VectraOwnersManual Feb07

Sami G. Kilic, Kubilay Ertan, M. Faruk Kose (Eds.
)
Robotic Surgery
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Robotic Surgery
Practical Examples in Gynecology
Edited by
Sami G. Kilic, Kubilay Ertan, M. Faruk Kose
DE GRUYTER
Editors
Sami G. Kilic M. Faruk Kose
The University of Texas Medical Branch Bahcesehir University
School of Medicine School of Medicine
Department of Obstetrics and Gynecology Head of Obstetrics & Gynecology
Minimally Invasive Gynecology Liv Hospital Ulus
301 University Boulevard Ahmet Adnan Saygun Cad Canan Sok 12 Ulus
Galveston 34340 Istanbul
TX77555-0587 Turkey
United States mfarukkose@gmail.com
gokilic@utmb.edu
Kubilay Ertan
Klinikum Leverkusen gGmbH
Klinik fr Frauenheilkunde und Geburtsmedizin
Am Gesundheitspark 11
51375 Leverkusen
Germany
kubilay.ertan@klinikum-lev.de
ISBN 978-3-11-030655-2
e-ISBN 978-3-11-030657-6
Set-ISBN 978-3-11-030658-3
Library of Congress Cataloging-in-Publication data

A CIP catalog record for this book has been applied for at the Library of Congress.
Bibliographic information published by the Deutsche Nationalbibliothek

The Deutsche Nationalbibliothek lists this publication in the Deutsche Nationalbibliografie; detailed
bibliographic data are available in the Internet at http://dnb.dnb.de.
2014 Walter de Gruyter GmbH, Berlin/Boston
Typesetting: Compuscript Ltd, Shannon, Ireland

Printing and binding: Hubert & Co. GmbH & Co. KG, Gttingen
Cover image: Jupiterimages/Kollektion/Thinkstock
Printed on acid-free paper
Printed in Germany
www.degruyter.com
Preface
One must examine what concerns it, not only on the basis of the conclusion and the premises
on which the argument rests, but also on the basis of things said about it.
Aristotles Nicomachean Ethics
In this book, all the contributing authors agreed that this virtue must pertain to all
aspects of this new technique in gynecologic surgery. Having said that we all also
agreed that it was our obligation to share our experience with our colloquies the way
it was pointed out by Johann Wolfgang von Goethe earlier;
Knowing is not enough, we must apply

Willing is not enough, we must do
The way we practice changes parallel to the changes in technology in faster speed
more than ever. Our aim was to serve the latest, most updated developments in our
field in the essence of:
Try not to resist the changes that come your way. Instead let life live through you. And do not
worry that your life is turning upside down. How do you know that the side you are used to is
better than the one to come?
Rumi
Sami G. Kilic, Kubilay Ertan and M. Faruk Kose

October 2013
Acknowledgements
Sami G. Kilic:
I thank my wife, Banu, and sons, Emre and Burak, for allowing me to spend countless
hours away from home working on this book. I also thank my parents, Mete and Nezihe
Kilic, who encouraged me to always pursue excellence in life. I thank my mentors for
nurturing me in my career by giving endless hours of their time: Dr. Turgay Atasu,
Dr. Harrith M. Hasson, Dr. Ozay Oral, Dr. Hyung-Shik Kang, and Dr. Josef Blankstein.
Finally, I thank the administrative and support staff in UTMBs Department of Obs-
tetrics & Gynecology for editorial and organizational assistance: Misty Byrd, LeAnne
Garcia, Alan Sheffield, and Robert G. McConnell, who applied tireless and meticulous
effort to this project.
Kubilay Ertan:
My thanks go first of all to my patients who gave me their full confidence and made
this project possible. I am especially thankful for all the European contributions to
this book. Many thanks go also to Dr. Alexander di Liberto for his steadfast support
and diligent work as my colleague, a surgeon, and a scientist. I wish to thank my
wife, Dr. Anke Ertan, my daughters, Lara and Samira, and my son, Tarkan, for their
patience while I spent innumerable hours working on this book. I am grateful to have
them at my side. Finally, thank you to the de Gruyter Verlag, especially Dr. Sven Fund
and Dr. Alexander Grossmann for their friendly cooperation and support.
M. Faruk Kose:
I would like to thank my wife Gulsen who supported me during my medical and marri-
age life. In addition, thanks to my daughter, Pinar and my son, Orhun who has shown
the inspiration and support. I would like to express the deepest appreciation to my
excellent mentors team, especially starting with Firat Ortac, MD, Demir Ozbasar, MD,
Rifat Gursoy, MD, Cihat Unlu, MD, and Esat Orhon, MD who have shown their tre-
mendous desire to teach the residency of obstetrics and gynecology. I also wish to
thank all prominent colleagues for taking time to put a state of art work in this book
as an author.
Index of authors
Silvia Agramunt Ibrahim Alanbay

Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology
Gynecologic Oncology Unit Glhane Military Medical Academy School
Hospital del Mar General Tevfik Salam Cad.
Parc de Salut Mar 06010 Ankara
Paseo Maritimo 25 Turkey
08003 Barcelona ialanbay@gata.edu.tr
Spain ialanbay@gmail.com
silvia.agramunt@gmail.com Chapters 8, 21, 25
sagramunt@parcdesalutmar.cat
Chapter 16 Omer Burak Argun
Department of Urology
Sarfraz Ahmad Acibadem Maslak Hospital
Florida Hospital Gynecologic Oncology Bykdere cad. No:40
Florida Hospital Cancer Institute 34457 Maslak, Sariyer
2501 N. Orange Avenue Istanbul
Orlando Turkey
FL 32804 drburakargun@gmail.com
United States Chapter 24
sarfraz.ahmad@flhosp.org
Chapter 18 Banu Arun
Co-Director Clinical Cancer Genetics
Ahmed Sekotory M. Ahmed Breast Medical Oncology
Department of Gynaecology Oncology University of Texas MD Anderson Cancer Center
The Christie NHS Foundation Trust 1155 Pressler Street
550 Wilmslow Road Houston
Manchester TX 77030
M20 4BX United States
United Kingdom barun@mdanderson.org
ashamed@doctors.org.uk Chapter 21
Chapter 10
Masoud Azodi
Bahriye Aktas Department of Obstetrics, Gynecology, and
Department of Gynecology and Reproductive Sciences
Obstetrics Gynecologic Oncology Section
University Clinic Essen Yale University School of Medicine
West German Cancer Center 333 Cedar Street, FMB 332
University of Duisburg-Essen New Haven
Hufelandstrae 55 CT 06510
45147 Essen United States
Germany masoud.azodi@yale.edu
bahriye.aktas@uk-essen.de Chapter 22
Chapter 23
x Index of authors
Eralp Baer Alexander di Liberto

Department of Gynecologic Oncology Department of Gynaecology and Obstetrics
Zekai Tahir Burak Womens Health Education Leverkusen Municipal Hospital
and Research Hospital Am Gesundheitspark 11
Talatpaa bulvar 51375 Leverkusen
PK 06230, Altnda Germany
Ankara alexander.diliberto@klinikum-lev.de
Turkey Chapters 6, 11
eralpbaser@gmail.com
Chapter 3 Gregory L. Eads
Head of The Southwestern Robotic Surgery
Mostafa A. Borahay
Epicenter
Department of Obstetrics & Gynecology
1120 Medical Plaza Dr, Suite 200
The University of Texas Medical Branch
The Woodlands
at Galveston
TX 77380
301 Univeristy Boulevard
United States
Galveston
ge1295@yahoo.com
TX 77555-0587
Chapter 9
United States
maboraha@utmb.edu
Chapters 2, 5, 26
Cihangir Mutlu Ercan
Kristina A. Butler Gulhane Military Medical Faculty
Mayo Clinic Arizona Department of Obstetrics and Gynecology
5779 E Mayo Boulevard School of Medicine
Phoenix Tevfik Salam Cd. Etlik
AZ 85054 Keiren
United States 06018 Etlik
kbutler@mayo.edu Ankara
Chapter 17 Turkey
ercanmutlu@yahoo.com
Sai Daayana Chapter 19
Department of Gynaecology Oncology
The Christie NHS Foundation Trust Ilknur Erguner
550 Wilmslow Road Department of General Surgery
Manchester Acibadem University School of Medicine
M20 4BX Bykdere Cad. No:40
United Kingdom Maslak Sariyer
saidaayana@yahoo.co.uk 34457 Istanbul
Chapter 10 Turkey
Murat Dede ilknurerenler@hotmail.com
Department of Obstetrics and Gynecology Chapter 29
Gulhane Military Medical Faculty
School of Medicine Kubilay Ertan
Tevfik Salam Cd. Etlik Department of Gynaecology and Obstetrics
Keiren Leverkusen Municipal Hospital
06018 Etlik Am Gesundheitspark 11
Ankara 51375 Leverkusen
Turkey Germany
mdede@gata.edu.tr kubilay.ertan@klinikum-lev.de
Chapter 19 Chapters 6, 11
Index of authors xi
Jeffrey M. Fowler Ismail Hakki Hamzaoglu

Department of Obstetrics and Gynecology Department of General Surgery
The Ohio State University Wexner Maslak Acibadem Hospital
Medical Center Bykdere Cad. No:40
210m-SL Maslak Sariyer
320 W. 10th Ave 34457 Istanbul
Columbus OH 43210 Turkey
jeffrey.fowler@osumc.edu ihhamzaoglu@yahoo.com
Chapter 7 Chapter 29
Stefano Gidaro Martin Heubner

Clinical Validation Department of Gynecology and
Telelap-Alf-x-Project Obstetrics
SOFAR S.p.A. University Clinic Essen
Milan West German Cancer Center
Italy University of Duisburg-Essen
s.gidaro@libero.it Hufelandstrae 55
Chapter 31 45147 Essen
Germany
Ahmet Gmen martin.heubner@uk-essen.de
Department of Obstetrics and Gynecology Chapter 23
mraniye Education and Research Hospital
Adem Yavuz Cd. No.1 Robert W. Holloway
mraniye 34766 Florida Hospital Gynecologic Oncology
Istanbul Florida Hospital Cancer Institute
Turkey 2501 N. Orange Avenue
gocmenahmet@yahoo.com Orlando
Chapters 13, 14 FL 32804
United States
Murat Gltekin robhollowaymd@gmail.com
Cancer Control Department Chapter 18
Turkish Ministry of Health
lkiz Sok.No: 4/2 Shhiye Gustavo N. C. Inoue
PK 06430 Medical School
Cankaya University of So Paulo
Ankara Dr. Arnaldo Avenue, 455
Turkey 01246-000 So Paulo
murat.gultekin@thsk.gov.tr Brazil
Chapter 3 gustavo.inoue@usp.br
Chapter 27
Mete Gungor
Department of Obstetrics and Gynecology James E. Kendrick IV
School of Medicine Florida Hospital Gynecologic Oncology
Acibadem University Florida Hospital Cancer Institute
Acibadem Maslak Hospital 2501 N. Orange Avenue
Buyukdere cad. 40, 34457, Sariyer Orlando
Istanbul FL 32804
Turkey United States
mtgungor@gmail.com tkendrick2@gmail.com
xii Index of authors
Sami G. Kilic Eric Lambaudie

Department of Obstetrics and Gynecology Department of Surgery
School of Medicine Paoli Calmettes Institute
The University of Texas Medical Branch 232 Bd Sainte Marguerite
Minimally Invasive Gynecology 13009 Marseille
301 University Boulevard France
Galveston lambaudiee@ipc.unicancer.fr
TX 77555-0587 Chapter 3
United States
Yu Lee
gokilic@utmb.edu
Medical Branch at Galveston
Chapters 2, 4, 8, 14, 25, 26
The University of Texas
301 Univeristy Boulevard
Rainer Kimmig
Galveston
Department of Gynecology and
TX 77555
Obstetrics
United States
University Clinic Essen
yulee1@gmail.com
West German Cancer Center
yu.lee@phhs.org
University of Duisburg-Essen
yu.lee@utsouthwestern.edu
Hufelandstrae 55
yulee1@gmail.com
45147 Essen
Chapter 4
Germany
rainer.kimmig@uk-essen.de Lyuba Levine
Chapter 23 Department of Obstetrics and Gynecology
University of Texas Medical Branch at Galveston
M. Faruk Kose 301 Univeristy Boulevard
Head of Obstetrics & Gynecology Galveston
School of Medicine TX 77555-0857
Bahcesehir University United States
Liv Hospital Ulus lylevine@utmb.edu
Ahmet Adnan Saygun Cad Canan Sok 12 Ulus Chapter 20
34340 Istanbul
Javier F. Magrina
Turkey
Mayo Clinic Arizona
mfarukkose@gmail.com
5779 E Mayo Boulevard
Chapter 1
Phoenix
AZ 85054
Ali Riza Kural
United States
Head of Robotic Surgery and
jmagrina@mayo.edu
Urology Department
Chapter 17
Maslak Hospital
Acibadem University Georgia Mccann
Bykdere cad. No:40 Division of Gynecologic Oncology
34457 Maslak Saiyer Department of Obstetrics and Gynecology
Istanbul The University of Texas Health Science Center at
Turkey San Antonio
arkural@gmail.com 7703 Floyd Curl Dr.
Chapter 24 Mail code 7836
San Antonio
TX 78229
United States
georgia.a.mccann@gmail.com
Chapter 7
Index of authors xiii
Camran Nezhat Pooja R. Patel

Center for Minimally Invasive and Robotic Department of Obstetrics & Gynecology
Surgery Medical Branch at Galveston
Stanford University Medical Center The University of Texas
900 Welch Road, Suite 403 301 Univeristy Boulevard
Palo Alto Galveston
CA 94304 TX 77555
United States United States
drnezhat@gmail.com popatel@utmb.edu
Hiep T. Nguyen
Department of Urology Thomas N. Payne
Boston Childrens Hospital Medical Director
300 Longwood Avenue HU 353 Texas Institute for Robotic Surgery
Boston 12221 Renfert Way
MA 02115 Austin
United States TX 78758
hiep.nguyen@childrens.harvard.edu United States
Chapter 27 tnpayne@hotmail.com
Chapter 9
Can Obek John Y. Phelps

Department of Urology Medical Branch at Galveston
Cerrahpasa School of Medicine The University of Texas
Istanbul University 301 Univeristy Boulevard
Istanbul 34098 Galveston
Turkey TX 77555
canobek@yahoo.com United States
Chapter 24 jyphelps@utmb.edu
Chapter 4
Fikret Fatih nol
Urology Clinic Pedro T. Ramirez
mraniye Training & Research Hospital Director of Minimally Invasive Surgical Research
Adem Yavuz Cd. No.1 & Education
mraniye 34766 Department of Gynecologic Oncology
Istanbul The University of Texas MD Anderson Cancer
Turkey Center
ffonol@yahoo.com 1515 Holcombe Boulevard Unit 1362
Chapter 25 Houston
TX 77030
Chandhana Paka United States
Center for Minimally Invasive and Robotic peramire@mdanderson.org
Surgery Chapter 16
Stanford University Medical Center
900 Welch Road, Suite 403
Palo Alto
CA 94304
United States
paka.chandhu@gmail.com
Chapter 12
xiv Index of authors
Gwyn Richardson Dan-Arin Silasi

Medical Branch at Galveston Division of Gynecologic Oncology
The University of Texas Department of Obstetrics, Gynecology &
301 Univeristy Boulevard Reproductive Sciences
Galveston Yale University School of Medicine
TX 77555 333 Cedar Street
United States New Haven
gwrichar@utmb.edu CT 06520
Chapter 20 United States
dan-arin.silasi@yale.edu
Emilio Ruiz Morales Chapter 22
ALF-X Surgical Robotics Department
SOFAR S.p.A. Michael Stark
Via Firenze 40 The New European Surgical Academy (NESA)
2060 Trezzano Rosa (MI) Unter den Linden 21
Italy 10117 Berlin
emilio.ruiz@sofarfarm.it Germany
Chapter 31 mstark@nesacademy.org
Chapter 31
Fatih anlikan
Department of Obstetrics and Gynecology Giovanni Taibbi
mraniye Education and Research Hospital Department of Ophthalmology and Visual
Adem Yavuz Cd. No.1 Sciences
mraniye 34766, The University of Texas Medical Branch
Istanbul 301 Univeristy Boulevard
Turkey Galveston
fatihroland@hotmail.com TX 77555-1106
Chapters 13, 14 United States
gitaibbi@utmb.edu
Fatih Sendag Chapter 30
Chief of Minimally Invasive Gynecology
Department of Obstetrics and Gynecology Omer Lutfi Tapisiz
Ege University Department of Gynecologic Oncology
Cemal Grsel Cad. N.436 Etlik Zubeyde Hanim Womens Health
olak Ap. 4/7 Training and Research Hospital
Karyaka Yeni Etlik Caddesi, No:55
zmir Etlik, 06680
Turkey Ankara
fatih.sendag@gmail.com Turkey
Chapter 21 omertapisiz@yahoo.com.tr
Chapter 8
Index of authors xv
Courtney M. Townsend, Jr. Mfit Cemal Yenen

Department of Surgery Gulhane Military Medical Faculty
Medical Branch at Galveston Department of Obstetrics and Gynecology
The University of Texas School of Medicine
301 Univeristy Boulevard Tevfik Salam Cd. Etlik
Galveston Keiren
TX 77555 06018 Etlik
United States Ankara
ctownsen@utmb.edu Turkey
Chapter 28 mcyenen@gata.edu.tr
mcyenen@gmail.com
Gianmarco Vizzeri Chapter 19
Department of Ophthalmology
and Visual Sciences Mjdegl Zayfolu Karaca
The University of Texas Medical Branch Department of Cancer Control
301 Univeristy Boulevard Turkish Ministry of Health
Galveston lkiz Sok.No: 4/2 Shhiye
TX 77555-1106 PK 06430
United States Cankaya
givizzer@utmb.edu Ankara
Chapter 30 Turkey
mujdegul.karaca@thsk.gov.tr
Chapter 3
Contents
Preface v
Acknowledgements vii
Index of authors ix
Part I: Basics 1
1 Robotic gynecologic surgery introduction 3

M. Faruk Kose
1.1 History 3
1.2 Robotics systems 4
1.3 Endoscopic surgery in gynecology 7
1.4 The advantages of robotic surgery 9
1.5 Limitations of robotic surgery 9
1.6 Telemedicine and robotic surgery: future aspects 9
1.7 Final suggestions 10
References 10
2 Launching a successful robotic program 13

Mostafa A. Borahay and Sami G. Kilic
2.1 Introduction 13
2.2 Phases of a successful robotic gynecologic program 13
2.2.1 Planning phase 13
2.2.2 Implementation phase (learning curve or initial
robotic program) 18
2.2.3 Evolving program 18
2.3 Academic activities 20
2.3.1 Education 20
2.3.2 Research 21
2.4 Financial analysis 21
2.5 Conclusion 22
References 22
3 Financial analysis of robotic surgery in gynecology 23

Eralp Baer, Mjdegl Zayfolu Karaca, Eric Lambaudie
and Murat Gltekin
3.1 Introduction 23
3.2 Cost of robotic surgery 23
3.3 Cost effectiveness of robotic surgery vs. laparoscopic
and open approaches 24
xviii Contents
3.4 Coverage of robotic surgery by health systems 27

3.5 How to use robotics more cost efficiently? 28
3.6 Conclusion 28
References 28
4 Training and credentialing in robotic gynecologic surgery

and legal issues 31
John Y. Phelps, Yu Lee and Sami G. Kilic
4.1 Introduction 31
4.2 Training and credentialing 31
4.2.1 Training 31
4.2.2 Credentialing 32
4.3 Legal issues 33
4.3.1 Components of medical malpractice 33
4.3.2 Insufficient training and credentialing legal issues 33
4.3.3 Robotic proctors and legal issues 34
4.4 Conclusion 35
References 35
5 Patient positioning, trocar placement, and docking for robotic

gynecologic procedures 37
Mostafa A. Borahay
5.1 Introduction 37
5.2 Importance of proper patient positioning and trocar placement 37
5.3 Patient positioning 38
5.3.1 Principles of patient positioning 38
5.4 Trocar placement 41
5.4.1 Peritoneal access 41
5.4.2 Trocar placement 41
5.5 Initial survey 45
5.6 Docking 45
5.6.1 Docking types 46
5.7 Conclusion 46
References 47
6 Role of the robotic surgical assistant 49

Alexander di Liberto and Kubilay Ertan
6.1 The surgeon in the area of conflict between autonomy
and dependency 49
6.2 Tasks of the robotic surgical assistant 50
6.2.1 Tasks of the robotic surgical assistant previous to the beginning
of the surgical intervention 50
Contents xix
6.2.2 Tasks of the robotic surgical assistant between beginning

of the surgery and start of the console phase 52
6.2.3 Tasks of the robotic surgical assistant during the
console phase 52
6.2.4 Tasks of the robotic surgical assistant after
termination of the console phase until
the skin closure 55
6.3 Selection criteria of the robotic surgical assistant 55
6.4 Training/education of the robotic surgical assistant 56
6.4.1 Practical and virtual simulation/simulator systems 57
6.4.2 Training programs request and reality 58
6.5 Aspects of spatial arrangement and structures
of communication 59
6.6 Available data relating to the role of the robotic surgical
assistant/existing evidence 62
6.7 Conclusions 63
References 64
7 Strategies for avoiding complications from robotic

gynecologic surgery 67
Georgia A. Mccann and Jeffrey M. Fowler
7.1 Introduction 67
7.2 Patient positioning prevention of neurologic injuries 68
7.3 Complications of pneumoperitoneum and steep
Trendelenburg 70
7.4 Robotic equipment 71
7.4.1 Electrosurgical principles 71
7.4.2 Monopolar electrosurgery 71
7.4.3 Bipolar electrosurgery 73
7.5 Avoiding surgical complications 73
7.5.1 Avoiding port complications 74
7.5.2 Gastrointestinal complications 75
7.6 Genitourinary complications 76
7.6.1 Bladder 76
7.6.2 Ureter 77
7.7 Complications of pelvic and para-aortic lymph node
dissection 78
7.8 Incisional hernia 79
7.9 Vascular injuries 80
7.10 Vaginal cuff dehiscence 81
7.11 Summary 81
References 82
xx Contents
Part II: General gynecology 87
8 Robotically-assisted simple hysterectomy 89

Sami Gokhan Kilic, Omer L. Tapisiz and Ibrahim Alanbay
8.1 Introduction 89
8.1.1 Background 89
8.1.2 Robotic hysterectomy vs. laparoscopy: surgical outcomes 91
8.1.3 Cost analysis 95
8.2 Robot-assisted simple hysterectomy procedure 95
8.2.1 Positioning the patient 95
8.2.3 Docking 97
8.2.4 Instrument selection 99
8.2.5 Step-by-step approach to simple hysterectomy 99
8.2.6 New innovative techniques for robotic hysterectomy: robotic surgery to
laparoendoscopic single-site surgery (R-LESS) 106
8.3 Comment 107
References 107
9 Approach to the big uterus for hysterectomy 111

Gregory L. Eads and Thomas N. Payne
9.1 Introduction 111
9.2 How large is possible? 111
9.3 Technique 112
9.4 Creating the bladder flap 112
9.5 Approach to vessels 113
9.6 Making the colpotomy 113
9.7 Tissue removal 114
References 115
10 The difficult robotic hysterectomy 117

Sai Daayana and Ahmed Sekotory M. Ahmed
10.2 The scenarios of difficult and complex hysterectomy 117
10.3 Patients selection for robotic hysterectomy 118
10.4 Pre-operative preparation for a difficult hysterectomy 119
10.5 Technical operative factors and considerations 119
10.5.1 Anesthesia considerations 119
10.5.2 Following induction of anesthesia 120
10.5.3 Patient positioning 120
10.5.4 Entry 121
10.5.5 Uterine manipulation 122
Contents xxi

10.5.7 Docking 124
10.5.8 Steps of robotic hysterectomy 124
10.6 General considerations 126
10.6.1 Choice of instruments 127
10.6.2 How to avoid trocar site hernia? 127
10.6.3 How to avoid losing pneumo peritoneum? 128
10.6.4 How to avoid vaginal cuff infection/dehiscence? 128
10.6.5 Data collection 129
10.6.6 Learning curve 129
10.6.7 Continuing professional development 129
References 129
11 Robot-assisted laparoscopic myomectomy (RALM) 131

Kubilay Ertan and Alexander di Liberto
11.1 Principles of surgical therapy of uterine myomas 131
11.2 Patient selection for robot-assisted laparoscopic
myomectomy (RALM) 134
11.3 Technical and logistic aspects of robot-assisted myomectomies 134
11.3.1 Patient positioning 134
11.3.2 Equipment 135
11.3.3 Selection of robotic instruments (EndoWrist instruments) 136
11.3.4 Uterine manipulation 137
11.3.6 Operation schedule for RALM 138
11.3.7 Camera work (0 vs. 30 endoscope) 140
11.3.8 Features and characteristics of robot-assisted myomectomy 140
11.3.9 Suturing techniques and suture material 141
11.3.10 Adhesion prophylaxis 141
11.3.11 Intraabdominal asservation/storage of removed myomas 142
11.4 Advantages of robotic assistance concerning
myomectomies 142
11.5 Disadvantages and deficiencies of robotic assistance concerning
myomectomy 143
11.6 Preoperative preparations/perioperative management 143
11.6.1 Indications for robot-assisted myomectomy 143
11.6.2 Organ-specific diagnostics 146
11.6.3 Medicamentous pretreatment 146
11.6.4 Preparation of the surgery 148
11.6.5 Patient information and informed consent 149
11.7 Recommendations for further diagnostics and treatment/time interval
to pregnancy/mode of delivery 149
xxii Contents
11.8 Case studies 150

11.9 Authors data of robot-assisted myomectomy 152
11.10 Available data from robot-assisted myomectomies/
existing evidence 155
11.11 Summary and conclusion 157
References 158
12 Endometriosis: robotic-assisted laparoscopic surgical

approaches 161
Chandhana Paka and Camran Nezhat
12.2 Application to endometriosis 161
12.3 Surgical approach 162
12.4 Lysis of adhesions 163
12.5 Peritoneal and tubo-ovarian endometriosis 163
12.6 Intestinal endometriosis 164
12.7 Genitourinary endometriosis 166
12.8 Diaphragmatic and thoracic endometriosis 168
12.9 Hepatic endometriosis 169
12.10 Conclusion 169
References 170
13 Robotic-assisted tubal reanastomosis 175

Ahmet Gmen and Fatih anlkan
13.2 Surgical technique 176
13.2.1 Positioning of the robotic surgical system 176
13.2.2 Robotic-assisted tubal reversal procedure 177
13.3 The surgical outcomes of robotic-assisted tubal reversal 178
References 180
14 Robotic-assisted abdominal cerclage 181

Ahmet Gmen, Fatih anlkan and Sami Gokhan Kilic
14.2 Operative technique 181
14.3 Outcomes 183
References 184
15 Single-port robotic surgery 187

Mete Gungor
15.2 Surgical technique 189
Contents xxiii
15.3 Discussion 191

15.4 Conclusion 193
References 193
Part III: Gynecologic onocology 195
16 Update on robotic surgery in the management of

cervical cancer 197
Silvia Agramunt and Pedro T. Ramirez
16.2 Early-stage disease 197
16.2.1 Radical hysterectomy 197
16.2.2 Radical trachelectomy 201
16.3 Locally advanced disease 203
16.4 Incidental invasive cervical cancer: robotic-radical
parametrectomy 204
16.5 Conclusions 205
References 206
17 Robotic-infrarenal aortic lymphadenectomy: A step-by-step

approach 209
Kristina A. Butler and Javier Magrina
17.2 Patient selection 209
17.3 Advantages 211
17.4 Approaches 211
17.5 Transperitoneal techniques 212
17.5.1 Midline approach, pelvic trocars, no table rotation 212
17.5.2 Midline approach, pelvic trocars, 180 table rotation 212
17.5.3 Midline approach, subcostal trocars 214
17.5.4 Left lateral approach 216
17.6 Extraperitoneal technique 216
17.7 Conclusion 217
References 217
18 Robotic-pelvic and aortic lymphadenectomy for gynecologic

malignancies one approach 221
James E. Kendrick IV, Sarfraz Ahmad and Robert W. Holloway
18.2 The rationale for lymphadenectomy 221
18.3 The minimally-invasive shift 222
18.4 Operating room set-up and patient preparation 223
xxiv Contents
18.5 Surgical technique for center-docked robotic-assisted aortic

lymphadenectomy 226
18.6 Surgical technique for robotic-assisted pelvic
lymphadenectomy 228
18.7 Comparative studies 230
18.8 Managing obese patients with endometrial cancer 230
18.9 Future directions 232
References 233
19 Robotic-extraperitoneal lymphadenectomy: A step-by-step

approach 237
Murat Dede, Mfit Cemal Yenen and Cihangir Mutlu Ercan
19.2 Robotic-assisted retroperitoneal laparoscopic para-aortic
lymphadenectomy: Technique 239
19.2.1 Informed consent 239
19.2.2 Examination under anesthesia and cystoscopy 239
19.2.3 Position of patient 240
19.2.4 Diagnostic laparoscopy 240
19.2.5 Entering the extraperitoneal space with intraperitoneal laparoscopic
guidance 241
19.2.6 Placement of balloon trocar and the formation of the
retroperitoneal space 241
19.2.7 Placement of surgical trocars into the retroperitoneal
space 241
19.2.8 Formation of the surgical plan at the retroperitoneal space 242
19.2.9 Left aortic and paracaval nodal dissection 242
19.2.10 Marsupialization of the retroperitoneal space 243
19.3 Conclusion 243
References 245
20 Robotic surgery for ovarian cancer 249

Lyuba Levine and Gwyn Richardson
20.2 Benefits of minimally-invasive surgery 250
20.3 Low-malignant potential or borderline ovarian tumors 250
20.4 Early-stage invasive ovarian cancer 252
20.5 Advanced stage invasive ovarian cancer 254
20.6 Considerations 254
References 256
Contents xxv
21 Risk-reducing bilateral salpingo-oopherectomy in BRCA

mutations career 259
Ibraham Alanbay, Banu Arun and Fatih Sendag
21.1 BRCA1/2 mutations 259
21.2 Risk reducing strategies 259
21.3 Risk reducing salpingo-oopherectomy (RRSO) 260
21.4 Time of RRSO 262
21.5 Primary peritoneal carcinoma after RRSO 262
21.6 Occult cancer at the time of RRSO 263
21.7 Health proplems after RRSO 264
21.8 Technique of RRSO 264
21.9 RRSO with/without hysterectomy 264
21.10 Radical fimbriectomy: As a new temporary risk
reducing surgery 265
21.10.1 Laparoendoscopic single port surgery (LEES) for RRSO 265
21.11 Pathologic examination of tuba 266
21.12 Complication of RRSO 267
21.13 Surveilance 267
21.14 Cost analysis 268
References 268
22 Robotic surgery for uterine cancer 273

Dan-Arin Silasi and Masoud Azodi
22.1 Epidemiology 273
22.2 Presentation 273
22.3 Surgical treatment 273
22.4 Preoperative evaluation 274
22.5 Surgical staging 274
22.6 Patient positioning 275
22.7 Pneumoperitoneum, port placement,
and instruments 275
22.8 Anesthesia concerns 276
22.9 Pelvic lymphadenectomy 277
22.10 Para-aortic lymphadenectomy 279
22.11 Omentectomy 282
22.12 Extrafascial hysterectomy 284
22.13 Closure of the vaginal apex 285
References 285
xxvi Contents
23 Compartment-based radical surgery: The TMMR, FMMR

and PMMR family in uterine cancer 287
Rainer Kimmig, Bahriye Aktas and Martin Heubner
23.2 Therapeutic pelvic and periaortic lymphadenectomy
(rtLNE) 288
23.3 Total mesometrial resection (rTMMR) 297
23.4 Fertility preserving mesometrial resection (rFMMR) 305
23.5 Peritoneal mesometrial resection (rPMMR) 307
Acknowledgements 316
References 316
Part IV: Urogynecology 319
24 Robotic surgery for urogynecologic diseases 321

Omer Burak Argun, Can Obek and Ali Riza Kural
24.2 Robotic-vesicovaginal fistula repair 321
24.3 Robotic ureteral reconstructive surgery 322
24.4 Robot-assisted laparoscopic sacrocolpopexy (RALS) 323
References 325
25 Robotic sacrocolpopexy for the management of uterine

and vaginal vault prolapse 327
Sami Gokhan Kilic, Ibrahim Alanbay and Fikret Fatih Onol
25.2 Evaluation and surgical indications 328
25.3 Technique and concomitant procedure 329
25.3.1 Preoperative preparation 329
25.3.2 Patient positioning and initial preparation 329
25.3.3 Access and port placement 330
25.3.4 Surgical technique 332
25.3.5 Sacral dissection 333
25.3.6 Anterior dissection 335
25.3.7 Posterior dissection 336
25.3.8 Mesh preparation 337
25.3.9 Follow-up 341
25.4 Outcomes and complications 342
25.4.1 Anatomical and functional outcomes of RASC 342
25.4.2 Complications 345
25.4.3 Disadvantages 345
Contents xxvii
25.5 Conclusion 346

References 346
26 Robotic-retropubic urethropexy 349

Sami Gokhan Kilic, Pooja R. Patel and Mostafa A. Borahay
26.2 Midurethral sling versus robotic retropubic urethropexy 349
26.3 Evolution of the robotic Burch colposuspension 350
26.4 Step-by-step description of the robotic-assisted Burch
colposuspension 351
26.4.1 Preoperative planning 351
26.4.2 Positioning the patient and Foley insertion 351
26.4.3 Docking 351
26.4.4 Trocar insertion 352
26.4.5 Concomitant procedures 352
26.4.6 Repositioning the patient 352
26.4.7 Retrograde filling of the bladder 352
26.4.8 Dissection to create the retropubic space of Retzius 353
26.4.9 Identification of urethro-vesicular junction (UVJ) using
hand in the vagina 353
26.4.10 Suturing 353
26.4.11 Cystoscopy 354
References 356
Part V: Specialties 359
27 Pediatric gynecology for robotic surgery 361

Gustavo N. C. Inoue and Hiep T. Nguyen
27.2 Sling procedure for bladder outlet incompetence 361
27.3 Vaginoplasty 365
27.4 Hysterectomy 366
27.5 Surgical management of endometriosis 367
27.6 Conclusion 368
References 368
xxviii Contents
28 Robotic-assisted surgery advances benefit patients 371

Courtney M. Townsend, Jr.
29 Gynecology-related general surgery 373

Ilknur Erguner and Ismail Hakki Hamzaoglu
29.1 How do gastrointestinal injuries occur? 373
29.2 Management of the gastrointestinal injuries 373
29.2.1 Bowel injuries 373
29.2.2 Small bowel injuries 374
29.2.3 Large bowel injuries 375
29.2.4 Rectal injury 376
29.2.5 Stomach Injury 376
29.3 Prevention of gastrointestinal injury 377
References 377
30 Ophthalmology and steep Trendelenburg 379

Giovanni Taibbi and Gianmarco Vizzeri
30.2 Posture-induced ocular changes 379
30.3 Post-operative ophthalmological complications 380
30.4 Ophthalmological patient management 381
30.4.1 Preoperative evaluation 381
30.4.2 Intraoperative period 382
30.4.3 Postoperative assessment 382
30.6 Acknowledgements 383
References 383
31 The future of telesurgery and new technology 385

Emilio Ruiz Morales, Stefano Gidaro and Michael Stark
31.2 Technical description 387
31.3 First preclinical studies 389
References 389
Index 391
Part I: Basics
1 Robotic gynecologic surgery introduction
M. Faruk Kose
There is no excuse today for the surgeon to learn on the patient.

William J. Mayo, 1927
1.1History
The word robot (from the Czech word robota meaning compulsory labor) was defined
by the Robotic Institute of America (1979) as A reprogrammable, multifunctional
manipulator designed to move materials, parts, tools, or specialized devices through
various programed motions for the performance of a variety of tasks [1]. Leonardo
di ser Piero da Vinci (14521519), is famous as an artist, but he was also a scientist,
mathematician, engineer, inventor, anatomist, architect, botanist, musician and
writer, and is recorded as being the creator of the first robot in human form (1495).
The robot is a knight in appearance wearing the traditional outfit for the time, and
is clad in Italian-German medieval armour (Fig. 1.1). The design is likely to be based
on his anatomical research recorded in the Vitruvian Man (Fig. 1.2) [2, 3]. In 1738,
Jacques de Vaucanson began building an automata in Grenoble, France and created
a duck, called moving anatomy. The duck moved, quacked, flapped its wings
and even ate and metabolized food [4]. This was then followed by Joseph Marie
Jacquard (17521834) in 1801; Jacquard built an automated loom that was controlled
with punched cards. Punch cards were later used as an input method for some of the
20th centurys earliest computers [5, 6] (Fig. 1.3).
The acclaimed Czech playwright Karel Capek (18901938) was the first to use the
word robot in his play R.U.R. (Rossums Universal Robots) which opened in Prague
in January 1921. In R.U.R., Capek creates a paradise, where the machines initially
bring many benefits but in the end bring an equal amount of blight in the form of
unemployment and social unrest [7]. Isaac Asimov used the word robotics initially
in Runaround, a short story published in 1950. Asimov also proposed his three Laws
of Robotics, and he later added a zeroth law (Tab. 1.1) [8]. His laws refer to the pro-
tection of humanity above humans, that robots must obey humans unless it conflicts
with a higher law. These principles of safety, initially raised by Asimov, are applicable
for current robotic surgical systems.
The use of robots in surgical approaches has grown exponentially within the past 20
years. The first implementation of the robot in surgery was in neurosurgery [9], known as
the PUMA 560 (Staubli Corporation, Duncan, SC, USA). Meanwhile, at Imperial College in
London in 1988, urologists were performing transurethral resection of the prostate with
a robotic guidance system called PROBOT [10]. Subsequently in 1992, ROBODOC (Curexo
Technology Corporation, Sacramento, CA, USA) was used in orthopedic surgery for
4 1 Robotic gynecologic surgery introduction
Fig. 1.1: Model of Leonardos robot with inner workings, as displayed in Berlin. Photo by Erik Mller.
Leonardo da Vinci. Mensch Erfinder Genie exhibit, Berlin 2005. (Leonardos robot. From wikipedia, the
free encyclopedia. Accessed November 1, 2013 at http://en.Wikipedia.org/wiki/Leonardo % 27_robot)
aiding in total hip replacements [11]. All these robotic applications were passive models
with a preoperative plan or in a supervisory role and this would evolve into a more active
one, known as robotic telepresence technology. The robotic telepresence technology was
developed under the auspices of the military to allow surgeons to perform surgery on
injured soldiers from a safe and remote location. Soon, research was also focused on
robotic surgery to further improvements in laparoscopic and minimally-invasive surgery
(MIS) for civilians. Although robotic telepresence surgery originated for cardiovascular
surgery [12], it was widely used for urologic and gynecologic surgeries.
1.2Robotics systems
The first application of robotic surgery in the civilian operating room was to assist
surgery in laparoscopic approaches with a voice-activated arm. This device was called
AESOP (Automated Endoscopic Systems for Optimal Positioning; Computer Motion,
Inc., Goleta, CA, USA). The second system was the ZEUS (Computer Motion, Inc.,
Goleta, CA, USA), which included three remotely controlled robotic arms that were
attached to the surgical table. Two handles housed in a workstation called a robotic
console control the arms that hold the surgical instruments. The robotic console can be
1.2Robotics systems 5
Fig. 1.2: The Vitruvian Man is a world-renowned drawing created by Leonardo da Vinci circa 1487 [3].
(Vitruvian Man. From wikipedia, the free encyclopedia. Accessed November 1, 2013 at http://
en.wikipedia.org/wiki/Vitruvian_man)
positioned anywhere in the operating room and provides the instrument controls and
three-dimensional (3D) vision with the aid of special glasses. The surgeon was moved
Fig. 1.3: The most famous image in the early history of computing [6]. (Joseph Marie Jacquard. From
wikipedia, the free encyclopedia. Accessed November 1, 2013 at http://en.wikipedia.org/wiki/
Joseph_Marie_Jacquard)
Tab. 1.1: Asimovs Laws of Robotics [8]
Law Zero: A robot may not injure humanity, or, through inaction, allow humanity to come to harm.
Law One: A robot may not injure a human being, or, through inaction, allow a human being to
come to harm, unless this would violate a higher order law.
Law Two: A robot must obey orders given it by human beings, except where such orders would
conflict with a higher order law.
Law Three: A robot must protect its own existence as long as such protection does not conflict
with a higher order law (k-4).
to a remote console for the first time with this system. In 1999, the first robotically assis-
ted gynecologic surgery was performed and reported with the Zeus robotic system [13].
The third, most sophisticated of the surgical robotic systems is the da Vinci
system (Intuitive Surgical Inc, Sunnyvale, CA, USA), represents the most signifi-
cant advancement in MIS of this decade. The U.S. Food and Drug Administration
(FDA) approved this device for abdominal surgeries in 2000. Robotic assisted lapa-
roscopic surgery (robotic surgery) was cleared in 2001 for urologic procedures in the
USA, in 2002 for thorascopically-assisted cardiotomy, and in 2004 for coronary reva-
scularization by the FDA. In April 2005, the da Vinci system was FDA-cleared for
1.3Endoscopic surgery in gynecology 7
Fig. 1.4: The da Vinci robot system. Copyright Intuitive Surgical, Inc.
gynecologic procedures based on preliminary evidence of safety and efficacy from

their early experience [14]. The standard three and four arm da Vinci units were
upgraded with a high definition vision 4-arm S system in 2006. The da Vinci
system utilization in gynecologic surgery has been rapidly improved in the last
5 years [15]. The da Vinci surgical system is composed of three parts: first, the sur-
geons console with two finger-controlled handles and foot pedals, allows control
of the robotic wristed instruments inside the patient; second, the surgical cart,
with four multi-joint robotic arms and EndoWrist instruments allows for seven
degrees of rotation; third, the vision cart (the camera) allows a 3D view of the surgi-
cal location (Fig. 1.4). After providing a pneumo-peritoneum, placing laparoscopic
ports, and docking the robot, the surgeon sits at a console and views the pelvis
with the 3D, high-definition vision system [16]. Robotic approaches in gynecologic
surgery, and the technical and medical subjects will be mentioned in detail in the
following chapters.
1.3Endoscopic surgery in gynecology
MIS often provides distinct, significant, consistently reproducible advantages com-

pared to open approaches including smaller incisions, reduced intraoperative blood
loss and postoperative pain, and shorter length of hospital stay [1719]. The first gyne-
cologic laparoscopy performed by Ott in Petrograd, evaluated the abdominal cavity
with a head mirror and an abdominal wall speculum in 1901 [20]. The International
Symposium of Gynecologic Endoscopy was original organized in 1964, and in the fol-
lowing years the laparoscopic tubal sterilization [21], intratubal gamete transfer [22],
and the other gynecologic procedures were documented [23]. The first laparoscopic
hysterectomy was reported by Harry Reich in 1989 [24] and the use of laparoscopy
to treat a variety of benign gynecological conditions was reported over the following
20 years. The introduction of robotic technology to assist these minimally-invasive

procedures has been shown to significantly improve outcomes [25, 26]. Robotic-
assisted surgery, also known as surgical telemanipulation or computer-assisted
surgery enables surgeons to overcome human limitations and eliminate handicaps
associated with conventional surgery and interventions [2529]. In the subspecialty
of gynecologic surgery for both benign and malign conditions, performing surgical
procedures with robotic systems has increased significantly in recent years. Many
general gynecologists have changed their approaches and prefer robotic surgery for
procedures such as hysterectomies, myomectomies, adnexal surgery, surgical treat-
ment for endometriosis and tubal anastomosis [3039]. Also, robots have been uti-
lized for sacrocolpopexies and fistula repairs in urogynecologic surgeries [4042].
Currently, robots have mostly been used in the field of gynecologic oncology, where
hysterectomies and lymphadenectomies for endometrial cancer staging, radical hys-
terectomies and trachelectomies for cervical cancer, and even for the staging and
debulking of early ovarian cancer are being increasingly performed with robotic
systems [4350] (Tab. 1.2).
Tab. 1.2: Gynecologic procedures performed with robotics
A.Reproductive surgery
Simple hysterectomy
Myomectomy
USO, BSO
Tubal reanastomosis
Ovariopexy, ovarian transposition
Resection of endometriosis
B.Reconstructive pelvic surgery
Burch procedure
Sacrocolpopexy
Bladder repair
Vesicovaginal fistule repair
C.Gynecologic oncology
Radical hysterectomy
Pelvic and paraaortic lymphadenectomy
Radical parametrectomy
Radical vaginal trachelectomy
Radical cystectomy
Ovarian cystectomy
Sentinel lymph node biopsy
Appendectomy
Omentectomy
Laparoscopic assisted vaginal hysterectomy (LAVH)
Laparoscopic assisted robotic vaginal hysterectomy (LARVH)
1.4The advantages of robotic surgery 9
1.4The advantages of robotic surgery
The advantages of robotic surgery compared to laparoscopy and open surgery inclu-
ded better visualization of the operating site with a 3D vision system, wristed ins-
trumentation, improved dexterity, ergonomic positioning allows comfort for the
surgeon with less hand fatigue and frustration, and eliminates hand tremors. The
robot fingertip hand control mechanism is intuitive, which means that the robotic
instruments move as the hands move. In addition, the robotic system eliminates the
fulcrum effect observed in laparoscopy in which a surgeon must move his hand in the
opposite direction to the intended location and provides intra-abdominal articulation
with most instruments, which allows for difficult laparoscopic or microsurgical move-
ments in seven different planes [5153]. The MIS becomes more accessible without
advanced laparoscopic training because of its short learning curve.
1.5Limitations of robotic surgery
The use of a robotic system has some limitations. The major disadvantage of robotic
surgery is the high cost of purchase, maintenance and instruments of the robotic system.
There is a significant difference in operative costs between open, laparoscopic, and
robotic surgery due to the added expense of particular equipment. The other major limi-
tation is the lack of tactile feedback or habits during the procedure, requiring the use of
visual marks. While this is initially noted to be a limitation, most quickly adapt heigh-
tened visual feedback from the magnified 3D vision system. The bulky size of both the
robotic unit and the console require a large operating room and limit the ability of surgi-
cal assistants to maneuver around the patient. As the system is attached to the patient,
the system must be undocked with any changes in position of the surgical table resulting
in increased operation time [52]. The need to train residents, attending surgeons and
the operating room personnel in the use of this system is another disadvantage of this
system. Finally, increased surgical operation time due to moving the robot to the opera-
ting table, docking or attaching the robotic arms to the trocars and prolonged console
time is another major limitation of these systems. Some side effects including anesthetic
complications can occur associated with increased operation time [53]. Further research
and development may improve these undesirable disadvantages.
1.6Telemedicine and robotic surgery: future aspects
Telemedicine is the use of telecommunication and information technologies in order

to provide clinical health care from a distance. In other words it is the use of medical
information exchanged from one site to another via electronic communications for
the health and education of the patient or healthcare provider and for the purpose of
improving patient care [54]. Telemedicine, specifically applied to surgical subspe-

cialties such as telesurgery, is the ability for a doctor to perform surgery on a patient
from a distance [55]. The first telerobotic remote surgical services were performed by
Anvari and colleagues in Canada in 2003. They designed a program by which the Zeus
TS microjoint system (Computer Motion Inc., Goleta, CA, USA) was set up 400 km
away from patient. Twenty-one laparoscopic surgeries were completed and surgeons
operated on the patients simultaneously with little time delay for communication and
signal reception [56]. Research and development on this subject continues. The possi-
bility of long-distance operations depends on the patients access to a robotic system
and personnel being available to put the ports. The da Vinci surgical system can the-
oretically be used to operate over long distances. Overall, developing telesurgical
technology that allows surgery remotely from a patient, may further improve patient
outcomes while presenting new options for the minimally-invasive management of
gynecologic pathology in the future.
1.7Final suggestions
Over the past three decades the field of gynecologic MIS has advanced rapidly. However,
the most substantial improvements have come with the presence of robotic surgery.
Currently, there is a lack of published knowledge about robotic gynecologic surgery.
Thus, we decided to design a book on robotic gynecologic surgery which illustrates the
information for the utilization of all professionals, especially general gynecologists,
urogynecologists, and gynecologic oncologists. Here readers can find detailed infor-
mation regarding robotic gynecologic surgery. We would like to thank all the contribu-
ting authors and to all those involved in aiding the publication of this book.
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2 Launching a successful robotic program
Mostafa A. Borahay and Sami G. Kilic
2.1Introduction
Over the last decade, robotic surgery has become an integral part of minimally-
invasive gynecologic programs in many parts of the world. Since FDA approval of the
da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale, CA, USA) for clinical use
in 2000 and, subsequently for hysterectomy in 2005, the new technology has been
rapidly adopted, with 2,462 da Vinci surgical systems (1,789 in the USA, 400 in Europe,
and 273 in the rest of world) installed as of September 30, 2012 [1]. However, the simple
purchase and installation of the robotic system do not necessarily lead to a success-
ful robotic surgery program. Rather a successful program with a maximized return on
investment (ROI) is more likely to be the outcome of a comprehensive approach inclu-
ding surgeons, hospital administration, and other stakeholders. It is the aim of this
chapter to describe such a comprehensive program.
2.2Phases of a successful robotic gynecologic program
A successful robotic gynecologic program advances through three phases: the plan-
ning phase, the implementation phase, and the evolving program (Fig. 2.1, Tab. 2.1). The
planning phase starts with an initial business analysis, recruitment and/or training of
staff, and other preparatory steps, ending with performing the first robotic case. The
implementation phase (also known as the learning curve) describes the initial robotic
program experience before reaching proficiency and full capacity. The goal should be a
short, seamless, and trouble-free implementation phase. Once proficiency is reached,
the established program enters the evolving program phase, where the focus should be
on maintenance and, equally important, expansion. Some programs stay in a protrac-
ted implementation phase and do not reach proficiency. This is a warning sign that the
program may not become cost effective, which if not swiftly addressed, may lead to its
stagnation. It is the goal of this discussion to build efficient and thriving programs.
2.2.1Planning phase
Planning is probably the most critical phase and sets the tone for the whole programs
future. It includes all preparatory steps to make sure the program is feasible, the launch is
smooth, and the program will thrive. Planning may last from a few months to more than
a year. Hospital leadership and lead surgeons (first robotic surgeons in each specialty at
a certain hospital, discussed in details in section 2.2.14) should work closely during this
phase.
14 2 Launching a successful robotic program
Number of Cases
Planning Phase Implementation Phase Evolving Program

