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da Vinci Robotic Radical Hysterectomy in a 90 Years Woman with Early Stage Cervix Cancer
Abstracts / Journal of Minimally Invasive Gynecology 23 (2016) S1–S252
S247
Measurements and Main Results: All 18 patients with severe secondary dysmenorrhea and pelvic pain visited Seoul St. Mary’s hospital between 2012 and 201. Except only one patient, all 17 patients were nulliparous woman. Adenomyosis was diagnosed by pelvic ultrasonography and pelvic MRI. Patients’ characteristics were measured including age, marital status, BMI, gravida. Preoperative and postoperative characteristics were measured including the extent of adenomyosis lesion, CA-125 level. Surgical outcomes were measured including operative time, estimated intraoperative blood loss, length of hospital stay, and perioperative complications. Their mean age was older in open surgery group (robot vs open 33.294.3 vs 37.553.41 years old) and mean body mass index (BMI) was higher in robot surgery (robot vs open 25.866.01 vs 21.092.4 kg/m2). The amount of estimated blood loss was significantly larger in open surgery group than robot surgery group (robot vs open 250249.6 vs 690.91776.47 ml) and the length of hospital stay was also longer in open surgery group than robot surgery group (robot vs open 2.570.53 vs 4.01.09 days). In all 18 patients, dysmenorrhea and pelvic pain nearly disappeared after surgery. One patient who received robot-assisted laparoscopic adenomyomectomy were pregnant naturally after surgery. Another patient who received open adenomyomectomy were pregnant twin babies after surgery by IVF. Both patients delivered healthy babies via cesarean section in pelvic MRI. Conclusion: Adenomyosis usually affects premenopausal women and the standard treatment is hysterectomy. However, the challenge comes in when treating symptomatic woman who want to maintain fertility. Adenomyomectomy is a conservative surgical option for preserving fertility. Comparing with open surgery, robot-assisted laparoscopic adenomyomectomy is a feasible option of uterus-sparing surgery. 779 Removal of a 15 cm Ovarian Torsion During Second Trimester Pregnancy Using a Single-Site Robotic Platform: Case Report and Surgical Technique Ramirez ER. Obstetrics and Gynecology, St. John’s Regional Medical Center, Oxnard, California Study Objective: Here we describe the management of a 15 cm ovarian torsion in a 17 week gestational pregnancy using the da Vinci Single-Site Surgical Platform. Design: Case Report. Setting: Teaching Hospital Patients: 27 year old pregnant patient at 17 weeks gestation presented to the emergency room with a 15 cm left ovarian torsion. Intervention: Single-Site Robotic Platform. Measurements and Main Results: The management of ovarian teratomas during pregnancy can be expectantly managed, but in certain circumstances surgical intervention may be required. This 27 year old multi gravid female presented to the emergency department at 17 weeks gestation with nonspecific upper abdominal pain, nausea and vomiting. Ultrasound demonstrated a 15 cm left ovarian teratoma with absent arterial and venous blood flow. A decision was made to remove the left ovarian adnexa using the da Vinci Single-Site Surgical Platform. The robotic was docked between the patients legs and the 3D 8.5-mm high definition laparoscope confirmed the presence of a 15 cm necrotic left ovarian torsion and a 17 week gravid uterus. Once the left salpingo-oophorectomy was completed, the robot was then undocked and a 15 mm endobag was advanced into the patients abdomen between the outer edge of the single site port and the lower edge of the umbilical incision to help guide in the delivery of the ovarian teratoma. The operative procedure was successful and the patients pregnancy progressed well. Conclusion: In conclusion, the da Vinci Single-Site Surgical Platform may be a safe and effective alternative to laparotomy in patients with large adnexal masses. 780 Single Port Robotic Hysterectomy for Deep Infiltrative Endometriosis Using GelPOINT Access Platforms Chen Y-C, Ting W-H, Lu HF, Peng F-S, Chuang Y-C. Ob/Gyn, Far Eastern Memorial Hospital, New Taipei City, Taiwan
