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A Comparison between Robotic and Laparoscopic Rectosigmoid Resection in Gynecology: Technique and Outcomes
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Abstracts / Journal of Minimally Invasive Gynecology 17 (2010) S25–S46
Design: The primary outcome is operative time in minutes from start to finish of surgical procedure as abstracted from operating room records. The secondary outcomes included estimated blood loss (EBL), rate of conversion to laparotomy, intra-operative complications, major immediate postoperative complications, and length of hospital stay. Demographic characteristics of each group were analysed, including patient age, prior surgeries and body-mass index. As the study started at the initiation of robotic program we analysed robotic learning curve. Statistical analysis included ANOVA and Kruskal-Wallis test. Setting: Retrospective case series study of minimally-invasive apical sacropexy (MI-APSC) techniques was done a single academic centre. Patients: All women who planned MI-APSC surgery were included in the analysis. Women for whom an abdominal sacral colpopexy (via laparotomy) was planned were excluded from the study. Intervention: MI-APSC included laparoscopic and robotic-assisted sacrocolpopexy, sacral hysteropexy, sacrocervicoopexy. For all sacrocolpo- and cervicopexies a Y-shape piece of mesh was sutured to the vagina (approximately 12 sutures for anterior and posterior portions) and 2 sutures were used for anchoring into anterior longitudinal ligament at sacral promontory. For sacral hysteropexy a rectangular piece of mesh was used to attach to the posterior cervix and vaginal wall.
Summary of MI-APSC operating room experience.
OR time (min)* EBL (cc)* MIS (minimally-invasive sling) Hysterectomy Other procedures LOA Conversion Hospital stay (days) Age (years) BMI (kg/m2)* Prior surgeries
Laparoscopic (N=46)
Robotic (N=33)
p-value
236 (+/- 60) 91 (+/- 72) 15/46
248 (+/- 48) 83 (+/- 78) 11/33
0.3y 0.6y 0.9z
8/46 22/46 12/46 1/46 2 (2-6) 61 (36-79) 28 (+/- 5) 35/46
2/33 15/33 8/33 1/33 2(2-5) 60 (37-77) 27 (+/- 4) 29/33
0.1z 0.6z 0.8z 0.8z 0.3z 0.8y 0.2y 0.2z
*Mean (SD); y ANOVA; z Kruskal-Wallis Test
Measurements and Main Results: 46 Laparoscopic MI-APSC and 33 Robotic MI-APSC were reviewed. The robotic learning curve was relatively short: after completion of first 10 cases robotic time decreased by about average of 60 minutes to an overall average of 248 (48) minutes. Conclusion: Our data suggests that introduction of robotic program for pelvic reconstructive surgery, performing MI-APSC offers comparable operating room experience as the laparoscopic approach. Robotic learning curve is short in surgeon with experience in laparoscopic MI-APSC. 111
Open Communications 5dRobotics (4:14 PM d 4:19 PM)
Leukocytosis after Robotic Surgery: Commonly Observed but Clinically Insignificant Goel M, Muntz HG, McGonigle KF. Women’s Cancer Care of Seattle, Northwest Hospital and Medical Centre, Seattle, Washington Study Objective: Laboratory studies are commonly performed on the day after surgery, but with little evidence of clinical utility. We evaluated our experience with measuring a complete blood count (CBC) to determine peripheral blood leukocyte count (WBC) on the first postoperative day (POD 1) following consecutive robotic surgeries. Design: Retrospective analysis. Patients: From January 2008 through November 2009 two surgeons (KM, HM) performed 204 robotic surgeries. Patient age, weight, height, indication for surgery, surgical procedure, operative time, estimated blood
loss, hospital length of stay, post op fever and complications were prospectively recorded, and correlated with WBC on POD-1. All patients had urinary catheter placement so this factor was not considered clinically relevant in the analysis. Measurements and Main Results: For 59/204 (29%) patients, the post-operative WBC was elevated (>11,000/cc and in 8 (4%) patients the WBC was >15,000/cc. (Maximum 16,600/cc). Eleven patients had leukocytosis pre-operatively, 17% of these patients had elevated WBC postoperatively, and one patient with elevated WBC preoperatively did not have elevated WBC postoperatively. There was no correlation between post-operative leukocytosis to operative time, BMI, performance of lymphadenectomy, or length of hospitalization (c2 test). Also, there was no correlation between POD-1 leukocytosis with fever and other infectious complications. The mean Tmax was 37.1 and Tmax of 38 and 38.2 was seen in 4 and 5 patients respectively. The only factor significantly associated with elevated postoperative WBC was preoperative elevated WBC. Two patients developed infectious complications: pneumonia on POD-9 and pelvic abscess on POD-4 had normal POD-1 WBC count of 8.53 and 8.95, respectively. Conclusion: Routine measurement of WBC on POD-1 after robotic surgery is not useful. In about 25-30% of cases there will be a slight leukocytosis, and rarely (about 4%) will the WBC exceed 15,000/cc. In no case the WBC count on POD-1 was found clinically useful. 112
