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2010823 8da Vinci S HD da Vinci S HD da Vinci S HD da Vinci S HD 309 201092-3 INTUITIVE SURGICAL SURGEON CONCOLE
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Kar F. Tam, MBBS, and Hextan Y.S. Ngan, MBBS, M.D. Department of Obstetrics & Gynaecology Queen Mary Hospital Robotic Radical Hysterectomy Using a Side-Docking Approach Objective:The objective of this study was to describe the use of a robotic surgical system for radical hysterectomy in a side-docking approach. Methods:We report a series of laparoscopic radical hysterectomies performed using the da Vinci Robotic Surgical System in a side-docking approach. The patient s record and operative findings were reviewed. Results:A series of laparoscopic radical hysterectomies using the da Vinci Robotic Surgical System in a side-docking approach were performed from July 2009 to November 2009. Vaginal access was readily available to surgeons. The working space for the first assistant was improved comparing to the central-docking approach. The median operative time was 257 minutes and median blood loss was 200 ml. There was no major complication from the operations. All patients recovered from the operation without significant sequelae. Conclusions: A series of laparoscopic radical hysterectomies using the da Vinci Robotic Surgical System in a side-docking approach was reported. This approach provides better vaginal access and improved the working spaces for the assistants. (J GYNECOL SURG 26:99) Introduction The role of laparoscopic surgery in gynecological cancers has been in creasing in the last decade The feasibility of laparoscopic radical hysterectomy has been demonstrated in earlier publications. More recent reports also confirmed the adequacy of performing radical hysterectomy laparoscopically. However, laparoscopic radical hysterectomy still is not widely adopted because of the long operating time and long learning curve. One of the most significant advancements in minimal access surgery is the introduction of the da Vinci system(intuitive Surgical Systems, Inc.,Sunnyvale,CA).The first robotic-assisted laparoscopic radical hysterectomy was first reported in 2006. Subsequently, a number of series on robotic assisted laparoscopic radical hysterectomy were published, which showed good results with short operating time and learning curve. With the advancements in da Vinci operations, more and more procedures were performed laparoscopically and the need for manipulations through the vagina was getting more common. Traditionally, the patient cart was positioned between the legs of the patients; however, a lot of the vaginal procedures or manipulations become very difficult or even impossible because of limited spaces. From the experiences of joint da Vinci operations between colorectal surgeons and gynecologic oncologists for patients with carcinoma of rectum and uterine invasion, using the side-docking approach did not affect the performance of laparoscopic hysterectomy. Moreover, it provided a good vaginal access for vaginal procedures including the removal of uterus and rectum as well as reanastomosis of the sigmoid and rectum with a transanal approach. In view of that, the side-docking approach has been adopted since July 2009. Laparoscopic hysterectomy was first started using two instrument arms and later proceeded to laparoscopic radical hysterectomy using three instrument This article reports our experience of laparoscopic radical hysterectomy with and without pelvic lymphadenectomy using the sidedocking approach. Materials and Methods Between September 2009 and November 2009, 8 patients underwent robotic laparoscopic radical hysterectomy and bilateral pelvic lymphadenectomy (except 1 patient who had multifocal stage
1a1 cervical squamous cell carcinoma), in the Department of Obstetrics and Gynecology, University of Hong Kong. Among those patients, 5 had stage 1b1, 1 had multifocal stage 1a1, 1 had stage 2a1 cervical squamous cell carcinoma, and 1 patient had stage 2 endometrioid endometrial carcinoma. The mean age of patients was 59 (range 35 72). All the patients were told of the diagnoses and the indications for the planned operation. The use of the da Vinci_ System, the procedures, and the related risks were fully explained to the patients and consent forms were signed before operation. All the operations were performed by the 2 authors, who are gynecologic oncologists, together with fellows or residents in the team. Operative procedures The patients were put in Trendelenberg position with the abduction of hips at an angle between 18 and 22 degrees. A metallic bar was put in front of the patient s chin to protect her face. The patient was draped, and the rectangular operating area was bound by the symphysis pubis, xiphisternum, and the anterior superior iliac spines (ASIS). A nasogastric tube was inserted to empty the stomach. A Foley catheter was inserted and the vagina was cleansed. The veress needle was inserted at the Palmer s point and pneumoperitoneum was created using carbon dioxide at a pressure of 12mm Hg. A 5-mm port was inserted at the Palmer s point (at the left midclavicular line, below the 12th rib or rib cage) and a general inspection was performed using a 5-mm laparoscope. Another 5-mm port was inserted 2 3 cm above andmedial to the right ASIS under direct vision. Peritoneal washing for cytology was performed if appropriate. The patient was then moved to headdown position until the bowels had fallen away from the pelvis. The intraabdominal pressure was increased to 25mm Hg. The 12-mm camera port was inserted under direct vision at 22 25 cm above the symphysis pubis and 2 cm to the right of the midline. Another three 8-mm ports were inserted, as shown in Figure 1. The intraabdominal pressure was reduced to 12mm Hg. The patient cart was positioned on the left side of the operating table about 40 degrees between the midline of the patient cart and the side of the operating table (Fig. 2).The 8-mm and 12-mm ports were all docked to the robotic arms. The correct positions of the ports were confirmed with the 5-mm laparoscope. The 5-mm port at the Palmer s point was used as the second assistant port. Photographs of the operating fields are shown in Figure 3. ROBOT-ASSISTED RADICAL HYSTERECTOMY FIG. 1. Positions of the ports on the abdomen. (A) Illustration by a diagram. (B) Port positions on a patient. FIG. 2. A graphic illustration of the position of the patient and the robot. (A) An oblique view. (B) A top view.
