Computer-enhanced robotic surgery in gynecologic oncology
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This study aimed to report the computer-enhanced robotic surgery experience of the authors’ gynecologic oncology division.
From January 2001 to August 2006, 41 patients underwent laparoscopic surgery by our gynecologic oncology service using a computer-enhanced surgical robot. This report describes a retrospective review of these patients.
The patients ranged in age from 27 to 77 years (mean, 44.2 years), in weight from 44 to 131 kg (mean, 72.1 kg), in operative time from 1 h and 50 min to 9 h (mean, 5 h and 2 min), and in estimated blood loss from 50 to 1,500 ml (mean, 253 ml). Of the 20 patients with gynecologic malignancies, 14 had cervical cancer. A total of 21 patients had benign indications for surgery. Complications included shoulder palsy, robot failure, colotomy, bradycardia, and intraabdominal bleeding requiring minilaparotomy and ligation of a bleeding pedicle.
This case series is one of the first to report the use of a computer-enhanced surgical robot in gynecologic oncology. This approach proved to be feasible and well tolerated in this series of patients and deserves further study for clarification of its indications, benefits, and safety.
KeywordsComputer-enhanced robotic surgery Gynecologic oncology
Gynecologists were the first surgeons to use laparoscopy. Although laparoscopic surgery avoids the morbidity of an abdominal incision and shortens both the hospital stay and the recovery period, there are inherent problems with this technique. The increase in operative time and experience required to attain proficiency is even more pronounced with cancer patients . These issues have limited the role of laparoscopy in the field of gynecologic oncology.
Computer-enhanced robotic surgery using the da Vinci Robotic Surgical System (Intuitive Surgical, Inc., Mountain View, CA, USA) has been applied successfully in cardiac , urologic , and foregut surgery . This system consists of a remote control console in the same room as the patient and a surgical cart at the patient’s bedside. The surgeon’s control console has binocular viewing ports, providing the surgeon a three-dimensional view of the operative field. The surgical team views the surgery on two-dimensional monitors. The surgeon’s hand and wrist movements are precisely translated to Endo-wrist instruments within the operative field. Foot pedals control camera focus and position as well as cautery and instrument switching. The surgical cart’s three robotic arms, and an available fourth arm, manipulate the camera and various instruments including graspers, monopolar and bipolar cautery, and a harmonic scalpel. Wristed instruments offer the surgeon greater maneuverability than conventional laparoscopic instruments.
Previously, we have reported our experience with 11 hysterectomies using a computer-enhanced surgical robot . The current report elaborates on our experience with computer-enhanced robotic surgery for gynecologic oncology procedures.
Methods and materials
A total of 41 patients consented to undergo laparoscopic surgery using the da Vinci Computer-Enhanced Robotic Surgical System at the University of Texas Medical Branch. The consent included the patient’s acknowledgment that the procedure involved a novel surgical method. A single surgeon performed all the operations. Our Institutional Review Board (IRB) approved a review of the charts for data collection. Statistics are not included because this is a descriptive article.
The patients were positioned in dorsal lithotomy and deep Trendelenburg before positioning of the robotic instrument cart. For vaginal cases, preparation was made for converting patients to the deep dorsal lithotomy position once the laparoscopic portion of the case was completed. For omentectomy and paraaortic lymph node dissections, the surgical cart was positioned over the patient’s right shoulder, then moved to a position either between the patient’s legs or over the patient’s right leg. Surgical cart and trocar position alignment, previously described , are critical for optimal functioning. Patients cannot be repositioned once trocars are connected to the robot.
An 11-mm disposable trocar was placed in the periumbilical position for the camera. A 30° scope was used for best viewing of the internal iliac vessel branches. The scope was angled up to prevent the robotic camera arm from interference with the bump guard, protecting the patient’s face. Two 8-mm reusable trocars were placed in the right and left lower quadrant 8 to 10 cm from the umbilical trocar at an obtuse angle to prevent interference between camera and instrument arms. A fourth trocar was placed either above or below the umbilicus between the umbilical and left lower quadrant trocars for the surgical assistant. Suture ligatures were used initially to ligate pedicles, but were discontinued later in favor of the harmonic scalpel once it was available for use with the robot.
