 344 operative time 67, 91, 178, 193, 215, 216, 230, 231, 273, 343, 344 Optiview 41 Palmer point 97 palsy – Erb’s 69 – Klumpke’s 69 paper roll 114, 115 patient load 28 peer review 14, 20 pelvic – brim 77, 216, 264, 334 – desensus 90 – floor laxity 361 – pain 89, 118, 151, 153, 170, 171, 367 – radiation 350 periaortic lymphatic system 310 perineal body 332, 337 peritoneal closing 340

396  

  Index

peritoneum 7, 41–43, 52, 53, 70, 76, 79, 81, 83, 97, 103, 101, 115, 118, 121, 123, 125, 128, 138, 148, 162, 163, 165, 166, 182, 201, 204, 205, 212, 214, 216, 224, 226, 227, 241–243, 249, 250, 252, 254, 257, 270, 275–280, 282, 284, 285, 290, 291, 298, 306, 309, 310, 312, 314, 315, 331, 334–336, 339–341, 354, 356, 362, 367, 368 permanent perioperative vision loss 380 pessary 349 PK forceps 353 planning phase 13–15 PlasmaJet 165 plasma kinetic 332 pleura 168, 173 plexus – aortic 297 – brachial 37, 38, 69, 83, 126, 135, 154, 223, 329 – hypogastric 295, 297–301, 303, 304 – hypogastricus superior 290 – inferior hypogastric 298–301, 303 – inferior mesenteric 297 – S1–S4 of sacral 293 pneumoperitoneum 41, 42, 70, 81, 83, 97, 103, 115, 123, 128, 224, 241, 250, 254, 275, 276, 331, 378 polyglactin 910 106, 332, 354 port placement 40–46, 106, 177, 215, 225, 240, 241, 275, 330–332, 362 positioning 4, 9, 11, 28, 37, 38, 40, 50, 52, 53, 55, 60, 68–70, 73, 82–84, 95, 96, 119, 120, 122, 134, 135, 137, 149, 161, 176, 187, 209, 214, 215, 223, 231, 241, 275, 276, 282, 288, 291, 324, 329, 330, 351, 352, 357, 362, 363, 366, 372, 381, 390 – patient 37, 38, 46, 50, 68–70, 119, 120, 122, 134, 176, 275, 324, 329, 330, 381 – Trendelenburg 83, 119, 214, 223, 231, 288, 291 postoperative pain 7, 23, 38, 43, 90, 96, 250, 327, 344 postoperative specimen 314 pregnancy rate 150, 157, 175, 178, 179 presentation 24, 53, 64, 78, 80, 140, 142, 145, 151, 152, 164, 172, 237, 273, 328, 378 pressure points 39, 120 primary repair 172, 321, 374, 375 private healthcare system 27

probe – blunt 336 – vaginal 118, 183, 335 proctor 32–35 – robotic 34, 35 ProGrasp 99, 127, 136, 276, 353 prolapse 12, 29, 89, 281, 323, 324, 326, 327–329, 335, 340, 342, 344, 346, 347, 349, 356, 357 – apical 327, 328 – pelvic organ (POP) 323, 326, 327, 344, 346, 347, 349 – pelvic organ prolapse quantification (POP-Q) 323, 324, 342–344, 347 – uterine 89, 327, 329 – vault 12, 326–328, 346, 347 psoas hitch 77, 322, 325 pubic bone 350, 363 quality of life 67, 91, 94, 191, 199, 264, 271, 328, 342–344, 368 radical trachelectomy 197, 201–203, 206, 207, 305, 306 real-time magnified view 371 rectocele 93, 328, 351 rectosigmoid 118, 164, 166, 167, 172, 281, 290 rectovaginal 125, 162, 170, 172, 173, 201, 205, 298, 309, 327, 367 rectovaginal septum 162, 165, 172, 309, 327, 367 remote center 43, 190 resection 374–376 – fertility preserving mesometrial (FMMR) 287, 305–307, 309 – peritoneal mesometrial (rPMMR) 287, 290, 294, 295, 309, 310, 313–316 – segmental 76, 172 – total mesometrial (rTMMR) 287, 288, 290, 294, 297, 298, 304–307, 309, 310, 313, 314, 316 retraction 53, 55, 96, 112, 114, 121, 123, 127, 162, 187, 214, 232, 275, 276, 281, 324, 332, 333, 340, 352, 367 retroperitoneal 38, 44–46, 77, 80, 113, 118, 126, 162, 166, 173, 204, 207, 211, 216, 219, 226, 239, 241–244, 246, 254, 255, 266, 277, 280, 290, 291, 341, 345