(Learning Curve) Phase
Fig. 2.1: Phases of a successful robotic program
Tab. 2.1: Phases of a successful robotic gynecologic program
I. Planning phase
Business plan
Forming an interdisciplinary robotic steering committee
Hiring a robotic coordinator
Lead surgeon
Establishing institutional physician credentialing guidelines
Building a robotic team
OR optimization
Marketing
Database building
Acquisition of a robotic system
II. Implementation phase (learning curve)
III. Evolving program

Improving OR efficiency
Growth
Ongoing evaluation of financial position and cost effectiveness
Further marketing
Continuous education and in-service training
Peer review of cases for case selection, operative time, morbidity and mortality
Participation in quality control programs and designation as excellence center
2.2.1.1Business plan
For hospitals, the acquisition of the da Vinci surgical system represents a substantial
investment. With a price tag of $12.3 million for the system alone, in addition to
$100,000$170,000 in annual maintenance costs [1], the system requires a well-
designed business plan to recapture these costs and maintain a satisfactory return on
investment (ROI) for the hospital, especially in the current healthcare funding climate.
2.2Phases of a successful robotic gynecologic program 15
Therefore, adequate cost effectiveness studies, along with sound financial analysis,
should be completed beforehand. Costs include 1) the purchase of the robotic system,
2) system maintenance and instrument costs, 3) team member hiring and/or training
(surgeon, coordinator, and other staff), and 4) administrative and marketing costs.
Revenues include cases reimbursements and possibly research and/or training grants.
Revenue analysis should be based on projected robotic surgical volume, growth poten-
tial, and insurance reimbursements. The patient catchment area should be carefully
assessed, including potential competitors with currently existing robotic programs
as well as those planning to acquire it in the near future. One possible outcome of a
business analysis is the finding that the institutions best course is to postpone the
launch. In certain situations, it may be better to wait than to prematurely launch a
program. Finally, financial analysis should include a projected date for the program to
start having a positive operating margin (revenues exceeding costs).
2.2.1.2Forming an interdisciplinary robotic steering committee

Typically, institutional leadership makes the decision to proceed with establishing a
robotic program after initial financial analysis demonstrates that it will be financially
feasible, sustainable, and possibly profitable. At this point, it is advisable to form
a robotic program steering committee. This committee includes 1) representative(s)
from hospital administration; 2) surgeon champions from each specialty, including
anesthesiology; 3) a robotic program coordinator; 4) the OR director; 5) a nurse
as a representative of the robotic OR team; and 6) the institutions marketing vice
president (VP). The committees duties include, among others [2], 1) defining insti-
tutional physician credentialing guidelines; 2) deciding on OR robotic block time;
3) overseeing instrument purchases and maintenance; 4) observing physician and ser-
vices OR utilization and quality of care; 5) setting, monitoring, and modifying marke-
ting efforts; 6) writing and modifying clinical pathways; 7) developing, maintaining,
and improving the database; 8) setting and monitoring program expansion plans;
9) setting plans, organizing, and monitoring research activities; and 10) developing
and overseeing robotic surgery education [2]. The committee should meet as fre-
quently as is needed during the planning phase and quarterly thereafter. Committee
meetings constitute excellent opportunities for communication between surgeons
and hospital administration as well as interspecialty discussions.
2.2.1.3Hiring a robotics coordinator

The robotics coordinator is one of the key people in the robotic program. He/she is
the first contact for the da Vinci system and is responsible for system maintenance,
purchases, case scheduling, database development and updating, staff training,
coordinating with hospital administration as well as across specialties.
2.2.1.4Lead surgeon
The lead surgeon is a crucial member of the robotic team and has a significant impact
on the success of the whole program. He/she takes a leadership role and communica-
tes with other team members as well as those outside the robotic team, e.g., hospital
leadership, patients, referring physicians, and the community. Two approaches for
appointing the lead surgeon include hiring a surgeon already trained in robotics or
training one of the institutions own surgeons [3]. The advantage of hiring a previ-
ously trained surgeon is avoiding the learning curve, or at least shortening it, while
a disadvantage is the higher expense associated with hiring. Once the lead surgeon
reaches the proficiency stage, he/she will be expected to train other surgeons and
encourage them to adopt robotic technology.
2.2.1.5Establishing institutional physician credentialing guidelines

While there are no nationwide or board-approved certification criteria for robotic surgery,
many hospitals have adopted institutional credentialing guidelines. This process is typi-
cally handled by the credentialing section in a hospitals medical staff office in collabo-
ration with the robotic steering committee. Intuitive Surgical has a certification process
[4] that many institutions adopt (or a modification of it). We propose the following modi-
fication of Intuitive Surgicals scheme: 1) online modules and didactic content addres-
sing basic robotic knowledge as well as trouble-shooting tutorials; 2) simulation exer-
cises and dry drives; 3) wet drives using an animal lab to become familiar with basic
robotic surgical skills; 4) observation of actual cases (typically 5) performed by other
surgeons, preferably with the opportunity to assist; 5) performance of proctored cases
where candidates perform a certain number of cases (typically 5) under supervision of
another experienced surgeon; and 6) subsequent performance of independent cases.
After a surgeon completes a certain number of cases (typically 20), Intuitive Surgical
adds the surgeons name to its online list of certified da Vinci surgeons.
Over the last few years, robotic surgery has become part of routine obstetrics
and gynecology residency training in US hospitals that have robotic programs with
adequate surgical volume. Although the residency review committee (RRC) currently
does not set minimum targets for robotic training during residency, many obstetrics
and gynecology residency graduates in the US are robotically trained and ready to
practice at the time of graduation.
2.2.1.6Building a robotic team

Begin by training a complete robotic team, including a surgical technician and
circulating nurse in addition to the lead surgeon and a robotic-oriented anesthesio-
logist. Orienting one or more hospital coders about reimbursement in robotic cases
is also important. It is advisable that team members meet at least once before the
first case to make sure everyone is familiar with the robot and procedures and under-
stands his/her individual responsibilities. Finally, once the program is established, it
is important to add new team members later on only one new member at a time.
2.2.1.7OR optimization
Preparing a state-of-the-art operating room theater for the robotic system is of para-
mount importance. We strongly recommend having one dedicated OR for robotic
surgery to avoid moving the robot between operating rooms. In addition to saving
time, this protects the system from possible transportation-related damage. The
robotic operating room design should include adequate setup room for the operating
table (with full Trendelenburg control capabilities), towers, and surgeon console (as
well as assistant console if dual consoles are used). Also, storing the robotic instru-
ments either inside the room or nearby is advisable for obtaining replacements and
troubleshooting during cases [3]. We strongly recommend having these OR accommo-
dations addressed early before purchasing the robotic system.
2.2.1.8Marketing
Cost analysis studies for robotic programs (discussed in more detail later in this
chapter) demonstrate that a certain minimal surgical volume is required for a
program to break even or become profitable due to both the high initial capital
investment and maintenance costs. To reach these surgical volume targets, compre-
hensive marketing plans should be adopted. Marketing should be directed to pati-
ents as well as referring physicians. For patients, the first step is usually building a
user-friendly website with information about the institutions surgeons, procedures
performed, contact information, patient testimonials, and educational material. In
addition to online advertisement, local media (TV, radio, newspaper, magazines,
billboards) can be used. Finally, program surgeons can host community lectures and
outreach campaigns. To reach out to potential referring physicians, robotic surge-
ons should visit local community hospitals and give lectures at regional Continuing
Medical Education (CME) programs. If the programs institution has a residency or
fellowship training program, then robotic surgery should be an integral part of its
advertisement directed toward potential candidates. Finally, all of these marketing
efforts should be organized through the robotic steering committee and focused on
the catchment area. At our institution, the University of Texas Medical Branch, we
established a marketing subcommittee comprising two surgeons and a representa-
tive of the universitys marketing VP.
2.2.1.9Database building
Starting database building early is critical for both short- and long-term success.
A well-designed database allows the robotic team to 1) obtain regular statistics about
surgical volume for monitoring the program progress and accomplished targets,
2) compare outcomes to national averages, 3) provide material for research pur-
poses, and 4) find areas for potential improvement and expansion. The database
should include clinical information, such as relevant history, operative data, hospi-
talization course, pathologic findings, post-operative course and complications, and
financial aspects. Database building can be simplified by utilizing an electronic

medical records system, if available. Database compliance with patient privacy pro-
tection regulations is critical. Finally, the database can be designed for an instituti-
onal level or can be part of a national database, e.g., the one run by the American
Association of Gynecologic Laparoscopists (AAGL) Centers of Excellence in Minimally
Invasive Gynecology (COEMIG) program [5].
2.2.1.10Acquisition of robotic system

This is perhaps the biggest price tag item. Currently, Intuitive Surgical is the only
vendor of an FDA-approved robotic system, and the currently available system
costs $12.3 million. Purchase contracts typically include maintenance, which costs
$100,000$170,000 annually [1]. These costs, in addition to costs associated with
OR design changes, hiring and/or training of surgeons/coordinator/staff, as well as
administrative and marketing costs, should be included in the cost analysis as will be
discussed later in this chapter.
2.2.2Implementation phase (learning curve or initial robotic program)
This phase starts when the robotic team performs their first case and ends when they
reach proficiency. Therefore, it represents those cases done while team members
are going through the learning curve. There is no agreed-upon number of cases
performed to reach proficiency, but many authors consider 20 cases performed over
about 150 days a reasonable target [4]. During this phase, we advise 1) starting with
uncomplicated cases, avoiding patients with large uteri, multiple previous surge-
ries, morbid obesity, or other medical problems; 2) meeting as a team before the first
case to discuss each members tasks and make sure that appropriate resources and
instruments are available; 3) documenting any comments after each case (debrie-
fing session) from all team members so the process can be improved in the future;
4) holding regular meetings to discuss progress and goal achievement; and
5) having the appropriate case frequency. To having one case weekly during this
stage is advisable to make sure surgeons and other team members are gaining the
necessary skills.
2.2.3Evolving program
2.2.3.1Improving OR efficiency
Established programs should have a mechanism in place to monitor and improve
its efficiency, and therefore, competitiveness and sustainability. This task is the
responsibility of the robotic steering committee and can be accomplished through
adopting, and sometimes inventing, new approaches. At the University of Texas

Medical Branch, we created a robotic OR efficiency subcommittee to find ways
to improve efficiency. The subcommittee was able to slash surgical time by mul-
tiple measures, including multitasking activities in the OR, where team members
perform their assigned tasks simultaneously rather than serially. In addition, we
began discharging cases the same day, which resulted in a significant savings
without compromising the quality of care.
2.2.3.2Growth
Successful robotic programs tend to spontaneously grow through patients word of
mouth. The robotic steering committee, along with hospital administration, should
also work to expand surgical volume through ongoing marketing. Additional surgical
cases can be accommodated through 1) improving OR efficiency and use of current
resources, 2) increasing robotic OR dedicated time, and 3) hiring and/or training
more robotic surgeons and staff. These steps can be undertaken after careful review
of current volumes and reasonable projections for future expansion.
2.2.3.3Ongoing evaluation of financial position and cost effectiveness

Closely monitoring the financial balance of the program is imperative to prevent
unanticipated funding difficulties that may prevent necessary maintenance or repla-
cement. The programs financial status should be reviewed as a permanent item in
the quarterly meetings of the robotic steering committee. Committee members should
look at ways for 1) cost cutting through minimizing hospital stays, decreasing repla-
ceable usage in the OR, decreasing OR time to increase case volume, and 2) growing
revenue through marketing, staff hiring if necessary, and assuring appropriate coding
and reimbursement of cases.
2.2.3.4Further marketing
Marketing should be an ongoing process through the same approaches as previously
discussed. It should be continuously reviewed and adapted to changes in the catch-
ment area and achievement of targeted goals.
2.2.3.5Continuous education and in-service training

Program surgeons should participate in conferences, workshops, and other academic
and educational activities to keep up with state-of-the-art technology. In addition,
OR staff members should participate in regular quality assurance and in-service pro-
grams, especially when major upgrades are introduced, e.g., switching from the da
Vinci S to the da Vinci Si system.
2.2.3.6Peer review of quality of care

Regular peer review of surgical cases is critical, including preoperative case selec-
tion and preparation, operative technique and time, intraoperative and postoperative
complications, and postoperative care. Reviews can be accomplished as part of the
obstetrics and gynecology department morbidity and mortality (M&M) meetings or
as a separate robotic cases peer review. This review is important to assure that outco-
mes are close to or above national averages. In addition, patients questionnaires and
online feedback are great tools for finding potential areas for improvement.
2.2.3.7Participation in quality control programs and designation

as excellence center
Participating in third-party quality assurance programs at local, state, and/or national
levels is recommended for robotic gynecologic programs. These programs help main-
tain quality of care and can be used as marketing tools as well. An example of such
a program in the USA is the Center of Excellence in Minimally Invasive Gynecology
(COEMIG) program [5]. Surgical Review Corporation (SRC), an independent health-
care quality organization, was contracted by the American Association of Gynecologic
Laparoscopists (AAGL) to run the COEMIG program. The COEMIG program designates
surgeons and healthcare facilities as centers of excellence, running sites through a
preliminary phase to assure multiple prerequisites are in place before giving a provi-
sional approval status. Full designation is granted after a site inspection. In addition
to ensuring minimal standards, COEMIG builds a national database with participa-
ting minimally-invasive gynecologic centers in accordance with The Health Insurance
Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules [5].
2.3Academic activities
Some robotic programs focus only on patient care, while others (both in academic
institutes and private practice) incorporate education and research as well. Advan-
tages for programs include maintaining state-of-the-art technology, promoting com-
munication and collaboration with other programs, and capitalizing on the robotics
program as a recruiting and marketing tool. These endeavors should be tackled with
clear vision and well-defined targets and action plans.
2.3.1Education
Programs in academic centers are typically expected to participate in training of resi-

dents and fellows as well as education of medical students. In fact, robotic training is
becoming part of residency training in many US centers.
2.4Financial analysis 21
In these programs, developing a structured robotic training program is important.

Residents are asked to complete a didactic or online module to learn about basic con-
cepts about robotics, followed by simulation training. After reaching a minimal skill
level, residents can participate in surgery. At the University of Texas Medical Branch,
we established a simulation lab where we combine a structured program for simula-
tion training including robotic, laparoscopic, and hysteroscopic simulation modules.
Dual console systems are helpful so that surgeons can switch control to and from the
learning resident sitting on a second console. Finally, education can bring funding
to institutions through educational grants, especially those tailored to educational
research.
2.3.2Research
Robotic programs represent an excellent research opportunity which can be accom-

plished in collaboration with other institutions. Advantages gained through research
include 1) improved quality of care, 2) increased cost effectiveness and competitive-
ness, 3) new opportunities for marketing, and 4) funding through grants. Successful
research requires a strong database and protected research time for surgeons [2].
2.4Financial analysis
Keeping an eye on the financial health of the robotic program is important to ensure
its sustainability and expansion. Analysis should be based on a sound understan-
ding of the underlying economics of robotic programs. Costs include system acqui-
sition, hiring and/or training of surgeons and staff, OR modifications, marketing,
and administrative costs. Revenues include reimbursement for surgical cases and
possibly research and education grants. Costs are subdivided into fixed and varia-
ble categories. Fixed costs include purchasing the system (US $12.3 millions) and
annual maintenance (US $100,000$170,000) [1]. Variable costs include 1) the cost
of instruments used, e.g., shears, needle drivers, and graspers, which are replaced
every 10 surgeries at a cost of approximately $2,200 each; 2) hospital stays; and
3) marketing. Because of longer OR time and costs of robotic instruments used in addi-
tion to capital investment, OR costs associated with robotic surgery are higher than
conventional surgery. On the other hand, shorter hospital stays in robotic cases drive
down the overall cost per case. Jonsdottir et al [6] showed that while operative costs for
robotic hysterectomy were higher than that for open hysterectomy ($10,528 2,968 vs.
$6,214 2,030), total costs were lower ($11,004 4,208 vs. $12,678 $7,471). There-
fore, it is important that hospital stays in robotic cases are minimized to 1 day or less.
Leddy et al [7] demonstrated that because of high fixed costs associated with robotic
surgery, robotic surgical volume should be high enough to drive down the average
cost per case. In conclusion, to drive down costs associated with robotic surgery, it
is advisable to 1) minimize routine hospital stays in uncomplicated low-risk cases;
2) avoid unnecessary use of robotic instruments during surgery; 3) avoid long opera-
ting hours, especially in programs with residents in training, by adopting simulation
training; and 4) increase surgical volume through marketing and outreach programs
to decrease the per-case share of capital investment and other fixed expenses.
2.5Conclusion
Given the significant investment, genuine commitment is necessary from hospital

administration for the development of a robotic surgery programs eventual success.
Adequate planning and preparation are keys for seamless introduction, while moni-
toring and adjustment of the program are essential for sustainability, growth, and
profitability. Robotic steering committees have become nearly universal in robotic
centers in the US and are probably needed everywhere. As with any program, well-
defined, realistic goals based on facts, along with clear vision and the ability to adjust
to the environment, are indicators of ultimate success.
References
[1] Investor FAQ. Intuitive Surgical. http://investor.intuitivesurgical.com/phoenix.zhtml?c=122359&
p=irol-faq#22324. Updated 2012. Accessed on 7/6/2012.
[2] Kilic GS, Borahay M, Phelps JY. Introduction of Robotic Surgery: Pitfalls and Future. In:
Textbook of Gynaecological Oncology. 2nd ed. Ankara, Turkey, Gunes Publishing, 2011,
60614.
[3] Palmer KJ, Orvieto MA, Rocco BM, et al. Launching a Successful Robotic Program. In: Patel VR,
ed. Robotic Urologic Surgery. London, Springer-Verlag, 2012.
[4] Recommendations for Building a da Vinci Surgery Program. 871455 Rev. A. Intuitive Surgical,
2006.
[5] COEMIG Program. Surgical Review Corporation. http://www.surgicalreview.org/coemig/. Updated
2013. Accessed on 19/12/2012.
[6] Jonsdottir GM, Jorgensen S, Cohen SL, et al. Increasing minimally invasive hysterectomy: effect
on cost and complications. Obstet Gynecol 2011, 117, 11429.
[7] Leddy LS, Lendvay TS, Satava RM. Robotic surgery: applications and cost effectiveness. Open
Access Surgery [Online] 2012, 2010, 99107.
3 Financial analysis of robotic surgery in gynecology
Eralp Baer, Mjdegl Zayfolu Karaca, Eric Lambaudie
and Murat Gltekin
3.1Introduction
Robotic surgery (RS) enables surgeons to perform complex operations with a

minimally-invasive approach, due to its enhanced technology that provides improved
visualization of the operative field and instrument flexibility. The term robot is
actually a misnomer, as the device by itself does not perform any tasks except in a few
orthopedic and neurosurgical procedures. Although computer assisted tele-manipu-
lator term is more appropriate to define the purpose of the device, robotic surgery
is now the universally accepted name.
Many surgical procedures that would previously require open surgery are today
carried out through 12 cm incisions with the help of these systems. Since their intro-
duction in 1988, surgical robots have gained increasing acceptance among surgeons
from various disciplines such as gynecology, gynecologic oncology, urology, cardi-
ovascular, head and neck, general, colorectal and thoracic surgery [1, 2]. Kim et al
reported that by the year of 2008, there were more than 645 da Vinci systems in use
worldwide, and by the year of 2013 it was more than 2000 [3]. Following the U.S. Food
and Drug Administration (FDA) approval for use in gynecologic procedures, adoption
of robotic systems for use in daily practice acquired significant popularity [4].
Advantages of minimally-invasive surgery (MIS) (e.g., laparoscopic and robotic)
are well appreciated. Main advantages of these techniques over open surgery are
decreased blood loss, less postoperative pain, shorter hospital stay, improved cos-
metic results and earlier return to regular daily activity or work [5]. Robotic surgery
further adds to these advantages (Tab. 3.1) [58]. The difference concerning morbidity
between conventional laparoscopy and robot-assisted laparoscopy is being evaluated
in a French randomized multi-centric trial for oncological indications. The results of
this study will be available in 2015.
In this chapter, financial aspects of using robotic surgery systems are discussed.
3.2Cost of robotic surgery
Despite its many advantages, robotic systems are expensive for institutions in both
purchasing and maintenance. Thus, the financial burden of robotic surgery on health-
care systems and patients is an important issue. Currently, a da Vinci robotic surgery
system costs more than $1.75 million and another $140,000340,000 is required for
24 3 Financial analysis of robotic surgery in gynecology
Tab. 3.1: Advantages of robotic surgery vs. laparoscopic (L/S) and open (L/T) surgeries
Advantages of robotic surgery compared to open (L/T) and laparoscopic (L/S) surgery
Lower blood loss (compared to L/T)

Lower intraoperative complications (compared to L/T)
Lower postoperative complications (compared to L/T)
Lower wound infections (compared to L/T)
Shorter hospital stay (compared to L/T)
Earlier return to daily activities (compared to L/T)
Shorter learning curve (compared to L/S)
Permits micromanipulations in regards to tremor filtration (compared to L/T)
3-D visualization (compared to L/S)
Less conversions to open surgery (compared to L/S)
yearly maintenance [9]. Training cost of surgeons also adds to this expense. Each
robotic instrument arm costs about $2,0003,000 and is limited to 10 uses.
Many institutions worldwide have started using robotic systems at the time of its
initial presentation, although there were inadequate evidence-based data regarding
its cost effectiveness. Rapid adoption of robotic procedures in gynecology was in con-
trast with laparoscopy. In a previous study by Wu et al, it was reported that 11.8%
of gynecologic procedures were performed by laparoscopy, despite proven benefits
supporting this technique [10]. However, robotic surgery gained significant popula-
rity even among surgeons who did not have prior experience in laparoscopy. This
difference may be due to a shorter learning curve in robotic surgery compared to con-
ventional laparoscopy. Although the robotic approach provides significant technical
advantages over conventional laparoscopy, high costs associated with the adoption of
this technology necessitate a cost effectiveness determination.
3.3Cost effectiveness of robotic surgery vs. laparoscopic

and open approaches
A number of studies that address the cost effectiveness of robotic systems in gyne-
cology have been published recently. Nevertheless, well-designed randomized cont-
rolled trials (RCT) are currently lacking.
A review of cost effectiveness analysis of robotic surgery compared with lapa-
roscopy or open procedures utilized in the most common application fields of MIS
such as general surgery, urology and gynecology has been published [11]. In this
review, although it was shown that the robotic surgery generally cost the most, some
exceptional situations for this have also been mentioned. The authors suggested that
when the initial expense for the robotic system setup was ignored, robotic surgery
was the more cost effective and feasible method for general surgical or urological
3.3Cost effectiveness of robotic surgery vs. laparoscopic and open approaches 25
procedures [11]. Considering the shorter hospitalizations and shorter learning curve
that robotic surgery offered, it had significant advantages over open surgery and con-
ventional laparoscopy.
In order to investigate the feasibility of robotic surgery for institutions that are
planning to purchase a robotic system, a break-even analysis has been done [11]. The
authors created two examples of clinical scenarios based on the number of procedu-
res performed within a year. In the given examples, two hypothetical hospitals that
performed 126 (Example A) and 330 (Example B) robotic cases a year were compared
(Tab. 3.2). They made cost effectiveness assumptions based on studies by Bolenz et
al [9] and Anderberg et al [12]. They pointed out that, institutions performing robotic
surgery would primarily benefit from short hospital stays associated with these pro-
cedures. They also emphasized that, the higher number of cases performed within a
given amount of time would ultimately result in a higher number of available beds
that would give the opportunity for more procedures.
Sarlos et al compared robotic vs. conventional laparoscopic surgery for hyste-
rectomy in benign gynecologic cases [13]. In this prospective study, they compared
outcome and cost of 40 consecutive total robot-assisted hysterectomies (RAH) with
matched controls that had total laparoscopic hysterectomy (TLH). On average, RAH
and TLH cost their institution 4,067 and 2,151, respectively. Although the robotic
approach provided better ergonomic features for the surgeons, RAH had similar
Tab. 3.2: Two examples of financial impact on hospital economics due to usage of robotic surgical
systems (adapted, with permission, from Dove Medical Press Ltd.; Leddy L, Lendvay T, Satava R.
Robotic surgery: applications and cost effectiveness. Dovepress J 2010, 99107). [11]
Example A Example B
Robotic cases (per year) 126 330

Hospital days saved (per case) 1.0 4.0
Hospital days saved (additional over-night capacity 126 1,320
available)
Nights stay after procedure 1.0 1.0
Number of procedures made possible by freed up 126 1,320
beds
Average contribution margin per procedure $3,500 $3,500
(including stay)
Annual value (CM) created from increased bed $441,000 $4,620,000
capacity
Maintenance ($340,000) ($340,000)
Disposable/limited use instruments ($60,000) ($60,000)
Net annual benefit (capacity value minus $41,000 $4,220,000
incremental cost)
Upfront investment to acquire and install robot $1,500,000 $1,500,000
Years to pay off acquisition 36.6 0.4
Return on investment (ROI) 2.7% 281.3%
operative outcome with higher costs [13]. The authors concluded that further assess-
ment in terms of cost effectiveness was warranted.
In another study that compared the cost of robotic, laparoscopic and open
approaches for sacrocolpopexy, the robotic approach was significantly more expen-
sive than others, even when the price of the robotic system was excluded from the
calculation model [14]. The costs for robotic, laparoscopic and open sacrocolpopexy
were $8,508, $7,353, and $5,792, respectively. A randomized study comparing lapa-
roscopic and robotic sacrocolpopexy also demonstrated that a robotic approach was
associated with higher costs [15].
A recent study by Wright et al compared robotic surgery (RS) vs. laparoscopic
(L/S) approach performed for endometrial cancer treatment [16]. In this study,
1,027 women (41.7%) underwent L/S, whereas 1,437 women (58.3%) underwent RS.
Overall surgery related morbidities were similar between the groups; however, mean
costs of RS and L/S were $10,618 vs. $8,996, being significantly higher in the RS
group. In a multivariable model, RS was significantly more expensive ($1,291;
95% CI $985$1,597). The authors advocated that, taking into account the similar
outcome between these two approaches, comparative long-term efficacy assess-
ment was needed to justify the preference of a robotic system over traditional
laparoscopy. Holtz et al also compared RS and L/S in endometrial cancer treat-
ment [17]. The authors found that RS was significantly more expensive than L/S
in terms of hospital ($5,084 vs. $3,615, P = 0.002) and operative costs ($3,323 vs.
$2,029, P < 0.001). In another study by Barnett et al, three calculation models
were used to compare robotic, laparoscopic and open hysterectomy in patients
with endometrial cancer [18]. In the first model (societal perspective), they inclu-
ded inpatient hospital costs, robotic expenses, lost wages and caregiver costs.
In the second model (hospital perspective plus robot costs), they excluded lost
wages and caregiver costs from the societal perspective model. In the third model,
they also excluded the initial cost of the robotic system. In the societal perspec-
tive model, L/S ($10,128) was the least expensive approach, followed by robotic
($11,476) and open surgery ($12,847). However, if the cost of robotic disposable
equipment could be lowered below $1,046 per case (baseline cost $2,394), robotic
surgery would cost less than L/S. In conclusion, authors stated that currently L/S
was the least expensive approach for endometrial cancer treatment. They also
found that robotic hysterectomy was less costly than open surgery, due to the
shorter recovery associated with this approach. They also suggested that expenses
in robotic surgery could further decrease, if disposable equipment costs are mini-
mized. Lau et al also compared 143 patients that underwent robotic surgery for
endometrial cancer, with 160 historic controls who were operated before the intro-
duction of the robotic system [19]. Interestingly, overall hospital costs were signi-
ficantly lower in the robotic surgery group (Can $7,644 [Canadian dollars] vs. Can
$10,368; P < 0.001) even when the costs of robotic system and maintenance were
included in analysis (Can $8,370 vs. Can $10,368; P = 0.001).
3.4Coverage of robotic surgery by healthcare systems 27
A very recent article by Coronado et al also included costs resulting from

conversion to other surgical approaches, complications, transfusions, need for
intensive unit care stay in the calculation model when comparing the robotic, L/S
and open approaches in endometrial cancer treatment [20]. Although surgical costs
were highest with the robotic approach, global costs were similar between the three
groups. This result was attributable to the fact that, robotic surgery cost least in terms
of hospitalization expenses [20].
In a recent review by the Cochrane group, two trials involving 158 participants
that underwent operative procedures for benign gynecologic disease were analyzed
[21]. With the available data, the authors concluded that robotic surgery for benign
gynecologic disease did not have an additional benefit in terms of effectiveness or
safety. They also stated that future well-designed RCTs were required before making
a final decision.
The Society of Gynecologic Oncology (SGO) has recently published a consensus
statement on robotic-assisted surgery in gynecologic oncology [22]. They suggested
that, an ideal model for cost comparison between robotic and other approaches has
to include both direct and indirect costs. In this model, fixed costs of the approach,
costs of all operating room supplies and disposable equipment are considered; ope-
rating and recovery room time, physicians fees, laboratory, radiology, and phar-
macy costs, and hospital room and board. They also stated that it was important to
account for costs due to complications, care-giving, and lost productivity associated
with the recovery period. It was concluded that, gaining efficiency in the operating
room was the most important point to maximize utilization and minimize hospital
costs associated with robotic surgery. The authors also stated that they anticipated
decreased costs in time, as a result of increasing physician experience, the growing
market and industry competition [22].
In Europe, the results of the COELCO Study are being awaited, which is a medico-
economic evaluation of laparoscopy in oncological indications, including robotic
procedures.
3.4Coverage of robotic surgery by healthcare systems
Robotic surgery is actually robot-assisted laparoscopic surgery. Thus, costs associa-

ted with this approach are generally covered by health insurance systems that cover
laparoscopic operations. However, coverage may vary between government and private
healthcare systems, as well as insurance companies and individual coverage plans.
In some countries in which the healthcare system is dependent on tax payments,
robotic surgery may be covered partly, and the patient may have to make extra payments
in order to be treated with this approach. It may be anticipated that, as robotic surgery
systems become more readily available and accepted by healthcare professionals,
coverage rates will also increase.
3.5How to use robotics more cost efficiently?
In order to use the robotics technology in a cost efficient way, several solutions may
be suggested such as;
Renting a used version of a robot rather than buying a new one.
Collection of robots centrally so that many doctors in different institutions will
have the opportunity for learning robotics, and for performing operations. In this
way, the patient load may be high enough to make the robotics cost efficient.
Instead of paying for the machine, with high patient loads, departments may
invest on a predefined patient number per year.
Robotics should be strictly planned according to the population demographics
and disease burdens.
Oncological tourism may be encouraged in order to increase patient volume.
3.6Conclusion
The introduction of robotic surgery has resulted in the beginning of a new era in
minimally-invasive treatment of gynecologic as well as gynecologic oncological
diseases. Nearly all of the previously conducted studies reported comparable if
not superior medical outcomes for operations performed with robotic surgery.
However, considering the importance of individual and healthcare system costs,
high quality evidence acquired from randomized controlled trials will be necessary
to reach a final conclusion.
References
CT guided stereotactic brain surgery. IEEE Trans Biomed Eng 1988, 35(2), 15360.
[2] Mettler L, Ibrahim M, Jonat W. One year of experience working with the aid of a robotic assistant
(the voice-controlled optic holder AESOP) in gynaecological endoscopic surgery. Hum Reprod
1998, 13(10), 274850.
[3] Kim YT, Kim SW, Jung YW. Robotic surgery in gynecologic field. Yonsei Med J 2008, 49(6),
88690.
[4] Advincula AP, Song A. The role of robotic surgery in gynecology. Curr Opin Obstet Gynecol 2007,
19(4), 3316.
[5] ElSahwi KS, Hooper C, De Leon MC, et al. Comparison between 155 cases of robotic vs. 150
cases of open surgical staging for endometrial cancer. Gynecol Oncol 2012, 124(2), 2604.
[6] Bell MC, Torgerson J, Seshadri-Kreaden U, et al. Comparison of outcomes and cost for
endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic
techniques. Gynecol Oncol 2008, 111(3), 40711.
[7] Payne TN, Dauterive FR. A comparison of total laparoscopic hysterectomy to robotically
assisted hysterectomy: surgical outcomes in a community practice. J Minim Invasive Gynecol
2008, 15(3), 28691.
References 29
[8]Lim PC, Kang E, Park do H. A comparative detail analysis of the learning curve and surgical
outcome for robotic hysterectomy with lymphadenectomy versus laparoscopic hysterectomy with
lymphadenectomy in treatment of endometrial cancer: a case-matched controlled study of the
first one hundred twenty two patients. Gynecol Oncol 2011, 120(3), 4138.
[9] Bolenz C, Gupta A, Hotze T, et al. Cost comparison of robotic, laparoscopic, and open radical
prostatectomy for prostate cancer. Eur Urol 2010, 57(3), 4538.
[10] Wu JM, Wechter ME, Geller EJ, et al. Hysterectomy rates in the United States, 2003. Obstet
Gynecol 2007, 110(5), 10915.
[11] Leddy L, Lendvay T, Satava R. Robotic surgery: applications and cost effectiveness. Dovepress J
2010, 3, 99107 .
[12] Anderberg M, Kockum CC, Arnbjornsson E. Paediatric robotic surgery in clinical practice: a cost
analysis. Eur J Pediatr Surg 2009, 19(5), 3115.
[13] Sarlos D, Kots L, Stevanovic N, et al. Robotic hysterectomy versus conventional laparoscopic
hysterectomy: outcome and cost analyses of a matched case-control study. Eur J Obstet
Gynecol Reprod Biol 2010, 150(1), 926.
[14] Judd JP, Siddiqui NY, Barnett JC, et al. Cost-minimization analysis of robotic-assisted,
laparoscopic, and abdominal sacrocolpopexy. J Minim Invasive Gynecol 2010, 17(4), 4939.
[15] Paraiso MF, Jelovsek JE, Frick A, et al. Laparoscopic compared with robotic sacrocolpopexy for
vaginal prolapse: a randomized controlled trial. Obstet Gynecol 2011, 118(5), 100513.
[16] Wright JD, Burke WM, Wilde ET, et al. Comparative effectiveness of robotic versus laparoscopic
hysterectomy for endometrial cancer. J Clin Oncol 2012, 10, 30(8), 78391.
[17] Holtz DO, Miroshnichenko G, Finnegan MO, et al. Endometrial cancer surgery costs: robot vs
laparoscopy. J Minim Invasive Gynecol 2010, 17(4), 5003.
[18] Barnett JC, Judd JP, Wu JM, et al. Cost comparison among robotic, laparoscopic, and open
hysterectomy for endometrial cancer. Obstet Gynecol 2010, 116(3), 68593.
[19] Lau S, Vaknin Z, Ramana-Kumar AV, et al. Outcomes and cost comparisons after introducing a
robotics program for endometrial cancer surgery. Obstet Gynecol 2012, 119(4), 71724.
[20] Coronado PJ, Herraiz MA, Magrina JF, et al. Comparison of perioperative outcomes and cost of
robotic-assisted laparoscopy, laparoscopy and laparotomy for endometrial cancer. Eur J Obstet
Gynecol Reprod Biol 2012, 165(2), 28994.
[21] Liu H, Lu D, Wang L, et al. Robotic surgery for benign gynaecological disease. Cochrane
Database Syst Rev 2012, 2:CD008978.
Gynecologic Oncologys Clinical Practice Robotics Task Force. Gynecol Oncol 2012, 124(2),
1804.
4 Training and credentialing in robotic gynecologic
surgery and legal issues
John Y. Phelps, Yu Lee and Sami G. Kilic
4.1Introduction
Since the 2005 U.S. FDA (Food and Drug Administration) approval for use of the da Vinci
robot in gynecology, there has been a rapid rise in not only the utilization of robotics-
assisted gynecologic cases but interest among the general public. Inevitably, with
any new technologic advances in medicine, several facets will need to be addressed.
Among these, most importantly, are in regards to physician licensing, credentialing,
and training. Also, closely intertwined, liability issues such as medical negligence,
informed consent and the physician-patient relationship will need to be reexamined
to adapt to the changing paradigm robotics presents to gynecologic surgery.
4.2Training and credentialing
4.2.1Training
Appropriate training is a crucial aspect in developing competent surgical skills in the

novice surgeon. As is seen in prior medical technology advances, a lag tends to exist
between the emergence of the novel technique and in establishing the necessary stan-
dards and requirements needed for a surgeons skill to be deemed competent. The
advances of robotic-assisted gynecologic surgery evolved after the majority of practi-
cing gynecologists had already completed their residency training. Furthermore,
postgraduate training opportunities available for gynecologists are limited. To date,
there is not yet a universal standard in training or regulating credentialing among
robotic gynecologic surgeons. The minimum U.S. FDA certification standard is a 12
day training practicum in the use of the da Vinci surgical platform. Currently, there
are 17 active Intuitive Surgical training centers in the United States [1]. The Intuitive
Surgical product training involves an introduction to the surgical platform and system
training typically employed within a dry laboratory environment. Familiarity with the
functions of the robot, the attachment of the robotic arms to the robotic trocars and
the overall functions of the robotic console, as well as simple techniques involving
grasping, intracorporeal knot tying and cutting are reviewed [2].
Additional training experience after this mandatory certification course is recom-
mended. While there are no current universally established training guidelines,
most hospital committee panels still require further experience to gauge adequate
robotic surgical competence. As robotic gynecologic surgery continues to expand, two
32 4 Training and credentialing in robotic gynecologic surgery and legal issues
distinct classes of gynecologic surgeons will emergenewly graduating physician resi-

dents with integrated robotic training from residency programs and a group of post-
graduate surgeons with no prior robotic residency training. Ultimately it will be up to
the hospitals and credentialing committees to determine the appropriate guidelines.
4.2.2Credentialing
Several multidisciplinary panels and forums have recommendations for gynecologic

robotic credentialing. Intuitive Surgical provides recommendations for further robotic
training. Included in their recommendations are 8 h (depending on type of case and
number of cases) of case observation, 48 h of video case observation, 4 h of onsite
da Vinci training, 2 h of two suturing sessions, 2040 h of simulation exercises, and
lastly two to five proctored cases. Case observation allows the novice robotic gyne-
cologic surgeon to observe a da Vinci trained gynecologist performing robotic cases
at an Intuitive EpiCenter. The video case observations provide additional opportu-
nity for gynecologic surgeons to watch two to four videos of a trained robotic surgeon
complete an intended procedure. Other informal recommendations detail a different
approach. In a previous publication in the Journal of Minimally Invasive Gynecology
by the authors of this chapter we outlined an informal guideline that first includes
the mandatory completion of the robotic certification course and then a progressive
approach involving a series of cases to be performed with the novice robotic surgeon
assisting the more experienced robotic surgeon and then a switch in roles with the
experienced robotic surgeon assisting the novice surgeon. Because learning curves
vary among physicians, a set number of cases were intentionally not specified. In
addition, establishing such parameters would be difficult and would not account for
the variance in surgical skills among gynecologists. Also from a legal perspective once
an institution sets their own internal written standard for a precise number of cases
needed for credentialing, plaintiff attorneys may use the institutions own written
declared number of required cases in an attempt to prove a breach in the standard of
care in the event an injury occurs by the novice robotic surgeon who has not reached
the precise number of cases. Other authors have also provided recommendations for
credentialing. Visco and Advincula recommend the gynecologic surgeon to have at
least 8 hours of hands on training in use of the robotic surgical system, or proof of
a minimum of 10 robotic surgical procedures of the same type [2]. In addition, they
recommend a minimum of two proctored robotic surgical cases demonstrating com-
petence for that particular procedure.
The field of urology has been implementing the use of the robotics technology
since the beginning of the 21st century. Therefore, it would be pertinent to not only
examine but also highlight some of the recommendations set forth by the Society
of Urologic Robotic Surgeons. First, to establish a centralized certification autho-
rity which would institute and regulate standards. This centralized authority would
identify proctors and develop standardized reports for the proctors to complete.
4.3Legal issues 33
Second, to establish regional centers to assist novice robotic surgeons with precepto-
ring. Such endeavors would essentially help to develop and uniformly assess compe-
tency among gynecologic surgeons while mitigating liability issues [4].
4.3Legal issues
As the integral role of robotics assisted surgery in gynecology continues to grow,

novel legal implications and questions began to surface. Such legal issues demand
physicians and the medical arena to confront and adapt to these new changes. Many
current robotic gynecologic surgeons completed their residency trainings prior to the
integration of robotics technology in the residency curriculum. In addition, credentia-
ling and surgical privilege standards are typically determined by individual hospitals.
Because a universal standard in regulating credentialing among robotic gynecologic
surgeons has yet to be set, these discrepancies in requirements could potentially
pose additional liability risks among robotic gynecologic surgeons. Furthermore,
robotic surgical instructors or proctors, a vital asset in the field of robotic surgery,
may also face unforeseen legal issues.
4.3.1Components of medical malpractice
In order for a plaintiff attorney to claim medical malpractice, four components must
be demonstrated. First, it must be established the physician had a duty of care to
patient. Second, there must be evidence that this duty was breached, and third,
an alleged injury must be present, and last, a causal connection must be shown
that this breach in duty led to the proximate alleged injury. A plaintiff attorney can
potentially have cause of action against gynecologists performing robotic surgery
for breach in the standard of care from insufficient training and failure to obtain
informed consent.
4.3.2Insufficient training and credentialing legal issues
A breach in the standard of care for negligence in obtaining proper informed consent
was highlighted in the 2010 robotic case of Long v. Wentworth-Douglass Community
Hospital [5]. The plaintiff filed malpractice following a known surgical complication
despite full disclosure of risks prior to case. Typically, known inherent surgical mal-
occurrences and complications are not grounds for malpractice, however, the plaintiff
attorney alleged improper informed consent, not because the patient was unaware
of the known intrinsic complications that arose, but because prior knowledge of the
gynecologists insufficient training and experience with robotics might have influ-
enced the patients decision to undergo the da Vinci-assisted procedure [5].
34 4 Training and credentialing in robotic gynecologic surgery and legal issues
Plaintiff attorneys are also using insufficient training and credentialing in the field
of robotic surgery to seek negligent litigation claims. For example, in the pending case
of Mohler v. St. Lukes Medical Center, a complaint of negligent credentialing in robotic
surgery was filed [6]. During the robotic-assisted procedure, the plaintiff alleged the
defendant caused injury to his bowels from improper use of the robotic equipment. The
plaintiff filed a suit to hold the hospital liable for negligence in properly credentialing
[the surgeon] to use robotic equipment. This case emphasizes the importance in recog-
nizing the partnership between gynecologic surgeons and healthcare facilities. Because
the robotics field in minimally-invasive surgery (MIS) is still evolving, hospitals have
different guidelines and standards. At its 38th Global Congress, the American Associa-
tion of Gynecologic Laparoscopists (AAGL) established its own robotics special interest
group to undertake establishing uniform credentialing guidelines as its initial goal [7].
4.3.3Robotic proctors and legal issues
Robotics surgical proctors provide additional assistance after robotics training for
novice robotic gynecologic surgeons. Traditionally, proctors serve only to observe
and evaluate a physicians competence, however, the scope of the current robotic
proctor may expand to include the additional responsibility of providing instruction.
The landmark 1985 Clark v. Hoek ruling found that proctors, as observers, do not con-
stitute a physician-patient relationship. The court ruled, individual proctors do not
owe a duty of care to the patient, and therefore are not held up to a standard of care
or obligation to the patient in the event of a mis-occurrence [8]. However, this ruling
was formed from a variety of facts, one of which implicitly stated that the proctor only
observed and did not undertake to intervene in, supervise, or control the operation.
If the roles of robotics proctors are expected to expand beyond pure observation to
incorporate an active role in teaching or intervention, these instructors may be under-
taking a duty of care by establishing a special physician-patient relationship and may
not be afforded legal protection. To date there is no existing case law that provides a
context on determining whether robotics instructors do assume this duty of care or
physician-patient relationship. Typically, the court will consider several factors when
determining if a physician-patient relationship exists. Some of these factors include
whether the physician and patient met, whether the physician examined the patient,
if the physician reviewed the patients record, and if there was a fee for the servi-
ces rendered [8]. Legal cases such as the Walters v. Rinker and Peterson v. St. Cloud
Hospital, in which pathologists were found to hold a physician-patient relationship,
can argue that a special physician-patient relationship can be established despite
direct contact between the two parties [9, 10].
Another legal issue that could arise for the robotic proctor is the potential to
be joined in a malpractice lawsuit by the primary surgeon. The primary operating
surgeon may join the proctor as a responsible party in the lawsuit by filing a cross
4.4Conclusion 35
claim. However, the primary surgeon must claim the proctor provided improper ins-
truction that was relied upon and that the improper instruction was the proximate
cause of the patients injury.
4.4Conclusion
As robotics-assisted technology continues to expand in the field of gynecology, estab-

