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Journal ArticleDOI

Perioperative outcomes of three-port robotically assisted hysterectomy: a continuous series of 53 cases

11 Mar 2014-Journal of Robotic Surgery (Springer London)-Vol. 8, Iss: 3, pp 221-226
TL;DR: Three-port RALH is feasible and safe for simple hysterectomy, and this experience using minimum ports to be useful to prepare for robotically assisted single-port hystEREctomy.
Abstract: This study evaluated the feasibility and safety of 3-port robotically assisted laparoscopic hysterectomy (RALH), using a consecutive series of women who underwent 3-port RALH in a university hospital. From November 2010 until June 2013 we operated on 53 women, whose mean age was 48.4 ± 7.7 years (range 35–68 years), and mean body mass index was 27.1 ± 5.1 kg/m2 (range 19.5–42.9 kg/m2). The indications for hysterectomy were myoma in 31 (58.5 %), adenomyosis in 10 (18.9 %), cervical dysplasia in 4 (7.5 %), neoplasia in 4 (7.5 %), and recurrent polyps or postmenopausal bleeding in the remaining 4 women (7.5 %). We performed total RALH in 50 cases (94.3 %) and subtotal in the others. The median duration of total intervention was 169 min (interquartile range 147.5–206.5 min). The mean weight of the uterus was 209.8 ± 166.6 g (range 36–790 g) and mean estimated blood loss was 72.3 ± 75.9 ml (range 0–300 ml). There were no perioperative complications, in particular no blood transfusions nor conversions to laparotomy. The median hospital stay was 4 days (interquartile range 3–4 days). One patient was reoperated 1 month later for vaginal vault hematoma and another was readmitted 3 weeks post-operatively due to vaginal vault dehiscence after premature intercourse, but did not require reoperation. Three-port RALH is feasible and safe for simple hysterectomy. We believe this experience using minimum ports to be useful to prepare for robotically assisted single-port hysterectomy.

Summary (2 min read)

Jump to: [Introduction][Patients and method][Results][Discussion] and [Conclusion]

Introduction

  • Hysterectomy is the most commonly performed gynecological surgical procedure.
  • Over the past two decades, the use of minimally invasive approaches for hysterectomy has increased.
  • Gynecological surgeons did not embrace single-site surgery until recently, but at the expense of longer operative time and higher post-operative pain scores as well as discomfort for the surgeon [10, 11].
  • It can also be performed with only two suprapubic 5-mm ports, or even smaller 3-mm ports nowadays.
  • The authors present their experience with three-port robotically assisted laparoscopic hysterectomy.

Patients and method

  • Implementation of a robotic program took place at their institution in November 2010 after institutional approval from the Geneva University Hospitals.
  • One experienced surgeon performed the majority of cases with resident and/or fellow assistance, and three other surgeons were progressively introduced to the method.
  • After introducing the da Vinci optic, the authors placed one 8-mm metallic da Vinci cannula in the left iliac fossa and one 8-mm cannula with outlet in the right iliac fossa at an intraabdominal pressure of 20 mmHg (Fig. 2).
  • The vaginal cuff was closed robotically with two needle drivers (of which one was a Mega Suture-Cut) with three to four figures-of-eight O polyglactin sutures (Vicryl O, Ethicon Endo Surgery, Inc., Cincinnati, OH, USA) on a CT-2 needle.

Results

  • Thirty patients (56.6 %) had previous abdominal surgery.
  • One patient was readmitted 3 weeks post-operatively due to vaginal vault dehiscence after premature intercourse, but did not require reoperation.

Discussion

  • To their knowledge, this is the first reported series of RALH with only three ports.
  • In two recent randomized trials comparing conventional laparoscopic hysterectomy and RALH, total operative time for RALH was only 106 min in Sarlos et al.’s [17] team and 172.8 min in Paraiso et al.’s [7] team for very similar indications and uterine weights with respect to their series.
  • It is well known that the authors should use electrosurgical techniques that result in minimal thermal spread to minimize tissue destruction and necrosis leading to poor healing.
  • To overcome disadvantages of longer operative time and higher costs, the authors believe that RALH might become beneficial for the patients only if technology improves and leads to less invasive procedures such as single-port RALH.
  • Robotic assistance might help overcome these difficulties and enhance development of the technique, but only with the emergence of new technology.