Surgical procedures A zero-degree camera was inserted. A Hot shearstm (a pair of scissors with monopolar diathermy, which are used with the da Vinci Robotic Surgical System) was inserted through the right 8-mm port. Plasma-Kinetic Tissue Management System (Gyrus Medical) was inserted through the left medial 8-mm port (second arm) and fenestrated bipolar forceps through the left lateral 8-mm port (third arm). The broad ligaments were opened. Ureters and the iliac vessels were identified and isolated. Paravesicle and pararectal spaces were opened. The uterine arteries were desiccated and divided at the origins. The ureters were freed from the pelvic peritoneum and the pararectal spaces were developed. The infundibulopelvic/ ovarian ligaments were desiccated and divided. The pelvic peritoneumoverlying the uterosacral ligaments and the peritoneal reflection overlying the cul-de-sac were opened and the rectal vaginal space was developed. The uterosacral ligaments were isolated from the cardinal ligaments and they were desiccated and divided. The round ligaments were cut and the uterovesicle fold was opened. A McCartney tube (Tyco Healthcare), 35=45mm depending on the size of the vagina, was then inserted into the vagina. The bladder was pushed down by sharp and blunt dissections. The uterine arteries were freed from the surrounding structures. The ureteric tunnels were deroofed. The ureters were freed away from the cardinal ligaments. The cardinal ligaments were desiccated and divided at the two-thirds point and to the vagina. The vagina was cut open with monopolar shears, with a cuff of about 2 3cm removed. The specimen was removed through the vagina by applying suction through an opening in the McCartney tube. The tube was reinserted after the removal of the uterus to stop the leakage of carbon dioxide. Pelvic lymphadenectomy was performed on both sides. Lymph nodes removed were taken out through the McCartney tube. Hemostasis was ascer- tained. The shears were replaced with a mega needle driver. The vagina was closed with O Biosyn (Tyco Healthcare)with the knots tied via the vagina. The peritoneal cavity was rinsed with normal saline. Ports were undocked from the robot and removed after releasing the carbon dioxide. The rectus sheath of the supraumbilical woundwas closed with O PDS (Ethicon). Skin wounds of all ports were closed with 3 0 undyed Vicryl (Ethicon). Results All the procedures were performed smoothly without undocking during the operations. The median total operating time was 257 minutes (225 325 minutes). The total operating time was defined as the time taken from the first skin incision to the completion of the whole operation. The median docking time was 10.5 minutes (range 6 19 minutes). The median estimated blood loss was 200mL (30 400 ml). No blood transfusion was required for any of the patients. During the procedures, there was no collision between the robotic arms. The instruments inserted through the first assistant port next to the ASIS could reach both pelvic sidewalls in all of the cases without being obstructed by the first robotic arm (Fig. 4). The median hospital stay was 7 days (3 13 days).
Prolonged hospitalization was due to febrile morbidity. Two (2) patients had urinary tract infection, 1patient had deep vein thrombosis, and 2 had unexplained fever despite intensive investigations. The diagnoses of all the patients were confirmed histologically. The resection margins were clear in all of the cases. The median number of lymph nodes removed in the 7 cases with pelvic lymphadenectomy was 27 (21 58). None of the patients had lymph node metastasis. The biggest uterus was 8 weeks gravid size and weighed 376 g. During reassessment at 3 weeks after operation, all patients recovered well from the operation and Foley s catheters were weaned off. One (1) patient was on warfarin because of deep vein thrombosis. on the right side of the operating table was also improved, which increased the degrees of movement of the instruments inserted through the assistant port next to the ASIS. Conclusions A series of laparoscopic radical hysterectomies using the da Vinci Surgical System in a side-docking approach was reported. This approach provides better vaginal access and improved working spaces for the assistants. Disclosure Statement No competing financial interests exist. Discussion R o b o t - a s s i s t e d l a p a r o s c o p i c s u r g e r y i s a n advancement from conventional laparoscopic surgery, which made minimal access surgery more widely adopted in gynecologic oncology. Selfcontrolled camera with three-dimensional view and zero tremor is one of the major advantages. Fine instruments with fine control and dexterity made manipulation of delicate tissue deep inside the pelvis much easier compared to conventional laparoscopic operations. Feasibility of robot-assisted hysterectomies was well shown in the literature.5 10 To perform laparoscopic simple or radical hysterectomies, the application of a colpotomizer or vaginal tube facilitates a safer procedure and becomes routine. When robotic surgery was first started for gynecologic operations, the patient cart remained between the patients legs. This made vaginal access very limited. The assistants had to squeeze into the space and movements were limited. Procedures such as exteriorization of specimens, repair of vaginal tears, or application of an endoscopic bag through the vagina were very difficult or even impossible without undocking. With the use of the sidedocking approach described above, vaginal access is readily available. It allows more complicated procedures and even space for additional assistants.from this small series, it was noted that the operative performance was not affected by this side-docking approach. On the contrary, the working space for the first assistant
da Vinci 2010930 1661 1228 292 141 da Vinci 2010930 169
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