Gynecologic laparoscopy

Gynecologic laparoscopy is an evolving discipline. Major advances in technology have facilitated the transition from traditional "open" surgery to minimally invasive procedures. This article reviews the basic tenets of gynecologic laparoscopy: pelvic anatomy, general procedures, laparoscopic instruments, complications, and common gynecologic surgeries. Highlighted procedures include adnexal surgery, laparoscopic hysterectomy, and operations for female malignancies.     

Perioperative Outcomes of Robotic Assisted Laparoscopic Surgery Versus Conventional Laparoscopy Surgery for Advanced-Stage Endometriosis

Background and Objectives:

To determine perioperative outcome differences in patients undergoing robotic-assisted laparoscopic surgery (RALS) versus conventional laparoscopic surgery (CLS) for advanced-stage endometriosis.

Methods:

This retrospective cohort study at a minimally invasive gynecologic surgery center at 2 academically affiliated, urban, nonprofit hospitals included all patients treated by either robotic-assisted or conventional laparoscopic surgery for stage III or IV endometriosis (American Society for Reproductive Medicine criteria) between July 2009 and October 2012 by 1 surgeon experienced in both techniques. The main outcome measures were extent of surgery, estimated blood loss, operating room time, intraoperative and postoperative complications, and length of stay, with medians for continuous measures and distributions for categorical measures, stratified by body mass index values. Robotically assisted laparoscopy and conventional laparoscopy were then compared by use of the Wilcoxon rank sum, χ², or Fisher exact test, as appropriate.

Results:

Among 86 conventional laparoscopic and 32 robotically assisted cases, the latter had a higher body mass index (27.36 kg/m² [range, 23.90–34.09 kg/m²] versus 24.53 kg/m² [range, 22.27–26.96 kg/m²]; P < .0079) and operating room time (250.50 minutes [range, 176–328.50 minutes] versus 173.50 minutes [range, 123–237 minutes]; P < .0005) than did conventional laparoscopy patients. After body mass index stratification, obese patients varied in operating room time (282.5 minutes [range, 224–342 minutes] for robotic-assisted laparoscopy versus 174 minutes [range, 130–270 minutes] for conventional laparoscopy; P < .05). No other significant differences were noted between the robotic-assisted and conventional laparoscopy groups.

Conclusion:

Despite a higher operating room time, robotic-assisted laparoscopy appears to be a safe minimally invasive approach for patients, with all other perioperative outcomes, including intraoperative and postoperative complications, comparable with those in patients undergoing conventional laparoscopy.     

Robotic minimally invasive mitral valve reconstruction yields less blood product transfusion and shorter length of stay

BACKGROUND: Robotic-assisted minimally invasive mitral valve reconstruction has gained popularity recently. Initial reports suggest that this approach can be used with relative safety and efficacy. Direct comparisons with a traditional sternotomy approach have not yet been explored extensively. METHODS: All mitral valve procedures that were performed by a single surgeon during a 3-year period of time were analyzed (n = 142 procedures). Patients whose condition required concomitant coronary artery bypass grafting or aortic valve surgery were excluded subsequently from analysis, because all of these patients were approached obligatorily by sternotomy (n = 71 patients). Six patients underwent right thoracotomy mitral valve procedures without robotic assistance, and 1 patient in cardiogenic shock underwent emergent mitral valve reconstruction by sternotomy. Of the remaining 64 patients who were eligible theoretically for sternotomy or robotic-assisted minimally invasive surgery, 39 patients underwent sternotomy, and 25 patients underwent right chest minimally invasive robotic-assisted surgery. Randomization between these 2 approaches would be almost impossible in the United States. The primary determinant for the choice of approach was request of the referring physician or patient. Multiple perioperative outcomes were then compared. RESULTS: Patients who underwent sternotomy and robotic-assisted surgery exhibited equivalent preoperative characteristics and experienced an equivalent degree of correction of mitral regurgitation in repairs and in need for replacement. Complex mitral valve repairs that entailed leaflet resection and reapproximation, annular plication, sliding annuloplasty, chordal transfer, and GoreTex neochordal construction were accomplished successfully with the robotic system. Cross-clamp and bypass times were longer for patients in the minimally invasive group (110 vs 151 minutes; P = .0015; 162 vs 239 minutes; P < .001, respectively). Mean packed red blood cell transfusion was lower among patients who underwent robotic-assisted surgery (5.0 vs 2.8 units; P = .04). Patients who underwent robotic-assisted surgeries experienced shorter mean duration of postoperative hospitalization (10.6 vs 7.1 days; P = .04). There was 1 death among the patients who underwent sternotomy, and no deaths among the patients who underwent robotic-assisted surgery. CONCLUSION: Patients can undergo mitral valve reconstruction with minimally invasive robotic assistance, avoid a sternotomy, require less blood product transfusion, and experience shorter hospitalization.     

