Pedro T. Ramirez, Michael Frumovitz, and Pedro F. Escobar
INTRODUCTION
Minimally invasive surgery is currently considered a safe and viable option in the management of most gynecologic malignancies. Compared to standard laparotomy, laparoscopic or robotic surgery is associated with lower blood loss and transfusion rates, lower intraoperative complication rates, decreased analgesic requirements in the immediate postoperative period, shorter length of hospitalization, lower postoperative complication rates, quicker return of bowel function, and improved short-term quality of life.
This chapter provides an overview of the standard laparoscopic procedures and robotic surgery. Details on the preoperative evaluation and postoperative care of patients undergoing the procedures described and specific steps for the more commonly performed procedures are provided. Because the anatomical dissections are the same as for open procedures (see Chapters 25 and 26), the illustrations and figures are limited to those aspects specific to the minimally invasive surgical approach.
LAPAROSCOPIC SURGERY
Cervical Cancer
Laparoscopic Radical Hysterectomy
Procedure Overview
Since the initial publications by Nezhat et al1 and Canis et al,2 several retrospective studies have documented the safety and feasibility of total laparoscopic radical hysterectomy (TLRH), with a major complication rate of just 5%.3In a study by Frumovitz et al,4 the authors compared 35 women who had undergone TLRH to 54 women who had open radical hysterectomy (ORH) and found significantly less blood loss, shorter length of hospital stay, and increased operative time for the TLRH group. Transfusion rates were low in both groups (15% for ORH vs. 11% for TLRH). Intraoperative and postoperative noninfectious complications were the same for both groups, but the ORH group had a significantly higher postoperative infectious complication rate than the TLRH group (53% vs. 18%, respectively). These complications included postoperative febrile morbidity, wound cellulitis, urinary tract infections, pneumonia, and intra-abdominal abscesses.
In evaluating oncologic outcomes, it appears that there is equivalency between TLRH and ORH. In their large series of 295 women who underwent TLRH, Chen et al3 reported overall disease-free survival rates of 95% for women with stage IA disease and 96% for women with stage IB disease.
Box 31-1 Master Surgeon’s Corner
Proper patient positioning with steep
Trendelenburg will facilitate pelvic exposure and dissection.
Develop the avascular paravesical and pararectal spaces early in the course of operation to facilitate exposure to the parametria for ureteral dissection.
Preoperative Management
Patients with early-stage cervical cancer scheduled for a radical hysterectomy should routinely undergo a chest x-ray and blood type and cross. The use of other imaging modalities such as computed tomography (CT) or magnetic resonance imaging (MRI) scans is not recommended, unless there is evidence to suspect metastatic disease.
All patients should undergo bowel preparation 1 day prior to surgery and receive antibiotic prophylaxis on the day of surgery. The choice of bowel preparation used by the authors is HalfLytely (polyethylene glycol), and the antibiotic regimen most frequently recommended is cefoxitin 2 g intravenously. Although there is no standard regimen for thromboembolic prophylaxis, patients should either undergo administration of subcutaneous heparin (5000 U) preoperatively or have compression devices used during the procedure and subsequently until ambulation.
Surgical Technique
Initial Steps. After induction of general anesthesia, the patient is placed in the low lithotomy position using Allen stirrups. Typically, the patient’s arms are tucked at her sides. Care must be taken to protect the patient’s hands and fingers when the foot of the table is raised or lowered (Figure 31-1). Monitors are placed at the foot of the table.
FIGURE 31-1. Patient positioning for laparoscopic surgery.
After the patient is prepared and draped, a Foley catheter is placed under sterile conditions. A sterile speculum is then placed into the vagina, and a single-toothed tenaculum is used to grasp the anterior lip of the cervix. A uterine manipulator is placed. The preferred uterine manipulator used by the authors is the V-Care manipulator (Conmed Endosurgery, Utica, NY).