lishing a universal guideline in training and credentialing is important. Crucial in this
process is identifying and recognizing the partnership between surgeons and health-
care facilities. Not only will healthcare facilities and committees ultimately decide
appropriate guidelines for credentialing, but they will also play an integral role in
facilitating the role and legal protection of robotic proctors. As standardized training
and curriculum in robotics technology becomes further integrated in residency trai-
ning, a more uniform front can be taken in regards to training requirements. It will
require a collaborative effort from all involved parties. Such measures will also likely
mitigate many of the legal issues discussed above.
References
[1] Training Approach. Intuitive Surgical. N.d. Website. http://www.intuitivesurgical.com/training/

training_approach.html. Updated September 2010. Accessed on 19/3/2012.
[2] Visco AG, Advincula AP. Robotic gynecologic surgery. Obstet Gynecol 2008, 112(6), 136982.
[3] Lee Y, Phelps JY. Medicolegal review of liability risks for gynecologists stemming form lack of
training in robot-assisted surgery. J Minim Invas Surg 2011, 18(4), 5125.
[4] Zorn KC. Training, credentialing, proctoring and medical legal risks of robotic urological surgery:
Recommendations of the Society of Urological Robotic Surgeons. J Urol 2009, 182(3), 112632.
[5] Carreyrou J. Botched operation using da Vinci robot spurs lawsuit. The Wall Street Journal May
25, 2010. Available at: http://online.wsj.com/article/SB10001424052748703341904575266952
674277806.html. Accessed on 10/3/2012.
[6] Mohler v. St. Lukes Medical Center, LP, No. C 08-0078, slip op. (Arizona. August 2010). Public
documents accessed at: http://www.superiorcourt.maricopa.gov/docket/CivilCourtCases/
caseInfo.asp.
[7] AdvinculaAP. Roadmap to robotics. AAGL News Scope 2010, 24, 9.
[8] Clark v. Hoek. 174 Cal App 3d 208 (1985).
[9] Walters v. Rinker. 520 Ind App 2d 468 (1988).
[10] Peterson v. St. Cloud Hospital. 460 Minn App 2d 635 (1990).
5 Patient positioning, trocar placement, and
docking for robotic gynecologic procedures
Mostafa A. Borahay
5.1Introduction
The da Vinci surgical system (Intuitive Surgical Inc, Sunnyvale, CA, USA), currently
the only FDA-approved robotic surgical system, is composed of three components:
surgeons console, patient cart, and video cart. After the patient is properly positioned
and trocars are placed, the patient cart is moved toward the patient and docked.
One of the critical differences between robotic and conventional surgery (both open
and laparoscopic) is the difficulty in changing patient position during a procedure. In
fact, such attempts typically necessitate robot undocking and redocking. This beha-
vior wastes a great deal of valuable operating room time and should be avoided as
much as possible.
Correct patient positioning, appropriate trocar placement, and docking are cri-
tical skills for safe and successful robotic surgery. Currently, most surgeons learning
robotic techniques have some degree of prior laparoscopic experience. Although
this implies some knowledge of laparoscopic operative principles, it often leads to
missing critical differences between conventional laparoscopic and robot-assisted
approaches. As we will see, certain differences should be taken into consideration
when switching to a robotic platform. Although knowledge of laparoscopic principles
is expected for many readers, this text is intended to be appropriate for novice learners
as well, e.g., those in residency training programs. The overall goals of this chapter
are to maximize operative field exposure, minimize robotic arm collisions and other
technical difficulties, improve the surgical teams efficiency, improve ergonomics for
the staff, and ensure patient safety.
5.2Importance of proper patient positioning

and trocar placement
Inappropriate positioning and/or trocar placement can cause several technical dif-
ficulties, wasting valuable operating time and potentially introducing serious patient
complications. For example, inappropriate positioning can lead to nerve injuries
(e.g., brachial plexus, femoral, and common peroneal nerve palsies). Improper trocar
placement can lead to potentially serious complications, such as vascular (major
vessels and abdominal wall vessels) or bowel injuries, hernias, and infections. Fur-
thermore, improper trocar placement may cause a novice surgeon to struggle during
procedure. Examples include placing trocars too close together causing robotic
38 5 Patient positioning, trocar placement, and docking
arms to collide during surgery, or placing trocars too close to target anatomy (e.g.,
with a significantly enlarged uterus) limiting operating space and causing technical
difficulties. In contrast, placing them too far from target organs can be problematic,
also, if, for example, the instruments do not reach far enough for cuff closure after
removal of a massively enlarged uterus.
5.3Patient positioning
5.3.1Principles of patient positioning
Goals for appropriate positioning are maximizing efficiency of surgical technique

while minimizing surgery-associated risks. Advanced and complex robotic cases can
be lengthy, and improper positioning can be associated with serious complications.
Except for procedures done through a retroperitoneal approach, almost all robotic
gynecologic procedures are performed in the Trendelenburg position. Basically, the
patient is placed in a modified dorsal lithotomy position. Legs are separated and
positioned using adjustable boot Allen stirrups (Allen Medical Systems, Acton, MA,
USA). Hips and knees are flexed, and legs (Fig. 5.1) are abducted. Typically, thighs
are placed almost horizontal at table level with hips slightly flexed not more than
15. Knees should be flexed less than 60 to prevent femoral nerve compression [1].
Extra care should be paid to ensure that the legs weight rests on the heels of the feet
and not on the calves. This positioning is important to avoid nerve palsies and avoid
compromising venous blood flow with possible vascular thrombosis. It is a common
practice to tuck the arms during robotic surgery. Typically, this is accomplished
by wrapping the under-patient sheet around the arms while hands, forearms, and
elbows are padded by egg-crate sponge (Fig. 5.1). The team should be careful about
protecting fingers and securing IV lines and the blood pressure cuff without undue
pressure. In our experience, this seems to be a practice inherited from laparosco-
pic surgery with no clear benefit for robotic surgery. The benefits of not tucking the
arms include more accurate blood pressure measurement by placing an unrestric-
ted blood pressure cuff and easier access for anesthesiologists in case another IV
is needed intra-operatively. Untucked arms do not seem to interfere with the flow
of the procedure. Importantly, arms need to be well supported and restrained by
adhesive tape.
Prolonged procedures with patients in a steep Trendelenburg position can lead
to patient sliding, and many approaches have been applied to prevent such sliding
(Fig. 5.1). Some surgeons recommend using shoulder blocks. While blocks prevent
skidding, they have been associated with cases of brachial plexus injuries and post-
operative pain and nerve palsies. Other methods include using gel pads (if used,
be careful when moving the patient to avoid skin scratches) or vacuum bean bags.
In our experience, using adhesive gel pads along with gently wrapping adhesive
5.3Patient positioning 39
Fig. 5.1: Modified lithotomy position used in most robotic gynecologic procedures. Please note:
a) tray mounted to a bar to protect patients face, b) Bair Hugger to prevent hypothermia, c) tape on
mid-thorax to help prevent sliding, d) arm is tucked in, e) hip is at 170 angle, f) knee is flexed at
90 and lower extremity is resting on knee, g) lower extremities resting on heel
tape around the patients chest has been enough to adequately and safely prevent
skidding. It is imperative to adequately pad all pressure points. Some robotic procedu-
res may last for many hours, especially early in the learning curve. Unprotected pres-
sure points can predispose patients to deep venous thrombosis (DVT) and/or nerve
palsies.
An accumulating body of evidence associates hypothermia during surgery with
poor perioperative outcomes, including increased infections. Therefore, patient
core temperature should be maintained, and body warming techniques should be
employed as necessary and as available in each institution. At the University of Texas
Medical Branch, we use Bair Huggers (Arizant Healthcare Inc., a 3M company, Eden
Prairie, MN, USA) along with a Foley catheter with a temperature sensor that tracks
core body temperature throughout the procedure.
Prophylaxis against DVT is of critical importance. We follow published guidelines
by the American College of Obstetricians and Gynecologists (ACOG) for prophylaxis
[2]. Most cases occupy the moderate- or high-risk groups where a mechanical or phar-
macologic prophylactic method is indicated. Since mechanical and pharmacologic
methods give similar results, we prefer to use mechanical methods to avoid associated
costs, side effects, increased bleeding, and hematoma formation. In most cases, we
use a combination of TED hose and sequential compression devices. Both are placed
in the preoperative holding area. Cases with highest risk, e.g., malignancy in patients
over 60 years of age, prior DVT/PE, etc., are managed by combined pharmacologic
and mechanical prophylaxis as indicated. Many institutions have protocols for DVT
prophylaxis, and robotic surgeons are encouraged to follow these protocols.
In robotic cases, the head should be adequately protected (Fig. 5.1). We use a metal
tray mounted to a metal bar and attached to a table to protect the patients head from
any injuries from instruments moved by the surgeon or assistant. Also, this ensures
adequate visualization and access to the patients face and endotracheal tube for the
anesthesiologist throughout the procedure. As with other surgical procedures, it is
important to close the patients eyes and use eye ointment to prevent corneal ulcera-
tion. It is also advisable to insert a nasogastric or orogastric tube to decompress the
stomach, which helps prevent potential stomach injuries in cases using the left hypo-
chondrial area for peritoneal access. Patients with previous gastric bypass surgeries
may require additional care. An orogastric tube is considered less invasive compared
to a nasogastric tube.
Before robot docking, position the patient in the maximum tolerable Trendelen-
burg position by lowering the head 1530 [1]. Factors that might affect the degree
of tilt include obesity, ophthalmologic problems with elevated intraocular pressure,
pulmonary or cardiovascular conditions, and cerebrovascular diseases. After comple-
ting the patients positioning and prior to prepping, we typically perform a tilt test,
where we position the patient in the maximum tolerated Trendelenburg and check for
sliding as well as cardiopulmonary parameters. However, recent evidence suggests
the maximum Trendelenburg position might not be necessary. For example, Ghomi
et al [3] showed that 20 robotic gynecologic procedures were successfully performed
with a median Trendelenburg of 16.4.
After a successful tilt test, level the patient back to a horizontal position and
perform a routine examination under anesthesia. This step is critical, as it gives an
idea about uterine size and can affect the plan for port placement. Adequately prep
the vagina and perineum by povidone-iodine antiseptic (unless allergic to iodine),
followed by prep of the abdomen and upper thigh by DuraPrep (3M, St. Paul, MN,
USA) or other commercially available antiseptic preparations. Follow this step by
patient draping. We prefer to place a 16-Fr Foley catheter after draping the patient
and prior to placing the uterine manipulator.
In many cases of robotic gynecologic surgery, a uterine manipulator needs to
be placed. Different types of uterine manipulators are commercially available [e.g.,
RUMI, RUMI II, ZUMI (CooperSurgical Inc, Trumbull, CT, USA), VCare (ConMed
Endosurgery, Utica, NY, USA), Advincula Arch Handle (CooperSurgical Inc, Trum-
bull, CT, USA), and others]. Regardless of the brand used, these systems typically
include a uterine manipulating tip, colpotomy ring, and vaginal occluding balloon.
The surgeon and team should familiarize themselves with the manipulator brand
5.4Trocar placement 41
they plan to use and pay attention to properly sounding the uterus. Placing a manipu-
lator tip that is too short or too long may cause inadequate uterine control during the
procedure. Manipulators are usually used for two purposes: moving the uterus during
surgery and providing an edge to perform a colpotomy. Although some surgeons do
not use uterine manipulators during surgery, the vast majority do.
5.4Trocar placement
Robotic gynecologic surgeons and team members are expected to complete adequate
training including trocar placement prior to their first case. This includes didactic
education, relevant anatomic principles, and animal labs. Proper port placement
maximizes exposure of the operative field, minimizes arms/instruments collision and
assures patient safety and adequate and comfortable access to bedside assistant.
5.4.1Peritoneal access
Peritoneal access can be obtained using various approaches, including a Veress

needle followed by camera trocar placement, camera trocar insertion prior to pneu-
moperitoneum, and open (Hasson) technique. Many surgeons still use a Veress needle
at the umbilicus (or left hypochondrium if adhesions are suspected underneath the
umbilicus) to create a pneumoperitoneum, followed by insertion of the first trocar
under visualization using an Endopath Optiview trocar (Ethicon Endo-Surgery, Inc.,
Cincinnati, OH, USA). Surgeons commonly use a 510 mm laparoscopic camera for
initial entry and survey, reserving the robotic camera until after docking. Most surge-
ons use an initial pressure less than 10 mm Hg as suggestive of proper intraperitoneal
insufflation. Once a camera is inside the abdomen, an immediate check for entry-
associated injuries is critical before tilting the patient or manipulating the bowel.
5.4.2Trocar placement
The total number of ports used in most robotic gynecologic surgeries ranges from three
to six. Most surgeons use a 3-arm configuration where one port is used for a camera and
two ports for robotic instrument arms. In a 4-arm configuration, an additional port is
placed for a third robotic instrument arm. The majority of surgeons routinely place an
additional assistant port. A single-port robotic surgery platform is currently under trial
and is expected to be available for clinical gynecologic practice in 2013.
Many factors affect the number and location of port placement. These factors
include patient factors (e.g., obesity, prior surgeries, anticipation of adhesive disease),
procedure type (e.g., if para-aortic lymphadenectomy is planned), target anatomy
factors (e.g., large uterus), the available system (e.g., robotic standard and S system
arms are larger and require wider spacing to avoid collisions), and surgeon expertise
and preference. Also, surgeons should bear in mind while determining port locations
that the maximum working length of da Vinci standard instruments is 25 cm, while the
length for da Vinci S instruments is 30 cm [4]. Placing instruments at longer distan-
ces may lead to a surgeons inability to reach the pelvis during surgery. The following
trocar placements apply to most gynecologic robotic surgeries (e.g., hysterectomy and
myomectomy). Special considerations for certain procedures will be discussed later.
5.4.2.1Primary (robotic camera) port

Examination under anesthesia prior to patient prepping is a critical step. Determine
the uterine size and place the robotic camera (available in 8.5- and 12-mm sizes) trocar
810 cm cephalad to the upper limit of the elevated uterine fundus. This placement will
help create the necessary space for visualizing the operative field and moving inst-
ruments while minimizing instrument collisions. Determine camera port placement
prior to the pneumoperitoneum , but measure for the locations of the other trocars
afterwards. Alternatively, especially in cases of prior surgeries and suspected adhesi-
ons, a 510 mm regular laparoscopic camera can be inserted in the left hypochondrial
area to survey the abdomen and pelvis before safely placing the robotic camera trocar
under direct visualization.
5.4.2.2Port placement for a 3-arm configuration

Place right and left robotic arm instrument ports (8 mm diameter) 810 cm lateral
and 23 cm caudal to the robotic camera port. Alternatively, many surgeons place
robotic instrument ports slightly caudal to the camera port and along an arc centered
at the symphysis pubis and about 23 cm medial to the anterior superior iliac spine.
Place an assistant port in the patients left or right side about 23 cm cephalad to
the camera port and 810 cm from the camera and robotic instrument arm ports.
See Fig. 5.2.
5.4.2.3Port placement for a 4-arm configuration

While some surgeons use a 4-arm configuration as their default, many reserve this
approach for when more extensive manipulation is anticipated, e.g., sacrocolpopexy
and lymph node dissection. An important principle for 4-arm use is to make sure
that one of the two ipsilateral ports (typically the most lateral/fourth arm) is cepha-
lad (or caudal) to the other to maximize interarm space and minimize arm collisions.
In this configuration (Fig. 5.3), the first and second robotic instrument ports are
typically placed 810 cm lateral and cephalad (or caudal) to the camera port on both
5.4Trocar placement 43
Fig. 5.2: Port placements for 3-arm configuration. Please note use of bariatric trocar for camera,
even in nonobese patients, to allow for easier accessibility and maneuverability. a) Camera port,
b) and c) robotic instrument ports, d) assistant port
sides. Place a third robotic instrument port 8 cm lateral and caudal to the second
trocar site.
In all situations, maintaining at least 8 cm between all ports is recommended
to minimize instrument collisions. Using a long needle to infiltrate local anesthetic
at the instrument port sites may be helpful for locating and confirming port sites
internally under vision. Confirming that the trocar remote center (marked by a broad
black band see Chapter 8) lies at the level of the peritoneum is critical. Misplacing
the remote center leads to excessive fascial stretching and significant postoperative
pain. Many surgeons prefer to attach an insufflation line to the assistant (or one of
the robotic instrument) port during surgery and use the camera port for smoke evacu-
ation. This arrangement helps minimize camera fogging and improve visualization.
Finally, using bariatric trocar cannulas is important for obese patients. In fact, at the
University of Texas Medical Branch, we made it the rule to use bariatric trocar cannu-
las for all cases to avoid errors and opening more than one instrument set.
Fig. 5.3: Port placements for 4-Arm configuration: a) camera port, b), c), and d) robotic instrument
ports, e) assistant port
5.4.2.4Special considerations for port placement for specific procedures
Procedures including lymph node dissection (especially para-aortic LN)

Insert the camera port cephalad to the umbilicus, about 2428 cm from the symphysis
pubis. Most surgeons use 4 robotic arms (see Chapter 23).
Sacrocolpopexy
Place a camera port at or superior to the umbilicus. If a 4-arm approach is adopted,
locate the patient-side assistant in the patients right side. Place the first and second
robotic instruments arms 10 cm lateral and 30 inferior to the umbilicus at both sides.
Place the third robotic arm as laterally as possible (about 3 cm from the iliac crest) and
just inferior to the level of the camera port (see Chapter 25).
Retroperitoneal robotic approach

Magrina et al [5] described a robotic retroperitoneal approach (Fig. 5.4). In this
approach, insert an 8 mm robotic trocar through a 1012 mm Spacemaker Plus Diss-
ector System placed 3 cm medial to the left anterior superior iliac spine. Introduce the
12 mm camera trocar through the patients left flank along the posterior axillary line,
10 cm cranial and lateral from the caudal robotic trocar. Insert a second 8 mm robotic
5.5Initial survey 45
Fig. 5.4: Port placements for retroperitoneal robotic approach. Anatomic landmarks: a) camera port,
b) costal margin, c) and d) trocar sites, e) anterior superior iliac spine
trocar 10 cm cranial and medial to the laparoscope, immediately below the left costal
margin and in line with the caudal robotic trocar. Place the assistant trocar immedi-
ately adjacent to the anterosuperior iliac spine, equidistant between the laparoscope
and the caudal robotic trocar.
5.5Initial survey
After port placement is complete, place the patient in a steep Trendelenburg posi-
tion. Perform an initial survey of the abdomen and pelvis, comprising inspection of
the pelvis (including uterus and adnexa) and upper abdomen (including liver, gall
bladder, spleen, and stomach), followed by moving the bowel to the upper abdomen
to improve pelvic visualization.
5.6 Docking
It may be helpful, especially during the learning curve, to place marks on floor to help
with proper robot docking. When three robotic instrument arms are used, placing
the camera arm setup joint to the side opposite the third robotic arm is advisable to
minimize arm collisions. First, determine the sweet spot by making sure the blue
arrow lies within the blue marker line on the second joint. The marked sweet spot on
the patient cart applies only to straight docking, not to side docking. The second step
is to align the camera arm, the camera arm setup joint, the column, and the target
operative field. Prior to moving the patient cart toward the patient, clear the path
of overhead lights to maintain sterility and position the robotic arms high to avoid
hitting the patients legs (patient legs can be lowered temporarily). Push the robotic
patient cart until reaching target anatomy. Dock the camera arm first, taking care to
maneuver the robotic arm (using the arm clutch) rather than the patient port. Next,
dock the robotic instruments arms, keeping the farthest possible distance between
the robotic arms. Finally, relieve any tension at the robotic trocars.
5.6.1Docking types
5.6.1.2Straight docking
In the straight docking approach (Fig. 5.5a), position the robotic patient cart between
the patients legs while facing the patient directly. The main disadvantage is the tight
space available for assistance manipulating the uterus, especially in cases needing
uterine morcellation.
5.6.1.3Side docking
For side docking (Fig. 5.5b), introduce the robotic patient cart while embracing one
of patient legs with an arm positioned in between patient legs with the other arm
coming from the patients side. The main advantage is leaving space for assistance
in manipulating the uterus. Side docking is typically adapted for the retroperitoneal
approach.
5.7Conclusion
Proper patient positioning, trocar placement, and docking are critical steps for a suc-
cessful and safe robotic procedure since attempts to change the patients position
or trocars during the procedure are costly in terms of procedure time and frequently
necessitate patient cart undocking and redocking. Robotic surgeons should have a
clear understanding of the general principles of patient positioning, port placement,
and docking. In addition, adequate preprocedure planning takes into consideration
the specifics of each case. These specifics include patient characteristics (e.g., obesity
and prior surgery), procedure type (e.g., simple hysterectomy vs. sacrocolpopexy vs.
para-aortic lymphadenectomy), and characteristics of targeted anatomy (e.g., uterine
References 47
Fig. 5.5: Robot docking: a) straight docking, b) side docking
size and anticipated adhesions). Finally, a team approach should be adopted, and
each team should clearly understand and anticipate an efficient and seamless flow of
activities in the OR.
References
[1] Boggess JF. da Vinci Hysterectomy for Early Stage Endometrial Cancer Procedure Guide.
871402 Rev F. Sunnyvale, CA: Intuitive Surgical, 2010.
[2] ACOG Practice Bulletin No. 84. Prevention of deep vein thrombosis and pulmonary embolism.
Obstet Gynecol 2007, 110, 42940.
[3] Ghomi A, Kramer C, Askari R, et al. Trendelenburg position in gynecologic robotic-assisted
surgery. J Minim Invasive Gynecol 2012, 19, 4859.
[4] Visco AG. da Vinci Sacrocolpopexy Procedure Guide. 871619 Rev B. Sunnyvale, CA: Intuitive
Surgical, 2007.
[5] Magrina JF, Kho R, Montero RP, et al. Robotic extraperitoneal aortic lymphadenectomy:
Development of a technique. Gynecol Oncol 2009, 113, 325.
6 Role of the robotic surgical assistant
Alexander di Liberto and Kubilay Ertan
6.1The surgeon in the area of conflict between autonomy

and dependency
The possibility for the robotic surgeon to dispose of three or four laparoscopic accesses
simultaneously or consecutively (camera arm and two to three robotic surgical arms) is
an important characteristic and a significant advantage of robot-assisted surgery with
the da Vinci system (Intuitive Surgical Inc, Sunnyvale, CA, USA). It makes it easier
for the surgeon in contrast to traditional laparoscopic surgery, where only two laparo-
scopic accesses can be used at the same time, and provides a high degree of autonomy
with regard to the core area of the surgical intervention, that is the actual therapeuti-
cal procedure. On the other hand, the work at the console in a non-sterile area results
in a loss of control over the required accessory and logistic tasks of the surgical envi-
ronment which are associated with the surgical access; the acquirement (passing ins-
truments to, from or across the operating table from the circulating nurse), the change
or the removal of the equipment (for instance, interference of the trocar positions,
instrument exchange, taking over of additional instruments, etc.), the optimization of
the visibility conditions (by suction and irrigation, cleaning of the camera, etc.), and
the retrieval of the surgical specimen and tissues. In consequence of the work at the
console the surgeon is quasi segregated from the sterile field of the operating table
and the operating area and can focus on the virtual surgical work (dissection, sutu-
ring, etc.). The loss of control of particular activities such as direct engagement at the
operating table leads the robotic surgeon to rely more on the robotic surgical assistant
and the scrub nurse as in traditional laparoscopic interventions. This restriction of
the operating range in favor of the manifold advantages resulting from the technique
of the da Vinci system has to be counterbalanced by the robotic surgical assistant. As
regards haptics and tactile feedback it comports similarly. Indeed, the surgeon can
compensate for the absence of haptics partially by means of the tridimensional spatial
view, but the surgical assistant can give more reliable feedback concerning the consis-
tency of tissues and stiffness of anatomic structures.
In addition to this, the use of the fourth arm can be relinquished for economic
reasons or in order to minimize the amount of surgical accesses through the abdomi-
nal wall in an effort to limit the surgical trauma as a basic principle of all laparosco-
pic, minimally-invasive surgical (MIS) techniques. Subsequently, the robotic surgical
assistant has to take over further tasks.
Due to specific selection criteria for robot-assisted operations the increase of
complexity of minimally-invasive interventions imposes auxiliary requirements
and challenges on the surgical assistant, which frequently exceed the measure
of tasks in traditional laparoscopic interventions. For this reason, the criteria of
50 6 Role of the robotic surgical assistant
choice, competence, skills and experience of the robotic surgical assistant have to
be defined. This is illustrated in the following.
6.2Tasks of the robotic surgical assistant
The robotic surgical assistant has many tasks and responsibilities in the preope-
rative prearrangement of the operation theatre (patient positioning, disinfection,
draping of the patient, other preparations at the operating table such as secu-
ring the camera position, wiring, etc.), the performance of or assistance in the
traditional laparoscopic part of the operation prior to the docking of the patient
side cart (depending on the specific allocation of tasks of a particular gynecolo-
gic department, respectively, depending on the level of training and experience
of the particular surgical assistant, but in most cases in collaboration with the
console surgeon), the proper robotic surgical assistance during the therapeutic
part of the operation (console phase), the closing section after termination of the
console phase and undocking of the patient side cart, and the postoperative care
and post-processing procedures (neutralization of the intraoperative patient posi-
tion, review and wrap-up of the intervention, documentation, etc.).
Preoperative and postoperative patient care in the operating theatre hardly differs
from traditional laparoscopic operations, and are described elsewhere (as regards
specifics of patient positioning in robot-assisted interventions). The duties, tasks and
functions of the robotic surgical assistant in the particular operation phase (between
incision and cutaneous suture) are given below. In principle, it can be asserted that
the robotic surgical assistant besides the handling of the robotic arms and their ins-
trumentation accomplishes activities which are essentially the same as were used in
traditional laparoscopic surgery, this means that he or she must be skilled and trained
in conventional laparoscopy (Fig. 6.1).
6.2.1Tasks of the robotic surgical assistant prior to beginning

the surgical intervention
The responsibility for the correct and safe positioning of the patient relies generally
on the medical team, the anesthesiologist is in charge of those body regions which
are used for the anesthesiological instrumentation (mostly the head and arms), the
other parts of the body are the responsibility of the surgical team. For this reason
the surgeon and/or the surgical assistant are involved in the positioning of the
patient and in ensuring that the patient is protected from intraoperative positio-
ning injury and damage (peripheral nerve injury, lesion of the plexus brachialis,
compartment syndrome, etc.) in every case, predominantly in close collaboration
with the OR nursing staff. However, the surgical team have dominion over and the
6.2Tasks of the robotic surgical assistant 51
Fig. 6.1: a) Docking maneuvre; the robotic surgical assistants are positioned at the operating table
and act independently, the console surgeon is not scrubbed in; b) console phase; the robotic
surgical assistant acts independantly at the patients side
main responsibility for the correctness of the positioning measures and procedures.
The importance of the robotic surgical assistant consists in performing the required
tasks routinely and efficiently and in the knowledge of the specific demands of the
respective robot-assisted interventions and types of surgery. Moreover, the robotic
surgical assistant is constantly involved in the prearrangement of the surgical table
(the laying down of the endoscope on the surgical table for later use before the
placement of the trocars, fixing and protection of the da Vinci endoscope, arrange-
ment of the cables, installation of suction/irrigation, placing of instrument pockets,
etc.). A detailed knowledge of the layout of the accessory material for each robot-
assisted intervention is required as regards the docking position of the patient side
cart (between legs docking, side docking, etc.). Optimal training and adequate
experience are required.
6.2.2Tasks of the robotic surgical assistant between beginning

the surgery and starting the console phase
The surgical steps required between beginning surgery and taking over the surgical
console are: the attachment of the uterine manipulator (if used), the establishing of
the capnoperitoneum, the insertion and placement of the da Vinci trocars and of the
assistant ports (12), the performance of adhesiolysis, where required (provided that
the insertion of the trocars and the placement of the robotic instruments are encum-
bered by adhesions), and the docking of the patient side cart to the da Vinci trocars
as well as the insertion of the EndoWrist instruments and their correct placement
in the abdominal cavity. Notably, the adhesiolysis can prove to be extremely compli-
cated and sometimes requires a high degree of experience in traditional laparoscopic
surgery. According to the allocation of tasks the robotic surgical assistant can perform
this preliminary surgical steps alone, i.e., independently and being primarily respon-
sible, or the surgical assistant supports the main surgeon in his activities. Usually
these acitivities and tasks are done in equitable collaboration between the surgeon
and surgical assistant, all movements and maneuvers have to be coordinated in order
to ensure an uninterrupted trocar placement and a short docking time. Importantly,
the time between beginning the surgery and the docking maneuver can be shortened
by the experience of the robotic surgical assistance.
6.2.3Tasks of the robotic surgical assistant during the console phase
Besides the function of surgical assistance (this means the support of the console
surgeon) the robotic surgical assistant is the responsible scrubbed physician and
surgeon at the operating table during the console phase, so that he fulfils a dual
6.2Tasks of the robotic surgical assistant 53
assignment: on the one hand, he assists and on the other hand, he assumes respon-
sible tasks, where necessary. This clearly exceeds the common function of the surgi-
cal assistant in traditional surgical interventions in which the surgeon stands at the
operating table; the robotic surgical assistant guards the patient safety at the opera-
ting table.
The specific assisting tasks for robotic interventions after docking of the patient
side cart are (usually in collaboration with the operation nurse) the instrument
exchange, which have to be carried out as quickly and with as little disturbance
as possible, the cleaning of the da Vinci camera and, as the case may be, of the
EndoWrist instruments (depending on the established division of work between
surgical assistances and nursing staff in the particular department), which also have
to be performed without unnecessary delay, the surveillance, monitoring and adjust-
ment of the capnoperitoneum, the correction of the robotic arms and the position of
the trocars (modulation of penetration depth and stretching of the abdominal wall,
primarily the camera arm in case of gas loss or requested low gas pressure), depen-
ding on the desired range of motion and expansion of the operating field (e.g., from
the rectouterine excavation up to the renal veins in endometrial cancer staging),
and troubleshooting at the patient side cart (e.g., in case of collision of the robotic
arms, repositioning of the robotic arms in the event of dislocation due to unexpec-
ted movements). All these activities call for a fundamental and broad understanding
of the robot system, and of the EndoWrist instruments and the patient side cart,
notably the functionality, the mode of operation and the dimension of movements of
the robotic arms including their manipulation, and an adequate experience in whose
handling. At this juncture, the surgical assistant has to operate and act in a self-
directing manner because the virtual surgeon at the console cannot engage directly
at the operating table. The experienced handling of the da Vinci system is indispen-
sable in case surgical intervention is required with the minimum of hesitation. The
surgeon at the console is dependent on the competence of the surgical assistant
during the activities at the operating table; the surgeon can direct the assistant ver-
bally. The tasks of the surgical assistant which are not specific for the robotic device
act are most often in accordance with the type of intervention required, mostly they
concern holding functions (retraction, presentation of structures which have to be
removed, or protection of tissues and organs which are near the surgical field, e.g.,
the ureter), optimization of the view in the surgical area by suction and irrigation, if
necessary inserting of pads, and the placement of further surgical materials (endo-
bags, suture material, hemostatic agents and material, vessel loops, staplers, etc.),
and their removal, including the secure removal of tissues, organs and other surgical
specimens (in case of hysterectomy, the vaginal retrieval can be a particular challenge
if there is a unfavorable relation between the uterine size and the width of the vagina,
especially if a contamination in case of malignant diseases has to be avoided. A dila-
tation and widening of the vagina to the point of an episiotomy can become necessary.
Frequently, instruments have to be placed transvaginally in order to grasp specimens

intraabdominally; this can be hindered due to a deficient accessibility to the vagina
and reversed movements). Here, the selection of adequate laparoscopic instruments
(traumatic and non-traumatic grasping forcipes, tenacula, bowel retractors, spoon
forcipes, etc.) and their optimal placement is crucial. Even more requirements are
called for by the surgical assistant in case of the use of transabdominal applications
(e.g., injection of epinephrinehydrochloride prior to myomectomy), employment of
sealing instruments (e.g., LigaSure, HarmonicD, etc.), or staplers, or, for instance,
performance of clip applications and of insertion of ureteral stents, etc. The basic
principle in all these activities is the anticipation of each action, as well as in other
surgical interventions (this applies both to abdominal and traditional laparoscopic
interventions); but in robot-assisted surgery the anticipation of assistant activities
seems to be more relevant because of the direct communication (quasi face to face)
between the surgeon and the surgical assistant is interrupted or complicated due to
the spatial distance (see the paragraph below about structures of communication).
Additionally, the docked patient side cart provokes a restriction in the accessibility to
the assistant ports, posing further requirements to the accuracy of the robotic surgical
assistant.
The optimal accomplishment of the mentioned activities and tasks require a
detailed acknowledgement of the particular course of each surgical intervention.
Most of the assistant activities that occur are not camera-guided, therefore they must
be carried out unerringly and precisely as much as possible on the edge of the surgi-
cal field; furthermore, these movements should happen without collision with the
robotic instruments or restricting the surgeons view.
Where the fourth robotic arm is used robotic assistants tasks are transmitted to
the surgeon. Sometimes, due to an increasing complexity of the robot-assisted ope-
ration, the placement of two assistant ports can be required; the manipulation of two
assistant ports escalates the demands for the robotic surgical assistant.
The intraoperative insertion of an additional assistant port in case of unexpected
intraoperative conditions (due to a restricted surgical view or anatomic proportions)
or complications (e.g., major bleeds) given the docking situation of the patient side
cart is a task of the robotic surgical assistant and belongs to his field of expertise.
Depending on departmental and personal specific conditions the robotic surgical
assistant could take over the task of uterine manipulation, which increases the com-
plexity of his function even more. In consequence of the at least temporary autono-
mic work of the console surgeon as a specification of robot-assisted operations there
are periods of nonactivity for the robotic surgical assistant on the other side, when
he has no tasks at all. These can result in a lack of attention of which the robotic sur-
gical assistant has to be conscious at any time. Therefore, the function of the surgical
assistant during these periods can be labeled as attentive passiveness.
In critical situations during the surgery (e.g., in case of an unexpected and major
bleed) the robotic surgical assistant has to perform self-determined responsible
6.3Selection criteria of the robotic surgical assistant 55
activities, such as applying clip application, utilization of several materials for

hemostasis which may be applied in a complex way (e.g., Gelitacel, Tachosil,
Floseal, etc.), up to the emergency undocking procedure of the patient side cart,
which requires appropriate training, and the urgent performance of laparotomy
(longitudinal and transverse incision), the last one up to the time when the console
surgeon is scrubbed and can take over the surgery at the operating table (Tab. 6.1).
6.2.4Tasks of the robotic surgical assistant after termination of the console

phase until the skin closure
The tasks of the robotic surgical assistant between termination of the console phase
and the end of the operation which are performed, depending on departmental divi-
sion of labor, with or without the console surgeon, include the undocking of the
patient side cart from the trocars (after removal of the robotic instruments), the
insertion and placement of drainages [including a suprapubic catheter in case of
radical hysterectomies (mainly type C hysterectomy according to the classification
of Querleu-Morrow)], the removal of a temporarily stored specimen outside of the
peritoneal cavity (including endobags), if necessary after restricted widening of the
incisions or via natural orifices, where required (i.e., in myomectomies, supracervi-
cal hysterectomies and hysterectomies with large uteri not extractable through the
vagina) the application of morcellation techniques, the peritoneal lavage, and the
closure of the incisions (particularly the fascia closure). These activities require an
adequate expertise of the robotic surgical assistat as well, especially with regard to
the traditional laparoscopic experiences, skills and capabilities.
6.3Selection criteria of the robotic surgical assistant
Due to the fact that the robotic surgical assistant has to show both sufficient capa-
bilities and experiences in complex traditional laparoscopic interventions and
a comprehensive knowledge of the robotic system and whose functionality and
Tab. 6.1: Tasks of the robotic surgical assistant during the console phase
Central tasks of the robotic OR assistant
concerning robot specific tasks concerning laparoscopic, assistant tasks

instrument change and positioning retraction of tissues and organs
troubleshooting suction/irrigation
correction of the position of the robotic arms providing of material (sutures, endobags, etc.)
and position of the trocars
cleaning of the camera (and instruments) specimen extraction
uterus manipulation (if applicable)
characteristics as demonstrated in the preceeding chapters the surgical assis-

tant will usually be an experienced fellow or resident. Furthermore, selection crite-
ria are a sufficient and practical training in the robotic system, interest, and enthu-
siasm for robot-assisted interventions. Commonly, the da Vinci surgeons alternate
their work at the console and as surgical assistants from case to case. This no doubt
shows an optimal combination concerning the efficient course of the intervention
because the surgical assistant knows through their experience as a surgeon the
outcome of the intervention, and therefore he is capable of performing all the assis-
tant activities effectively and expeditiously. However, this reduces possibility and
potential for educating and training residents and fellows. The latter also concerns
the number of cases performed in the particular gynecologic department and the
degree of complexity of robot-assisted interventions, the employee turnover, and
the level of the particular department as university or teaching hospital. Due to the
importance of the formation of a robotic team resulting from the complexitiy of the
preparations and postprocessing procedures and the specific components of the
da Vinci system, whose correct handling is essential for the unobstructed advan-
cement of the intervention, the existence of a core team is indispensable. Adding
a resident or fellow for training and education in robotic assistance to the core
team may provoke a delicate disturbance of the operation sequence, especially in
complex cases. The education and training of a robotic surgical assistant requi-
res a minimum number of robot-assisted cases per year which is approximately
50 cases per year for an effective assistant training. The additional training at the
surgeon console depends on the spectrum of the robot-assisted interventions of
each gynecologic department. The higher the complexity of the robotic interven-
tions, the stricter the selection criteria for using the robotic assistance, the more
problematic is the realization of an additional console training. The basic principle
for the selection of a qualified robotic surgical assistant is the existence of satisfac-
tory experience and expertise in traditional laparoscopic surgery because robotic
assistance essentially contains components of conventional laparoscopic activities
and exercises.
6.4Training/education of the robotic surgical assistant
The question how to accomplish and to optimize the training of the robotic surgi-
cal assistant is mostly associated with the issue how to educate and to train robotic
surgeons in general. In this respect, the sequence is mostly assumed that there
exists a structured program and schedule in the particular department the admis-
sion of a medical assistant to the robotic team, training at the device in terms of a
dry run, the change over to robot-assisted interventions, instructed assistance, and
finally independent robotic surgical assistance. As the robotic surgical assistance is
6.4Training/education of the robotic surgical assistant 57
in essence a traditional laparoscopic exercise (direct guidance of the instruments

in a two-dimensional view including the fulcrum effect, with physiological tremor
and loss of the natural eye-hand alignment, etc.) sufficient training in traditio-
nal laparoscopic surgery and techniques is a mandatory prerequisite for assisting
robotic surgery (because in existing and experienced robotic programs preferably
complex cases are robot-assisted, thus the basics has to be acquired elsewhere). In
this context, the spectrum of performed robot-assisted interventions is important.
In the case of the (economic) possibility of a gynecologic department to do easier
robot-assisted interventions (such as simple hysterectomy in benign diseases or
non-complex myomectomies) the education and training at the da Vinci system
is considerably easier. Moreover, the type and intensity of the training and its
organization depends on the number of the performed robot-assisted cases of a
gynecologic department and coincidentally is associated with the economic and
the personal situation of the department and the whole hospital. There exist no
international accredited standards for education and training both concerning
the robotic surgeon and the robotic surgical assistant (including credentialing).
However, professional societies (e.g., SERGS, SGO Clinical Practice Robotics Task
Force [1]) are making efforts to establish standardized programs for the education
of robotic surgeons and assistants; at this juncture both positions, surgeon and
assistant, are associated and are simply components or different levels of a single
field of work, namely robot-assisted surgery.
6.4.1Practical and virtual simulation/simulator systems
Diverse alternatives of simulation exist, both for traditional laparoscopic and for trai-
ning in robotic surgery. These range from simple arrangements in a laboratory (e.g.,
the Pelvitrainer) to large animal models (mainly porcine models) or even to experi-
mental models with human cadavers. The elaborate and expensive practical simula-
tion models should be centralized in the surgical department where robotic surgery
will be carried out. For the virtual training there are apart from numerous online
tools for education diverse laparoscopic and robotic surgical digital simulation pro-
grams available (e.g., the da Vinci Skills Simulator [for the da Vinci SI system], or
SimSurgery, LapSim, LAP Mentor, ProMIS Hybrid Surgical Simulator, etc.,
Fig. 6.2).
All of these systems are focused on surgical operating activites and less on the
surgical assistance, but this demonstrates the close association and relationship
between surgical and assisting functions.
For the robotic surgical assistance intensive 12 day-training sessions on the da
Vinci system in specialized training centers and laboratories are most effective, but
Fig. 6.2: da Vinci Skills Simulator (source: Intuitive Surgical Inc, Sunnyvale, CA, USA); examples
for simulation tasks
are expensive and have long waiting lists, especially for whole robotic teams (surge-
ons, surgical assistants and surgical nurses).
6.4.2Training programs request and reality
The ideal sequence for adaptation of robot-assisted interventions into the clinical
routine is a bespoke training centre from which instruction in and operating from can
be done. An alternating work pattern between operating and assisting function is ideal
because only then can the surgical team amass the required experience. This applies
to both open abdominal and traditional laparoscopic as well as robot-assisted surgery.
There exist numerous structured conditions for training with the da Vinci system
(examples are depicted in the Fig. 6.3), mostly from American robotic surgical teams
because in the USA there is a large amount of da Vinci systems in use and subse-
quently a high number of cases. In Europe, the availability of da Vinci systems is
lower (counted as number of da Vinci systems relating to the population), the scepti-
cism towards robot-assisted surgery is larger and the economic constraints are higher,
so that selection criteria for robot-assisted interventions are stricter. All this results in
a lower number of performed robotic cases (this causes a lower turnover, less effici-
ency and longer operating times), this again aggravates the initiation and implemen-
tation of structured training programs and the admission of residents and training
fellows into the robotic programs.
6.5Aspects of spatial arrangement and structures of communication 59
(a) (b)
Docking practicum Education and training
sequence
Stage I: camera arm positioning
- camera arm set-up I. didactic overview
- camera arm sweet spot - understand robotic vision, electronics,
- camera arm alignment and instrumentation
- understand robotic ergonomics, and
robotic limitations
Stage II: instrument arm
positioning and port placement
- instrument arm positioning II. inanimate laboratory
- patient cart positioning - master operative console, and robotic
- port placement philosophy operative cart
- master instrument and camera control
Stage III: docking III. animal laboratory

- docking camera arm - console surgeon - master suturing,
- arm positioning during docking tissue cutting, suture tying
- docking instrument arms - patient-side assistant - master:
instrument exchanges, camera cleaning
cauterization, clip application
Stage IV: checking system set-up retraction, trocar positioning
- camera arm set-up
- instrument arm set-up
- instrument arm postioning IV. cadaver laboratory
- master trocar positioning
- apply I-III to human anatomy and to
variable body habitus
Stage V: instrument insertion and
removal
- instrument insertion
- instrument removal V. operative observation
- guided tool change - determine differences from I-IV
- observe interaction with adjunctive
surgical technology
Fig. 6.3: a) example of a structured training program (modified from Geller et al [2]); b) example
for a educational and training program; robotic surgical training curriculum levels (modified from
Chitwood et al [3])
6.5Aspects of spatial arrangement and structures

of communication
The spatial and functional position of the robotic surgical assistant in the operation
theatre should be considered as a central or a key position. The surgical assistant has
direct contact with the scrub nurse, the circulating nurse and to the anesthesiologist
and he should be in easy communication with the console surgeon (Fig. 6.4), thus
the surgical assistant is important for the coordination the whole OR team. For this
reason the spatial positioning of the robotic surgical assistant has to be chosen wisely
in relation to the da Vinci system and with respect to the particular docking situation
of the patient side cart, even if there are frequently constraints and limitations due to
the spatial limitation of the OR. The following basic principles concerning the posi-
tion of the surgical assistant have to be considered (Fig. 6.5):
in case of the between legs docking the surgical assistant should be placed vis-
-vis the scrub nurse and both should have uninterrupted visibility, likewise he
should have a direct line of sight to the surgeon at the a Vinci console; this means
that the robotic surgical assistant, the console surgeon and the scrub nurse are
arranged in a triangular alignment
in the case of a side docking position (valid for both from upper and lower patient
side, and both for the docking from the right and the left side) the surgical assis-
tant should be placed opposite to the patient side cart, vis--vis to the scrub nurse
(then rather diagonal) and as well as the console surgeon.
Due to the spatial distance of the surgeon to the operating table and for this reason
to the surgical assistant and the scrub nurse in robot-assisted operations in contrast
to traditional laparoscopic interventions, where communication routes are shorter
or non-verbal communication can take place easily by gestures and eye-contacts,
special features and an increased intensity and difficulty of communication arise, or
rather particular principles of communication in the operation theatre attain a major
impact in robot-assisted operations. Basic rules of communication are the expression
of explicit instructions and commands (mainly from the surgeon at the console), clear
verbal confirmations and feedbacks (mainly from the surgical assistent, the scrub
nurse and the anesthesiologist explicit communication), the mutual respect of
the particular tasks, as well as the reduction of conversation foci and ambient noises
in the operating theatre in order to ensure an undisturbed and optimal flow of work
Anesthesiologist Anesthesia nursing
Surgeon
OR assistant OR nurse
2nd OR assistant Circulating nurse
Fig. 6.4: Lines and structures of communication in robot-assisted interventions