Robotic-Assisted Repair of Iatrogenic Ureteral Ligation Following Robotic-Assisted Hysterectomy

Background and Objectives:

Ureteral injuries, while rare, do occur during gynecologic procedures. The expansion of laparoscopic and robotic pelvic surgical procedures increases the risk of ureteral injury from these procedures and suggests a role for minimally invasive approaches to the delayed repair of ureteral injuries. We present, to our knowledge, the first case of delayed robotic-assisted ureteral deligation and ureterolysis following iatrogenic ureteral injury occurring during a robotic abdominal hysterectomy.

Methods:

We present a case report and review of the literature.

Results:

A 57-year-old female underwent a seemingly uncomplicated robotic-assisted laparoscopic total abdominal hysterectomy and bilateral oophorectomy for symptomatic fibroids. On postoperative day 8, she presented with persistent right flank pain. Imaging studies revealed high-grade ureteral obstruction consistent with suture ligation of the right ureter. She underwent successful robotic-assisted ureteral deligation and ureterolysis. Her postoperative course was unremarkable, and she was discharged home on postoperative day 1 from the deligation.

Conclusion:

Robotic-assisted management of complications from urologic or gynecologic surgery is technically feasible. This can potentially preserve the advantages to the patient that are being seen from the initial less-invasive surgery.     

Robotic assistance provides excellent outcomes during the learning curve for laparoscopic Roux-en-Y gastric bypass: results from 100 robotic-assisted gastric bypasses

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) has a reported learning curve of 100 cases. Robotic-assisted surgery decreases the learning curve in complex laparoscopic surgeries. We hypothesize that robotic-assisted, hand-sewn gastrojejunostomy during a LRYGB will improve results during the initial 100 cases when compared with the literature. METHODS: Our first 100 robotic-assisted gastrojejunostomies performed during LRYGB were reviewed from a prospective database. Patient demographics, operative times, length of stay, reoperations, anastomotic leak, pulmonary embolus, and death were all evaluated. RESULTS: The mean age and body mass index were 42 and 50, respectively. Operative times ranged from 148 minutes to 437 minutes (mean = 254). There were no leaks or deaths. Four patients had complications, including reoperation (1), incisional hernia (1), pulmonary embolus (1), and recurrent umbilical hernia (1). CONCLUSIONS: Robotic-assisted LRYGB is feasible and safe, as evidenced by the excellent outcomes from this series during the initial learning curve for LRYGB.     

Short-Term Outcomes After Robotic-Assisted Total Mesorectal Excision for Rectal Cancer

Background Laparoscopic total mesorectal excision for rectal cancer remains a difficult procedure with high conversion rates. We have sought to improve on some of the pitfalls of laparoscopy by using the DaVinci robotic system. Here we report our two-year experience with robotic-assisted laparoscopic surgery for primary rectal cancer. Methods A prospectively maintained database of all rectal cancer cases starting in November 2004 was created. A series of 39 consecutive unselected patients with primary rectal cancer was analyzed. Clinical and pathologic outcomes were reviewed retrospectively. Results 22 patients had low anterior, 11 intersphincteric and six abdominoperineal resections. Postoperative mortality and morbidity were % and 12.8%, respectively. The median operative time was 285 minutes (range 180–540 mins). The conversion rate was 2.6%. A total mesorectal excision with negative circumferential and distal margins was accomplished in all patients, and a median of 13 (range 7–28) lymph nodes was removed. The anastomotic leak rate was 12.1%. The median hospital stay was 4 days. There have been no local recurrences at a median follow-up of 13 months. Conclusions Robotic-assisted surgery for rectal cancer can be carried out safely and according to oncological principles. This approach shows promising short-term outcomes and may facilitate the adoption of minimally invasive rectal surgery.     

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??Characteristics and strategies for pancreatic fistula after open??laparoscopic and robotic pancreaticoduodenectomy PENG Cheng-hong??SHI Yu-sheng. Department of General Surgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine??Shanghai 200025??China
Corresponding author??PENG Cheng-hong??E-mail??chhpeng@188.com
Abstract The development of minimally invasive surgery pointed out the new direction for the development of pancreatic surgery. But the postoperative complications??especially the occurrence of pancreatic fistula??PF?? is still threatening the postoperative recovery of patients. Laparoscopic and robotic-assisted surgeries provide a new researching field for reducing the incidence of PF. According the present experience??robotic-assisted pancreatic surgery can not reduce the incidence of postoperative PF significantly. But robotic-assisted surgery is more minimally invasive and exact than open and laparoscopic surgery.     

