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Robotic hysterectomy: A review of indications, technique, outcome, and complications
apollo medicine 12 (2015) 91–99
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/apme
Review Article
Robotic hysterectomy: A review of indications, technique, outcome, and complications Rooma Sinha a,*, S. Madhumati a, Rupa Bana b, Fozia Jeelani b, Samita Kumari c a
Senior Consultant, Department of Obstetrics and Gynecology, Apollo Health City, Hyderabad, Telangana, India Senior Registrar, Department of Obstetrics and Gynecology, Apollo Health City, Hyderabad, Telangana, India c Resident (DNB), Department of Obstetrics and Gynecology, Apollo Health City, Hyderabad, Telangana, India b
article info
abstract
Article history:
Hysterectomy is the second most common surgery performed on women after cesarean
Received 14 May 2015
section. The advantages of minimally invasive hysterectomy such as reduced hospitaliza-
Accepted 14 May 2015
tion, quick recovery with more rapid return to normal activities, and less postoperative
Available online 15 June 2015
morbidity are well known. Although most guidelines recommend that minimally invasive hysterectomy should be the standard of care, the gynecologists have been slow in adopting
Keywords:
minimally invasive laparoscopic techniques to perform this operation. Since its approval in
Hysterectomy
2005 for gynecological surgeries, robot-assisted hysterectomy has been found to be feasible
Robotic hysterectomy
and safe both in benign and malignant indications. This significant difference is mainly due
Laparoscopic hysterectomy
to ergonomics, endowrist movements of instruments, and stereoscopic three-dimensional
Endometriosis
magnified vision. The specific indications for hysterectomy where the robotic technology
Fibroid
can benefit women are the ones with adhesions such as severe endometriosis, large uterus with large or multiple fibroids, early carcinoma cervix, and/or endometrial carcinoma. However the main benefit of this procedure was seen in the reduction of open surgery including conversions during laparoscopic hysterectomies. In the long run, we need to critically examine the long-term benefits and appropriate indications for robot-assisted hysterectomy especially in benign conditions, thus reducing the incidence of open surgery in gynecology. This review describes the operative procedure of robotic hysterectomy in eight steps. # 2015 Published by Elsevier B.V. on behalf of Indraprastha Medical Corporation Ltd.
1.
Introduction
Hysterectomy is the second most common surgery performed on women after cesarean section, and most are done for benign condition. Harry Reich was the first to describe laparoscopic
hysterectomy in 1989, 50% are still conducted by open method. The gynecologists have been slow in adopting minimally invasive technique to perform this operation. Both the American Association of Gynecologic Laparoscopists (AAGL) and the American Congress of Obstetricians and Gynecologists (ACOG) issued statements that minimally invasive hysterectomy
* Corresponding author at: A 402, Aparna Towers, Kondapur, Hyderabad 500084, Telangana, India. Mobile: +91 9849008180. E-mail addresses: [email protected], [email protected] (R. Sinha). http://dx.doi.org/10.1016/j.apme.2015.05.014 0976-0016/# 2015 Published by Elsevier B.V. on behalf of Indraprastha Medical Corporation Ltd.
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should be the standard of care.1,2 The slow adoption of minimally invasive hysterectomy techniques among practicing obstetrician-gynecologists is mainly due to conventional ‘‘straight-stick’’ laparoscopic skills requiring long learning curve along with insufficient laparoscopic training and exposure during their residency program.3 So when FDA approved robotic technology for hysterectomy in 2005, the incidence of minimally invasive hysterectomy was expected to rise with 3dimensional optics, wrist like motion with robotic instruments, and shorter learning curves than traditional laparoscopy for the surgeons.4 The advantages of minimally invasive hysterectomy are well known such as reduced hospitalization, quick recovery with more rapid return to normal activities, and less postoperative morbidity.2 These advantages have been also shown in a meta-analysis, comparing total laparoscopic hysterectomy (TLH) with total abdominal hysterectomy (TAH). These advantages are reduction in morbidity—specifically, fewer perioperative morbidity and complications, lower estimated blood loss, and shorter hospital stay.5
2.
Indication of robotic hysterectomy
Hysterectomy for any benign indication can be performed with robotic assistance. It has its application in gynecological oncology, especially in early cervical carcinoma and endometrial carcinoma. However, choosing the route of hysterectomy in benign cases is important. Vaginal hysterectomy especially non-descent vaginal hysterectomy (NDVH) is the ultimate minimally invasive method of performing hysterectomy. There is no doubt about that. Laparoscopic or robotic hysterectomy should not replace vaginal hysterectomy. Minimally invasive techniques become crucial in situations where NDVH is not feasible or is contraindicated. In today's era, surgical situation that pose difficulty in performing hysterectomy via a laparoscope like pelvic adhesive disease or significant endometriosis, the robotic assistance is of great value and should be used where available to avoid open surgery and its associated morbidity. Robotic hysterectomy is also a good option in patients who need concomitant sacral colpopexy. The route of hysterectomy is often influenced by uterine weight and size, previous surgeries, pelvic adhesions or endometriosis, and presence of uterine descent as well as the body habitus and BMI of the patient. Landeen et al. carried out a retrospective study of 1474 hysterectomies, comparing four techniques: abdominal, vaginal, conventional laparoscopy, and robotically assisted laparoscopy. Their analysis of this study showed reduced blood loss and hospital stay with robotic surgery (P < 0.0001), and higher overall complication rate with the laparotomy (14%). However, the rate of complications was lowest with the vaginal hysterectomy. The conversion to open surgery is four-fold higher with the laparoscopic technique.6
3.
Hysterectomy and robotic assistance
The da Vinci Robotic Surgical System (Intuitive Surgical) is an advanced laparoscopic-assisted surgical system that can address many of the current limitations of conventional
laparoscopy. It is a logical next step in performing minimally invasive gynecological surgeries, and is only the beginning of numerous advances in the field of gynecological surgeries in the future. It has 3 components. The first component of the da Vinci system is the vision cart. It has vision system that provides 2dimensional imaging through a 12-mm, dual optical endoscope. The endoscope has 2 telescopes that gives a 3D vision to the surgeon on the console. The second component of the da Vinci system is the patient-side cart with robotic arms and endowrist instruments. Most da Vinci system now has provision for 3 robotic arms in addition to the arm that is docked to the camera port. Whether to use two or three instruments will depend on the surgeon's decision depending on the case profile. The third component is the surgeon console that is located away from the patient bedside but in the same operating room. The surgeon seated at this console, with the help of masters can control instruments that are inserted via the 8 mm ports into the patient's abdomen. This is aided by the surgeon's 3D view with the aide of a stereoscopic viewer. The surgeon console has additional foot pedals for energy sources, camera adjustment, and a swapping mechanism that helps the surgeon to control 3 instruments all by herself. Thus, maneuvers such as lysis of adhesions, suturing, and knot tying are easier due to wristed movements of the instruments and magnified vision, thus providing unique advantages over 2D straight stick approach of standard laparoscopy.
4.
Selection of cases for robotic hysterectomy
Three situations that often tip the balance towards open surgery are presence of severe adhesions, large uterus, and malignancy. In all these three situations robotic assistance can help overcome the surgical challenges and reduce incidence of open surgery thus reducing the post operative morbidity. Advanced scarring of the pelvis poses challenges to hysterectomy by any route. Especially, when attempted by minimally invasive hysterectomy with conventional laparoscopic equipment, the altered anatomy poses technical limitations and the conventional laparoscopic surgical skill limits the ability to compensate for the altered anatomy. Hysterectomy for the larger uterus is also difficult by minimally invasive method. This is true for both laparoscopic surgery as well as robotic assisted surgery, and to our experience is the most challenging. Port positioning is tricky, the ability to maneuver instruments is compromised in the presence of a large uterus. Moreover, vaginal removal of the specimen is difficult, when the specimen is >150 g and often requires morcellation.
5. Special situations suitable for robotic assisted hysterectomy 5.1.
Endometriosis
Conventional laparoscopy in endometriosis is a challenging task due to the complexity of pelvic dissection. The adhesive nature of the disease with obliteration of the surgical planes
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makes dissection and ability to remove all endometriotic implants difficult. Added to this is the variability of surgical skill levels of surgeons. The straight stick laparoscopy limits the surgeons from reaching the corners of the pelvis to complete the surgery. Robotic endowrist instruments simulate the normal mechanics of the human hand and is of great advantage in such situation along with the 3-dimensional visualization. Decreased surgeon's fatigue and hand tremors help in improving surgical precision. Eight international clinical centers participated in a study including 164 women from November 2008 to April 2012, with stage IV endometriosis who underwent robotic-assisted laparoscopy. Patients were divided into 4 groups according to the localization of the nodule(s): rectum (n = 88), bladder (n = 23), ureter and uterosacral ligaments (n = 115), and on uterus in case of hysterectomy (n = 28). In the rectal nodule group, one laparotomy conversion, 2 cases needed suturing for rectal injuries. In the bladder group, one vesicovaginal hematoma and one case with prolonged intermittent self-catheterization were reported. In the ureter and uterosacral ligaments group, there were 2 ureteral fistulas. The hysterectomy group did not report any complication. This is one of the largest series published in the literature on robotic-assisted laparoscopy for deep infiltrating endometriosis. Robotic-assisted laparoscopy in deep infiltrating endometriosis appears to be a feasible option with no increase in surgical time, blood loss, and intra- and postoperative complications.7
5.2.