Incision Placement. A 12-mm Xcel Bladeless Trocar (Ethicon Endo-Surgery, Cincinnati, OH) that incorporates a 0-degree laparoscope is placed at the level of the umbilicus and introduced into the abdominal cavity under direct visualization. In patients with a prior midline incision, the initial entry into the abdominal cavity is made approximately 2 cm below the left costal margin at the level of the midclavicular line to avoid injury to bowel adherent to the anterior abdominal wall. Once the trocar has been safely introduced into the abdominal cavity, the cavity is insufflated. The intra-abdominal pressure is maintained at 16 mm Hg. Two additional 5- or 12-mm Xcel Bladeless Trocars are placed in the right and left lower quadrants, and an additional 5-mm Xcel Bladeless Trocar is inserted in the midline above the pubic symphysis (Figure 31-2).
FIGURE 31-2. Trocar placement for standard laparoscopic procedures. LLQ, left lower quadrant; RLQ, right lower quadrant.
Retroperitoneal Exploration. The pelvis and abdomen are thoroughly explored to rule out intraperitoneal disease. The bowel is then mobilized into the upper abdomen, and the round ligaments are transected bilaterally. An incision is made in the peritoneum over the psoas muscle immediately lateral to the infundibulopelvic ligament. The infundibulopelvic ligament is retracted medially to permit identification of the ureter. The iliac vessels are also exposed at this time. The lymph-bearing tissue is then probed to rule out any obvious metastatic disease to the pelvic lymph nodes. Any suspicious nodes are removed and sent for frozen-section examination. Barring obvious lymph node metastasis, the pelvic lymph node dissection is completed after the radical hysterectomy.
Parametrial and Bladder Dissection. The paravesical space is dissected by following the external iliac vessels distally and placing medial traction on the superior vesical artery. The pararectal space is identified by dissecting between the internal iliac vessels and the lateral aspect of the ureter. Once these spaces have been created, one can easily identify the uterine vessels. After identification, the uterine vessels are transected at the point of origin from the internal iliac vessels. The uterine artery and vein are transected together. The bladder peritoneum is incised across the anterior aspect of the uterus and dissected down off the cervix. The bladder should be mobilized to below the level of the cup of the uterine manipulator to assure there is an adequate surgical margin of at least 1 to 2 cm. This can be performed by pushing the uterine manipulator cephalad with the uterus straight along its axis. We take particular care at this point in the procedure to completely separate the bladder fibers from the anterior vagina because this facilitates closure of the vaginal cuff at the end of the procedure.
The ureters are separated from their medial attachments to the peritoneum. The parametrial tissue is mobilized medially over the ureters. The ureters are unroofed to the point of their insertion into the bladder bilaterally. The lateral aspect of the vesicouterine ligament is then divided, and the bladder is further mobilized inferiorly to ensure adequate vaginal margins. The uterus is anteflexed using the uterine manipulator, and blunt graspers are used to apply counter traction across the posterior cul-de-sac. The peritoneum above the sigmoid colon and rectum is then incised, exposing the rectovaginal space. The attachments between the rectum and the vagina are cut in the midline, exposing the uterosacral ligaments. The uterosacral ligaments are then divided.
Circumferential Vaginotomy and Closure. Once the previously described procedures are complete, the cervix is now free of all its vascular and suspensory attachments, and the specimen can be removed. A circumferential incision is made into the vagina along the ring of the uterine manipulator. The specimen is completely separated from the upper vagina and removed. The vaginal cuff is sutured laparoscopically.
Box 31-2 Caution Points
Ensure that the patient’s legs are properly positioned and the hands protected to avoid inadvertent injury.
Maintain direct visualization of the ureter when using thermal energy for parametrial dissection and division of vascular pedicles.
Postoperative Management
Patients undergoing laparoscopic radical hysterectomy are routinely placed on a demand intravenous analgesic pump and an oral analgesic regimen. All patients are ordered a regular diet on the evening of surgery. A Foley catheter is left in place postoperatively for a total of 5 to 7 days. A trial of void is attempted at that time, and if the postvoid residual is less than 150 mL, the catheter is removed. If the patient fails the voiding trial, then the catheter is left in place for another week. We do not routinely recommend thromboembolic prophylaxis postoperatively in patients undergoing minimally invasive surgery. A study by Nick et al5 in patients undergoing laparoscopic surgery showed that the rate of a deep venous thromboembolism or pulmonary embolism was 0.7%.
