- Email: [email protected]
Robotic hysterectomy: technique and initial outcomes
Surgeon’s Corner
www. AJOG.org
Robotic hysterectomy: technique and initial outcomes Rosanne M. Kho, MD; Wesley S. Hilger, MD; Joseph G. Hentz, MS; Paul M. Magtibay, MD; Javier F. Magrina, MD
P ROBLEM : O PTIMIZE O PERATING T IME Compared with the abdominal approach, laparoscopic hysterectomy offers shorter hospital stays and recovery periods.1 However, conventional laparoscopy has limitations imposed by incision size and the normal mechanics of the human hand. Surgical robots are designed to overcome these. For example, the da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale, California) provides a steady 3-dimensional image and instrumentation with articulating tips that allow for 7 degrees of movement, surpassing wrist mobility. Master controls at the surgeon’s console eliminate hand tremors and the fulcrum effect encountered in conventional laparoscopy. In addition, the surgeon’s movements are downscaled (3 to 1), increasing accuracy and precision. Published reports about robotic hysterectomy (RH) are few and include small case series.1,2
A surgical robot can move in ways that the human wrist cannot. Is it a practical substitute for the conventional hands-on approach? Cite this article as: Kho RM, Hilger WS, Hentz JG, Magtibay PM, Magrina JF. Robotic hysterectomy: technique and initial outcomes. Am J Obstet Gynecol 2007;197;113.e1-113.e4.
botic team, and efficient surgical techniques. These techniques included use of only 3 of the da Vinci’s EndoWrist instruments to limit exchanges during the procedure; shorter precut sutures; and suture clips to avoid intracorporeal knot-tying. Subsequently, we reviewed the surgical times and the intra- and postoperative outcomes for 91 consecutive patients who underwent RH, with or without salpingo-oophorectomy or concomitant appendectomy, at our institution between March 2004 and December 2005. The study was approved by the
Mayo Foundation Institutional Review Board. Patient selection criteria for the laparoscopic approach included a narrow pelvis, suspicious adnexal mass, pelvic pain not previously evaluated, or moderate to severe endometriosis. Eligible patients were offered a robotic operation. Those requiring lymphadenectomy were excluded. Four trocars were placed in the patient’s abdomen (Figure 1): a 12-mm trocar by the open Hasson technique in the umbilicus; 2 robotic trocars, 8-mm each, bilater-
FIGURE 1
O UR S OLUTION We developed a surgical technique to optimize operating time—and thus, associated cost— using the da Vinci robotic system, a dedicated gynecologic ro-
From the Department of Obstetrics and Gynecology (Drs Kho, Hilger, Magtibay, and Magrina) and the Section of Biostatistics (Mr Hentz), Mayo Clinic, Scottsdale, AZ. Portions of this manuscript have been presented in abstract form at the 32nd Scientific Meeting of the Society of Gynecology Surgeons, Tucson, AZ, Apr. 3-5, 2006. The use of brand names in this article does not imply endorsement by Mayo Clinic. Received Apr. 11, 2006; accepted May 1, 2007. 0002-9378/$32.00 © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2007.05.005
VIDEO
Click “Add-On” under the title of this article in the Table of Contents.
Four trocars are placed in the abdomen of a patient undergoing robotic hysterectomy. A long 12-mm Hasson trocar is in the umbilicus, 2 shorter 8-mm robotic trocars are placed bilaterally at the level of the umbilicus, and an accessory 10-mm trocar is between the umbilical trocar and the left lateral trocar.
JULY 2007 American Journal of Obstetrics & Gynecology
113.e1
Surgeon’s Corner
www.AJOG.org
FIGURE 2
TABLE 1
Patient characteristics, indications, and surgical measures Variable
Finding
Patient characteristic
Mean (SD); n⫽91
.....................................................................................................................................................................................................................................
Age, years
50.29 (12.13)
BMI, kg/m
27.87 (7.52)
..................................................................................................................................................................................................................................... 2 .....................................................................................................................................................................................................................................
