Issuu

Manual of

Robotic Surgery in Gynecology

Manual of

Robotic Surgery in Gynecology Editors

Richa Sharma MS MNAMS FICOG FICMCH FMAS Director-Professor Department of Obstetrics and Gynaecology University College of Medical Sciences and GTB Hospital, Delhi

Bijoy Kumar Nayak MBBS MD

Anuradha Panda MD DGO FICOG

Head Department of Gynecology, Endoscopy and Robotic Surgery Max Super Speciality Hospital, Dwarka, Delhi

Senior Consultant Laparoscopic and Robotic Surgeon Apollo Hospitals Hyderabad

CBS Publishers & Distributors Pvt Ltd New Delhi • Bengaluru • Chennai • Kochi • Kolkata • Lucknow • Mumbai Hyderabad • Jharkhand • Nagpur • Patna • Pune • Uttarakhand

Disclaimer Science and technology are constantly changing fields. New research and experience broaden the scope of information and knowledge. The authors have tried their best in giving information available to them while preparing the material for this book. Although, all efforts have been made to ensure optimum accuracy of the material, yet it is quite possible some errors might have been left uncorrected. The publisher, the printer and the authors will not be held responsible for any inadvertent errors, omissions or inaccuracies.

All rights reserved. No part of this eBook may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system without permission, in writing, from the authors and the publisher. Published by Satish Kumar Jain and produced by Varun Jain for CBS Publishers & Distributors Pvt. Ltd. Corporate O ice: 204 FIE, Industrial Area, Patparganj, New Delhi-110092 Ph: +91-11-49344934; Fax: +91-11-49344935; Website: www.cbspd.com; www.eduport-global.com; E-mail: eresources@cbspd.com Head O ice: CBS PLAZA, 4819/XI Prahlad Street, 24 Ansari Road, Daryaganj, New Delhi-110002, India. Ph: +91-11-23289259, 23266861, 23266867; Fax: 011-23243014; Website: www.cbspd.com; E-mail: publishing@cbspd.com; eduportglobal@gmail.com.

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Representatives Hyderabad Pune Nagpur Manipal Vijayawada Patna

vii

Foreword

t is my privilege to write the Foreword to the Manual of Robotic Surgery in Gynecology. After being initiated into the robotic programme, I find that it does make complex gynecological surgeries easy with unprecedented precision, dexterity and control. It would be a good proposition to learn the art, a good book on robotics is necessary with more and more laparoscopic surgeons venturing into the new field. This book provides an authoritative and up-to-date overview of the subject, technical nuances and practical tips. The editors and authors have done a commendable job in selecting the topics and keeping the narrative to the point. Readers will gain an insight into patient selection, surgical steps and postoperative care. This book will be valuable for budding gynecologists, beginners and those into the field of robotic surgery.

Padmashri Dr Alka Kriplani

MBBS, MD, FRCOG, FAMS, FICOG, FIMSA, FICMCH, FCLS

Chairperson—Obstetrics, Gynaecology & ART Paras Health, Gurugram

xiii

Contents Contributors Foreword by Padmashri Dr Alka Kriplani Preface

v vii ix

Part 1: Basics: Understanding the Robot and Its Working 1. Evolution of Robotics in Gynecological Surgeries