6.5Aspects of spatial arrangement and structures of communication 61
Fig. 6.5: a) position of the robotic surgical assistant in relation to the console surgeon, the scrub
nurse and the anaesthesiologist, fourth arm on left patient side; triangular alignment of the surgical
team (source: modification of an Intuitive Surgical Inc. image); b) position of the robotic surgical
assistant in relation to the console surgeon, the scrub nurse and the anaesthesiologist, fourth arm
on right patient side; triangular alignment of the surgical team (source: modification of an Intuitive
Surgical Inc. image)
and to minimize the sense of physical and psychological isolation of the surgeon
at the console [4]. The application of a microphone/speaker system can simplify the
communication between the console surgeon and the staff at the operating table. The
communication between the console surgeon and the robotic surgical assistant has
been shown in operation analyses as the predominant communication channel [5];
this emphasizes the outstanding importance and position of the surgical assistant.
6.6Available data relating to the role of the robotic surgical

assistant/existing evidence
Hardly one study or trial deals explicitly with the role of the robotic surgical assis-
tant. To date there are only two publications which investigate the function and the
importance of the surgical assistant, namely one analysis of a Romanian study group
from a department of general surgery [20]. This study assigns to the robotic surgical
assistant a key role in the robotic surgical workflow (the decisive role of the pati-
ent-side surgeon in robotic surgery), and an urologic working group concerning the
subject of training in robot-assisted prostatectomies [6]. These studies will be descri-
bed in detail. Some studies and statements from non-gynecologic and gynecologic
departments [712] even suggest that by the use of the fourth arm and an optimally-
trained scrub nurse the robotic surgical assistant could be partially replaced. Pub-
lications with the explicit topic of demonstration and description of the role of the
robotic surgical assistant in gynecologic robot-assisted operations are not available.
A series of papers presents structured programs and schedules showing how to lead
surgeons and training fellows and residents gradually in robot-assisted interventions,
with respect to how to design and optimize the training and education to attain best
possible learning curves and results by using simulation systems as well [3, 1319, 2],
or the importance and the interaction of the robotic surgical team as a whole are ana-
lyzed [22]; for the most part there is no decided discrimination between the functions
and tasks of the surgeon and surgical assistant, but rather the robotic surgical assis-
tance is specified as a certain stage or component of the robotic education and trai-
ning [2]. This reveals that the role and position of the surgical assistant is not fixed
or could be considered separately, but rather that the formation at the robotic system
commonly combines both the assistant and the surgical function, or rather shows
that the surgical assistance merely can be performed if a minimum of surgical expe-
rience at the surgical console has been acquired (comprehension and appreciation
of the requirements to the surgical assistance from the own practical experience as
surgeon).
In the study of Sgarbura and Vasilescu [20] several different activities of the
robotic surgical assistant are analyzed and quantified (trocar placement, docking and
undocking of the patient side cart, insertion and change of robotic instruments, and
6.7Conclusions 63
maneuvers for hemostatis). The survey of these activities took place in the context
of 280 robot-assisted interventions in digestive, thoracic, and gynecologic surgery,
whereupon three trained robotic teams with three console surgeons and four certi-
fied robotic surgical assistants (here indicated as patient-side surgeons) have been
grouped. Four more patient-side assistants were trained at the reporting center. The
results revealed that assistants which are intensely trained and educated in training
centers (e.g., with the help of animal models) are more comfortable in handling the
robotic instruments and with docking and undocking of the patient side cart com-
pared to those who are trained locally. Furthermore, the authors demonstrated that
experienced surgical assistants (who finalized their residency or attended in their
final year) are more accurate and precise with the insertion of laparoscopic inst-
ruments and performing haemostatic activities (e.g., clip applications, LigaSure
handling). In interventions with a need of a high degree of participation and atten-
dance of the surgical assistant a significantly shorter assistant-dependent time inter-
val was demonstrated at the end of the learning curve compared to at its beginning.
The authors concluded that besides the importance of the complete team in robot-
assisted surgery, the robotic surgical assistant accounts in the effective accomplish-
ment of the intervention to a great extent, in addition, there are clear detectable
differences between structured (e.g., by means of animal models in surgical labora-
tories) and locally (mainly by instruction and tutorial during robotic interventions)
trained surgical assistants (Tab. 6.2). That a structured education and formation with
respect to a periodical training can improve the course of robot-assisted operations
has also been demonstrated on the basis of a three-phase hands-on RARP (robot-
assisted radical prostatectomy) bedside assistant training [6].
6.7Conclusions
In the opinion of the authors, the robotic surgical assistant in robot-assisted inter-
ventions with the da Vinci system has a greater higher importance compared to
non-robot-assisted operations (abdominal and traditional laparoscopic). On the
one hand, this results from the fact that the surgical assistant not only has to have
experience in traditional laparoscopic surgery but also the differentiated knowledge
and skills in the handling of the robotic system, and on the other hand, the surgical
assistant has to take over or have the ability to take over tasks and activities (parti-
ally in cooperation with the entire robotic team) which cannot be accomplished by
the console surgeon because of his work at a remote place. The console surgeon has
a higher level of autonomy for the specific surgical work (dissection, etc.), but he is
more dependent on the reliability of the patient-side assistant concerning accessory
surgical activities. In this respect, it is permissible to characterize the relationship
between the console surgeon and the patient-side assistant as the complementary
work of two surgeons, namely the console surgeon and the patient-side surgeon
Tab. 6.2: Differences between formal and local trained robotic surgical assistants; (according to
Sgarbura [20]) n concerns number of assistants and not the number of measurements
Differences between the assistants formally trained/experienced in laparoscopy and the

assistants locally trained/less experienced in laparoscopy
Formal training (n = 4) Local training (n = 4) P value

Docking time (min) 10.67 2.4 16.3 4.5 0.05
Instrument exchange time (s) 5.9 2.7 7.7 3.7 0.0004
experienced in less experienced in P value
laparoscopy (n = 5) laparoscopy (n = 3)
Time for insertion of the instruments 4.6 1.3 8.2 3.5 0.0001
in the operative filed (s)
LigaSure/clip application time (s) 4 1.7 7.8 2.6 0.0001
Rate of unsuccessful applications 4% 15% 0.007
(the scrubbed surgeon, [21]). The education and training of robotic surgical assis-
tants are essential; it has been demonstrated that a formal training (i.e., in a trai-
ning center) is beneficial related to the effectiveness of the assistance compared to
a local, unstructured training. Furthermore, novel and unresolved problems concer-
ning team coordinating strategies, characterization of interactions between the team
members, and their choreography in the performance of the particular tasks arise for
each department performing robot-assisted interventions.
References
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[9] Sundaram CP, Koch MO, Gardner T, et al. Utility of the fourth arm to facilitate robot-assisted
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Further reading 65
[10] Esposito MP, Ilbeigi P, Ahmed M, et al. Use of fourth arm in da Vinci robot-assisted
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[11] Van Appledorn S, Bouchier-Hayes D, Agarwal D, et al. Robotic laparoscopic radical
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[12] Kimmig R. Robotic Surgery in der Gynkologie Chirurgie der Zukunft oder teurer PR-Gag?
Eine persnliche Betrachtung. Gynkologe 2011, 44, 4014.
[13] Ali MR, Rasmussen J, BhaskerRao B. Teaching robotic surgery: a stepwise approach. Surg
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[15] Gobern JM, Novak CM, Lockrow EG. Survey of robotic surgery training in obstetrics and
gynecology residency. J Minim Invas Gynecol 2011, 18, 75560.
[16] Hashimoto DA, Gomez ED, Danzer E, et al. Intraoperative resident education for robotic
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[17] Hoekstra AV, Morgan JM, Lurain JR, et al. Robotic surgery in gynecologic oncology: Impact on
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[18] Kilic GS, Walsh TM, Borahay M, et al. Effect of Residents Previous Laparoscopic Surgery
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Gynecol 2012, Article ID 569456: 14.
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Further reading
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Gynecol 2009, 114, 11535.
Chandra V, Nehra D, Parent R, et al. A comparison of laparoscopic and robotic assisted suturing
performance by experts and novices. Surgery 2010, 147, 8309.
Drasin T, Dutson E, Gracia C. Use of a robotic system as surgical first assistant in advanced
laparoscopic surgery. J Am Coll Surg 2004, 199, 36873.
Einarsson JI, Hibner M, Advincula AP. Side docking: An alternative docking method for gynecologic
robotic surgery. Rev Obstet Gynecol 2011, 4(3/4), 1235.
Sfakianos GP, Frederick PJ, Kendrick JE, et al. Robotic surgery in gynecologic oncology fellowship
programs in the USA: a survey of fellows and fellowship directors. Int J Med Robotics Comput
Assist Surg 2010, 6, 40512.
7 Strategies for avoiding complications from robotic
gynecologic surgery
Georgia A. Mccann and Jeffrey M. Fowler
7.1Introduction
Minimally-invasive surgery (MIS) has progressed from being limited to diagnostic

procedures and tubal sterilization to more advanced laparoscopic (LS) and now
robotic surgeries. Over the past two decades, improvements in instrumentation, accu-
mulated surgical experience and specialized surgical training have all contributed
to advances in the ability to perform a wide range of major surgical procedures via
MIS for complex benign and malignant conditions. Many postoperative complica-
tions associated with laparotomy are comparatively less when the same procedure is
performed via MIS. However, incorporating LS into the comprehensive management
of general gynecology and gynecologic oncology patients has been only moderately
successful secondary to technologic limitations, a difficult and long learning curve,
variability in surgeon experience, longer operative times and patient factors such as
surgical history and obesity. The robotic platform overcomes many of the technologic
limitations of LS.
The surgical goal of MIS is for equivalent or improved disease-related outcomes
but with the expectation of a decrease in perioperative morbidity, disability, and
improved quality of life. Therefore, patient and physician expectations are very high
with MIS procedures and any complication is likely to be perceived as more unac-
ceptable under these conditions. Advantages to a MIS include smaller incisions, less
tissue manipulation and damage, and decreased adhesion formation. The operator
of the robotic platform not only has improved vision but also controls the direction
and distance of the camera from the operative field without relying on the assistant.
In addition, the surgeon has up to three other port sites to use for a dissector, cutting
instrument and another retracting instrument. The marked technological improve-
ments provided by robotic surgery has allowed experienced surgeons to offer more
patients, requiring complex procedures, the advantage of a MIS approach. Neverthe-
less, these are still major surgical procedures performed via minimized access and
therefore major surgical complications are possible, some which are unique to MIS.
MIS introduces additional layers of technological, human and procedural com-
plexity for any given surgical procedure traditionally performed via laparotomy.
Prevention of complications begins long before the actual operative procedure with
appropriate treatment selection and preoperative counseling. Selection of a surgical
route will often be based on a surgeons formal training and experience. It is recom-
mended that surgeons develop a careful accumulated experience of increasingly
complex robotic procedures. It is important for the surgeon to develop a consistent,
68 7 Strategies for avoiding complications from robotic gynecologic surgery
step-wise approach to major MIS procedures. Preoperative planning in regards to

setting ones surgical strategy is extremely helpful. Anesthesia consultation and/or
preoperative medical clearance may be necessary regarding pulmonary and ocular
sequelae unique to MIS. Once in the OR, proper patient position is critical to facilitate
the procedure and minimize extremity-related complications. Skilled surgical assis-
tance must be arranged and the operating room set-up properly orchestrated. A team
approach with excellent communication between all members in the OR is critical.
OR staff experienced with the robotic platform such as the circulating nurse, scrub
technologists and biomedical support are necessary for efficiency and safety.
7.2Patient positioning prevention of neurologic injuries
In addition to optimizing visualization and surgical conditions, the most important

function of patient positioning is minimizing the risk of neurologic injuries. Nerve
injury is ultimately the result of ischemia, hemorrhage, tissue necrosis, and endoneu-
ral edema. There are two major mechanisms in which improper patient positioning
can result in neurologic injury: stretch and compression.
Lithotomy is the position most commonly associated with lower extremity nerve
injury and is the position in which all gynecologic robotic procedures are performed.
The risk of sensory and motor deficits in patients placed in lithotomy position is 1.5%
and 0.03%, respectively [1, 2]. Prolonged hip flexion, abduction and external rotation
can result in obturator nerve stretch as well as compression of the femoral and lateral
femoral cutaneous nerves as they course under the inguinal ligament. The common
peroneal nerve courses around the lateral fibula and can be injured as a result of
lateral compression or can suffer stretch injury during extended flexion of the knee
with external hip rotation [3]. Although rare, stretch injury to the sciatic nerve can
result from prolonged hyperflexion and external rotation of the hips with the knees
extended [1, 4]. The genito-femoral and obturator nerves are at risk of direct injury
during gynecologic oncology procedures [5]. The genito-femoral nerve can easily be
transected during dissection of external iliac lymph nodes, resection of pelvic sidewall
mass or adhesiolysis of the sigmoid colon to the pelvic sidewall and often results in
temporary sensory neuralgia. Likewise, the obturator nerve can be transected during
pelvic lymphadenectomy and, unlike the genito-femoral nerve, usually should be
repaired [6, 7]. Endometrial cancer is the most common indication for robotic surgery
performed by gynecologic oncologists [810]. There is no prospective data on the rate
of neurologic injury in robotic gynecologic surgery. Retrospective data suggests that
the rate of neurologic injury is approximately 5% with the great majority resulting in
sensory neuralgia resulting from injury to the genito-femoral nerve [11].
Prevention of nerve complications related to patient positioning starts with
understanding the mechanism of lower extremity nerve injury. The ideal lithotomy
position is a trunk-to-thigh angle between 60170. The knees should be flexed, never
7.2Patient positioning prevention of neurologic injuries 69
extended, such that the thigh to calf angle is between 90120. Positioning should
also minimize external hip rotation so that the angle of hip adduction results in no
more than 90 between inner thighs. The use of Allen stirrups helps to minimize neu-
rologic injury both by making the correct lithotomy position easily obtainable and by
minimizing compression injury with the additional padding it provides [12].
Upper extremity neurologic injury is rare with an incidence in MIS of 0.16% and
is usually the result of compression injury to the brachial plexus [13]. There are two
main palsys associated with brachial plexus injury. When the superior aspect of the
nerve plexus (C57) is injured the result is an Erbs palsy: the arm is straight and wrist
fully bent (waiters tip); this is usually a stretch injury. Klumpkes palsy results from a
stretch injury to the inferior aspect of the plexus (C8T1) causing weakness or paraly-
sis of the intrinsic hand muscles and finger flexors. A retrospective review by Roma-
nowski et al found that steep Trendelenburg position, use of shoulder braces, and
extension of the arms at 90 or more were all associated with brachial plexus injuries
[12, 13]. In their study of surgical positioning in cadavers, Jackson et al identified five
positions that increased the risk of brachial plexus injury [14]:
1. Dorsal extension of the head with lateral flexion to the contralateral side
2. Abduction of the arm greater than 90 (especially if externally rotated and
extended)
3. Compression over acromion or 23 inches medially by shoulder braces
4. Lateral pressure by shoulder braces
5. Use of wristlets to prevent sliding
Knowledge of the mechanisms by which neurologic injury occurs during patient posi-
tioning allows for the establishment of general guidelines. EKG leads and IV tubing
should be placed on top of the arms as opposed to under the arms, over the acromion
or along the lateral shoulder. Yellowfin stirrups should be used to position the patient
in low lithotomy. In general, the ankle, knee and hip should be aligned to the opposite
shoulder and the legs should be placed as low as possible. Lowering the legs prevents
repositioning once the robot is docked and thus limits maneuvers that could incre-
ase the risk of lower extremity injury. One of the difficulties with steep Trendelen-
burg is maintaining that position/preventing the patient from sliding down the bed.
A gel mattress has a high friction coefficient and thus having the patient lay directly on
it can help prevent slippage. This in addition to a beanbag helps stabilize the patient
in the correct position. Additional padding along the patients wrist, elbows, and
shoulder also helps further minimize risk of nerve injury. The chest is also padded to
prevent injury from the robotic arms. For further support the patient is secured to the
table by taping around the beanbag and stirrups [15]. It is important to have the anes-
thesiologist be an active participant of patient positioning. Often, they assist with
padding and protection of the shoulders and correct placement of EKG wires and IV
tubing. It is also imperative to repeatedly assess the patients positioning throughout
the surgery, especially when adjustments in patient position are made. The surgeon
must also be cognizant of the operating time. In their large retrospective analysis,
Romanowski et al found that duration of operation was significantly correlated with
nerve injury such that each additional hour increased the risk of lower extremity neu-
ropathy 100-fold [13]. Having a team that is trained in robotic surgery is of the utmost
importance. Patient safety in the operating room is dependent on everyone [16].
7.3Complications of pneumoperitoneum and steep

Trendelenburg
While the requirement of pneumoperitoneum is not unique to robotic surgery, patient

positioning in steep or maximal Trendelenburg position is vital to obtaining adequate
exposure to perform most complex robotic pelvic surgical procedures. These conditions
are usually well tolerated but may offer a challenge in the obese population as well
as those with compromised respiratory function [17, 18]. While the anesthesiologist
manages the majority of these physiologic changes intraoperatively, it is incumbent on
the surgeon to be aware of the associated risks as well as avoidance/management of
these potential problems.
Pneumoperitoneum is usually achieved with insufflation of CO2 gas to obtain a
pressure of 15 mmHg, which can require anywhere from 2.55.0 L of gas within the
abdomen. This has physiological effects on multiple organ systems. It can result in
decreased renal cortical perfusion and an increase in the secretion of anti-diuretic
hormone and ultimately in decreased GFR and urine output by approximately 50%.
The cardiovascular system is also affected [19, 20]. Pneumoperitoneum can result in
increased systemic and pulmonary vascular resistance with resultant hypertension.
At pressures greater than 15 mmHg, the IVC can be compressed with consequent
venous stasis, decreased preload and decreased cardiac output and hypotension
[21, 22]. Furthermore, increased abdominal pressure restricts diaphragmatic excur-
sion and lung expansion that results in increased peak inspiratory pressure and
mean airway pressure resulting in decreased pulmonary compliance and functio-
nal residual capacity [23]. The ventilation-perfusion mismatch and intrapulmonary
shunting that results manifests as hypercapnea and hypoxemia [18, 24]. This is exa-
cerbated by the intravascular absorption of CO2. In order to compensate for these
changes, the anesthesiologist must make adjustments to minute ventilation (respi-
ratory rate tidal volume) to prevent the development of acidosis [25]. Both pneu-
moperitoneum and steep Trendelenburg increase the risk of aspiration of gastric
contents. This can be reduced with the use of cuffed endotracheal tubes, having
the patient be NPO for at least 8 h prior to the procedure. Orogastric tube placement
and decompression of the stomach may not decrease the rate of aspiration due to its
overall low incidence. However, it is good practice and can help improve exposure
and decrease the risk of stomach injury.
7.4Robotic equipment 71
There is limited data on the ocular changes associated with robotic or laparosco-
pic surgery, however there are reports of complications including retinal detachment
and post-operative vision loss, thought to result at least in part from the steep Trende-
lenburg position. In a study by Awad et al, patients undergoing robotic prostatectomy
were found to have a mean increase in intraocular pressure 13 mmHg higher after
being placed in steep Trendelenburg position as compared to pre-induction anesthe-
sia. In addition, length of procedure and end-tidal CO2 were the only significant pre-
dictors of increased intraocular pressure [26]. The exact mechanism by which steep
Trendelenburg may result in increased intra-ocular pressure and post-operative vision
loss in some is mostly theorized and likely multi-factorial. While current research will
help identify any modifiable factors, it is the current practice of the authors to not
offer robotic procedures to patients with underlying ocular disease especially those
with glaucoma or retinopathy.
7.4Robotic equipment
7.4.1Electrosurgical principles
In order to understand and be able to prevent electrosurgical injuries, one must

first have a fundamental understanding of basic electrosurgical principles. Unlike
household current, electrosurgical current uses high frequency (300600 kHz) alter-
nating current. This range of frequency is so high that it flows through the patients
body without being detected and thus does not result in electrocution, nerve depo-
larization, or muscular twitching as with household current. There are three main
tissue effects of electrosurgery: cutting, fulguration, and desiccation. Both cutting
and fulguration are non-contact phenomena. Cutting uses unmodulated current
(i.e., current flows 100% of the duty cycle) and results in tissue vaporization due to
the rapid heating. Fulguration involves modulated current in which current is only
flowing for a small percentage of time, resulting in short bursts of high voltage, which
is important since electrosurgical complications are directly related to the amount of
voltage. Nonetheless, the electrical sparks created by fulguration denature proteins
resulting in superficial tissue effects over a large surface area. Desiccation is a contact
phenomenon in which current passes through tissue resulting in dehydration and
coagulation through heating.
7.4.2Monopolar electrosurgery
Monopolar electrosurgery (ES) involves an active electrode at the surgical site (i.e., the
electrosurgical instrument) and a return electrode somewhere on the patients body.
In general, monopolar ES (as compared to bipolar) is more effective at hemostasis

and provides deeper tissue penetration, which can be both an advantage and disad-
vantage. There are three main complications associated with the active electrode in
monopolar ES: insulation failure, direct coupling, and capacitive coupling.
There are four major zones in which insulation failure can result in injury [27].
Zone 1 includes the distal end of the laparoscopic instrument that is in the surgical
view. It is the most common location for insulation failure and is usually secondary to
wear and tear of the instrument through the protective sheath [28, 29]. However, insu-
lation failure can also result from high voltage associated with open circuit activation.
For example, resistance develops if the monopolar instrument is activated while not
in close tissue proximity. In order to overcome the resistance, higher voltage is gene-
rated and can essentially blow through the insulation. Zone 2 incudes the shaft of the
instrument and is the area along the active electrode from just outside the laparosco-
pic view. Thus a defect in insulation can result in tissue injury that is outside of the
surgical view and can go unrecognized. Zone 3 is the portion of the instrument that
is within the cannula; the potential for injury is dependent on the type of cannula
that is used. If a plastic, non-conductive cannula is used then insulation failures are
usually not detectable. However, a metal cannula can conduct low frequency currents
that usually manifest as muscular twitching or interference with the monitors. Zone
4 complications are rare and involve exposed metal in the handle of the instrument.
This can result in injury to the handler of the instrument [27].
Direct coupling occurs when the active electrode is in direct contact with another
metal instrument and can be intentional or inadvertent. As long as the instruments
are passed through a metal cannula the currents will be dispersed through the ante-
rior abdominal wall without issue. However, if the cannula is plastic the current may
be directed to surrounding tissue including the bowel [27, 30]. To prevent this compli-
cation, all conducting instruments should be passed through metal cannulas.
Capacitive coupling occurs when current is passed from the active electrode
through a non-conductive material (instrument insulation) to another conductor.
Higher voltage increases capacitive coupling and thus is more likely to happen with
the coag mode as well as in open circuit activation. While it is best to avoid high
voltage generators and not use the coagulation mode, both of these are usually neces-
sary to produce the desired tissue effect. Thus the surgeon must be cognizant of the
potential complications and use surgical technique to avoid them [27, 30].
Problems with the active electrode are the second leading cause of electrosurgical
injuries. Prevention includes inspecting the insulation on all instruments and using
the lowest power setting necessary to achieve the desired effect. If there is a change
in the tissue effect, it is important to not increase the power without first checking the
circuit as a sudden change in effect can be a sign that there is a short in the circuit.
Use of a low-voltage cut waveform will also minimize risk of injury, remembering not
to activate in an open circuit. It is also important to keep the instruments clean from
tissue eschar and when intentionally performing direct coupling it is important to
touch the desired instrument prior to activation of the monopolar energy [31, 32].
7.5Avoiding surgical complications 73
The importance of the return electrode is commonly over-looked as 70% of elec-

trosurgical injuries in fact involve the return electrode [33]. To avoid these injuries,
it is important to ensure that the site is clean, shaved and dry and the electrode is
applied in a location that minimizes the amount of resistance (i.e., a place without a
significant amount of adipose, hair, scar tissue, or along bony prominences). It is also
important to use the largest pad possible with a full-surface adhesive. Throughout
the surgery, the electrode should be continually examined, especially after patient
re-positioning.
7.4.3Bipolar electrosurgery
In bipolar electrosurgery the instrument has two arms, one of which acts as the active
electrode and one that serves as the return electrode. There is a small space between
the two arms in which tissue is grasped and thus the circuit consists of the active elec-
trode, the tissue being grasped, and the return electrode. Unlike monopolar electro-
surgery, current does not flow through the patient. Furthermore, there is a preset level
of resistance at which the circuit automatically becomes deactivated and an ammeter
(instrument used to measure current) that notifies the surgeon when electrical activity
has ceased. While one of the advantages of bipolar energy is localized tissue effect,
thermal spread is possible and is usually the result of steam bubbles that spread to
surrounding tissue. Ways to minimize the amount of thermal spread include ending
current flow when the tissue blanches and steam is no longer seen. While ammeters
can be beneficial, they usually result in over-desiccation of tissue. In addition bipolar
electrosurgery has the ability to occlude sizeable vessels. However, it is important to
remember that more heat is generated with larger pedicles, resulting in greater degree
of thermal spread. When dealing with bulkier tissue it may be beneficial to have the
jaws slightly open and use them to directly tamponade and then desiccate the tissue
[30]. Other advantages of bipolar energy include the ability to use lower currents, the
lack of the capacitance effects, and the ability to use it while submersed in fluid.
7.5Avoiding surgical complications
The overall incidence of MIS complications is difficult to quantitatively define as it

is primarily based on retrospective reports and very likely underreported. The data
on LS complications is mostly anecdotal, based on single institutional experience
and even less commonly based on meta-analysis and rarely prospective and/or ran-
domized studies. This is not unique to MIS as most data on surgical complications is
retrospective and therefore biased and imprecise. Various series on LS in gynecology
and gynecologic oncology report the incidence to be <1% to >10% [3437]. Data from
relatively large series of robotic procedures in gynecology and gynecologic oncology
are rapidly emerging. The overall complication rates are below that of equivalent
procedures performed via laparotomy and even less than LS is some series [38]. The
actual rate of surgical complications that occur in MIS will depend on institutional/
surgeon experience, types and mix of surgical procedures, and associated patient
co-morbidities.
The improved visualization, precision and control over the operative field that
the robotic platform offers is likely to improve the surgeons ability to dissect sur-
gical planes, minimize blood loss and perform complicated adhesiolysis all giving
the potential for decreased complications. However, with the availability of robotic
technology, surgeons may attempt more difficult cases via MIS than they would have
tried with LS. Loss of haptic feedback with the robotic platform is a potential disad-
vantage however the experienced surgeon is able to overcome loss of this sense with
heightened visual feedback and meticulous surgical technique. Many complications
related to the specific robotic surgical procedures will occur at least at a minimum
rate and can vary with complexity of the procedure and surgeon experience. Gas-
trointestinal and urologic injuries are more common than major vascular injuries.
Potential complications unique to MIS can be minimized by an expert knowledge of
anatomy, smooth movement of the surgical instruments, learning visual cues that
replace haptic feedback, always keeping instruments in the visual field, careful use of
electrosurgical instruments and meticulous surgical dissection technique. Vigilance
and focus throughout the procedure is critical.
7.5.1Avoiding port complications
Access to the peritoneal cavity is different than the traditional laparotomy approach
and most critical to the success of MIS procedures. The most hazardous portion of the
procedure is the primary trochar placement and location of secondary ports is critical
in actually facilitating the planned procedure. There is not an accepted standard
approach among the three most common primary port entry techniques, however,
approximately 50% of major injuries and most deaths resulting from MIS are from
insufflation and trocar injuries [35]. Consensus opinion reports do not agree on the
preferred or optimal approach to placement of the primary port [39]. The technique
for placement of the primary port will vary according to surgeon experience and pre-
ference and also with the patients body habitus, previous surgical history and goals
of the surgical procedure. Safe placement is optimized with excellent control of inser-
tion force and a minimum of subcutaneous tunneling facilitates the effectiveness of
robotic instrument use during the operative procedure. All secondary ports must be
placed under direct visualization. Port site locations are chosen based on the instru-
ment needs for the specific procedure. While there is an emphasis to not only mini-
mize the size of surgical incisions but also reduce the number of sites such as single
site access MIS, it is imperative that the surgeon use as many ports as necessary to
eliminate any potential surgical compromise.
7.5Avoiding surgical complications 75
7.5.2Gastrointestinal complications
There are a variety of mechanisms by which gastrointestinal injuries occur during

laparoscopic surgery. In a large review by van der Voort et al, the overall incidence of
bowel injury or perforation during laparoscopy was approximately 0.13% and 0.22%,
respectively, and is higher in patients with prior abdominal surgery or previous intra-
abdominal infection [40]. The small intestine is the most commonly injured (55.8%
of cases), followed by the large intestine (38.5%) and stomach (3.9%). The majority
of injuries are the result of Veress needle or trocar placement (41.8%) followed by
thermal injuries (25.6%), grasping forceps (1.1%) and scissors (0.7%). To date it is not
clear if one method of entry (open Hasson vs. closed Veress/trocar) is superior to
the other. Merlin et al performed a meta-analysis to answer this question. The open-
entry group had a higher rate of bowel injury but lower rate of vascular injury however
the incidence is low enough that at this point it remains inconclusive. Gastric injury
may also be prevented with placement of an orogastric or nasogastric tube to allow
for decompression of the stomach, especially following difficult intubation where
the stomach can potentially be distended with air [41]. The most clinically significant
intervention after bowel injury is early recognition as mortality associated with bowel
injury is approximately 3.6% and is time dependent. If small bowel injury is suspected
at the time of laparoscopy, the surgeon should run the intestines in their entirety with
bowel graspers. Also, the surgeon should consider the possibility of other injuries
caused to other organs. A leak test can be performed at the time of laparoscopy to eva-
luate for possible injury to the recto-sigmoid colon; the pelvis is filled with saline and
air is injected through the anus. The presence of bubbles in the pelvis suggests that a
leak or injury is present. After MIS patients should be counseled to expect continuous
improvement. Increasing pain, tachycardia, or fever should raise concern. Due to the
high bacterial load, large bowel injuries generally have higher rates of infectious and
febrile morbidity. In addition, unlike laparotomy, ileus is not common after laparo-
scopy and must be thoroughly evaluated. An upright abdominal film to demonstrate
free intra-abdominal air may not be as reliable after laparoscopic surgery as patients
can have up to 2 cm of free air 24 h after laparoscopy that can persist for up to a week.
If the amount of free air is increasing or not improving, the clinician should suspect
a bowel injury.
Small intestinal injury can be repaired via robotic instrumentation or laparotomy,
depending on the size, location and physician comfort level. Non-thermal injuries
can be repaired in two layers with care not to increase the risk of stricture formation
by placement of sutures perpendicular to the long axis of the bowel. Small injuries
(<2 mm), such as those made with the Veress, often do not require repair. Small defects
in the large intestines can also be repaired in two layers. A diverting colostomy is
usually not necessary but may be indicated for larger injuries, those involving the
mesentery, and those diagnosed post-operatively. When large bowel injury occurs,
the surgeon should use copious irrigation after repair given the high bacterial load
of the colon. Repair of injuries to the stomach follow the same rules as for the small
and large intestine: small defects need not be repaired if not bleeding and larger ones
should be closed in two layers.
Thermal injuries to the intestines are a completely different entity. The tissue
surrounding the thermal injury will undergo coagulative necrosis that may not be
evident to the naked eye for days. Thus the integrity of the surrounding tissue cannot
be guaranteed. Thus the majority thermal injuries must be treated with segmental
resection.
7.6Genitourinary complications
7.6.1Bladder
The overall incidence of genitourinary injury in laparoscopic surgery is approxi-

mately 0.023% [42, 43]. The bladder is the most frequent site of injury and may occur
during placement of a secondary trocar, especially in the suprapubic location [35, 38].
This is less of an issue in robotics, where there is little role for the suprapubic port.
Trocar-induced bladder injuries are prevented by placing trocars under direct visua-
lization and have the bladder decompressed with a Foley catheter. The bladder can
also be injured during dissection of the vesicouterine peritoneum during a hysterec-
tomy, specific urogynecologic or oncologic procedures. When dissecting around or
near the bladder it is best to use sharp dissection as thermal injury usually evolves
over days and thus can go unrecognized intra-operatively. The presence of blood or
air in the Foley bag should alert the surgeon to the possibility of a bladder injury
intra-operatively. If injury is suspected, cystoscopy should be performed and/or the
bladder should be retrograde filled with methylene blue or indigo carmine. In fact,
in an argument for universal cystoscopy after hysterectomy, Vakili et al performed a
multi-institutional prospective study and found that with an incidence of GU injury of
5.3%; only 13% of ureteral injuries and 35% of bladder injuries were detected before
cystoscopy [44].
The general trend is for injuries detected at the time of surgery to be repaired via
robotics as compared to injuries delayed postoperatively which are usually treated
with laparotomy [45]. Robotic technology provides dexterity and precision needed
to accomplish the appropriate surgical repair. Either way, bladder injuries should
be repaired in two layers with an absorbable suture and should be watertight. Care
should be made to avoid the ureteral orifices and stents should be placed if there is
any concern. A Foley catheter should be left in place for approximately 7 days, as it
takes 34 days for the bladder mucosa to re-epithelialize. In some cases, imaging of
the GU tract is performed prior to removal of the Foley catheter.
Thermal injuries to the bladder often are unrecognized at the time of surgery as
they typically take time to evolve and on occasion can manifest as a vesicovaginal
7.6Genitourinary complications 77
fistula. As with the GI tract, thermal injuries result in surrounding tissue necrosis and
repair should include debridement of unhealthy tissue. Therefore, it is recommended
that drainage with a Foley catheter for up to 3 weeks after repair.
7.6.2Ureter
Ureteral injuries are less common than bladder injuries in general, however the inci-
dence of ureteral injuries in MIS is higher in cases of surgery performed for mali-
gnancy, extensive endometriosis, or other conditions that result in retroperitoneal
fibrosis [46]. The three most common anatomic locations where the ureter is injured
are (in order of decreasing frequency):
1. At the pelvic brim as it courses under the infundibulopelvic ligament
2. At the level of the internal cervical os where it courses just below the uterine artery
3. In the ureteral canal where it enters the bladder
The ureter can be injured in a variety of ways including transection, laceration, obst-
ruction, stenosis, fistulization, and thermal trauma. The key to avoiding ureteral inju-
ries is to directly observe and follow the course of the ureter throughout the entire
surgical field and dissection. This typically requires entry into the retroperitoneal
spaces and dissection of the ureter off of the medial leaf of the broad ligament; this
should be done sharply so as to minimize risk of thermal injury to the ureter. The
most effect method for preventing GU injury during a robotic hysterectomy consists of
wide mobilization of the bladder flap off of the lower uterine segment and incision of
the medial leaf of the broad ligament with skeletonization of the uterine vessels. This
surgical dissection allows the bladder and ureters to fall out of the field of dissection
and thus out of harms way.
If ureteral injury is suspected an ampule of indigo carmine should be given int-
ravenously and cystoscopy performed. Lack of a ureteral jet should raise concern
of an injury and be further investigated. Repair of ureteral injuries depends largely
in part to the location and mechanism of the injury, as an ideal repair requires the
tissue to be healthy and the repair to be tension free. If the injury is above the pelvic
brim, then a ureteroureterostomy should be performed. A ureteroneocystostomy
with psoas hitch should be used to repair ureteral injuries below the pelvic brim. In
both cases, the ends of the ureter are spatulated and re-approximated to the other
ureter or bladder with delayed 40 absorbable sutures. Ureteral stents are placed
and remain in place for 24 weeks to prevent stricture formation (in the case of
ureteroneocystostomy a Foley catheter should be placed for as long as the stents
are in place). Jackson-Pratt drain should is usually placed in close proximity to
the repair to monitor output and the potential for urinary leak. If the injury is
thermal in nature, then the injured and surrounding tissue should be resected and
re-implanted.
7.7Complications of pelvic and para-aortic lymph node

dissection
Complications in women undergoing a pelvic and para-aortic lymph node dissection
are multifactorial and usually related to the surgical route selected, patient age, length
of the surgery, existing patient co-morbidities and the other concurrent surgical pro-
cedures. MIS procedures have less post-operative morbidity as compared to those per-
formed via laparotomy but all the surgical approach options can be associated with
major intra-operative complications. The incidence of major organ and vessel injury
related to lymphadenectomy is very low. Patients undergoing surgery for gynecologic
malignancy have an increased risk of thromboembolic disease although it is not clear
that the risk of DVT is higher with or without lymph node dissection. The combination
of longer surgical case duration, hypercoagulability from cancer and immobilization
give these patients a relatively higher risk for DVT as the incidence of thromboembolic
disease has been reported in 25% of cases [11, 4750].
Complications related to lymphatic drainage are specific to the lymph node
dissection. Lymphocyst formation is the most common complication of pelvic
lymphadenectomy with incidences in gynecologic cancer ranging from 1 to 50%
and typical presentation of 57 days postoperatively [34, 51, 52]. Retrospective data
suggests that the incidence of lymphocyst formation is lower with MIS as com-
pared to laparotomy. In the only prospective randomized trial comparing MIS to
laparotomy for the treatment of endometrial cancer (LAP-2) the rate of lymphocyst
formation was not reported [50]. In a retrospective review by Ghezzi et al the rate
of lymphocyst formation was significantly higher with laparotomy as compared to
laparoscopy with rate of 15.4% and 1.4%, respectively. Patients who had laparosco-
pic staging also had significantly fewer symptomatic lymphocysts but no difference
in the incidence of lymphorrhea or lymphedema [52]. Backes et al in a review of 503
patients who underwent robotic staging for endometrial cancer, reported rates of
lymphocyst of 5.7% [11]. The cervical cancer literature on the other hand does not
describe the same benefit from robotic surgery. In a meta-analysis, Cho et al found
that in the treatment of cervical cancer there were more lymph-related complica-
tions in the robotic as compared to typical laparoscopy and laparotomy with rates if
8%, 6% and 0.7%, respectively [47]. However, these included a variety of procedures
being performed including radical hysterectomy, trachelectomy, lymphadenectomy
alone and thus the data cannot clearly be interpreted. Finally, there does not appear
to be an increased risk of lymphocyst, lymphedema, or thrombosis when a paraa-
ortic lymphadenectomy is performed in addition to pelvic lymphadenectomy [53].
In general, primary prevention of lymphedema and/or lymphocyst formation
includes a transperitoneal approach, precise dissection and use of bipolar coagu-
lation or clipping of lymphatic vessels. Risk factors associated with development of
lower extremity lymphedema in the treatment of endometrial cancer include adju-
vant treatment with radiation therapy, resection of more then 31 nodes, and removal
7.8Incisional hernia 79
of the external iliac nodes distal to the circumflex iliac vein [54]. In a follow-up study
of patients with intermediate and high risk endometrial cancer the incidence of meta-
stasis in the circumflex iliac nodes distal to the external iliac nodes was zero in those
patients with grade 1 tumors and 2.5% in grade 2 tumors suggesting that one way to
prevent the formation is to eliminate these nodes in the dissection in patients with
grade 1 tumors [55]. Use of sentinel lymph node evaluation has been shown to decre-
ase the incidence of lymphedema in breast and vulvar cancer [56]. Encouraging data
on the utility of sentinel lymph node evaluation is emerging in cervical cancer but is
ambiguous for endometrial cancer [57, 58]. There is data in the urologic literature to
suggest that FloSeal may reduce the risk of lymphocyst formation after pelvic LND.
In a matched comparison analysis Waldert et al found that the rate of lymphocele
formation was 3.1% in the FloSeal group vs. 14.5% in the no FloSeal group [59]. Others
have suggested that the use of the Ligaclip may decrease the incidence of lymphocyst
after MIS [60].
The majority of lymphocysts are asymptomatic. Intervention is usually indicated
when the lymphocyst is superinfected, causes pain or obstructive hydronephrosis and
percutaneous drainage is typically all that is required. Some may require sclerothe-
rapy or marsupialization of the lymphocyst. Lymphedema typically requires lifestyle
modifications including complete decongestive therapy, as there is no cure. There are
new experimental procedures being performed including surgical intervention. Chen
et al describe success with the transfer of a vascularized submental lymph node flap
to the ankle for treatment of lower extremity lymphedema [61]. Chyloperitoneum has
also been described after lymphadenectomy for gynecologic cancer. Treatments for
this rare diagnosis can include serial paracentesis, a medium-chain triglyceride diet
and some have even described successful treatment with early initiation of octreotide
infusion. If conservative management fails then surgical interventions can include
peritoneovenous shunting [62].
7.8Incisional hernia
The risk for post-operative hernia after MIS is increased by the use of multiple ports,
the use of instruments that require 10 and 12-mm size ports, increased OR time
and manipulation of ports as well as the use of port anchoring-devices. In a multi-
institutional review Boike et al reported on 19 bowel herniations. The majority
(57%) occurred at the 12-mm port site and 38% at the 10-mm port site with one
hernia at an 11-mm port site. In addition, hernias were more likely to occur at extra-
umbilical port sites (64%) [63]. In a retrospective review of 3,560 laparoscopies
there were six incisional hernias (0.17%) and all were at extra-umbilical sites.
There was a significantly higher rate of hernia at 12-mm port sites as compared to
10-mm, 3.1% and 0.23%, respectively [64]. There is one case report of small bowel
evisceration at a 8-mm port site after robotic hysterectomy and staging for endome-
trial cancer [65]. Prevention of port site hernias should include closing the fascia of
port sites 10 mm, removing the ports under direct visualization and either remo-
ving the top of the port or inserting an instrument through it during removal to
avoid the creation of a vacuum. There is also some evidence to suggest that the use
of a non-cutting obturator decreases the risk of incisional hernia as it results in an
overall smaller fascial defect as compared to cutting obturators [36]. In addition
to the presence of a bulge, patients with port site hernias will often present with
symptoms of a bowel obstruction and one must be vigilant in the evaluation of a
post-operative patient with this presentation as it is a surgical emergency.
7.9Vascular injuries
The most common vascular injuries in MIS occur during entry into the abdominal
cavity and the vessels most commonly affected are the superficial epigastric and the
inferior epigastric vessels. While the most common vascular injuries, they are also the
most preventable. The superficial epigastrics can be visualized via trans-illumination
of the anterior abdominal wall and the inferior epigastrics can be directly visualized
transperitoneally. If these two steps are performed and the surgeon is careful to avoid
subcutaneous tracking, then injuries to these vessels can always be prevented.
The incidence of injury to the major vessels during MIS is reportedly around 0.8%
although it is likely under-reported. Despite the low incidence, mortality associated
with major vessel injury is as high as 17% [66]. The most commonly affected are the
aorta, IVC and common iliac vessels and injury most commonly occurs during initial
insertion of a Veress needle or trocar. Such injuries are usually the result of excessive
force, or too deep of an insertion. There have been a number of studies evaluating
the best method of entry into the peritoneal cavity, which has been recently sum-
marized in a Cochrane database review by Ahmad et al that included nearly 5,000
patients and 28 randomized trials. While there was no difference in vascular or bowel
injury with closed versus open entry, open entry had three clear advantages: decre-
ased rates of failure, extraperitoneal insufflation and omental injury [39]. Ultimately
the decision about method of entry is dependent on the surgeons comfort level, the
patients body habitus, anatomy and number of previous abdominal surgeries. In the
non-obese patient, it is important to remember that the distance to major vessels can
be as short as 2 cm. If a vascular injury is identified after Veress needle entry (as deter-
mined by blood coming through the Veress) it is important to remember to not remove
it as keeping it in place serves a number of functions including marking the area of
injury, provision of a tamponade effect, and can help reduce the development of a ret-
roperitoneal hematoma. The surgeon should also be aware of the possibility of injury
to other organs in addition to the known vascular injury. Exploratory laparotomy is
usually indicated to repair most vascular injuries. If attempt at laparoscopic repair is
attempted, the surgeon must be continually cognizant of the amount of blood lost,
7.10Vaginal cuff dehiscence 81
as blood will usually accumulate in upper abdomen because of the Trendelenburg

position. If repaired laparoscopically it is also important to decrease the pneumoperi-
toneum to ensure adequate repair as often times the increased pressure will tempora-
rily tamponade any bleeding. Robotic technology affords the surgeon a much better
opportunity to repair a vascular injury via MIS. Repair of vascular injury should be
done with 4/0 prolene. Most complications can be avoided with the judicious use of
caution and proper surgical technique.
7.10Vaginal cuff dehiscence
Vaginal cuff dehiscence is a complication of any hysterectomy, however the literature

does suggest an increased risk of dehiscence associated with MIS. In a single institu-
tion review from 2000 to 2006, Hur et al found that the overall incidence of vaginal
cuff dehiscence was 0.14%. The incidence by type of hysterectomy was significant in
that 4.93% among total laparoscopic hysterectomies, 0.29% among total vaginal hys-
terectomies, and 0.12% among total abdominal hysterectomies [67]. They published
a follow-up study reporting the overall incidence to be 0.39% (adjusted 1.35%) with
an incidence of 0.75% after TLH, 0.38% after TAH, and 0.11% after vaginal hysterec-
tomy with a significant risk ratio in favor of TAH and TVH over TLH [68]. Kho et al
described their single-institution experience of vaginal cuff dehiscence after robotic
procedures; reporting an overall incidence of 4.1% (n = 510 patients) [69]. Nick et al
found no difference in incidence of cuff dehiscence between laparoscopic and robotic
procedures, but did find that radical hysterectomy was associated with a significantly
increased risk of dehiscence [70]. Currently, 50% of the reported cases of cuff dehis-
cence have occurred after robotic hysterectomy or TLH [70]. Other risk factors include
increasing age, vaginal atrophy, increasing number of vaginal surgeries, post-ope-
rative vaginal cuff hematoma or infection, and increased valsalva testing [70]. It is
hypothesized that the increased rate of vaginal cuff dehiscence after TLH or robotic
surgery is associated with the degree of electrocautery used, the possibility that less
tissue is grasped during MIS cuff closure (due to the magnification), and the fact
that the faster recovery has patients performing more activities that increase their
risk for dehiscence. For this reason, selective used of cautery along the vaginal cuff
angles is recommended. Some have also suggested a 2-layer cuff closure and use of a
bidirectional, barbed suture [71].
7.11Summary
In general, MIS offers many potential advantages and some disadvantages to the
surgeon (and therefore the patient). Counter-intuitive movement, depth perception
and blind aspects to the surgical field are all unique potential compromises to LS.
The robotic platform eliminates or improves many of the deficiencies related to LS
however there is no substitution for knowledge of anatomy, steps in the surgical

procedure itself and the natural history of the patients disease or condition. Major
complications in MIS can often be attributed to misperception rather than a pure tech-
nical error. These are all obviated, especially earlier in the surgeons experience, by
deliberate camera work and meticulous dissection, which eventually becomes more
instinctual and automatic as the surgeon gains experience. On that note, there is no
substitute for continued practice and accumulated experience that allows for deve-
lopment of innate skills in avoiding potential problems. Knowledge of energy sources
used is critical in preventing MIS surgical complications. Meticulous skeletonization
of pedicles and mobilization of adjacent structures away from the field of dissection
reduces the chance of unintended thermal damage. The robotic platform enhances
the surgeons ability to accomplish difficult cases via a MIS route. However, if one
does not adhere to the basic surgical principles of efficient and safe surgery then there
is no advantage to using this advanced MIS technology.
Surgical complications, specifically MIS, are possible with any procedure even
in the most experienced hands. Patients should be counseled and consented pre-
operatively that robotic cases are major surgeries performed via small incisions, and
although the goal is improved outcomes, surgical complications are possible. Inten-
sive training and continuous practice, and perhaps surgical sub-specialization can
minimize potentially avoidable injuries. If a complication occurs it is important that
the surgeon maintain calm in the OR and direct a well thought out plan to address
the problem. The level of communication required between the surgeons, nurses
and other OR staff is high and unnecessary distractions should be eliminated. The
concept of Crew Resource Management transformed the commercial airline indus-
try and improved safety [72]. Many of the practices from this system have already been
employed in ORs around the world [7376]. While the robotic surgeon is the captain
of the ship, he/she must be supported by knowledgeable OR staff, skilled anest-
hesiologists, technological support, well-maintained equipment and a system that
minimizes avoidable errors.
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Part II: General gynecology
8 Robotically assisted simple hysterectomy
Sami Gokhan Kilic, Omer L. Tapisiz and Ibrahim Alanbay
8.1Introduction
Hysterectomy is the most frequent nonobstetrical surgery in women [1].

