Robotic Surgery (eBook)

lt;!doctype html public "-//w3c//dtd html 4.0 transitional//en"> Sami Kilic, University of Texas, USA; Kubilay Ertan, Klinikum Leverkusen, Germany; M. Faruk Kose, Senaturk, Turkey.

Preface 
5 
Acknowledgements 7
Index of authors 9
Part I: Basics 29
1 Robotic gynecologic surgery – introduction 31
1.1 History 31
1.2 Robotics systems 32
1.3 Endoscopic surgery in gynecology 35
1.4 The advantages of robotic surgery 37
1.5 Limitations of robotic surgery 37
1.6 Telemedicine and robotic surgery: future aspects 37
1.7 Final suggestions 38
References 38
2 Launching a successful robotic program 41
2.1 Introduction 41
2.2 Phases of a successful robotic gynecologic program 41
2.2.1 Planning phase 41
2.2.2 Implementation phase (learning curve or initial robotic program) 46
2.2.3 Evolving program 46
2.3 Academic activities 48
2.3.1 Education 48
2.3.2 Research 49
2.4 Financial analysis 49
2.5 Conclusion 50
References 50
3 Financial analysis of robotic surgery in gynecology 51
3.1 Introduction 51
3.2 Cost of robotic surgery 51
3.3 Cost effectiveness of robotic surgery vs. laparoscopic and open approaches 52
3.4 Coverage of robotic surgery by health systems 55
3.5 How to use robotics more cost efficiently? 56
3.6 Conclusion 56
References 56
4 Training and credentialing in robotic gynecologic surgery and legal issues 59
4.1 Introduction 59
4.2 Training and credentialing 59
4.2.1 Training 59
4.2.2 Credentialing 60
4.3 Legal issues 61
4.3.1 Components of medical malpractice 61
4.3.2 Insufficient training and credentialing legal issues 61
4.3.3 Robotic proctors and legal issues 62
4.4 Conclusion 63
References 63
5 Patient positioning, trocar placement, and docking for robotic gynecologic procedures 65
5.1 Introduction 65
5.2 Importance of proper patient positioning and trocar placement 65
5.3 Patient positioning 66
5.3.1 Principles of patient positioning 66
5.4 Trocar placement 69
5.4.1 Peritoneal access 69
5.4.2 Trocar placement 69
5.5 Initial survey 73
5.6 Docking 73
5.6.1 Docking types 74
5.7 Conclusion 74
References 75
6 Role of the robotic surgical assistant 77
6.1 The surgeon in the area of conflict between autonomy and dependency 77
6.2 Tasks of the robotic surgical assistant 78
6.2.1 Tasks of the robotic surgical assistant previous to the beginning of the surgical intervention 78
6.2.2 Tasks of the robotic surgical assistant between beginning of the surgery and start of the console phase 80
6.2.3 Tasks of the robotic surgical assistant during the console phase 80
6.2.4 Tasks of the robotic surgical assistant after termination of the console phase until the skin closure 83
6.3 Selection criteria of the robotic surgical assistant 83
6.4 Training/education of the robotic surgical assistant 84
6.4.1 Practical and virtual simulation/simulator systems 85
6.4.2 Training programs – request and reality 86
6.5 Aspects of spatial arrangement and structures of communication 87
6.6 Available data relating to the role of the robotic surgical assistant/existing evidence 90
6.7 Conclusions 91
References 92
7 Strategies for avoiding complications from robotic gynecologic surgery 95
7.1 Introduction 95
7.2 Patient positioning – prevention of neurologic injuries 96
7.3 Complications of pneumoperitoneum and steep Trendelenburg 98
7.4 Robotic equipment 99
7.4.1 Electrosurgical principles 99
7.4.2 Monopolar electrosurgery 99
7.4.3 Bipolar electrosurgery 101
7.5 Avoiding surgical complications 101
7.5.1 Avoiding port complications 102
7.5.2 Gastrointestinal complications 103
7.6 Genitourinary complications 104
7.6.1 Bladder 104
7.6.2 Ureter 105
7.7 Complications of pelvic and para-aortic lymph node dissection 106
7.8 Incisional hernia 107
7.9 Vascular injuries 108
7.10 Vaginal cuff dehiscence 109
