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Three Arm Robotic Hysterectomy for a 24 Week Size Uterus
Abstracts / Journal of Minimally Invasive Gynecology 19 (2012) S71–S122 bilateral fallopian tubes are prepared for anastomosis using electrocautery and sharp dissection. Upon completion of tubal preparation, the only instrument exchange for the entire procedure occurs. This eliminates the need for multiple instrument changes and therefore promotes surgical efficiency, expediting completion of the procedure. The fallopian tubes are stented with a 0-prolene suture cut to twelve centimeters. The stent is used to guide the approximation of the fallopian tube segments with interrupted stitches of 7-0 PDS. Chromopertubation, performed at the end of the case, demonstrates tubal patency without leakage from the anastomotic site. 328
Video Session 10dRobotics (3:28 PM d 3:36 PM)
Tubal Reanastomosis as a Teaching Tool for Robotics Flyckt RL, Catenacci M, Falcone T. Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio The use of the surgical robot for gynecologic surgery is increasing, and institutions responsible for educating trainees in robotic techniques must ensure that basic robotic skills are being taught. Especially for fellowships in reproductive endocrinology and infertility and reproductive surgery, tubal reanastomosis is an ideal technique for trainees to refine their robotic skills in tissue handling, use of cautery, needle driving, and knot tying. In this video, suggestions for techniques that both assist in successful tubal reanastomosis and in the teaching of trainees are given, with a focus on docking and suturing techniques, dry lab practice, intraluminal stents, and onscreen instructor feedback. 329
Video Session 10dRobotics (3:37 PM d 3:45 PM)
Perils of Insulation Failure in Robotic Hysterectomy Orady ME. Obstetrics and Gynecolog and Women’s Health Institue, Cleveland Clinic, Cleveland, Ohio This video illustrates a complication that can occur when the insulator tip for the Robotic monopolar scissors fail, discussing detection, repair, and prevention methods. The robotic approach to laparoscopic hysterectomy is currently being adopted as a method of approaching complex hysterectomy procedures. As with any new technology, new dangers can be encountered. It has been recently noted that the mono-polar scissor insulation tip can develop microtears or defects during use. As mono-polar energy is then applied, inadvertent thermal injuries to bowel, bladder, or ureter can occur. In this case of robotic hysterectomy for an enlarged uterus, extensive manipulation was required during dissection. During colpotomy a spark was seen to emanating from the insulated area of the monopolar scissors to the sigmoid colon causing a superficial burn. General surgery recommended oversewing the area with imbricating sutures parallel to the bowel lumen with telestration used to guide proper placement of the sutures. 330
Video Session 10dRobotics (3:46 PM d 3:54 PM)
Three Arm Robotic Hysterectomy for a 24 Week Size Uterus Jackson TR, Advincula AP. Florida Hospital Celebration, Celebration, Florida The large uterus presents a challenge to performing a hysterectomy laparoscopically. This video demonstrates a robot-assisted total laparoscopic hysterectomy for a 24 week size fibroid uterus. Three robotic arms and a 5mm accessory port were used to complete the procedure on a 1200 gram fibroid uterus. The morcellation time was approximately 15 minutes and the operating time was approximately 90 minutes. The estimated blood loss was 75mL and there were no complications. 331
Video Session 10dRobotics (3:55 PM d 4:03 PM)
Robot-Assisted Hysterectomy Using a Retroperitoneal Approach Im DD, Hew KE. Division Gynecologic Oncology, Mercy Medical Center, Baltimore, Maryland
S107
This is a case of a 50 year old para 2002 female who underwent surgical staging and was found to have stage IIIC1 endometrial cancer. She had an uncomplicated post operative course. We have described a novel approach to robot assisted hysterectomy by entering the retroperitoneal space using the infundibulopelvic ligament as a guide to locate the ureter. The ureter is then skeletonized within the pelvis and by following its course, the pararectal space can be found. The uterine artery is then dissected and ligated at its origin from the hypogastric artery. This technique offers several advantages when performing complex cases such as treatment of gynecologic cancers, enlarged leiomyomata uteri, stage IV endometriosis and resection of adnexal masses with severe pelvic adhesive disease. These include complete visualization of the ureter along its course in the pelvis and decreasing the blood supply to large uteri, minimizing blood loss during surgery. 332
