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Robotic-assisted surgery spreads to gynecology: hysterectomy, myomectomy, tubal ligation.

LAS VEGAS -- A robotic surgical system may be capable of helping surgeons remove complex gynecologic pathology in a minimally invasive fashion, speakers said at an international congress of the Society of Laparoendoscopic Surgeons.

Three presenters reported their early experience with tubal ligation, hysterectomy, or myomectomy performed laparoscopically with the help of a robotic surgical system originally designed for cardiac and general surgery

Approved for laparoscopic surgery in 2000, the da Vinci Surgical System, marketed by Intuitive Surgical, has been used primarily for mitral valve repair, pelvic lymph node dissection, cholecystectomy, adrenalectomy, Nissen fundoplication, and other nongynecologic procedures. There have been a few reports in the literature about use of the system for tubal reanastomosis or, more recently, hysterectomy. An estimated 134 of the da Vinci systems are in use in the United States, according to a spokesperson for the company.

In 2002, the FDA approved a second robotic surgical system for general and laparoscopic surgery, the Zeus Surgical System by Computer Motion.

Robotic systems have the potential to overcome several limitations of standard laparoscopic technique, such as two-dimensional imaging, hand tremors, and limited dexterity within the body. Drawbacks include a million-dollar price tag, lack of tactile feedback for the surgeon, and machinery set-up time.

During the surgery, one surgeon uses a remote master console to manipulate robotic arms, which maneuver instruments and a laparoscopic camera that provides three-dimensional images. A second surgeon stands at the patient's side, with other operating room personnel nearby.

Dr. James A. Daucher and his associates at East Carolina University, Greenville, N.C., used the system to perform four bilateral tubal ligations, as a way to make the transition from standard gynecologic laparoscopy to robotic laparoscopy. After an intensive, 2-day training program plus additional inanimate and animate laboratory sessions, they chose the Parkland method of tubal ligation as their first robotically assisted surgery, because it is a common, low-risk procedure involving a variety of laparoscopic maneuvers.

Total operating time varied from 1 hour and 25 minutes to 2 hours and 31 minutes, with operative times decreasing by 20% on the surgeons' second procedure. The average operating time was 1 hour and 56 minutes, compared with an average of 1 hour and 30 minutes for a standard laparoscopic tubal ligation at his institution, Dr. Daucher said.

The patients did well with no complications, he said in a poster presentation.

"While the initial training in robotic surgery was time-consuming, we believe the robotic system makes complex laparoscopic skills easier to perform and will therefore increase the surgeon's minimally invasive armamentarium," he said. Doing the tubal ligations helped surgeons ascertain where the robotic techniques would need to be supplemented with more standard laparoscopic instruments for gynecology, he added.

"It seems silly to use a million-dollar toy to do these simple procedures, but it really helped us with getting the robot into place and perfecting things before going on to hysterectomies," reported Dr. Todd M. Beste, the lead investigator of the study reported by Dr. Daucher.

In a separate study of 10 total laparoscopic hysterectomies, the robotic system enhanced the performance of tasks such as lysis of adhesions, suturing, and knottying, said Dr. Beste, also of East Carolina University.

One patient suffered a cystotomy during placement of a suprapubic trocar. Operative times ranged from 2 hours and 28 minutes to 4 hours and 37 minutes. Patients lost 25-350 mL of blood, and uterine weights ranged from 49 g to 227 g.

In a third study presented at the meeting, a total of 14 laparoscopic hysterectomies and 10 laparoscopic myomectomies assisted by the robotic surgical system were performed at the University of Michigan, Ann Arbor. Surgeons selected patients who had complex pathology thought to be a relative contraindication for conventional laparoscopy. Indications included advanced endometriosis, chronic pelvic pain, adenomyosis, and dysfunctional uterine bleeding, Dr. Arnold P. Advincula said.

Mean operative times were 4 hours and 14 minutes for hysterectomy and 4 hours and 16 minutes for myomectomy, with a trend toward faster times with more experience, said Dr. Advincula, director of the minimally invasive surgery program at the university.

Uterine specimens averaged 125 g, and mean weight of the removed leiomyomata was 246 g. Estimated blood loss averaged 98 mL for hysterectomy and 160 mL for myomectomy. Patients stayed in the hospital an average of 2 days for hysterectomy and 1 day for myomectomy.

One complication occurred in an early case: a delayed thermal bowel injury. Another patient developed postoperative pneumonia. Surgeons at the university have now treated a total of about 50 gynecologic cases with robotic assistance, mostly myomectomies. "We found that's where we've been able to exploit the use of suturing with the telerobotic system," Dr. Advincula said.

Although the gynecologic procedures done with robotic assistance could have been done by experienced laparoscopic surgeons alone, the fact that a large majority of hysterectomies in the United States are still done with an abdominal approach suggests that many physicians are not comfortable with laparoscopy, Dr. Advincula said.

"This may be the very tool in the future that somewhat levels the playing field and allows more people to approach things in a minimally invasive fashion," he said.

Dr. Daucher took a more cautious tone: "It has not yet been determined whether robotic systems will significantly help in complex gynecologic surgery."

In any case, medicine will continue to move toward robotic-assisted surgery, and the technology will be refined, Dr. Advincula said.

All the presenters said they have no financial relationships with either of the companies that make the robotic systems.
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Title Annotation:Gynecology
Author:Boschert, Sherry
Publication:OB GYN News
Date:Jan 1, 2004
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