Previous surgery
Dense adhesions are often encountered in cases with multiple previous surgeries such as cesarean sections, myomectomy, and hysterotomy. This is a common reason for surgeons to convert their surgeries to laparotomy. A series of six patients with suspected pelvic adhesive disease involving the anterior cul-de-sac, who underwent robot-assisted laparoscopic hysterectomy were reported by Advincula. All the cases were for benign indications, and none were converted to laparotomy. The average length of hospital stay was 1.3 days. They concluded that robot-assisted laparoscopic hysterectomy is a feasible technique in patients with a scarred or obliterated anterior cul-de-sac, and may provide a tool to overcome the surgical limitations seen with conventional laparoscopy.8 Chiu published a series of 216 patients, robotic total hysterectomy in 88 and laparoscopic total hysterectomy in 128. For cases with severe adhesions (adhesion score greater than 4), robotic surgery was associated with a less operation time (113.9 38.4 min versus 164.3 81.4 min, P = 0.007) and reduced blood loss (187.5 148.7 mL versus 385.7 482.6 mL, P = 0.044) compared with laparoscopy. Additionally, robotic group had lower postoperative pain, and this was found to be independent of adhesion score or uterine weight. Comparing to laparoscopic approach, robotic surgery is a feasible and potential alternative for performing total hysterectomy with severe adhesions.9
5.3.
Large uterus
Multiple fibroids or large adenomyotic uterus presents challenges due to its large size that tends to occupy the pelvis
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leaving little space for movement of instruments. With the use of robotic platform, the surgeon's ability to manipulate and control the third arm by herself is of great advantage in such situations. This manipulation helps to reach the corners in the pelvis and access tissues and planes that would have been difficult with straight stick laparoscopic instruments. A multicenter study was done in five community practice settings across the United States. 256 patients who had hysterectomy with robotic assistance from March 2006 to July 2009 and uterine weights of at least 250 g were included. The study concluded that robotically assisted hysterectomy with low morbidity was successful in this population with large uteri with low blood loss, and minimal risk of conversion to laparotomy. Results were reproducible among general gynecologists from geographically diverse community settings.10
5.4.
Early carcinoma of cervix
Skills to perform robotic radical hysterectomy can be acquired not only in a shorter time but also by a larger number of surgeons who perform open radical hysterectomy and encounter difficulties with conventional laparoscopy. Thus, converting open surgery to minimally invasive surgery offers a means to decrease the morbidity associated with endometrial cancer surgery. The first published report regarding robotic radical hysterectomy was in 2006.11 Sert et al. initially described the feasibility of robotic-assisted laparoscopic radical hysterectomy in 2007 for early stage cervical carcinoma cases. They reported better results than with traditional laparoscopic radical hysterectomy in 15 patients with earlystage cervical carcinoma as a pilot case-control study at a comprehensive cancer center-university teaching hospital setting.12 Subsequently in 2008, Ramirez reported a series of 5 cases with invasive squamous cell carcinoma of the cervix. One patient in their series experienced two postoperative complications, a vesicovaginal fistula and a lymphocyst formation post-operatively. These are complications known to radical hysterectomy procedure and cannot be attributed to the robotic technology alone. However, no patient had residual tumor as well as no patient underwent adjuvant therapy, but in the average follow-up of 7.5 months, there were no recurrences.13 Nerve-sparing radical hysterectomy by use of robotic assistance is a feasible approach for the treatment of cervical cancer patients, due to ergonomics and articulated movements of endowrist instruments and image magnification. These features contribute for correct identification and preservation of the pelvic anatomy in terms of innervation, reducing the risk of postoperative neurological sequelae.
5.5.
Carcinoma of the endometrium
Veljovich in 2008 published a case series of 118 patients underwent robotic surgery for endometrial carcinoma and compared their results with open surgery for the same indication. Patients who underwent robotic surgery had shorter length of stay (40.3 h versus 127 h, P < 0.0001) with comparable node yields (17.5 versus 13.1, P = 0.1109). 8 patients in the robotic group had major and 13 minor complications. They concluded that robotic surgery is feasible in gynecologic oncology. Despite longer operative times, estimated blood loss and length of stay
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are reduced and lymph node yields are comparable.14 Using a prospective protocol, Pearson et al. performed robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy on 80 women. All tumors were radically removed. Median number of retrieved lymph nodes was 26 (range 15–55). Five women needed resuturing for vaginal cuff dehiscence, two women were re-operated for trocar site hernias, and one woman had a ureteric stricture that resolved following stent treatment. 43 of eligible 46 women (93%) had a long-term follow-up (> or =12 months). They concluded that though this technique was feasible, effort should be made to ensure proper closure of the vaginal cuff, trocar sites, and to develop nerve-sparing techniques.15 Various studies have consistently reported that the number of lymph nodes retrieved is similar in the range between 17 and 32 for the robotic cohort and 16–23 for the laparoscopic cohort.16–18
6.
Operative technique
6.1.
Preoperative preparation
Preoperative preparation is of importance and can help in successful completion of the procedure. There is no evidence to use mechanical bowel preparation routinely, and we do not recommend it either. The patients will be advised clear liquid diet a day before and two tablets of Bisacodyl (Dulcolax®) in the night before surgery for clearing their bowels. Use of charcoal tablets on the night before the surgery helps to deflate the bowels for visualization, and is also part of our preoperative protocol. The patients will be advised to remain nil by mouth for 6 h prior to surgery. All the patients are screened for any preoperative use of blood thinners and medical conditions that need to be addressed before surgery. All the patients are given antibiotic prophylaxis preoperatively.
6.2.
Anesthesia and patient positioning
After induction of general anesthesia with endotracheal tube, the patient is positioned in the dorsal lithotomy position with buttock just off the table. The arms are tucked to the side and secured in neutral position with the thumb pointing up. This is done so that the arms do not slip during surgery nor do they obstruct the movement of robotic arms. The chest of the patient is strapped to avoid slipping when the patient is finally positioned in Trendelenburg position. Some form of protection of the face is usually done, and this can be done with the help of foam. The stomach is not routinely decompressed with a nasogastric tube but if the uterus is large, and the primary port needs to be put above the umbilical level, then we prefer to do this.
6.3.
Uterine manipulation
The bladder is drained with a Foley catheter, and is placed in situ. There are various types of manipulators available, and can be chosen according to individual surgeon's choice. We prefer to use RUMI uterine manipulator (Cooper Surgical), which is placed with a Koh colpotomy ring and vaginal pneumooccluder balloon for uterine manipulation, which is done by the
assistant at the vaginal end. Good access to this area by the second assistant is important and needs special attention. Hence, we position our patient cart to the right side, parallel to the operation table to keep the vaginal access free. An expert assistant for uterine manipulation can make hysterectomy simple and safe. When needed, the bedside assistant additionally provides traction or manipulation by using a myoma screw or laparoscopic forceps from the 5 mm port.
6.4.
Trocar placements and docking
We introduce our primary trocar (12 mm) with open method and the intraperitoneal position checked by pressure in pneumo-insufflator (<5 mm). Direct introduction of the camera through the primary trocar can also confirm intraperitoneal position of the primary trocar before we proceed with other 8 mm port placements. We choose 12 mm extra long (Ethicon) trocar; the extra length is important for docking of the camera arm as the subcutaneous fat at times can be up to 2 in. The 12-mm trocar is placed 2–5 cm above umbilicus, the location of this depends on several factors – upper level of the uterus, previous surgical scars, or any previous mesh repair. Two 8-mm robotic trocars are placed bilaterally: 10 cm lateral to and anywhere between 3 and 6 cm above the anterior superior iliac spine. This can at times be even at the level of the umbilicus if the size of uterus is large. The 8 mm trocars are classically placed with one on the left of the patient and 2 on the right. An accessory 5-mm trocar is placed in the left upper quadrant. Monopolar scissors is inserted through the right upper 8 mm port (arm 1); a prograsp through the right lower 8 mm port (arm 3) and a fenestrated bipolar dissecting forceps was inserted through the left 8 mm port (arm 2).