Study Objective: Despite improved ergonomics of robotic instruments compared to traditional laparoscopic instruments, arm collision is still a significant problem. In patients with total obliteration of cul-de-sac, it is a risky task to achieve maximal dissection of the plane between rectum and posterior uterine wall of uterus. The surgical management of DIE is risky due to severe adhesion of cul-desac and distorted pelvic anatomy. The surgical procedure of DIE includes temporary suspension of ovaries, adhesiolysis, skeletonization of ureters and uterosacral ligaments, creation of para- rectal space and excision of endometriotic nodules. Measurements and Main Results: Here we present a video of robotic single-port subtotal hysterectomy in a patient with severe adhesion of culde-sac due to deep infiltrative endometriosis. Conclusion: This video depicts the benefit of GelPOINT access platform that facilitate triangulation of robotic instruments. 781 da Vinci Robotic Radical Hysterectomy in a 90 Years Woman with Early Stage Cervix Cancer Chuang Y-C, Chen TA, Chen P, Ting W-HS. Ob/Gyn, Far Eastern Memorial Hospital, New Taipei City, Taiwan Study Objective: For elderly advanced or even early stage of cervix cancer, the radiation therapy or even no active treatment will be suggested. However, the side effects of radiation therapy exists and, as longevity increases, the population of women over age 80 with pelvic cancer increases.
S248
Abstracts / Journal of Minimally Invasive Gynecology 23 (2016) S1–S252
Aging is associated with an increasing prevalence of frailty and comorbidities .By decreasing complications and shortening length of hospital stay without affecting oncologic safety, surgery performed using the robot, rather than traditional laparotomy, improves the chances of a better outcome in our growing elderly populations. The major advantage of minimally invasive robotic surgery lies within the intraoperative period where blood loss is less in comparison with open radical hysterectomy . The main disadvantage is physiological disturbance, mainly due to the pneumoperitoneum and patient positioning. Patients: Here we presented our first experience of robotic type II radical hysterectomy for a 90 years old women with cervix cancer IB tumor 2 cm ,SCC ,presented with massive menopausal bleeding who had hypertension, mild dementia ,minor stroke ,sitting in wheelchair without bed-ridden status. Intervention: Prophylactic ureter double J insertion was done under local anesthesia the day before surgery. The da Vinci Si system 4 arms was used , after the pneumoperitoneum in 10 mmHg,the uterus was first suspended by suture for traction ante-verted position. By doing this, the steep Trendelenburg could be avoided. Only one side nerve sparing radical hysterectomy was tried due to limit of surgical interval. The surgical time is 190 minutes,the blood loss 100 cc. She was sent to surgical intentive care unit for 2 nights under the request of anesthesia team suggestion. Conclusion: She recovered well and went home 6 days after surgery with foley under training for one month.
782 Minimizing Blood Loss in Women with Huge Severe Adhesive Adenomyosis Using da Vinci Robot Chuang Y-C, Ting W-H, Lu HF, Peng F-S. Ob/Gyn, Far Eastern Memorial Hospital, New Taipei City, Taiwan Study Objective: Background: In cases with huge severe adhesive adenomyosis, adhesiolysis is often difficult and skill-demanding. It is also a tough task to identify and ligate the uterine vessels via
traditional laparoscopic approach. We would like to share our experience in performing the aforesaid surgical techniques using the da Vinci Robot. Material and Methods: Women with huge severe adhesive adenomyosis was selected for robotic subtotal hysterectomy. Bilateral uterine arteries were identified through retrograde tracking of the umbilical ligaments, and ligated with hem-o-locs or hemoclips. Dissection of the adhesive plane between uterus and rectosigmoid colon was attempted with care using the robotic instruments, followed by subtotal hysterectomy. Results: Ten women were recruited in this study, with average age of 45, mean uterine weight of 800 gm and mean estimated blood loss of 250 cc. No major complications such as ureteral injury or bowel injury were noted and none of the case was converted to laparotomy. Conclusions: Robotic surgery has the advantages of articulation beyond normal manipulation and three-dimensional magnification that results in improved ergonomics. Endowrist instruments offer a greater range of motion than the human hand, allowing rapid and precise dissection and tissue manipulation.
