Robot-assisted laparoscopic myomectomy: current status

Innovations in Hybrid Laparoscopic Surgery: Integrating Advanced Technologies for Multidisciplinary Cases

Combining conventional laparoscopic techniques with cutting-edge technologies, such as robotics, improved imaging, and flexible equipment, hybrid laparoscopic techniques represent a revolutionary advancement in minimally invasive surgery. These methods have several benefits, such as increased accuracy, quicker healing periods, and fewer complications, which makes them especially useful in complicated multidisciplinary situations. The historical evolution, uses, benefits, and drawbacks of hybrid laparoscopic procedures are examined in this narrative review, which also covers urological, gastrointestinal, cardiothoracic, and gynecological surgery. The review focuses on how these methods promote interdisciplinary cooperation and creativity by enabling more accurate and successful surgical operations. It also discusses the equipment needs, integration difficulties, and technical difficulties that need to be resolved to reach the full potential of hybrid laparoscopic surgery. For hybrid laparoscopic procedures to become more widely used and effective in the future, there is a need for specialized training programs, interdisciplinary research collaborations, and ongoing technological advancements.

Effect and Safety of Diluted Vasopressin Injection for Bleeding Control During Robot-assisted Laparoscopic Myomectomy in Reproductive Women With Uterine Fibroids: A Randomized Controlled Pilot Trial (VALENTINE Trial)

BACKGROUND/AIM

Vasopressin injected during myomectomy is known to effectively reduce bleeding but is sometimes associated with intraoperative vasoconstriction and hypertension due to systemic absorption. Although there is a growing preference for the use of diluted vasopressin, evidence of its effect and safety is still lacking.

PATIENTS AND METHODS

We performed a randomized controlled pilot trial to evaluate the effect and safety of vasopressin diluted in a constant volume during robot-assisted laparoscopic myomectomy (RALM), where a total of 39 women with uterine fibroids were randomly assigned into the following three groups (group 1, 0.2 IU/ml; group 2, 0.1 IU/ml; group 3, 0.05 IU/ml with a total of 100 ml of normal saline). The primary endpoint was to compare estimated blood loss (EBL), and the secondary endpoints were to compare postoperative value and drop ratio of hemoglobin, operation time, transfusion, hospitalization, and complications among the three groups.

RESULTS

There were no differences in the number and largest size of uterine fibroids, total weight of uterine fibroids, console time, and volumes of intravenous fluid administered during RALM among the three groups, whereas combined operation was performed more commonly in group 2 than in groups 1 and 3 (53.9% vs. 0 to 7.7%; p=0.01). The primary and secondary endpoints were also not different among the three groups. However, two patients in group 1 (15.4%) showed vasopressin-related hypertension.

CONCLUSION

Vasopressin diluted in a volume of 100 ml showed an effective hemostatic effect and safety during RALM (Trial No. NCT04874246 in ClinicalTrial.gov).

Implementation of robot-assisted myomectomy in a large university hospital: a retrospective descriptive study

Background

Background: Myomectomy is often the preferred treatment for symptomatic patients with myomas who wish to preserve their fertility, with a shift from open surgery towards minimally invasive techniques.

Objectives

Retrospective study assessing patient and surgery characteristics, follow-up, and outcomes of robot-assisted myomectomy (RAM) and abdominal myomectomy (AM) in women treated between January 1, 2018, and February 28, 2022, in a Belgian tertiary care hospital.

Materials and Methods

A descriptive analysis was conducted on consecutive patients who underwent myomectomies. 2018 was considered the learning curve for RAM.

Main outcome measures

We assessed rate of open surgery, operation time, postoperative hospital stay, and operative complications.

Results

In total, 94 RAMs and 15 AMs were performed. The rate of AMs was 56.5% in 2018 versus 2.3% after the learning curve. The median operation time for RAM was 136.5 minutes and 131 minutes for AM. Conversion rate for RAM was 0%. The median postoperative hospital stay after RAM was 1 night and 4 nights for AM. Postoperative complication rate was low, with only 14.9% and 33.3% of patients requiring pharmacological treatment of complications after RAM or AM, respectively. No surgical re-intervention was needed in any group.

Conclusions

Implementation of RAM at our centre resulted in a significant reduction of open surgery rate. RAM demonstrated shorter hospital stays and a lower incidence of complications compared to AM.

What is new?

Our study highlights the successful adoption of RAM, showcasing its potential to replace AM even in complex cases. The findings affirm the safety and feasibility of RAM, supporting its use as a valuable technique for minimally invasive myomectomy.

Efficacy and safety of robot-assisted laparoscopic myomectomy versus laparoscopic myomectomy: a systematic evaluation and meta-analysis

OBJECTIVE

Systematic evaluation of the efficacy and safety of robotic-assisted laparoscopic myomectomy (RALM) versus laparoscopic myomectomy (LM).