Uterine weight, g
135.53 (67.03)
..............................................................................................................................................................................................................................................
Indication
Number (%); n⫽91
.....................................................................................................................................................................................................................................
Menometrorrhagia
39 (43)
Ovarian neoplasm
18 (20)
..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................
Pelvic pain
9 (10)
Postmenopausal bleeding
7 (8)
CIN or unsatisfactory colposcopy
6 (7)
Abnormal endometrial stripe
3 (3)
.....................................................................................................................................................................................................................................
Mean (⫾ standard error) docking times generally decreased for sequential groups of 10 patients as the surgical team gained experience.
..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................
Dysfunctional uterine bleeding
3 (3)
BRCA-2 gene
2 (2)
Family history of breast, ovarian, or colon cancer
2 (2)
Adenocarcinoma in situ cervix
1 (1)
..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................
Persistent mole
1 (1)
..............................................................................................................................................................................................................................................
Procedure type
Number (%); n⫽91
.....................................................................................................................................................................................................................................
RH
6 (7)
RH⫹Appy
5 (5)
..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................
RH⫹USO or BSO
23 (25)
RH⫹USO or BSO⫹Appy
28 (31)
..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................
RH⫹LOA
2 (2)
RH⫹LOA⫹Appy
1 (1)
..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................
RH⫹USO or BSO⫹LOA
17 (19)
.....................................................................................................................................................................................................................................
RH⫹USO or BSO⫹LOA⫹Appy
9 (10)
..............................................................................................................................................................................................................................................
Pertinent measures
Mean (SD)
.....................................................................................................................................................................................................................................
Console time, min (n⫽81)
73.00 (30.00)
.....................................................................................................................................................................................................................................
Docking time, min (n⫽88)
2.95 (1.77)
transected by the first assistant with the EnSeal Tissue Sealing and Hemostasis System (SurgRx, Inc, Redwood City, CA). The round ligament was transected, and the incision was continued over the anterior leaf of the broad ligament toward the vesicouterine fold. Next, the bladder was dissected from the lower uterine segment, at least 2 cm inferior to the cervix. Using a vaginal probe, the scrub nurse delineated the lower limit of the cervix and defined the level of the vaginal incision. The uterine arteries and cardinal ligaments were sealed and transected with the EnSeal; the vagina was transected immediately distal to the cervix; and the uterus and adnexa were removed through the vaginal opening. Pneumoperitoneum was reestablished with a sterile occluding balloon and 60 mL of saline (Koh Colpotomizer System,
.....................................................................................................................................................................................................................................
Surgery start–end time, min (n⫽91)
127.82 (35.43)
.....................................................................................................................................................................................................................................
Length of stay, days (n⫽91)
1.35 (0.69)
.....................................................................................................................................................................................................................................
Estimated blood loss, mL (n⫽90)
FIGURE 3
78.56 (43.81)
..............................................................................................................................................................................................................................................
Appy, appendectomy; BSO, bilateral salpingo-oophorectomy; CIN, cervical intraepithelial neoplasia; LOA, lysis of adhesions; RH, robotic hysterectomy; SD, standard deviation; USO, unilateral salpingo-oophorectomy.
ally (10 cm distal to and level with the umbilicus); and an accessory 10-mm trocar between the umbilical and left lateral ports. To facilitate surgery, the assistant used the accessory port to insert instruments (eg, devices for vessel-sealing, retraction, and suction/irrigation) and sutures. After the 3-arm robotic tower was situated between the patient’s legs, the middle arm was attached to the umbilical trocar for the lapa113.e2
roscope, and the 2 lateral arms were attached to the lateral trocars. A monopolar spatula was introduced through the right lateral trocar, and a bipolar grasper was positioned through the left lateral trocar. An initial incision was made at the level of the pelvic brim to identify the ureter (Video). For salpingo-oophorectomy, the infundibulopelvic ligament was isolated and then sealed and
American Journal of Obstetrics & Gynecology JULY 2007
Similarly, the mean (⫾ standard error) console times tended to decrease for sequential groups of 5 patients who underwent robotic hysterectomy and bilateral salpingo-oophorectomy.