6.5.
Operative steps
The surgical team in the operating room consists of a console surgeon, a bedside assistant, and a nurse standing on the left side of the patient and a second assistant or a nurse at the vaginal end of the patient for uterine manipulation. A 308 camera is used by our surgical team.
6.5.1.
Eight steps
1. Survey of the pelvis and adhesiolysis: In the beginning, a survey of the operative field is performed to understand the altered anatomy. In cases where severe adhesions are expected, we recommend ureteric catheters placement preoperatively. The ureters are identified on both sides at the beginning of the procedure. Adhesiolysis is begun from either left or right side depending on the availability of surgical planes (Fig. 1). In cases of dense adhesion of endometrioma to the lateral pelvis wall, we try to lift the endometrioma from the lateral pelvis wall but are always alert regarding the location of ureter at this step. Also considered the crucial step as we believe that once the lateral wall adhesions are released it is easier to open the broad ligament after ligating the round ligament and reach for the uterine artery. 2. Opening of the broad ligament – both sides: The surgery is started with identification and transection of the round ligament. This is achieved by cauterizing using the
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[(Fig._1)TD$IG]
[(Fig._3)TD$IG]
Fig. 1 – Step 1: Survey of pelvis and adhesiolysis.
[(Fig._2)TD$IG]
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Fig. 3 – Step 3: Dissection of vesico-uterine fold.
[(Fig._4)TD$IG]
Fig. 2 – Step 2: Opening of broad ligament.
Fig. 4 – Step 4: Uterosacral ligament transection. fenestrated bipolar and cutting using the monopolar hot shears. Once this is done, the broad ligament is opened, and is dissected anteriorly and posteriorly. The anterior leaf of the broad ligament is then dissected and incised towards the bladder (Fig. 2). The traction at this point on the uterus is provided by the prograsp in arm 3 and the uterine manipulator inside the uterus. The infundibulopelvic ligament is then identified, cauterized with bipolar, and cut with hot shears where ovaries are being removed. At this step, it is essential to identify the ureters on the same side. If the ovaries are to be conserved, then the utero-ovarian ligament is cauterized, and cut using bipolar forces and hot shears. 3. Vesico-uterine reflection: The anterior leaf of the broad ligament is completely incised from both sides up to the vesico-uterine fold anteriorly (Fig. 3). The vesico-uterine reflection is tented up using the prograsp in arm 3; hot shears in arm 1 and the bipolar in arm 2 are used to dissect bladder gently but sharply off the uterus and cervix. By doing this step, the colpotomy ring (Koh ring) is adequately visualized. Cases where the anterior cul-de-sac adhesions are encountered or there is scarring of the vesico-uterine reflection, the bladder was filled with 100 mL of methylene blue stained saline to facilitate dissection. 4. Uterosacral ligaments transection: The uterosacral ligaments are coagulated and transected bilaterally after anteverting the uterus. The uterine manipulator is often sufficient at this
step (Fig. 4). If the uterus is large as in the case of multiple fibroids or the posterior pouch has adhesions, then the use of prograsp to push the uterus anteriorly is irreplaceable. 5. Ligation of the uterine vessels on both sides: Upward push by the assistant at the step of uterine artery coagulation ensures that the distance between the uterine artery and ureter is at least 2 cm preventing its damage. Adequate skeletonization of the uterine arteries ensures sufficient lateral displacement of the ureters. The uterine arteries are coagulated using the bipolar and cut with the shears (Fig. 5). Coagulation of the ascending branch of the uterine artery reduces backflow of blood making surgery at the level of Mackenrodt's ligament safer and neater. 6. Colpotomy: Anterior and posterior colpotomy is facilitated by the Koh colpotomy ring, while upward uterine traction is provided by the vaginal assistance as well as with the help of prograsp in the arm 3 (Fig. 6). The same upward push at and at the level of vaginal cuff incision pushes the ureter and bladder laterally, hence reducing the chances of ureteric injury. Colpotomy can begin either anteriorly, posteriorly, or from the lateral angles, but all depends on the anatomy encountered or sometimes the surgeon's comfort. After colpotomy the uterus is extracted vaginally.
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[(Fig._5)TD$IG]
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[(Fig._7)TD$IG]
Fig. 5 – Step 5: Ligation of uterine vessel (right).
[(Fig._6)TD$IG]
Fig. 7 – Step 7: Vaginal cuff closure.
[(Fig._8)TD$IG]
Fig. 6 – Step 6: Colpotomy with Koh cup in view. Fig. 8 – Step 8: Survey of pelvis and checking for hemostasis under water.
7. Vaginal cuff closure: Pneumoperitoneum is now maintained by repositioning the inflated vaginal pneumo-occluder balloon. Irrigation is done to check oozing any significant bleeding is controlled. Excessive cautery for minimal oozing should be avoided. The bipolar fenestrated and shears are replaced with needle holders for vault suturing. At times we only replace the hot shears in arm 1 with needle holder and continue using the bipolar in arm 2 during suturing. It serves two purpose – hemostasis during suturing can be done easily, and it also economical. The vault is closed using either 0-Vicryl or 1-0 V loc suture. The vault is closed with continuous sutures (Fig. 7). The suture is passed directly into the pelvis via the open vagina and retrieved by the 5 mm assistant port using the same technique we use in laparoscopic suturing. The needle is held about 3–4 cm from the needle hub, and removed along with the trocar tract. 8. Survey of the pelvis: A low-pressure check as well as underwater check is performed for ensuring hemostasis, and the robotic arms are undocked after removing the instruments under vision (Fig. 8). The abdomen is deflated,
and the primary trocar site is repaired using 1-0 Vicryl. The rate of bowel herniation at the 12 mm bladeless trocar sites has been reported to be 0.7%; hence attention to the closure of this port is warranted.
7.
Specimen retrieval
In cases with benign indications, we retrieve our specimen via the vaginal route. If the specimen is large, then we fall back on our long standing experience of NDVH, and the technique of morcellation of the uterus will be used during this procedure. The specimen can also be put in a bag and retrieved vaginally. Procedures such as hemisection, intramyometrial coring, wedge morcellation, and perhaps myomectomy can help in retrieval of the specimen.19 At times to gain access to the vagina, the robot has to be undocked, as one proceeds with morcellation. In such situations, the vaginal opening is closed vaginally by standard suturing.
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8. Robotic hysterectomy in contemporary gynecological practice Until 2005, although it had been approximately 40 years, since the early publications of laparoscopic approach, most hysterectomies are still performed through laparotomy. Only after the introduction of robotic-assisted da Vinci platform, did the rate of open surgery begin to decrease. An interesting publication by Payne et al. compared cases of total laparoscopic hysterectomy to robotic assisted hysterectomy in a community hospital. They did a retrospective analysis of 100 patients who underwent laparoscopic hysterectomy before the robotic program, and 100 patients who underwent robotic hysterectomy after the implementation of robotic program. Overall the robotic group experienced longer operative times by an average of 27 min. However, when compared with the last 25 robotic cases laparoscopic group had longer operative times. The mean blood loss in the pre-robotic group was twice that of the robotic group. The mean length of hospital stay was half a day longer in the pre-robotic group than in the robotic group. The incidence of adverse events was the same in both groups. The total number of exploratory laparotomies in the pre-robotic group was significantly greater than in the robotic group (11% versus 0%). The rate of intraoperative conversions to total abdominal hysterectomy from laparoscopy was approximately 2-fold higher in the prerobotic group as compared with the robotic group (9% versus 4%). The most important benefit of robotic hysterectomy highlighted in this study is the reduction in conversion to open surgery.20 As the robotic assisted surgery began to integrate into clinical practice, robotic assisted hysterectomy increased from 4.1% to 6.3% of all hysterectomies. This was mainly due to the reduction in the rates of abdominal hysterectomy, however the vaginal hysterectomy rates remained unchanged. At present, numerous studies do not show any significant difference between analgesic use and return to normal activity. Robotic hysterectomy is associated with longer operative time although the quality-of-life index was better.21 However, the main benefit of this procedure was seen in the reduction of open surgery including conversions during laparoscopic hysterectomies. Analysis of the impact of robotic surgical system on hysterectomy trends on 4440 women who underwent a hysterectomy in a period of 5 years was published in 2015. There were 3127 cases of benign gynecology, 1001 cases of gynecologic oncology, and 312 cases of urogynecology. The overall rate of hysterectomy performed via laparotomy decreased from 62.2% to 39.1% (P < 0.001). The rate of robotically assisted hysterectomy increased from 0.0% to 26.4% (P < 0.001). Re-analyzing the data for subspecialty the rate of radical hysterectomy by a gynecologic oncologist via laparotomy decreased from 89.7% to 20.0% (P < 0.001). The rate of robotically assisted hysterectomy for general gynecologist increased from 0.0% to 78.3% (P < 0.001). Amongst urogynecologists, the rate of hysterectomy performed vaginally decreased from 80.0% to 33.6%, P < 0.001, while the rate of robotically assisted hysterectomy increased from 0.0% to 54.2%, P < 0.001.22 Luciano has published similar results in a recent publication. In the period of 2005–2010, of 289,875 hysterectomies,
abdominal approaches were 0.04% laparoscopy
9.