Video Session 10dRobotics (4:04 PM d 4:09 PM)
McCall Culdoplasty Robotically Revisited Mackenzie MW. Obstetrics and Gynecology, Mount Auburn Hospital, Cambridge, Massachusetts Mindful of the proliferation of vaginal hysterectomies then being performed, Milton McCall in 1957 described a vaginal approach resuspension of the vaginal apex with simultaneous closure of the posterior cul de sac following total vaginal hysterectomy. The principles of resuspension he outlined included approximation closure to the midline of the uterosacral ligaments, the suturing of the vaginal apex onto a high point of the uterosacral ligaments and underneath this a gathering closure of the early enterocoele sac. He also argued the value of the technique as an enterocoele/vault descent prophylaxis. Now in 2012 with the proliferation of laparoscopic supracervical hysterectomies, resuspension of the cervix and closure of enterocoele is equally relevant. Robotically performed, a modified McCall culdoplasty is demonstrated showing the suspensory and closure effects. 333
Video Session 10dRobotics (4:10 PM d 4:15 PM)
Robotic Resection of Rectovaginal Mass Nahas S,1 Magrina JF.2 1Obstetric and Gynecology, Mayo Clinic, Scottsdale, Arizona; 2Obstetric and Gynecology, Mayo Clinic, Scottsdale, Arizona Objective: demonstrate a safe robotic dissection of a rectovaginal tumor. It’s important that all gynecologists should have adequate knowledge and skills to master the pelvic retroperitoneal structures and spaces. With such knowledge surgeons are capable of performing safe, efficient and effective surgeries without compromise. In this video, we are demonstrating the excising of a rectal-vaginal GIST. The same steps could be used in the excision of any Gynecological mass, or fistula in the rectovaginal space. 334
Video Session 10dRobotics (4:16 PM d 4:23 PM)
Robotic Assisted Resection of a Noncommunicating Rudimentary Uterine Horn with a Broad Connection to the Uterus Smorgick N, As-Sanie S, Hoffman M, Kaskowitch A, Lanham M, Quint EH. Obstetrics and Gynecology, University of Michigan Health System, Ann Arbor, Michigan Unicornuate uteri are often associated with a rudimentary uterine horn. When this horn contains a functional endometrium, surgical removal in indicated. However, when the connection between the unicornuate uterus and the rudimentary horn is broad, extensive suturing of the myometrial defect is required. In this video, the large obstructed rudimentary horn was removed in an 11 year-old teen who initially presented with leg pain at time of menstruation. Robotic assistance was used to facilitate dissection and suturing.
Video Session 10dRobotics (3:28 PM d 3:36 PM)
Tubal Reanastomosis as a Teaching Tool for Robotics Flyckt RL, Catenacci M, Falcone T. Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio The use of the surgical robot for gynecologic surgery is increasing, and institutions responsible for educating trainees in robotic techniques must ensure that basic robotic skills are being taught. Especially for fellowships in reproductive endocrinology and infertility and reproductive surgery, tubal reanastomosis is an ideal technique for trainees to refine their robotic skills in tissue handling, use of cautery, needle driving, and knot tying. In this video, suggestions for techniques that both assist in successful tubal reanastomosis and in the teaching of trainees are given, with a focus on docking and suturing techniques, dry lab practice, intraluminal stents, and onscreen instructor feedback. 329
Video Session 10dRobotics (3:37 PM d 3:45 PM)
Perils of Insulation Failure in Robotic Hysterectomy Orady ME. Obstetrics and Gynecolog and Women’s Health Institue, Cleveland Clinic, Cleveland, Ohio This video illustrates a complication that can occur when the insulator tip for the Robotic monopolar scissors fail, discussing detection, repair, and prevention methods. The robotic approach to laparoscopic hysterectomy is currently being adopted as a method of approaching complex hysterectomy procedures. As with any new technology, new dangers can be encountered. It has been recently noted that the mono-polar scissor insulation tip can develop microtears or defects during use. As mono-polar energy is then applied, inadvertent thermal injuries to bowel, bladder, or ureter can occur. In this case of robotic hysterectomy for an enlarged uterus, extensive manipulation was required during dissection. During colpotomy a spark was seen to emanating from the insulated area of the monopolar scissors to the sigmoid colon causing a superficial burn. General surgery recommended oversewing the area with imbricating sutures parallel to the bowel lumen with telestration used to guide proper placement of the sutures. 330
