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Robotic single-site hysterectomy.

Originally credentialed to perform robotic surgery in 2007, I quickly returned to conventional laparoscopy. I was disillusioned with the need to increase port numbers and the dependency on my bedside assistant to perform such mundane tasks as suction irrigation.

When I returned to robotics in 2011, it was at a time of tremendous change, both at the console as well as in terms of instrumentation. The robotic suction irrigator and the multifunctional vessel sealer were about to be introduced. Smart pedal technology allowed the ability to select instrumentation in any robotic arm independent of the other. Thus, for the first time, suction irrigation could be performed along with bipolar coagulation.

In addition, I was intrigued with the thought of single-site robotic surgery. Having attempted conventional single-site laparoscopic surgery, I found the technique to be frustrating. Not only was I discouraged by the loss of instrument triangulation, but I found the surgery to be counterintuitive; because of the instruments crossing in the single port, I had to work with my left hand on the patient's right and vice versa. I was encouraged by the potential of both improved triangulation and the ability to work on the right side with the right da Vinci robotic arm and the left side with the left da Vinci robotic arm because of software improvements developed by Intuitive Surgical.

With the Food and Drug Administration approval of robotic da Vinci Single-Site hysterectomy in May 2013, I was very proud to perform the first procedure in the Midwest. Although not having nearly the experience of Dr. Dwight D. Im, our guest author of this edition of the Master Class in Gynecologic Surgery I believe the following:

* Robotic single-site hysterectomy is definitely feasible, but proper case selection is imperative.

* The procedure will certainly evolve. It has already improved with the introduction of the fenestrated bipolar. On the horizon are articulating instruments.

* At times, the 250 mm and 300 mm length cannulas are too long for a woman with a short torso. In this case, the sleeves must be brought back to allow more flexibility

* Consider starting with a noncupped uterine manipulator to allow better mobili7ation of the uterus.

* Use bipolar cautery at right angles to vessels. To desiccate the vessels, place the bipolar as follows: infundibulopelvic ligament--ipsilateral; utero-ovarian ligament--contralateral; uterine vessels--ipsilateral.

* One can use alternative energy modalities through the assist port.

* Salpingectomy is actually easier to perform post hysterectomy.

* Flexibility of the curved needle holder does not allow the needle to pass through tissue as easily. So use a cutting needle (2-0 Maxon). Push the needle through tissue rather than roll it. Place the tip of the needle on the concave side (inside curve), rather than the convex (outside curve), with the needle tip pointing downward toward the instrument shaft.

Because of decreased triangulation and no articulation of instrumentation, intracorporeal knots can be challenging. Perform intracorporeal knot tying using the needle to provide required separation. Use a barbed suture.

I am pleased to have Dr. Im describe his approach performing the da Vinci Single-Site hysterectomy. Dr. Im is director of the Gynecologic Oncology Center at Mercy Medical Center, and clinical assistant professor of obstetrics, gynecology, and reproductive services at the University of Maryland, both in Baltimore. He has been course director for a number of courses on robotic gynecologic surgery and gynecologic oncology surgery-.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago, immediate past president of the International Society for Gynecologic Endoscopy (www.isge.org), and a past president of the AAGL (www.aagl.org). He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in. private practice in Naperville, Ill., and Schaumburg, Ill.; the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, M.; and the medical editor of this column. Dr. Miller said he is a consultant and on the speakers bureau for Intuitive Surgical, and has received grants for research from the company.

Caption: DR. MILLER

BY CHARLES E. MILLER, M.D.
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Title Annotation:MASTER CLASS
Author:Miller, Charles E.
Publication:OB GYN News
Date:Feb 1, 2014
Words:666
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