Surgeon’s Corner
www.AJOG.org
FIGURE 4
TABLE 2
Correlation of baseline characteristics with console time Characteristic
r
95% CI
p value
BMI, kg/m2
0.001
–0.22 to 0.22
⬎.99
Uterine weight, g
0.26
–0.04 to 0.45
.02
LOA
0.33
0.12 to 0.51
.002
.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
BMI, body mass index; CI, confidence interval; LOA, lysis of adhesions; r, Pearson Correlation Coefficient.
Except for the 5th “group,” which contained only 1 patient, the mean (⫾ standard error) console times decreased for sequential groups of 5 patients who underwent robotic hysterectomy, bilateral salpingo-oophorectomy, and appendectomy. n⫽21.
CooperSurgical, Inc, Trumbull, CT). The right monopolar spatula was removed and switched to a needle holder. A precut (15-cm) 0 continuous polyglyconate absorbable suture and a CT-2 needle (Ethicon, Inc, Somerville, New Jersey) were used to close the vaginal cuff, starting at the right angle toward the midline. To provide vaginal support, the uterosacral ligament was incorporated at the right angle and at midline. Lapra-Ty suture clips (Ethicon-Endosurgery, Inc, Cincinnati, OH) eliminated intracorporeal knot tying. Similar steps were performed on the left angle toward the midline to complete vaginal cuff closure. For the appendectomy, the mesoappendix was sealed and transected using the EnSeal. The appendiceal stump was ligated with a 0 absorbable pretied suture (EndoLoop; Ethicon-Endosurgery, Inc, Cincinnati, OH). Finally, the appendix
was transected with the EnSeal and removed from the abdomen through the 10-mm accessory port. Once the robotic arms were disengaged from the trocars and the robotic column removed, the fascia were closed at the umbilical and 10-cm accessory trocar sites and skin incisions. Intravenous indigo carmine was injected, and a cystoscopy confirmed ureteral patency and excluded bladder injury.
S AFE AND T IMELY Total operating time (from incision to closure at trocar sites, including cystoscopy time), console time (for surgeon to perform procedure at console, from beginning of RH to closure of vaginal cuff), docking time (to advance robot to bedside and attach its arms to trocars), intraoperative complications, and postoperative course were all examined (Table 1). The relationship between body mass index, uterine weight, and lysis of adhesions to console time was quantified with the Pearson correlation coefficient. A weighted least-squares analysis was used to evaluate effects of appendectomy and adhesiolysis on console time. The general linear model was stratified by type of concomitant procedure, with strata weighted by sample
size. Statistical computations were accomplished with SAS Version 9 software (SAS Institute, Inc, Cary, North Carolina). The mean docking time was 2.95 minutes (standard deviation or SD, 1.77 minutes); times decreased for subsequent groups of 10 patients (Figure 2). Mean console and operating times were 73 minutes (SD, 30 minutes) and 128 minutes (SD, 35 minutes), respectively. Console times for RH plus bilateral salpingo-oophorectomy and appendectomy also decreased with experience (Figures 3 and 4). While console time was not significantly associated with body mass index, it was significantly associated with uterine weight and adhesiolysis (Tables 2 and 3). The mean estimated blood loss was 79 mL (SD, 44 mL). No blood transfusions were required, and the mean hospital stay was 1.3 days. A single intraoperative complication arose; an enterotomy was repaired robotically in a patient with extensive pelvic adhesions. There were no conversions to conventional laparoscopy or laparotomy and no bladder or ureteral injuries occurred. One patient was admitted to the intensive care unit for exacerbation of congestive heart failure. Six were readmitted postsurgically within 6 weeks: 1 each for ileus, pneumonia, vaginal cuff ab-
TABLE 3
Mean procedure times for robotic hysterectomy Procedure
Mean procedure time (minutes)*
Number of procedures
With appendectomy
77
37
Without appendectomy
68
44
With lysis of adhesions
93
26
Without lysis of adhesions
65
55
Difference (minutes)
95% CI
p-value
................................................................................................................................................................................................................................................................................................................................................................................
