Application of robotic single-site surgery with optional additional port for endometriosis: a single institution's experience

Robotic assisted versus laparoscopic surgery for deep endometriosis: a meta-analysis of current evidence

Endometriosis is a benign inflammatory onco-mimetic disease affecting 10-15% of women in the world. When it is refractory to medical treatments, surgery may be required. Usually, laparoscopy is the preferred approach, but robotic surgery has gained popularity in the last 15 years. This study aims to evaluate the safety and efficacy of robotic-assisted laparoscopic surgery (RAS) versus conventional laparoscopic surgery (LPS) in the treatment of endometriosis. This study adheres to PRISMA guidelines and is registered with PROSPERO. Studies reporting perioperative data comparing RAS and LPS surgery in patients with endometriosis querying PubMed, Google Scholar and ClinicalTrials.gov were included in the analysis. The Quality Assessment of Diagnostic Accuracy Studies 2 tool (QUADAS-2) was used for the quality assessment of the selected articles. Fourteen studies were identified, including 2709 patients with endometriosis stage I-IV for the meta-analysis. There were no significant differences between RAS and LPS in terms of intraoperative and postoperative complications, conversion rate and estimated blood loss. However, patients in the RAS group have a longer operative time (p < 0.0001) and longer hospital stay (p = 0.020) than those in the laparoscopic group. Robotic surgery is not inferior to laparoscopy in patients with endometriosis in terms of surgical outcomes; however, RAS requires longer operative times and longer hospital stay. The benefits of robotic surgery should be sought in the easiest potential integration of robotic platforms with new technologies. Prospective studies comparing laparoscopy to the new robotic systems are desirable for greater robustness of scientific evidence.

Laparoendoscopic single-site surgery for deep infiltrating endometriosis based on retroperitoneal pelvic spaces anatomy: a retrospective study

Transumbilical single-port laparoscopy is widely used in gynecological surgery. However, it is rarely used in the treatment of deep infiltrating endometriosis due to its own shortcomings and the complex condition of deep infiltrating endometriosis. The study aims to introduce a transumbilical single-port laparoscopic surgery based on retroperitoneal pelvic spaces anatomy, which can complete the operation of deep infiltrating endometriosis more easily. A retrospective analysis of 63 patients with deep infiltrating endometriosis treated by transumbilical single-port laparoscopy using this method was conducted. The operation duration was 120.00 (85.00 ± 170.00) (35-405) min, the estimated blood loss was 68.41 ± 39.35 ml, the postoperative hospital stay was 5.00 (4.00-6.00) days, and the incidence of postoperative complications was 4.76% (3/63). 1 patient was found to have intestinal injury during operation, 1 patient had ureteral injury after operation, and 1 patient had postoperative pelvic infection, with a recurrence rate of 9.52%. The postoperative scar score was 3.00 (3.00-4.00) and the postoperative satisfaction score was 9.00 (8.00-10.00). In summary, this study demonstrates the feasibility of transumbilical single-port laparoscopic surgery for deep infiltrating endometriosis based on retroperitoneal pelvic spaces anatomy. Hysterectomy, adenomyosis resection, etc. are also feasible with this method, boasting more obvious advantages. This method can make transumbilical single-port laparoscopy more widely used in deep infiltrating endometriosis.

Indocyanine Green-Assisted Retrograde Ureterolysis in Robotic Transvaginal NOTES for the Management of Stage IV Endometriosis with Obliterated Cul-de-sac

STUDY OBJECTIVE

To explore the use of indocyanine green (ICG) in highlighting ureteral anatomical landmarks for the successful and safe execution of robotic-assisted transvaginal NOTES hysterectomy with resection of deeply infiltrated endometriosis.

DESIGN

Stepwise demonstration with narrated video footage.

SETTING

An academic tertiary care hospital. Our patient is a 38-year-old G4P1031 with a symptomatic enlarged uterus secondary to adenomyosis and uterine myomas, dense adhesions between the posterior uterus, and left uterosacral ligament.