Approximately 80,000 hysterectomies are performed each year in the United Kingdom,
and over 600,000 in the United States [2, 3]. Benign indications, such as abnormal
vaginal bleeding (21%), fibroids (33%), pelvic pain (3%), and uterine prolapse (28%),
constitute more than 70% of all hysterectomies [3]. Simple hysterectomy is the route for
all benign cases. Among all hysterectomies, abdominal surgery accounts for 64% of
cases, followed by the vaginal route in 22% and the laparoscopic route in 14%, respec-
tively [4]. After the introduction of robotic technology, hysterectomies performed utiliz-
ing minimally-invasive surgery (MIS) increased significantly [5, 6].
In our experience, a robotics program is generally in place for a year before a noti-
ceable number of cases begins to switch from open to MIS, a trend which seems to be
common nationwide in the United States (Fig. 8.1) [7]. This trend can be partially exp-
lained in that robotic systems have a short learning curve and flexible instruments,
facilitating more complex cases compared to laparoscopy [810]. Most gynecologic
MIS surgeons, including general gynecologists, urogynecologists, and gynecologic
oncologists, are usually introduced to robotic surgery through simple hysterectomies.
In this chapter, we aim to lay out a step-by-step approach to simple hysterectomy,
highlighting the differences between robotic and laparoscopic approaches.
8.1.1Background
Determining the most suitable surgical approach for each patient is a complex multi-
factorial decision involving indications for hysterectomy; the surgeons comfort level,
experience, and training level; specimen size; uterine association with surrounding
pelvic organs; comorbidities, and, last but not least, the patients lifestyle expecta-
tions. To help with this process, the American Association of Gynecologic Laparosco-
pists (AAGL) released an advisory statement in 2011:
It is the position of the AAGL that most hysterectomies for benign disease should
be performed either vaginally or laparoscopically and that continued efforts should
be taken to facilitate these approaches. Surgeons without the requisite training and
skills required for the safe performance of [vaginal hysterectomy] VH or [laparoscopic
hysterectomy] LH should enlist the aid of colleagues who do or should refer patients
requiringhysterectomyto such individuals for their surgical care [11].
90 8Robotically assisted simple hysterectomy
5 12.2 15.6 12.5

10.2
22.4 40
Procedures performed (%) 40.7 33.3
18.4
15.6
46.9 17.5
44.1
35.6
30
First Second Third Fourth

Robotic Group Robotic Group Robotic Group Robotic Group
(2008Jun 2009) (Jul 2009Dec 2009) (Jan 2010Jun 2010) (Jul 2010Feb 2011)
Vaginal Hysterectomy
Robotic Hysterectomy
Laproscopic Hysterectomy
Abdominal Hysterectomy
Fig. 8.1: The shift over time from abdominal to robot-assisted hysterectomies
The American College of Obstetricians and Gynecologists first preference for

simple hysterectomies is the vaginal route [12]. However, vaginal hysterectomy is
not feasible for all hysterectomy cases, such as with large uterine specimens or no
pelvic desensus. In case vaginal hysterectomy is not feasible, a minimally-invasive
approach is the method preferred next. MIS techniques for performing hysterectomy
have many advantages over laparotomy, such as faster recovery time, reduced post-
operative pain, decreased blood loss, shorter length of hospital stay, better cosme-
sis, and quicker resumption of regular activity [1315]. Unfortunately, no strong data
exist to facilitate the decision between laparoscopic and robotic approaches due to
the great deal of overlap in indications and outcomes of hysterectomies. However,
robotic surgery seems to have certain advantages over laparoscopy for obese pati-
ents and those who require more dissection (endometriosis, severe pelvic-abdominal
adhesions) [16, 17].
Due to instrument limitations and a long learning period, laparoscopy did not
become the most popular approach even though it has been used more than 20 years
in gynecology [18, 19]. The commonly accepted opinion is that robotic surgery provi-
des a shorter learning curve, with only 20 cases required for the surgeon to reach a
comfort level [20, 21]. The main disadvantages of robotic surgery are the cost, the large
size of the robot and console, and the lack of tactile feedback [22].
A Cochrane Review comparing all surgical approaches to hysterectomy for benign
gynecological disease found no definite evidence for favoring a technique and stated
8.1Introduction 91
that the surgical approach should be decided by the woman in discussion with her
surgeon in light of the relative benefits and hazards [23]. A new review recently pub-
lished by Cochrane about robotic surgery for benign gynecological disease indica-
ted that robotic surgery did not benefit women in effectiveness or in safety. However,
this statement was limited by the small sample size since only two trials involving
158 participants were included. Since one included trial was published in conference
proceedings, limited usable data were available for further analysis [24]. Robotic
surgery may lead to reduced blood loss, favorable complication rates, and short hos-
pital stays. However, this systematic review found only limited evidence to refute the
previous points of view and does not support the use of robotic surgery for women
with benign gynecological disease. The only analysis in this trial showed comparable
rates of conversions to open surgery between the robotic group and the laparoscopic
group (OR 1.41, 95% CI 0.22 to 9.01; P = 0.72). One RCT showed longer operation time
(MD 66.00, 95% CI 40.93 to 91.07; P < 0.00001) and higher cost (MD $1,936.00, 95%
CI $445.69 to $3,426.31; P = 0.01) in the robotic group compared with the laparosco-
pic group. Robotic and laparoscopic surgery seemed comparable, however, regarding
intraoperative outcome, complications, length of hospital stay, and quality of life.
The authors concluded that the limited evidence currently available shows robotic
surgery does not benefit women with benign gynecological disease in effectiveness
or safety and further well-designed RCTs with complete reported data are required to
confirm or refute this conclusion [24].
8.1.2Robotic hysterectomy vs. laparoscopy: surgical outcomes
Major surgical outcomes, such as operating time, hospital stay, estimated blood
loss, and complication rates, are used to compare hysterectomy approaches. Operat-
ing times were significantly longer in the robotic group compared with the conven-
tional laparoscopic group. In the study by Payne and Dauterive [10], the robotic cases
took an average 27 minutes longer. Other studies had longer operative times for the
robotic cohort, including the studies from Shashoua et al [17], Nezhat et al [16], Sarlos
et al [25], and Kilic et al [26], where operative times were increased by 20, 70, 26, and
78 minutes, respectively. However, a review of robotic hysterectomy concluded that
large robotic series have shorter overall operating times. These results show that even
experienced laparoscopic surgeons will have a learning curve (Tab. 8.1) [5].
The most important variables that can influence operative times are the surgeons
experience, uterine weight and presence of difficult patient-related conditions, such
as adhesions or obesity. Also, until recently, not enough randomized controlled trials
have compared both procedures or examined the effect of surgeons experience. The
conventional laparoscopic group has no procedure corresponding to robot docking
that might affect the operating time between robotic and laparoscopic hysterectomy
approaches.
Tab. 8.1: Comparison of observational studies evaluating robot-assisted hysterectomy vs. other procedures
92
Reference Surgery N Study design/ Operation EBL (mL) Hospital Conversion Intraoperative Postoperative
type center time (min) stay (days) rate (%) complications complications
Giep et al 2010 RH vs. 237 vs. HC/SC 90 vs. 125 59 vs. 1.0 vs. 1.2 1.7 vs. 0.4 1/237 vs. Major: 2 vs. 1 PE (1)
[29] LAVH-LH 265 168 1/265 abcess (1) vs.
cystotomies abcess (1)
Minor: 6/237 vs.
3/265
Sarlos et al 2010 RH vs. LH 40 vs. CC/SC 109 vs. 83 <50 vs. 81 3.3 vs. 3.9 0 none Major: none
[25] 40 Minor: 5/40 vs. 0
Matthews et al RH vs. 65 vs. 21 HC/SC NS vs. NS vs. 82 vs. 260 1.5 vs. 1.8 0 vs. 12% Major intraoperative and postoperative
2010a [27] LH vs. vs. 63 NS vs. NS vs. 190 vs. vs. 1.7 vs. vs. 3.4% complications: 4.3% vs. 7.0% vs. 11%
VH vs. AH vs. 113 430 3.5 vs. 23%
Shashooua et al RH vs. LH 22 vs. HC/MC 142 vs. 122 114 vs. 1.0 vs. 1.4 0 none Major: 0 vs. 1
2009 [17] 44 99 (cuff dehiscense)
8Robotically assisted simple hysterectomy
Minor: 1/24 vs. 0

Nezhat et al RH vs. LH 26 vs. HC/MC 276 vs. 206 250 vs. 1.00 vs. 0 none NS vs. NS
2009 [16] 50 300 1.05
Payne and RH vs. LH 100 vs. HC/SS 119 vs. 92 61 vs. 1.0 vs. 1.6 4 vs. 9 1/100 vs. 2/100 Major: none
Dauterive 2008 100 113 cystotomy (1) vs. Minor: 1/100 vs. 0
[10] enterotomy (1),
vaginal tear (1)
(Continued)
Tab. 8.1: Comparison of observational studies evaluating robot-assisted hysterectomy vs. other procedures (Continued)
Kilic et al 2011 RH vs. LH 25 vs. 34 CC/SC/SS 286 vs. 208 137 vs. 1.8 vs. 2.3 8 vs. 5.9 1/25 vs. 1/34 Major: 1 vs. 1 vs. 0
[26] vs. VH vs. 11 vs. 164 243 vs. vs. 2.0 vs. none (cuff cellulitis vs.
243 (serious) cuff cellulitis vs.
none)
Minor: 4/25 vs.
9/34 vs. 3/11
Geppert et al RH vs. AH 25c vs. CC/SC 136 vs. 110 100 vs. 1.6 vs. 3.8 NS 2/25 [cuff dehiscence (1), rectocele
2011b [28] 64 300 (1)] vs. 23/64
Pasic et al 2010d RH-RRH vs. 1,661 vs. HC/MC (193180)e NS vs. NS 1.37 vs. NS vs. NS NS vs. NS <1% vs. <1%
[6] LAVH-LH- 34,527 vs. (169147)e 1.49 (cardiac,
LRH neurologic, wound,
vascular)f
12% vs. 13%
(genitourinary)f
9% vs. 7%
(gastrointestinal)f
7% vs. 5% (Post-
surgical infection)f
5% vs. 6%
(hemorrhage)f
RH: Robotic-assisted hysterectomy, RRH: Robotic radical hysterectomy, LH: Laparoscopic hysterectomy, LAVH: Laparoscopic assisted vaginal hysterectomy,
LRH: Laparoscopic radical hysterectomy, VH: Vaginal hysterectomy, AH: Abdominal hysterectomy, N: Sample size, HC: Historic cohort, MC: Multicenter,
SC: Single center, CC: Case control, EBL: Estimated blood loss, SS: Single surgeon, NS: Not stated.
a Second time period following initial experience with robotic surgery, Jul 2008June 2009, when number of robotic surgeries was higher.
b Only obese patients (BMI >30 kg/m2) were included.
8.1Introduction
c Late robotic group was considered (associated with learning curve).

d The largest sample size study in the literature; differs from the other studies due to the heterogeneity of the patients (included oncologic cases).
e Outpatient vs. inpatient hospital setting, respectively.
93
f Complication.
The estimated blood loss is lower in robotic hysterectomies compared with total
laparoscopic hysterectomies. Other authors found similar results with 52-mL, 50-mL,
15-mL, and 31-mL differences favoring robotic hysterectomies [10, 16, 17, 25]. However,
no significant differences in blood loss were noted in most studies (Tab. 8.1) [5].
Surgical complication data for total laparoscopic vs. robotic hysterectomies have
shown conflicting results. The vast majority of studies has shown no statistically
significant difference between groups [6, 16, 28] in terms of complications, but the
number of complicated cases in studies might be too small for reach statistical signi-
ficance.
With respect to rate of conversion to laparotomy, most comparative studies had
found no statistically significant difference between the total laparoscopic and robotic
hysterectomy groups [5, 6, 28] except for Payne and Dauterive et al [10], who showed
decreased conversion to laparotomy in the robotic hysterectomy group compared with
the total laparoscopic approach (4% vs. 9%, respectively). In many studies, however,
no case required conversion to laparotomy [16, 17, 25].
In the some studies, hospital stay is longer for the conventional laparoscopic
group [6, 10, 17, 25, 26, 29]: 1 vs. 1.6 days; 1.37 vs. 1.49; 1 vs. 1.4; 3.3. vs. 3.9; 1.6 vs. 3.8;
and 1.0 vs. 1.2 for robotic vs. conventional laparoscopy or abdominal surgery, respec-
tively (Tab. 8.1). These findings have to be interpreted carefully because of their clini-
cal relevance and differing hospitalization practices in various countries.
Three major prospective comparative studies were published in the literature:
Sarlos et al, then by Geppert et al, and one published by our group at UTMB. All
agreed the robotic approach is a safe and feasible technique compared to laparo-
scopy [25, 26, 28]. Current medical literature reports only one randomized controlled
trial, which is inadequate for drawing concrete conclusions about robot-assisted
hysterectomy compared to laparoscopy [30]. In this study, 100 patients with benign
indications of total hysterectomy were randomized into conventional laparoscopic
or robot-assisted laparoscopic hysterectomy groups to compare surgical outcomes,
such as total operating time, perioperative outcome, blood loss, and quality of life.
Although total operating time and change in preoperative to postoperative quality-
of-life index (quality of life measured on a linear scale from 0 to 100) for the robotic
group were significantly higher than for the conventional group, blood loss, compli-
cations, analgesics use, and return to activity for both groups were comparable. The
authors concluded that robot-assisted laparoscopic hysterectomy and conventional
laparoscopy compare well in most surgical aspects, but the robotic procedure is
associated with longer operating times. The quality-of-life index was better for the
robotic group immediately following surgery; however, there was no difference in
the long-term, and subjective postoperative parameters, such as analgesic use and
return to activity, showed no significant difference between the groups. As a result,
the authors advised that in experienced laparoscopic centers, patients with a benign
pathology should be treated by conventional laparoscopic hysterectomy unless a
patient specifically prefers robotic hysterectomy [30].
8.2Robot-assisted simple hysterectomy procedure 95
8.1.3Cost analysis
The only robotic device that has been approved by the FDA for gynecological laparo-
scopic procedures is the da Vinci surgical system (Intuitive Surgical Inc, Sunnyvale,
CA, USA). The investment costs for the whole robotic system depend on the techni-
cal equipment and range from $2$2.3 million USD (quote from Intuitive Surgical,
February 2011).
However, comparison of cost is difficult due to the variety of healthcare system reim-
bursement, the amortization of the device, complex surgery, comorbidity, hospital site
and other variables and cost is calculated for inpatient and outpatient setting. In the
study by Pasic et al [6], the comparative costs between robot-assisted and conventional
laparoscopic hysterectomies were adjusted for possible factors mentioned above. In this
study, adjusted costs were $9,640 USD for the robotic group and $6,973 for the conventi-
onal laparoscopic group. This difference of $2,667 was statistically significant (P < 0.01).
Another matched case-control study in Europe analyzed the comparative costs
for surgery, defining operating room costs operating to include personnel and mate-
rial costs. Differences in personnel costs were small: 1,771 ($2,431 USD) in the robotic
group and 1,329 ($1,824) in the conventional laparoscopic group. Materials costs
were significantly higher (P < 0.05), however, in the robotic group at 2,217 ($3,152)
vs. 822 ($1,128) for laparoscopic. Material costs included all costs for disposable
surgical material, including draping material and EndoWrist instruments. The total
surgical cost was 4,067 ($5,583) in the robotic group and 2,151 ($2,952) in the con-
ventional laparoscopic group, amounting to a significant difference of $2,631 [25]. For
more detail, please refer to the chapter for cost analysis.
8.2Robot-assisted simple hysterectomy procedure
8.2.1Positioning the patient
The patient is placed in the dorsal lithotomy position, then prepped below the breast
line, down to the bilateral knees, and laterally to the posterior axillary line. After
anesthesia, tuck in both of the patients arms by passing the sheet passes under the
patient, wrapping around the arms, and passing back underneath the patient once
again for traction to prevent the patient from sliding. Place legs in Allen stirrups
(Allen Medical System, Acton, MA, USA; refer to Chapter 5).
To gain maximum exposure to the pelvic area, a 30 Trendelenburg is optimal.
Old operating room tables may not allow more than a 25 tilt, so check the table for its
maximum capacity before proceeding with the first robotic case.
Surgical team members should synchronize their duties until the docking process
to decrease the operating room time. For instance, while the uterine manipulator is
placed by the surgeon and the assistant, the scrub and circulating nurses should be
focusing the robotic camera and setting up laparoscopic instruments for initial ent-
rance to the intraabdominal space.
Worldwide, the most commonly used uterine manipulators for hysterectomy are
the V-Care (V-CARE Standard, CONMED Corporation, Utica, NY, USA) and Rumi (Rumi
Koh-Efficient 4.0 cm, CooperSurgical, Trumbull, CT, USA), which both give the oppor-
tunity to manipulate the uterus and delineate the vaginal cuff properly. Rumi recently
developed a more user friendly model called the Rumi II System (Rumi Koh-Efficient
4.0 cm, CooperSurgical, Trumbull, CT, USA).
The uterine manipulator with a balloon at the tip will be insufflated with 7 mL
air in a normally sized uterus. This will facilitate manipulating the uterus as well as
pulling the uterus transvaginally after freeing the specimen inside the patient. It is
the authors opinion that fixing the uterine manipulator with anchor sutures at the
3 and 9 oclock positions on the cervix provides better traction for uterine manipula-
tion and is helpful for larger sized uteruses.
Before trocar placement, all trocar sites will be injected with 0.25% plain Mar-
caine (total 20 mL) to prevent trocar-site postoperative pain. Depending on the
size of the uterus, surgeries additional to the hysterectomy, and the surgeons
comfort level, total trocar numbers may vary from three to five. Usually, the 8-mm
robotic working trocars are placed lateral to the rectus abdominis muscle about 3
cm below umbilical level.
If no assistant arm is used, two 8-mm robotic trocars will be placed one in each
of the patients sides in addition to the 12-mm camera trocar placed in the midline.
Sutures to be used later in the surgery for cuff closing and 2 Ray-tech (4 4) X-ray
detectable sponges will be dropped into the abdominal cavity at the beginning of the
surgery through the 12-mm robotic camera trocar under direct visualization of a lapa-
roscopic 5-mm scope.
In some cases, a third robotic arm could be helpful for retraction, repositioning of
organs or adjacent tissue, and for surgeries in addition to hysterectomy. The third arm
also gives extra comfort to the surgeon and alleviates the need for assistant interven-
tion. The third arm is also used for vaginal closure, as Cadiere forceps grasp tightly,
allowing repositioning of a suture without getting loose and maintaining maximal
anatomical position of the vaginal edge for precise suturing.
In our practice, we introduce a Veress needle via the umbilicus until reaching
20 mmHg intraabdominal pressure and enter the intraabdominal cavity with a 5-mm
laparoscopic scope in the midline. Keeping the distance between the entry side and
the uterine fundus at least 10 cm gives enough space for the robotic camera to view
the whole surgical field. Laparoscopic entry proceeds by using either a visual cannula
Endoscopic Threaded Imaging Port (EndoTIP, Karl Storz GmbH & Co, Tuttlingen,
Germany) or optical trocar VISIPORT (Covidien Surgical, Mansfield, MA, USA).
For patients with histories of multiple previous surgeries, the Palmer point
(located 2 cm below the left arcus costarium in the midaxial line) is preferred for ent-
rance. After introducing all the trocars, decrease intraabdominal pressure to 15 mmHg
from 20 mmHg.
All robotic trocars have reducer caps to utilize 5-mm laparoscopic instruments.
Entering with the 5-mm laparoscopic scope in the beginning reduces potential injury
to the surrounding organs. In addition, at the end of the surgery, it can be inserted
through one of the robotic 8-mm trocar site to close the 12-mm robotic camera trocar
fascia under direct visualization.
Data is inconclusive at this point about for the need to close the 8 mm trocar
site. In our first 100 robotic hysterectomy cases, we experienced one trocar-site
hernia (Fig. 8.2). We speculated robotic arms are placed where abdominal fascia
is weaker in a more lateral position than in laparoscopy cases. Keep in mind that
the robot will recognize the solid line on the trocar as a fascial line. Inserting the
trocar more than the solid line indicates or shorter than it requires will extend the
fascial excision during surgery, which will be a set-up for hernia (Fig. 8.3).
Maintaining pneumoperitoneum during the colpotomy might be challenging in
patients with copious vaginal space. To overcome this effect, two separate insuffla-
tors running simultaneously will be useful for maintaining occlusion.
8.2.3Docking
Robotic docking is made either centrally where the robotic column is between the
patients legs or patient side where the robotic column is placed on a 3045 angle
Fig. 8.2: Laparoscopic view of bowel herniation penetrating the peritoneal layer after
robot-assisted hysterectomy
Fig. 8.3: Robotic trocar fascial line
to the patients horizontal axis. The advantage of the side docking approach is that it
creates more space for the assistant to manipulate the uterus more comfortably and
for removal of surgical specimens through the vagina.
The sweet spot marked as a solid blue line on the camera arm should match to
the arrow on the wrist joint in central docking (Fig. 8.4). Camera movement will not
be restricted during the surgery as long as the arrow points to the blue line; however,
this lineup does not apply to side docking.
Fig. 8.4: The sweet spot for the camera arm occurs when the solid blue line aligns with the arrow
8.2.4Instrument selection
Monopolar EndoWrist curved scissors are commonly used on the right, with a bipolar
grasper or PK (Robotic PK 400, Gyrus, Minneapolis, MN, USA) on the left. When a third
robotic arm is used, the preferred forceps is usually a ProGrasp or Cadiere grasper. As
needed, a traumatic grasper (alligator grasper) or suction irrigator may be used via
the assistant arm. This arm is also used to transport sutures. A harmonic scalpel is
also available for robotic use per the surgeons preference.
8.2.5Step-by-step approach to simple hysterectomy
Pelvic space and the upper abdominal area will be explored initially during laparo-
scopy. For ergonomic reasons, hysterectomy starts with transection of the round liga-
ment on the patients left side using a 3-step approach:
Step 1: Using the PK/bipolar cutting forceps, grasp and coagulate the round liga-
ment close to the uterus (Fig. 8.5).
Step 2: Grasp and coagulate the ligament 1 cm distal to the first bite (Fig. 8.6).
Step 3: Without letting the PK go, use monopolar scissors to cut between the 2
previous bites to the tip of the PK, simultaneously using sharp and cutting modes of
the monopolar power (Fig. 8.7).
After completing the round ligament transaction, the PK instrument is used to
dissect the broad ligament parallel to the uterus anteriority. Carefully avoid getting
too close to the uterus to avoid injuring the ascending branch of the uterine vessels
Fig. 8.5: Step 1, coagulating the round ligament

Fig. 8.6: Step 2, second line of coagulation, placed 1 cm away from the first bite
Fig. 8.7: Step 3, transecting the round ligament with monopolar scissors
and to prevent unintended bleeding. When the dissection reaches to the utero-
vesical junction, it should turn at approximately a 90 angle toward the cervix
(Fig. 8.8). Continue broad ligament dissection until reaching the contralateral round
ligament (Fig. 8.9). The right-side broad ligament will be coagulated and transected
using same three-step technique. The only difference from the left side is that the
first-step coagulation is performed laterally to the uterus to prevent the two robotic
Fig. 8.8: Broad ligament dissection turning at an approximately 90 angle

at the utero-vesical junction
Fig. 8.9: Broad ligament dissection to contralateral round ligament
arms from crossing each other. Then turn attention to completing the bladder flap
using monopolar scissors (Fig. 8.10). Drop cutting power to 20 W to prevent bladder
coagulation injuries later.
Using the uterine manipulator, antevert the uterus completely. After transectio-
ning the round ligament, extend the broad ligament dissection posteriorly. The poste-
rior broad ligament dissection is usually performed parallel to the infundibulopelvic
(IP) ligament since this approach makes ureter control easier if necessary. Coagulate
and transect the IP or utero-ovarian ligaments with the same three-step technique.
Drop the posterior peritoneum to the lower uterine segment.
Fig. 8.10: Bladder flap formation using monopolar scissors
Give special care to skeletonization of both uterine vessels (Fig. 8.11). PK is used to
coagulate, not to transect, the ascending branch of the uterine vessels to prevent back
bleeding (Fig. 8.12). Uterine vessels should be coagulated after pushing the uterus
maximally cephaled with the uterine manipulator to decrease the risk of urethral
injuries.
Uterine vessels should first be transected inside the ring provided by uterine
manipulator (Fig. 8.13). After transecting the uterine vessels, clamp the vessels
stumps from the uterine lower segment toward the uterine manipulator ring. Conti-
nue until vessel bundles peel off outside the uterine manipulator ring (Fig. 8.14).
Fig. 8.11: Skeletonization of the uterine vessels

Fig. 8.12: First step coagulation of the uterine vessels to prevent back bleeding (patients right side)
Fig. 8.13: Transection of the uterine vessels after coagulation (patients right side)
At this point, the vaginal cuff will be delineated by the uterine manipulator ring,
and it is safe to start the colpotomy since all the major vessels are transected and
moved away from the incision area. Increase the cut mode on the monopolar scissors
to 40 W before cutting the vaginal cuff. If using a Rumi, insufflate the vaginal occlu-
der balloon with 60 cc normal saline and activate two separate insufflators through
the trocars. Cut the vaginal cuff with monopolar scissors layer by layer using brush-
stroke-type movements (Fig. 8.15), which will help maintain the pneumoperitoneum
until the last moment. After completing the colpotomy, remove the specimen vagi-
nally, using morcellation as needed (refer to Chapter 9).
Fig. 8.14: Lateralization of the uterine vessels stumps (patients left side)
Fig. 8.15: Layer-by-layer excision of the vaginal cuff with monopolar scissors
Occlude the vagina using laparotomy sponges covered by a sterile glove depen-
ding on the size of the vagina. Avoid aggressive homeostasis using the energy modality
to preserve vascularization and facilitate cuff healing. Replace the robotic instruments
for cuff closing. Different combinations of two robotic instruments are available. Two
needle holders provide an advantage in handling the suture needle. One needle holder
and one grasper provide an advantage in holding the vaginal cuff during suturing (Fig.
8.16). Either option provides opportunity and trade-offs; the final choice will depend
on the surgeons discretion. Commonly used suture material is barbed bidirectional
suture 2-0 absorbable polyglyconate (V-LocTM 180 Absorbable Polyglyconate Knotless
Wound Closure Device, Covidien Ilc, Mansfield, MA, USA).
Fig. 8.16: Robot-assisted cuff suturing
In no assistant arm is used during the surgery, the CT-1 needle can be introduced
into the abdominal cavity by bending it slightly to fit into the 8-mm robotic trocar.
Previous meta-analyses show that cuff dehiscence is slightly higher in MIS cases
compared to open and vaginal hysterectomies: 0.6%, 1.2%, and 4% for open, lapa-
roscopic, and robotic, respectively [31]. Therefore, longer acting suture material is a
reasonable choice for cuff closing in robotic surgery (Fig. 8.17).
During the undocking process, give special care to avoid letting the robotic
arms touch the patient. Exchange the robotic camera for a 5-mm laparoscopic
camera. Place caps on the robotic trocars to serve as 5-mm laparoscopic access ports.
Fig. 8.17: Appearance of the vaginal cuff at the end of the procedure
Introduce the laparoscopic camera into one of these 8-mm robotic trocars. Drop intra-
abdominal pressure to 5-mmHg to assure homeostasis, and reverse the Trendelen-
burg to the horizontal level after the pressure reaches 17-mmHg again.
Close the fascia for all 10-mm and larger trocar incisions. The author prefers using
an endoclose technique (Carter-Thompson CloseSure System , CooperSurgical, Trum-
bull, CT, USA) under direct visualization. Close robotic trocar incisions between the
skin and the fascia using 2/O vicryl UR-6 needle (Polyglactin 910 Synthetic Absor-
bable Suture, Ethicon, INC, Somerville, NJ, USA). The skin can be closed with the
surgeons preferred method.
8.2.6New innovative techniques for robotic hysterectomy: robotic surgery to

laparoendoscopic single site surgery (R-LESS)
Although a single-site laparoscopic approach is used for different medical fields, the
requirements of the learning curve and technical considerations including external
clashes, poor visualization of critical structures, and surgeon fatigue continue to be
major disadvantages of single-site surgery. To overcome some of these difculties,
novel articulated instrumentation, such as flexible scopes, angle instruments, and
novel robotic technologies (platforms), have been developed and/or applied.
Single-site surgery and robotic technology are areas of enthusiastic research and
innovation for minimally invasive surgery. The application of robotic surgery to lapa-
roendoscopic single-site surgery (LESS) has already been introduced for gynecologic
surgical procedures [32], and the feasibility, reproducibility, and performance of a
da Vinci single-port robotic platform for various gynecologic procedures in cadavers
has been reported [33]. A surgical procedure was successfully completed with single-
port robotics in 87.5% of cases in the cadaver study. Also, the study showed that
while increasing BMI was correlated with difculty docking the robot, increasing
BMI was not correlated with inability to complete the planned procedure. Docking
approach (side vs. central) was not correlated with difculty docking or likelihood
of case completion. In this study, port placement was performed using a standard
Hassons technique, a 2.0-cm2.5-cm midline intra-umbilical incision, and special
da Vinci single-site port equipment, which has five lumens: four to hold cannulas
and one for the insufation adapter. The authors concluded that the versatility and
superior 3-dimensional visual perception of robotics, as well as the improved ergo-
nomics, allowed completion of the procedures despite wide anthropometrical diffe-
rences in the cadavers. Nam et al [34] recently reported the largest retrospective study
at a single institution to examine robotic single-port total hysterectomy (R-SPH) for
benign and malignant gynecologic disease, including a robotic single-port transum-
bilical radical hysterectomy. Seven patients were treated with robotic single-port total
hysterectomy for benign gynecological disease (n = 5), extra-fascial hysterectomy due
to cervical carcinoma in situ (n = 1), and radical hysterectomy due to cervical cancer
IB1 (n = 1). The study used a single 34-cm umbilical incision with a multichannel
8.3Comment 107
system consisting of a wound retractor, a surgical glove, and two 10/12-mm and two
8 mm trocars. The study showed that the median total operative time was 109 min
(range 105311 min), the median blood loss was 100 mL (range 10750 mL), and the
median weight of the resected uteri was 200 g (range 40310 g). One benign case was
converted to 3-port robotic surgery due to severe pelvic adhesions, and no postope-
rative complications occurred. The authors concluded that R-SPH was technically
feasible in selected patients with gynecological disease, and the robotic unit may
enhance surgical skills during single-port transumbilical hysterectomy, especially in
patients with gynecologic cancers [34].
8.3Comment
One in three women in the USA will have a hysterectomy before she turns 60 [35].
Although abdominal hysterectomy still accounts for approximately two-thirds of all
benign hysterectomies performed in the USA [4], minimally-invasive techniques for this
procedure have advanced in the last 15 years [5, 36]. Robot-assisted surgery is emer-
ging as a new technique for hysterectomy, and many gynecologists have begun to prefer
the robot-assisted procedure [4, 37]. The number of robotic systems available in hospi-
tals across the USA has risen rapidly from 2002 to 2012 [38]. As of March 31, 2012, the
number of robotic systems worldwide reached 22261615 in the USA, 379 in Europe, and
232 in the rest of the world [39]. Meanwhile, half of the Society of Gynecologic Oncology
members responding to a 2008 survey were using robotically assisted surgery in their
practices, with 66% of respondents planning to increase robot usage [7, 40].
Results from a recent survey of US gynecologic oncology fellowship programs
indicated that 95% of the programs had robots at their institutions [41]. With the
growing popularity of robotic surgery, Ob/Gyn residency programs nationwide have
started implementing structured teaching in robotic surgeries, including hysterecto-
mies. Ideally, simulation-based training programs should be implemented. Simula-
tion will eventually reduce challenges and help to decrease surgical time, even for
programs that have only recently integrated a robotic approach into their department.
In this chapter, we describe the step-by-step approach to robot-assisted simple
hysterectomy and provide updated useful knowledge about robotic-assisted hyste-
rectomy practice for all professionals, especially general gynecologists, urogynecolo-
gists, and gynecologic oncologists.
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9 Approach to the big uterus for hysterectomy
Gregory L. Eads and Thomas N. Payne
9.1Introduction
The big uterus is defined differently by each gynecological surgeon. In this chapter
it will be defined as a uterus large enough to create problems either with its removal
from its attachments or problems with removal from the patient after detachment.
Generally this is defined as too large to remove through the vagina intact and there-
fore any uterus larger than 14-week gestational size.
Minimally-invasive surgeons differ in how large of a uterus they will attempt
with most stopping at 1618-week size mainly due to problems with removal of the
specimen from the patient and the time involved. As minimally-invasive surgeons we
should try to learn the procedures necessary to remove nearly any uterus. In 2010 the
AAGL (American Association of Gynecological Laparoscopists) strongly stated that
most hysterectomies should be performed via a minimally-invasive approach [1].
9.2How large is possible?
Discussion should be held regarding terminology of the size of uteri. Typically the size
clinically stated is in relation to gestational size. This is in relation to the size of the
patient and therefore a 38-week size uterus may not weigh 4,000 g. However, surgi-
cally the size of the uterus relative to the patient size is critical and not the bragging
rights of the weight of the uterus which can also vary according to being weighed in
the OR or later in pathology.
The size of uterus that is possible to remove depends upon the surgeons expe-
rience, the overall size of the uterus, position and size of fibroids, as well as other
factors such as endometriosis, adhesions and other pathology. One of the authors
has removed a uterus at 38-week gestational size. Payne et al in a multi-site commu-
nity study found that uteri as large as 3,020 g could be removed with the da Vinci
robot with low morbidity, low blood loss and minimal risk of conversion to laparo-
tomy [2]. The key in this study was that these were all performed by general gyneco-
logists in geographically diverse community settings. There has also been a robotic
hysterectomy for a fibroid uterus weighing 3,300 g with the patient having a history
of previous cesarean section and skin to skin time of 3 h with use of a laparoscopic
morcellator.
With the superior 3D vision and extreme articulation of the da Vinci (Intuitive
Surgical, Sunnyvale, CA, USA) instruments more surgeons can remove much larger
uteri safely.
112 9 Approach to the big uterus for hysterectomy
9.3Technique
The first consideration is the placement of the robotic ports. It is best, if possible,
to place the camera and lateral robotic ports at least 8 cm above the uterus when it
is pushed in with the uterine manipulator but frequently this is not possible. If the
patients abdomen is lax then insufflation with a Veress needle to 1618 mmHg can
help give room for safe insertion of the ports. A recent study found that using intra-
abdominal pressure instead of volume of CO2 gives a better distance from abdomi-
nal organs [3]. Since the actual surgery on the uterus is not at the top of the uterus,
the term paradoxical trocar placement has been coined. This refers to placing the
camera trocar at the umbilicus regardless of the size of the uterus and may be utilized.
A note of caution: when inserting the initial trocar above the umbilicus, the anes-
thetist should decompress the stomach with suction via a NG or OG tube. Puncture
of the stomach has occurred. Also the aorta is directly below the insertion site and
therefore it is recommended to use the Veress needle followed by a visual trocar with
great control of insertion.
The use of the third arm of the robot can help with retraction. The position of
the trocars are beyond the scope of this chapter but in general are either placed in an
arch, a M configuration or a W configuration trying to get at least 8-cm spacing.
The use of a 30 up or down scope can help with visualization. Myomectomies and/
or performing a supracervical hysterectomy after cauterization of the major vessels
below the level of the transection can also be of assistance. The cervix can then be
removed or left in place for a SCH (supracervical hysterectomy). After cauterization of
the great vessels a partial in-situ morcellation can also be utilized to debulk the uterus.
9.4Creating the bladder flap
It is imperative to identify the colpotomizer ring as soon as possible. This can be dif-
ficult with anterior fibroids and a myomectomy and/or use of a 30 down scope can
help here. Placing the scope way into the anterior compartment and even pushing the
uterus down with the scope can help. Sometimes it is easier to identify the ring pos-
teriorly but with large uteri this can be difficult. Also the ring may not get all the way
into the posterior fornix due to anatomical distortion. Visualization of the cervical
insertion of the uterosacral ligaments can help with this.
There are many uterine manipulators on the market but the most commonly
used in this country are the V-Care and Rumi which both have a colpotomizer ring
for identification of the fornices and to push the ureters laterally to decrease injury.
One technique that one of the authors uses is to use the phrase lift the skillet for
the assistant controlling the vaginal manipulator. For whichever manipulator is being
used, the assistant just lifts straight up (as in lifting a skillet full of water off of a stove)
to help identify the ring anteriorly and this also helps to give room for the posterior
colpotomy. The bedside assistant or the surgeon can also tap on the supposed ring
9.5Approach to vessels 113
and ask the assistant who is controlling the uterine manipulator if they can feel the
tapping. In the very rare incidence that the ring cannot be identified, test colpotomies
can be made anteriorly after the bladder is well dissected distally. These should be
made high on the uterus and then progressively moved distally.
With the ring identified, the bladder flap can be created. This allows safe colpo-
tomy later and gives a good margin of anterior vagina to close at the end of the pro-
cedure. If the patient has bladder scarring from endometriosis or previous cesarean
sections then this can be addressed at this time.
If there is difficulty visualizing the bladder flap then the 30 down scope and/
or placing the robotic scope in to hold down the fundus may help. Also performing a
myomectomy of an anterior fibroid can give better visualization.
9.5Approach to vessels
It is imperative to appreciate that the anatomy of the ovarian and uterine vessels are
frequently distorted. Frequently the uterus will rotate as it grows with the uterine
vessels even entering the uterus at the 12 oclock position. This rotation can also pull
the ureters into the normal operating field. It is recommended to proceed slowly ente-
ring the retroperitoneal space to identify and avoid the ureters. Another frequently
used approach is to clamp or cauterize the uterine arteries lateral to the ureters.
Frequently due to differential growth of a fibroid uterus, the ovarian vessels (IP
ligaments) are not too far from their normal location. One fact to remember is that
the robotic instruments can be changed from their usual position. For example, the
cautery instrument can be placed on the opposite side than normal and can even
be used for cautery then replaced for transection with the scissors through the same
port. Also the camera can be placed in a lateral port (if an 8-mm robotic scope) or
the assistant port (if a 12-mm port) for visualization down one side of the uterus. It is
important that the surgical assistant move the uterus for visualization and dissection.
This is best done with a laparoscopic tenaculum but it should always be opened and
closed under direct visualization to prevent injury. This instrument will cause more
bleeding but this is usually not significant unless placed through large vessels.
The vessels feeding these large uteri are usually much larger and instruments
such as the Maryland and PK may not be adequate. The authors frequently switch
to the fenestrated bipolar for better cauterization but visual clues should be used to
assure complete cautery of the pedicle with this instrument unless a generator such
as the Erbe is used which gives an audible feedback.
9.6Making the colpotomy
The colpotomy can be started anteriorly or posteriorly but the anterior approach may be
safer since the uterine vessels are visible as well as the ureteric position. To continue the
114 9 Approach to the big uterus for hysterectomy
colpotomy posteriorly can be difficult with a large uterus, which cannot be lifted. The
key is to work from the side (which is the safest for control of the uterine vessels). Star-
ting on the left side, the colpotomy is made from at least 12 oclock to at least 6 oclock
and then repeated from the right side.
Some surgeons advocate starting with the posterior colpotomy so that the uterine
manipulator is less likely to pull out of the uterus from the weight of the uterus.
It is important to use the least amount of cautery on the vaginal cuff to potenti-
ally decrease the risk of cuff dehiscence. Therefore it is recommended to use the pure
cutting mode (on the Si) on the anterior cuff from 10 to 2 oclock and on the posterior
cuff from 8 to 4 oclock. If using the older S da Vinci robot then the blend cautery
instrument should be moved quickly to minimize the cautery effect. It is acceptable
to have some bleeding from the cuff in these areas which will be addressed at cuff
closure especially if using the barbed suture.
9.7Tissue removal
There are different options for tissue removal. This should be planned early in the
case noticing the size of the vaginal area and depending on the skills and preference
of the surgeon. One of the authors prefers to vaginally morcellate uteri up to 18-week
gestational size if there is an adequate vaginal diameter. This is much quicker than
a laparoscopic morcellator and avoids intra-abdominal spill. To do this use a goose
neck weighted speculum place INTO the peritoneal cavity, a right angle retractor
also placed INTO the peritoneal cavity anteriorly and a long handled straight scalpel.
There are basically three common vaginal morcellation techniques: 1) to bi-valve the
cervix from 12 to 6 oclock and then to morcellate through the uterine cavity (this is
difficult to visualize in most cases) 2) to core the uterus. Here the scalpel approxi-
mates a large morcellator cutting in a circular fashion with good traction on the cervix
and 3) to excise wedges of uterus as can be seen and moving around the uterus in a
progressive fashion. It is important to use the weighted speculum and the right angle
retractions as backdrops to prevent accidently cutting other structures. The use of a
good grasper such as Lehey clamps can help with traction. At the end of every case
where a large uterus is removed vaginally, it is imperative to do a thorough vaginal
exam to find and repair any small lacerations or tears. This can prevent a return to the
OR for a vaginal laceration after a long case.
There have been reports of different vaginal morcellation techniques such as a
helical incision [4] and paper roll technique [5]. There have also been anecdotal reports
of using the laparoscopic morcellators through the vagina but since the rule of safety
with these devices is to never push the device in but pull the tissue towards it, as well as
the fact that this use is not FDA approved, the authors do not recommend this technique.
If the uterus is too large for vaginal morcellation then either morcellating through
a small laparotomy incision (not really MIS) or using the laparoscopic morcellator
References 115
is utilized. The key safety tip as noted above is to keep the morcellator tip up close
to the abdominal wall and never push it in but to pull the tissue to it. The objective
for the quickest morcellation is to keep changing the angle of the morcellator blade
(with the beak of the guard up) to skim across the top of the specimen to get semi-
lunar pieces of tissue and onion peel the uterus. If the ovaries are also removed then
they should be morcellated first and alone to assure their removal or removed via
an endobag such as the Anchor brand bag. If the fibroid is rock hard then the coring
may be beneficial although slower. It is important to remove all tissue fragments.
There have been studies showing growth of these if left in the abdomen. These can
be removed piece-by-piece or placed in a laparoscopic bag such as the Anchor Bag
by Progressive Medical which is nylon and very resistant to tearing. Lastly after all
visual fragments are removed then flooding the upper abdomen with approximately
1 L of irrigation fluid followed by slowly reversing the Trendelenburg position and suc-
tioning in the pelvis can help remove small fragments.
There are many laparoscopic morcellators on the market with GyneCare (15-mm
size), the Storz (12- and 15-mm size) and Blue-Endo (12.5-, 15- and 20-mm size) being
some of the most commonly used. Obviously the larger 20-mm size can markedly
speed up morcellation.
Some surgeons are performing the practices of intra-abdominal bi-valving, tri-
valving and just excising part of the uterus with the monopolar instruments. It should
be noted that the monopolar current needs to return to the generator through some
pathway. Therefore, if these techniques are used the uterus should not be comple-
tely detached from the vagina to help prevent accidental cautery burns of vessels or
bowel.
References
[1] AAGL Position Statement: Route of hysterectomy to treat benign uterine disease. J Minim
Invas Gynecol 2011, 18(1), 13.
[2] Payne T, Dauterive F, Pitter M, et al. Robotically assisted hysterectomy in patients with large
uteri. Obstst Gynecol 2010, 115(3), 53542.
[3] Thomson A, Shoukrey M, Gemmell I, et al. Standardizing pneumoperitoneum for laparoscopic
entry. Time, volume, or pressure: which is best? J Minim Invas Gynecol 2012, 19(2), 196200.
[4] Lin Y. New helical incision for removal of large uteri. J Am Assoc Gynecol Laparosc 2004, 11(4),
51924.
[5] Wong W, Lee T, Lim C. Novel vaginal paper roll uterine morcellation technique for removal
of large uterus. J Minim Invas Gynecol 2010, 17 (3), 3748.
10 The difficult robotic hysterectomy
Sai Daayana and Ahmed Sekotory M. Ahmed
10.1Introduction
The first vaginal and abdominal hysterectomies were reported back in 1801 and
1843, respectively. Since then, safety and acceptance of the hysterectomy procedure
vastly improved with advancements such as supra-pubic transverse incision by
Johanns Pfannenstiel in the 1920s, refinements of the surgical techniques described
by Richardson in the 1930s and the introduction of anaesthesia and antibiotics. The
major development however has been the introduction of laparoscopic approach for
hysterectomy by Harry Reich from Pennsylvania in 1988 [1]. Laparoscopic surgery in
the interim witnessed major advances in optics, range of instruments, energy devices,
techniques, ergonomics and most importantly its clinical applications. However, the
shift provided by the advent of robotically assisted minimal-access surgery could not
be rivaled.
Hysterectomy is the most commonly performed gynecological surgery, and abdo-
minal approach remains the most usual route [2]. In 2002, only about 10% of hyste-
rectomies in USA were performed in a minimally-invasive fashion. A recent statement
by the American Association of Gynecologic Laparoscopists emphasizes the need to
perform hysterectomies in as minimally invasive a manner as possible [3]. The tech-
nology of robotic assistance with improved surgical precision, better visualization,
and more intuitive/ergonomic instrument control thus leading to faster surgical lear-
ning curves for surgeons has overcome the limitations of conventional laparoscopy,
thereby securing an important role in microsurgical procedures.
This chapter is assigned to identification and management of clinical situations
when a difficult robotic hysterectomy is either anticipated or encountered.
10.2The scenarios of difficult and complex hysterectomy
Aptitude towards conceptualization of potential difficulties associated with complex

robotic hysterectomy helps not only in adequate pre-operative preparation but also
in appropriate patient counseling. It is important to uncover details of any previous
complicated abdominal, pelvic, cervical or vaginal surgical procedures, if necessary
by contacting the surgeon who performed them. Previous cesarean delivery, cervical
excisional procedures or vaginal repair surgery are sometimes known to herald sig-
nificant bladder adhesions to the upper cervix and the uterine isthmus increasing
the risk of bladder injury during subsequent pelvic surgery. Past history of infection
or radiation treatment is a warning sign for adhesions and obliteration of surgical
118 10 The difficult robotic hysterectomy
planes. Needless to say, evidence of meticulous pre-operative preparation provides