8 should be 9?
–3 to 20
.16
................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................
28
14 to 42
⬍.001
................................................................................................................................................................................................................................................................................................................................................................................
CI, confidence interval. * Means were stratified by type of concomitant procedure and weighted by sample size of each stratum.
JULY 2007 American Journal of Obstetrics & Gynecology
113.e3
Surgeon’s Corner scess requiring surgical drainage, and Clostridium difficile colitis, and 2 for pain control. Our initial experience using these surgical techniques in 91 patients shows that RH can be performed safely and effectively with acceptable operating times in eligible patients. Lack of tactile or haptic feedback during RH can be compensated for by attending to visual cues (increased blanching of tissues with traction and tissue-give with applied pressure). Handling tissues gently
113.e4
www.AJOG.org and using slow, deliberate, movements minimized trauma and bleeding. These key principles helped avoid conversion to conventional laparoscopy or laparotomy. Robotic technology, with its 3-dimensional visualization and articulated instrumentation, overcomes many limitations of f conventional laparoscopy. ACKNOWLEDGMENTS Graphics expertise was provided by Marvin H. Ruona, Media Support Services, Mayo Clinic
American Journal of Obstetrics & Gynecology JULY 2007
Editing, proofreading, and reference verification were provided by the Section of Scientific Publications, Mayo Clinic.
REFERENCES 1. Diaz-Arrastia C, Jurnalov C, Gomez G, Townsend C Jr. Laparoscopic hysterectomy using a computer-enhanced surgical robot. Surg Endosc 2002;16:1271-3. Epub 2002 Jun 27. 2. Reynolds RK, Advincula A. Robot-assisted laparoscopic hysterectomy: technique and initial experience. Am J Surg 2006;191:555-60.
www. AJOG.org
Robotic hysterectomy: technique and initial outcomes Rosanne M. Kho, MD; Wesley S. Hilger, MD; Joseph G. Hentz, MS; Paul M. Magtibay, MD; Javier F. Magrina, MD
P ROBLEM : O PTIMIZE O PERATING T IME Compared with the abdominal approach, laparoscopic hysterectomy offers shorter hospital stays and recovery periods.1 However, conventional laparoscopy has limitations imposed by incision size and the normal mechanics of the human hand. Surgical robots are designed to overcome these. For example, the da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale, California) provides a steady 3-dimensional image and instrumentation with articulating tips that allow for 7 degrees of movement, surpassing wrist mobility. Master controls at the surgeon’s console eliminate hand tremors and the fulcrum effect encountered in conventional laparoscopy. In addition, the surgeon’s movements are downscaled (3 to 1), increasing accuracy and precision. Published reports about robotic hysterectomy (RH) are few and include small case series.1,2
A surgical robot can move in ways that the human wrist cannot. Is it a practical substitute for the conventional hands-on approach? Cite this article as: Kho RM, Hilger WS, Hentz JG, Magtibay PM, Magrina JF. Robotic hysterectomy: technique and initial outcomes. Am J Obstet Gynecol 2007;197;113.e1-113.e4.