Conclusion

  • The authors study shows that three-port RALH is feasible and safe for simple hysterectomy.
  • The authors believe this experience using minimum ports to be useful to prepare for robotically assisted single-port hysterectomy, where the use of a minimal number of ports will be mandatory.
  • Conflict of interest Patrick Dällenbach and Patrick Petignat declare that they have no conflict of interest.
  • All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000.
  • Informed consent was obtained from all patients for being included in the study.

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Reference
Perioperative outcomes of three-port robotically assisted
hysterectomy: a continuous series of 53 cases
DAELLENBACH, Patrick Peter, PETIGNAT, Patrick
DAELLENBACH, Patrick Peter, PETIGNAT, Patrick. Perioperative outcomes of three-port
robotically assisted hysterectomy: a continuous series of 53 cases. Journal of robotic surgery
, 2014, vol. 8, no. 3, p. 221-226
DOI : 10.1007/s11701-014-0454-3
Available at:
http://archive-ouverte.unige.ch/unige:77318
Disclaimer: layout of this document may differ from the published version.
1 / 1

1 23
Journal of Robotic Surgery
ISSN 1863-2483
J Robotic Surg
DOI 10.1007/s11701-014-0454-3
Perioperative outcomes of three-port
robotically assisted hysterectomy: a
continuous series of 53 cases
Patrick Dällenbach & Patrick Petignat

1 23
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ORIGINAL ARTICLE
Perioperative outcomes of three-port robotically assisted
hysterectomy: a continuous series of 53 cases
Patrick Da
¨
llenbach
Patrick Petignat
Received: 10 January 2014 / Accepted: 17 February 2014
Ó Springer-Verlag London 2014
Abstract This study evaluated the feasibility and safety of
3-port robotically assisted laparoscopic hysterectomy
(RALH), using a consecutive series of women who under-
went 3-port RALH in a university hospital. From November
2010 until June 2013 we operated on 53 women, whose mean
age was 48.4 ± 7.7 years (range 35–68 years), and mean
body mass index was 27.1 ± 5.1 kg/m
2
(range 19.5–42.9 kg/
m
2
). The indications for hysterectomy were myoma in 31
(58.5 %), adenomyosis in 10 (18.9 %), cervical dysplasia in 4
(7.5 %), neoplasia in 4 (7.5 %), and recurrent polyps or
postmenopausal bleeding in the remaining 4 women (7.5 %).
We performed total RALH in 50 cases (94.3 %) and subtotal
in the others. The median duration of total intervention was
169 min (interquartile range 147.5–206.5 min). The mean
weight of the uterus was 209.8 ± 166.6 g (range 36–790 g)
and mean estimated blood loss was 72.3 ± 75.9 ml (range
0–300 ml). There were no perioperative complications, in
particular no blood transfusions nor conversions to laparot-
omy. The median hospital stay was 4 days (interquartile
range 3–4 days). One patient was reoperated 1 month later
for vaginal vault hematoma and another was readmitted
3 weeks post-operatively due to vaginal vault dehiscence
after premature intercourse, but did not require reoperation.
Three-port RALH is feasible and safe for simple hysterec-
tomy. We believe this experience using minimum ports to be
useful to prepare for robotically assisted single-port
hysterectomy.
Keywords da Vinci system Robotic surgery
Hysterectomy Robotically assisted laparoscopic
hysterectomy Reduced ports
Introduction
Hysterectomy is the most commonly performed gyneco-
logical surgical procedure. More than 500,000 hysterecto-
mies are performed in the USA annually [1]. The first
laparoscopic hysterectomy was performed by Harry Reich
in 1988 [2]. Over the past two decades, the use of mini-
mally invasive approaches for hysterectomy has increased.
However, in 2005, only 14 % of all hysterectomies were
performed laparoscopically in the USA. Robotically
assisted laparoscopic hysterectomy has gained popularity,
especially in the USA, and might have the potential to help
increase the proportion of laparoscopic hysterectomies [3].
Outcomes appear comparable to standard laparoscopic or
vaginal hysterectomy, but it is more costly [47]. One of
the potential benefits for the patient might be reduction of
post-operative pain [8]. Moreover, the ergonomics offers
an evident benefit for the surgeon, which is rarely
quantified.
Laparo-endoscopic single-site surgery (LESS), also
referred to as single-port laparoscopy, is one of the recent
advances in the field of minimally invasive surgery. The
first hysterectomy by a single trocar technique was reported
by Pelosi et al. [9] in 1991. Despite these pioneering
efforts, gynecological surgeons did not embrace single-site
surgery until recently, but at the expense of longer opera-
tive time and higher post-operative pain scores as well as
discomfort for the surgeon [10, 11]. The use of this tech-
nique is still limited in gynecology [12]. With the use of
robotic assistance, single-site hysterectomy might become
P. Da
¨
llenbach (&) P. Petignat
Division of Gynecology, Department of Gynecology and
Obstetrics, Geneva University Hospitals, 30 boulevard de la
Cluse, 1211 Geneva 14, Switzerland
e-mail: Patrick.dallenbach@hcuge.ch
123
J Robotic Surg
DOI 10.1007/s11701-014-0454-3
Author's personal copy