783 Uterine Leiomyomas – Minimally Invasive Outcomes on Management and Hospital Stay (MIOMAHS): A Disease Specific Approach Agochiya J, Champion N, Burchfield H, Mikhail M, Shah AJ. Obstetrics and Gynecology, Bronx Lebanon Hospital, Bronx, New York Study Objective: Primary objective is to look at the changes in the types of hysterectomy on women with Fibroid disease since the introduction of the Fibroid Center and Robotic Program at a community hospital. The secondary objective was to look at the impact of the Fibroid center on the outcomes. Design: The retrospective study collected the data for hysterectomies performed for Uterine Fibroids in the year before the introduction of Fibroid Center and Robotic program (Sep 2013- Aug 2014) and the year after the introduction of the program(Sep 2014- Aug 2015). The patients were divided into 3 groups - Group 1 included the patients who had hysterectomies prior to the introduction of the Fibroid Center, Group 2 included the patients from the Fibroid Center and Group 3 included the patients undergoing hysterectomies after the introduction of the program but were not seen in the Fibroid Center. The frequency distribution of the surgical approach, length of stay in the hospital and rate of complications were compared for the 3 groups. Setting: A first of its kind program offering Robotic Gynecological Surgery, established in an Inner-city Community Hospital. Patients: N/A Intervention: Introduction of Fibroid Center - a disease specific clinic aimed to treat a high prevalence condition in the community served by our inner-city hospital. Measurements and Main Results: Randomly selected charts demonstrated changes in distribution of Surgery as in Table 1. Comparison of outcomes in Hysterectomy is shown in Table 2. Conclusion: Since the introduction of the Fibroid Center, there has been a shift towards Robotic Hysterectomy, even for Uteri weighing > 250g.
Distribution of Hysterectomy
Group 1 - Pre-Robot Group 2 - Fibroid Center Group 3 - Non Fibroid Center
Robotic Hyst
Abdominal Hyst
Laparoscopic Hyst
Vag Hyst
19 4
8
4
27
25
11
1
S247
Measurements and Main Results: All 18 patients with severe secondary dysmenorrhea and pelvic pain visited Seoul St. Mary’s hospital between 2012 and 201. Except only one patient, all 17 patients were nulliparous woman. Adenomyosis was diagnosed by pelvic ultrasonography and pelvic MRI. Patients’ characteristics were measured including age, marital status, BMI, gravida. Preoperative and postoperative characteristics were measured including the extent of adenomyosis lesion, CA-125 level. Surgical outcomes were measured including operative time, estimated intraoperative blood loss, length of hospital stay, and perioperative complications. Their mean age was older in open surgery group (robot vs open 33.294.3 vs 37.553.41 years old) and mean body mass index (BMI) was higher in robot surgery (robot vs open 25.866.01 vs 21.092.4 kg/m2). The amount of estimated blood loss was significantly larger in open surgery group than robot surgery group (robot vs open 250249.6 vs 690.91776.47 ml) and the length of hospital stay was also longer in open surgery group than robot surgery group (robot vs open 2.570.53 vs 4.01.09 days). In all 18 patients, dysmenorrhea and pelvic pain nearly disappeared after surgery. One patient who received robot-assisted laparoscopic adenomyomectomy were pregnant naturally after surgery. Another patient who received open adenomyomectomy were pregnant twin babies after surgery by IVF. Both patients delivered healthy babies via cesarean section in pelvic MRI. Conclusion: Adenomyosis usually affects premenopausal women and the standard treatment is hysterectomy. However, the challenge comes in when treating symptomatic woman who want to maintain fertility. Adenomyomectomy is a conservative surgical option for preserving fertility. Comparing with open surgery, robot-assisted laparoscopic adenomyomectomy is a feasible option of uterus-sparing surgery. 