Open Communications 5dRobotics (4:20 PM d 4:25 PM)
A Comparison between Robotic and Laparoscopic Rectosigmoid Resection in Gynecology: Technique and Outcomes Jacob KA, Kapetanakis VE, Klauschie JL, Magtibay PM, Magrina JF, Kho RM. Gynecology, Mayo Clinic, Phoenix, Arizona Study Objective: To compare clinical outcomes of patients undergoing rectosigmoid resection with primary anastomosis by robotics and laparoscopy in a gynecologic surgical setting. Design: A consecutive series of patients undergoing rectosigmoid resection with anastomosis and concomitant gynecologic surgery was retrospectively identified from 1/2003 to 1/2010. Clinical outcomes were compared among robotic and laparoscopic surgery. Data was analyzed using the student’s ttest. Setting: Tertiary referral center. Patients: A total of 15 patients affected by endometriosis, ovarian cancer, sigmoidovaginal fistula, diverticular disease and ovarian remnant syndrome underwent robotic rectosigmoid resection. The cases were compared to 6 patients undergoing laparoscopic rectosigmoid resection. Intervention: Rectosigmoid resection by robotics and laparoscopy. Measurements and Main Results: The mean operating times for patients undergoing robotic and laparoscopic surgery were 293 and 320 min, respectively; the mean blood loss was 250 and 241 mL; and the mean length of hospital stay was 6.46 and 6.83 days, no statistical significance was found. Concomitant robotic procedures included hysterectomy (N=5), oophorectomy (N=6), fistula repair with omental flap (N=3), lymphadenectomy (N=3), adhesiolysis/ureterolysis (N=8), other bowel resection (N=1), and appendectomy (N=7). Concomitant laparoscopic procedures were similar. Thirteen (87%) patients had undergone prior abdominal surgery in the robotic group. In the robotic group, two patients experienced pelvic seroma with one requiring imaged guided drainage. In the laparoscopic group, one anastomotic leak underwent reoperation with diversion. The rates of intraoperative complications, postoperative intervention, hospital readmission and reoperation were similar between groups. Robotic surgical technique involved mobilization of the colon. The distal rectosigmoid junction was divided using an endoscopic stapler. The proximal stump was brought extracorporeally through a mini-incision for anvil insertion. The anvil was then directed intracorporeally and joined to the transanal shaft establishing the anastomosis. Conclusion: Rectosigmoid resection and anastomosis is feasible with robotic surgery. When compared to laparoscopy it is at least equivalent and may possess potential advantages.
Abstracts / Journal of Minimally Invasive Gynecology 17 (2010) S25–S46
Design: The primary outcome is operative time in minutes from start to finish of surgical procedure as abstracted from operating room records. The secondary outcomes included estimated blood loss (EBL), rate of conversion to laparotomy, intra-operative complications, major immediate postoperative complications, and length of hospital stay. Demographic characteristics of each group were analysed, including patient age, prior surgeries and body-mass index. As the study started at the initiation of robotic program we analysed robotic learning curve. Statistical analysis included ANOVA and Kruskal-Wallis test. Setting: Retrospective case series study of minimally-invasive apical sacropexy (MI-APSC) techniques was done a single academic centre. Patients: All women who planned MI-APSC surgery were included in the analysis. Women for whom an abdominal sacral colpopexy (via laparotomy) was planned were excluded from the study. Intervention: MI-APSC included laparoscopic and robotic-assisted sacrocolpopexy, sacral hysteropexy, sacrocervicoopexy. For all sacrocolpo- and cervicopexies a Y-shape piece of mesh was sutured to the vagina (approximately 12 sutures for anterior and posterior portions) and 2 sutures were used for anchoring into anterior longitudinal ligament at sacral promontory. For sacral hysteropexy a rectangular piece of mesh was used to attach to the posterior cervix and vaginal wall.
Summary of MI-APSC operating room experience.