botic team, and efficient surgical techniques. These techniques included use of only 3 of the da Vinci’s EndoWrist instruments to limit exchanges during the procedure; shorter precut sutures; and suture clips to avoid intracorporeal knot-tying. Subsequently, we reviewed the surgical times and the intra- and postoperative outcomes for 91 consecutive patients who underwent RH, with or without salpingo-oophorectomy or concomitant appendectomy, at our institution between March 2004 and December 2005. The study was approved by the
Mayo Foundation Institutional Review Board. Patient selection criteria for the laparoscopic approach included a narrow pelvis, suspicious adnexal mass, pelvic pain not previously evaluated, or moderate to severe endometriosis. Eligible patients were offered a robotic operation. Those requiring lymphadenectomy were excluded. Four trocars were placed in the patient’s abdomen (Figure 1): a 12-mm trocar by the open Hasson technique in the umbilicus; 2 robotic trocars, 8-mm each, bilater-
FIGURE 1
O UR S OLUTION We developed a surgical technique to optimize operating time—and thus, associated cost— using the da Vinci robotic system, a dedicated gynecologic ro-
From the Department of Obstetrics and Gynecology (Drs Kho, Hilger, Magtibay, and Magrina) and the Section of Biostatistics (Mr Hentz), Mayo Clinic, Scottsdale, AZ. Portions of this manuscript have been presented in abstract form at the 32nd Scientific Meeting of the Society of Gynecology Surgeons, Tucson, AZ, Apr. 3-5, 2006. The use of brand names in this article does not imply endorsement by Mayo Clinic. Received Apr. 11, 2006; accepted May 1, 2007. 0002-9378/$32.00 © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2007.05.005
VIDEO
Click “Add-On” under the title of this article in the Table of Contents.
Four trocars are placed in the abdomen of a patient undergoing robotic hysterectomy. A long 12-mm Hasson trocar is in the umbilicus, 2 shorter 8-mm robotic trocars are placed bilaterally at the level of the umbilicus, and an accessory 10-mm trocar is between the umbilical trocar and the left lateral trocar.
JULY 2007 American Journal of Obstetrics & Gynecology
113.e1
Surgeon’s Corner
www.AJOG.org
FIGURE 2
TABLE 1
Patient characteristics, indications, and surgical measures Variable
Finding
Patient characteristic
Mean (SD); n⫽91
.....................................................................................................................................................................................................................................
Age, years
50.29 (12.13)
BMI, kg/m
27.87 (7.52)
..................................................................................................................................................................................................................................... 2 .....................................................................................................................................................................................................................................
Uterine weight, g
135.53 (67.03)
..............................................................................................................................................................................................................................................
Indication
Number (%); n⫽91
.....................................................................................................................................................................................................................................
Menometrorrhagia
39 (43)
Ovarian neoplasm
18 (20)
..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................
Pelvic pain
9 (10)
Postmenopausal bleeding
7 (8)
CIN or unsatisfactory colposcopy
6 (7)
Abnormal endometrial stripe
3 (3)
.....................................................................................................................................................................................................................................
Mean (⫾ standard error) docking times generally decreased for sequential groups of 10 patients as the surgical team gained experience.
..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................
Dysfunctional uterine bleeding
3 (3)
BRCA-2 gene
2 (2)
Family history of breast, ovarian, or colon cancer
2 (2)
Adenocarcinoma in situ cervix
1 (1)
..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................
Persistent mole
1 (1)
..............................................................................................................................................................................................................................................
Procedure type
Number (%); n⫽91
.....................................................................................................................................................................................................................................
RH
6 (7)
RH⫹Appy
5 (5)
..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................
RH⫹USO or BSO
23 (25)
RH⫹USO or BSO⫹Appy
28 (31)
..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................
RH⫹LOA
2 (2)
RH⫹LOA⫹Appy
1 (1)
..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................
RH⫹USO or BSO⫹LOA
17 (19)
.....................................................................................................................................................................................................................................
RH⫹USO or BSO⫹LOA⫹Appy
9 (10)
..............................................................................................................................................................................................................................................
Pertinent measures
Mean (SD)
.....................................................................................................................................................................................................................................
Console time, min (n⫽81)
73.00 (30.00)
.....................................................................................................................................................................................................................................