Video Session 10dRobotics (3:46 PM d 3:54 PM)
Three Arm Robotic Hysterectomy for a 24 Week Size Uterus Jackson TR, Advincula AP. Florida Hospital Celebration, Celebration, Florida The large uterus presents a challenge to performing a hysterectomy laparoscopically. This video demonstrates a robot-assisted total laparoscopic hysterectomy for a 24 week size fibroid uterus. Three robotic arms and a 5mm accessory port were used to complete the procedure on a 1200 gram fibroid uterus. The morcellation time was approximately 15 minutes and the operating time was approximately 90 minutes. The estimated blood loss was 75mL and there were no complications. 331
Video Session 10dRobotics (3:55 PM d 4:03 PM)
Robot-Assisted Hysterectomy Using a Retroperitoneal Approach Im DD, Hew KE. Division Gynecologic Oncology, Mercy Medical Center, Baltimore, Maryland
S107
This is a case of a 50 year old para 2002 female who underwent surgical staging and was found to have stage IIIC1 endometrial cancer. She had an uncomplicated post operative course. We have described a novel approach to robot assisted hysterectomy by entering the retroperitoneal space using the infundibulopelvic ligament as a guide to locate the ureter. The ureter is then skeletonized within the pelvis and by following its course, the pararectal space can be found. The uterine artery is then dissected and ligated at its origin from the hypogastric artery. This technique offers several advantages when performing complex cases such as treatment of gynecologic cancers, enlarged leiomyomata uteri, stage IV endometriosis and resection of adnexal masses with severe pelvic adhesive disease. These include complete visualization of the ureter along its course in the pelvis and decreasing the blood supply to large uteri, minimizing blood loss during surgery. 332
Video Session 10dRobotics (4:04 PM d 4:09 PM)
McCall Culdoplasty Robotically Revisited Mackenzie MW. Obstetrics and Gynecology, Mount Auburn Hospital, Cambridge, Massachusetts Mindful of the proliferation of vaginal hysterectomies then being performed, Milton McCall in 1957 described a vaginal approach resuspension of the vaginal apex with simultaneous closure of the posterior cul de sac following total vaginal hysterectomy. The principles of resuspension he outlined included approximation closure to the midline of the uterosacral ligaments, the suturing of the vaginal apex onto a high point of the uterosacral ligaments and underneath this a gathering closure of the early enterocoele sac. He also argued the value of the technique as an enterocoele/vault descent prophylaxis. Now in 2012 with the proliferation of laparoscopic supracervical hysterectomies, resuspension of the cervix and closure of enterocoele is equally relevant. Robotically performed, a modified McCall culdoplasty is demonstrated showing the suspensory and closure effects. 333
Video Session 10dRobotics (4:10 PM d 4:15 PM)
Robotic Resection of Rectovaginal Mass Nahas S,1 Magrina JF.2 1Obstetric and Gynecology, Mayo Clinic, Scottsdale, Arizona; 2Obstetric and Gynecology, Mayo Clinic, Scottsdale, Arizona Objective: demonstrate a safe robotic dissection of a rectovaginal tumor. It’s important that all gynecologists should have adequate knowledge and skills to master the pelvic retroperitoneal structures and spaces. With such knowledge surgeons are capable of performing safe, efficient and effective surgeries without compromise. In this video, we are demonstrating the excising of a rectal-vaginal GIST. The same steps could be used in the excision of any Gynecological mass, or fistula in the rectovaginal space. 334
Video Session 10dRobotics (4:16 PM d 4:23 PM)
Robotic Assisted Resection of a Noncommunicating Rudimentary Uterine Horn with a Broad Connection to the Uterus Smorgick N, As-Sanie S, Hoffman M, Kaskowitch A, Lanham M, Quint EH. Obstetrics and Gynecology, University of Michigan Health System, Ann Arbor, Michigan Unicornuate uteri are often associated with a rudimentary uterine horn. When this horn contains a functional endometrium, surgical removal in indicated. However, when the connection between the unicornuate uterus and the rudimentary horn is broad, extensive suturing of the myometrial defect is required. In this video, the large obstructed rudimentary horn was removed in an 11 year-old teen who initially presented with leg pain at time of menstruation. Robotic assistance was used to facilitate dissection and suturing.