METHODS

PubMed, Embase, The Cochrane Library, and Web of Science database were searched by computer to seek relevant literature in order to compare the efficacy and safety of RALM with that of LM from the establishment of the databases to January 2023, and Review Manager 5.4 software was utilized to perform a meta-analysis on the literature.

RESULTS

A total of 15 retrospective clinical controlled studies were included. There exists a total of 45,702 patients, among 11,618 patients in the RALM group and the remaining 34,084 patients in the LM group. Meta-analysis results revealed that RALM was associated with lesser intraoperative bleeding (MD =  - 32.03, 95%CI - 57.24 to - 6.83, P = 0.01), lower incidence of blood transfusions (OR = 0.86, 95%CI 0.77 to 0.97, P = 0.01), shorter postoperative hospital stay (MD =  - 0.11, 95%CI - 0.21 to - 0.01, P = 0.03), fewer transitions to open stomach (OR = 0.82, 95%CI 0.73 to 0.92, P = 0.0006), and lower incidence of postoperative complications (OR = 0.58, 95%CI 0.40 to 0.86, P = 0.006) than LM, whereas LM is more advantageous in terms of operative time (MD = 38.61, 95%CI 19.36 to 57.86, P < 0.0001). There was no statistical difference between the two surgical methods in terms of maximum myoma diameter (MD = 0.26, 95%CI - 0.17 to 0.70, P = 0.24).

CONCLUSION

In the aspects of intraoperative bleeding, lower incidence of blood transfusions, postoperative hospital stay, transit open stomach rate, and postoperative complications, RALM has a unique advantage than that of LM, while LM has advantages over RALM in terms of operative time.

Multi-Port Robotic-Assisted Laparoscopic Myomectomy: A Systematic Review and Meta-Analysis of Comparative Clinical and Fertility Outcomes

BACKGROUND

Uterine fibroids are the most frequently diagnosed gynaecological tumours, and they often require surgical treatment (conventional laparoscopic myomectomy-CLM). The introduction and evolution of robotic-assisted laparoscopic myomectomy (RALM) in the early 2000s has expanded the range of minimally invasive options for the majority of cases. This study aims to compare RALM with CLM and abdominal myomectomy (AM).

METHODS AND MATERIALS

Fifty-three eligible studies adhered to the pre-established inclusion criteria and were subsequently evaluated for risk of bias and statistical heterogeneity.

RESULTS

The available comparative studies were compared using surgical outcomes, namely blood loss, complication rate, transfusion rate, operation duration, conversion to laparotomy, and length of hospitalisation. RALM was significantly superior to AM in all assessed parameters other than operation duration. RALM and CLM performed similarly in most parameters; however, RALM was associated with reduced intra-operative bleeding in patients with small fibroids and had lower rates of conversion to laparotomy, proving RALM as a safer overall approach.

CONCLUSION

The robotic approach for surgical treatment of uterine fibroids is a safe, effective, and viable approach, which is constantly being improved and may soon acquire widespread adoption and prove to be superior to CLM in certain patient subgroups.

Coaxial-Robotic Single-Site Myomectomy: Surgical Outcomes Compared with Robotic Single-Site Myomectomy by Propensity Score Matching Analysis

BACKGROUND

The aim of this study was to introduce a coaxial-robotic single-site myomectomy (C-RSSM) technique to compensate for the shortcomings of robotic single-site myomectomy (RSSM) using semi-rigid instruments and to compare the surgical outcomes of C-RSSM and RSSM.

METHODS

The medical records of 13 consecutive women who had undergone C-RSSM and 131 consecutive women who had undergone RSSM were retrospectively reviewed. Patient characteristics and surgical outcomes after propensity score matching were evaluated and compared between the two groups.

RESULTS

According to the propensity score matching results, the C-RSSM group had a lower estimated blood loss (75.0 vs. 210.5 mL, p = 0.001) and a shorter operating time (101.0 vs. 146.1 min, p = 0.008) relative to the RSSM group. In RSSM, there was one case of conversion to conventional laparoscopy and four cases of conversion to the multi-site robotic approach. There was no case of conversion from C-RSSM to conventional laparoscopy or the multi-site robotic approach.

CONCLUSIONS

C-RSSM was found to be associated with shorter operative time and lower estimated blood loss. However, further prospective studies are needed to confirm these advantages.

Effect and safety of diluted vasopressin injection on bleeding during robot-assisted laparoscopic myomectomy: a protocol for a randomised controlled pilot trial

INTRODUCTION

Even though the injection of diluted vasopressin into the uterus is expected to reduce intraoperative bleeding with decreased adverse effects during robot-assisted laparoscopic myomectomy (RALM), there is a lack of relevant trials to show its effect and safety. Thus, this study was designed to compare the effect and safety of vasopressin injection on bleedings based on dilution levels of vasopressin with constant volumes during RALM.