Box 31-3 Complications and Morbidity
Ureteral or bladder injury (1%-3%)
Delayed recovery of bladder function
Port site hematoma or hernia
Laparoscopic Staging for Locally Advanced Cervical Cancer
Procedure Overview
Surgical staging of patients with locally advanced cervical cancer remains controversial. An open transperitoneal approach is associated with high morbidity and mortality secondary to bowel complications, particularly when surgery is followed by radiotherapy. An extraperitoneal approach by laparotomy has been shown to decrease the complication rate from 30% to 2% compared with the transperitoneal approach.6
As many as 22% of patients with stage IB2 to IV cervical cancer and negative para-aortic lymph nodes on preoperative CT or combined positron emission tomography (PET)/CT imaging will be found to harbor metastatic disease in the para-aortic nodes when submitted to laparoscopic extraperitoneal staging.7 These findings strongly argue for the consideration of surgical staging in patients with locally advanced cervical cancer for diagnostic purposes. In addition, LeBlanc et al8 found a therapeutic effect from surgical staging of locally advanced cervical cancer. In their study of 184 patients with stage IB2 to IVA cervical cancer, they found that women with microscopic metastatic disease to the para-aortic lymph nodes had the same survival as women who had pathologically negative lymph nodes.
Box 31-4 Master Surgeon’s Corner
Detection of microscopic metastatic para-aortic nodal disease will facilitate disease-directed radiation therapy field selection for patients with locally advanced cervical cancer.
Both transperitoneal and extraperitoneal laparoscopic staging techniques are preferable to open laparotomy for preradiation treatment staging of cervical cancer.
Carefully mark out planned incision sites according to anatomic landmarks.
Preoperative Management
Patients scheduled to undergo surgical staging of locally advanced cervical cancer routinely undergo a PET/CT imaging evaluation. Alternatively, a CT scan of the chest, abdomen, and pelvis is recommended. Patients should have no evidence of metastatic disease prior to undergoing surgery. Routine bowel preparation, antibiotic prophylaxis, and thromboembolic prophylaxis are recommended.
Surgical Technique
Initial Steps. The patient is placed in a supine position under general anesthesia with the right arm adducted and secured and the left arm placed at a right angle to the patient. A 5-mm endoscope is placed at the inferior margin of the umbilicus. The abdominal and pelvic cavities are inspected for intraperitoneal metastatic disease.
Development of Extraperitoneal Space. If the intraperitoneal inspection is clear, a 15-mm incision is made 3 to 4 cm medial and superior to the left anterior iliac spine. The skin, fascia, transverse muscles, and deep fascia are incised, with care taken not to open the peritoneum. The surgeon’s left forefinger is introduced in the incision to free the peritoneal sac from the deep surface of the muscles of the abdominal wall under laparoscopic monitoring. A 10-mm balloon-tip trocar is then placed in the extraperitoneal space of the flank. The retroperitoneum is insufflated to a pressure not exceeding 15 mm Hg. At the same time, the peritoneal cavity is deflated. The laparoscope is then introduced through the balloon-tip trocar. A second 10-mm trocar is then introduced into the extraperitoneal space. The penetration point is located in the midaxillary line under the subcostal margin approximately 5 cm cephalad to and 3 to 4 cm lateral to the initial point. A 5-mm trocar is then placed 3 to 4 cm cephalad to this second 10-mm trocar (Figure 31-3).
FIGURE 31-3. Trocar placement for extraperitoneal para-aortic lymphadenectomy.