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cases decreased, and minimally invasive increased from 40% to 67%. Conversion rates for vaginal, 2.5% for robotic, and 7.2% for (P < 0.001).23
Complications
Intra-operative surgical complications like vessel injury, bladder, or bowel injury are known, and may not be attributed to robotic technology alone. Complication rates are different, and expected to be higher for gynecologic oncologic surgeries than that of benign gynecologic cases due to more dissection and longer operating time. Early post-operative complications such as febrile morbidity, leg pain or edema, leg weakness, vaginal vault bleeding or infection can be seen. Additionally problems like urinary tract infection, voiding difficulty or hematuria are also encountered at times. Delayed complications that may present are leg weakness, voiding difficulty, and hydronephrosis or urinary fistula. Two complications require special mention – port site metastasis and vaginal vault dehiscence.
10.
Port-site metastasis
The reported incidence of port-site metastases in patients undergoing laparoscopic surgery for malignant disease is approximately 1–2%. Port-site metastasis is a known complication of minimally invasive laparoscopic or robotic surgery, although it has been described less in robotic surgery. The reasons for port-site metastasis are unclear. Even low risk patients can develop port-site metastasis. Multiple factors contribute to this complication. One of the proposed mechanism of tumor implantation at the port site the leakage of insufflation gas through the ports (chimney effect) along with the impact of pneumoperitoneum can lead to port site metastasis. Local immune reaction of the patient has contributory effect in its development. Careful patient selection, modifications of surgical techniques, through lavage of the peritoneal cavity are some of the preventive measures suggested. Some reports of applying cytotoxic agents at port wounds are also in the literature. Grabosch and Xynos reported isolated port-site metastasis in two patients who underwent robotic-assisted radical hysterectomy for lowgrade, early-stage, and endometrial carcinoma. Both patients required resection followed by chemotherapy and radiation.24
11.
Vaginal cuff dehiscence
Vaginal cuff dehiscence is an uncommon but potentially morbid complication after hysterectomy. The patient may present with vaginal bleeding and sudden watery discharge after hysterectomy. Once the dehiscence takes place, there is a direct communication between the peritoneal cavity and the vagina. The abdominal or pelvic contents may extrude through the vagina. The incidence of this condition as reported in the literature is 0–7%, and is generally reported to be higher after laparoscopic and robotic surgery when
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compared to vaginal or abdominal approaches.25 The risk factors are not clearly defined, and may include factors that influence wound healing. Hematoma at the vault level can cause primary healing defect. Overuse of electro cautery to achieve maximal hemostasis causes extensive tissue necrosis leading to poor healing of the vaginal scar. An over cauterized vaginal edge with small suture bites tends to cut through vaginal edges, or as the suture loses its tensile strength, partial separation of the vaginal cuff occurs, and the patients present with vault dehiscence. Perhaps a less hemostatic surgical bed ‘‘slightly juicy rather than bone dry’’ at the vaginal cuff level may be better. Some mechanical factors such as early resumption of sexual activity, trauma, and increased intra-abdominal pressure can also cause this complication in the postoperative phase. Study published in 2015 suggests that the risk of dehiscence is influenced mainly by the scope and complexity of the surgical procedure. Different colpotomy techniques do not influence the rate of cuff dehiscence. This study concludes that continuous suturing of the cuff may be superior to interrupted suturing.26 Prevention of the risk factors causing vault dehiscence is the most important intervention for this complication.
12.
Single port robotic hysterectomy
The single port robotic procedures are in use in various surgical specialties, and in the last few years and single port robotic hysterectomy is also slowly gaining ground. It is an attractive option for benign gynecology surgery, however some studies have also shown feasibility of robotic singleport pelvic lymphadenectomy as well. This system of surgical intervention allows several ports to be introduced into the abdomen via one central incision.27 The size of the port is about 4 cm and fits through a 2 cm incision. Once this scar heals, it is almost unnoticeable. The ergonomic limitations of single-port laparoscopy are now overcome by development of articulated or flexible instruments and camera in the robotic system. Single port robotic technique is useful in patients whose uterus is less than 16 weeks in size. The proficiency with the steps of conventional robotic hysterectomy helps in performing the same via a single port. Arm collision and difficult mobilization of the uterus are some of the drawbacks.
13.
Conclusion
In the last 10 years, robotic technology has seen an increased application especially in gynecological surgery. Robotic assisted hysterectomy is feasible and safe both in benign and malignant conditions.28 The most important contribution of robotic surgery is the reduction in open hysterectomies both as a primary procedure as well as in conversion rates. This significant difference is mainly due to the ergonomics, endowrist movements of instruments, and stereoscopic three-dimensional vision. Robotic hysterectomy is safe, however issues such as lack of haptic feedback and cost will have to be addressed. So will abdominal hysterectomy become
an operation of historical interest? In the coming years, this technology will find its place in clinical practice of minimally invasive gynecology, but we need to critically examine the long-term benefits especially in benign situations. However one thing is certain; the number of minimally invasive hysterectomies and myomectomies will increase. But we need to critically examine the long-term benefits especially in benign conditions, thus reducing the incidence of open surgery in gynecology.
Conflicts of interest The authors have none to declare.
references
1. AAGL position statement: route of hysterectomy to treat benign uterine disease. AAGL Advancing Minimally Invasive Gynecology Worldwide. J Minim Invasive Gynecol. 2011;18 (January–February (1)):1–3. 2. Choosing the route of hysterectomy for benign disease. ACOG Committee Opinion 444. Obstet Gynecol. 2009;144:1156–1158. 3. Jacoby VL, Autry A, Jacobson G, Domush R, Nakagawa S, Jacoby A. Nationwide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches. Obstet Gynecol. 2009;114(November (5)):1041–1048. 4. Smorgick N, Patzkowsky KE, Hoffman MR, Advincula AP, Song AH, As-Sanie S. The increasing use of robot-assisted approach for hysterectomy results in decreasing rates of abdominal hysterectomy and traditional laparoscopic hysterectomy. Arch Gynecol Obstet. 2014;289(January (1)):101–105. 5. Walsh CA, Walsh SR, Tang TY, Slack M. Total abdominal hysterectomy versus total laparoscopic hysterectomy for benign disease: a meta-analysis. Eur J Obstet Gynecol. 2009;144:3. 6. Landeen LB, Bell MC, Hubert HB, Bennis LY, Knutsen-Larson SS, Seshadri-Kreaden U. Clinical and cost comparisons for hysterectomy via abdominal, standard laparoscopic, vaginal and robot-assisted approaches. S D Med. 2011;64(6):197–199. 201, 203. 7. Hanssens S, Nisolle M, Leguevaque P, et al. Robotic-assisted laparoscopy for deep infiltrating endometriosis: the Register of the Society of European Robotic Gynaecological Surgery. Gynecol Obstet Fertil. 2014;42(November (11)):744–748. 8. Advincula AP, Reynolds RK. The use of robot-assisted laparoscopic hysterectomy in the patient with a scarred or obliterated anterior cul-de-sac. JSLS. 2005;9(July–September (3)):287–291. 9. Chiu LH, Chen CH, Tu PC, Chang CW, Yen YK, Liu WM. Comparison of robotic surgery and laparoscopy to perform total hysterectomy with pelvic adhesions or large uterus. J Minim Access Surg. 2015;11(January–March (1)):87–93. 10. Payne TN, Dauterive FR, Pitter MC, et al. Robotically assisted hysterectomy in patients with large uteri: outcomes in five community practices. Obstet Gynecol. 2010;115(March (3)):535–542. 11. Sert BM, Abeler VM. Robotic-assisted laparoscopic radical hysterectomy (Piver type III) with pelvic node dissection – case report. Eur J Gynaecol Oncol. 2006;27(5):531–533. 12. Sert B, Abeler V. Robotic radical hysterectomy in early-stage cervical carcinoma patients, comparing results with total laparoscopic radical hysterectomy cases. The future is now? Int J Med Robot. 2007;3(September (3)):224–228.