Salvatore Giovanni Vitale, Liliana Mereu, Stefania Saponara

2. Robotic da Vinci System: Machine and Instruments

Anupama Bahadur, Richa Sharma

3. Energy Sources in Robotics

Anuradha Panda, M Keerthi Reddy

4. Robotic OT Setup and Ergonomics

Anuradha Panda, Deepika HK

5. Training and Learning Curve in Robotic Surgery

Rooma Sinha, Rupa Bana

6. Role of First Assistant in Robotic Surgery

Mariam Anjum Ifthikar, Neha Kamath

Part 2: Robotic Benign Surgery

7. Robotic Hysterectomy for Benign Conditions

Rooma Sinha, Rupa Bana

8. Robot-Assisted Laparoscopic Myomectomy (RALM)

Anupama Bahadur, Rajlaxmi Mundhra

9. Robotic Surgery for Endometriosis

Abhishek Mangeshikar

10. Robot-Assisted Pelvic Organ Prolapse Repair

Dinesh Kansal, Supriya Mahipal, Yamini Kansal

11. Robotics in Infertility Management

101

Mala Srivastava, Neema Tufchi, Ankita Srivastava

12. Robotics in Adnexal Surgery

108

Mala Srivastava, Neema Tufchi, Ankita Srivastava

13. Robotic Management of Urinary Fistulas Amita Jain

114

xiv

Manual of Robotic Surgery in Gynecology

Part 3: Robotic Management in Malignancy

14. Robotic Assisted Pelvic and Para-aortic Lymph Node Dissection

125

Rohit Raghunath Ranade, Shree Bharati

15. Robot-Assisted Surgery in Cervical Cancer

143

Rohit Raghunath Ranade, Abhirami Giri Ramani

16. Robotic Surgery for Endometrial Cancer

157

Yogesh Kulkarni, Deepali Raina

17. Robotic Surgery in Ovarian Cancer

168

Yogesh Kulkarni, Deepali Raina

Part 4: Miscellaneous

18. Anesthesia in Robotic Gynecological Surgery

177

Sanath Reddy, Santhosh Kumari

19. Minimal Invasive vs Robotics: Evidence-based Practices in Gynecology

198

Bijoy Nayak, Dhiranjali, Richa Sharma

20. Complications in Robotic Surgery: Prevention and Management Strategy

202

Abhishek Chandna, Gourab Misra, Lyndon Gommersall, Girdhar Singh Bora

21. Robotic Management of Complex Vesico-vaginal Fistula

212

Abhishek Chandna, Lyndon Gommersall, Giridhar Singh Bora

Index

221

Evolution of Robotics in Gynecological Surgeries

robotic systems expanded, including myomectomies, ovarian cystectomies, and even some cancer surgeries.1–3 The early 2000s also saw the development of training programs and certification processes for surgeons wishing to specialize in robotic surgery.2,3 These programs were crucial in ensuring surgeons were adequately prepared to use the new technology safely and effectively. The development of these training programs marked a significant step forward in integrating robotic systems into mainstream surgical practice.

Key Robotic Procedures in Gynecology Hysterectomy Robotic-assisted hysterectomy is frequently employed to remove the uterus, often addressing benign conditions like uterine fibroids or endometriosis. This minimally invasive procedure has gained popularity due to its numerous benefits, including smaller incisions, reduced blood loss, and quicker recovery times than traditional open surgery.4 The precision provided by robotic systems allows surgeons to navigate complex anatomical structures with ease, ensuring accuracy and care.4 A recent meta-analysis found no significant differences between robotic and laparoscopic hysterectomies for benign disease regarding estimated blood loss, bleedingrelated complications, hospital stay length, postoperative pain levels, recovery time, and total operating time. Despite ongoing debates about the utility of robotic hysterectomy

Fig. 1.1: Key robotic procedures in gynecology

Basics: Understanding the Robot and Its Working

Current State of Robotic Surgery in Gynecology Today, robotic surgery is widely used in various gynecological procedures (Fig. 1.1). The da Vinci® system remains the leading platform, continuously evolving with newer models such as the da Vinci® Xi and da Vinci® 5, which offer improved capabilities and flexibility2 (Fig. 1.2A and B).

Manual of Robotic Surgery in Gynecology

(A)

(B)

Part 1

for benign diseases, postoperative quality of life has been reported to be significantly higher in the robotic group.5

Myomectomy Robotic-assisted myomectomy is another prevalent application in gynecology, involving the surgical removal of uterine fibroids. This method offers several advantages over conventional approaches, such as enhanced visualization and dexterity, allowing surgeons to remove fibroids while preserving the uterus.4 This is particularly beneficial for women aiming to maintain fertility. The minimally invasive approach reduces postoperative pain and shortens hospital stays, improving patient experience.4 A recent meta-analysis indicated better outcomes with robotic-assisted myomectomy, including fewer complications, less estimated blood loss, fewer blood transfusions, and shorter hospital stays, though the surgery duration was longer than open myomectomy.6 The conversion rate to laparotomy was also much lower than that of laparoscopic surgery. The robotic platform’s 3D vision system allows for precise and ergonomic suturing, reducing complication rates compared to laparoscopic and open surgeries.6 Further studies are needed to assess long-term outcomes such as postoperative pain and fertility. Ovarian Cystectomy Robotic-assisted ovarian cystectomy involves the removal of cysts from the ovaries with minimal damage to surrounding tissues, preserving ovarian function and fertility. The precision and control offered by robotic systems allow for the excision of cysts while maintaining ovarian integrity. Enhanced visualization helps identify and remove cysts that might be challenging to detect using traditional surgical methods.4

Evolution of Robotics in Gynecological Surgeries

Advantages and Limitations of Robotic Surgery in Gynecology Advantages Robotic surgery has revolutionized gynecological surgical practices, offering numerous benefits that enhance surgical precision and patient outcomes (Table 1.1). A key advantage is the improved operative field visualization, allowing for more precise and accurate procedures. Surgeons gain a clear, magnified view of anatomical structures, enabling them to navigate intricate surgical pathways with confidence. This enhanced visual clarity significantly improves surgical outcomes and increases patient safety.33 The dexterity provided by the robot’s arms is another crucial benefit, giving surgeons greater precision and control. This capability allows for the execution of complex procedures with increased ease and efficiency, achieving optimal results while minimizing the risk of errors. The intuitive motion-scaling technology of robotic systems enables precise tissue manipulation, facilitating delicate navigation through complex anatomical structures.2,33 Robotic surgery also mitigates the effects of surgeon tremors by providing steady robotic arms, reducing the risk of complications. Surgeons can perform precise Table 1.1: Advantages and limitations of robotic surgery in obstetrics and gynecology Advantages