Removal of Common Iliac and Para-Aortic Nodes. The dissection is performed bilaterally from the level of the common iliac vessels to the level of the left renal vein (Figure 31-4). When there is evidence of grossly positive lymph nodes, these are sent to pathology for frozen-section evaluation. If metastatic disease is confirmed, the laparoscopic procedure is aborted. At the completion of the procedure, all patients have an incision performed in the peritoneum overlying the left paracolic gutter to minimize the likelihood of development of postoperative lymphocysts. If a patient is found to have a grossly positive node, then the incision on the peritoneum is not performed. This is to reduce the potential of spread of disease to the peritoneal cavity. No drains are placed at the completion of surgery.
FIGURE 31-4. Completed extraperitoneal para-aortic lymphadenectomy. IMA, inferior mesenteric artery.
Box 31-5 Caution Points
Careful blunt dissection is required to avoid entering the peritoneal cavity when developing the extraperitoneal space.
Ensure that the ureters are under direct visualization when using thermal energy to dissect nodal tissue.
Postoperative Management
This procedure is routinely performed as an outpatient procedure. No drains are placed at the completion of surgery. Most patients are placed on an oral analgesic regimen and are discharged from the hospital once they have voided and tolerated a regular diet. Generally, patients are able to start treatment with chemotherapy and radiation within 14 days from their surgery.
Box 31-6 Complications and Morbidity
Vascular injury
Ureteral injury
Retroperitoneal lymphocyst formation
Uterine Cancer
Simple Hysterectomy and Staging
Procedure Overview
The introduction of minimally invasive surgery as a treatment option for women with endometrial cancer began in the early 1990s with multiple reports of laparoscopic-assisted vaginal hysterectomy and lymph node staging. In 1996, the Gynecologic Oncology Group opened LAP2, a randomized controlled trial assigning patients to laparoscopy or laparotomy in a 2:1 ratio. Upon completion, 2516 patients were evaluable.9
As expected, operative time was longer in the laparoscopy group versus the laparotomy group (204 minutes vs. 104 minutes, respectively), but hospital length of stay was shorter (3 days vs. 4 days, respectively). Only 52% of patients who underwent laparoscopy stayed for more than 2 days compared to 94% of patients who had a laparotomy. There was no difference in intraoperative complications between the 2 groups, although 26% of patients in the laparoscopy group required conversion to laparotomy. Grade 2 or greater postoperative complications were significantly higher in the laparotomy group compared to the laparoscopy group (21% vs. 14%, respectively).
Box 31-7 Master Surgeon’s Corner
Laparoscopic hysterectomy and staging for endometrial cancer are feasible in the majority of patients, including the obese and morbidly obese.
Procedural success is dependent on achieving steep Trendelenburg position with adequate exposure to the abdominal retroperitoneum.
Preoperative Management
Patients with a diagnosis of endometrial cancer routinely undergo a chest x-ray evaluation prior to surgery. If the patient has a preoperative diagnosis of a high-risk type of endometrial cancer such as papillary serous carcinoma, clear cell, or sarcoma, then a more extensive evaluation such as a CT or MRI scan of the abdomen and pelvis is recommended.
Surgical Technique
Laparoscopic Hysterectomy. The patient setup and port placement for a simple hysterectomy are the same as those described earlier for a radical hysterectomy. Once all ports have been placed and the patient is in steep Trendelenburg position, the procedure is started by coagulating and transecting the round ligaments. While the assistant places lateral traction on the right round ligament, the surgeon holds the medial aspect of the round ligament, and the peritoneum over the external iliac vessels is opened to expose the retroperitoneal space. The ureter is identified. The infundibulopelvic ligament is then transected. While placing upward traction on the uterus, the uterine vessels are skeletonized.
The same procedure is performed on the left side. Care must be taken to dissect the reflection of the colon off the left infundibulopelvic ligament to assure an adequate distance between bowel and the instrument coagulating the left infundibulopelvic ligament. Similarly, the left uterine vessels are skeletonized. Attention is then placed on mobilizing the bladder peritoneum inferiorly. This is performed while placing upward traction on the uterus.