OR time (min)* EBL (cc)* MIS (minimally-invasive sling) Hysterectomy Other procedures LOA Conversion Hospital stay (days) Age (years) BMI (kg/m2)* Prior surgeries
Laparoscopic (N=46)
Robotic (N=33)
p-value
236 (+/- 60) 91 (+/- 72) 15/46
248 (+/- 48) 83 (+/- 78) 11/33
0.3y 0.6y 0.9z
8/46 22/46 12/46 1/46 2 (2-6) 61 (36-79) 28 (+/- 5) 35/46
2/33 15/33 8/33 1/33 2(2-5) 60 (37-77) 27 (+/- 4) 29/33
0.1z 0.6z 0.8z 0.8z 0.3z 0.8y 0.2y 0.2z
*Mean (SD); y ANOVA; z Kruskal-Wallis Test
Measurements and Main Results: 46 Laparoscopic MI-APSC and 33 Robotic MI-APSC were reviewed. The robotic learning curve was relatively short: after completion of first 10 cases robotic time decreased by about average of 60 minutes to an overall average of 248 (48) minutes. Conclusion: Our data suggests that introduction of robotic program for pelvic reconstructive surgery, performing MI-APSC offers comparable operating room experience as the laparoscopic approach. Robotic learning curve is short in surgeon with experience in laparoscopic MI-APSC. 111
Open Communications 5dRobotics (4:14 PM d 4:19 PM)
Leukocytosis after Robotic Surgery: Commonly Observed but Clinically Insignificant Goel M, Muntz HG, McGonigle KF. Women’s Cancer Care of Seattle, Northwest Hospital and Medical Centre, Seattle, Washington Study Objective: Laboratory studies are commonly performed on the day after surgery, but with little evidence of clinical utility. We evaluated our experience with measuring a complete blood count (CBC) to determine peripheral blood leukocyte count (WBC) on the first postoperative day (POD 1) following consecutive robotic surgeries. Design: Retrospective analysis. Patients: From January 2008 through November 2009 two surgeons (KM, HM) performed 204 robotic surgeries. Patient age, weight, height, indication for surgery, surgical procedure, operative time, estimated blood
loss, hospital length of stay, post op fever and complications were prospectively recorded, and correlated with WBC on POD-1. All patients had urinary catheter placement so this factor was not considered clinically relevant in the analysis. Measurements and Main Results: For 59/204 (29%) patients, the post-operative WBC was elevated (>11,000/cc and in 8 (4%) patients the WBC was >15,000/cc. (Maximum 16,600/cc). Eleven patients had leukocytosis pre-operatively, 17% of these patients had elevated WBC postoperatively, and one patient with elevated WBC preoperatively did not have elevated WBC postoperatively. There was no correlation between post-operative leukocytosis to operative time, BMI, performance of lymphadenectomy, or length of hospitalization (c2 test). Also, there was no correlation between POD-1 leukocytosis with fever and other infectious complications. The mean Tmax was 37.1 and Tmax of 38 and 38.2 was seen in 4 and 5 patients respectively. The only factor significantly associated with elevated postoperative WBC was preoperative elevated WBC. Two patients developed infectious complications: pneumonia on POD-9 and pelvic abscess on POD-4 had normal POD-1 WBC count of 8.53 and 8.95, respectively. Conclusion: Routine measurement of WBC on POD-1 after robotic surgery is not useful. In about 25-30% of cases there will be a slight leukocytosis, and rarely (about 4%) will the WBC exceed 15,000/cc. In no case the WBC count on POD-1 was found clinically useful. 112
Open Communications 5dRobotics (4:20 PM d 4:25 PM)
A Comparison between Robotic and Laparoscopic Rectosigmoid Resection in Gynecology: Technique and Outcomes Jacob KA, Kapetanakis VE, Klauschie JL, Magtibay PM, Magrina JF, Kho RM. Gynecology, Mayo Clinic, Phoenix, Arizona Study Objective: To compare clinical outcomes of patients undergoing rectosigmoid resection with primary anastomosis by robotics and laparoscopy in a gynecologic surgical setting. Design: A consecutive series of patients undergoing rectosigmoid resection with anastomosis and concomitant gynecologic surgery was retrospectively identified from 1/2003 to 1/2010. Clinical outcomes were compared among robotic and laparoscopic surgery. Data was analyzed using the student’s ttest. Setting: Tertiary referral center. Patients: A total of 15 patients affected by endometriosis, ovarian cancer, sigmoidovaginal fistula, diverticular disease and ovarian remnant syndrome underwent robotic rectosigmoid resection. The cases were compared to 6 patients undergoing laparoscopic rectosigmoid resection. Intervention: Rectosigmoid resection by robotics and laparoscopy. Measurements and Main Results: The mean operating times for patients undergoing robotic and laparoscopic surgery were 293 and 320 min, respectively; the mean blood loss was 250 and 241 mL; and the mean length of hospital stay was 6.46 and 6.83 days, no statistical significance was found. Concomitant robotic procedures included hysterectomy (N=5), oophorectomy (N=6), fistula repair with omental flap (N=3), lymphadenectomy (N=3), adhesiolysis/ureterolysis (N=8), other bowel resection (N=1), and appendectomy (N=7). Concomitant laparoscopic procedures were similar. Thirteen (87%) patients had undergone prior abdominal surgery in the robotic group. In the robotic group, two patients experienced pelvic seroma with one requiring imaged guided drainage. In the laparoscopic group, one anastomotic leak underwent reoperation with diversion. The rates of intraoperative complications, postoperative intervention, hospital readmission and reoperation were similar between groups. Robotic surgical technique involved mobilization of the colon. The distal rectosigmoid junction was divided using an endoscopic stapler. The proximal stump was brought extracorporeally through a mini-incision for anvil insertion. The anvil was then directed intracorporeally and joined to the transanal shaft establishing the anastomosis. Conclusion: Rectosigmoid resection and anastomosis is feasible with robotic surgery. When compared to laparoscopy it is at least equivalent and may possess potential advantages.