7.11 Summary 109
References 110
Part II: General gynecology 115
8 Robotically-assisted simple hysterectomy 117
8.1 Introduction 117
8.1.1 Background 117
8.1.2 Robotic hysterectomy vs. laparoscopy: surgical outcomes 119
8.1.3 Cost analysis 123
8.2 Robot-assisted simple hysterectomy procedure 123
8.2.1 Positioning the patient 123
8.2.2 Trocar placement 124
8.2.3 Docking 125
8.2.4 Instrument selection 127
8.2.5 Step-by-step approach to simple hysterectomy 127
8.2.6 New innovative techniques for robotic hysterectomy: robotic surgery to laparoendoscopic single-site surgery (R-LESS) 134
8.3 Comment 135
References 135
9 Approach to the big uterus for hysterectomy 139
9.1 Introduction 139
9.2 How large is possible? 139
9.3 Technique 140
9.4 Creating the bladder flap 140
9.5 Approach to vessels 141
9.6 Making the colpotomy 141
9.7 Tissue removal 142
References 143
10 The difficult robotic hysterectomy 145
10.1 Introduction 145
10.2 The scenarios of difficult and complex hysterectomy 145
10.3 Patients selection for robotic hysterectomy 146
10.4 Pre-operative preparation for a difficult hysterectomy 147
10.5 Technical operative factors and considerations 147
10.5.1 Anesthesia considerations 147
10.5.2 Following induction of anesthesia 148
10.5.3 Patient positioning 148
10.5.4 Entry 149
10.5.5 Uterine manipulation 150
10.5.6 Trocar placement 150
10.5.7 Docking 152
10.5.8 Steps of robotic hysterectomy 152
10.6 General considerations 154
10.6.1 Choice of instruments 155
10.6.2 How to avoid trocar site hernia? 155
10.6.3 How to avoid losing pneumo peritoneum? 156
10.6.4 How to avoid vaginal cuff infection/dehiscence? 156
10.6.5 Data collection 157
10.6.6 Learning curve 157
10.6.7 Continuing professional development 157
References 157
11 Robot-assisted laparoscopic myomectomy (RALM) 159
11.1 Principles of surgical therapy of uterine myomas 159
11.2 Patient selection for robot-assisted laparoscopic myomectomy (RALM) 162
11.3 Technical and logistic aspects of robot-assisted myomectomies 162
11.3.1 Patient positioning 162
11.3.2 Equipment 163
11.3.3 Selection of robotic instruments (EndoWrist™ instruments) 164
11.3.4 Uterine manipulation 165
11.3.5 Trocar placement 166
11.3.6 Operation schedule for RALM 166
11.3.7 Camera work (0° vs. 30° endoscope) 168
11.3.8 Features and characteristics of robot-assisted myomectomy 168
11.3.9 Suturing techniques and suture material 169
11.3.10 Adhesion prophylaxis 169
11.3.11 Intraabdominal asservation/storage of removed myomas 170
11.4 Advantages of robotic assistance concerning myomectomies 170
11.5 Disadvantages and deficiencies of robotic assistance concerning myomectomy 171
11.6 Preoperative preparations/perioperative management 171
11.6.1 Indications for robot-assisted myomectomy 171
11.6.2 Organ-specific diagnostics 174
11.6.3 Medicamentous pretreatment 174
11.6.4 Preparation of the surgery 176
11.6.5 Patient information and informed consent 177
11.7 Recommendations for further diagnostics and treatment/time interval to pregnancy/mode of delivery 177
11.8 Case studies 178
11.9 Authors data of robot-assisted myomectomy 180
11.10 Available data from robot-assisted myomectomies/ existing evidence 183
11.11 Summary and conclusion 185
References 186
12 Endometriosis: robotic-assisted laparoscopic surgical approaches 189
12.1 Introduction 189
12.2 Application to endometriosis 189
12.3 Surgical approach 190
12.4 Lysis of adhesions 191
12.5 Peritoneal and tubo-ovarian endometriosis 191
12.6 Intestinal endometriosis 192
12.7 Genitourinary endometriosis 194
12.8 Diaphragmatic and thoracic endometriosis 196
12.9 Hepatic endometriosis 197
12.10 Conclusion 197
References 198
13 Robotic-assisted tubal reanastomosis 203
13.1 Introduction 203
13.2 Surgical technique 204