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13. Ramirez PT, Schmeler KM, Wolf JK, Brown J, Soliman PT. Robotic radical parametrectomy and pelvic lymphadenectomy in patients with invasive cervical cancer. Gynecol Oncol. 2008;111(October (1)):18–21. 14. Veljovich DS, Paley PJ, Drescher CW, Everett EN, Shah C, Peters 3rd WA. 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(June (6)):679. 15. Persson J, Reynisson P, Borgfeldt C, Kannisto P, Lindahl B, Bossmar T. Robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy with short and long term morbidity data. Gynecol Oncol. 2009;113(May (2)): 185–190. http://dx.doi.org/10.1016/j.ygyno.2009.01.022. [Epub 2009 Feb 28]. 16. Bell MC, Torgerson J, Seshadri-Kreaden U, Suttle AW, Hunt S. Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques. Gynecol Oncol. 2008;111(December (3)):407–411. 17. Seamon LG, Henretta M, Kim KH, Carlson MJ, Cohn DE, Fowler JM. Robotic versus laparoscopic hysterectomy and lymphadenectomy for endometrial cancer: conversion rates and operating times. Gynecol Oncol. 2008;108(suppl 1):A142. 18. Hoekstra AV, Jairam-Thodla A, Rademaker A, et al. The impact of robotics on practice management of endometrial cancer: transitioning from traditional surgery. Int J Med Robot. 2009;5(December (4)):392–397. 19. Sinha R, Jyothsna B. Optimal Route of Hysterectomy. Update in Obstetrics & Gynecology. Paras Publications; 2011:370–384.
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20. 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(May–June (3)):286–291. 21. Sarlos D, Kots L, Stevanovic N. Robotic compared with conventional laparoscopic hysterectomy: a randomized controlled trial. Obstet Gynecol. 2012;120 (September (3)):604–611. 22. Wasson MN, Hoffman MK. Impact of a robotic surgical system on hysterectomy trends. Del Med J. 2015;87(February (2)):45–50. 23. Luciano AA, Luciano DE, Gabbert J, Seshadri-Kreaden U. The impact of robotics on the mode of benign hysterectomy and clinical outcomes. Int J Med Robot. 2015 [March 4]. 24. Grabosch S, Xynos F. Isolated port-site metastasis after robotic hysterectomy for stage IA endometrial adenocarcinoma. Obstet Gynecol. 2013;122:437–439. 25. Cronin B, Sung VW, Matteson KA. Vaginal cuff dehiscence: risk factors and management. Am J Obstet Gynecol. 2012;206 (April (4)):284–288. 26. Weizman NF, Einarsson JI, Wang KC, Vitonis AF, Cohen SL. Vaginal cuff dehiscence: risk factors and associated morbidities. JSLS. 2015;19(April–June (2)). e2013.00351. 27. Joseph RA, Goh AC, Cuevas SP, et al. ‘‘Chopstick’’ surgery: a novel technique improves surgeon performance and eliminates arm collision in robotic single-incision laparoscopic surgery. Surg Endosc. 2010;24(June (6)):1331–1335. 28. Reynolds RK, Advincula AP. Robot-assisted laparoscopic hysterectomy: technique and initial experience. Am J Surg. 2006;191(April (4)):555–560.
Available online at www.sciencedirect.com
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Review Article
Robotic hysterectomy: A review of indications, technique, outcome, and complications Rooma Sinha a,*, S. Madhumati a, Rupa Bana b, Fozia Jeelani b, Samita Kumari c a
Senior Consultant, Department of Obstetrics and Gynecology, Apollo Health City, Hyderabad, Telangana, India Senior Registrar, Department of Obstetrics and Gynecology, Apollo Health City, Hyderabad, Telangana, India c Resident (DNB), Department of Obstetrics and Gynecology, Apollo Health City, Hyderabad, Telangana, India b
article info
abstract
Article history:
Hysterectomy is the second most common surgery performed on women after cesarean
Received 14 May 2015
section. The advantages of minimally invasive hysterectomy such as reduced hospitaliza-
Accepted 14 May 2015
tion, quick recovery with more rapid return to normal activities, and less postoperative
Available online 15 June 2015
morbidity are well known. Although most guidelines recommend that minimally invasive hysterectomy should be the standard of care, the gynecologists have been slow in adopting
Keywords:
minimally invasive laparoscopic techniques to perform this operation. Since its approval in
Hysterectomy
2005 for gynecological surgeries, robot-assisted hysterectomy has been found to be feasible
Robotic hysterectomy
and safe both in benign and malignant indications. This significant difference is mainly due
Laparoscopic hysterectomy
to ergonomics, endowrist movements of instruments, and stereoscopic three-dimensional
Endometriosis
magnified vision. The specific indications for hysterectomy where the robotic technology
Fibroid
can benefit women are the ones with adhesions such as severe endometriosis, large uterus with large or multiple fibroids, early carcinoma cervix, and/or endometrial carcinoma. However the main benefit of this procedure was seen in the reduction of open surgery including conversions during laparoscopic hysterectomies. In the long run, we need to critically examine the long-term benefits and appropriate indications for robot-assisted hysterectomy especially in benign conditions, thus reducing the incidence of open surgery in gynecology. This review describes the operative procedure of robotic hysterectomy in eight steps. # 2015 Published by Elsevier B.V. on behalf of Indraprastha Medical Corporation Ltd.
1.
Introduction
Hysterectomy is the second most common surgery performed on women after cesarean section, and most are done for benign condition. Harry Reich was the first to describe laparoscopic
hysterectomy in 1989, 50% are still conducted by open method. The gynecologists have been slow in adopting minimally invasive technique to perform this operation. Both the American Association of Gynecologic Laparoscopists (AAGL) and the American Congress of Obstetricians and Gynecologists (ACOG) issued statements that minimally invasive hysterectomy
* Corresponding author at: A 402, Aparna Towers, Kondapur, Hyderabad 500084, Telangana, India. Mobile: +91 9849008180. E-mail addresses: [email protected], [email protected] (R. Sinha). http://dx.doi.org/10.1016/j.apme.2015.05.014 0976-0016/# 2015 Published by Elsevier B.V. on behalf of Indraprastha Medical Corporation Ltd.
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should be the standard of care.1,2 The slow adoption of minimally invasive hysterectomy techniques among practicing obstetrician-gynecologists is mainly due to conventional ‘‘straight-stick’’ laparoscopic skills requiring long learning curve along with insufficient laparoscopic training and exposure during their residency program.3 So when FDA approved robotic technology for hysterectomy in 2005, the incidence of minimally invasive hysterectomy was expected to rise with 3dimensional optics, wrist like motion with robotic instruments, and shorter learning curves than traditional laparoscopy for the surgeons.4 The advantages of minimally invasive hysterectomy are well known such as reduced hospitalization, quick recovery with more rapid return to normal activities, and less postoperative morbidity.2 These advantages have been also shown in a meta-analysis, comparing total laparoscopic hysterectomy (TLH) with total abdominal hysterectomy (TAH). These advantages are reduction in morbidity—specifically, fewer perioperative morbidity and complications, lower estimated blood loss, and shorter hospital stay.5
2.
Indication of robotic hysterectomy
Hysterectomy for any benign indication can be performed with robotic assistance. It has its application in gynecological oncology, especially in early cervical carcinoma and endometrial carcinoma. However, choosing the route of hysterectomy in benign cases is important. Vaginal hysterectomy especially non-descent vaginal hysterectomy (NDVH) is the ultimate minimally invasive method of performing hysterectomy. There is no doubt about that. Laparoscopic or robotic hysterectomy should not replace vaginal hysterectomy. Minimally invasive techniques become crucial in situations where NDVH is not feasible or is contraindicated. In today's era, surgical situation that pose difficulty in performing hysterectomy via a laparoscope like pelvic adhesive disease or significant endometriosis, the robotic assistance is of great value and should be used where available to avoid open surgery and its associated morbidity. Robotic hysterectomy is also a good option in patients who need concomitant sacral colpopexy. The route of hysterectomy is often influenced by uterine weight and size, previous surgeries, pelvic adhesions or endometriosis, and presence of uterine descent as well as the body habitus and BMI of the patient. Landeen et al. carried out a retrospective study of 1474 hysterectomies, comparing four techniques: abdominal, vaginal, conventional laparoscopy, and robotically assisted laparoscopy. Their analysis of this study showed reduced blood loss and hospital stay with robotic surgery (P < 0.0001), and higher overall complication rate with the laparotomy (14%). However, the rate of complications was lowest with the vaginal hysterectomy. The conversion to open surgery is four-fold higher with the laparoscopic technique.6
3.