much easier to perform and pain might be reduced, thus
offering a new benefit for women.
In standard laparoscopy, hysterectomy is traditionally
performed using 4 ports (one umbilical port of 12 mm and
three suprapubic ports of 5–10 mm). It can also be per-
formed with only two suprapubic 5-mm ports, or even
smaller 3-mm ports nowadays. Robotically assisted hys-
terectomy is classically performed with 4–5 ports (12 mm
for the optics, 8 mm for the robotic arm trocars and one
assistant port of 5 or 10 mm). Since the beginning of our
experience in robotic surgery, we decided to use only three
ports for all standard hysterectomies, so as to offer similar
benefits as in laparoscopy and to prepare for future robot-
ically assisted single-port procedures. Robotic assistance
for single-site laparoscopic surgery represents, from our
point of view, the potential benefit of robotic assistance in
minimally invasive gynecological surgery. The use of a
reduced number of ports and instruments is inevitable in
single-port hysterectomy, which is challenging for the
surgeon. We present our experience with three-port
robotically assisted laparoscopic hysterectomy.
Patients and method
Implementation of a robotic program took place at our
institution in November 2010 after institutional approval
from the Geneva University Hospitals. As a center highly
trained in laparoscopy and performing laparo-endoscopic
single-site surgery (LESS), we decided from the beginning
of our program to perform robotically assisted hysterec-
tomy with only three ports as opposed to the standard 4–5
ports advised by Intuitive Surgical and previous reports.
We already performed our laparoscopic hysterectomies
with the use of only three 5-mm ports. All patients gave
their informed consent for the procedure. We started our
robotic cases with small uteri and simple cases and
enlarged our indications to larger uteri and more complex
cases with increase in our experience. Each case was
evaluated for its complexity based on preoperative diag-
nosis, prior pelvic or abdominal surgery, patient’s body
mass index (BMI), and uterine size. One experienced sur-
geon performed the majority of cases with resident and/or
fellow assistance, and three other surgeons were progres-
sively introduced to the method. Complex procedures such
as pelvic lymphadenectomy or patients with high risk of
complex adhesions were not included, and additional tro-
cars were used from the start.
The patients were placed in the dorsal lithotomy posi-
tion. All patients had preoperative prophylactic antibiotics
[Cefazolin 2 g IV (Kefzol
Ò
)] at anesthetic induction.
A Hohl uterine manipulator (Karl Storz Company, Tutt-
lingen, Germany) was placed after appropriate preparation
and draping (Fig. 1). This manipulator was moved later on
during the robotic procedure by a fellow sitting between
the legs of the patient. Patients were placed in a steep
Trendelenburg position. We used either the da Vinci S or
SI system (Intuitive Surgical
Ò
) to perform the procedure as
they were the two models available in our institution during
that period. We performed insufflations of CO
2
with a
Veress needle introduced either in the umbilicus or at the
Palmer point in the left upper quadrant. A 12-mm trocar
(Ethicon
Ò
D12 XT) 150 mm in length was introduced
intra- or supra-umbilically depending on the size of the
uterus at an intra-abdominal pressure of 25 mmHg. After
introducing the da Vinci optic, we placed one 8-mm
metallic da Vinci cannula in the left iliac fossa and one
8-mm cannula with outlet in the right iliac fossa at an intra-
abdominal pressure of 20 mmHg (Fig. 2). The cannula
with outlet was useful to evacuate smoke if necessary.
Intra-abdominal pressure was reduced to 12 mmHg during
the procedure. We performed the initial diagnostic lapa-
roscopy and survey of the abdomen directly with the da
Vinci optics. Adhesiolysis was performed with standard
laparoscopic instruments when necessary before docking
the robot. We docked the robotic system on the left side of
the patient to allow the fellow sitting between the legs to
have good access to the vagina for further manipulation
and consecutive removal of the uterus. We also used a
vaginal extractor (Karl Storz Company) as previously
described in a 1994 publication to introduce the sutures and
needle for vaginal cuff closure (Figs. 3, 4)[13]. We used
either a 0° or 30° optic depending on the size of the uterus.
The 30° optic was chosen in a few cases to allow for better
visualization and access to uterine arteries, vesico-vaginal
fold or culdotomy in some cases of large myomas. We used
monopolar EndoWrist scissors and Maryland or fenestrated
bipolar grasper (Intuitive Surgical) to perform the proce-
dure. The vaginal cuff was closed robotically with two
needle drivers (of which one was a Mega Suture-Cut) with
three to four figures-of-eight O polyglactin sutures
(Vicryl
Ò
O, Ethicon Endo Surgery, Inc., Cincinnati, OH,
USA) on a CT-2 needle. Suture material was introduced
through the previously described vaginal extractor, and
removed through the 8-mm trocars after having closed the
vaginal vault. In cases of subtotal hysterectomy, the patient
had preoperative endometrial biopsy as a routine investi-
gation, and we performed telescoping (introduction of an
8-mm da Vinci trocar in a 12-mm laparoscopic trocar) and
morcellation through the same incision in the left iliac
fossa. When necessary, aspiration of blood was performed
by the fellow or resident on the operating field through one
of the 8-mm trocars, after removal of one of the robotic
instruments, with or without undocking the robotic arm, or
at the end of the procedure after undocking the robot. The
robotic system was undocked and all trocars were removed
J Robotic Surg
123
Author's personal copy

