Olga A. Tusheva1, Sarah L. Cohen1 and Karen C. Wang1
Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, MA, USA
Karen C. Wang
12.2 Robotic Myomectomy
12.2.1 Surgical Outcomes
12.2.2 Reproductive Outcomes
12.2.3 Patient Selection
12.2.4 Tips and Techniques
The integration of robotics into the field of gynecologic surgery initially involved a voice-recognition system and robotic control of laparoscopic camera movement (AESOP® Endoscope Positioner (Computer Motion Inc., Goleta, CA)). This technology further evolved with the ZEUS® Surgical System (Computer Motion Inc., Goleta, CA) to include two robotic arms, thereby allowing the surgeon to operate from a console away from the operative table. The da Vinci Surgical System® (Intuitive Surgical, Sunnyvale, CA, USA), which was approved for gynecologic surgery in 2005 by the United States Food and Drug Administration, incorporates three or four robotic arms to allow surgeon control of the visual field and up to three laparoscopic instruments.
Advantages of the robotic platform for laparoscopic surgery include: three-dimensional stereoscopic vision, wristed instrumentation with seven degrees of freedom, diminished tremor effect, and enhanced ergonomics for the operator. In addition, the surgeon is able to control virtually all aspects of the operation from the surgeon console (aside from uterine manipulation) with the use of foot pedals and clutches. Disadvantages compared to traditional laparoscopy include lack of haptic feedback, which may result in inadvertent administration of excessive tension on tissues or suture materials. Robotic tubal reanastomosis was the first surgery in gynecology performed with robotic assistance in 1999 (Falcone et al. 1999). An early application of robotics in reproductive surgery and in particular to tubal reanastomosis is not surprising considering enhanced microsurgical capability of robotic approach. Hysterectomy was the next gynecologic procedure to adapt the robotic approach in 2002 (Diaz-Arrastia et al. 2002), followed by several studies supporting the feasibility of this method (Marchal et al. 2005; Fiorentino et al. 2006; Advincula 2006). Reports of robotic approach to multiple procedures in benign and reproductive gynecology, gynecologic oncology, and urogynecology eventually emerged, including surgical management of endometriosis (Nezhat et al. 2010), leiomyomas (Nezhat et al. 2009b), adnexectomy (Nezhat et al. 2009a; Magrina et al. 2009), ovarian (Magrina et al. 2011), uterine (Paley et al. 2011), and endometrial (Hong et al. 2011) cancer staging and resection, as well as sacrocolpopexy (Geller et al. 2008; Germain et al. 2013).
Surgical management of uterine fibroids includes hysterectomy or myomectomy, depending on the number and location of fibroids, as well as child-bearing potential of a woman. Myomectomy is a common indication for women desiring fertility preservation.
12.2 Robotic Myomectomy
Laparoscopic management of uterine fibroids has been established as a safe, feasible, and potentially advantageous method compared to laparotomy (Advincula et al. 2004; Pitter et al. 2008; Nezhat et al. 2009b). When appropriate, robotic approach to the management of uterine fibroids can be indicated. One of the purported advantages of using a robotic platform for laparoscopic removal of fibroids is the ease of suturing utilizing the wristed instrumentation when compared to conventional laparoscopy.
12.2.1 Surgical Outcomes
126.96.36.199 Robotic Versus Open Approach
Several studies compared the outcomes of robotic vs open approach to myomectomy, as well as laparoscopic vs robotic myomectomy outcomes. A retrospective cohort study by Advincula et al. reported reduced blood loss and shortened hospital stay in patients who underwent robotic myomectomy compared to the open abdominal approach group. Robotic approach was also associated with prolonged operative times and increased cost (Advincula et al. 2007). These outcomes of increased operative times and increased cost are supported by two retrospective studies of 38 Canadian and 27 US-based patients undergoing robotic myomectomy and compared to 21 and 106 historical controls, respectively, treated by open approach (Mansour et al. 2012; Nash et al. 2012). Robotic approach was also associated with decreased post-operative pain and shortened hospital stay but not blood loss or complication rate (Nash et al. 2012).
Since increased cost appears to be a major drawback associated with robotic surgery, a decision model was developed for cost analysis of different approaches to myomectomy (Behera et al. 2012). Based on the cost-minimization analysis, abdominal myomectomy was least expensive if length of stay was less than 4.6 days and cost was less than $2410. Otherwise, laparoscopic myomectomy was found to be the least expensive method. Robotic approach was associated with a significantly increased cost unless robotic disposable equipment costs were less than $1400.