The uterine vessels are coagulated and transected bilaterally. The pedicles of the descending branches of the uterine vessels are then coagulated and cut. Once the reflection of the ring of the uterine manipulator is visualized, a colpotomy is performed circumferentially around the demarcation of the ring, and the specimen is removed vaginally. The vaginal cuff is then sutured closed by laparoscopy.
Lymph Node Dissection. In patients requiring a lymph node dissection, the pelvic lymphadenectomy is performed by removing all lymph node–bearing tissue along the pelvic vessels. The most cephalad point of the dissection is the common iliac vessels, and the distal margin is the circumflex iliac vessels. Inferiorly, the margins of dissection extend to the obturator nerve, and the medial margins are the internal iliac vessels.
To perform a para-aortic lymphadenectomy, it is recommended that all monitors are moved to a location near the patient’s right and left shoulder. The surgeon stands on the patient’s left side, and the assistant stands on the patient’s right side. The surgeon holds a grasper in his or her left hand through the suprapubic port and a coagulating-cutting device in the right hand through the left lower quadrant port. The assistant holds a grasper in his or her right hand through the right lower quadrant port and the camera in the left hand at the umbilicus. The procedure is started by transecting the peritoneum over the bifurcation of the aorta medial to the right ureter. While the assistant places upward and lateral traction on the peritoneum, the surgeon develops a space above the inferior vena cava and the right ureter to identify the lateral boundary of dissection, the psoas muscle. The lymphatic tissue over the vena cava is removed to the level of the insertion of the right gonadal vein. The left para-aortic nodes are retrieved by placing lateral traction on the peritoneum, identifying the left ureter, and subsequently removing all the lymphatic tissue below the inferior mesenteric artery. Dissection of the lymph nodes above the inferior mesenteric artery is more challenging and requires excellent exposure to minimize injury to the renal vessels. The peritoneum is further mobilized laterally; the lymphatic tissue is then removed to the level of the left renal vessels.
Box 31-8 Caution Point
If a uterine manipulator is used, it should be placed under direct laparoscopic visualization to avoid inadvertent uterine perforation and spillage of malignant cells into the peritoneal cavity.
Postoperative Management
Patients undergoing laparoscopic simple hysterectomy and staging are routinely placed on a demand intravenous analgesic pump and an oral analgesic regimen. All patients are ordered a regular diet on the evening of surgery. A Foley catheter is left in place until the morning after surgery. The use of thromboembolic prophylaxis postoperatively is not routinely recommended. Patients are usually discharged home on the first postoperative day when they are ambulating, tolerating a regular diet, and voiding spontaneously.
Box 31-9 Complications and Morbidity
Ureteral or bladder injury (1%-3%)
Conversion to laparotomy (7%-26%)
ROBOTIC SURGERY
The da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) was approved by the Food and Drug Administration for gynecologic indications in 2005. Introduction of this robotic surgical system has addressed many of the obstacles of conventional laparoscopy including lack of depth perception, limited range of motion, unstable camera, and a steep learning curve. The da Vinci system provides 3-dimensional visualization, improved dexterity with 7 degrees of freedom mimicking the surgeon’s actual wrist movements, restoration of proper hand-eye coordination, and an ergonomic position.
Cervical Cancer
Robotic Radical Hysterectomy
Procedure Overview
Since the initial report of robotic radical hysterectomy in 2006 by Sert and Abeler,10 a number of other investigators have reported on the safety and feasibility of this approach in the management of patients with early-stage cervical cancer. Magrina et al11 compared 3 groups of patients who underwent radical hysterectomy: robotic, laparoscopy, and laparotomy. The authors concluded that surgical outcomes in the robotic and laparoscopy groups were similar and that these procedures were preferable to laparotomy. Blood loss and length of hospital stay were similar for the 2 minimally invasive groups and were reduced significantly when compared with laparotomy. There were no significant differences in complications between the 3 groups.