METHODS AND ANALYSIS

This is a randomised controlled pilot trial, where a total of 39 patients will be randomly divided into three experimental groups in a 1:1:1 ratio. All patients will be classified into the three groups based on the dilution level of vasopressin: group 1-a solution prepared by mixing 20 units of vasopressin with 100 mL of normal saline to make a total of 100 mL; group 2-a solution prepared by mixing 20 units of vasopressin with 200 mL of normal saline to make a total of 100 mL and group 3-a solution prepared by mixing 20 units of vasopressin with 400 mL of normal saline to make a total of 100 mL. During RALM, we will inject diluted vasopressin at different concentrations with a total of 100 mL. As the primary endpoint, estimated blood loss would be compared. As secondary endpoints, we will check the level of haemoglobin and haematocrit, operation time, amount of transfusion, and the period of hospitalisation. In addition, we will check other complications related to vasopressin injection.

ETHICS AND DISSEMINATION

This pilot study has been approved by the Institutional Review Board of the Seoul National University Hospital (No. H-2011-107-1174). All potential subjects will be provided written informed consent. The results of this study will be published in peer-reviewed journals and be presented at academic conferences.

TRIAL REGISTRATION NUMBERS

NCT04874246 and CKCT0006225.

Robot-Assisted Surgery in Gynecology

The advancement of robotics-based procedures in the medical industry is the subject of this review article. The purpose of the surgical robot is to increase surgical abilities and address human shortcomings. The robot's success has been predicated on its ability to accurately and consistently repeat tasks. The following are a few objectives and quantifiable benefits of robotic technology improving surgical maneuverability and physical capabilities. In 2005, the FDA granted gynecological surgery approval for the Da Vinci surgical system. It has been quickly embraced and has already taken on a significant role at many of the locations where it is offered. It consists of a cart with robotic branches next to the patient and a high-resolution three-dimensional (3D) vision system. This study covers laparoscopy via robots in benign gynecological surgeries, myomectomy surgery, hysterectomies, endometriosis, tubal anastomosis, and sacrocolpopexy. The appropriate published studies were evaluated after a PubMed search was conducted. Additionally, procedures that may be used in the future are highlighted. In benign gynecological illness, most currently available research does not show a substantial benefit over traditional laparoscopic surgery. Robotics, however, does provide help in more complicated operations. Compared to laparoscopy, robotic assistance has a lower conversion rate to open procedures. Endo wrist movement of an automated machine during myomectomy surgery can perform proper and better suturing than traditional laparoscopy. The automated program is a noticeable improvement over laparoscopic surgery and, if price issues are resolved, can gain popularity among gynecological surgeons around the globe.

Tips and Details for Successful Robotic Myomectomy: Single-Center Experience with the First 125 Cases

With the continuous development of minimally invasive and precise surgical techniques, laparoscopic myomectomy has become a mainstream surgical method due to its aesthetic outcomes and rapid postoperative recovery. However, during laparoscopic myomectomy, clinicians often encounter unfavorable factors, such as limited vision, inaccurate suturing, difficulty in removing tumors, and susceptibility to fatigue in the operating position. In recent years, robot-assisted surgery has been widely used in gynecology. The advantages of this technique, such as a three-dimensional surgical view, reducing the surgeon’s tremor, and the seven degrees of freedom of the robotic arms, compensate for the defects in laparoscopic surgery. The Department of Gynecology in our hospital has accumulated a wealth of experience since robot-assisted surgery was first carried out in 2017. In this article, the surgical skills of the robotic myomectomy process are described in detail.

Total Robotic Myomectomy in a Complex Case: Extending the Limits

We present the case of a 30-year-old female with primary infertility who had multiple large myomas up to 22 weeks uterine size. She had a body mass index of 42 kg/m² and also concurrent endometriosis, for which she was on medical management. After meticulous preoperative planning, total robotic myomectomy and endometriosis clearance was done. Four large myomas weighing a total of 750 g were removed after morcellation. Console time was 160 min, and she made an uneventful recovery with only 0.1 g/dL drop in hemoglobin. Robotic myomectomy is considered as an improvement over laparotomy for patients with up to three myomas and when the surgical time does not exceed 4 hours. We were successful in our attempt at total robotic myomectomy to extend these limits and had a positive surgical outcome.

Role of robotic surgery in treating fibroids and benign uterine mass

Fibroid uterus can be managed medically, surgically, or through non-extirpative procedures, depending on the clinical situation. Myomectomy may be beneficial, especially to those desiring to preserve the uterus and/or fertility, with outcomes comparable to those of hysterectomy, with a laparoscopic approach being favored when feasible. For definitive therapy, hysterectomy can be pursued where the surgical approach should be individualized. Comparison of robotic-assisted laparoscopic approach shows that the robotic approach may be favored for cases with higher complexity and multiple fibroids in myomectomy; however, no clear advantage is seen with hysterectomy at this time, necessitating further research in the area of robotics for hysterectomy in benign uterine mass treatment to justify the cost.