188.8.131.52 Robotic Versus Laparoscopic Approach
Several studies compared robotic and laparoscopic approaches to myomectomy and reported the following outcomes. Bedient et al. conducted a retrospective case control analysis of 40 robotic and 41 laparoscopic myomectomy cases (Bedient et al. 2009). No statistically significant differences in surgical outcomes, including blood loss, mean operating time, hospital stay <2 days, or complications were reported after adjusting for uterine and fibroid size and number. A retrospective case–control analysis of 15 robotic cases by Nezhat concluded that robotic myomectomy is associated with a significantly longer operating time with no difference in other surgical outcomes and overall lacked any major advantage in the hands of a skilled laparoscopic surgeon (Nezhat et al. 2009c). Two other retrospective studies of 75 and 89 robotic cases reported prolonged operating times but improved surgical parameters with the robotic approach, including reduced blood loss, hospital stay, improved febrile morbidity, and faster return of a bowel function (Ascher-Walsh and Capes 2010; Barakat et al. 2011). Finally, a retrospective cohort study of 115 laparoscopic and 174 robotic myomectomies reported significantly longer operating times associated with robotic approach, although this can be partially attributed to the choice of suture for defect repair (Gargiulo et al. 2012a). In particular, all robotic cases were performed with conventional suture, while laparoscopic myomectomy team utilized barbed suture known to decrease operative times and perioperative blood loss (Alessandri et al. 2010; Einarsson et al. 2011a). This difference in closure technique and material may have contributed to increased blood loss associated with robotic myomectomy (110 mL vs 85.9 mL), although the estimate-based scale used to report the blood loss could be another factor responsible for the difference observed. Other short-term outcomes and complication rates were comparable between the two approaches.
The evidence outlined earlier suggests that when indicated, robotic myomectomy compares favorably with an open approach in terms of blood loss and postoperative stay, yet is associated with increased operative times and increased cost. The difference in outcomes between the standard laparoscopy and robotic approach to myomectomy appears less defined, with most studies, agreeing on prolonged surgical times associated with robotic myomectomy. This is likely a result of several contributing factors, including time spent on set-up and undocking of robotic system, difference in surgeon’s skill, and variation in procedural techniques and approaches, such as use of conventional versus barbed suture. Other outcomes, including blood loss and hospital stay, appear to be similar between the two approaches.
12.2.2 Reproductive Outcomes
Since the majority of patients undergoing myomectomy are interested in preserving or restoring their fertility, ensuring satisfactory reproductive outcomes following robotic myomectomy is a task of an utmost importance. While safety and reproductive benefits of laparoscopic myomectomy compared to the open abdominal approach have been established in literature (Mais et al. 1996; Seracchioli et al. 2000; Palomba et al. 2007), limited data is available about the robotic myomectomy. One prospective observational study reported the pregnancy rate of 68 % in 22 women interested in conception following robotic myomectomy for symptomatic deep intramural myomas (Lönnerfors and Persson 2011). The authors reported 18 pregnancies resulting in 3 miscarriages, 2 terminated pregnancies, 10 successful term deliveries, and 3 ongoing pregnancies. The rate of natural conception was 55 %. Five women (50 %) delivered vaginally, while five underwent a c-section. Another retrospective cohort study reported the pregnancy rate of 75 % among 16 patients attempting conception following robotic myomectomy procedure with no reported complications, including entry to the uterine cavity (Tusheva et al. 2013). The rate of natural conception was 67 %, while 33 % of patients conceived with the help of ART. Of those who conceived, one patient (8 %) underwent three consecutive miscarriages, and two patients (17 %) delivered prematurely at 28 and 32 weeks, respectively. All 11 deliveries were done via c-section. No incidents of uterine rupture were reported in either study.
12.2.3 Patient Selection
Appropriate patient selection is vital to ensure successful outcomes following robotic myomectomy. From the surgical standpoint, robotic myomectomy may be contraindicated in patients with one of the following (Seracchioli et al. 2000; Prentice et al. 2004; Quaas et al. 2010):
· a uterus larger than 16-week size or palpable above the umbilicus
· more than 15 total fibroids
· a single fibroid larger than 15 cm
· myomas close or originating from the cervix, broad ligament, uterine arteries, uterine cornua
· diffuse adenomyosis diagnosed by magnetic resonance imaging (MRI)
· women whose uterine cavity cannot be clearly visualized by MRI
A recent study by Nash et al. supports these findings from the efficiency standpoint by demonstrating a significant positive correlation between the specimen size and operating time during robotic myomectomy as compared to the open approach (Nash et al. 2012). Decreasing operating efficiency with the increasing specimen size is likely due to prolonged time spent on morcellation and would be expected to significantly improve with the development of newer more efficient methods of specimen retrieval.