Recently, Cantrell et al12 evaluated survival outcomes for women who underwent robotic type III radical hysterectomy for cervical cancer. The authors assessed progression-free survival (PFS) and overall survival (OS) as their primary end points. Comparison was made to a group of historical open radical hysterectomies. The authors found that at 3 years, there was no statistically significant difference in PFS or OS between the 2 groups.
Preoperative Management
The preoperative evaluation and postoperative management of patients undergoing robotic radical hysterectomy are the same as those described earlier for laparoscopic radical hysterectomy.
Surgical Technique
Initial Steps. The patient is placed in the semilithotomy position using the Allen stirrups (Allen Medical, Acton, MA) with the arms loosely tucked to each side. Foam padding is used to protect both arms and legs. The patient is placed on her back directly on an antiskid foam material (Figure 31-5). Two monitors are located at each side of the operating table at the level of the patient’s knees. The robotic tower and the tower containing the electrosurgical generators are positioned lateral to the patient’s right foot. The da Vinci column may be positioned between the patient’s feet or to the side of the patient (side-docking) to allow ample access to the vagina.
FIGURE 31-5. Patient positioning for robotic surgery.
Trocar Placement. A 12-mm Xcel trocar is placed approximately 2 cm below the left costal margin. This trocar will be used by the assistant during the case. The patient is then placed in steep Trendelenburg position, and the abdomen is inspected for any evidence of meta-static disease. If none is found, then a 12-mm transumbilical trocar is introduced under direct visualization. Three 8-mm trocars, specific for the da Vinci robotic system, are placed. The first is placed 8 to 10 cm lateral to the assistant trocar on the left side. The second is placed 8 to 10 cm lateral and to the right of the umbilical trocar, and the third is placed 8 to 10 cm lateral to the right abdominal robotic trocar (Figure 31-6). Similar to the laparoscopy approach, we use a V-Care uterine manipulator.
FIGURE 31-6. Routine trocar placement for robotic surgery.
The robotic column is advanced to the operating table and placed between the patient’s feet. The robotic arms are attached to each robotic trocar, and the robotic instruments are introduced. An EndoWrist Precise bipolar grasper (Intuitive Surgical) is used in the left robotic arm. An EndoWrist monopolar scissors (Intuitive Surgical) is used in the right robotic arm. An EndoWrist Cardiere grasper (Intuitive Surgical) is placed in the fourth robotic arm. For vaginal cuff closure, the monopolar scissors is replaced by an EndoWrist needle holder (Intuitive Surgical).
Radical Hysterectomy. The steps of the radical hysterectomy by the robotics approach are the same as those for the laparoscopic radical hysterectomy described earlier.
Postoperative Management
Patients undergoing robotic radical hysterectomy are routinely placed on a demand intravenous analgesic pump and an oral analgesic regimen. All patients are ordered a regular diet on the evening of surgery. A Foley catheter is left in place postoperatively for a total of 5 to 7 days. A trial of void is attempted at that time, and if the postvoid residual is less than 150 mL, the catheter is removed. If the patient fails the voiding trial, then the catheter is left in place for another week. Routine use of thromboembolic prophylaxis is not recommended.
Robotic Radical Trachelectomy
Procedure Overview
Radical trachelectomy is performed in selected patients diagnosed with early-stage cervical cancer who wish to preserve their fertility. Since the procedure was first described by Dargent et al13 in 1994, numerous reports have documented the safety and feasibility of the vaginal approach.14,15 Alternatively, the procedure may also be performed successfully via the abdominal approach.16,17
Persson et al18 were the first to report on the robotic approach in performing fertility-sparing surgery in patients with gynecologic malignancies. Since that time, others have added their experience to the published literature.19 To date, there is a paucity of data regarding whether the robotics approach is equivalent to the open or vaginal approach with regard to oncologic and obstetrical outcomes.
Preoperative Management
Patients considered for robotic radical trachelectomy are counseled regarding the option of radical hysterectomy. A formal infertility evaluation is not routinely performed; however, this is encouraged in patients who have been unsuccessful in prior pregnancy attempts. In the preoperative counseling, it is also important to stress the fact that approximately 30% of patients scheduled to have a radical trachelectomy will not be able to conceive due to factors such as lymph node positivity, close (< 5 mm) surgical margins, or the need for adjuvant radiation therapy postoperatively.