A current update on the evolution of robotic liver surgery

Laparoscopic liver surgery has evolved significantly over the past decade. Increasing understanding of hepatic anatomy and advancements in technology have extended the scope of the minimally invasive approach. Robotic-assisted technology offers solutions to the fundamental limitations of conventional laparoscopic liver resection. Several centers have begun to utilize robotic technology to perform complex liver surgeries. The purpose of this review is to provide a comprehensive analysis of published literature about the role of robotic-assisted laparoscopic technology in liver surgery. A literature search of Pubmed was used to identify all English publications about robotic liver surgery. Publications were selected to examine all unique patient series. Outcomes analyzed included operative time, estimated blood loss, length of stay, complication rate, conversion rate to open, cost, and oncologic outcomes. A total of eight series containing 134 unique patients were selected for review. Sixty-nine percent of patients had malignant lesions resected, while 31% had benign lesions. Segmentectomy/wedge (36%) was the most common resection performed, followed by left lateral sectionectomy (28%) right hepatectomy (16%) and left hepatectomy (9%). A meta-analysis of the remaining data was not possible due to heterogeneity in methods for reporting. Outcomes varied widely between studies. Based on analysis of early published series, robotic liver surgery is a feasible and safe tool for the minimally invasive resection of hepatic lesions. Further evaluation is required to assess for improvement in outcomes, and long-term oncologic outcomes are still pending.     

开放、腹腔镜及机器人辅助行胰十二指肠切除术后胰瘘特点及对策

微创手术的发展为胰腺外科手术指明了新的发展方向,然而其术后并发症尤其是胰瘘的发生仍严重影响病人的术后恢复。腹腔镜及机器人手术系统为减少胰十二指肠切除术术后胰瘘发生提供了新的研究领域。根据现有经验,机器人手术并不能明显降低术后胰瘘发生率,但在微创化和精确化方面明显优于开放和腹腔镜手术。     

Robotic applications in reproductive endocrinology and infertility

In reproductive medicine, minimally invasive techniques are commonly used to perform various surgeries (e.g., tubal reanastomosis and myomectomy) in the infertile patient. In recent years, robotic technology has been utilized to perform these surgeries. This article will review the laparoscopic and robotic applications for tubal reanastomosis and myomectomy within the field of reproductive medicine. In addition, current robotic techniques utilized at our institution will be reviewed. In reproductive medicine, robotic-assisted technology provides a feasible option for minimally invasive surgery.     

单孔腹腔镜在妇科恶性肿瘤治疗中的利与弊

单孔腹腔镜手术(laparoendoscopic single site surgery,LESS)是新一代外科微创手术,在微创理念上优于传统腹腔镜手术,是传统多孔腹腔镜技术的发展和补充。近几年,LESS在妇科领域快速发展,在妇科恶性肿瘤治疗中也逐渐开展。由于LESS所需腔镜和操作器械均通过单一部位切口,与传统多孔腹腔镜手术区别很大。笔者结合文献及开展妇科恶性肿瘤LESS经验对单孔腹腔镜在妇科恶性肿瘤治疗中的利与弊进行阐述。     

Time management in the operating room: an analysis of the dedicated minimally invasive surgery suite.

BACKGROUND: Dedicated minimally invasive surgery suites are available that contain specialized equipment to facilitate endoscopic surgery. Laparoscopy performed in a general operating room is hampered by the multitude of additional equipment that must be transported into the room. The objective of this study was to compare the preparation times between procedures performed in traditional operating rooms versus dedicated minimally invasive surgery suites to see whether operating room efficiency is improved in the specialized room. METHODS: The records of 50 patients who underwent laparoscopic procedures between September 2000 and April 2002 were retrospectively reviewed. Twenty-three patients underwent surgery in a general operating room and 18 patients in an minimally invasive surgery suite. Nine patients were excluded because of cystoscopic procedures undergone prior to laparoscopy. Various time points were recorded from which various time intervals were derived, such as preanesthesia time, anesthesia induction time, and total preparation time. A 2-tailed, unpaired Student t test was used for statistical analysis. RESULTS: The mean preanesthesia time was significantly faster in the minimally invasive surgery suite (12.2 minutes) compared with that in the traditional operating room (17.8 minutes) (P=0.013). Mean anesthesia induction time in the minimally invasive surgery suite (47.5 minutes) was similar to time in the traditional operating room (45.7 minutes) (P=0.734). The average total preparation time for the minimally invasive surgery suite (59.6 minutes) was not significantly faster than that in the general operating room (63.5 minutes) (P=0.481). CONCLUSION: The amount of time that elapses between the patient entering the room and anesthesia induction is statically shorter in a dedicated minimally invasive surgery suite. Laparoscopic surgery is performed more efficiently in a dedicated minimally invasive surgery suite versus a traditional operating room.     