Citations
More filters
Journal ArticleDOI
TL;DR: A higher body mass index, more adhesiolysis, and difficult bladder dissection imply a more challenging nature of women who underwent robotic hysterectomy, despite which RH was shown to be feasible and safe with a lower blood loss.
Abstract: Background and Objectives We compared the outcome of robotic hysterectomy (RH) with laparoscopic hysterectomy (LH) for large uteri (≥16 weeks). Methods This was a retrospective review over 5 years of 165 women (RH, 46; LH, 119). Demographic data, conversion, hemoglobin drop, indication, operating time, postoperative stay, and intra-operative strategies (adhesiolysis, myomectomy) were recorded. Results Mean age was 45.7 ± 6.4 years and 44.5 ± 5.4 years (no diff) and body mass index was 30.2 ± 6.3 kg/m2 and 27.8 ± 4.8 kg/m2 (P = .009) in the RH and LH groups. There was no difference in percentage of women with previous laparotomy (RH, 15.2% vs LH, 13.4%) and mean number of lower-segment caesarean section (RH, 1.0 vs LH, 0.8). Mean size of uterus was similar (RH, 20.0 weeks vs LH, 17.4 weeks). The mean number of ports was higher in the RH group (RH, 4.2 vs LH, 3.4; P < .001) as was needed for adhesiolysis (RH, 71.7% vs LH, 35.3%; P < .001). Difficult bladder dissection was more in the RH group (56.5% vs 26.1%; P < .001). Vaginal morcellation was similar in both groups (RH, 89.1%; LH, 83.2%). RH took longer operating time (131.0 vs 110.6 minutes; P = .006). RH had less drop in Hb (1.0 vs 1.8 g/dL; P < .001) and remained the same after multiple regression analysis. Postoperative stay was similar in both groups (1.4 days). Requirement of intravenous analgesia was significantly lower in the RH group (12.5 vs 30.9 hours; P < .001). Open conversion rate was 4.3% (RH) and 10.9% (LH) but not significant. Conclusion A higher body mass index, more adhesiolysis, and difficult bladder dissection imply a more challenging nature of women who underwent RH. Despite this, RH was shown to be feasible and safe with a lower blood loss.