Limitations

Enhanced visualization for precise and accurate High cost of robotic surgery procedures Greater precision and control with robot's arms

Steep learning curve requiring extensive training

Reduced surgeon tremors and improved Need for more high-quality evidence and longinstrument control term data Ergonomic design reduces surgeon fatigue and Longer operative times during initial stages strain Minimally invasive procedures with smaller Maintenance and calibration of robotic equipment incisions and faster recovery add complexity and cost Shorter hospital stays and less postoperative pain Limited accessibility in certain regions or healthcare for patients systems Reduced risk of infection and complications Risks of complications such as infection, bleeding, associated with larger incisions or tissue damage Promotes surgeon well-being and performance

Need for standardization in robotic surgery techniques

Basics: Understanding the Robot and Its Working

patients with endometrial cancer has an advantage in terms of reduced invasiveness for patients in the first BMI class.32 R-LSS appears to be a viable and effective alternative to traditional multi-port laparoscopic and robotic-assisted surgeries in gynecology. It offers several technical advantages, such as restored triangulation at the surgical site, enhanced ergonomics, and improved cosmetic outcomes.24,27 However, more randomized controlled trials are necessary to establish high-quality evidence regarding its non-inferiority and safety compared to other minimally invasive approaches. Additionally, comprehensive costbenefit analyses are crucial to justify the higher financial costs associated with robotic surgery, limiting its application to selected patients.

Manual of Robotic Surgery in Gynecology

Part 1

maneuvers without the interference of involuntary movements, ensuring consistent instrument control and minimizing tissue trauma. This feature is particularly beneficial in delicate procedures, enhancing surgical accuracy and patient safety.2,33 Additionally, the ergonomic design of the robotic platform reduces surgeon fatigue and strain, leading to a more comfortable surgical experience. This ergonomic advantage is crucial during lengthy procedures, allowing surgeons to maintain their focus and precision throughout the operation, ultimately benefiting patient outcomes. Surgeons operate seated at a console with ergonomic hand controls and adjustable display settings, minimizing physical discomfort during prolonged procedures. This ergonomic optimization promotes surgeon well-being and enhances overall surgical performance. The console’s design allows surgeons to maintain a comfortable posture, reducing the risk of musculoskeletal strain and fatigue, which is particularly important during lengthy and complex surgeries.2,33 The robotic platform’s ability to facilitate minimally invasive procedures results in smaller incisions, reduced blood loss, and faster patient recovery times. These benefits contribute to a more positive patient experience, less postoperative pain and shorter hospital stays. The minimally invasive nature of robotic surgery also reduces the risk of infection and other complications associated with larger incisions, further enhancing patient safety and recovery.1,33 This combination of advantages makes robotic surgery an attractive option for patients and surgeons, driving its continued adoption and integration into gynecologic practice.

Limitations Despite its numerous advantages, robotic surgery in obstetrics and gynecology also presents challenges and limitations that impact its widespread adoption and utilization (Table 1.1). The high cost of robotic surgery is a significant barrier, as it is considerably higher than traditional surgical techniques, potentially limiting access for patients and healthcare institutions.2,11 Additionally, there is a steep learning curve associated with robotic surgery, requiring surgeons to undergo extensive training to attain proficiency. This learning curve can result in longer operative times and increased costs during the initial stages of implementation.2,11 Moreover, the need for more high-quality evidence and long-term data comparing the outcomes of robotic surgery with traditional techniques poses a challenge. While robotic surgery offers improved visualization and dexterity, it may not necessarily translate into shorter operative times compared to open or conventional laparoscopic techniques. Furthermore, the maintenance and calibration of robotic equipment add to surgical procedures’ complexity and overall cost. Accessibility to robotic surgery may be limited due to its high cost and restricted availability in certain regions or healthcare systems, contributing to disparities in patient access to advanced surgical care.2,11 Like any surgical procedure, robotic surgery carries risks of complications such as infection, bleeding, or damage to surrounding tissues. The need for standardization in robotic surgery techniques further complicates matters, leading to inconsistencies in surgical approach and outcomes. While robotic surgery offers considerable advantages in obstetrics and gynecology, including improved precision and patient outcomes, it also presents significant challenges that must be addressed to optimize its utilization and accessibility in clinical practice.2,11 Efforts to mitigate these challenges, such as reducing costs, enhancing