All patients undergo a routine chest x-ray to rule out the possibility of spread of disease to the chest. An MRI of the pelvis is recommended to evaluate the extent of the tumor in the cervix and assure that the tumor does not extend to the upper endocervical margin because this could increase the likelihood of having to convert to a radical hysterectomy. In addition, this imaging study allows for evaluation of the pelvic lymph nodes to determine whether there is any suspicion of lymph node metastases. A preoperative pregnancy test should be performed on the day of surgery.
Surgical Technique
Initial Steps. The patient is placed in the dorsal lithotomy position. A V-Care manipulator is placed in the uterus for manipulation. Once the manipulator is placed, attention is focused on the abdominal part of the procedure. Trocar placement is as described earlier for the robotic radical hysterectomy.
Retroperitoneal Dissection and Division of Uterine Vessels. First, an incision is made over the round ligament, and the peritoneum lateral to the infundibulopelvic ligament is opened bilaterally. The paravesical and pararectal spaces are then developed. The ureters are then separated from the peritoneum down to where they enter the lateral parametrial tissue. The level of resection of the parametria is as follows: The ureters are dissected from the parametria and mobilized completely to the bladder after division of the anterior and posterior vesicouterine ligaments. The peritoneum over the bladder is then incised, and the bladder is mobilized inferiorly over the anterior vaginal wall. The uterine vessels are transected bilaterally at their origin and dissected over the ureters bilaterally. The anterior vesicouterine ligaments are then divided.
Excision of Cervix and Closure. The peritoneum over the rectovaginal space is then incised, and the uterosacral ligaments are divided bilaterally. While upward traction is placed on the vaginal cuff, a circumferential incision is made approximately 2 cm below the vaginal stump. The V-Care manipulator is then removed. The specimen is then held by the parametria bilaterally using graspers. A monopolar scissors is used to amputate the cervix, leaving approximately 1 cm of residual cervical stump. The specimen—including cervix, bilateral parametria, and upper vaginal margin—is then removed through the vagina. The specimen is then sent for frozen-section evaluation. The endocervical margin should be tumor free at least 10 mm from the level of the tumor. A Smit sleeve cannula (Nucletron, Columbia, MD) (Figure 31-7) is then introduced vaginally and placed into the uterus by using the robotic graspers. The Smit sleeve is secured to the uterus with 3-0 chromic sutures. We use the Smit sleeve cannula to decrease the potential for scarring of the residual cervix. It is usually left in the uterus for approximately 2 to 4 weeks. A cerclage is placed using 0 Ethibond suture, and the uterus is sutured to the upper vagina using 0 Vicryl sutures placed using the EndoWrist Mega Needle driver. The cerclage is placed abdominally using the robotic system. The pelvic lymphadenectomy is performed bilaterally using the same anatomical landmarks as for a radical hysterectomy.
FIGURE 31-7. Smit sleeve used for radical trachelectomy.
Postoperative Management
Patients undergoing robotic radical trachelectomy have a similar plan of management as patients undergoing a radical hysterectomy. An intravenous analgesic pump and an oral analgesic regimen are ordered. A regular diet is ordered on the evening of surgery. A Foley catheter is left in place postoperatively for a total of 5 to 7 days. A trial of voiding is attempted at that time, and if the postvoid residual is less than 150 mL, the catheter is removed. If the patient fails the voiding trial, then the catheter is left in place for another week. Routine use of thromboembolic prophylaxis is not recommended. The Smit sleeve is removed approximately 4 weeks postoperatively.