an acceptable level of immunity to the surgeon in litigious situations.
Patients with increased body mass index (BMI), midline abdominal scars, large
and/or fixed uterus, could be the subjects of a potential difficult hysterectomy. Sig-
nificant pelvic pain and tenderness upon vaginal examination (suggestive of pelvic
inflammatory disease), as well as palpable induration in posterior vaginal fornix,
particularly if accompanied by a retroverted uterus with restricted mobility, are all
indicative of difficult posterior and lateral dissection with the risk of damage to the
rectosigmoid or ureters respectively. In women with a large cervical fibroid or sizeable
cervical sessile polyp, difficulty is often encountered with uterine manipulation and
devascularization, ureteric mobilization, and colpotomy during robotic hysterectomy.
Transvaginal ultrasonography allows real time assessment of anatomical rela-
tions, tenderness and extent of pelvic adhesions. Advancement of the transvaginal
probe into the pouch of Douglas whilst observing the sliding movement between the
posterior uterus, rectosigmoid and the ovaries gives some indication of the extent
of pelvic adhesions. MR scan of the abdomen and the pelvis helps delineate tissue
planes between uterus, bladder, colon, rectum and the pelvic side-wall. Dilatation of
the ureters evident on radiological imaging could be due to strictures at the level of
either the pelvic side-wall or uterine isthmus. This could be due to a variety of factors
amongst which are endometriosis, pelvic inflammatory disease and previous pelvic
surgery. Use of appropriate dye or contrast with imaging for both the urinary tract
as well as colon is useful when anticipating difficult surgery or involvement of other
pelvic organs.
Discussions at the multidisciplinary pelvic surgical team (MDT), involving other
specialists in examination under anesthesia (EUA) with or without endoscopic evalu-
ation of the bladder (cystoscopy) and/or the colon (sigmoidoscopy) provide valuable
information in some cases. Extensive pelvic endometriosis with suspicion of bladder
or rectosigmoid involvement is one such example.
In summary, it is pragmatic to offer robotic hysterectomy to patients with scarred
or obliterated surgical planes. The fine dissection feasible with the robotic system
further enhanced by the 3-D vision is most beneficial to patients with fibroid uterus,
endometriosis with obliteration of cul de sac, pelvic inflammatory disease where
ovaries are closely adherent to pelvic side-walls and parametrium, and severe uterine
adhesions to the bladder and anterior abdominal wall (e.g., following previous
cesarean section, myomectomy). Morbidly obese women with increased retroperito-
neal adiposity equally benefit from robotic approach as described below.
10.3Patients selection for robotic hysterectomy
There are no absolute contra-indications to robotic hysterectomy. The need for

pneumo-peritoneum and steep Trendelenburg position may make patients with
10.4Pre-operative preparation for a difficult hysterectomy 119
severe cardiovascular, respiratory and peripheral vascular disease poor candidates

for robotic procedures. This group may benefit from carefully thought protective
strategies based on patient specific factors and a thorough pre-operative anaest-
hetic assessment. A lower than normal threshold should be maintained for pre-
operative investigations like CXR, echocardiography, pulmonary function tests and
so on. In certain doubtful situation when the ordinary investigations are borderline,
and patients appear clinically to pose a medical anesthetic and therefore surgical
challenge, a cardiopulmonary exercise test (CPET) is warranted and will indicate
the cardiorespiratory reserve for whether the patient will be able to tolerate exten-
ded surgery with Trendelenburg positioning.
10.4Pre-operative preparation for a difficult hysterectomy
Review of the patients past medical history prior to planning patient positioning
and entry technique is important. Ultrasonography to determine placement of
the initial trocar has been described as a handy accessory when anticipating
adhesions due to previous abdominal surgery [4, 5].
If the indication for hysterectomy is fibroids or endometriosis, a course of pre-
operative GnRH analogues may be beneficial [6].
Bowel preparation the day before surgery whilst the patient is on clear liquid
diet allows better visualization and mobilization of the bowel, safer adhesiolysis
and/or bowel surgery.
Consideration should be given to extended DVT prophylaxis as per local throm-
boprophylaxis protocol, if patient is obese or if procedure is been carried out for a
malignant indication. Intermittent compression devices lower the risk of DVT and
promote venous return to the heart even with elevated intra-abdominal pressure.
It is important for the surgeon to choose the instruments pre-operatively depen-
ding on the individual patient requirements such as long trocars and instrument
shafts in obese patients (see below).
Patients should be warned of possible facial and ocular oedema causing transi-
ent blurred vision. They should, however, be prepared for an early discharge as
long as any symptoms are within the realm of normal and do not affect recovery
or discharge.
10.5Technical operative factors and considerations
10.5.1Anesthesia considerations
The combination of Trendelenburg positioning and CO2 insufflation could make

ventilating obese patients and/or for long durations challenging. Pressure controlled
ventilation and mild hyperventilation to avoid development of hypercarbia is

recommended. Regular arterial blood gas analysis with a low threshold for advanced
monitoring such as arterial blood pressure monitoring, pulmonary artery catheters,
transesophageal echocardiography is required. Insertion of oro or nasogastric tube
with antigastric acid prophylaxis should always be considered in difficult situations.
When the standard high insufflation pressure for primary trocar insertion in
supine position is not suitable in patients with cardio-respiratory compromise or in
the very obese, setting the initial pressure low at 15 mmHg is acceptable. The open
entry technique conveniently avoids the need for initial insufflation altogether
allowing further trocars insertion under direct vision at a lower pressure. Setting the
intraabdominal pressures as low as 710 mmHg for the duration of the procedure
allows an adequate angle of Trendelenburg even in the morbidly obese patients [7].
10.5.2Following induction of anaesthesia
1. Intravenous antibiotics administration is a requisite in all cases of robotic hys-

terectomy. This need is accentuated when anticipating extensive adhesiolysis or
bowel intervention. Subject to local protocols, a suitable broad-spectrum anti-
biotic or a combination to cover gram positive and negative bacteria and anaero-
bes would be beneficial.
2. Mechanical and pharmacological DVT prophylaxis is mandatory as prolonged
difficult procedures increase the risk of thromboembolic disease.
3. Intravenous tranexamic acid infusion is a useful preparation when excessive
intra-operative bleeding is anticipated.
4. It is safer to prophylactically stent the ureters in patients with advanced pelvic
endometriosis, large fibroid uterus, pelvic adhesions and in those cases with
apparent ureteric dilatation on imaging. It is prudent to insert an indwelling ure-
thral catheter for the duration of the procedure to keep the bladder draining and
also monitor urinary output.
10.5.3Patient positioning
1. For a difficult hysterectomy it is imperative to adequately pad the pressure points

to avoid tissue and nerve impingement and also perform regular checks to verify
the position of the gel pads. Allen stirrups in place of calf supports are more likely
to prevent increase in compartment pressures.
2. Contrary to the usual placement of egg crate foam, taping a foam egg mattress
with the convoluted side of the foam facing down to the operating table and
with the smooth side in contact with the patient is found to be effective in pre-
venting the patient from sliding off the table [8]. Given the benefits of steep
10.5Technical operative factors and considerations 121
Trendelenburg position, it is crucial in certain difficult cases to have the table

tilted as close to 30 as possible. Unsurprisingly, some robotic surgeons resort
to measuring the angle of the table with a spirit level before docking the robot
for every case or even mount a nautical clinometer to the bed to facilitate rapid
and accurate Trendelenburg position. Several inclinometer software appli-
cations are now available as mobile (cellular) phone applications. It is crucial
to always do the Trendelenburg test before the robot is docked to ascertain the
patient is secure and not sliding off the table.
3. Constant liaison with the anesthetic team is mandatory as it might intermittently
become necessary to undock the robot and rest the patient flat to restore normal
cardiorespiratory function and lower the risk of cerebral and ocular edema.
Venous engorgement due to intravascular fluid overload also increases the risk of
vascular injury and/or excessive bleeding further emphasizing the need to inter-
mittently restore normal vitals.
10.5.4Entry
1. Standard closed umbilical entry: The initial trocar and camera entry always take
place with the patient lying supine and parallel to the floor. The position of the
umbilicus in relation to the aortic bifurcation depends on the patients BMI. On
average, the umbilicus was found to lay 0.4-, 2.4- and 2.9-cm caudal to the aortic
bifurcation in normal weight, overweight and obese women, respectively. At the
initial insufflation entry, the Veress needle is first anchored to the fibrous sheath
at the base of the umbilicus. The subsequent introduction angle of the Veress/
trocar at the umbilicus hence should vary according to the BMI of the patient
from 45 in non-obese women to 90 in obese women [9, 10]. In obese patients, it
is important to place the primary and secondary trocars in an initial perpendicu-
lar position on the fibrous sheath before angling it accordingly. This ensures the
shortest distance traveled by the trocar between the skin and peritoneal surfaces.
Otherwise tunneling through the subcutaneous fat, risking trocar slippage and
retraction as well as subcutaneous gas emphysema may occur.
2. Hasson open-entry technique [11]: A popular technique with surgeons where
the initial Veress needle insufflation and blind primary trocar entry are both
avoided. Normally, 2-cm long incision is made at the base of the umbilicus,
rectus sheath and the peritoneum are opened and the abdominal cavity is
entered under direct vision. This technique allows peri-umbilical adhesiolysis
by blunt finger dissection. Careful sweep of the finger from normal to an abnor-
mal area is likely to breakdown filmy avascular bowel adhesions. This entry
technique does not however reduce the risk of injury to bowel fixed densely
beneath the incision site. When dense adhesions are expected, non-umbilical
entry should be considered.
3. Left upper quadrant entry: Palmers point typically lies approximately 23 cm

below the left costal margin in the mid-clavicular line. Insertion of naso or oro
gastric tube should always be considered prior to insertion of Veress needle in this
position. The indications for this entry are obesity, suspected adhesive disease,
prior ventral hernia repair or midline abdominal scars, extreme thinness, preg-
nancy, abdominal wall laxity and large pelvic mass. The contraindications to this
entry are hepatosplenomegaly, portal hypertension, gastropancreatic masses
and prior gastric bypass [12, 13].
4. Trans-vaginal entry: A long Veress needle is placed in the midline of a taut pos-
terior fornix approximately 1.75 cm into the peritoneal cavity. The indications for
this entry are obesity and those where umbilical and left upper quadrant entry is
not feasible due to previous extensive surgery. The contraindications to this entry
are fixed retroverted uterus and previous pelvic infection.
5. Trans-uterine entry: A long Veress needle is inserted through the fundus with the
patient placed in the Trendelenburg position and the uterus in anteverted position.
This is a useful entry technique in obese patients and in those patients with contra-
indications to umbilical and left upper quadrant entry. This method is not suitable
for patients with fibroid uterus and suspected or confirmed gynecological malig-
nancy.
10.5.5Uterine manipulation
Effective uterine manipulation is essential when performing a difficult hysterectomy.

Currently an array of uterine manipulators is available depending on the demands of
the procedure offering multifunctional assistance. The three commonly used uterine
manipulators for robotic hysterectomy which come with a colpotomy ring are Vcare
Uterine Manipulator (ConMed Corporation, Utica, NY, USA), and the Rumi and the
ZUMI Uterine Manipulators (Cooper Surgical, Trumbull, CT, USA) with a Koh ring and
balloon pneumo-occluder attached. The fundamental principle when considering a
particular manipulator is to ensure the colpotomy ring fits well all around the cervix
by a sweep of the index and middle fingers. It is always useful to check the range
of movement offered by the manipulator before embarking the procedure. Proper
patient positioning with the coccyx resting at the most distal end of the operating
table facilitates better anteversion and retroversion of the uterus.
The principles of peritoneal access and strategic trocar placement should be standar-
dized, yet individualized depending on the procedure planned, type of pathology,
volume of disease and patient specific risk factors.
Obesity per se is not a problem. Due to the increasing prevalence of obesity,

development of robotic surgical techniques to appropriately manage these patients
is important. The safety and feasibility of robotic hysterectomy in morbidly obese
women in comparison to open surgery is now established [13]. Furthermore, the third
robotic arm aiding in retraction of the bowel and the immobile and fixed position of
the trocars due to robotic configuration allow reduction of intraperitoneal pressures,
thereby lessening the burden on anaesthetic ventilation of the patient.
In obese patients, Hasson open entry is strongly recommended. Orientation with
fixed anatomical landmarks such as anterior superior iliac spine and pubic sym-
physis is likewise essential. It is practical to place all the ports above any pannus at
the level of the umbilicus or even higher. As the ports will then be distantly placed
for pelvic surgery, the choice of instruments should be at least 45-cm long. As a
general principle, the camera port is best placed approximately a hand-breadth
(810 cm) above the uterine fundus and 2023 cm from the symphysis pubis. The
two operating arms (usually robotic arms 1 and 2) are placed at least 8 cm away from
the camera port in an arc centered at the midpoint of pelvic pathology or the target
organ. In difficult situations, however, such as a large fibroid uterus reaching above
the umbilicus, the camera and operating ports may need to be placed below the
uterine fundus to allow visualization and tackling of the uterine vessels and dissec-
ting the urinary bladder. The position of the fourth robotic arm is at the discretion
of the surgeon depending on the choice of procedure, patient specific factors and
docking of the robot. Benefits of using a fourth arm include intraoperative uterine
manipulation; bowel, bladder or peritoneal retraction and holding on to tissues,
while dissection takes place with the other two active arms. In addition to the four
robotic arms, the use of an extra patient-side assistant port for retraction, suction/
irrigation and displacement of intra-abdominal fat and bowel is an integral part of
a difficult hysterectomy.
One unit report initially placing morbidly obese women just before surgery (after
the onset of anaesthesia) in reversed Trendelenburg position to stretch and fix the fat
panniculus against the patients thighs with surgical tape prior to aseptic preparation
and draping. The authors claim this helps prevent the panniculus from falling back
and makes the abdominal wall thinner and lighter facilitating trocar placement and
lifting of abdominal wall with pneumoperitoneum. This group also advocate entering
via Hasson direct entry, in the mid-line 2023 cm above pubic symphysis irrespective
of the position of the umbilicus [14]. Accurate initial pneumoperitoneal insufflation
is important to avoid extraperitoneal gas leakage, which may lead to peritoneal splin-
ting and poor visualization.
In case of suspected adhesions around the umbilicus or other planned port sites,
initial assessment and adhesiolysis with a standard laparoscope (either 0 or 30
angle) instead of the robotic scope enables division of adhesions with extra ease, as
robotic scope is heavier and cumbrous to manoeuvre around adhesions.
10.5.7Docking
It is imperative when anticipating a difficult hysterectomy to have ready access to the

perineum and vagina. With the robot docked at approximately 45 angle to the lower
torso and aligned with the outer border of the left stirrup, there is adequate space for
all the robot arms. Side docking allows better access to the perineum in comparison
to end-on docking facilitating uterine manipulation, specimen delivery and vaginal
vault examination or suturing should this become necessary. Also, gentle tugging on
the ureteric stents might be needed to facilitate easier identification and dissection of
the ureters in case of dense pelvic scarring. These tasks to be performed by the assis-
tant are less cumbersome when the robot is side-docked.
10.5.8Steps of robotic hysterectomy
The basic principles of careful assessment of the entire abdominal cavity, spotting
the accessible anatomical landmarks, exploring the extent of disease, planning
alternative surgical steps in case needed, should always be adopted. If possible, it is
recommended to begin with the uncomplicated part of the procedure first and deal
with the vascular pedicles sooner to avoid complications and minimize blood loss.
The order of surgical steps may however vary depending on the individual pathology
and circumstances. When it is difficult to displace and mobilize the sigmoid colon
outside the pelvis, a suture through the sigmoid colon seromuscular wall fixing it to
the left anterior abdominal wall, above or lateral to the operating instrument ports,
is an option. Multiple omental/bowel adhesions to the anterior abdominal wall are
better dealt with via a conventional laparoscope before proceeding with robotic
hysterectomy.
1. Entering the pelvic side wall
Pelvic side-wall is routinely accessed by dividing the round ligament and procee-
ding cephalic lateral to the iliac vessels. However, in difficult hysterectomy, diss-
ection commencing lateral to the infundibulopelvic or utero-ovarian ligament
and working caudal toward the round ligament sometimes allows adequate visu-
alization of the broad ligament. Either way, identifying the ureters close to the
common iliac bifurcation and their course along the posterior leaflet of the broad
ligament is mandatory. The development of the para-vesical and para-rectal
fossae with their anatomical boundaries is important in difficult hysterectomy,
particularly for cases with extensive endometriosis.
2. Securing the infundibulopelvic ligament and ovarian pedicle
When performing hysterectomy and bilateral salpingo-oophorectomy, following
entry into the pelvic side-wall and identification of the ipsilateral ureter, the
infundibulopelvic ligament and the ovarian pedicles are secured. In case of
ovarian conservation, the tubo-ovarian pedicle is secured instead. In difficult
procedures, it might be useful also to secure the tubo-ovarian pedicle to access
the uterine arteries posteriorly as mentioned below. Mobilization of the ureters

allows safe incision along the posterior leaflet of the broad ligament to either
coagulate the ovarian vessels or expose the uterine arteries posteriorly close to
the uterine isthmus. Moving the uterus to the extreme right and left under stretch
facilitates opening and easier dissection along tissue planes.
3. Reflecting the vesico-uterine peritoneum
In difficult scenarios, this part of the procedure can be postponed until after dis-
section of the posterior compartment with or without securing the uterine blood
supply posteriorly, as mentioned below. In case of dense bladder adhesions to the
uterus, pushing the uterus into an axial (neutral) position facilitates delineation
of the bladder reflection. Bladder adhesions to the anterior uterine wall above the
isthmus, often due to previous cesarean sections are best dealt with by dissecting
close to the uterine wall. To minimize bleeding, coagulation of the uterine arte-
ries prior to full bladder dissection can be considered, provided the ureters are
distinctly identified.
Bladder adhesions to the upper cervix below the isthmus and to the anterior
vaginal fornix may occur as a result of previous cone biopsy of the cervix or multi-
ple cervical excisions. This also merits dissection close to the uterine and anterior
vaginal fornix, with the uterus pushed up axially. If the surgeon is not absolutely
sure of bladder reflection or there is any suspicion of bladder injury, retrograde
filling of the bladder should be considered. In case of confirmed bladder injury,
the normal practice is to repair the bladder in two layers using fine absorbable
suture with free drainage via a urethral catheter for 1 to 2 weeks. A cystogram
is typically arranged before catheter removal to ensure and document complete
bladder healing.
4. Dealing with uterine vessels
When the hysterectomy gets difficult, it is good practice to laterilise the ureters
up to the crossing of the uterine arteries before dissecting the rectovaginal space
and the uteroscaral ligaments. However, securing the uterine blood supply close
to the uterus is vital to avoid outspread of any thermal damage to the ureters.
Knowledge of the variations of vascular anatomy in the pelvis mainly that of the
uterine artery is equally important.
If uterine artery coagulation or clipping is not possible in the conventional
manner due to pathology, an alternative approach should be considered i.e.,
anterior or posterior approach to the ascending branch of the uterine artery or a
lateral approach to the uterine artery at its origin from the anterior division of the
internal iliac artery.
a) For the anterior approach, anteriorly ligating the ascending branch of the
uterine artery without opening the posterior broad ligament is a good tech-
nique for large fibroid uterus with poor access to the cul de sac or not maneu-
verable by the manipulator. This however can be difficult in patients with
fibrosis in the parametrium from endometriosis or dense bladder adhesions
from cesarean sections.
b) The ascending branch of the uterine artery can also be accessed posteriorly
without developing the bladder flap. This is a suitable and valuable option
in patients with extensive and dense uterine adhesions to the bladder and
anterior abdominal wall.
c) The lateral approach is regular in radical hysterectomy for cervical cancer. This
is an equally valuable technique for retroperitoneal fibrosis in the parametrium
seen in severe endometriosis. Developments of the pararectal and paravesical
fossae as well as ureteric mobilization are prerequisites to this technique.
When using Hem-o-lok clips for thick uterine vessel pedicle, there should
be no hesitation in applying up to two or three clips on each side.
5. Colpotomy
A well-fitted colpotomiser with the uterus under stretch, good exposure of the
vaginal fornix all around delineating the edge of the vaginal manipulator allows
safe entry into the anterior or posterior vagina. Infrequently, recto-vaginal dissec-
tion opening the cul-de-sac may become necessary to expose and access the pos-
terior vaginal fornix. Judicious use of diathermy or the harmonic device avoids
excessive diathermy damage or smoke generation during this step.
6. Vaginal cuff closure
Excessive cautery should be avoided at the vaginal cuff as this may predispose
to cuff dehiscence. Bleeding from the vaginal edges can often be controlled with
adequate vault closure facilitated by a decent suction and irrigation device. Rela-
ting to the several methods of cuff closure is beyond the scope of this chapter;
however, a running suture using absorbable material is the commonest. Closure
by both conventional and robot-assisted laparoscopic surgery rely heavily on the
principles of adequate bites of tissue beyond the cut electrosurgical edge, not to
suture through devitalised tissue and to incorporate both vaginal epithelium and
fascia in the suture.
10.6General considerations
The surgeon should be well acquainted with his team and should have selected the
tools in the operating set. Albeit subtle, issues such as how low does the table go,
is the table at the maximum degree of Trendelenburg possible? every now and then
make all the difference.
In the immediate post-operative period, patient should be placed in reversed
Trendelenburg position for 30 min to reduce cerebral, ocular and facial edema. Active
surveillance for any symptoms or signs of compartment syndrome i.e., calf swelling,
lower limb paraesthesia, weakness of toe flexion or pain during passive toe extension
should be carried out, particularly in patients with epidural analgesia. Positional neu-
ropathy due to ulnar nerve, brachial plexus, sciatic nerve, popliteal plexus injury and
any evidence of barotrauma, especially in obese patients should be actively looked for
before discharging the patient.
10.6General considerations 127
10.6.1Choice of instruments
The following list of instruments although not comprehensive gives an overview of

some of the essential instruments needed for both standard and difficult robotic hys-
terectomy.
For complex surgery an angled 30 or 45 telescope is more appropriate than a
0 telescope. Angled telescope allows better visualization of the pelvic side-walls
and the anterior and posterior uterine walls. For example, it would not be possible
to view the vesico-uterine reflection with a 0 scope in case of a sizeable anterior
uterine fibroid.
The EndoWrist instruments include three different bipolar forcepsthe PK diss-
ecting forceps, the Maryland bipolar forceps, and the fenestrated bipolar forceps.
The choice of coagulation device largely depends on local availability and the
surgeons preference
The monopolar devices include the Hot Shears (monopolar curved scissors) and
the permanent cautery spatula
Needle drivers include the SutureCut, Mega and large needle driver
For retraction, instrument options include the Tenaculum forceps, ProGrasp
forceps, and the Graptor
Other instruments include Cadiere forceps and the double-fenestrated grasper
Longer instruments (at least 45-cm long) should be considered in obese patients
or for distantly placed trocars
A laparoscopic bowel retractor is a valuable instrument in the context of an obese
patient
Tonsil swabs are practical for controlling venous ooze
TilePro (Intuitive Surgical, Inc., Sunnyvale, CA, USA) is a feature of the latest
robotic system that allows for image and video input to the console. Radiolo-
gic data from ultrasonography, computed tomography, or magnetic resonance
imaging can be visualized superimposed on the live console picture to enable
surgeon precisely localize the area of interest. This feature can be hugely benefi-
cial when localizing small tumours or during lymphadenectomy.
10.6.2How to avoid trocar site hernia?
It is customary that all fascial puncture sites that are 10 mm or more undergo fascial
closure [15]. While there is no evidence to show that closing 5-mm ports is beneficial,
there are multiple reports in the literature of 5-mm trocar sites that subsequently
develop incisional hernias [16]. Whether or not to close 5-mm ports remains contro-
versial. Various risk factors such as large BMI, diabetes, age (>60 years), duration of
surgery, poor general nutritional status (low pre-operative albumin levels) have all
been identified as risk factors for 5-mm trocar site incisional hernia. Additionally, the
morbidly obese patients are as such at a high risk for pre peritoneal hernias because
1
2 3
Skin
Subcutaneous fat/Muscle
Peritoneum
3 2
1
Fig. 10.1: Extension and widening of the 5-mm initial defect in the peritoneum: extensive movement
of the port in caudal (2) and cephalic (3) directions as well as movement in lateral and medial
directions can result in widening of the peritoneal defect
of their substantially thicker pre-peritoneal space and elevated intra-abdominal

pressure [17].
Extensive manipulation of the port site from causes such as specimen removal,
multiple reinsertions of the sheath, surgical difficulty requiring increased force and
torque on the fascia of the trocar port site is considered to result in extension and
widening of the initial defect in the peritoneum, resulting in fascial and peritoneal
stretching of the original incision as shown in Fig. 10.1. It is highly recommended to
routinely close all 5-mm ports that have been actively manipulated or if the patient is
vulnerable to any of the above mentioned risk-factors [18].
10.6.3How to avoid losing pneumo peritoneum?
Following colpotomy, to maintain the pneumoperitoneum, the uterus can serve

as a pneumo-occluder in the vagina, or the balloon occluder can be replaced into
the vagina. An alternative option is to use a gloved Raytec swab in the vagina, with
the glove often clinging to the vaginal walls. The glove is removed and swab count
accounted for at the end of the procedure.
10.6.4How to avoid vaginal cuff infection/dehiscence?
A multifactorial approach is recommended: appropriate use of colpotomizer, adequate

bladder flap development, efficient use of energy source and avoiding excessive dia-
thermy during colpotomy, adequate suturing including both fascia and epithelium
and pelvic rest for 8 weeks (advice to avoid sexual intercourse, tampons, vaginal
douches) all aid towards a healthy vaginal cuff.
References 129
10.6.5Data collection
A close collaboration between teams/countries with comprehensive and accurate data

collection locally with centralized gathering and analysis of data is vital for a proven
yet emerging technique such as robotic hysterectomy in difficult scenarios. When colla-
ting the data, it is useful to categorize the hysterectomies clearly into simple/complex/
malignant with universally accepted definitions for each of these individual categories.
10.6.6Learning curve
Robotic surgery in difficult scenarios has its own learning curve. The newest da
Vinci Si system launched in April 2009 has dual-console capability to support trai-
ning in addition to enhanced high-definition three-dimensional vision and updated
user interface.
Telestration
The current version of the daVinci robotic surgical system, the da Vinci S (with or
without high definition) also allows for telestration. This allows the instructing surgeon
to write on a touch screen with a finger or an electronic pen that is visible to both the
console surgeon and the bedside staff. This feature allows the instructor to guide the
dissection, supervise which direction a particular robotic instrument should be moved,
assist with suture tying, and outline vital structures to be avoided. It is, however, impor-
tant to confirm that proper target alignment of the cameras has been performed to allow
the exact location that is highlighted to be appreciated by the console surgeon.
10.6.7Continuing Professional Development
The National Institute of Clinical Excellence recommends prospective audits of all

robotic cases for short- and long-term outcomes. Issues exist regarding how to appro-
priately train and credential robotic surgeons. In general, either a national, country
wide professional society or the institution where the surgeon is employed, can grant
the credentialing based on the evidence of technical training, surgical capability, and
outcome of the robotic surgery cases.
References
[1] Sutton C. Past, present, and future of hysterectomy. J Minim Invasive Gynecol 2010, 17, 42135.
[2] Wu JM, Wechter ME, Geller EJ, et al. Hysterectomy rates in the United States, 2003. Obstet
Gynecol 2007, 110, 10915.
[3] AAGL position statement: route of hysterectomy to treat benign uterine disease. J Minim
Invasive Gynecol 2011, 18, 13.
[4] Larciprete G, Valli E, Meloni P, et al. Ultrasound detection of the sliding viscera sign
promotes safer laparoscopy. J Minim Invasive Gynecol 2009, 16, 4459.
[5] Kolecki RV, Golub RM, Sigel B, et al. Accuracy of viscera slide detection of abdominal wall
adhesions by ultrasound. Surg Endosc 1994, 8, 8714.
[6] Lethaby A, Vollenhoven B, Sowter M. Pre-operative GnRH analogue therapy before
hysterectomy or myomectomy for uterine fibroids. Cochrane Database Syst Rev 2001,
CD000547.
[7] Madhuri TK, Hamzawala I, Tailor A, et al. Robot assisted surgery in gynaecologic oncology -
starting a program and initial learning curve from a UK tertiary referral centre: the Guildford
perspective. Int J Med Robot 2012, 8, 496503.
[8] Sullivan MJ, Frost EA, Lew MW. Anesthetic care of the patient for robotic surgery. Middle East
J Anesthesiol 2008, 19, 96782.
[9] Hurd WW, Bude RO, DeLancey JO, et al. The relationship of the umbilicus to the aortic
bifurcation: implications for laparoscopic technique. Obstet Gynecol 1992, 80, 4851.
[10] Hurd WH, Bude RO, DeLancey JO, et al. Abdominal wall characterization with magnetic
resonance imaging and computed tomography. The effect of obesity on the laparoscopic
approach. J Reprod Med 1991, 36, 4736.
[11] Hasson HM. A modified instrument and method for laparoscopy. Am J Obstet Gynecol 1971,
110, 8867.
[12] Advincula AP. Surgical techniques: robot-assisted laparoscopic hysterectomy with the da Vinci
surgical system. Int J Med Robot 2006, 2, 30511.
[13] Bernardini MQ, Gien LT, Tipping H, et al. Surgical outcome of robotic surgery in morbidly
obese patient with endometrial cancer compared to laparotomy. Int J Gynecol Cancer 2012,
22, 7681.
[14] Geppert B, Lonnerfors C, Persson J. Robot-assisted laparoscopic hysterectomy in obese and
morbidly obese women: surgical technique and comparison with open surgery. Acta Obstet
[15] Comajuncosas J, Vallverdu H, Orbeal R, et al. [Trocar site incisional hernia in laparoscopic
surgery]. Cir Esp 2011, 89, 726.
[16] Yamamoto M, Minikel L, Zaritsky E. Laparoscopic 5-mm trocar site herniation and literature
review. JSLS 2011, 15, 1226.
[17] Sakamoto K, Niwa S, Tanaka M, et al. Influence of obesity on the short-term outcome of
laparoscopic colectomy for colorectal cancer. J Minim Access Surg 2007, 3, 98103.
[18] Kulacoglu IH. Regarding: Small bowel obstruction and incisional hernia after laparoscopic
surgery: should 5-mm trocar sites be sutured? J Laparoendosc Adv Surg Tech A 2000, 10,
2278.
11 Robot-assisted laparoscopic myomectomy
(RALM)
Kubilay Ertan and Alexander di Liberto
11.1Principles of surgical therapy of uterine myomas
Due to a high incidence of uterine myomas and their occurrence between the ages
of 20 and 40 years and thus partially in the early fertility period, therapy is often
required when relevant symptoms or existing restrictions of fertility occur. In women
who no longer want to conceive this consists mostly in a type of hysterectomy (total
hysterectomy or supracervical hysterectomy) where the preservation of the uterus is
not required. Frequently myoma therapy concerns women who wish to conceive so
that uterus preserving therapy is mandatory. Given the increasing age of primipara
women the organ preserving treatment of myomas becomes more important. Beside
the well-established medicamentous treatment with GnRH agonists (such as leupro-
reline acetate; temporary volume reduction of the myomas up to 3060%) the range
of myoma treatment has become wider with the implementation of new treatment
options such as the use of the progesterone antagonist ulipristal acetate (Esmya,
volume reduction of the myomas up to 21%), the MRI-guided focused ultrasound
(HIFUS, MRGFUS) or the embolization of myomas (uterine artery embolization, UAE).
However, most of the non-surgical treatment options in patients with uterine myomas
who wish to conceive children are either contraindicated (e.g., UAE) or the applica-
tion is not sufficiently evaluated in clinical trials (ulipristal acetate, MRGFUS, in the
latter inadequate data with only non-randomized case series and currently with no
estimable effects concerning subsequent pregnancies). Thus, precaution is deman-
ded in using these treatments. In this respect the surgical treatment of patients with
myomas who wish to conceive is the most important and most investigated therapy
option. For this several surgical procedures are available, which are partially depen-
dent on localization and size of the myomas, and partly dependent on the surgical
expertise of the medical practitioner:
hysteroscopic myoma resection
abdominal myomectomy
laparoscopic myomectomy (traditional laparoscopy)
robot-assisted myomectomy (RALM)
combined surgical procedures
In a considerable percentage of cases the patients suffer from multiple myomas

with complications due to myomas. Often it remains unclear which of the myomas
are responsible for the existing symptoms or would constitute problems concerning
fertility or during pregnancies. Therefore it is necessary to remove all myomas as
132 11 Robot-assisted laparoscopic myomectomy (RALM)
much as possible. This, in turn, requires a high degree of surgical expertise, espe-
cially regarding hysteroscopic and minimally-invasive procedures. But this exper-
tise requires longer learning curves and years of experience. During myomectomy
the suturing of the myometrium is usually the essential surgical step and constitu-
tes the cardinal challenge in laparoscopic surgery; especially in relation to the dex-
terity of the surgeon but also to the technical prerequisites required (accessibility of
the particular region for suturing) as such the traditional laparoscopic technology is
limited. For this reason complex or multiple myomectomy nowadays is still done by
laparotomy, or there are if performed with traditional laparoscopy constrictions
in completeness of myomectomy. It may be that further surgical interventions are
necessary, or myomas symptoms may persist or recur so pregnancy may be delayed
or be complicated. Hence, the performance of robot-assisted myomectomies promise
basically by simplification of the myometrial suturing and the improvement of the
accessibility even in unfavorable myoma locations a distinct advantage over tradi-
tional laparoscopy. This will be demonstrated in the following chapters.
For all surgical procedures on symptomatic uterine myomas and the necessity
of uterus preserving therapy the following questions have to be taken into account:
is the myoma/s effectively responsible for the prevalent symptoms, and in the
case of a desired pregnancy is the myoma/s a significant impairment of fertility
or an obstacle to pregnancy, and what is the probability of myoma-associated
complications in the course of such a pregnancy?
is a sufficient relief of symptoms or a complete abolishment of symptoms attaina-
ble by a surgical treatment?
is a medical pretreatment (GnRH agonists, ulipristal acetate) necessary or reaso-
nable, what can be achieved with this treatment; will be the definitive surgical
treatment significantly delayed; complicates this pretreatment even the surgical
procedure?
is it reasonable to preserve the fertility at all, and is it possible to give the patient
a guarantee with satisfactory likelihood to remain the uterus with an adequate
functionality with association of an effective treatment at the same time; what is
the primary objective of the surgical intervention?
is a sufficient reconstruction of the uterus endoscopically even possible? Can all
the symptomatic and trouble evoking myomas be removed laparoscopically? Is
the success of the surgery more probable by choosing the abdominal myomec-
tomy, and in this respect has the effectivity of the myomectomy priority over the
type of surgical access?
which patients can be treated by traditional laparotomy, which will benefit from
robot-assisted laparoscopy?
11.1Principles of surgical therapy of uterine myomas 133
Tab. 11.1: Options of organ preserving treatment in uterine myomas
Treatment option Advantage Disadvantage
Medicamentous GnRH agonists No surgery, reduction of Temporary effect, a new

myoma volume between growth after termination of
3060% treatment; delay of family
planning, severe climacteric
symptoms
Ulipristal No surgery, reduction In case of missing treament
acetate of myoma volume up to response unnecessary delay
(Esmya) 21%, ongoing effect, no of familiy planning; long-
complaints concerning term results not available
hypoestrogenemia (in terms of pregnancy and
pregnancy outcome)
Surgical treatment Hysteroscopy Fast convalescence, no scars Hypervolemic syndrome,
limited and narrowed
operating range, restricted
technical possibilities
Abdominal Fast hemostasis and quick, Protracted convalescence,
(laparotomy) effective suturing, good greater extent of adhesions,
accessibility to all myomas, long scar, more and longer
shorter duration of the pain
surgery
Laparoscopy Short convalescence, fewer Longer duration of surgery;
(traditional) adhesions, fewer pain; increase of blood loss
marginal scars (longer duration of suturing),
remaining of myomas
(incomplete myomectomy),
insufficient suturing;
exhaustive procedure for the
surgeon
Robot-assisted Short convalescence, fewer Excess of costs, longer
laparoscopic adhesions, fewer pain, less duration of surgery
myomectomy blood loss, improvement
(RALM) of accessibility of the
myomas, even in challenging
localizations
Combined
surgical
procedures
Other treatment MRGFUS/ No surgery Expensive; sparse data
options HIFUS concerning long term
efficacy and pregnancy
Uterus artery No surgery Contraindication for women
embolization who want to become
(UAE) pregnant
11.2Patient selection for robot-assisted laparoscopic

myomectomy (RALM)
In general it is noticed similar to other surgical indications for robotic

assistance that patients with myomas are suitable for robot-assisted myomecto-
mies when conventional laparoscopic intervention may not be desirable and an
open procedure would be more suitable. In this context the threshold of laparoscopic
feasibility is not a fixed dimension but is dependent on the surgical expertise of the
particular surgeon. However, patients with complex uterine myomas are suited for
robot-assisted myomectomy:
a high number of myomas (e.g., >5 myomas), independent of size, which might
necessitate extensive suturing
problematic localization of myomas; i.e., deep intraligamentary localized
myomas with embedding into the uterine vascular system, myomas close to the
tubal ostiums with a risk of tubal damage or destruction, transmural expansion
of myomas with a high probability of opening of the uterine cavity, myomas
located at the inferior and posterior wall of the uterus, myomas with closeness
to the cervix and bigger myomas with localization inside of the uterine cavity,
notably submucosal myomas (especially bigger type II myomas according to the
classification of the European Society of Hysteroscopy, ESH)
an expected increase of surgical complexity due to previous surgical interven-
tions (especially in the lesser pelvis) with suspected formation of adhesions or a
higher grade endometriosis genitalis externa
Basic contraindications for minimal-invasive surgery (MIS) (such as a higher grade

cardiac insufficience, and others) have to be considered for robot-assisted myomecto-
mies as well, but these contraindications constitute an exception in this patient cohort.
11.3Technical and logistic aspects of robot-assisted myomectomies
The basic principles of robot-assisted operations with the da Vinci (Intuitive Surgical Inc,
Sunnyvale, CA, USA) system are not substantially different for robot-assisted myomecto-
mies to other da Vinci procedures, such as benign or radical hysterectomy. Several cha-
racteristics are described in the following and reflect the experience of the authors.
11.3.1Patient positioning
Due to the utilization of uterine manipulators in the most cases of robot-assisted

myomectomy, the frequent additional performance of diagnostic and interventional
11.3Technical and logistic aspects of robot-assisted myomectomies 135
hysteroscopy and the option of intraoperative tubal patency assessment (both

before and after myomectomy) a flat-angled lithotomy position is recommen-
ded, combined with uninterrupted disinfected and covered operation field from
the abdominal wall to the external genital. The inevitable positioning procedure
using a steep Trendelenburg position (vacuum mattress with adequate support
and padding of the shoulders, protection of the legs with appropriate medical leg
stirrups, e.g., Allen Stirrups, and others) has to be considered. In most cases of
myomectomy an excessive Trendelenburg position is not required (compared to
radical hysterectomy with pelvic and paraaortic lymph node dissection), however,
both arms should be attached to the trunk and padded sufficiently in order to avoid
an overexpansion of the brachial plexus and pressure marks and lesions. Usually
the flat-angled lithotomy position is valid for between legs docking of the patient
side cart; in case of a preferred side docking a simple supine position is also feasi-
ble if vaginal manipulation and instrumentation (for hysteroscopy, tubal patency
testing, etc.) is not intended.
11.3.2Equipment
Likewise all types of da Vinci systems of any generation are convenient as techni-
cal equipment for a robot-assisted laparoscopic myomectomy. The increased range
of motion of the da Vinci S and SI systems (compared to the standard system,
which is decreasingly in use) is rather subsidiary performing a robot-assisted
myomectomy because the area of the surgical field is limited (see Chapter 5 trocar
placement).
Due to the extensive suturing in myomectomy procedures which is an essential
surgical step the da Vinci single port system seems is not currently suitable; the single
port system and the instruments are too rigid and are unable to do many sutures in a
short time. However, if more flexible single port systems and instruments are availa-
ble in the future, robot-assisted myomectomies will be done with the potential to
reduce surgical invasiveness even more.
For the supporting activity at the surgical table done by traditional laparos-
copic surgery an appropriate armamentarium has to be available (e.g., tenacu-
lum forceps, other graspers, a morcellator system, spoon forceps, etc.). For robot-
assisted myomectomy a reduction of blood flow around the myoma by application
of vasoconstrictive agents (such as vasopressin, epinephirn, and others) is also
recommended. The application can be done either via a long, flexible cannula
(e.g., a spinal needle) placed through the abdominal wall or superiorly with an
endoscopic cannula which has a better range. As regards uterine manipulation
and suture material see section 11.3.4 resp. 11.3.9.
11.3.3Selection of robotic instruments (EndoWrist instruments)
For all robot-assisted procedures, including the robot-assisted myomectomy, the

principle as few as possible should be valid. The aim is to minimize the number
of instruments for limitation of costs. Minimum requirements of instruments for
robot-assisted myomectomy (with three robot arms) are four EndoWrist instru-
ments (monopolar scissors, bipolar forceps and two needle holders: e.g., a Mega
Needle Driver and a SutureCut Needle Driver). The use of two needle holders in
case of extensive suturing is strongly recommended due to the deficient holding
force of other instruments (e.g., Maryland Bipolar Forceps), especially with regard
to a sufficient hemostasis and re-adaption of the myometrium. A sufficient hemos-
tasis and re-adaption of the uterine muscle layers can only be assured if the surgical
stitches are sufficiently tightened. Furthermore, the use of weak and fragile inst-
ruments (e.g., Maryland Bipolar Forceps) for tightening the stitches can cause the
stitches to be damaged.
Additional instruments in case of the application of four robotic arms are notably
the Tenaculum Forceps and other traumatic and non-traumatic graspers (e.g., Cobra
Grasper, ProGrasp Forceps, Cadire Forceps, etc.). The use of the EndoWrist
Suction/Irrigator for the fourth arm is a reasonable option and also increases the appli-
cation of the Tenaculum Forceps the autonomy of the surgeon at the console. On the
other hand, the material costs raises. In this context every gynecologic department
using the da Vinci system for myomectomies has to consider the number of robotic arms
used according to the particular health care system and the reimbursement of the inter-
vention. In the opinion of the authors in the case of a good and reliable robotic surgical
bedside assistance the console surgeon can dispense with the fourth arm. Moreover,
the abdiction of the fourth arm provides the benefit of reduction of surgical incisions to
the abdominal wall, and ameliorates the minimalization of surgical injury.
Tab. 11.2: Eligible EndoWrist instruments for robot-assisted laparoscopic myomectomy
3 robotic arms 4 robotic arms
Obligatory monopolar scissors Obligatory monoplar scissors

bipolar forceps (Maryland, bipolar forceps (Maryland, PK
PK Dissection Forceps, Dissection Forceps, Fenestrated
Fenestrated Bipolar Forceps) Bipolar Forceps)
2 big needle holders (e.g., 2 at least 1 big needle holder (if
Mega Needle Drivers, or 1 another instrument for the 4th arm
Mega Needle Driver and 1 has a good grasping function, e.g.,
SutureCut Needle Driver) Cadire Forceps)
Tenaculum Forceps
Optional Tenaculum Forceps Optional Suction/Irrigator
Permanent Cautery Hook or Cobra Crasper
Spatula Permanent Cautery Hook or Spatula
11.3.4Uterine manipulation
Additional instrumentation with a specific uterine manipulator is optional but

recommended for the majority of cases, especially for myomas at the posterior
uterine wall, then an adequate ventral positioning of the uterus is essential. An
uterine manipulation is also reasonable in cases of multiple myomas when frequent
changes of the uterine position are required and if only three robotic arms are used.
The fourth arm instrument, if employed, can take over the task of fixing the uterus.
In summary, the uterine manipulation for robot-assisted myomectomy offers the fol-
lowing advantages:
simplification of the exposition of the surgical field (e.g., posterior uterine wall,
but also the inferior anterior wall, intraligamentary area)
holding and fixing the uterus (adequate counter bearing for suturing, etc.)
when a suitable manipulator implementation for an additional tubal patency
testing is used (e.g., VCare manipulator)
improved detection of the opening of the uterine cavity (in complex myomec-
tomy), or inversely enhancement of the probability to avoid such an opening
Diverse models of uterine manipulators are applied for myomectomy; mostly a simple
intrauterine probe, such as the so-called Hulka tenaculum, is sufficient; for simulta-
neous testing of tubal patency caulking manipulators should be used (e.g., VCare
manipulator, ZUMI manipulator, Rumi manipulator with Advincula Arch, and
others) (Fig. 11.1).
Fig. 11.1: ad) Demonstration of diverse uterine manipulators applicable for myomectomy;
a) VCare manipulator (ConMed Inc.); b) ZUMI manipulator (CooperSurgical Inc.); c) Hulka
tenaculum; d) RUMI manipulator with Advincula Arch (CooperSurgical Inc.)
The trocar placement is highly variable in RALM as well as in other robot-assisted

interventions; it depends on the circumstances in the operating theatre, the pati-
ent-specific and operation-specific prerequisites. The basic principles for trocar
placement in robot-assisted myomectomies are the same as in other robot-assisted
interventions (hysterectomy, pelvic lymph node dissection, etc.). An internal stan-
dard setting for RALM ist recommended (both for three and four robotic arms), only
the cranial extension which shifts the trocars can be varied depending on the uterine
and myoma size (each with 4 or 5 incisions). Examples for a standard setting for trocar
placement is shown in Fig. 11.2.
11.3.6Operation schedule for RALM
The surgical schedule of a robot-assisted laparoscopic myomectomy proceeds accor-

ding to the extent of the intervention involved and the number and localization of
the myomas. If only laparoscopic surgical steps are planned the robot-assisted ope-
ration part is flanked by the uterine manipulator (if used) and the traditional lapa-
roscopic instrumentation (establishing of the capnoperitoneum, trocar placement),
which sometimes performs adhesiolysis and others (e.g., taking of biopsy samples
from another anatomical region which is not accessible after docking, e.g., the upper
abdomen), before docking the patient side cart of the da Vinci system and takes over
of the operation at the surgeon console. Traditional laparoscopic surgical steps after
detachment of the patient side cart, concerning myomectomy is mainly the morcelle-
ment, insertion of a wound drain and procedures for adhesion prophylaxis. Usually,
tubal patency testing is done with the docked patient side cart (if necessary before
and after the myomectomy).
Additionally to the laparoscopic myomectomy a hysteroscopic myomectomy is
often necessary. This is carried out typically before the RALM, but a controled hyste-
roscopy may be required after completion of the laparoscopic operation (essentially
inspection and check-up of the uterine cavity after opening during the myomectomy
procedure, exclusion of a narrowing of the cavity and confirmation of disengaged
ostiums of the fallopian tubes).
If an intraoperative hysteroscopy is requested during a complex myometrial
reconstruction a side docking is required. In any case the logistic activities and the
organizational effort are increased if a interventional or diagnostic hysteroscopy is
added to the surgical procedure of the myomectomy; in addition to that the operation
time increases. This must be taken into consideration for the operation schedule.
Fig. 11.2: af) Proposals for trocar placement in RALM; a)/b) normal to slight augmented uterus;
c)/d) uterine size up to the umbilicus; e)/f) uterine size supraumbilical; in each case with three and
four robotic arms (ra = robotic arm, ap = assistant port, ca = camera arm)
11.3.7Camera work (0 vs. 30 endoscope)
Essentially, the application of the 0 or 30 endoscope of the da Vinci system for