11 citations

References
More filters
Journal ArticleDOI
20 Feb 2013-JAMA
TL;DR: The use of robotically assisted hysterectomy for benign gynecologic disorders increased substantially between 2007 and 2010, and the use of robotic technology resulted in substantially more costs.
Abstract: Importance Although robotically assisted hysterectomy for benign gynecologic conditions has been reported, little is known about the incorporation of the procedure into practice, its complication profile, or its costs compared with other routes of hysterectomy. Objectives To analyze the uptake of robotically assisted hysterectomy, to determine the association between use of robotic surgery and rates of abdominal and laparoscopic hysterectomy, and to compare the in-house complications of robotically assisted hysterectomy vs abdominal and laparoscopic procedures. Design, Setting, and Patients Cohort study of 264 758 women who underwent hysterectomy for benign gynecologic disorders at 441 hospitals across the United States from 2007 to 2010. Main Outcome Measures Uptake of and factors associated with utilization of robotically assisted hysterectomy. Complications, transfusion, reoperation, length of stay, death, and cost for women who underwent robotic hysterectomy compared with both abdominal and laparoscopic procedures were analyzed. Results Use of robotically assisted hysterectomy increased from 0.5% in 2007 to 9.5% of all hysterectomies in 2010. During the same time period, laparoscopic hysterectomy rates increased from 24.3% to 30.5%. Three years after the first robotic procedure at hospitals where robotically assisted hysterectomy was performed, robotically assisted hysterectomy accounted for 22.4% of all hysterectomies. The rates of abdominal hysterectomy decreased both in hospitals where robotic-assisted hysterectomy was performed as well as in those where it was not performed. In a propensity score–matched analysis, the overall complication rates were similar for robotic-assisted and laparoscopic hysterectomy (5.5% vs 5.3%; relative risk [RR], 1.03; 95% CI, 0.86-1.24). Although patients who underwent a robotic-assisted hysterectomy were less likely to have a length of stay longer than 2 days (19.6% vs 24.9%; RR, 0.78, 95% CI, 0.67-0.92), transfusion requirements (1.4% vs 1.8%; RR, 0.80; 95% CI, 0.55-1.16) and the rate of discharge to a nursing facility (0.2% vs 0.3%; RR, 0.79; 95% CI, 0.35-1.76) were similar. Total costs associated with robotically assisted hysterectomy were $2189 (95% CI, $2030-$2349) more per case than for laparoscopic hysterectomy. Conclusions and Relevance Between 2007 and 2010, the use of robotically assisted hysterectomy for benign gynecologic disorders increased substantially. Robotically assisted and laparoscopic hysterectomy had similar morbidity profiles, but the use of robotic technology resulted in substantially more costs.

455 citations

Journal ArticleDOI
TL;DR: A higher likelihood of exploratory laparotomy for hysterectomy in the prerobotic cohort versus the robotic cohort and aHigher likelihood of intraoperative conversion to laparotomies with the preRobotic cohort than with the robotic cohorts existed.

253 citations

Journal ArticleDOI
TL;DR: In addition to age and clinical diagnosis, nonclinical factors such as race/ethnicity, insurance status, income, and region appear to affect use of laparoscopic hysterectomy compared with abdominal hystEREctomy and vaginal hysteretomy.

248 citations


"Perioperative outcomes of three-por..." refers background in this paper

  • ...More than 500,000 hysterectomies are performed in the USA annually [1]....

    [...]

Journal ArticleDOI
TL;DR: It is postulate that the use of thermal energy in addition to other factors unique to laparoscopic surgery may be responsible for the increased risk of vaginal cuff dehiscence compared with other modes of total hysterectomy.

228 citations


"Perioperative outcomes of three-por..." refers background in this paper

  • ...It is well described that women should defer vaginal intercourse for at least 6–8 weeks after hysterectomy, because sexual intercourse before complete healing of the vaginal cuff is considered the main trigger event [18, 19]....

    [...]

Journal ArticleDOI
TL;DR: A surgical robot can move in ways that the human wrist cannot, and is it a practical substitute for the conventional hands-on approach?

171 citations


"Perioperative outcomes of three-por..." refers background in this paper

  • ...’s [15] initial series of 91 patients published in 2007, but their mean uterine weight was smaller (135....

    [...]

Frequently Asked Questions (2)
Q1. What have the authors contributed in "Perioperative outcomes of three-port robotically assisted hysterectomy: a continuous series of 53 cases" ?

This study evaluated the feasibility and safety of 3-port robotically assisted laparoscopic hysterectomy ( RALH ), using a consecutive series of women who underwent 3-port RALH in a university hospital. The authors performed total RALH in 50 cases ( 94. 3 % ) and subtotal in the others. The authors believe this experience using minimum ports to be useful to prepare for robotically assisted single-port hysterectomy. 

The future of robotic surgery is strongly linked with innovation and improvement of technology and with miniaturization, but also with coupling of imaging allowed by computer assistance. The objective of their study was to show that it is possible to minimize the use of trocars in RALH without compromising its success, and the authors compared their results to those reported by previous authors using at least one supplementary assistant trocar.