Hysterectomy and robotic assistance
The da Vinci Robotic Surgical System (Intuitive Surgical) is an advanced laparoscopic-assisted surgical system that can address many of the current limitations of conventional
laparoscopy. It is a logical next step in performing minimally invasive gynecological surgeries, and is only the beginning of numerous advances in the field of gynecological surgeries in the future. It has 3 components. The first component of the da Vinci system is the vision cart. It has vision system that provides 2dimensional imaging through a 12-mm, dual optical endoscope. The endoscope has 2 telescopes that gives a 3D vision to the surgeon on the console. The second component of the da Vinci system is the patient-side cart with robotic arms and endowrist instruments. Most da Vinci system now has provision for 3 robotic arms in addition to the arm that is docked to the camera port. Whether to use two or three instruments will depend on the surgeon's decision depending on the case profile. The third component is the surgeon console that is located away from the patient bedside but in the same operating room. The surgeon seated at this console, with the help of masters can control instruments that are inserted via the 8 mm ports into the patient's abdomen. This is aided by the surgeon's 3D view with the aide of a stereoscopic viewer. The surgeon console has additional foot pedals for energy sources, camera adjustment, and a swapping mechanism that helps the surgeon to control 3 instruments all by herself. Thus, maneuvers such as lysis of adhesions, suturing, and knot tying are easier due to wristed movements of the instruments and magnified vision, thus providing unique advantages over 2D straight stick approach of standard laparoscopy.
4.
Selection of cases for robotic hysterectomy
Three situations that often tip the balance towards open surgery are presence of severe adhesions, large uterus, and malignancy. In all these three situations robotic assistance can help overcome the surgical challenges and reduce incidence of open surgery thus reducing the post operative morbidity. Advanced scarring of the pelvis poses challenges to hysterectomy by any route. Especially, when attempted by minimally invasive hysterectomy with conventional laparoscopic equipment, the altered anatomy poses technical limitations and the conventional laparoscopic surgical skill limits the ability to compensate for the altered anatomy. Hysterectomy for the larger uterus is also difficult by minimally invasive method. This is true for both laparoscopic surgery as well as robotic assisted surgery, and to our experience is the most challenging. Port positioning is tricky, the ability to maneuver instruments is compromised in the presence of a large uterus. Moreover, vaginal removal of the specimen is difficult, when the specimen is >150 g and often requires morcellation.
5. Special situations suitable for robotic assisted hysterectomy 5.1.
Endometriosis
Conventional laparoscopy in endometriosis is a challenging task due to the complexity of pelvic dissection. The adhesive nature of the disease with obliteration of the surgical planes
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makes dissection and ability to remove all endometriotic implants difficult. Added to this is the variability of surgical skill levels of surgeons. The straight stick laparoscopy limits the surgeons from reaching the corners of the pelvis to complete the surgery. Robotic endowrist instruments simulate the normal mechanics of the human hand and is of great advantage in such situation along with the 3-dimensional visualization. Decreased surgeon's fatigue and hand tremors help in improving surgical precision. Eight international clinical centers participated in a study including 164 women from November 2008 to April 2012, with stage IV endometriosis who underwent robotic-assisted laparoscopy. Patients were divided into 4 groups according to the localization of the nodule(s): rectum (n = 88), bladder (n = 23), ureter and uterosacral ligaments (n = 115), and on uterus in case of hysterectomy (n = 28). In the rectal nodule group, one laparotomy conversion, 2 cases needed suturing for rectal injuries. In the bladder group, one vesicovaginal hematoma and one case with prolonged intermittent self-catheterization were reported. In the ureter and uterosacral ligaments group, there were 2 ureteral fistulas. The hysterectomy group did not report any complication. This is one of the largest series published in the literature on robotic-assisted laparoscopy for deep infiltrating endometriosis. Robotic-assisted laparoscopy in deep infiltrating endometriosis appears to be a feasible option with no increase in surgical time, blood loss, and intra- and postoperative complications.7
5.2.
Previous surgery
Dense adhesions are often encountered in cases with multiple previous surgeries such as cesarean sections, myomectomy, and hysterotomy. This is a common reason for surgeons to convert their surgeries to laparotomy. A series of six patients with suspected pelvic adhesive disease involving the anterior cul-de-sac, who underwent robot-assisted laparoscopic hysterectomy were reported by Advincula. All the cases were for benign indications, and none were converted to laparotomy. The average length of hospital stay was 1.3 days. They concluded that robot-assisted laparoscopic hysterectomy is a feasible technique in patients with a scarred or obliterated anterior cul-de-sac, and may provide a tool to overcome the surgical limitations seen with conventional laparoscopy.8 Chiu published a series of 216 patients, robotic total hysterectomy in 88 and laparoscopic total hysterectomy in 128. For cases with severe adhesions (adhesion score greater than 4), robotic surgery was associated with a less operation time (113.9 38.4 min versus 164.3 81.4 min, P = 0.007) and reduced blood loss (187.5 148.7 mL versus 385.7 482.6 mL, P = 0.044) compared with laparoscopy. Additionally, robotic group had lower postoperative pain, and this was found to be independent of adhesion score or uterine weight. Comparing to laparoscopic approach, robotic surgery is a feasible and potential alternative for performing total hysterectomy with severe adhesions.9
5.3.
Large uterus
Multiple fibroids or large adenomyotic uterus presents challenges due to its large size that tends to occupy the pelvis
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leaving little space for movement of instruments. With the use of robotic platform, the surgeon's ability to manipulate and control the third arm by herself is of great advantage in such situations. This manipulation helps to reach the corners in the pelvis and access tissues and planes that would have been difficult with straight stick laparoscopic instruments. A multicenter study was done in five community practice settings across the United States. 256 patients who had hysterectomy with robotic assistance from March 2006 to July 2009 and uterine weights of at least 250 g were included. The study concluded that robotically assisted hysterectomy with low morbidity was successful in this population with large uteri with low blood loss, and minimal risk of conversion to laparotomy. Results were reproducible among general gynecologists from geographically diverse community settings.10
5.4.
Early carcinoma of cervix
Skills to perform robotic radical hysterectomy can be acquired not only in a shorter time but also by a larger number of surgeons who perform open radical hysterectomy and encounter difficulties with conventional laparoscopy. Thus, converting open surgery to minimally invasive surgery offers a means to decrease the morbidity associated with endometrial cancer surgery. The first published report regarding robotic radical hysterectomy was in 2006.11 Sert et al. initially described the feasibility of robotic-assisted laparoscopic radical hysterectomy in 2007 for early stage cervical carcinoma cases. They reported better results than with traditional laparoscopic radical hysterectomy in 15 patients with earlystage cervical carcinoma as a pilot case-control study at a comprehensive cancer center-university teaching hospital setting.12 Subsequently in 2008, Ramirez reported a series of 5 cases with invasive squamous cell carcinoma of the cervix. One patient in their series experienced two postoperative complications, a vesicovaginal fistula and a lymphocyst formation post-operatively. These are complications known to radical hysterectomy procedure and cannot be attributed to the robotic technology alone. However, no patient had residual tumor as well as no patient underwent adjuvant therapy, but in the average follow-up of 7.5 months, there were no recurrences.13 Nerve-sparing radical hysterectomy by use of robotic assistance is a feasible approach for the treatment of cervical cancer patients, due to ergonomics and articulated movements of endowrist instruments and image magnification. These features contribute for correct identification and preservation of the pelvic anatomy in terms of innervation, reducing the risk of postoperative neurological sequelae.
5.5.
Carcinoma of the endometrium
Veljovich in 2008 published a case series of 118 patients underwent robotic surgery for endometrial carcinoma and compared their results with open surgery for the same indication. Patients who underwent robotic surgery had shorter length of stay (40.3 h versus 127 h, P < 0.0001) with comparable node yields (17.5 versus 13.1, P = 0.1109). 8 patients in the robotic group had major and 13 minor complications. They concluded that robotic surgery is feasible in gynecologic oncology. Despite longer operative times, estimated blood loss and length of stay
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are reduced and lymph node yields are comparable.14 Using a prospective protocol, Pearson et al. performed robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy on 80 women. All tumors were radically removed. Median number of retrieved lymph nodes was 26 (range 15–55). Five women needed resuturing for vaginal cuff dehiscence, two women were re-operated for trocar site hernias, and one woman had a ureteric stricture that resolved following stent treatment. 43 of eligible 46 women (93%) had a long-term follow-up (> or =12 months). They concluded that though this technique was feasible, effort should be made to ensure proper closure of the vaginal cuff, trocar sites, and to develop nerve-sparing techniques.15 Various studies have consistently reported that the number of lymph nodes retrieved is similar in the range between 17 and 32 for the robotic cohort and 16–23 for the laparoscopic cohort.16–18
6.
Operative technique
6.1.