robot-assisted myomectomy results from the preference of the surgeon. Normally,
the 0 endoscope provides satisfactory vision to the surgical field for the majority
of myomectomies. Thus, it is recommended to use the 0 endoscope as standard
equipment, especially if conventional laparoscopic surgical steps are planned before
docking of the patient side cart (e.g., adhesiolysis) and no classic endoscope for tradi-
tional laparoscopy is utilized. The morcellation of the myomas is in view of the weight
of the da Vinci endoscope also much easier with the 0 view. The authors prefer
to minimize technical equipment in the OR with the exclusive application of the
da Vinci endoscope (i.e., no additional usage of the traditional laparoscopic endos-
cope, in the phases before docking and after undocking of the patient side cart).
In cases of very inferior and deep intramural localized myomas (posterior
or anterior uterine wall), particularly with regard to sprawling uterine corpus and
fundus, it is reasonable or even necessary to utilize a 30 endoscope to achieve an
optimal view of the area of the myomectomy. This should be considered in the course
of operation scheduling, and appropriate endoscopes should be available. Thus,
intraoperative changes of the endoscopes are more effective and less time-consuming.
11.3.8Features and characteristics of robot-assisted myomectomy
The surgicle principle of myomectomy both by laparoscopy and by laparotomy is the

hysterotomy and the myometrial incision, as close to the myoma as possible to avoid
damaging any anatomic structures (such as tubal ostia, uterine vessels, etc.), the
presentation of the myoma capsule, blunt dissection of the exposed myoma portion,
grasping of the myoma with a tenaculum or a grasping instrument and dissection
of the myoma. Large vessels should be coagulated, as the quantity and localization
of supplying vessels are very variable. Subsequently the suturing of the myometrial
layers and the hysterotomy is carried out. This should be done by strong and deep
sutures in the myometrial layers to ensure sufficient hemostasis on the one hand and
a firm adaptation of the wound area on the other hand. Mostly one to three layers
depending on the extent of the removed myoma are necessary. The superficial uterine
suture should provide hemostasis and re-adaptation but also inversion of the surface
to adapt serosa to serosa. This avoids exposure of sutures and reduces formation of
adhesions. Furthermore the suturing has to preserve relevant uterine and neighbo-
ring structures (tubal ostia, main branches of the uterine artery).
Also the surgical principles of myomectomy are valid for robot-assisted
myomectomy. By means of the stereoscopic view, the image magnification, the
elimination of tremor myoma and thus the precise instrument guidance myoma
preparation can be carried out more accurately, supplying vessels can be identified
and more easily coagulated, important anatomic areas (tubal ostia, uterine cavity,
main branches of the uterine artery) can be conserved. More precise and less
invasive dissection could also decrease the extent of the opening of the uterine
cavity. This also applies for the suturing technique. Potential drawbacks of robot-
assisted myomectomy are the correct identification of the myoma capsule due to
the lack of tactility and haptics. This can cause myoma dissection in an inapprop-
riate layer with excessive bleeding. In addition, the improved magnification could
evoke underestimation of the myometrial layer thickness above the myoma. There-
fore, the hysterotomy should always be done deep enough to identify the myoma
capsule. This applies for traditional laparoscopic myomectomy.
11.3.9Suturing techniques and suture material
Robot assisted suturing after myomectomy follows the principles of those of myomec-
tomy by laparotomy and traditional laparoscopy. The authors prefer delayed absor-
bable suture material (polydioxanone) for suturing the myometrium monofilament
which are easier to handle in robot-assisted surgery. They do not or rarely fray com-
pared to multifilament suture material. This is advantageous in view of the missing
tactility and haptics in robot-assisted surgery. Furthermore monofilament sutures can
be drawn across tissue almost without resistance. For suturing of the uterine cavity
suturing thread size of USP 3/0 is recommended, the strong myometrial sutures can
be done with polydioxanone USP 0. Interrupted sutures assure a good adaptation
and hemostasis, but running sutures are also practical (e.g., barbed running suture,
V-Loc) and permit a fast suture and hemostasis. This is much easier with the articu-
lated EndoWrist instruments compared to traditional laparoscopic suturing, espe-
cially in unfavorable locations (e.g., posterior uterine wall). For the superficial layer
running sutures are favored, e.g., barbed sutures, this can reduce exposure of knots
and suturing material and a running suture is quick to apply.
11.3.10Adhesion prophylaxis
Up to now there have been no specific recommendations for adhesion prophylaxis in

robot-assisted gynecological interventions, especially concerning myomectomy. Also
there is no evidence based data regarding the incidence and extent of adhesion after
robot-assisted myomectomy.
On the one hand, the assumption that robot-assisted surgery reduces forma-
tion of adhesions by improvement of suturing techniques and better reconstruction
of the uterine wall especially the superficial layers has been approved, on the other
hand, an enhanced wound area is expected as a result of the increase in complexity
of robot-assisted myomectomy due to the selection criteria of RALM. Thus, a specific
adhesion prophylaxis is recommended. The available data allow no preference con-

cerning one specific method of adhesion prophylaxis. Therefore there are fewer appro-
ved criteria for the use of robot-assisted interventions than endoscopic as regards
the wound area. In the case of localised, small-area wounds a membrane technique
is preferred (e.g., Seprafilm, Interceed, etc.), whereas in the case of extensive
uterine wounds (anterior and posterior uterine wall) methods of liquid adhesion pro-
phylaxis (e.g., SprayShield, Adept, etc.) are better.
11.3.11Intraabdominal asservation/storage of removed myomas
For a safe intraabdominal storage of removed myomas a reliable and simple system of
storage is advisable. The reasons are to avoid an unnoticed loss or leaving behind of
myomas in the abdomen, this can cause secondary complications (such as inflamm-
atory diseases, peritonitis), and to prevent the extension of OR time caused by
searching for dislodged myomas. Due to the established Trendelenburg position dis-
lodged myomas can drop into the upper abdomen or disappear under the omentum
or in to the mesenteric root area. This applies for traditional laparoscopic myomec-
tomy as well. But the risk of loss or dislocation of myomas increase with the number
of removed myomas, i.e., especially in complex myomectomy such as robot-assisted
myomectomy (in many cases involving the removal of 10 myomas). Furthermore,
a fast pivoting of the da Vinci camera in the docked status to look into the upper
abdomen in the case of a dislodged myoma may cause myomas to disappear quickly,
particularly in obese patients. The easiest storage is to deposit the myomas in an
endobag, or to thread them on a surgical suture. An additional counting check is
advisable in each case.
11.4Advantages of robotic assistance concerning

myomectomies
Essentially, the technical advantages of robot-assisted laparoscopic myomectomies

result from the improvement of visualization (i.e., stereoscopy und optical magnifi-
cation) and the suppleness of the extremely wristed instruments (with 7 of freedom)
which facilitate endoscopic suturing decisively even in difficult areas to access.
better presentation of the anatomic layers, especially in myomas with close local
and functional relation (uterine cavity, tubal ostia, uterine vessels, other intraliga-
mentary structures such as the ureters)
simplification of suturing, particularly with regard to required exstensive sutu-
ring improvement of reconstruction of the uterine wall (multilayer closure),
superiority of re-adaptation of the serosa
11.5Disadvantages and deficiencies of robotic assistance concerning myomectomy 143
potentially reduction of blood loss in consequence of simplification of myoma

dissection, more sufficient hemostasis by better identification of supplying
vessels during myomectomy
prevention of extensive use and reduction of necrosis of healthy myometrial
tissue due to selective application of electrosurgery
Here and elsewhere the advantages of the da Vinci system are cited (tremor elimina-
tion, fixed camera and camera autonomy of the surgeon, more ergonomic and less
exhausting work, even in multiple myomectomy) (Fig. 11.3).
11.5Disadvantages and deficiencies of robotic assistance

concerning myomectomy
The disadvantages of the da Vinci system in terms of robot-assisted myomectomy are

related to the lack of haptics (e.g., during dissection a blunt exposure of the myoma
is limited, furthermore locating the myoma could be complicated if the myoma is not
visible or identifiable by a protrusion), the partially insufficient grasping function
of the EndoWrist instruments, which could handicap the tightening of stitches
notably in dehiscent and wide open uterine wounds (it is a fine line between suffici-
ent adaptation and hemostasis and rupture of sutures) and the poor holding function
of the EndoWrist instruments to fix the uterus). In addition, the needle often pivots,
shifts or slips in the EndoWrist needle holders. To decrease this handicap an accu-
rate suturing technique is necessary, this means that the needle has to be clamped
orthogonal into the needle holder and to be penetrated exactly perpendicular into
the tissue.
Furthermore and as described elsewhere the common disadvantages of the
da Vinci system are also relevant for robot-assisted myomectomy [additional OR training,
increase of costs, prolongated OR times (equipment, setup, docking and undocking),
need for a trained and well-rehearsed team, risk of mechanical failure] (Fig. 11.4).
11.6Preoperative preparations/perioperative management
11.6.1Indications for robot-assisted myomectomy
The indication for robot-assisted myomectomy depends on particular symptoms,

the wish to become pregnant, the age of the patient and basically is based on accu-
rate patient selection (see Chapter 2); this in turn results from the organ specific
diagnostics, which have to show appropriate pathologies indicating the need for a
11.6Preoperative preparations/perioperative management 145
Fig. 11.3: a) Myomectomy close to the left fallopian tube; b) myomectomy close to the left fallopian
tube; c) presentation of multiple myomas close to the left fallopian tube; d) myoma resection at
the anterior uterine side; demonstration of the enhanced view; e) suturing directy next to the right
uterine artery (arrow); the intraligamentary myoma is already removed; f) myomectomy at the
posterior and inferior uterine wall; g) suturing the dorsal uterine incision with two needle holders;
h) suturing at the posterior inferior uterine wall; i) V-Loc suture at the anterior uterine wall;
j) V-Loc suture (no exposure of suture material, sero-serous adaptation)
Fig. 11.4: a) The needle is pivotable in the needle holder (reduced grasping power of the
instruments); b) deficient grasping power of the needle holders with gaping uterine wound,
hindered adaptation of the wound; c1) thread rupture, due to absent haptics (thread tension is
underestimated) intense strain with the needle holder; c2) thread rupture, due to absent haptics
(thread tension IS underestimated) immediately after thread rupture
complex and extensive surgical treatment on the one hand and the objective to do this
treatment in a minimally-invasive way on the other hand.
11.6.2Organ-specific diagnostics
The basis for the special preoperative organ-specific diagnostics is the transvaginal
and transabdominal ultrasound examination, which is easy to do, cheap and com-
monly available. The disadvantages are the poor reproducibility and the extremely
limited informative value of photo documentation. Therefore, a pelvic MRI should
be conducted without hesitation in the case of suspected complex myomas with
the intention of optimizing the OP scheduling and the determination of the surgical
strategy and to dispose of an intraoperative myoma mapping. In detail the following
reasons for a preoperative pelvic MRI have to be mentioned:
presence of multiple myomas
desired illustration of neighboring structures and organs, and the anatomic rela-
tion of the myomas to these structures
reliable mapping of the pelvic anatomy and preoperative correlation of the pelvic
tumor to the uterus (differential diagnosis, adnexal masses)
differential diagnosis to adenomyosis uteri which is a contraindication for myo-
mectomy with respect to organ preserving surgical treatment
improvement of intraoperative detection and localization of the myomas which
are intended to remove mainly small and deep intramural localized myomas;
(this is more relevant in robot-assisted surgery because of the lack of haptics)
The da Vinci SI sytem has outstanding facilities to integrate preoperative imaging,

furthermore, it provides the option to superimpose intraoperative, real-time ultra-
sound to the viewer (Fig. 11.5).
11.6.3Medicamentous pretreatment
In the context of scheduling a surgical myoma treatment the question if a medica-

mentous pretreatment would result in a simplification of the operation is frequently
asked. The answer is never standard and always is specific for each individual case.
The alternatives are medicamentous pretreatment (see Tab. 11.1) with GnRH agonists
and more recently the progesterone antagonist ulipristal acetate. Concerning GnRH
agonists a good effect on myoma size is described (up to 60% volume reduction), but
after discontinuation of the treatment a quick reversion to the previous size can be
expected. It is beneficial for a subsequent surgical treatment that the vascularization
of the myomas is diminished. Otherwise, a more difficult surgical exposition and diss-
ection of the myomas is needed, which can cause a higher blood loss. Furthermore
11.6Preoperative preparations/perioperative management 147
Fig. 11.5: a) MRI images; a 41-year-old patient with a wish to become pregnant. All detected myomas
in the MRI were removed (n = 15; with a weight of 611 g, skin-to-skin time 484 min); b) MRI images;
a 35-year-old patient with a 330 g atypical intraligamentary myoma on the right side; additionally
submucosal myoma (right image) which is detectable intraoperative much easier with the guidance
of the MRI pictures (T2 weighted images, transversal, frontal and sagittal); c) MRI images;
a 28-year-old patient with multiple myomas in two layers surrounding the uterine cavity, marginal
healthy myometrium; 10 removed myomas of an estimated 20; cessation of surgery due to severe
blood loss, requiring two erythrocyte concentrates; second surgery planned; d) MRI images;
a 38-year-old patient with 16 myomas mainly subserous, total weight 110 g, hemoglobine difference
3.1 g/dl, skin-to-skin time 444 min
the distinctive side effects of GnRH agonists have to be considered. A minor effect on
volume reduction is expected by the use of ulipristal acetate, but an achieved volume
reduction seems to persist after discontinuation of the medicament for a longer time
period. But there is also a risk of treatment failure, for which no predictive factors are
known.
In the case of multiple, smaller myomas a medicamentous pretreatment seems
not to be reasonable because intraoperative detection becomes more difficult or
impossible with the risk of remaining myomas which could cause a recurrence of
symptoms. A medicamentous pretreatment in the case of huge myomas may be reaso-
nable over a time period of 3 to 6 months. Concerning treatment with ulipristal acetate
long-term results remain to be seen. Thus, a medicamentous pretreatment is always
an individual case decision, both on the part of the patient and the surgeon:
in the case of desired delay or displacement of the surgical treatment (e.g., if blee-
ding disorders are the main complaints and the wish to become pregnant is cur-
rently not dominant) a medicamentous treatment is expedient
in women with the immediate desire to become pregnant frequently women >35
years, this is in line of the authors patient cohort no delay of the surgical treat-
ment (if indicated) by trials of medicamentous pretreatments with questionable
benefit should occur, because, effectively, the time for planning a pregnancy
could pass; against this background it is important that these patients frequently
suffer from coexistent factors which diminish fertility
A detailed discussion with the patient and her partner should is most important to
impart all the relevant information to them. Due to the more precise dissection of
uterine myomas in robot-assisted myomectomies and the potentially more selective
hemostasis during myoma dissection and myoma removal a medicamentous pretreat-
ment seems to have a secondary relevance. At present, however, there are no availa-
ble data, neither prospective nor retrospective.
11.6.4Preparation of the surgery
There exists no essential differences in preoperative preparations of patients desig-

nated for robot-assisted myomectomy compared to those who are planned for tradi-
tional laparoscopic myomectomy. Beside the routine laboratory diagnostics and the
obligatory pregnancy test the provision of blood should be considered in the case of
multiple myomas. The surgical sequence and operation scheduling should be clari-
fied if additional diagnostic and interventional hysteroscopy is planned, anesthesio-
logical and nursing staff should be instructed. The preoperative imaging should also
be reconsidered. In the case of a medicamentous pretreatment a pelvic MRI is neces-
sary before and after treatment. Within the scope of the anesthesiological preparation
contraindications for a prolonged and extended Trendelenburg position with respect
to a long-lasting capnoperitoneum should be excluded (e.g., severe cardiac insuffici-
ency, chronic heart failure, high-grade pulmonary emphysema, significant increase
of intracranial pressure, etc.). Cases of contraindications are very uncommon in the
usual patient cohort who are considered for myomectomy.
11.7Recommendations for further diagnostics and treatment 149
Informed consent before robot-assisted myomectomy should include the exten-

ded intraoperative monitoring with respect to the additional instrumentation [arterial
catheterization (improvement of blood pressure surveillance concerning hypovole-
mia due to hemorrhage and in case of accidental intravascular application of vaso-
constrictive agents during myomectomy), central venous catheter]. The sufficient
and anticipatory patient monitoring is very important in robot-assisted myomectomy
(as well as in all robot-assisted interventions) due to the reduced accessibility to the
patient after docking the patient side cart.
11.6.5Patient information and informed consent
The characteristics of patient information for robot-assisted myomectomies contain

information about the technique of robotic assistance, the indication for the number
of incisions and their position, especially in case of a large uterus which requires sup-
raumbilical placement of the camera trocar, and the allusion to the possibility of con-
version to traditional laparoscopy [e.g., in case of device defect (mechanical failure,
etc.)] and conversion to laparotomy (in case of minimally-invasive unforeseen com-
plications, mainly major bleeding). Regarding other complications adverse effects
concerning the intraoperative positioning should be emphasized (lengthended skin-
to-skin time implies a lengthened Trendelenburg position; e.g., risk of brachial ple-
xopathy). Other points of patient information depend on the other complications of
surgical treatment.
There is no difference in postoperative treatment and observation between tradi-
tional laparoscopic and robot-assisted myomectomy. Elements of postoperative treat-
ment and surveillance such as hospital stay, iron supplementation, wound drainage,
other diagnostics (transvaginal ultrasound, etc.) depend on duration and complexitiy
of surgery and hospital-specific algorithms.
11.7Recommendations for further diagnostics and treatment/

time interval to pregnancy/mode of delivery
Recommendation for further diagnostics and therapy after robot-assisted myomec-

tomy are dependent on the extent of the myomectomy, the course of the surgery,
localization of the removed myomas, or additional factors such as coexistent endo-
metriosis. Due to the expected cumulation of complexity of myomectomy by robot-
assisted surgery (as a result of selecting complex cases) the amount of associated
treatments could increase (postoperative implantation of an IUD in the case of
extensive intracavitary surgery, control hysteroscopies and laparoscopies inclu-
ding tubal patency testing or evaluation of the tubal patency by means of cont-
rast-enhanced ultrasound). Published data on this topic are not available. Also
recommendations for further treatments [e.g., treatment of endometriosis, assisted

reproductive techniques (ART), etc.] depends on the extent and complexity of the
myomectomy performed. Based on the patient selection criteria for robot-assisted
myomectomy, a higher incidence of associated treatments has also to be anticipated.
The recommendation for the interval between myomectomy and the attempt to
become pregnant lies between 3 and 6 months; but this is not based upon valid data.
Apart from the possible need for an after-treatment the dimension of myomectomy
plays a major role; this has to be decided individually, i.e., for every specific case. The
recommended mode of delivery behaves similarly, however, the advice to an elective
cesarean section will be given in the majority of cases in consequence of the fact that
in robot-assisted myomectomy frequently several, deep intramural myomas have been
removed and thus a considerable myometrial scarring is present. Indeed, the robot-
assisted suturing has to be considered as more effective but no prospective data are
available, concerning the question as to whether this has a significant impact on the
firmness and rigidity of the uterine wall during contractions and labor, or if a reduc-
tion of antepartual and intrapartual risk of uterine rupture results. Because of a high
number of cases needed to test the hypothesis that after robot-assisted myomectomy
the risk of uterine rupture will be significantly decreased valid data for this topic are not
expectable for the present.
At the very least, case series could identify preventive factors for a uterine rupture
after myomectomy (avoidance of excessive uterine scarring, multilayer uterine sutu-
ring, limited application of HF surgery; Parker 2010 [1] and others). Furthermore, due
to the fact that in the cohort of patients receiving a complex robot-assisted myomec-
tomy there is a high percentage of older primiparous women no one would take no
risks, particularly the rate of cesarean section is high in this cohort for several reasons.
In summary, significant differences between robot-assisted and traditional
laparoscopic myomectomy concerning pregnancy rate (also a high number of
cases needed), reduction of miscarriages, the mode of delivery, with respect to
recommendation for spontaneous delivery and the risk reduction of uterine rup-
tures have not as yet been elucidated. The evidence-based clarification of these
questions become increasingly difficult the more surgeons adopt robotic assis-
tance for complex myomectomy.
11.8Case studies
Case 1
A 43-year-old patient with hypermenorrhoea and menorrhagia, presented with the
desire to become pregnant; she had a 5-cm partially intramural, partially intracavitary
myoma in a transvaginal ultrasound (type II according to the classification of submuco-
sal myomas of the European Society of Hysteroscopy, ESH); an underwent an external
interventional hysteroscopy without success. The decision was made for a robot-assis-
ted myomectomy. The were no intraoperative or postoperative complications and there
has been no pregnancy to date (follow-up: 15 months) (Fig. 11.6).
11.8Case studies 151
Fig. 11.6: a) Presentation of an intracavitary myoma; b) luxation of the myoma from the uterine
cavity; c) demonstration of the opening of the uterine cavity; d) suturing of the uterine cavity
Case 2
A 35-year-old patient who wished to become pregnant presented with a 10-cm intra-
ligamentary and intramural myoma on the right side as well as a 2-cm intramural
myoma in the area of the uterine fundus (type II myoma according to EHS classifica-
tion); she had bleeding disorders and chronic pelvic pain syndrome, and compres-
sion of pelvic vessels on the right side. Robot-assisted myomectomy with removal of
both myomas, 330 g atypical myoma (without therapeutical implication) was prefer-
med with postoperative resolution of symptoms (Fig. 11.7).
Case 3
A 35-year-old patient with no wish to become pregnant presented with bleeding dis-
orders for the previous 15 years (hypermenorrhoea, menorrhagia), two miscarriages,
two interventional hysteroscopies with several submucosal myomas; multiple sub-
mucosal myomas illustrated by pelvic MRI and a hardly indentifiable uterine cavity
and further myoma of 5 cm at the junction of cervix and corpus uteri. Robot-assisted
myomectomy was carried out with a large opening of the uterine cavitiy and removal
of multiple (up to 10) nest-like arranged myomas; removal of the cervix myoma, post-
operative implantation of an IUD (for 3 months); with postoperative resolution of
symptoms; pregnancy after 15 months; delivery by elective cesarean section (36 weeks
of gestation) with suspect of placenta increta (pelvic MRI), consecutive cesarean hys-
terectomy due to placenta increta (histopathologic proved) and diffuse myomas. The
patient had an uncomplicated recovery (Fig. 11.8).
Fig. 11.7: a) The same patient as in Fig. 11.5b; presentation and removal of the submucosal myoma;
b) the same patient as in Fig. 11.5b; dissection of the polylobated, partially intramural , partially
intraligamentary myoma on the right side; c) the same patient as in Fig. 11.5b; closure of the uterine
wound first layer of suturing; d) the same patient as in Fig. 11.5b; closure of the uterine wound
second layer of suturing; e) the same patient as in Fig. 11.5b; closure of the uterine wound
superficial closure of the uterine incision
11.9Authors data of robot-assisted myomectomy
Between June 2008 and September 2012 the authors performed 65 robot-assisted
myomectomies. The mean age of the patients was at the time of surgery was 36.5
years (2348), only 21.5% of these women already has one to three children; 23.1%
11.9Authors data of robot-assisted myomectomy 153
Fig. 11.8: a) Preoperative pelvic MRI shows a nearly completely filled uterine cavity; scattering of
endometrial parts; b) intraoperative image with large-area opened uterine cavity (the tip of the
Hulka tenaculum for uterine manipulation is protruding out of the uterine cavity); c) corpus uteri
after completion of the uterine reconstruction; d) abdominal MRI with 30 weeks of gestation (there
are still myomas in the lower corpus uteri and in the cervix; the arrow highlights the membraneous
uterine scar)
had miscarriages in the patient history; on average 4.3 myomas had been removed
(118), the mean weight of the removed myomas totalled 154.5 g (4611), in nine
cases (respectively, 13.8%) the uterine cavity was opened during myomectomy. The
mean skin-to-skin time accounts for 219 min (82484). In one case an intraoperative
blood transfusion was done because of severe bleeding from the myoma bed (patient
with multiple myomas). In another case a conversion to traditional laparoscopy was
necessary due to a mechanical defect of the da Vinci system, where a conversion
to laparotomy was carried out. The mean hemoglobin difference (preoperative vs.
postoperative) was 1.5 g/dl (0.7 to 6.6). About a quarter of the patients (23%) have
delivered or are still pregnant in the observation period. The portion of cesarean sec-
tions was 83% [n = 10 (of 12)] given an nationwide rate of cesarean sections of ca.
35%. In more than 90% the existing myoma symptoms (bleeding disorders, pelvic
pain, etc.) resolved (Fig. 11.9).
(a) (b)
Patient characteristics and clinical data (I) Patientin characteristics and clinical data (II)
Number of patients n = 65 (06/200809/2012) Postoperative hospital stay [days] 4.92 (29)
Mean age 36.5 years (2348) Conversion to traditional laparoscopy 1.5%
Patients with children 21.5% Conversion to laparotomy 0
Patients with miscarriages 23.1% Blood transfusion 1 (1.5%)
Pts with 2 miscarriages 6.6% Other complications (brachial plexus

1 (1.5%)
lesion [temporary])
Mean number of removed myomas 4.4
1 myoma 31.1%
2 myomas 68.9%
Opening of the uterine cavity 13.8%
Mean difference of hemoglobin 1.5 g/dl (0.7 6.6)
Mean myoma weight 154.5 g (4611)
(c) 25
22 (d) 15
12.4
19 20
20 10.9
Hemoglobine [g/dl] 10
15
10
5
0 0
1 24 5 preop. postop.
350
(e) 2.5
2.2
(f) skin-to-skin time [min]
306 weight of myomas [g] 296.3
2.0 263
Hemoglobine [g/dl]
219
1.5 177.6 169
175
1.1 141
1.0 131
88
0.5
44
0 0
14 5 14 5
(g) 500 (h) 500
400 400
300 300
[min] [min]
200 200
100 100
0 0
0 5 10 15 20 0 175 350 525 700
[n myomas] [g]
Fig. 11.9: a) Authors data clinical characteristics; b) authors data clinical characteristics
c) number of removed myomas (y-axis: number of patients); d) mean hemoglobine difference
(preoperative vs. postoperative); e) mean hemoglobine difference preoperative vs. postoperative
(as a function of number of removed myomas); f) skin-to-skin time and myoma weight (dependent
on the number of the removed myomas); g) skin-to-skin time as a function of the number of removed
myomas; h) skin-to-skin time as a function of the myoma weight [9]
11.10Available data from robot-assisted myomectomies/existing evidence 155
11.10Available data from robot-assisted myomectomies/

existing evidence
Since 2007 there are only a few publications on robot-assisted laparoscopic myomec-
tomy with a large number of cases. Before 2007 only feasibility studies were publis-
hed. Thereafter, the most studies depict small case series, and show the feasibility of
robot-assisted myomectomy or particular aspects of this kind of myoma treatment.
Some important studies are indicated below.
Advincula (2007) [2] analyses in a retrospective case-matched study 29 robot-
assisted myomectomies vs. 29 cases with traditional laparotomy. As expected, a sig-
nificant reduction of the length of hospital stay (1.48 vs. 3.62 days) for robot-assisted
interventions, and a significant decreased blood loss as well (228.55 vs. 364.66 ml)
could be demonstrated. On the other hand, there has been a significant increase of
operation time for the da Vinci myomectomies (231.38 vs. 154.41 min). In the cohort
of traditional laparotomy a clear elevated incidence of postoperative complications
occured. In one patient in the robotic group an intraoperative cardiogenic shock as a
side effect of vasopressin application was seen. Advincula concludes that the advan-
tages concerning blood loss, length of stay and complication rate and the subsequent
societal benefits outweigh the upfront higher costs resulting from robot-assisted
myomectomy. Barakt (2011) [3] arrives at the same results and conclusions with a
higher number of cases. He suggests that the robotic technology may improve and
increase the use of MIS in the treatment of symptomatic myomas.
Nezhat (2009) [4] compares in a retrospective matched-control study robot-assisted
laparoscopic myomectomies (n = 15, RALM) with a matched pair control-group of
traditional laparoscopic myomectomy (n = 35). He shows that RALM compared to tra-
ditional laparoscopy has a significant longer operative time, whereas the amount of
blood loss and length of hospital stay are not different in both groups. Subsequently,
he concludes that RALM offers no relevant advantages for the trained and skilled
laparoscopic surgeon, but the technology of robotic surgery would provide exciting
potential applications while learning endoscopic surgery.
Bedient (2009) [5] compares in a retrospective chart review robot-assisted (n = 40)
and traditional laparoscopic (n = 41) myomectomies, as well. The study shows data
from myoma characteristics (localization, number of myomas, weight, pathologic fin-
dings) plus operative time, blood loss, complications and lenght of hospital stay. In
the group of traditional laparoscopy there are significantly larger uteruses, a signifi-
cantly elevated myoma size in respective of the largest myoma and a higher number
of removed myomas. When adjusted for uterine size and fibroid size and number, no
significant differences were noted between robotic vs. laparoscopic groups (concer-
ning mean operating time, mean blood loss, intraoperative or postoperative compli-
cations, hospital stay more of than 2 days, readmissions, and symptom resolution).
Long-term results have not been analyzed. As such, no advantages for robot-assisted
myomectomy could be identified. However, the primary selection criteria could be
held responsible for these results. Moreover, the cases have been recruited over a very
long time period from 2000 to 2008, this means partially in a period in which robotic
surgery recently started and in which robotic myomectomy was in the learning stage.
Thus, there may be a bias in this analysis.
Nash (2012) [6] compares the clinical outcome and the effectiveness between
robot-assisted laparoscopic myomectomy (n = 27) and abdominal myomectomy
(n = 106). Here, he stratifies groups of different uterine size (<12 weeks, 1216 weeks,
>16 weeks) and illustrates that patients with RALM have a significant decrease in post-
operative need of analgesics (IV hydromorphone) and length of hospital stay. But no
significant differences concerning blood loss can be demonstrated. Furthermore, he
reveals for RALM that the bigger a uterus size with respect to the removed myomas the
longer the operating time, and the lower the efficiency [represented as operating time
(min) per gramme removed myoma tissue] (Fig. 11.10).
Loennerfors (2011) [7] investigated in a prospective observational study the ferti-
lity after robot-assisted laparoscopic myomectomy of deep intramural myomas. The
follow-up of 31 patients (14 with known infertility) is shown. The target criterion of
the observation is the fertility and pregancy outcome after myomectomy. Fifteen of
22 (68%) of patients with an urgent desire to become pregnant became pregnant in a
median time of 10 months after surgery. A total of 18 pregnancies occured, resulting
in three miscarriages, two terminated pregnancies, 10 successful term deliveries (rate
of cesarean section: 50%) and three ongoing pregnancies at the time of reporting.
500 Abdominal
Robot
Abdominal
Minutes of Operating Room Time
400 Robot
300
200
100
0
.0 500.0 1000.0 1500.0 2000.0 2500.0 3000.0
Grams of Specimen Removed
Fig. 11.10: Trends in minutes of operating room time per specimen for abdominal vs. robot-assisted
laparoscopic myomectomy (Nash K, et al [6] Arch Gynecol Obstet 2012)
11.11Summary and conclusion 157
The subgroup of 14 women with known but otherwise unexplained infertility had a
pregnancy rate of 69% and of those, 55% conceived naturally. These results are com-
parable to these which have been reported from traditional laparoscopic myomecto-
mies and abdominal myomectomies.
In a multicenter (three center) retrospective analysis from Pitter (2013) [8] the
pregnancy rate and pregnancy outcome are reported in 872 women who received
a robot-assisted laparoscopic myomectomy (October 2005November 2010). One
hundred and twenty-seven pregnancies and 92 deliveries have been investigated.
The mean age of patients at the time of surgery was 34.8 years, in 20.6% of cases the
uterine cavity was opened. In this study the median time after surgery to conception
was 12.9 months, in 39.4% an assisted reproduction technique has been effected. A
multivariate regression analysis showed that a significantly higher preterm delivery
rate was associated with a higher amount of removed myomas and the anterior loca-
lization of the largest uterine incision (P = 0.01). The rate of cesarean section was
95.7 in this study. A similar conclusion as in the mentionned study before has shown
that pregnancy rate and pregnancy outcome are comparable to these after traditio-
nal laparoscopic.
In summary, the conclusion that no prospective randomized trials to prove the
superiority of robot-assisted myomectomy are available is needed. Furthermore
there are only a small number of studies analyzing the resolution of symptoms
intermediate-term or long-term after RALM. Two retrospective studies engage in the
investigation of pregnancy and pregnancy outcome after RALM. They have shown
at least that the results after RALM are equivalent to these after abdominal and tra-
ditional laparoscopic myomectomies.
11.11Summary and conclusion
The technique of robotic assistance is very suitable for complex myomectomy, espe-
cially in cases with unfavorable myoma localization, in patients with multiple myomas
and with large and deep intramural myomas which require extensive and otherwise
very exhaustive and fatiguing suturing of the uterine wall. The three-dimensional view
and the enormous versatility of the robot-assisted instruments offer major advanta-
ges compared to traditional laparoscopy. Economic aspects and the question of the
provable advantages over traditional laparoscopy concerning symptom reduction
and resolution and pregnancy specific parameters (pregnancy rate, mode of delivery,
etc.) are still unresolved. Due to the assumption that this questions could never be
answered on the basis of prospective randomized trials, the improvement and advan-
cement of endoscopic feasibility and perioperative outcomes and the simplification
of the surgical intervention resulting in a maximum of minimal invasive conducted
proportion of myomectomies are essential in judging the method of robot-assisted
myomectomy.
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12 Endometriosis: robotic-assisted laparoscopic
surgical approaches
Chandhana Paka and Camran Nezhat
12.1Introduction
The robotic platform entered the surgical playing field more than 20 years ago, and the
introduction of the commercially available da Vinci robotic system (Intuitive Surgical
Inc, Sunnyvale, CA, USA) in the early 2000s was followed by a rapid application of this
computer-assisted technology. Advocates of this platform revere the systems ergonomic
positioning, three-dimensional surgical view allowing for depth perception, wristed ins-
trumentation, motion scaling and 7 of freedom mimicking open surgery [1, 2]. Further-
more, it boasts a shorter learning curve, thus enabling surgeons to complete complex
surgical procedures formerly performed by laparotomy [37]. However, this technology
is not without limitations, including lack of haptic feedback requiring the surgeon to
utilize visual cues, limited instruments and higher costs [8]. Despite these limitations,
robot-assisted laparoscopy has made surgeries, which are challenging via traditional
laparoscopy, more easily performed in a minimally-invasive way [7, 9]. This platform is
a reliable and durable way to be precise in surgical dissection and reconstruction, ena-
bling surgeons to bridge the gap between laparotomy and laparoscopy [10, 11].
12.2Application to endometriosis
Endometriosis is an estrogen-dependent chronic inflammatory condition affecting

6 to 10% of reproductive-aged women [12, 13]. It is the leading cause of pain and infer-
tility in women [14]. Endometriosis is characterized by the presence of endometrial-
like tissue outside the uterine cavity. Three clinically distinct forms exist: peritoneal
endometriosis, ovarian endometriosis and extragenital endometriosis [13, 15]. Al-
though endometriosis was described as early as 1690 by Shroen, a German physician,
[16, 17] and a year later, Ruysch, a Dutch anatomist, proposed an early version of ret-
rograde menstruation, [16, 17] its pathogenesis remains elusive.
The progress of this clinical enigma can be moderated by the use of hormonal
therapy. Medical management, used to suppress symptoms, includes non-steroidal
anti-inflammatory drugs, oral contraceptives, antigestogens and GnRH agonists.
However, this intervention is not desired in those seeking fertility, and the rate of
recurrence is high after discontinuation [1822]. Laparoscopy is the gold standard
for definitive diagnosis and surgical treatment of endometriosis. Numerous studies
support the use of laparoscopy in order to ameliorate pain and enhance fertility [2327].
Laparoscopy offers many advantages over conventional laparotomy; namely a
162 12 Endometriosis: robotic-assisted laparoscopic surgical approaches
magnified view of the pelvis and greater exposure that allows for close examination
and visualization of endometriotic implants. Larger implants or deep endometriotic
nodules are best treated with resection. Surgical excision of all endometriosis has
been proven to be the most effective method for symptom relief and prevention of
recurrence [24, 28, 29]. Advanced laparoscopic techniques have replaced laparotomy
as the mode of choice [24, 30, 31]. However, severe cases of endometriosis are dif-
ficult and can pose a surgical challenge, resulting in either incomplete treatment via
laparoscopy or the need for conversion into a laparotomy. During a surgery for endo-
metriosis, after initial evaluation of the abdomen and pelvis with a laparoscope, more
complex and challenging cases may lend themselves to the robotic platform, facilita-
ting the continued use of a minimally-invasive route of treatment without compromise.
12.3Surgical approach
Surgical intervention of endometriosis has evolved from indiscriminate use of hyste-

rectomy and bilateral salpingo-oophorectomy to more precise and directed excision
of all endometriotic implants and restoration of normal anatomy. For application of
the robotic platform to the treatment of endometriosis steps are taken to maximize
treatment potential with use of both laparoscopy and the robot to effectively address
all aspects of endometriosis.
Initially, the surgeon explores the pelvic cavity to assess the extent of disease and
identify abnormalities or distortions of the pelvic organs. The location and bounda-
ries of the bladder, ureter, colon, rectum, pelvic gutters, uterosacral ligaments and
major blood vessels are noted. The upper abdominal organs, abdominal walls, liver
and diaphragm should be evaluated for endometriosis or any other condition that
may contribute to the patients symptoms. The omentum and the small bowel are
evaluated for disease and to ensure that they were not injured during insertion of the
Veress needle or trocar. A rectovaginal examination is performed to evaluate deep and
retroperitoneal endometriosis found in the lower pelvis in the rectovaginal septum,
uterosacral ligament, descending colon and pararectal area. Deep retroperitoneal
endometriosis is rare without a connection to the surface peritoneum. In 15% of pati-
ents with endometriosis, the appendix is involved and thus should be examined [32].
With the forceps or probe, endometriotic implants are examined to gauge size, depth
and proximity to normal pelvic structures. A surgical plan is constructed to optimally
restore normal anatomy and excise all areas of endometriosis. The robot currently
has limited instrumentation for surgical stapling or sealing and cutting. Additionally,
many general laparoscopic procedures require movement in many quadrants around
the abdomen, which can also be difficult for the robot.
Once the initial survey is complete, the robot is docked using only three arms.
The assist port, which is either suprapubic or left upper quadrant, allows the bedside
assist to aid with retraction or with a suction-irrigator as needed. It is important to
12.4Lysis of adhesions 163
remember that robotic surgeons need to evolve their procedures because a standard
robotic approach does not yet exist [33]. Therefore traditional laparoscopic techniques
are applied to robotic surgery. Limited instrumentation is available in the robotic
platform that include; cautery hook, scissors and bipolar coagulation. All of which
allow for cauterization and resection of endometriotic implants [8]. We tend to use an
atraumatic grasping forceps in the left robotic arm and either a monopolar hook or
cold scissors in the right robotic arm.
12.4Lysis of adhesions
Adhesions vary in bulk, vascularity and extent of resultant anatomic distortion. The
methods used to restore normal anatomy and remove adhesions are determined by
type of adhesions encountered. Filmy adhesions can be separated by blunt dissection.
While more dense adhesions require electrosurgery at points of attachment to pelvic
organs. This can be accomplished by use of the monopolar hook and the atraumatic
grasping forceps. Structures requiring separation are teased apart via a cleavage plane.
Hydrodissection is useful to help create such planes. A safe area is sought, a small inci-
sion is made with a scissors or electrocautery and the suction-irrigator is brought into
the surgical field from the assist port. Care must be taken with electrosurgery near the
bowel, bladder and vessels. If concern exists as to proximity to such organs or thermal
spread, then the cold scissors is employed.
12.5Peritoneal and tubo-ovarian endometriosis
As mentioned previously, the main goal of surgical intervention in endometrio-

sis is restoration of anatomy and removal of all endometriotic implants, with the
hope of alleviating pain and in some cases improving fertility. Peritoneal implants
can be ablated or excised, depending on surgeon preference. Evidence does not
show superiority in pain relief when comparing excision versus ablation [34, 35].
When excision of implants is the technique employed, the atraumatic forceps is used
to elevate and tent the peritoneum towards the midline. The monopolar hook or the
cold scissors is then used to undermine and shave away the endometriotic implant.
This is done in a progressive manner until the implant is excised with visually clear
margins, and the underlying tissue appears healthy and not fibrotic. The decision of
whether to use the energy is based on proximity to bowel, ureters and vessels. If the
implant appears superficial and relatively small, the monopolar hook can be applied
directly to the implant.
For ovarian pathology, namely for endometriomas, it has been well established that
recurrence is less likely with complete excision versus drainage and ablation [3638].
Further caution is also taken with the use of energy on the ovary, as there is potential
for damage to normal surrounding ovarian tissue, though this is also possible with
excision alone [39]. Ideally, removal of an ovarian cyst involves removal of an intact
cyst wall with limited trauma to normal ovarian tissue. However, endometriomas
can be difficult to remove, and many cysts are ruptured even with delicate manipu-
lation. If necessary, controlled drainage of the cyst can be performed with a small
incision made into the ovary with a cold scissors or a puncture with the monopo-
lar hook. This incision should be made large enough to then allow for the suction-
irrigator to aspirate and irrigate the contents. The suction-irrigator is brought to the
level of the cyst by the bedside assist via the assist port. Once the cyst is irrigated,
the incision is made larger with the aid of scissors to allow for examination of the
internal surface. The cyst wall and the ovarian cortex are then identified. If there
is need for further delineation of planes, hydrodissection can occur with the assis-
tance of the bedside assist. Once this is accomplished, the cyst wall is grasped with
the nontraumatic forceps and the cortex is stabilized with the scissors. With the
use of traction and countertraction, the cyst wall is stripped away from the ovarian
cortex. If the cyst wall does not come away easily, the scissors can be used to dissect
the cyst away from the ovary. Hemostasis is then obtained with the use of either
monopolar or bipolar energy. Additionally, as the robotic platform makes sutu-
ring easier, bleeding can be controlled with suture. A needle driver is placed in the
surgeons dominant hand, and the needle is brought into the operating field via the
assist port.
12.6Intestinal endometriosis
The gastrointestinal tract is involved in endometriosis in up to 37% of patients with

pelvic endometriosis [40, 41]. However, in specialized practices, this may be an unde-
restimate. Endometriotic implants can be found anywhere between the small intes-
tine to the anal canal, and the clinical manifestations can range from asymptomatic
lesions to obstruction [42]. The most frequently involved site for endometriosis is the
rectosigmoid, accounting for 7088% of all cases. This is followed by the sigmoid
colon, rectum, appendix and cecum [15, 32, 43, 44].
Surgical intervention of intestinal endometriosis remains debatable [45]. In the
absence of bowel obstruction or other emergent presentation, the optimal timing
of surgery and extent of intervention has not been determined. Various minimally-
invasive surgical (MIS) techniques are currently available for treatment. Determining
which approach to use is based on the extent, location and expertise of the surgical
team. Less invasive approaches, as long as there is complete excision and adequate
margins, are often the preferable option [46]. The use of the robotic platform has allowed
for difficult surgical procedures to be attempted in a minimally-invasive approach. As
diathermy excision should be used with caution as thermal damage to the bowel may
result in a delayed postoperative fistula or other complications, it is used sparingly [45].
12.6Intestinal endometriosis 165
Use of hydrodissection can help delineate planes, thus allowing for less damage to
underlying normal tissue.
Superficial endometriotic implants can be shaved off the rectal wall, while main-
taining the integrity of the mucosa [47]. The rectum is first mobilized by freeing the
anterior and the lateral aspects of peritoneal attachments. This allows for access to
the extraperitoneal rectovaginal septum. With the use of the atraumatic grasping
forceps and the cold scissors, the implant is dissected off the anterior rectal wall,
separating it from the posterior vaginal wall. Care is taken to maintain bowel integ-
rity, and therefore the dissection is kept superficial. If the dissection requires deeper
resection in order to remove the implant in its entirety, then the defect is reinforced
with the use of sutures in order to prevent postoperative bowel perforation [48]. Upon
completion, to ensure integrity, a proctoscopy should be performed [4951].
For endometriotic implants that are deeper, a full thickness excision may be
required. As before, the rectum must be mobilized. The excision can be performed
using the electrocautery hook or an instrument like the PlasmaJet that is brought into
the field via the bedside assist. The bowel is then repaired with suture. The repair is
made in a transverse plane so as to prevent narrowing and potential stricture forma-
tion of the lumen [48, 51].
In a procedure performed for endometriosis the appendix must be carefully
assessed. It can be involved up to 22% of cases. The appendix can be easily assessed
and resected. The periappendiceal fat can be dessicated with thermal energy, ensu-
ring that the appendiceal artery is ligated. The resection of the appendix can be easily
performed then using endoloop device or by undocking the robot and using a endo-
scopic linear stapling device brought in from the umbilical port. Our practice has
been to resect the appendix early in the surgical procedure so as to then be able to
evaluate it again at the completion of the procedure [32, 52].
Because the sigmoid colon is the most commonly involved segment of the bowel,
it is more likely to be extensively involved and thus require a resection. A laparoscopi-
cally assisted resection of the involved segment with primary colorectal anastomosis
is the procedure of choice. However, due to technical difficulty, the application of the
laparoscopic approach has been slow. With the aid of the robot, this technically chal-
lenging approach can be attempted. The patient must be positioned in steep Trende-
lenburg position with a right tilt to allow for optimal visualization of the attachments
of the mesosigmoid colon to the retroperitoneum. The medial aspect of the perito-
neum overlying the mesosigmoid is opened up from the sacral promontory up to the
origin of the left colic artery. This dissection can be done more precisely with the use
of the robotic platform. During this process, care should be taken to avoid injury to
the ureter and gonadal vessels. The superior rectal artery is divided proximal to the
sigmoidal artery. This is secured with hemostatic clips, a thermal energy device or a
vascular stapler. These instruments are brought in via the accessory port as needed.
For such cases, the accessory port must be in the upper quadrant to allow for appro-
priate triangulation. The descending colon is then mobilized up to the splenic flexure
to provide a tension-free anastomosis. The robot is undocked because no commer-

cially available stapling device is available. The mesorectum is divided at the desired
level and the rectosigmoid junction is transected using a laparoscopic linear stapling
device through a 12-mm port. A specimen is extracted via extension of an incision
or via the vaginal cuff if a hysterectomy is being performed. The anvil of the circular
stapling device is secured with a purse-string suture extracorporeally at the proximal
open end of the bowel. Subsequently, a transanal circular stapling device is used to
perform the anastomosis. An air leak test and sigmoidoscopy used to ensure an intact
anastomosis. If there is any evidence of a leak, a reanastomosis versus additional
sutures must be made. Additionally, it is vital to ensure that both ends of the bowel
are vascularized, and the anastomosis is tension-free [51, 53].
The approach is similar for a low anterior resection as with a sigmoidectomy.
However, this procedure requires that the pelvic peritoneum is opened, the lateral
ligaments ligated and the anastomosis to occur below these. The rectum is thus
mobilized far inferiorly as to allow for complete resection of diseased tissue. When
mobilization occurs distal to the levator ani, dissection is carried out in the avascular
planes of the rectum and mesorectum. This can be done easily with the aid of the
robotic platform. Once the dissection is complete, the robot is undocked so that the
rectum can be transected transversely with an articulating linear stapler [51, 54].
When the ascending colon or the small bowel is involved, mobilization of the
small bowel mesentery and attachments of the right colon must be addressed. This
mobilization occurs from a medial to lateral fashion retroperitoneally in both blunt
and sharp fashion using the atraumatic grasping forceps and the cold scissors. With
the use of the robot, the surgeon is enabled more precise dissection. The robot is once
again undocked for creation of a side-to-side functional end-to-end stapled anasto-
mosis with an endo-linear stapling device [51].
12.7Genitourinary endometriosis
Pelvic endometriosis can infrequently involve the urinary tract system in approxi-
mately 1% of cases [55]. The bladder is the most commonly involved and the urethra
the least.
Bladder endometriosis can be intrinsic or extrinsic. Intrinsic disease involves the
detrusor muscle and is commonly associated with iatrogenic implantation [56, 57].
Extrinsic disease, which is more common, refers to disease involving the serosa or
peritoneal surface [58]. Treatment of bladder endometriosis is aimed at symptoma-
tic relief, as often it does not involve the ureteral openings. Medical management
is effective, but often disease recurs with discontinuation of continuous oral con-
traceptive pills or GnRH agonists [59, 60]. The surgical intervention that appears
to allow for complete removal of disease is a combination approach of cystoscopy
and laparoscopy [6164]. Intrinsic bladder disease is transmural and thus complete
12.7Genitourinary endometriosis 167
transurethral resection may lead to perforation of the bladder. Therefore the use of
the laparoscope can aid in visualization, as well as repair. In this combined approach
a partial bladder cystectomy should be considered the treatment of choice for bladder
lesions and surrounding disease and inflammation [58]. The surgical technique for
such cases all start with a cystoscopy at start of procedure, during which time bila-
teral ureteral stents are placed. This allows for easy recognition of the ureteral orifi-
ces, as well as easier identification in the pelvis. This also allows for a surgical plan to
be mapped out. In some instances, a total transurethral approach can be performed.
However, for intrinsic disease the risk of perforation during procedure or incomplete
excision warrants simultaneous visualization from above [58, 65]. Once the examina-
tion from above is complete, the robot is brought in via side docking or parallel docking
to allow for easier access to the perineal area. A atraumatic grasping forceps is placed
in the left robotic arm and the monopolar scissors in the right. The bladder is identified
and careful dissection is carried out to separate the uterus and cervix away [66]. Once
this is accomplished, a cystoscopy is performed. In this way, the bladder cystotomy can
be performed under visualization, allowing for visually clear margins and assurance
of integrity of the ureteral orifices. The cystoscope is then withdrawn and the defect is
repaired intracorporeally. A watertight seal is confirmed with the cystoscope.
Ureteral endometriosis is a serious localization of disease burden. Asymmetric
involvement of endometriosis, with the left pelvis more commonly involved than the
right, is readily explained by anatomic differences of the pelvis [67]. The distal segment
of the ureters and bladder are the more frequently involved locations, due to the proxi-
mity of the reproductive organs [68]. Additionally, ureteral endometriosis is more likely
to be associated with rectosigmoid lesions as opposed to bladder involvement [69].
Two major pathological types exist: extrinsic and intrinsic ureteral endometriosis.
In the extrinsic type, which is the most common, endometrial glandular and stromal
tissue involve only the adventitia of the ureter or surrounding connective tissues. The
intrinsic type involves the muscularis propria, lamina propria or ureteral lumen [70].
Surgical interventions for relief of obstructive uropathy include: ureterolysis, ure-
teroureterostomy, distal ureterectomy and ureteral reimplantation or interposition
of ileal segment between the ureter and bladder [58, 60]. Nephroureterectomy is a
successful treatment alternative in refractory cases. Additionally, this is performed
if there are recurrent urinary tract infections or persistent flank pain. The robotic
platform is ideal for the careful dissection and potential suturing that is required for
ureteral manipulation and implantation. All surgical approaches begin with identi-
fication of the ureter. Ureterolysis is carried out starting proximal to diseased area,
at a level of healthy tissue, unaffected by endometriosis. Careful dissection proceeds
down to the level of damage. This is done using the atraumatic graspers and scissors.
Care should be taken with use of thermal energy near the ureter. Techniques such
as hydrodissection with the the suction-irrigator brought in from the assist port by
the bedside assist greatly facilliates. Based on the extent and localization of disease,
the decision is made whether ureterolysis will be adequate to relieve obstruction.
Ureterolysis is often acceptable in cases of extrinsic, nonobstructive disease [58, 60,