INTERVENTIONS

Stage IV endometriosis with obliterated cul-de-sac is a challenging procedure in the surgical management of endometriosis. Ureterolysis is the key step to performing this surgery successfully and safely; however, the routine dissection of ureters from the sacral promontory level to the uterine artery is challenging in obliterated cul-de-sacs with pelvic side wall adhesions with the proximal ureter at greatest risk [1-4]. Using the ICG firefly technique allowed us to rapidly identify and safely dissect the ureter through robotic transabdominal endometriosis surgery [5,6]. The angle of approach in transvaginal NOTES surgery for hysterectomy with obliterated cul-de-sac endometriosis leads to far more difficulty in identifying the ureter at the beginning of surgery [3]. Therefore, an obliterated cul-de-sac was associated with a potentially increased risk of ureteral injury and bowel injury. We used ICG to help identify the ureter at the beginning of the case leading to reducing the risk of surgical complication, in which the concept of ureterolysis from the level of the uterine artery to the bifurcation of common iliac vessels in vNOTES surgery will be referred to as "vNOTES retrograde ureterolysis." With the cystoscope in place, a ureteral catheter was inserted into the right ureter and 5 cc of ICG was injected, and the same procedure was done on the left [1,5]. Bovie electrosurgical device was used to incise circumferentially around the cervix. The bladder was dissected off the pubovesical cervical fascia anteriorly and posteriorly with a combination of the Bovie as well as blunt and sharp dissection. Bilateral uterosacral and cardinal ligaments, as well as uterine arteries, were then clamped, transected with Mayo scissors, and secured. Entry into the anterior cul-de-sac was completed, and a stitch using 0 vicryl was used to tag the anterior peritoneum to the anterior vaginal cuff. Posterior entry was attempted unsuccessfully. The Gelpoint mini device was then placed, and the Da Vinci XI robot was docked. Bilateral ureters were identified and dissected out of bilateral pelvic sidewalls using the firefly mode at the level of the uterine artery. The ureters were easily dissected away from the uterus. The left broad ligament was then cauterized and transected using the vessel sealer. The plane between the uterus and the rectum was identified laterally, and the rectum was taken down from the uterus from the right to the left side. Bilateral broad ligaments were then cauterized and transected using the vessel sealer, followed by cauterization and transection of the round ligaments, utero-ovarian ligaments, and mesosalpinx bilaterally. The vaginal cuff angles were secured with a figure-of-eight stitch of 0 vicryl, and the vaginal cuff was then closed in a running fashion with 0 V-Loc. The patient was discharged in one day with reports of minimal pain (Videos 1-3).

CONCLUSION

Robotic-assisted NOTES hysterectomy with deeply infiltrated endometriosis resection is feasible and safe with ICG-assisted ureteral labeling in a case of obliterated cul-de-sac. The unique green color labeling of ureters offers a prominent landmark in assisting the ureteral dissection while avoiding ureteral and bowel injury, resulting in the possibility of using vNOTES surgery in challenging cases.

The current role of robotic surgery in endometriosis management

INTRODUCTION

Endometriosis is a chronic inflammatory disease that affects approximately 10%-15% of women of childbearing age. Laparoscopic surgery is the preferred surgical approach. Recently, robotic surgery has been used for benign gynecologic surgery, but its role in the treatment of endometriosis is still unknown.

AREAS COVERED

We included studies that evaluated the outcomes of robotic surgery for endometriosis. Using the keywords 'endometriosis' and 'robotics', a comprehensive literature search on PubMed, Embase, and the Cochrane Library was performed in July 2021.

EXPERT OPINION

Robotic surgery for endometriosis has similar outcomes as conventional laparoscopy, with no evidence of increased complication rates. Despite the non-inferiority of the surgical route, the associated costs of robotic surgery limit its availability. Rapid development of robot-assisted surgery necessitates long-term prospective randomized controlled trials. However, the limitations of robotic surgery should not be overlooked. If robotic surgery can facilitate the spread of minimally invasive surgery, it will be necessary to evaluate the cost, availability, complexity of the lesions, and most importantly, the results of patient satisfaction and values of value-based medicine.

Feasibility of two robotic single-site surgery techniques for adolescent endometriosis: Focal versus butterfly

OBJECTIVE

This study examined the feasibility of robotic laparoendoscopic single-site surgery (LESS) for the treatment of adolescent endometriosis (n = 36). Additionally, we assessed a novel technique known as butterfly resection for severe cases.

METHODS

This was a retrospective study of women from 12 to 21 years old who received therapeutic robotic LESS for symptomatic endometriosis by a single experienced surgeon.

RESULTS

There were 32 cases of peritoneal and four cases of deep infiltrating endometriosis (DIE). Focal resection was performed in 9/32 peritoneal and all DIE cases; butterfly resection was performed in the remaining 23/32 peritoneal. At 3 months, 16/23 had complete resolution of pelvic pain in the butterfly group versus 10/13 in the focal group (P = 0.64).

CONCLUSION

Robotic LESS produces safe outcomes with low complication rates. Butterfly resection may be considered for extensive lesions, with similar levels of pain relief compared to traditional focal resection techniques.