13.2.1 Positioning of the robotic surgical system 204
13.2.2 Robotic-assisted tubal reversal procedure 205
13.3 The surgical outcomes of robotic-assisted tubal reversal 206
References 208
14 Robotic-assisted abdominal cerclage 209
14.1 Introduction 209
14.2 Operative technique 209
14.3 Outcomes 211
References 212
15 Single-port robotic surgery 215
15.1 Introduction 215
15.2 Surgical technique 217
15.3 Discussion 219
15.4 Conclusion 221
References 221
Part III: Gynecologic onocology 223
16 Update on robotic surgery in the management of cervical cancer 225
16.1 Introduction 225
16.2 Early-stage disease 225
16.2.1 Radical hysterectomy 225
16.2.2 Radical trachelectomy 229
16.3 Locally advanced disease 231
16.4 Incidental invasive cervical cancer: robotic-radical parametrectomy 232
16.5 Conclusions 233
References 234
17 Robotic-infrarenal aortic lymphadenectomy: A step-by-step approach 237
17.1 Introduction 237
17.2 Patient selection 237
17.3 Advantages 239
17.4 Approaches 239
17.5 Transperitoneal techniques 240
17.5.1 Midline approach, pelvic trocars, no table rotation 240
17.5.2 Midline approach, pelvic trocars, 180° table rotation 240
17.5.3 Midline approach, subcostal trocars 242
17.5.4 Left lateral approach 244
17.6 Extraperitoneal technique 244
17.7 Conclusion 245
References 245
18 Robotic-pelvic and aortic lymphadenectomy for gynecologic malignancies – one approach 249
18.1 Introduction 249
18.2 The rationale for lymphadenectomy 249
18.3 The minimally-invasive shift 250
18.4 Operating room set-up and patient preparation 251
18.5 Surgical technique for center-docked robotic-assisted aortic lymphadenectomy 254
18.6 Surgical technique for robotic-assisted pelvic lymphadenectomy 256
18.7 Comparative studies 258
18.8 Managing obese patients with endometrial cancer 258
18.9 Future directions 260
18.10 Conclusions 261
References 261
19 Robotic-extraperitoneal lymphadenectomy: A step-by-step approach 265
19.1 Introduction 265
19.2 Robotic-assisted retroperitoneal laparoscopic para-aortic lymphadenectomy: Technique 267
19.2.1 Informed consent 267
19.2.2 Examination under anesthesia and cystoscopy 267
19.2.3 Position of patient 268
19.2.4 Diagnostic laparoscopy 268
19.2.5 Entering the extraperitoneal space with intraperitoneal laparoscopic guidance 269
19.2.6 Placement of balloon trocar and the formation of the retroperitoneal space 269
19.2.7 Placement of surgical trocars into the retroperitoneal space 269
19.2.8 Formation of the surgical plan at the retroperitoneal space 270
19.2.9 Left aortic and paracaval nodal dissection 270
19.2.10 Marsupialization of the retroperitoneal space 271
19.3 Conclusion 271
References 273
20 Robotic surgery for ovarian cancer 277
20.1 Introduction 277
20.2 Benefits of minimally-invasive surgery 278
20.3 Low-malignant potential or borderline ovarian tumors 278
20.4 Early-stage invasive ovarian cancer 280
20.5 Advanced stage invasive ovarian cancer 282
20.6 Considerations 282
References 284
21 Risk-reducing bilateral salpingo-oopherectomy in BRCA mutations career 287
21.1 BRCA1/2 mutations 287
21.2 Risk reducing strategies 287
21.3 Risk reducing salpingo-oopherectomy (RRSO) 288
21.4 Time of RRSO 290
21.5 Primary peritoneal carcinoma after RRSO 290
21.6 Occult cancer at the time of RRSO 291
21.7 Health proplems after RRSO 292
21.8 Technique of RRSO 292
21.9 RRSO with/without hysterectomy 292
21.10 Radical fimbriectomy: As a new temporary risk reducing surgery 293
21.10.1 Laparoendoscopic single port surgery (LEES) for RRSO 293
21.11 Pathologic examination of tuba 294
21.12 Complication of RRSO 295
21.13 Surveilance 295
21.14 Cost analysis 296
References 296
22 Robotic surgery for uterine cancer 301
22.1 Epidemiology 301
22.2 Presentation 301