Robotic Extraperitoneal Para-Aortic Staging
Procedure Overview
The robotics approach has also been reported in the setting of surgical staging of patients with locally advanced cervical cancer prior to chemotherapy and radiation. The first series published on the robotics approach in this setting was by Vergote et al.20 In that series, the authors reported on 5 patients who underwent the procedure. The median body mass index of the group was 24.4 kg/m2 (range, 19.3-28.8 kg/m2). The median number of lymph nodes retrieved was 9 (range, 7-12 nodes).
Preoperative Management
The preoperative preparation for robotic extraperito-neal para-aortic staging is the same as for the laparoscopic approach.
Surgical Technique
Incision Placement and Development of Extraperitoneal Space. Under direct visualization through an umbilical port, a small incision is made 3 cm medial to the anterior superior iliac spine. The extraperitoneal space is developed by finger dissection of the peritoneum over the psoas muscle and left flank. A 10- to 12-mm Spacemaker Plus Dissector System (US Surgical, Norwalk, CT) is inserted 3 cm medial to the anterior superior iliac spine. The obturator with a balloon is inserted in a craniolateral direction through the trocar, and the balloon is inflated to its maximum. An 8-mm robotic trocar is inserted through the 10- to 12-mm Spacemaker Plus Dissector System. The 12-mm optical trocar is introduced through the patient’s left flank along the posterior axillary line, 10 cm cranial, and lateral, from the caudal robotic trocar. A second 8-mm robotic trocar is placed 10 cm cranial, and medial, to the laparo-scope, immediately below the left costal margin and in line with the caudal robotic trocar. The assistant trocar is inserted immediately adjacent to the anterior superior iliac spine, equidistant between the laparoscope and the caudal robotic trocar. A 30-degree laparoscope (InSite Vision System; Intuitive Surgical) is used.
Lymph Node Dissection. A retroperitoneal lymph-adenectomy is performed including the left external iliac, presacral, and bilateral common iliac pelvic nodes and the aortic nodes from the aortic bifurcation to the renal vessels. For the removal of the presacral and common iliac nodes, the laparoscope is rotated 45 degrees counterclockwise, which provides additional instrument reach by avoiding collision of the robotic arms with the scope.
Postoperative Management
This procedure is routinely performed as an outpatient procedure. No drains are placed at the completion of surgery. Most patients are placed on an oral analgesic regimen and are discharged from the hospital once they have voided and tolerated a regular diet. Generally, patients are able to start treatment with chemotherapy and radiation within 14 days from their surgery.
Uterine Cancer
Simple Hysterectomy and Staging
Procedure Overview
Robotic surgery has also been shown to provide similar benefits as laparoscopic surgery when performing standard simple hysterectomy, bilateral salpingo-oophorectomy, and staging. In the largest series to date, Lowe et al21evaluated perioperative outcomes and learning curve characteristics from a multi-institutional experience with robotic surgical staging for endometrial cancer. Four hundred five patients were identified, with a mean age of 62.2 years and a mean body mass index of 32.4 kg/m2. The mean operative time was 170.5 minutes, and the mean estimated blood loss was 87.5 mL. The mean lymph node count was 15.5, and the mean hospital stay for all patients was 1.8 days. An intraoperative complication occurred in 3.5% of the patients, and conversion to laparotomy occurred in 7%. The rate of postoperative complications was 14.6%.
Preoperative Management, Surgical Technique, and Postoperative Management
Preoperative preparation for patients scheduled to undergo a robotic simple hysterectomy and staging is the same as for laparoscopic hysterectomy. The patient setup, port placement, and instrumentation for the robotic simple hysterectomy are the same as for the robotic radical hysterectomy. The steps for this procedure and postoperative management are the same as those described for a laparoscopic simple hysterectomy.
SUMMARY
Minimally invasive surgery currently encompasses multiple modalities that allow the surgeon and the patient versatility in the surgical approach for the management of gynecologic malignancies. Laparoscopic surgery remains the foundation of the minimally invasive approach and should be a priority in the training of fellows and residents. Robotic surgery provides a more technologically advanced platform, enhancing surgeon dexterity, visualization, and comfort while at the same time offering equivalent or improved results compared with laparoscopy.
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