Another consideration with robotic approach to myomectomy is the patient’s BMI. Several studies demonstrated improved surgical outcomes compared to laparoscopy in patients with BMI >30 undergoing robotic adnexectomy for adnexal mass and robotic hysterectomy with pelvic–aortic lymphadenectomy for endometrial cancer, as well as robotic surgery for uterine cancer staging (Magrina et al. 2009; Paley et al. 2011; Seamon et al. 2008). With respect to robotic myomectomy, one study reported no association between increased BMI in the morbid range and poor surgical outcomes. Although additional data is needed to investigate the possibility of improved outcomes, it is reasonable to conclude that robotic myomectomy can be safely performed in patients with BMI >30.
12.2.4 Tips and Techniques
In this chapter, we briefly describe the technique of robotic myomectomy as performed at our institution along with useful tips and advice on how to achieve best outcomes and avoid complications.
Preoperative preparation is important when planning a robotic myomectomy. High quality MRI imaging is important in the work up as it partially compensates for the loss of tactile feedback by mapping all existing uterine masses, in order to develop an effective strategy of their surgical management. The goals of preoperative imaging include identifying the number, size, and locations of all fibroids; assessing for the presence of adenomyosis; and evaluating the malignant potential of uterine masses (Gargiulo and Nezhat 2011). Smaller fibroids may be better assessed with transvaginal ultrasound (Gargiulo and Nezhat 2011), while large masses commonly require MRI with gadolinium enhancement in order to identify the uterine cavity (Gargiulo and Nezhat 2011). As previously noted, evidence of diffuse adenomyosis on MRI is a relative contraindication for the robotic approach, while isolated adenomyomas can still be successfully tackled with robotic surgery (Gargiulo and Nezhat 2011). It is also important to rule out the possibility of malignancy as morcellation is contraindicated in such patients.
Once in the operating room, the patient should be placed in a dorsal lithotomy position lying on top of antiskid material (egg crate foam, bean bag, gel pad) to avoid movement during steep Trendelenburg position with arms padded and fully adducted, and knees placed in Allen or Yellofin stirrups in the same plane as pelvic girdle. The uterine positioning system may be used to assist with uterine manipulation and to check for endometrial perforation if suspected following myoma enucleation.
Several approaches to trocar placement during robotic myomectomy have been employed at our institution. A three-arm minimally invasive approach (Fig. 12.1) allows for superior cosmetic result at the cost of a limited robotic assistance (Gargiulo 2011). This approach may be utilized in younger patients with small fibroid(s) and nonsignificantly distended uterus. A preferred approach includes the use of four robotic arms and a 12 mm assistant port in the right lower quadrant for suction, irrigation, passage of needles, tissue retraction, and morcellation (Quaas et al. 2010) (Fig. 12.2). One advantage of placing an assistant trocar in this location is the ability to pass needles and other instruments in the field of direct view, thus minimizing the chance of needle loss or bowel injury (Quaas et al. 2010) as well as limiting inadvertent collision of the surgical assistant instruments with the robotic instrument on the same side. Additionally, should there be a need to convert to laparoscopy, the assistant port can be successfully converted to the “ultra lateral” port described by Koh et al. (Gargiulo and Nezhat 2011; Koh and Janik 2003). It is also critical to place trocars at an adequate distance from enlarged pathology to avoid limited visualization with the endoscope as well as limited access with the robotic instruments. A good guideline is to ensure that the endoscope is placed at least 8–10 cm above to the top most portion of the uterine fundus when pushing the uterus cephalad on bimanual examination. Robotic trocars and the assistant port would similarly be placed higher in order to adequately access the leiomyomas and allow for optimal movement of the robotic instruments.
A three-arm approach to port placement for improved cosmesis (From Gargiulo 2011)
Standard approach to robotic trocar placement. (a) Positioning of trocar sites: (1) 8 mm robotic trocar with versastep sleeve, (2) 12 mm assistant trocar, (3) 12 mm endoscope trocar, (4) 8 mm robotic trocar with versastep sleeve, (5) 8 mm robotic trocar with versastep sleeve. (b) Insufflated abdomen with robotic trocars in place (Courtesy of Karen Wang, MD)
Patients with large intramural myomas >10 cm in diameter may be best treated with hybrid robotic myomectomy technique (Quaas et al. 2010). With this approach, enucleation of myoma is performed by laparoscopy, while suturing is done robotically. Major benefits of the hybrid approach in management of large fibroids include preservation of tactile feedback during separation of large mass from the delicate surrounding tissues; the ability to use a rigid tenaculum needed to exert significant pull force during enucleation; and easy access and navigation through all four pelvic quadrants, which may be limited during the robotic procedure.