22.3 Surgical treatment 301
22.4 Preoperative evaluation 302
22.5 Surgical staging 302
22.6 Patient positioning 303
22.7 Pneumoperitoneum, port placement, and instruments 303
22.8 Anesthesia concerns 304
22.9 Pelvic lymphadenectomy 305
22.10 Para-aortic lymphadenectomy 307
22.11 Omentectomy 310
22.12 Extrafascial hysterectomy 312
22.13 Closure of the vaginal apex 313
References 313
23 Compartment-based radical surgery: The TMMR, FMMR and PMMR family in uterine cancer 315
23.1 Introduction 315
23.2 Therapeutic pelvic and periaortic lymphadenectomy (rtLNE) 316
23.3 Total mesometrial resection (rTMMR) 325
23.4 Fertility preserving mesometrial resection (rFMMR) 333
23.5 Peritoneal mesometrial resection (rPMMR) 335
Acknowledgements 344
References 344
Part IV: Urogynecology 347
24 Robotic surgery for urogynecologic diseases 349
24.1 Introduction 349
24.2 Robotic-vesicovaginal fistula repair 349
24.3 Robotic ureteral reconstructive surgery 350
24.4 Robot-assisted laparoscopic sacrocolpopexy (RALS) 351
References 353
25 Robotic sacrocolpopexy for the management of uterine and vaginal vault prolapse 355
25.1 Introduction 355
25.2 Evaluation and surgical indications 356
25.3 Technique and concomitant procedure 357
25.3.1 Preoperative preparation 357
25.3.2 Patient positioning and initial preparation 357
25.3.3 Access and port placement 358
25.3.4 Surgical technique 360
25.3.5 Sacral dissection 361
25.3.6 Anterior dissection 363
25.3.7 Posterior dissection 364
25.3.8 Mesh preparation 365
25.3.9 Follow-up 369
25.4 Outcomes and complications 370
25.4.1 Anatomical and functional outcomes of RASC 370
25.4.2 Complications 373
25.4.3 Disadvantages 373
25.5 Conclusion 374
References 374
26 Robotic-retropubic urethropexy 377
26.1 Introduction 377
26.2 Midurethral sling versus robotic retropubic urethropexy 377
26.3 Evolution of the robotic Burch colposuspension 378
26.4 Step-by-step description of the robotic-assisted Burch colposuspension 379
26.4.1 Preoperative planning 379
26.4.2 Positioning the patient and Foley insertion 379
26.4.3 Docking 379
26.4.4 Trocar insertion 380
26.4.5 Concomitant procedures 380
26.4.6 Repositioning the patient 380
26.4.7 Retrograde filling of the bladder 380
26.4.8 Dissection to create the retropubic space of Retzius 381
26.4.9 Identification of urethro-vesicular junction (UVJ) using hand in the vagina 381
26.4.10 Suturing 381
26.4.11 Cystoscopy 382
References 384
Part V: Specialties 387
27 Pediatric gynecology for robotic surgery 389
27.1 Introduction 389
27.2 Sling procedure for bladder outlet incompetence 389
27.2.1 Surgical technique 390
27.3 Vaginoplasty 393
27.3.1 Surgical technique 393
27.4 Hysterectomy 394
27.4.1 Surgical technique 395
27.5 Surgical management of endometriosis 395
27.5.1 Surgical technique 396
27.6 Conclusion 396
References 396
28 Robotic-assisted surgery advances benefit patients 399
29 Gynecology-related general surgery 401
29.1 How do gastrointestinal injuries occur? 401
29.2 Management of the gastrointestinal injuries 401
29.2.1 Bowel injuries 401
29.2.2 Small bowel injuries 402
29.2.3 Large bowel injuries 403
29.2.4 Rectal injury 404
29.2.5 Stomach Injury 404
29.3 Prevention of gastrointestinal injury 405
References 405
30 Ophthalmology and steep Trendelenburg 407
30.1 Introduction 407
30.2 Posture-induced ocular changes 407
30.3 Post-operative ophthalmological complications 408
30.4 Ophthalmological patient management 409
30.4.1 Preoperative evaluation 409
30.4.2 Intraoperative period 410
30.4.3 Postoperative assessment 410
30.5 Conclusions 411
30.6 Acknowledgements 411
References 411
31 The future of telesurgery and new technology 413
31.1 Introduction 413
31.2 Technical description 415
31.3 First preclinical studies 417
References 417
Index 419