Surgical techniques: robot-assisted laparoscopic myomectomy with the da Vinci® surgical system
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Myomectomy remains the surgical option of choice for women with symptomatic leiomyomata who desire uterine conservation or in particular future fertility. The ability to enucleate leiomyomata and repair the uterus with a multilayer-sutured closure is both crucial and technically challenging. Advanced gynecologic pathology and the surgical limitations of conventional laparoscopy have often been cited as impediments to not only these critical steps but also to converting a myomectomy from a procedure predominantly performed by laparotomy to one accomplished by laparoscopy. Recently, the use of robotic technology as a means to facilitate the laparoscopic completion of a myomectomy was introduced. Advantages to this approach have been the improved dexterity and precision of the instruments coupled with three-dimensional imaging. Published preliminary data have shown the feasibility and safety to this approach. This paper will outline a safe and efficient surgical technique for completing a robot-assisted laparoscopic myomectomy with the da Vinci® surgical system.
KeywordsRobotics Myomectomy Laparoscopy Leiomyomata
Leiomyomata are the most common pelvic tumor in women. These benign tumors of fibrous tissue and smooth muscle are often implicated in excessive bleeding, pain, pressure, and/or infertility. Although newer modalities such as uterine artery embolization exist, myomectomy remains the surgical option of choice for women desiring uterine conservation or in particular future fertility [1, 2]. As a result of the advent of modern-day minimally invasive surgery techniques, many cases of intramural and subserous leiomyomata are managed by laparoscopy today. Despite the increasing acceptance of laparoscopy, laparotomy still remains the primary route of conservative surgical management for symptomatic leiomyomata, not approachable by hysteroscopy.
There is no doubt that the management of leiomyomata endoscopically is one of the more challenging procedures in minimally invasive surgery and requires a skilled surgeon. The ability to enucleate leiomyomata and repair the uterus with a multilayer-sutured closure is both crucial and technically challenging. These issues are thought to affect conversion rates to laparotomy and may play a role in cases of uterine rupture. Much of the steadfast adherence to the open approach has been due to the difficulties encountered with conventional laparoscopy and its associated learning curves [3, 4].
The use of robot-assisted technology may provide a means to overcome the challenges encountered with hysterotomy, enucleation, repair, and extraction that are seen with conventional laparoscopic management of leiomyomata. In other words, the use of computer-assisted surgery may provide surgeons with improved dexterity and precision coupled with advanced imaging and allow the endoscopic approach to be more accurately modeled after open surgical techniques. The following paper will describe the use of the da Vinci® surgical system (Intuitive Surgical®), which is the only Food and Drug Administration (FDA)-approved robotic device for use in gynecologic surgery as of April 2005. The focus will be on both surgical technique and instrumentation.
The da Vinci® surgical system
The da Vinci® surgical system is a laparoscopic assist device that is comprised of three components that exists as core technology within two platforms, the Standard and S™ systems. The first component is the surgeon console, which is located remotely, several feet from the patient bedside. In theory, this can also be located in an adjoining room. The surgeon seated at this console is able to control robot-assisted instruments, a camera, and an energy source within the patient with the aide of a stereoscopic viewer, hand manipulators and foot pedals.
The second component of the da Vinci® surgical system is the InSite® Vision System, which provides three-dimensional imaging through a 12 mm endoscope. A 5 mm endoscope is also available; however, this only provides two-dimensional imaging therefore these authors typically incorporate a 12 mm endoscope.
The third component of the da Vinci® surgical system is the patient-side cart with robotic arms and EndoWrist® instruments. Currently the system is available with either three or four robotic arms. One of the arms holds the endoscope while the other two to three arms hold the various EndoWrist® instruments, which come in either 8 or 5 mm sizes.
The EndoWrist® instruments are unique in that they lack haptic or tactile feedback for the surgeon operating them at the console. They do however possess a wrist-like mechanism that allows seven degrees of movement, thereby replicating the full range of motion of the surgeon’s hand. This in turn eliminates the fulcrum effect seen with conventional laparoscopy. A series of EndoWrist® instruments, such as needle drivers, scissors, and graspers can be interchanged on either of the lateral robotic arms.
Patient positioning is analogous to conventional laparoscopy. All patients are placed in low dorsal lithotomy position with arms padded and tucked at their sides after general endotracheal anesthesia is administered. Anti-skid measures should be incorporated at this time with either the proper use of shoulder braces or a foam egg-crate mattress directly behind the patient’s upper back in order to avoid patient slippage during the use of Trendelenburg.
Once all desired ports are in place, the patient is placed in steep Trendelenburg. The patient-side cart with robotic arms is brought between the patient’s legs and docked. This means that each port is attached to the assigned robotic arm with the exception of the accessory port. The bedside surgeon is responsible for EndoWrist® instrument exchanges and management of any accessory port activity such as providing suction/irrigation. At this point, the anesthesiologist must be notified that the operating room table cannot be moved unless the patient side-cart is undocked.
This results in improved hemostasis with minimal thermal spread, tissue sticking, and heating of the instrument.
Robot-assisted laparoscopic myomectomy technique
An approach that is modeled after open surgical technique is critical to the success of a robot-assisted laparoscopic approach to myomectomy. Determining the size and location of leiomyomata pre-operatively is also important. The authors recommend that all patients undergo appropriate radiologic imaging prior to myomectomy. Although ultrasound is diagnostic in the majority of cases, it has been the bias of the authors to utilize magnetic resonance imaging (MRI) in all patients prior to surgery in order to assess the size, number, and location of leiomyomata as well as rule out adenomyosis. This information also allows for a strategic uterine incision or hysterotomy to be performed.
Each case is begun with bipolar PK™ dissecting forceps or a non-energized Cadiere forceps® on the left arm and hot shears or a permanent cautery hook (both monopolar devices) on the right arm. This designation can be varied based on surgeon preference. It is important to note that the monopolar current provided to the hot shears is in coagulation mode therefore the power settings on the radio-frequency generator are typically kept to a minimum of 35 in order to avoid the risks of excessive energy delivery. Factory default settings on the Gyrus ACMI generator are used for the PK™ dissecting forceps.
At this point, there are several noteworthy points. If multiple leiomyomas are to be removed, it is the preference of the authors to repair each uterine defect after enucleation of a leiomyoma before moving on to another tumor in order to take advantage of the effects of the vasopressin at that site. Maximizing the number of leiomyomas extracted through a given hysterotomy is advisable and decreases the number of uterine incisions. Finally, whether single or multiple, specimens are retrieved at the end of the case, again, in order to take advantage of the effects of the vasopressin and minimize blood loss from an unrepaired uterine incision. Careful attention should be paid to keeping an accurate count of the number of leiomyoma enucleated and if need be they should be tagged with long suture in order to avoid loss within the abdominal cavity. This is recommended for smaller specimens.
Based on the described surgical technique, a myomectomy that adheres to open surgical principles can be accomplished with the aide of a laparoscopic assist device such as the da Vinci® surgical system. This approach to robot-assisted laparoscopic myomectomy has been used successfully by the authors for the past five years . Critical to the success of this technique has been a thorough understanding of all facets of robotic instrumentation including its limitations. Although an absence of haptic or tactile feedback may be viewed as a limitation during a robot-assisted laparoscopic myomectomy, the authors find that both the improved visualization and instrument dexterity in this approach overcome any difficulties that may be encountered with the dissection. This is by no means the only way to perform a robot-assisted laparoscopic myomectomy but represents a safe and efficient way of approaching a common gynecologic problem.