Robotic surgery in gynecologic oncology

Robotic-Assisted Minimally Invasive Surgery in Children

Currently, minimally invasive surgery (MIS) includes conventional laparo-thoracoscopic surgery and robot-assisted surgery (RAS) or robotic surgery. Robotic surgery is performed with robotic devices, for example the Da Vinci system from Intuitive Surgical, which has a miniaturized camera capable of image magnification, a three-dimensional image of the surgical field, and the instruments are articulated with 7 degrees of freedom of movement, and the surgeon operates in a sitting position at a surgical console near the patient. Robotic surgery has gained an enormous surge in use on adults, but it has been slowly accepted for children, although it offers important advantages in complex surgeries. The areas of application of robotic surgery in the pediatric population include urological, general surgery, thoracic, oncological, and otorhinolaryngology, the largest application has been in urological surgery. There is evidence that robotic surgery in children is safe and it is important to offer its benefits. Intraoperative complications are rare, and the frequency of postoperative complications ranges from 0–15%. Recommendations for the implementation of a pediatric robotic surgery program are included. The future will be fascinating with upcoming advancements in robotic surgical systems, the use of artificial intelligence, and digital surgery.

Incidence of port site hernias and/or dehiscence in robotic-assisted procedures in gynecologic oncology patients

OBJECTIVES

The incidence of port site hernia and/or dehiscence using bladeless trocars is 0-1.2%. Robotic surgery uses additional port sites and increases manipulation of instruments, raising the concern for more complications. We sought to characterize the incidence of port site complications following robotic surgery when fascia was not routinely closed.

METHODS

Robotically-assisted (RA) procedures performed for suspected gynecologic malignancy between 1/2006 and 12/2011 were retrospectively reviewed. Bladeless 12 mm and 8mm robotic trocars were used. Fascial closure was not routinely performed except after specimen removal through the port site. The decision to close the fascia remained at the discretion of the surgeon.

RESULTS

Data from 842 procedures were included. Mean patient age was 55.6 years. Mean Body Mass Index was 33.6 kg/m(2). RA-total laparoscopic hysterectomy (TLH)± unilateral or bilateral salpingo-oophorectomy (BSO)± lymphadenectomy (LND) accounted for 91.6% of procedures. Final pathology confirmed malignancy in 58.6% of cases, primarily endometrial cancer. In 35 cases, the specimen was removed through the port site; fascia was closed in 54.3% of them and no port site hernias or dehiscences occurred. Only one patient underwent a RA-TLH/BSO/LND for endometrial adenocarcinoma and had a port site dehiscence of the 8mm trocar site. No port site hernias occurred.

CONCLUSION

Port site hernias and dehiscences are rare in RA gynecologic oncology procedures. When bladeless dilating trocars are used, routine closure of even up to a 12 mm port site is unnecessary, even in cases requiring removal of the specimen through the trocar sites.

A Novel Technique for Transvaginal Retrieval of Enlarged Pelvic Viscera during Minimally Invasive Surgery

Introduction. With the widespread adoption of laparoscopic and robotic surgery, more and more women are undergoing minimally invasive surgery for complex gynecological procedures. The rate-limiting step is often the delivery of an intact uterus or an unruptured adnexal mass. To avoid conversion to a minilaparotomy for specimen retrieval, we describe a novel technique using an Anchor Tissue Retrieval System bag in conjunction with a pneumo-occluder to easily retrieve large specimens through a colpotomy incision. Surgical Technique. After completion of the robotic-assisted hysterectomy, the uterus, fallopian tubes, and ovaries were too large to be retrieved intact despite multiple attempts of delivery through the colpotomy incision. Prior to resorting to a minilaparotomy or morcellation of the specimen, a 15 mm anchor retrieval bag with a pneumo-occluder was placed through the vagina and the intact specimen was easily placed inside the bag under direct visualization and removed through the colpotomy incision intact. Conclusion. We routinely utilize this technique to retrieve hysterectomy specimens that are not readily delivered through the colpotomy incision and find this technique to be safe, highly efficient, and cost effective when there is a need to remove large intact specimens during minimally invasive surgery.