Docking time, min (n⫽88)
2.95 (1.77)
transected by the first assistant with the EnSeal Tissue Sealing and Hemostasis System (SurgRx, Inc, Redwood City, CA). The round ligament was transected, and the incision was continued over the anterior leaf of the broad ligament toward the vesicouterine fold. Next, the bladder was dissected from the lower uterine segment, at least 2 cm inferior to the cervix. Using a vaginal probe, the scrub nurse delineated the lower limit of the cervix and defined the level of the vaginal incision. The uterine arteries and cardinal ligaments were sealed and transected with the EnSeal; the vagina was transected immediately distal to the cervix; and the uterus and adnexa were removed through the vaginal opening. Pneumoperitoneum was reestablished with a sterile occluding balloon and 60 mL of saline (Koh Colpotomizer System,
.....................................................................................................................................................................................................................................
Surgery start–end time, min (n⫽91)
127.82 (35.43)
.....................................................................................................................................................................................................................................
Length of stay, days (n⫽91)
1.35 (0.69)
.....................................................................................................................................................................................................................................
Estimated blood loss, mL (n⫽90)
FIGURE 3
78.56 (43.81)
..............................................................................................................................................................................................................................................
Appy, appendectomy; BSO, bilateral salpingo-oophorectomy; CIN, cervical intraepithelial neoplasia; LOA, lysis of adhesions; RH, robotic hysterectomy; SD, standard deviation; USO, unilateral salpingo-oophorectomy.
ally (10 cm distal to and level with the umbilicus); and an accessory 10-mm trocar between the umbilical and left lateral ports. To facilitate surgery, the assistant used the accessory port to insert instruments (eg, devices for vessel-sealing, retraction, and suction/irrigation) and sutures. After the 3-arm robotic tower was situated between the patient’s legs, the middle arm was attached to the umbilical trocar for the lapa113.e2
roscope, and the 2 lateral arms were attached to the lateral trocars. A monopolar spatula was introduced through the right lateral trocar, and a bipolar grasper was positioned through the left lateral trocar. An initial incision was made at the level of the pelvic brim to identify the ureter (Video). For salpingo-oophorectomy, the infundibulopelvic ligament was isolated and then sealed and
American Journal of Obstetrics & Gynecology JULY 2007
Similarly, the mean (⫾ standard error) console times tended to decrease for sequential groups of 5 patients who underwent robotic hysterectomy and bilateral salpingo-oophorectomy.
Surgeon’s Corner
www.AJOG.org
FIGURE 4
TABLE 2
Correlation of baseline characteristics with console time Characteristic
r
95% CI
p value
BMI, kg/m2
0.001
–0.22 to 0.22
⬎.99
Uterine weight, g
0.26
–0.04 to 0.45
.02
LOA
0.33
0.12 to 0.51
.002
.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
BMI, body mass index; CI, confidence interval; LOA, lysis of adhesions; r, Pearson Correlation Coefficient.
Except for the 5th “group,” which contained only 1 patient, the mean (⫾ standard error) console times decreased for sequential groups of 5 patients who underwent robotic hysterectomy, bilateral salpingo-oophorectomy, and appendectomy. n⫽21.
CooperSurgical, Inc, Trumbull, CT). The right monopolar spatula was removed and switched to a needle holder. A precut (15-cm) 0 continuous polyglyconate absorbable suture and a CT-2 needle (Ethicon, Inc, Somerville, New Jersey) were used to close the vaginal cuff, starting at the right angle toward the midline. To provide vaginal support, the uterosacral ligament was incorporated at the right angle and at midline. Lapra-Ty suture clips (Ethicon-Endosurgery, Inc, Cincinnati, OH) eliminated intracorporeal knot tying. Similar steps were performed on the left angle toward the midline to complete vaginal cuff closure. For the appendectomy, the mesoappendix was sealed and transected using the EnSeal. The appendiceal stump was ligated with a 0 absorbable pretied suture (EndoLoop; Ethicon-Endosurgery, Inc, Cincinnati, OH). Finally, the appendix
was transected with the EnSeal and removed from the abdomen through the 10-mm accessory port. Once the robotic arms were disengaged from the trocars and the robotic column removed, the fascia were closed at the umbilical and 10-cm accessory trocar sites and skin incisions. Intravenous indigo carmine was injected, and a cystoscopy confirmed ureteral patency and excluded bladder injury.