Index  

retroperitoneum 165, 216, 227, 279, 280, 284, 290, 291, 340 retropubic urethropexy 349, 350 return on investment 13, 14, 25 Retzius space 353, 354 revenue 15, 21 robotic program 12–22, 57, 58, 108 robotic team 14, 16–18, 56, 58, 63 RUMI® 40, 96, 103, 112, 122, 137, 276 sacral promontory 165, 242, 280, 284, 332–334, 338–340 sacrocolpopexy 8, 12, 26, 29, 42, 44, 46, 47, 321, 323, 324, 326, 327, 328, 330, 332, 334, 337, 341–344, 346, 347, 372, 386 – abdominal (ASC) 323, 324, 327, 342–344, 346 – laparoscopic (LSC) 327, 342, 343, 346 – robotic-assisted (RASC) 327, 328, 330, 337, 342–345 – robot-assisted laparoscopic (RALS) 323, 326, 347 sexual activity 328, 342 sexual function 261, 264, 270, 328, 343 shoulder block 38 sigmoid colon 68, 75, 124, 164, 165, 226, 275, 277, 279, 280, 281, 284, 294, 295, 331, 332, 333, 335, 340, 362, 366 simulation 16, 21, 22, 32, 57, 58, 62, 64, 107 single-port robotic platform 106, 109 single-site port 106 sling procedure 350, 356, 361, 367 spatial distance 54, 60 spleen 45, 214, 250, 283, 390 sponge 38, 90, 104, 225, 228, 232, 276, 280, 281, 285, 304 – egg-crate 38 steering committee 14–19, 22 stoma 374, 375 – primary repair, resection and anastomosis 375 sunrise distribution 275, 282 superficial epigastrics 80 supraumbilical 139, 149, 214, 288 surgery 3, 4, 6–13, 15–17, 21–29, 31–35, 37–43, 46, 49, 50, 52, 54–58, 62–65, 67–71, 73, 75–78, 81–85, 89–92, 94–98, 105–109, 112, 117–119, 122, 123, 126, 127, 129, 130, 132–135, 141, 146–150, 152, 155–164, 168–171, 173–181, 184, 187, 189, 191–193,

  397

197–199, 202–204, 206, 207, 209–212, 214–218, 221, 223, 230–235, 238, 239, 249–254, 256, 259–267, 269–271, 273, 274, 276, 277, 282, 283, 287, 305, 315–317, 321–332, 338, 340–342, 344–346, 349–351, 356, 357, 361, 365–369, 371–373, 375–386, 389, 390 – compartment based radical 287, 316 – feasibility of robotic 25 – laparoendoscopic single-site (LESS) 106, 367 – minimally-invasive (MIS) 4, 6, 7, 9, 10, 23, 25, 34, 49, 67–69, 73–75, 77–82, 89, 90, 106, 114, 134, 155, 164, 169, 171, 176, 184, 187, 197, 199, 210, 211, 218, 221–223, 230, 244, 250, 252, 254, 257, 273, 285, 287, 361, 371, 372 – robotic 4, 6, 8–13, 15–17, 21–29, 33, 34, 37, 38, 41, 57, 62, 64, 65, 67, 68, 70, 78, 81, 83, 89–91, 93, 105–109, 129, 130, 155, 156, 159, 163, 176, 178–181, 184, 187, 191, 192, 197, 198, 200, 206, 209, 214, 217, 221, 230, 231, 233, 235, 238, 247, 249, 250, 254, 256, 257, 266, 273, 274, 285, 316, 321, 322, 324, 327, 330, 342, 345, 346, 349, 350, 356, 361, 373, 377, 380, 390 – robotic-assisted 8, 12, 27, 29, 47, 64, 109, 160, 178, 191, 197, 218, 223, 231, 232, 234, 325, 349, 371, 381, 382 – single-port robotic 41, 187, 192 – video-assisted thoracoscopic (VATS) 168 surgical – anatomy 290, 317 – instructor 33 – mal-occurrences 33 – staging 28, 84, 85, 215, 217–219, 221, 222, 233–235, 238, 245–247, 249, 251–253, 257, 274, 285, 286 Surgical Review Corporation (SRC) 20, 22 suture – barbed 81, 86, 114, 141, 338, 339, 340 – barbed running 141 – of the myometrium 132 – sacral 334, 339 sweet spot 46, 98 tamponade 73, 80, 81, 280, 281 technique 11, 12, 20, 23, 24, 28, 31, 37–39, 41, 47, 49, 55, 57, 65, 72, 74, 81, 84, 86, 90, 94, 100, 101, 106–109, 112, 114, 115,