Preoperative preparation
Preoperative preparation is of importance and can help in successful completion of the procedure. There is no evidence to use mechanical bowel preparation routinely, and we do not recommend it either. The patients will be advised clear liquid diet a day before and two tablets of Bisacodyl (Dulcolax®) in the night before surgery for clearing their bowels. Use of charcoal tablets on the night before the surgery helps to deflate the bowels for visualization, and is also part of our preoperative protocol. The patients will be advised to remain nil by mouth for 6 h prior to surgery. All the patients are screened for any preoperative use of blood thinners and medical conditions that need to be addressed before surgery. All the patients are given antibiotic prophylaxis preoperatively.
6.2.
Anesthesia and patient positioning
After induction of general anesthesia with endotracheal tube, the patient is positioned in the dorsal lithotomy position with buttock just off the table. The arms are tucked to the side and secured in neutral position with the thumb pointing up. This is done so that the arms do not slip during surgery nor do they obstruct the movement of robotic arms. The chest of the patient is strapped to avoid slipping when the patient is finally positioned in Trendelenburg position. Some form of protection of the face is usually done, and this can be done with the help of foam. The stomach is not routinely decompressed with a nasogastric tube but if the uterus is large, and the primary port needs to be put above the umbilical level, then we prefer to do this.
6.3.
Uterine manipulation
The bladder is drained with a Foley catheter, and is placed in situ. There are various types of manipulators available, and can be chosen according to individual surgeon's choice. We prefer to use RUMI uterine manipulator (Cooper Surgical), which is placed with a Koh colpotomy ring and vaginal pneumooccluder balloon for uterine manipulation, which is done by the
assistant at the vaginal end. Good access to this area by the second assistant is important and needs special attention. Hence, we position our patient cart to the right side, parallel to the operation table to keep the vaginal access free. An expert assistant for uterine manipulation can make hysterectomy simple and safe. When needed, the bedside assistant additionally provides traction or manipulation by using a myoma screw or laparoscopic forceps from the 5 mm port.
6.4.
Trocar placements and docking
We introduce our primary trocar (12 mm) with open method and the intraperitoneal position checked by pressure in pneumo-insufflator (<5 mm). Direct introduction of the camera through the primary trocar can also confirm intraperitoneal position of the primary trocar before we proceed with other 8 mm port placements. We choose 12 mm extra long (Ethicon) trocar; the extra length is important for docking of the camera arm as the subcutaneous fat at times can be up to 2 in. The 12-mm trocar is placed 2–5 cm above umbilicus, the location of this depends on several factors – upper level of the uterus, previous surgical scars, or any previous mesh repair. Two 8-mm robotic trocars are placed bilaterally: 10 cm lateral to and anywhere between 3 and 6 cm above the anterior superior iliac spine. This can at times be even at the level of the umbilicus if the size of uterus is large. The 8 mm trocars are classically placed with one on the left of the patient and 2 on the right. An accessory 5-mm trocar is placed in the left upper quadrant. Monopolar scissors is inserted through the right upper 8 mm port (arm 1); a prograsp through the right lower 8 mm port (arm 3) and a fenestrated bipolar dissecting forceps was inserted through the left 8 mm port (arm 2).
6.5.
Operative steps
The surgical team in the operating room consists of a console surgeon, a bedside assistant, and a nurse standing on the left side of the patient and a second assistant or a nurse at the vaginal end of the patient for uterine manipulation. A 308 camera is used by our surgical team.
6.5.1.
Eight steps
1. Survey of the pelvis and adhesiolysis: In the beginning, a survey of the operative field is performed to understand the altered anatomy. In cases where severe adhesions are expected, we recommend ureteric catheters placement preoperatively. The ureters are identified on both sides at the beginning of the procedure. Adhesiolysis is begun from either left or right side depending on the availability of surgical planes (Fig. 1). In cases of dense adhesion of endometrioma to the lateral pelvis wall, we try to lift the endometrioma from the lateral pelvis wall but are always alert regarding the location of ureter at this step. Also considered the crucial step as we believe that once the lateral wall adhesions are released it is easier to open the broad ligament after ligating the round ligament and reach for the uterine artery. 2. Opening of the broad ligament – both sides: The surgery is started with identification and transection of the round ligament. This is achieved by cauterizing using the
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[(Fig._1)TD$IG]
[(Fig._3)TD$IG]
Fig. 1 – Step 1: Survey of pelvis and adhesiolysis.
[(Fig._2)TD$IG]
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Fig. 3 – Step 3: Dissection of vesico-uterine fold.
[(Fig._4)TD$IG]
Fig. 2 – Step 2: Opening of broad ligament.
Fig. 4 – Step 4: Uterosacral ligament transection. fenestrated bipolar and cutting using the monopolar hot shears. Once this is done, the broad ligament is opened, and is dissected anteriorly and posteriorly. The anterior leaf of the broad ligament is then dissected and incised towards the bladder (Fig. 2). The traction at this point on the uterus is provided by the prograsp in arm 3 and the uterine manipulator inside the uterus. The infundibulopelvic ligament is then identified, cauterized with bipolar, and cut with hot shears where ovaries are being removed. At this step, it is essential to identify the ureters on the same side. If the ovaries are to be conserved, then the utero-ovarian ligament is cauterized, and cut using bipolar forces and hot shears. 3. Vesico-uterine reflection: The anterior leaf of the broad ligament is completely incised from both sides up to the vesico-uterine fold anteriorly (Fig. 3). The vesico-uterine reflection is tented up using the prograsp in arm 3; hot shears in arm 1 and the bipolar in arm 2 are used to dissect bladder gently but sharply off the uterus and cervix. By doing this step, the colpotomy ring (Koh ring) is adequately visualized. Cases where the anterior cul-de-sac adhesions are encountered or there is scarring of the vesico-uterine reflection, the bladder was filled with 100 mL of methylene blue stained saline to facilitate dissection. 4. Uterosacral ligaments transection: The uterosacral ligaments are coagulated and transected bilaterally after anteverting the uterus. The uterine manipulator is often sufficient at this
step (Fig. 4). If the uterus is large as in the case of multiple fibroids or the posterior pouch has adhesions, then the use of prograsp to push the uterus anteriorly is irreplaceable. 5. Ligation of the uterine vessels on both sides: Upward push by the assistant at the step of uterine artery coagulation ensures that the distance between the uterine artery and ureter is at least 2 cm preventing its damage. Adequate skeletonization of the uterine arteries ensures sufficient lateral displacement of the ureters. The uterine arteries are coagulated using the bipolar and cut with the shears (Fig. 5). Coagulation of the ascending branch of the uterine artery reduces backflow of blood making surgery at the level of Mackenrodt's ligament safer and neater. 6. Colpotomy: Anterior and posterior colpotomy is facilitated by the Koh colpotomy ring, while upward uterine traction is provided by the vaginal assistance as well as with the help of prograsp in the arm 3 (Fig. 6). The same upward push at and at the level of vaginal cuff incision pushes the ureter and bladder laterally, hence reducing the chances of ureteric injury. Colpotomy can begin either anteriorly, posteriorly, or from the lateral angles, but all depends on the anatomy encountered or sometimes the surgeon's comfort. After colpotomy the uterus is extracted vaginally.
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[(Fig._5)TD$IG]
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[(Fig._7)TD$IG]
Fig. 5 – Step 5: Ligation of uterine vessel (right).
[(Fig._6)TD$IG]
Fig. 7 – Step 7: Vaginal cuff closure.
[(Fig._8)TD$IG]
Fig. 6 – Step 6: Colpotomy with Koh cup in view. Fig. 8 – Step 8: Survey of pelvis and checking for hemostasis under water.
7. Vaginal cuff closure: Pneumoperitoneum is now maintained by repositioning the inflated vaginal pneumo-occluder balloon. Irrigation is done to check oozing any significant bleeding is controlled. Excessive cautery for minimal oozing should be avoided. The bipolar fenestrated and shears are replaced with needle holders for vault suturing. At times we only replace the hot shears in arm 1 with needle holder and continue using the bipolar in arm 2 during suturing. It serves two purpose – hemostasis during suturing can be done easily, and it also economical. The vault is closed using either 0-Vicryl or 1-0 V loc suture. The vault is closed with continuous sutures (Fig. 7). The suture is passed directly into the pelvis via the open vagina and retrieved by the 5 mm assistant port using the same technique we use in laparoscopic suturing. The needle is held about 3–4 cm from the needle hub, and removed along with the trocar tract. 8. Survey of the pelvis: A low-pressure check as well as underwater check is performed for ensuring hemostasis, and the robotic arms are undocked after removing the instruments under vision (Fig. 8). The abdomen is deflated,
and the primary trocar site is repaired using 1-0 Vicryl. The rate of bowel herniation at the 12 mm bladeless trocar sites has been reported to be 0.7%; hence attention to the closure of this port is warranted.