Regardless of timing, docking of robotic system can be done in various ways. One traditional approach involves positioning of the robot between the patient legs (Fig. 12.3). Vaginal access in this midline approach is limited which makes uterine manipulation difficult. More recently, side docking was developed and successfully adopted for the majority of robotic procedures (Einarsson et al. 2011b). With side docking, the robot is positioned at the left or right patient’s knee at a 45° angle from the lower torso (Fig. 12.4). Parallel docking similarly positions the robot at the patient’s side with the robot parallel to the operative table (Silverman et al. 2012) (Fig. 12.5). Such side-access set ups allow for significantly improved vaginal access and ability to use and adjust uterine manipulator intraoperatively.
Traditional docking of the robot between the patient’s legs
Robotic side docking (From Einarsson et al. 2011b)
Robotic parallel docking (From Silverman et al. 2012)
Several approaches to blood loss control during myomectomy have been described, including tourniquet application, uterine vessel clipping, vasopressin injection, and others. While approved by the US Food and Drug Administration, vasopressin use is not permitted in several European countries. Vasopressin, as well as misoprostol, bupivacaine plus epinephrine, tranexamic acid, gelatin–thrombin matrix, pericervical tourniquet, and mesna, but not oxytocin or morcellation, were found to significantly reduce bleeding during myomectomy (Kongnyuy and Wiysonge 2011). Clipping of uterine vessels is another method shown to effectively reduce blood loss during the procedure (Sinha et al. 2004; Vercellino et al. 2012; Rosen et al. 2009).
Following the appropriate measures to ensure intraoperative hemostasis, the uterine incision is made in a longitudinal or transverse manner (Quaas et al. 2010). The approach to myoma enucleation is similar to one employed during an open procedure, with robotic tenaculum, robotic bipolar coagulator, and ultrasonic or monopolar energy employed to assist in this process (Fig. 12.6a–h). The bedside assistant can place additional traction on myoma(s).
Technique of robotic myomectomy. (a, b) After the fibroid location has been exactly determined, a dilute concentration of vasopressin is injected into the myometrium surrounding the myoma. (c) Using the robotic harmonic shears, a hysterotomy is made over the myoma. (d–g) A multilayer closure is performed employing sutures and suturing techniques that are identical to those of an open myomectomy. (h) An adhesion barrier may be placed onto the closed hysterotomy to prevent future scar tissue formation (From Quaas et al. 2010)
Following removal, the myoma is placed in the posterior cul-de-sac or upper quadrant(s) to allow unobstructed access to the uterus; it is later morcellated. Whether morcellating with a power morcellotor device or via minilaparotomy, efforts should be made to contain all tissue fragments and avoid tissue dissemination during this process. It is also important to keep track of the number of fibroids extracted to ensure that all are removed at the end of the procedure.
The closure of the myometrial defect is best performed in a multilayer fashion in order to minimize the risk of uterine rupture (Parker et al. 2010). Other factors to consider include the judicious use of electrosurgery, CO2pneumoperitoneum effect on wound healing, and individual wound healing characteristics, including thinning myometrium (Parker et al. 2010). Successful application of the bidirectional barbed suture in laparoscopic myomectomy was previously tested and described (Greenberg and Einarsson 2008). In our practice, QuillTM (Angiotech Pharmaceuticals, Inc., Vancouver, BC, Canada), V-lockTM (Covidien, Mansfield, MA) or STRATAFIXTM (Ethicon, Somerville NJ) have been successfully utilized, and their choice depends on surgeon’s preference. The use of bidirectional suture decreases operative time and could be one of the key reasons behind the longer operating times associated with robotic myomectomy in a recent comparison of the two minimally invasive techniques at our institution (Gargiulo et al. 2012a).
With the advancements in the field of minimally invasive surgery, additional approaches to laparoscopic myomectomy are now available. A single port laparoscopic myomectomy technique has been successfully attempted in the past (Einarsson 2010), and more recently, applied to robotics (Gargiulo et al. 2012b) (Fig. 12.7). Although safe and reproducible with outcomes comparable to conventional robotic myomectomy, robot-assisted single-incision laparoscopic approach was found to be associated with additional technical challenges typical for single incision surgery, such as crowding of instruments, loss of optimum instrument triangulation, and inability to use all three robotic arms. In particular, partial loss of dexterity was noted by authors due to crowding of 8 mm instruments.