经脐单孔腹腔镜妇科手术32例

目的探讨经脐单孔腹腔镜下妇科手术的方法和实际应用价值。方法自2008年1月至2010年12月实施经脐单孔腹腔镜妇科手术32例。其中16例患者行卵巢破裂修补术,10例行宫外孕手术（7例输卵管切除术,3例孕物取出术）,4例行双侧输卵管绝育术,2例行节育环穿孔取环术,经脐行半环形切口,置入腹腔镜和操作钳实施手术。结果 32例手术均获成功,手术时间10～55min,术中出血量5～145ml,术后体温36.3℃～37.5℃,肛门排气时间0.4～2.0d。腹部无外观伤口。结论经脐单孔腹腔镜手术是一种安全可行、微创、美容效果好的手术,值得在妇科手术中推广。     

Partielle Nephrektomie – pro robotisch assistierte laparoskopische Operation

An ever increasing use of imaging in medicine during recent years has resulted in accidental detection of an increasing number of asymptomatic small renal masses. To prevent secondary cardiovascular morbidity through loss of renal function, nephron-sparing surgery is performed for most of these masses. Minimally invasive surgery is a way to prevent postoperative complications, such aspneumonia and pain by avoiding wide incisions and by earlier mobilization of the patient. Since 2004 robotic-assisted laparoscopic nephron-sparing surgery has become a feasible alternative. It shows good functional results, less blood loss and shorter warm ischemia time compared to conventional laparoscopy. The complications can be assigned to Clavien scale grades I and II and can be treated conservatively in most cases. New surgical techniques reduce the number of tumors that cannot be operated on robotically because of size and location of the tumor. Robotic-assisted laparoscopic nephron-sparing surgery is a safe and useful alternative to conventional laparoscopy and open surgery for small renal masses.     

Robotic-assisted laparoscopic cystoprostatectomy for prostatic carcinosarcoma.

Carcinosarcoma of the prostate is a rare neoplasm with malignant epithelial and mesenchymal components. Herein, we report the case of a patient who underwent multiple transurethral resections of the prostate showing adenocarcinoma initially then carcinosarcoma. He underwent a robotic-assisted laparoscopic cystoprostatectomy, bilateral pelvic lymph node dissection, and ileal conduit urinary diversion and was discharged on postoperative day 7. Carcinosarcoma is discussed as an extremely rare malignancy of the prostate, with less than 50 cases reported in the literature. Robotic-assisted radical cystoprostatectomy is also discussed as a new procedure in minimally invasive surgery and as the first reported use for prostatic carcinosarcoma.     

Robotic surgical training of the urologic oncologist

Robotic-assisted surgery has become an increasingly popular approach to the treatment of a variety of urologic malignancies. The use of minimally invasive techniques for treatment of genitourinary cancers has evolved from conventional laparoscopy to the use of robotic-assisted instrumentation. Many questions remain regarding the safest and most effective way to teach robotic surgery to trainees. Work hour restrictions, medical and legal concerns, and the unique operative set-up of the robotic system have made it increasingly difficult to provide “hands on” operative training to residents and fellows. We review the current literature regarding robotic surgical training, highlight potentially effective training strategies, and discuss future improvements in robotic surgical training of the urologic oncologist.     

Making the transition from standard gynecologic laparoscopy to robotic laparoscopy.

OBJECTIVES: To determine the feasibility of using a simple procedure, a bilateral tubal ligation, as a transition procedure when adopting robotic laparoscopy for gynecologic surgery. METHOD: To obtain robotic credentialing and gain experience with the robotic system, the surgeons first went through robotic training, then 4 women desiring permanent sterilization had robotically assisted laparoscopic bilateral tubal ligations performed, using the Parkland method. RESULTS: Total operating room time varied from 1 hour 25 minutes to 2 hours 31 minutes. Improvement in operating time for each surgeon was noted with each successive case. Best times in robotic cases were similar to those of standard laparoscopy. CONCLUSION: Robotically assisted laparoscopic tubal ligation using the Parkland method is a satisfactory procedure to provide transition for gynecologic surgeons and operating room personnel to gynecologic robotic surgery.     

Robotic-assisted laparoscopic repair of a vesicouterine fistula

Background:

As cesarean sections become a more common mode of delivery, they have become the most likely cause of vesicouterine fistula formation. The associated pathology with repeat cesarean deliveries may make repair of these fistulas difficult. Computer-enhanced telesurgery, also known as robotic-assisted surgery, offers a 3-dimensional view of the operative field and allows for intricate movements necessary for complex suturing and dissection. These qualities are advantageous in vesicouterine fistula repair.

Case:

A healthy 34-year-old woman who underwent 4 cesarean deliveries presented with a persistent vesicouterine fistula. Conservative management with bladder decompression and amenorrhea-inducing agents failed.

Results:

Robotic-assisted laparoscopic repair was successfully performed with the patient maintaining continence after surgery.

Conclusion:

Robotic-assisted laparoscopic repair of vesicouterine fistulas offers a minimally invasive approach to treatment of a complex disease process.