Surgeries were performed from January 2001 to August 2006. A total of 41 women underwent computer-enhanced robotic surgery in the gynecologic oncology service of the University of Texas Medical Branch. The indications for surgery were early-stage cervical cancer, pelvic mass, recurrent grade 3 cervical intraepithelial neoplasia, well-differentiated endometrial carcinoma, ovarian cancer, symptomatic fibroids, menorrhagia, and endometriosis. Surgeries included laparoscopically assisted vaginal hysterectomy (LAVH), unilateral and bilateral salpingo-oophorectomy, paraaortic and pelvic lymph node dissection (PA + PLND), sentinel pelvic lymph node biopsy, omentectomy, laparoscopically assisted radical vaginal hysterectomy (LARVH), ovarian cystectomy, laparoscopic hysterectomy, radical parametrectomy, and radical vaginal trachelectomy.
The patients had a mean age of 44.2 years (range, 27–77 years), a mean height of 63.1 in. (range, 59–69 in.), a mean weight of 72.1 kg (range, 44–131 kg), and a mean body mass index of 28 kg/m2.
According to the review, 20 women underwent LAVH, 9 underwent LARVH, 15 underwent PLND, 2 underwent PA + PLND, 2 underwent laparoscopic hysterectomy, 2 underwent ovarian cystectomy, 1 underwent LARVT, 1 underwent sentinel pelvic lymph node biopsy, and 2 underwent radical parametrectomy. A total of 22 bilateral salpingo-oophorectomies and 2 unilateral salpingo-oophorectomies were performed alone or in combination with other procedures. The setup time, from the beginning of surgical skin preparation to the start of surgery ranged from 4 min to 2 h and 15 min (mean, 31.7 min). The operative time ranged from 1 h and 50 min to 9 h (mean, 5 h and 2 min). The 9-h case consisted of a hysterectomy plus a staging procedure for ovarian cancer, including pelvic and paraaortic lymph node biopsies and infracolic omentectomy, and required the surgical cart to be positioned twice. The 2-h and 15-min setup was complicated by a robot failure, which resulted from failure of a robotic instrument and required changing of the instrument, redraping of the surgical cart, and rebooting of the robot.
The average estimated blood loss was 253 ml (range, 50–1,500 ml). Minilaparotomy and blood transfusion were required for our fifth patient because of bleeding from the right infundibulopelvic ligament. This was our first premenopausal patient with larger caliber ligaments and vessels. Additional suture ligatures were placed on vascular pedicles in response to this complication. Once the laparoscopic harmonic scalpel became available, we used it exclusively and have subsequently had no problems with bleeding.
A total of 20 cases were managed for cancer. All were early-stage cases, involving stages IA to IIA. Of the 20 cases, 14 involved cervical cancer, 3 involved endometrial cancer, and 3 involved ovarian cancer. Eight cases involved persistent cervical dysplasia. The patients were discharged home at an average of 2.5 days postoperatively (range, 0–12 days).
Complications included shoulder palsy, which resolved in 2 days; colotomy with repair; and bradycardia from pneumoperitoneum at 15 mmHg, which resolved once pneumoperitoneum was released. This procedure was completed using 12 mmHg of pneumoperitoneum. None of these complications had long-lasting sequelae.
Minimally invasive surgery benefits patients by reducing hospital stay and speeding both recovery and return to normal activities. Surgical procedures in gynecologic oncology, including lymphadenectomy, are technically demanding. Only a few advanced laparoscopic surgeons have successfully and routinely performed these procedures laparoscopically. Computer-enhanced robotic surgery enables a greater number of surgeons to offer the benefits of minimally invasive surgery to more patients.
The first successful report of computer-enhanced robotic surgery in gynecology was for tubal reanastomosis . Our experience with computer-enhanced laparoscopic surgery supports the safety and utility of robotic surgery in gynecologic oncology. We believe that robotic surgery has a shorter learning curve than laparoscopy. This is likely because of improved visualization and enhanced ability to manipulate tissues in the operative field. Procedures that are technically difficult in an open case were performed more easily with the robot.
A dedicated robotic surgical team is valuable. Our setup time decreased significantly with increased experience. Robotic operative systems are increasingly available in academic and community medical centers. This experience is with a first-generation surgical robot. Future robot models likely will be easier to position, possibly ceiling mounted, and may require fewer position changes. Further study comparing open or laparoscopic surgery with computer-enhanced robotic procedures in gynecologic oncology is necessary for full assessment of the indications, benefits, and safety of robotic surgery in gynecologic oncology.