779 Removal of a 15 cm Ovarian Torsion During Second Trimester Pregnancy Using a Single-Site Robotic Platform: Case Report and Surgical Technique Ramirez ER. Obstetrics and Gynecology, St. John’s Regional Medical Center, Oxnard, California Study Objective: Here we describe the management of a 15 cm ovarian torsion in a 17 week gestational pregnancy using the da Vinci Single-Site Surgical Platform. Design: Case Report. Setting: Teaching Hospital Patients: 27 year old pregnant patient at 17 weeks gestation presented to the emergency room with a 15 cm left ovarian torsion. Intervention: Single-Site Robotic Platform. Measurements and Main Results: The management of ovarian teratomas during pregnancy can be expectantly managed, but in certain circumstances surgical intervention may be required. This 27 year old multi gravid female presented to the emergency department at 17 weeks gestation with nonspecific upper abdominal pain, nausea and vomiting. Ultrasound demonstrated a 15 cm left ovarian teratoma with absent arterial and venous blood flow. A decision was made to remove the left ovarian adnexa using the da Vinci Single-Site Surgical Platform. The robotic was docked between the patients legs and the 3D 8.5-mm high definition laparoscope confirmed the presence of a 15 cm necrotic left ovarian torsion and a 17 week gravid uterus. Once the left salpingo-oophorectomy was completed, the robot was then undocked and a 15 mm endobag was advanced into the patients abdomen between the outer edge of the single site port and the lower edge of the umbilical incision to help guide in the delivery of the ovarian teratoma. The operative procedure was successful and the patients pregnancy progressed well. Conclusion: In conclusion, the da Vinci Single-Site Surgical Platform may be a safe and effective alternative to laparotomy in patients with large adnexal masses. 780 Single Port Robotic Hysterectomy for Deep Infiltrative Endometriosis Using GelPOINT Access Platforms Chen Y-C, Ting W-H, Lu HF, Peng F-S, Chuang Y-C. Ob/Gyn, Far Eastern Memorial Hospital, New Taipei City, Taiwan
Study Objective: Despite improved ergonomics of robotic instruments compared to traditional laparoscopic instruments, arm collision is still a significant problem. In patients with total obliteration of cul-de-sac, it is a risky task to achieve maximal dissection of the plane between rectum and posterior uterine wall of uterus. The surgical management of DIE is risky due to severe adhesion of cul-desac and distorted pelvic anatomy. The surgical procedure of DIE includes temporary suspension of ovaries, adhesiolysis, skeletonization of ureters and uterosacral ligaments, creation of para- rectal space and excision of endometriotic nodules. Measurements and Main Results: Here we present a video of robotic single-port subtotal hysterectomy in a patient with severe adhesion of culde-sac due to deep infiltrative endometriosis. Conclusion: This video depicts the benefit of GelPOINT access platform that facilitate triangulation of robotic instruments. 781 da Vinci Robotic Radical Hysterectomy in a 90 Years Woman with Early Stage Cervix Cancer Chuang Y-C, Chen TA, Chen P, Ting W-HS. Ob/Gyn, Far Eastern Memorial Hospital, New Taipei City, Taiwan Study Objective: For elderly advanced or even early stage of cervix cancer, the radiation therapy or even no active treatment will be suggested. However, the side effects of radiation therapy exists and, as longevity increases, the population of women over age 80 with pelvic cancer increases.
S248
Abstracts / Journal of Minimally Invasive Gynecology 23 (2016) S1–S252
Aging is associated with an increasing prevalence of frailty and comorbidities .By decreasing complications and shortening length of hospital stay without affecting oncologic safety, surgery performed using the robot, rather than traditional laparotomy, improves the chances of a better outcome in our growing elderly populations. The major advantage of minimally invasive robotic surgery lies within the intraoperative period where blood loss is less in comparison with open radical hysterectomy . The main disadvantage is physiological disturbance, mainly due to the pneumoperitoneum and patient positioning. Patients: Here we presented our first experience of robotic type II radical hysterectomy for a 90 years old women with cervix cancer IB tumor 2 cm ,SCC ,presented with massive menopausal bleeding who had hypertension, mild dementia ,minor stroke ,sitting in wheelchair without bed-ridden status. Intervention: Prophylactic ureter double J insertion was done under local anesthesia the day before surgery. The da Vinci Si system 4 arms was used , after the pneumoperitoneum in 10 mmHg,the uterus was first suspended by suture for traction ante-verted position. By doing this, the steep Trendelenburg could be avoided. Only one side nerve sparing radical hysterectomy was tried due to limit of surgical interval. The surgical time is 190 minutes,the blood loss 100 cc. She was sent to surgical intentive care unit for 2 nights under the request of anesthesia team suggestion. Conclusion: She recovered well and went home 6 days after surgery with foley under training for one month.