398  

  Index

117, 119–123, 125, 126, 129, 130, 141–143, 149, 150, 157–159, 162–164, 167, 168, 170, 172, 175–182, 184, 185, 189, 192, 193, 198, 199, 202, 204, 206, 207, 209, 211–219, 221–223, 226, 228, 231, 233, 234, 238–240, 244–247, 250–252, 256, 261, 264, 266–268, 274, 276, 283, 287, 290, 306, 310, 315, 316, 321–323, 326–329, 332, 336, 339, 341, 346, 347, 362, 365–369, 372, 374, 375, 377, 378, 389 – of repair 375 tenaculum 113, 127, 135–137, 140, 153, 336 – laparoscopic 113, 336 thermal trauma 77 thrombin 279 thromboembolic 78, 120 tidal volume 70, 83, 224, 276, 277 tilt test 40 tissue border control 315 tLNE 306, 315 transperitoneal 80, 203, 204, 211, 212, 218, 219, 235, 238, 240, 244, 246, 247, 284, 365 transperitoneal approach 78, 176, 212, 244, 277 transvaginal delivery 281, 328 tremor 9, 24, 57, 140, 143, 175, 176, 189, 191, 192, 197, 324, 327, 361, 372, 386, 388 Trendelenburg 17, 40, 69–71, 95, 106, 120, 121, 126, 224, 232, 330, 352 – position 38, 40, 45, 47, 69–71, 81, 83, 84, 115, 118–123, 126, 135, 142, 148, 149, 165, 176, 177, 190, 199, 212, 215, 224, 226, 231, 240, 276, 277, 281–283, 324, 332, 340, 345, 362, 367, 379–383 trocar – bariatric 43 – optical 96, 214, 215 – placement 37, 41, 42, 46, 52, 62, 75, 96, 112, 122, 123, 135, 138, 139, 200, 202, 209, 211, 212, 214, 215, 322, 330, 352, 372 troubleshooting 17, 53, 55 tubal – patency 135, 137, 138, 149, 177–179 – reanastomosis 8, 175, 177–180 – sterilization 7, 67, 175, 178, 180 tubal reversal 175–179 – robot-assisted 177, 178 tube – nasogastric 40, 75, 120, 240, 376 – orogastric (OG) 40, 70, 112, 329

tumor – borderline 210, 252, 254, 256 – debulking 254, 275 ulipristal acetate 131–133, 146–148, 158 umbilicus 41, 44, 96, 112, 121, 123, 130, 139, 176, 181, 182, 187, 189, 215, 216, 266, 275, 282, 283, 331, 332, 362, 366 undocking 37, 46, 50, 55, 62, 63, 105, 140, 143, 165, 209, 277, 374 – emergency 55 ureter 12, 53, 77, 101, 112, 113, 118, 120, 124–126, 142, 162, 163, 165–168, 172, 173, 199–202, 204, 205, 214, 216, 226–229, 239, 241–243, 255, 277–280, 284, 285, 290, 295, 297–299, 301–304, 310–312, 322, 324, 325, 333–335, 339–342, 345, 347, 367, 373 ureteral – reimplantation 167, 322, 325 – stent 54, 77, 167 ureterectomy 167, 322 uretero-calicostomy 322 ureterolysis 167, 168, 211, 322 uretero-pyelostomy 322 uretero-ureterostomy 77, 167, 173, 322 urodynamic 329, 365 uterine manipulation 54, 96, 118, 122–124, 135, 137, 153, 224 uterine manipulator 40, 41, 52, 95, 96, 101–103, 112–114, 122, 134, 137, 138, 199, 202, 224, 234, 276, 285, 368 vaginal apex 285, 327, 332, 335, 336, 338, 344 vaginally morcellate 114 vaginoplasty 365, 368 vaginotomy 336 vascular pedicle 124, 225, 276, 285 VCare® 40, 96, 112, 122, 137, 199, 224, 276 vein – gonadal 215, 227, 232 – left renal 211, 214, 217, 219, 225–227, 232, 242, 244, 246, 296 vena cava 204, 226–228, 239, 242, 279, 280, 281, 288, 295, 296, 310, 312 Veress needle 41, 75, 80, 96, 112, 121, 122, 162, 331, 373

Index  

vessel – iliac 80, 124, 200, 201, 203, 241, 242, 277, 278, 290–293, 295, 298, 302, 333 – middle sacral 334 – uterine 77, 99, 102–104, 113, 114, 123, 125, 140, 142, 181, 183, 202, 205, 285, 298, 302, 309, 314 visualization 9, 23, 24, 40–43, 45, 68, 74, 76, 80, 96, 97, 106, 112, 113, 117, 119, 123, 124, 127, 142, 162, 165, 167, 168, 175–177, 182, 183, 187, 189, 191, 192, 197, 199, 209, 211,

  399

214, 221, 225, 238, 266, 274–277, 279, 282–284, 294, 321, 331, 334, 336, 337, 339, 340, 341, 350, 361, 365–368 V-LocTM 104, 141, 338, 339, 340 waiter’s tip 69 watertight 76, 167 Y-shaped 337, 339 ZUMI® 40, 122, 137, 224