Single port robotic myomectomy: schematic (a) and live (b) set up. (1) Anterior abdominal wall; (2) GelPOINT device; (3) robotic arm one; (4) robotic arm three; (5) 30° “up” laparoscope; (6) uterine mass (From Gargiulo et al. 2012b)
Although robot-assisted single-incision laparoscopic myomectomy may be beneficial in patients with higher BMIs due to excellent cosmetic outcomes achieved with 4 cm skin incision (Gargiulo et al. 2012b), further studies are needed in order to definitively investigate the risk of umbilical hernia formation in this subset of patients based on its recently reported association with laparoscopic single-site approach (Gunderson et al. 2012).
Another useful adjunct to robotic myomectomy successfully implemented at our institution is flexible CO2 laser (Barton and Gargiulo 2012) (Fig. 12.8). The low thermal spread of laser energy, preserved seven degrees of freedom, sturdy design suitable for blunt dissection, as well as reliable hemostatic effect due to helium gas flow, make flexible CO2 laser a useful and practical tool in a variety of gynecologic applications, including robotic myomectomy. In particular, use of CO2 laser is expected to minimize the thermal damage of the myometrium, and therefore facilitate the healing process. Potential disadvantages of this approach include cost and fiber failure during extensive angling. At our institution, CO2 laser is considered based on surgeon preference in cases with leading tumor size <8 cm in diameter. In cases when the leading tumor diameter is >8 cm, the preference goes to the ultrasonic scalpel due to its better ability to control bleeding.
CO2 Laser application during single incision robotic myomectomy. (a) Flexible laser fiber introduced through the assistant port is used for hysterotomy. (b) Tenaculum is used in conjunction with robotic shears and the assistant countertraction with Allis forceps. (c) After enucleation, the hysterotomy is closed in layers with large needle drivers (From Gargiulo et al. 2012b)
Despite evidence supporting the safety, feasibility, and improved outcomes following the minimally invasive approach to myomectomy, the majority of cases in the United States are performed by laparotomy (Liu et al. 2010). This may be due to the fact that majority of benign procedures are performed by community surgeons presented with unique challenges of mastering the minimally invasive techniques, including inconsistent training across generations and programs, dependency on various nonstandardized review courses to initiate learning, “on the job” training to attain competency, and perceived long learning curves needed to become proficient (Payne and Pitter 2011; Lenihan et al. 2008). Some of the challenges associated with adopting the laparoscopic technique include increased need for dexterity and hand–eye coordination in a two-dimensional field of view, long rigid instruments, tremor amplification, and nonergonomic body positioning of the surgeon (Stylopoulos and Rattner 2003). In addition to providing the benefits of three-dimensional view, tremor reduction and increased dexterity with seven degrees of freedom, the robotic approach acts as an enabling technology by facilitating successful completion of minimally invasive laparoscopic procedures with the same outcomes as more advanced surgeons (Lenihan et al. 2008). Lim et al. estimated the learning curve for robotic surgeries to be half the number of cases required to attain the same level of proficiency in laparoscopy (Lim et al. 2011). Other studies did not find significant difference in learning curve between the robotic and laparoscopic approach (Lenihan et al. 2008; Yacoub et al. 2010). Such variation in findings could be due to the differences in prior level of proficiency in laparoscopic and robotic surgery among the surgeons participating in the study. On average, 20–75 procedures are required to transcend the early learning curves associated with robot-assisted surgery (Geller et al. 2011).
Recent introduction of a dual console robotic system and greater recognition of the importance of minimally invasive training among residents and fellows at many programs across the country has led to interest in evaluating the outcomes of these approaches. Due to limitations in residency work duty hours, the amount of time spent on surgical training has also decreased and poses additional challenges to incorporating the novel minimally invasive approach into residency and fellowship training curriculum (Advincula and Wang 2009). In this context, the benefits provided by the dual console training are especially important since they provide an opportunity for the trainee to operate under direct supervision and at the same time as an attending physician (Smith et al. 2012). Potential obstacles for dual console training implementation include the possibility of litigation issues for the instructors and the need for designing protective measures (Lee et al. 2012).
With accessibility of the robotic approach in mind, it is important to remember that it is not intended to replace laparoscopy. Although safe and efficient, with outcomes at least on par with laparoscopy, robotic surgery is associated with significantly increased cost of procedure and prolonged operative times (Weinberg et al. 2011). The lack of tactile feedback is another sensible disadvantage in robotic myomectomy and other procedures depending on haptic feedback (Weinberg et al. 2011). Continued advancements and innovations in robotic sector are likely to eventually overcome the limitations currently posed by robotic approach and may lead to a paradigm shift in the field of gynecologic minimally invasive surgery.
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