782 Minimizing Blood Loss in Women with Huge Severe Adhesive Adenomyosis Using da Vinci Robot Chuang Y-C, Ting W-H, Lu HF, Peng F-S. Ob/Gyn, Far Eastern Memorial Hospital, New Taipei City, Taiwan Study Objective: Background: In cases with huge severe adhesive adenomyosis, adhesiolysis is often difficult and skill-demanding. It is also a tough task to identify and ligate the uterine vessels via
traditional laparoscopic approach. We would like to share our experience in performing the aforesaid surgical techniques using the da Vinci Robot. Material and Methods: Women with huge severe adhesive adenomyosis was selected for robotic subtotal hysterectomy. Bilateral uterine arteries were identified through retrograde tracking of the umbilical ligaments, and ligated with hem-o-locs or hemoclips. Dissection of the adhesive plane between uterus and rectosigmoid colon was attempted with care using the robotic instruments, followed by subtotal hysterectomy. Results: Ten women were recruited in this study, with average age of 45, mean uterine weight of 800 gm and mean estimated blood loss of 250 cc. No major complications such as ureteral injury or bowel injury were noted and none of the case was converted to laparotomy. Conclusions: Robotic surgery has the advantages of articulation beyond normal manipulation and three-dimensional magnification that results in improved ergonomics. Endowrist instruments offer a greater range of motion than the human hand, allowing rapid and precise dissection and tissue manipulation.
783 Uterine Leiomyomas – Minimally Invasive Outcomes on Management and Hospital Stay (MIOMAHS): A Disease Specific Approach Agochiya J, Champion N, Burchfield H, Mikhail M, Shah AJ. Obstetrics and Gynecology, Bronx Lebanon Hospital, Bronx, New York Study Objective: Primary objective is to look at the changes in the types of hysterectomy on women with Fibroid disease since the introduction of the Fibroid Center and Robotic Program at a community hospital. The secondary objective was to look at the impact of the Fibroid center on the outcomes. Design: The retrospective study collected the data for hysterectomies performed for Uterine Fibroids in the year before the introduction of Fibroid Center and Robotic program (Sep 2013- Aug 2014) and the year after the introduction of the program(Sep 2014- Aug 2015). The patients were divided into 3 groups - Group 1 included the patients who had hysterectomies prior to the introduction of the Fibroid Center, Group 2 included the patients from the Fibroid Center and Group 3 included the patients undergoing hysterectomies after the introduction of the program but were not seen in the Fibroid Center. The frequency distribution of the surgical approach, length of stay in the hospital and rate of complications were compared for the 3 groups. Setting: A first of its kind program offering Robotic Gynecological Surgery, established in an Inner-city Community Hospital. Patients: N/A Intervention: Introduction of Fibroid Center - a disease specific clinic aimed to treat a high prevalence condition in the community served by our inner-city hospital. Measurements and Main Results: Randomly selected charts demonstrated changes in distribution of Surgery as in Table 1. Comparison of outcomes in Hysterectomy is shown in Table 2. Conclusion: Since the introduction of the Fibroid Center, there has been a shift towards Robotic Hysterectomy, even for Uteri weighing > 250g.
Distribution of Hysterectomy
Group 1 - Pre-Robot Group 2 - Fibroid Center Group 3 - Non Fibroid Center
Robotic Hyst
Abdominal Hyst
Laparoscopic Hyst
Vag Hyst
19 4
8
4
27
25
11
1