7.
Specimen retrieval
In cases with benign indications, we retrieve our specimen via the vaginal route. If the specimen is large, then we fall back on our long standing experience of NDVH, and the technique of morcellation of the uterus will be used during this procedure. The specimen can also be put in a bag and retrieved vaginally. Procedures such as hemisection, intramyometrial coring, wedge morcellation, and perhaps myomectomy can help in retrieval of the specimen.19 At times to gain access to the vagina, the robot has to be undocked, as one proceeds with morcellation. In such situations, the vaginal opening is closed vaginally by standard suturing.
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8. Robotic hysterectomy in contemporary gynecological practice Until 2005, although it had been approximately 40 years, since the early publications of laparoscopic approach, most hysterectomies are still performed through laparotomy. Only after the introduction of robotic-assisted da Vinci platform, did the rate of open surgery begin to decrease. An interesting publication by Payne et al. compared cases of total laparoscopic hysterectomy to robotic assisted hysterectomy in a community hospital. They did a retrospective analysis of 100 patients who underwent laparoscopic hysterectomy before the robotic program, and 100 patients who underwent robotic hysterectomy after the implementation of robotic program. Overall the robotic group experienced longer operative times by an average of 27 min. However, when compared with the last 25 robotic cases laparoscopic group had longer operative times. The mean blood loss in the pre-robotic group was twice that of the robotic group. The mean length of hospital stay was half a day longer in the pre-robotic group than in the robotic group. The incidence of adverse events was the same in both groups. The total number of exploratory laparotomies in the pre-robotic group was significantly greater than in the robotic group (11% versus 0%). The rate of intraoperative conversions to total abdominal hysterectomy from laparoscopy was approximately 2-fold higher in the prerobotic group as compared with the robotic group (9% versus 4%). The most important benefit of robotic hysterectomy highlighted in this study is the reduction in conversion to open surgery.20 As the robotic assisted surgery began to integrate into clinical practice, robotic assisted hysterectomy increased from 4.1% to 6.3% of all hysterectomies. This was mainly due to the reduction in the rates of abdominal hysterectomy, however the vaginal hysterectomy rates remained unchanged. At present, numerous studies do not show any significant difference between analgesic use and return to normal activity. Robotic hysterectomy is associated with longer operative time although the quality-of-life index was better.21 However, the main benefit of this procedure was seen in the reduction of open surgery including conversions during laparoscopic hysterectomies. Analysis of the impact of robotic surgical system on hysterectomy trends on 4440 women who underwent a hysterectomy in a period of 5 years was published in 2015. There were 3127 cases of benign gynecology, 1001 cases of gynecologic oncology, and 312 cases of urogynecology. The overall rate of hysterectomy performed via laparotomy decreased from 62.2% to 39.1% (P < 0.001). The rate of robotically assisted hysterectomy increased from 0.0% to 26.4% (P < 0.001). Re-analyzing the data for subspecialty the rate of radical hysterectomy by a gynecologic oncologist via laparotomy decreased from 89.7% to 20.0% (P < 0.001). The rate of robotically assisted hysterectomy for general gynecologist increased from 0.0% to 78.3% (P < 0.001). Amongst urogynecologists, the rate of hysterectomy performed vaginally decreased from 80.0% to 33.6%, P < 0.001, while the rate of robotically assisted hysterectomy increased from 0.0% to 54.2%, P < 0.001.22 Luciano has published similar results in a recent publication. In the period of 2005–2010, of 289,875 hysterectomies,
abdominal approaches were 0.04% laparoscopy
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cases decreased, and minimally invasive increased from 40% to 67%. Conversion rates for vaginal, 2.5% for robotic, and 7.2% for (P < 0.001).23
Complications
Intra-operative surgical complications like vessel injury, bladder, or bowel injury are known, and may not be attributed to robotic technology alone. Complication rates are different, and expected to be higher for gynecologic oncologic surgeries than that of benign gynecologic cases due to more dissection and longer operating time. Early post-operative complications such as febrile morbidity, leg pain or edema, leg weakness, vaginal vault bleeding or infection can be seen. Additionally problems like urinary tract infection, voiding difficulty or hematuria are also encountered at times. Delayed complications that may present are leg weakness, voiding difficulty, and hydronephrosis or urinary fistula. Two complications require special mention – port site metastasis and vaginal vault dehiscence.
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Port-site metastasis
The reported incidence of port-site metastases in patients undergoing laparoscopic surgery for malignant disease is approximately 1–2%. Port-site metastasis is a known complication of minimally invasive laparoscopic or robotic surgery, although it has been described less in robotic surgery. The reasons for port-site metastasis are unclear. Even low risk patients can develop port-site metastasis. Multiple factors contribute to this complication. One of the proposed mechanism of tumor implantation at the port site the leakage of insufflation gas through the ports (chimney effect) along with the impact of pneumoperitoneum can lead to port site metastasis. Local immune reaction of the patient has contributory effect in its development. Careful patient selection, modifications of surgical techniques, through lavage of the peritoneal cavity are some of the preventive measures suggested. Some reports of applying cytotoxic agents at port wounds are also in the literature. Grabosch and Xynos reported isolated port-site metastasis in two patients who underwent robotic-assisted radical hysterectomy for lowgrade, early-stage, and endometrial carcinoma. Both patients required resection followed by chemotherapy and radiation.24
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Vaginal cuff dehiscence
Vaginal cuff dehiscence is an uncommon but potentially morbid complication after hysterectomy. The patient may present with vaginal bleeding and sudden watery discharge after hysterectomy. Once the dehiscence takes place, there is a direct communication between the peritoneal cavity and the vagina. The abdominal or pelvic contents may extrude through the vagina. The incidence of this condition as reported in the literature is 0–7%, and is generally reported to be higher after laparoscopic and robotic surgery when
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compared to vaginal or abdominal approaches.25 The risk factors are not clearly defined, and may include factors that influence wound healing. Hematoma at the vault level can cause primary healing defect. Overuse of electro cautery to achieve maximal hemostasis causes extensive tissue necrosis leading to poor healing of the vaginal scar. An over cauterized vaginal edge with small suture bites tends to cut through vaginal edges, or as the suture loses its tensile strength, partial separation of the vaginal cuff occurs, and the patients present with vault dehiscence. Perhaps a less hemostatic surgical bed ‘‘slightly juicy rather than bone dry’’ at the vaginal cuff level may be better. Some mechanical factors such as early resumption of sexual activity, trauma, and increased intra-abdominal pressure can also cause this complication in the postoperative phase. Study published in 2015 suggests that the risk of dehiscence is influenced mainly by the scope and complexity of the surgical procedure. Different colpotomy techniques do not influence the rate of cuff dehiscence. This study concludes that continuous suturing of the cuff may be superior to interrupted suturing.26 Prevention of the risk factors causing vault dehiscence is the most important intervention for this complication.
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Single port robotic hysterectomy
The single port robotic procedures are in use in various surgical specialties, and in the last few years and single port robotic hysterectomy is also slowly gaining ground. It is an attractive option for benign gynecology surgery, however some studies have also shown feasibility of robotic singleport pelvic lymphadenectomy as well. This system of surgical intervention allows several ports to be introduced into the abdomen via one central incision.27 The size of the port is about 4 cm and fits through a 2 cm incision. Once this scar heals, it is almost unnoticeable. The ergonomic limitations of single-port laparoscopy are now overcome by development of articulated or flexible instruments and camera in the robotic system. Single port robotic technique is useful in patients whose uterus is less than 16 weeks in size. The proficiency with the steps of conventional robotic hysterectomy helps in performing the same via a single port. Arm collision and difficult mobilization of the uterus are some of the drawbacks.
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Conclusion
In the last 10 years, robotic technology has seen an increased application especially in gynecological surgery. Robotic assisted hysterectomy is feasible and safe both in benign and malignant conditions.28 The most important contribution of robotic surgery is the reduction in open hysterectomies both as a primary procedure as well as in conversion rates. This significant difference is mainly due to the ergonomics, endowrist movements of instruments, and stereoscopic three-dimensional vision. Robotic hysterectomy is safe, however issues such as lack of haptic feedback and cost will have to be addressed. So will abdominal hysterectomy become
an operation of historical interest? In the coming years, this technology will find its place in clinical practice of minimally invasive gynecology, but we need to critically examine the long-term benefits especially in benign situations. However one thing is certain; the number of minimally invasive hysterectomies and myomectomies will increase. But we need to critically examine the long-term benefits especially in benign conditions, thus reducing the incidence of open surgery in gynecology.
Conflicts of interest The authors have none to declare.
references
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