CAPSULE

Single-site robotic surgery produces safe outcomes with low complication rates in adolescents with endometriosis, with techniques customized based on disease severity.

Robot-assisted Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Management of Endometriosis: A Pilot Study of 33 Cases

STUDY OBJECTIVE

To describe the surgical techniques and short-term outcomes for 33 cases of robot-assisted transvaginal natural orifice transluminal endoscopic surgery (RvNOTES) to treat endometriosis.

DESIGN

Retrospective case series study.

SETTING

Academic tertiary care university hospital in Houston, TX.

PATIENTS

Patients who underwent RvNOTES resection of endometriosis between March 2020 and March 2021.

INTERVENTIONS

RvNOTES.

MEASUREMENTS AND MAIN RESULTS

A total of 33 cases of patients, with pathology-confirmed endometriosis, who underwent RvNOTES total hysterectomy with resection of endometriosis were included in the study. Thirty-two cases were completed successfully by RvNOTES, and 1 case was converted to robotic transumbilical single-incision laparoscopic surgery plus 1 additional port owing to an obliterated posterior cul-de-sac and upper abdominal wall endometriosis. The average operative time was 141.93 ± 40.22 (85-264) minutes, and the mean estimated blood loss was 52.25 ± 33.82 (25-150) mL. The mean preoperative pain score using the visual analog scale (VAS) score was 8.08 ± 2.39 (2-10). The mean VAS pain score 1 week after surgery was 6.73 ± 2.62 (0-10), which was significantly lower than the preoperative scores (p = .059). The mean VAS pain score in the second and third week after surgery was 4.81 ± 2.42 (0-9) and 2.63 ± 2.36 (0-7) respectively, which were both significantly lower than those before surgery (p = .001). There were 4 postoperative complications: urinary tract infection, pneumonia, headache requiring admission, and conversion disorder.

CONCLUSION

RvNOTES is a safe and feasible approach for the treatment of endometriosis, with promising short-term improvements in pain.

Postoperative opioid use for patients with chronic pelvic pain undergoing robotic surgery for resection of endometriosis

We aimed to identify the amount of opioids used in the postoperative setting for patients with a history of chronic pelvic pain undergoing robotic surgical excision of endometriosis and compare this to patients undergoing benign robotic gynecologic surgery for other indications. We conducted a retrospective cohort study in an urban academic university hospital from January 2019 to March 2020. Data regarding opioid use was collected via a patient-reported survey that was given at the 3 weeks follow-up visit. Data regarding opioid use was compared to patients undergoing robotic surgery for other benign gynecologic indications. Our study included 158 patients, 119 undergoing surgery for endometriosis and 39 patients undergoing robotic surgery for other benign gynecologic indications. Patients undergoing surgery for endometriosis used on average 105.9 morphine milligram equivalents (MME), equivalent to 14 tabs of oxycodone 5 mg. There was no statistically significant difference in the amount of opioids used postoperatively based on stage of endometriosis or need for hysterectomy. Patients undergoing surgery for other benign indications used on average 49.4 MME, equivalent to 6 tabs of oxycodone 5 mg. The difference in amount of opioids used between patients with and without endometriosis was statistically significant. In conclusion, patients undergoing robotic surgery for endometriosis used over two times as many opioids postoperatively as patients without endometriosis and have a higher perceived postoperative pain. Providers should be aware of this difference in order to provide better pain control for this patient population.

Identification of Inertial Parameters for Position and Force Control of Surgical Assistance Robots

Surgeries or rehabilitation exercises are hazardous tasks for a mechanical system, as the device has to interact with parts of the human body without the hands-on experience that the surgeon or physiotherapist acquires over time. For various gynecological laparoscopic surgeries, such as laparoscopic hysterectomy or laparoscopic pelvic endometriosis, Uterine Manipulators are used. These medical devices allow the uterus to be suitably mobilized. A gap needs to be filled in terms of the precise handling of this type of devices. In this sense, this manuscript first describes the mathematical procedure to identify the inertial parameters of uterine manipulators. These parameters are needed to establish an accurate position and force control for an electromechanical system to assist surgical operations. The method for identifying the mass and the center of mass of the manipulator is based on the solution of the equations for the static equilibrium of rigid solids. Based on the manipulator inertial parameter estimation, the paper shows how the force exerted by the manipulator can be obtained. For this purpose, it solves a matrix system composed of the torques and forces of the manipulator. Different manipulators have been used, and it has been verified that the mathematical procedures proposed in this work allow us to calculate in an accurate and efficient way the force exerted by these manipulators.