S AFE AND T IMELY Total operating time (from incision to closure at trocar sites, including cystoscopy time), console time (for surgeon to perform procedure at console, from beginning of RH to closure of vaginal cuff), docking time (to advance robot to bedside and attach its arms to trocars), intraoperative complications, and postoperative course were all examined (Table 1). The relationship between body mass index, uterine weight, and lysis of adhesions to console time was quantified with the Pearson correlation coefficient. A weighted least-squares analysis was used to evaluate effects of appendectomy and adhesiolysis on console time. The general linear model was stratified by type of concomitant procedure, with strata weighted by sample
size. Statistical computations were accomplished with SAS Version 9 software (SAS Institute, Inc, Cary, North Carolina). The mean docking time was 2.95 minutes (standard deviation or SD, 1.77 minutes); times decreased for subsequent groups of 10 patients (Figure 2). Mean console and operating times were 73 minutes (SD, 30 minutes) and 128 minutes (SD, 35 minutes), respectively. Console times for RH plus bilateral salpingo-oophorectomy and appendectomy also decreased with experience (Figures 3 and 4). While console time was not significantly associated with body mass index, it was significantly associated with uterine weight and adhesiolysis (Tables 2 and 3). The mean estimated blood loss was 79 mL (SD, 44 mL). No blood transfusions were required, and the mean hospital stay was 1.3 days. A single intraoperative complication arose; an enterotomy was repaired robotically in a patient with extensive pelvic adhesions. There were no conversions to conventional laparoscopy or laparotomy and no bladder or ureteral injuries occurred. One patient was admitted to the intensive care unit for exacerbation of congestive heart failure. Six were readmitted postsurgically within 6 weeks: 1 each for ileus, pneumonia, vaginal cuff ab-
TABLE 3
Mean procedure times for robotic hysterectomy Procedure
Mean procedure time (minutes)*
Number of procedures
With appendectomy
77
37
Without appendectomy
68
44
With lysis of adhesions
93
26
Without lysis of adhesions
65
55
Difference (minutes)
95% CI
p-value
................................................................................................................................................................................................................................................................................................................................................................................
8 should be 9?
–3 to 20
.16
................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................
28
14 to 42
⬍.001
................................................................................................................................................................................................................................................................................................................................................................................
CI, confidence interval. * Means were stratified by type of concomitant procedure and weighted by sample size of each stratum.
JULY 2007 American Journal of Obstetrics & Gynecology
113.e3
Surgeon’s Corner scess requiring surgical drainage, and Clostridium difficile colitis, and 2 for pain control. Our initial experience using these surgical techniques in 91 patients shows that RH can be performed safely and effectively with acceptable operating times in eligible patients. Lack of tactile or haptic feedback during RH can be compensated for by attending to visual cues (increased blanching of tissues with traction and tissue-give with applied pressure). Handling tissues gently
113.e4
www.AJOG.org and using slow, deliberate, movements minimized trauma and bleeding. These key principles helped avoid conversion to conventional laparoscopy or laparotomy. Robotic technology, with its 3-dimensional visualization and articulated instrumentation, overcomes many limitations of f conventional laparoscopy. ACKNOWLEDGMENTS Graphics expertise was provided by Marvin H. Ruona, Media Support Services, Mayo Clinic
American Journal of Obstetrics & Gynecology JULY 2007
Editing, proofreading, and reference verification were provided by the Section of Scientific Publications, Mayo Clinic.
REFERENCES 1. Diaz-Arrastia C, Jurnalov C, Gomez G, Townsend C Jr. Laparoscopic hysterectomy using a computer-enhanced surgical robot. Surg Endosc 2002;16:1271-3. Epub 2002 Jun 27. 2. Reynolds RK, Advincula A. Robot-assisted laparoscopic hysterectomy: technique and initial experience. Am J Surg 2006;191:555-60.