7173]. If stenosis is evident but limited to the ovarian fossa and distal ureter can be
preserved, then ureteral resection and end-to-end anastomosis can be performed over
a ureteral stent [58, 60, 64, 7375]. Surgical approach is changed if the ureteral steno-
sis is close to the vesicoureteral junction and is extensive. The ureter is resected before
the area of disease, and the proximal end is reimplanted into the bladder [58, 60,
71, 73, 76, 77].
12.8Diaphragmatic and thoracic endometriosis
Thoracic endometriosis is a rare disorder characterized by the presence of functioning

endometrial tissue in pleura, lung parenchyma, airways, and/or diaphragm. The
diagnosis of thoracic endometriosis syndrome (TES) has improved substantially
over the past two decades because of advances in video endoscopic techniques as
developed by Nezhat [78, 79] [video-assisted thoracoscopic surgery (VATS) as well as
laparoscopy] a higher level of clinical suspicion.
VATS is currently the gold standard for the surgical treatment of TES, especially
catamenial pneumothorax. Laparoscopy aids in the surgical treatment of implants
on the abdominal aspect of the diaphragm. VATS provides magnification and expo-
sure of possible defects that are sometimes better than that provided by thoraco-
tomy. Misdiagnosis may occur, especially if the patient is positioned for an axillary
thoracotomy, as complete visualization of diaphragm is difficult. A better approach
seems to be a VATS with the patient positioned for a postero-lateral thoracotomy.
When endometriotic implants are the sole findings during VATS and are superficial,
they can be carefully fulgurated using bipolar diathermy or CO2 laser, regardless of their
location (i.e., parietal, visceral, or diaphragmatic pleura). Larger endometriotic implants
of the visceral pleura may be excised using sharp dissection [80]. Nonetheless, large
lesions or deep parenchymal endometriotic nodules are best treated with parenchymal-
sparing procedures such as wedge resection [81] or subsegmentectomy [82]. Occasio-
nally, lobectomy may be required [83].
Diaphragmatic lesions (endometriotic implants or perforations) are probably
best treated by resection using endoscopic stapler devices, provided that the resec-
ted surface is relatively small [81, 84]. Laparoscopic treatment of diagphragmatic
endometriosis was first described Nezhat in 1992 [51]. Larger diaphragmatic perfo-
rations can be sutured, although significant recurrences have been reported with
the use of sutures [85]. The use of mesh to replace large diaphragmatic excisions
has been described in three women who at 45 months follow-up suffered no recur-
rences [86]. Although other authors have not confirmed these results [87]. Because
the robot has limited mobility and movement in to the upper quadrants is limited,
a thorough evaluation must be made at the initial survey of the abdomen prior to
docking the robot.
12.9Hepatic endometriosis 169
If the abdominal aspect of the diaphragm is involved with endometriotic

implants, an experienced team of gynecologic and thoracic surgeons can fulgurate
or excise small lesions. Hydrodissection, laser fulguration, or excision can be carried
out successfully [88]. However, if larger implants or defects are present, they should
be approached via VATS, as the liver bulk and limited subdiaphragmatic space may
not allow complete resection [89].
A multidisciplinary approach of VATS and laparoscopy, optimally addressing
pelvis, thoracic cavity and subdiaphragmatic region in a single operation and is
gaining momentum [90]. Unfortunately, until the robotic platform is able to move
freely in the upper abdomen, this aspect of endometrioisis surgery will remain with
laparoscopy.
12.9Hepatic endometriosis
Hepatic endometriosis is exceedingly rare and poses a diagnostic challenge. It can

present with right upper quadrant pain or be incidentally diagnosed. Nezhat et al
published their experience with laparoscopic treatment of hepatic endometriosis
in 2005 [91]. In a majority of cases that have been published, the patients had a
history of pelvic endometriosis, but preoperative symptoms and clinical findings
were inconsistent [92102]. As preoperative diagnosis of hepatic endometriosis is
if often difficult, laparoscopy offers an excellent opportunity to explore the upper
abdomen compared to a laparotomy [103]. Regardless of indication for surgery,
thorough inspection of the entire abdominal cavity should be undertaken. If an
extra-hepatic lesion is noted, a biopsy is taken and sent for frozen section. If this
confirms endometriosis, the cyst is stabilized with a grasping forceps and excised.
Once it is removed entirely, the hemostasis is ensured with use of electrocautery or
a hemostatic agent.
12.10Conclusion
The robotic platform has enabled and enhanced surgeons ability to perform MIS. Used
appropriately, in trained hands, it may improves patient care. Areas of improvement
presently being developed include systems with improved tactile feedback, multi-
functioning instruments and robotic miniaturization. New instrumentation, such as
robotically controlled stapling devices, will push the adoption even further. As with
any new technology, time and experience will dictate how this platform will integrate
into the surgical playing field.
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13 Robotic-assisted tubal reanastomosis
Ahmet Gmen and Fatih anlkan
13.1Introduction
The most widely used contraceptive method in the world is currently tubal ligation
and more than 153 million women of reproductive age have chosen sterilization as
their contraceptive method [1, 2]. As of June 2010, a recent decline of tubal ligation
procedures in the United States after two decades of stable rates was observed due to
an improved access to a wide range of highly effective reversible contraceptives [3].
A change in family circumstances such as the death of a child, improved econo-
mic situation, a change in marital status and desire of having more children are the
reasons for request of fertility restoration and 1%5% of the patients will request
sterilization reversal [4]. The women who are sterilized at a younger age have a univer-
sal risk indicator for tubal reversal due to longer period in which women can become
regretful. It has been estimated that women sterilized before age 25 years are 18 times
more likely to request reversal over the course of follow-up than women older than
30 years at the time of sterilization [5].
Tubal reversal and in vitro fertilization (IVF) are the options for the patients who
desire fertility after tubal ligation. Tubal reversal, also called tubal sterilization rever-
sal or tubal ligation reversal, is a surgical procedure that attempts to restore fertility
to women after a tubal ligation. The advantages of the successful surgical reanas-
tomosis are the possibility of natural conception and chance of multiple singleton
pregnancies. However, especially for older age women, the time to conception might
be long. When considering the IVF option, a relatively short time to conception might
be achieved, but the cost, risk of multiple pregnancies, ovarian hyperstimulation
syndrome and the need for repeating the procedure for desired pregnancy are the
disadvantages of IVF. Costs and reimbursement policies for each method may differ
between countries.
The results of tubal reversal were improved dramatically with the introduction
of microsurgical techniques. With this technique, reported pregnancy rates vary
between 57% and 84% with a risk for ectopic pregnancy of 2%7% [68]. Microsurgi-
cal tubal reversal techniques include laparotomy, laparoscopy and recently robotic-
assisted reanastomosis. The well-established advantages of laparoscopy over laparo-
tomy include reduced postoperative discomfort and morbidity, more rapid return to
activity and improved cosmesis. Laparoscopic tubal reversal is a difficult procedure
technically. Two-dimensional visualization, limited degrees of instrument motion
within the body as well as ergonomic difficulty and tremor amplification are the limi-
tations of laparoscopic surgery. In addition to these technical problems, long period
of operating time, long learning curve for the surgeon, inability to perform surgery
176 13 Robotic-assisted tubal reanastomosis
in some circumstances such as the presence of firm adhesions still remain as obsta-
cles to surgeons. To overcome such technical difficulties, the application of robotics
to surgical technology was introduced in the late 1990s. Robotic surgery is a step
forward in the field of minimally-invasive surgery (MIS). The limitations of traditional
laparoscopy can be eliminated mostly by this new technology. Advantages of robotic
surgery over laparoscopy include obtaining three-dimensional (3D) images, enabling
direct visualization by eye-hand axes, increased number of basic hand movements of
laparoscopic devices, ease of left-hand usage, easier suturing, easier tying, elimina-
tion of hand tremor, being less exhausting for the surgeon, shorter learning time, less
need for transition to laparotomy, enabling performance of more complex procedu-
res, and shorter operation duration [9]. The worlds first robotically-assisted laparo-
scopic surgery was performed in June of 1998 by Falcone et al [10].
13.2Surgical technique
The surgical technique needs total excision of the occluded portions, proper align-
ment and precise apposition of each layer of the proximal and distal tubal segments.
The type of anastomosis is usually described by its site and the diameter of the tube,
i.e.:
1. Ampullary-ampullary (same size)
2. Ampullary-isthmic (different sizes)
3. Isthmic-isthmic (same size)
4. Isthmic-cornual
13.2.1Positioning of the robotic surgical system
The operation is performed under general anesthesia. Dorsal lithotomy position in

the Trendelenburg position is usually used as the patient positioning. To provide the
access the uterine cavity for manipulation of the uterus and for choromopertubation,
a variety of manipulators can be used. For the robotic tubal reversal, a 4-trocar tran-
speritoneal approach is used. The abdominal cavity is insufflated with carbon dioxide
via a Verres needle or direct trocar entrance. A 12-mm blunt-tip disposable trocar is
introduced to abdomen for the robotic camera. Before the docking procedure, exami-
nation of the status of the fallopian tubes is recommended to assess the feasibility of
the anastomosis. In some circumstances, the patient may have previous total or partial
salpingectomy for tubal ligation or the tubal damage may be irreversible for reversal
procedure. If the status of the ligated tubes is feasible for the reversal, the 8-mm left
robotic instrument port was inserted 810 cm lateral to camera port at midclavicular
line and 23 cm below the umbilicus. The right robotic instrument port point is sym-
metrically contra lateral side of the left robotic port. A 5-mm trocar for assistance is
13.2Surgical technique 177
positioned in the area between the camera and either the left or the right robotic arm
port. Alternatively, the accessory trocar can be placed in the left or right lower quad-
rant. After port placement, the patient is placed in a steep Trendelenburg position to
aid in visualization and bowel mobilization away from the surgical field. The da Vinci
surgical system (Intuitive Surgical Inc, Sunnyvale, CA, USA) is docked either at the foot
of the patients in center or side. Side docking provides an easy access to the vagina and
the manipulation or choromopertubation can be easily made than the central docking.
EndoWrist instruments were introduced through trocars.
13.2.2Robotic-assisted tubal reversal procedure
Microsurgical techniques and principles of gentle tissue handling should be applied

during surgery. Precise dissection and accurate approximation of the different layers
of the proximal and distal tubal segments are crucial for the technique. The operative
technique of the robotic-assisted tubal reversal was shown in Fig. 13.1. The subse-
rosal injection of vasopressin diluted 20 U in 200 mL of normal saline in both pro-
ximal and distal ends and in the mesosalpinx may be used to facilitate subsequent
Fig. 13.1: Robot-assisted laparoscopic tubal reanastomosis. a) preparation of the proximal stump
with flow of methylene blue, b) preparation of the distal stump, c) four interrupted 7/0
polypropylene sutures used for suturing at 12, 3, 6, and 9 oclock and the closure of the serosa,
d) checking the tubal patency with chromotubation. (Photos archive of Ahmet Gmen, mraniye
Education and Research Hospital, stanbul, Turkey)
dissection of both ends and hemostasis. The tubal patency of the proximal segment
should be checked with chromopertubation. The ligated segment of the tube is resec-
ted proximally and distally using scissors. After checking the proximal passage of the
methylene blue or indigo carmine solution from the incised part of the proximal tube,
the distal patency may be checked by irrigation from the fimbrial end of the tube.
A stent may be used between the proximal and distal portion of the tubes before
reversal to make the suturing and alignment of the segments easy, but it is not man-
datory for technique. The mesosalpinx is reapproximated with one interrupted 7/0
or 8/0 suture to prevent tension on the anastomosis site. The submucosal and mus-
cular layers of the tube were sutured with four interrupted 7/0 or 8/0 polypropylene
or polyglactin sutures at the 3, 6, 9 and 12 oclock positions. It is recommended the
first suture position should be at 6 oclock. Attention to proper suturing will avoid
misalignment or rotation of the distal tubal segment along its longitudinal axis. After
checking the tubal patency with chromopertubation, the serosal part of the tube is
also sutured. The same procedure is performed on the other fallopian tube.
13.3The surgical outcomes of robotic-assisted tubal reversal
Traditionally, tubal reanastomosis has been performed microscopically via lapa-

rotomy. With the emergence of advanced laparoscopy techniques in recent times,
many centers have demonstrated good success through laparoscopy and this has
been widely regarded as the alternative route to perform microsurgical reversal of a
ligated tube [11]. The laparoscopic approach has revealed high pregnancy rates com-
parable with those obtained after microsurgery by laparotomy and yields important
advantages such a less postoperative discomfort and fewer complications, no incis-
ional scar, a shorter recovery time, and earlier resumption of normal activities [12].
The laparoscopic procedure for reversal of tubal sterilization is equally effective as
the laparotomic approach [13]. Robotic surgery in tubal reversal has been advocated
to bridge the learning gap between an open approach and laparoscopy. Microsurgical
tubal reversal is the predominant procedure using robotic technology in reproductive
surgery.
There are a few previously published data using robotic-assisted surgery in
tubal reversal. The first complete robotic assisted tubal reversal in six female pigs
was performed in 1997 by Falcone et al [14]. The same authors performed suc-
cessful reanastomosis in ten patients in a human pilot study with no complica-
tion in the following year [10]. The mean operative time was 159 33.8 min. The
patency rate 6 weeks after surgery with postoperative hysterosalpingogram was
89% (17/19 tubes anastomosed) with a pregnancy rate of 50% in 1 year. Goldberg
et al compared the surgical results of tubal reversal with robotic (n = 10) and lapa-
roscopic (n = 15) approach [15]. The operative times were 2 h longer with robotic
13.3The surgical outcomes of robotic-assisted tubal reversal 179
assistance (P < 0.001). The increased estimated blood loss with the use of the robot
(70 68 mL vs. 20 16 mL) was statistically but not clinically significant. Tubal
patency and clinical pregnancy rates were not significantly different. The robotic
system was used in the study was Zeus robotic system. However this study has
many potential biases which were small number of subjects and noncompara-
bility of groups (women in the laparoscopy group were significantly older and
tended towards having larger BMI and prior surgeries) [16]. The first tubal rever-
sal with the da Vinci robotic system was published by Degueldre et al [17]. Eight
patients underwent robotic tubal reversal. The tubal patency was confirmed. The
mean time was 140 min, and mean surgical time was 52 min per tube. Although
follow-up was limited to 4 months, two of the eight patients achieved a pregnancy
and 5/8 patients demonstrated at least unilateral patency. After their feasibility
study, they reported the study included 28 patients underwent robotic tubal rever-
sal and the operative time was 122 min [18]. Rodgers et al reported a case control
study to compare tubal anastomosis by robotic system (n = 26) compared with
outpatient minilaparotomy (n = 41) [19]. Surgical times for the robot and minilapa-
rotomy were 229 (205252) min and 181 (154202) min, respectively (P = 0.001).
Hospitalization times, pregnancy (61% robotic vs. 79% minilaparotomy) and
ectopic pregnancy rates were not significantly different. The robotic technique
was more costly. The median difference in costs of the procedures was $1,446
(P < 0.001). Complication rates in the robotic group were lower than the laparotomy
group. Dharia et al reported a comparative study including tubal reanastomosis
through either robotic approach (n = 18) or through a laparotomy (n = 10) [20].
The mean operative time for robotic group was 201 min and statistically greater
than the laparotomy. The hospitals stay in robotic and laparotomy group were 4 h
and 34.7 h, respectively. During the 8.9 months follow-up period, the pregnancy
rates were comparable between two groups (62.5% for robotic vs. 50% for lapa-
rotomy group). The cost per delivery was similar between two groups. They con-
cluded that robotic approach was feasible and cost effective. Caillet et al reported
a recent study which included 97 patients with available follow-up who under-
went the reversal of tubal ligation [21]. The follow-up of the patients was 2 years.
The overall pregnancy and birth rates were 71% and 62%, respectively. Ninety-one
percent of patients <35 years old became pregnant, and 88% delivered at least
once. This study represented satisfactory birth rates after tubal reanastomosis by
robot-assisted laparoscopy in patients aged 40 years or less.
Robotic technology can be used safely in creating laparoscopic microsurgical
anastomosis. Robotic surgical system offers the surgeon the advantages of a mini-
mally invasive option using a modality the traditional open surgeon can adopt with
a demonstrated steep but short learning curve. Further randomized-controlled trials
studies are warranted to determine if robotic surgery truly offers a benefit over lapa-
roscopy in terms of surgical and pregnancy outcomes of tubal reversal.
References
[1] United Nations. Population Division. Department of Economic and Social Affairs. World
Contraceptive Use 2007. http://www.un.org/esa/population/publications/contraceptive2007/
WallChart_WCU2007_Data.xls. Accessed on: 22/4/2013.
[2] UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research
Training in Human Reproduction (HRP), World Health Organization. Advances in female
sterilization research. Prog Reprod Health Res Newsl 1995, 36, 1.
[3] Chan LM, Westhoff CL. Tubal sterilization trends in the United States. Fertil Steril 2010, 94, 16.
[4] Hillis SD, Marchbanks PA, Tylor LR, et al. Poststerilization regret: findings from the United
States Collaborative Review of Sterilization. Obstet Gyecol 1999, 93, 88995.
[5] Hardy E, Bahamondes L, Osis MJ, et al. Risk factors for tubal sterilization regret, detectable
before surgery. Contraception 1996, 54, 15962.
[6] Boeckx W, Gordts S, Buysse K, et al. Reversibility after female sterilization. Br J Obstet Gynaecol
1986, 93, 83942.
[7] Yoon TK, Sung HR, Cha SH, et al. Fertility outcome after laparoscopic microsurgical tubal
anastomosis. Fertil Steril 1997, 67, 1822.
[8] Kim SH, Shin CJ, Kim JG, et al. Microsurgical reversal of tubal sterilization: a report on 1,118
cases. Fertil Steril 1997, 68, 86570.
[9] Oehler MK. Robot-assisted surgery in gynaecology. Aust N Z J Obstet Gynaecol 2009, 49, 1249.
anastomosis: a case report. J Laparoendosc Adv Surg Tech A 1999, 9, 10713.
[11] Dawood MY. Laparoscopic surgery of the fallopian tubes and ovaries. Semin Laparosc Surg
1999, 6, 5867.
[12] Ribeiro SC, Tormena RA, Giribela CG, et al. Laparoscopic tubal anastomosis. Int J Gynecol
Obstet 2004, 84, 1426.
[13] Wiegerinck MAHM, Roukema M, Kessel van PH, et al. Sutureless re-anastomosis by
laparoscopy versus microsurgical re-anastomosis by laparotomy for sterilization reversal: a
matched cohort study. Hum Reprod 2005, 20, 23558.
[14] Margossian H, Garcia-Ruiz A, Falcone T, et al. Robotically assisted laparoscopic tubal
anastomosis in a porcine model: a pilot study. J Laparoendosc Adv Surg Tech A 1998, 8, 6973.
[15] Goldberg JM, Falcone T. Laparoscopic microsurgical tubal anastomosis with and without robotic
assistance. Hum Reprod 2003, 18, 1457.
[17] Degueldre M, Vandromme J, Huong PT, et al. Robotically assisted laparoscopic microsurgical
tubal reanastomosis: a feasibility study. Fertil Steril 2000, 74, 10203.
[18] Cadire GB, Himpens J, Germay O, et al. Feasibility of robotic laparoscopic surgery: 146 cases.
World J Surg 2001, 25, 146777.
[19] Rodgers AK, Goldberg JM, Hammel JP, et al. Tubal anastomosis by robotic compared with
outpatient minilaparotomy. Obstet Gynecol 2007, 109, 137580.
[20] Dharia Patel SP, Steinkampf MP, Whitten SJ, et al. Robotic tubal anastomosis: surgical
technique and cost effectiveness. Fertil Steril 2008, 90, 11759.
[21] Caillet M, Vandromme J, Rozenberg S, et al. Robotically assisted laparoscopic microsurgical
tubal reanastomosis: a retrospective study. Fertil Steril 2010, 94, 18447.
14 Robotic-assisted abdominal cerclage
Ahmet Gmen, Fatih anlkan and Sami Gokhan Kilic
14.1Introduction
Cervical cerclage is a surgical procedure carried out during pregnancy which involves
suturing the neck of the cervix with a purse type stitch to keep the cervix closed for the
treatment of cervical incompetence (or insufficiency). Cervical insufficiency occurs
in 0.51% of all pregnancies, often resulting in second trimester pregnancy loss [1].
This surgical procedure has been used widely in the management of pregnancies con-
sidered to be at high risk of preterm delivery. There are three types of cerclage. These
are McDonald cerclage, Shirodkar cerclage and abdominal cerclage. The abdominal
cerclage is the least common type. This is usually only done if the cervix is too short
to attempt a standard cerclage due to extensive cervical conization, or if a vaginal cer-
clage has failed or is not possible. The abdominal cerclage was described by Benson
and Durfee in 1965 [2]. The disadvantage of the transabdominal approach has been
the necessity for two laparotomies, one associated with placement of the cerclage and
the other with cesarean delivery [3]. The minimally-invasive techniques, such as lapa-
roscopic and robotic surgery which offers short hospital stay, reduced postoperative
discomfort and morbidity, more rapid return to activity and improved cosmesis has
been considered for the abdominal cerclage in the last few years. Due to technical dif-
ficulties and limitations of the laparoscopic surgery, robotic surgery gives the oppor-
tunity to surgeons to perform operations requiring advanced suturing technique. The
first robotic assisted abdominal cerclage performed by Barmat et al was reported in
2007 and Fechner et al reported the first robotic-assisted laparoscopic cerclage in a
pregnant patient in 2009 [4, 5].
14.2Operative technique
The robotic trocar insertion sites in cerclage of pregnant and non pregnant women
are different. In pregnant women, entry in the left upper quadrant by closed Veress
technique, open Hassan technique at the umbilicus or a midline entry superior to
the umbilicus can be done. The vesicouterine peritoneal flap is taken down to visua-
lize the uterine vessels. An avascular area of the bilateral broad ligaments lateral to
uterine vessels is prepared before passing the suture. Opening a hole in this avascular
space may be done. The sutures used for cerclage may be a 5-mm mersilene tape with
a swaged needle or no 1 polypropylene suture. The suture can be passed in either an
anterior or posterior direction. The passed tape is tied firmly either posteriorly or ante-
riorly. During the tying of the suture, the surgeon should be aware to not strangulate
182 14 Robotic-assisted abdominal cerclage
the uterine arteries. The surgical technique of robotic-assisted abdominal cerclage is

shown in Fig. 14.1.
In our experience at University of Texas Medical Branch on a pregnant patient,
following induction of general endotracheal anesthesia, three robotic port sites were
placed as follows: 1) 12-mm trocar in the midline, 4 cm superior to the umbilicus as
the camera port, 2) 8-mm trocar to the right for monopolar scissors, 3) 8-mm trocar
on the left for Maryland bipolar forceps. A 10-mm assistant port was placed on the
left side for laparoscopic instruments. An intraabdominal pressure of 11 mmHg was
maintained throughout the case.
The peritoneum was incised at the vescicouterine reflection and the bladder
flap was developed with a sharp dissection. Careful manipulation of the cervix by
the assistants fingers allowed the surgeon at the da Vinci (Intuitive Surgical Inc,
Sunnyvale, CA, USA) console to better appreciate the margins of the cervicoisthmic
junction during creation of the bladder flap. Sharp dissection continued until the
cervicoisthmic junction, uterine arteries, and parametrial vessels were exposed bila-
terally. Further visualization of the anterior and posterior aspects of the uterus was
accomplished using a fan retractor in the assistant port.
The right side monopolar scissors were removed, and the robotic needle driver
was inserted. A 30-cm long, 5-mm wide Mersilene suture, (RS20, Ethicon, Inc.,
Somerville, NJ, USA) was prepared by straightening the two attached curved needles.
Fig. 14.1: Robot-assisted abdominal cerclage. a) Preparation of the vesicouterine peritoneal flap,
b) dissection of the uterine artery, c) passing of the suture, d) tying of the mersilen tape.
(Photos archive of Ahmet Gmen, mraniye Education and Researh Hospital, stanbul, Turkey)
14.3Outcomes 183
The suture was then introduced into the pelvis through the 10-mm assistant port.
Utilizing the TileProTM multi-input display feature, a transvaginal ultrasound probe
was connected to the da Vinci Si. This feature of the Si model allowed the surgeon
to view simultaneously both the operative field and the real time ultrasound images
captured by the transvaginal probe. Attention was paid to the posterior aspect of
the uterus where one needle tip was placed at the cervicouterine junction, medial
to the right uterine vessels. The needle was maintained in position by the robotic
arm, while the uterus was then lowered and gently pressed onto the needle by the
robotic forceps until the needle could be seen on the anterior surface of the uterus.
As the needle passed through the tissues, the split screen ultrasound images allowed
the path of the needle to be followed, until the needle was visualized on the ante-
rior aspect of the uterus. The needle was then grasped and pulled through with the
forceps. In a similar fashion, the second needle carrying the mercilene tape trans-
fixed the cervicouterine junction on the left side. On ultrasound, the mercilene tape
appeared to be within the uterine wall, medial to the uterine vessels and lateral to
the amniotic sac. Fetal heart tones were visualized on ultrasound throughout the
procedure. Care was then taken to ensure that the cerclage was lying flat against the
cervix, and the knot was then tied on the anterior of surface of the uterus.
The procedure was completed in 120 min with minimal blood loss. The patient was
observed overnight, and was discharged home on the following morning. Trans vaginal
ultrasound performed 2 weeks after the procedure showed the cerclage to be located
1 cm from the internal cervical os and 3.3 cm from the external os. The remainder of her
pregnancy was uncomplicated and she delivered at term via repeat cesarean section.
14.3Outcomes
Laparoscopic transabdominal cerclage is an effective, minimally-invasive alternative

for patients who are not suitable for transvaginal approach [6]. In a prospective
chort study which included the studies about the results of cervico-isthmic cerclage
by laparotomy and laparoscopy between 2003 and 2008, the fetal survival rate was
found 80% with a mean gestational age of 35.8 2.9 weeks. Intraoperative compli-
cation rate was 10.7. Lack of manual dexterity or poor visualization can cause some
complications during laparoscopic cerclage such as bleeding, suture displacement
and failure of placement [7].
To overcome the limitations of the laparoscopy, robotic-assisted abdominal cer-
clage has been considered as an alternative approach. There are only a few case report
studies including robotic-assisted abdominal cerclage in the literature. Barmat et al
reported a case study included the first robotic-assisted abdominal cerclage in a non
pregnant woman [4]. The patient had a history of cervical insufficiency and was not
a candidate for transvaginal cerclage placement due to extensive cervical conization
history, the presence of short cervix and second-trimester loss of pregnancy after in
184 14 Robotic-assisted abdominal cerclage
vitro fertilization. Prepregnancy abdominal cerclage using the da Vinci robotic surgi-
cal system was performed. The mean operation time was 120 min with minimal blood
loss.
The first robotic-assisted laparoscopic cerclage in a pregnant patient was perfor-
med by Fechner et al in 2009 [5]. The patient was at 12 weeks gestation with a history
of preterm delivery at 31 weeks gestation and a cold-knife conization for cervical
dysplasia which resulted in the removal of most of the vaginal portion of the cervix.
An elective abdominal cerclage was performed with robotic-assisted laparoscopic
technique. A 12-mm trocar in the midline 23 cm superior to the symphysis pubis for
the camera, 8-mm robotic trocar 10 cm to the right and 15 inferior to the camera
port, 8-mm robotic trocar on the right side 2 cm above and medial to the right supe-
rior iliac crest for the atraumatic forceps, 8-mm left robotic trocar symmetrical to
right trocar site were used. A pelvic accessory port site was also placed for use of the
suction-irrigator and passage of the Mersilene tape, and a 30 angled scope was used
to provide a view over the gravid uterus. The patient had an uneventful postopera-
tive course. The remainder of the pregnancy was uncomplicated, and she delivered a
healthy infant via elective cesarean section at 37 weeks gestation.
Transvaginal ultrasound could be used to assist in robotic cerclage placement.
The TileProTM multi-input display feature of the da Vinci Si model allowes a traditio-
nal ultrasound machine to be connected to the da Vinci console. This feature of the
da Vinci Si model allowes a transvaginal ultrasound image to be displayed simulta-
neously with the operative field in both the surgical console as well as the assistant
screens (Fig. 14.1). Transvaginal ultrasound enables correct cerclage placement by
following the trajectory of the needle through the uterine wall. Ultrasound-assisted
robotic cerclage combines the advantages of minimally invasive surgery with the
precision of ultrasound-guided placement granting the best outcomes for both the
mother and the fetus.
Further randomized-controlled trials studies are warranted to determine if robotic
surgery truly offers a benefit over laparoscopy in terms of surgical outcomes.
References
[1]DaCosta V, Wynter S, Harriott J, et al. Laparoscopic cervicoisthmic cerclage for the treatment of
cervical incompetence: case reports. West Indian Med J 2011, 60, 5903.
[2]Benson RC, Durfee RB. Transabdominal cervicouterine cerclage during pregnancy for treatment
of cervical incompetency. Obstet Gynecol 1965, 25, 14555.
[3]Lesser KB, Childers JM, Surwit EA. Transabdominal cerclage:a laparoscopic approach. Obstet
Gynecol 1998, 91, 8556.
[4]Barmat L, Glaser G, Davis G, et al. Da Vinci-assisted abdominal cerclage. Fertil Steril 2007, 88,
1437, e13.
[5]Fechner AJ, Alvarez M, Smith DH, et al. Robotic-assisted laparoscopic cerclage in a pregnant
patient. Am J Obstet Gynecol 2009, 200, e101.
References 185
[6]Burger NB, Brlmann HA, Einarsson JI, et al. Effectiveness of abdominal cerclage placed via
laparotomy or laparoscopy: systematic review. J Minim Invasive Gynecol 2011, 18, 696704.
[7]Whittle WL, Singh SS, Allen L, et al. Laparoscopic cervicoisthmic cerclage: surgical technique
and obstetric outcomes. Am J Obstet Gynecol 2009, 201, 364, e17.
15Single-port robotic surgery
Mete Gungor
15.1Introduction
Innovations in minimally invasive surgical technology, such as multi-channel ports,

articulating instruments, and flexible high-definition endoscopes, have allowed
laparo-endoscopic surgeons to perform increasingly complex surgeries through
smaller incisions. Single-incision laparoscopic surgery (SILS) is a recent techni-
cal advancement in minimally invasive surgery developed as a less invasive alter-
native to conventional laparoscopy. Recently, several investigators demonstrated
the feasibility of the single-port transumbilical approach for many gynecological
procedures including hysterectomy, adnexal surgery and myomectomy [13]. The
potential advantages of SILS include less pain, quicker recovery, and improved
cosmesis.
However, there are significant technical and ergonomic limitations with SILS. In
multiport-laparoscopic surgery (MLS), the placement of the ports allows for triangula-
tion to the target anatomy, fewer instrument collisions, wide angles of retraction, and
better surgeon ergonomic comfort, all of which improve the surgical procedure and
its safety. In current SILS, many of these advantages are lost. Instruments enter the
abdomen parallel through the umbilicus, resulting in the loss of the triangulation of
the target anatomy. In addition, the parallel approach and the resulting lack of space
between instruments impair visualization and cause greater collisions between inst-
ruments and/or the camera. This may also compromise the ability to retract the target
anatomy, resulting in suboptimal tissue exposure. The other disadvantages of SILS
are surgeon fatigue and discomfort secondary to unusual body positioning dictated
by instrumentation.
To minimize these issues, various surgical device manufacturers have developed
articulating instruments and flexible endoscopic cameras. These instruments are
complex to use, have a learning curve associated with their use, need for significant
laparoscopic skills and do not offset all of the ergonomic issues. Therefore, developing
a better surgical instrument for single-port surgery is essential.
Robotic surgery has greatly improved surgeon dexterity, surgical precision, visu-
alization, ergonomics and has allowed procedures that were performed by laparo-
tomy to be performed by laparoscopy. Fusion of both concepts of single-site surgery
and robotic technology is the next step in the evoluation of minimally-invasive
surgery (MIS).
Intuitive Surgical developed a novel set of single-site instruments and acces-
sories. The accessories include a multichannel access port (Fig. 15.1) with room for
four cannulae and an insufflation valve. Two curved cannulae are for robotically
controlled instruments. The other two cannulae are straight; one is 8.5 mm and
188 15 Single-port robotic surgery
accommodates the high-definition and three-dimensional (3D) endoscope and the

other is a 5-mm bedside assistant surgeon port (Fig. 15.2).
The da Vinci (Intuitive Surgical Inc, Sunnyvale, CA, USA) single-site instruments
are similar to those of the existing da Vinci Si EndoWrist except that the entire length
of the instruments are semi-rigid, allowing them to be inserted through the curved
cannulas and triangulation of the anatomy. These instruments do not have the wrist
at the tip of the instrument, in constrast to standard robotic instrumentation. The ins-
truments currently available for this platform include needle-drivers, Cadiere grasper,
Fig. 15.1: Intuitive multichannel single-port placed in a periumbilical incision
Fig. 15.2: a and b) The da Vinci SI robotic system docked to the two curved cannulae and camera
trocar after placement of the single-site access port
15.2Surgical technique 189
Maryland dissector, hook with cautery, curved shears, clip applier and suction irriga-
tion device.
Same sided hand-eye control of the instruments is maintained through assign-
ment of software of the SI system that enables the surgeons right hand to control
the screen right instrument even though the instrument is in the left robotic arm
and reciprocally the left hand controls the screen left instrument even though
the instrument is in the right robotic arms (Fig. 15.3). This coordination of screen
images with the operating hand removes many of the current issues of single-port
articulated instrumentation. Other benefits of the da Vinci surgical system for sin-
gle-port surgery include 3D visualization, motion scaling, and tremor filtration.
15.2Surgical technique
Patients undergo induction of general anesthesia, placement of a urinary cathe-

ter, and administration of preincision antibiotics. A single 2.02.5-cm transumbi-
lical incision is made through the midpoint of the umbilicus. The fascia is entered
sharply and the incision is extended and stretched with retractors to 3 cm. An open
laparoscopy technique (Hasson) is thus used to create an incision that allowed inser-
tion of a single-port robotic trocar system (Intuitive Surgical). The abdominal cavity
is insufflated directly through the port system with CO2 to an intra-abdominal pres-
sure of 15 mmHg.
Diagnostic laparoscopy is performed before robotic docking. The operative robot
then is brought in between the patients legs. Then the surgical table is tilted to a
Fig. 15.3: Curved cannulas and the ability to swap handedness at the robotic console allowing the
left appearing instrument to the screen to be controlled by the surgeons left and vice versa
35 Trendelenburg position to displace the abdominal viscera cranially. The robotic

camera used for all procedures is an 8.5-mm high definition camera. The 8.5-mm
camera trocar and camera is placed first through the access port. Each of the curved
cannulae is placed under direct vision so that the remote centers are located in the
middle of the of the access port and then docked to the two robotic arms. The camera
arm is docked and finally the 5-mm bedside assistant trocar is placed through the
access port. The operating surgeon then moves to the console. At the console the
surgeon confirms that the robotic arms are swapped such that the screen right instru-
ment is being controlled by the right master and vice versa.
The use of a 30 robotic camera is rotated to look upward allows additional space
for robotic arms to move more freely. No accessory trocar that is not part of the single-
site device is inserted. The assistant surgeon helps to retract bowel or the other tissues
by using a standard 5-mm endograsper, or coagulates the vessels with a bipolar grasper
and a vessel sealing device through the assistant channel within the robotic single-port
device (Figs. 15.4 and 15.5).
Fig. 15.4: Photographs of ovarian cystectomy using the new single-port platform. a) Making an
incision on the cyst wall with a hook monopolar cautery, b) a robotic grasper and a suction-irrigation
were used to remove the capsule of the cyst, c) hemostasis was performed with a laparoscopic
bipolar grasper that was used by the assistant surgeon
15.3Discussion 191
Fig. 15.5: A photograph of simple hysterectomy using the new single-port platform
15.3Discussion
In the last decade, numerous studies have demonstrated that laparoscopic approa-
ches to various gynecologic conditions including oncology is feasible and results in
shorter hospital stays, improved quality of life and comparable surgical outcomes to
those of laparotomy [4]. Single-port laparoscopy surgery has been introduced as a
further development of laparoscopy. The concept of multiple instruments and optics
operating through a single incision give rise to specific challenges and unique ergono-
mic problems not previously encountered with conventional laparoscopy. Significant
collisions between instruments, a limited degree of movement, inferior ergonomics
and a longer learning curve are the main obstacles keeping this procedure from full
integration into usual practice. When considering technical challenges introducing
the robotic system into single-port surgery has several advantages over laparoscopic
single-port surgery or conventional robotic surgery.
Robotic-assisted surgery offers advantages, such as three-dimensional visuali-
zation, a stable camera platform, tremor control, scaling of movement and range of
motion superior to that with conventional laparoscopy. Additional potential benefits
of the single-port robotic system include decreased pain, improved cosmesis, shorter
recovery, and higher patient satisfaction.
In addition operative complications related to trocar insertion, such as epigastric
vessel injury, operative wound infection and hematoma formation might be avoided
by reducing the number of ancillary ports penetrating the abdominal wall.
Initial experience with robotic single-port surgery was reported by Haber et al.
They performed 30 urologic robotic NOTES procedures on 10 porcine models using
the current da Vinci robotic system. A 12-and an 8-mm port were placed through
a single transumbilical incision to introduce the robotic camera and one of the
robotic arms. A flexible 12-mm cannula 20 cm long served as a transvaginal port,
through which the second robotic arm was docked. Nephrectomy and pyeloplasty
were performed and the kidney was extracted intact from the vagina [5]. Robotic
single-site transvesical approach was reported in a cadaver model in 2008. A

four-lumen single-port device was inserted into the bladder lumen through a
3-cm transverse skin incision placed in the suprapubic skin fold. A radical pro-
statectomy was technically successful, and the operative duration was 4.2 h,
including 30 min to obtain transvesical access and 50 min to perform the ana-
stomotic suturing [6]. Subsequently, Kaouk et al reported the first robotic sin-
gle-port transumbilical surgery in urology by performing a successful radical
prostatectomy and nephrectomy in human. The operation was completed in 5 h,
with 45 min required for the anastomosis. Blood loss was 250 mL, total hospital
stay was 36 h [7]. Robotic-assisted single-incision surgery has been applied to
cholecystectomy, appendectomy, hernia, colectomy and bariatric surgical pro-
cedures. Among these procedures, cholecystectomy currently is the most widely
used application of this technique within general surgery [8]. Escobar et al repor-
ted the first experience with robotic assisted single-port surgery utilizing the da
Vinci S platform. They reported that single-port robotic surgery using the novel
single-site platform is feasible and safe for a variety of gynecologic procedures [9].
Nam et al. report a single-institution retrospective series of seven women with
benign and malignant gynecologic disease who underwent robotic single-port
transumbilical total hysterectomy using a home-made surgical glove port system.
The median total operative was 109 min (range 105311 min), the median blood
loss was 100 mL (range 10750 mL). They reported that robotic single-port trans-
umbilical total hysterectomy is technically feasible in selected patients with
gynecological disease [10].
However, there are several factors and limitations intrinsic to using the da Vinci
SI platform for single-port surgery. The lack of haptic feedback and the need for a
well-trained surgical assistant are the limitations of robotic surgery. Also hardware
(robotic trocars, cannulas, instrumentation, optics) and software were not designed
for single-incision surgery. Inverting controls of the robotic systems (right to left
and vice versa) may allow the surgeon to operate without crossing the hands at the
console; however, the robotic arms are crossed internally. This internal crossing
presents a limitation of movement during pelvic surgery especially when working
laterally (i.e., side wall) or with large uteri.
Although the robotic single-port platform clearly offers advantages over conven-
tional single-port laparoscopy in terms of three-dimensional visualization of the ope-
rative field and decreasing tension tremor of the surgeon, it lacks wrist motion for
improved dexterity and surgical precision. Whether this platform would be superior
in terms of performance and surgical outcomes to conventional single-port laparo-
scopy remains to be seen in clinical trials.
There are no published data for single-port operative laparoscopy, but it is
expected that robotics will enable more surgeons to adopt this approach to surgery.
15.4Conclusion 193
15.4Conclusion
This new fusion technology of single-port laparoscopy and robotics may be the next
step in the evolution of minimally-invasive gynecologic surgery. Robotic single-
incision procedures have been described in both experimental and human models.
Technical refinements and further experience may continue to improve operative
times. The unique advantages of this robotic platform appear to be restoration of tri-
angulation in single-site access, increased dexterity and range of motion, a stable
operative platform, and diminished external instrument clashes. Also this technique
may improve cosmesis, pain and return to work.
References
[1] Jung YW, Kim YT, Lee DW, et al. The feasibility of scarless single-port transumbilical total
laparoscopic hysterectomy: initial clinical experience. Surg Endosc 2010, 24, 168692.
[2] Kim YW, Park BJ, Ro DY, et al. Single-port laparoscopic myomectomy using a new single-port
transumbilical morcellation system: initial clinical study. J Minim Invasive Gynecol 2010, 17, 58792.
[3] Kim TJ, Lee YY, Kim MJ, et al. Single-port access laparoscopic adnexal surgery. J minim Invasive
Gynecol 2009, 16, 6125.
[4] Johnson N, Barlow D, Lethaby A, et al. Surgical approach to hysterectomy for benign
gynecological disease. Cochrane Database Syst Rev. 2006, Issue 2. Art. No: CD003677.
[5] Haber GP, Crouzet S, Kamoi K, et al. Robotic NOTES (Natural orifice translumenal endoscopic
surgery) in reconstructive urology: initial laboratory experience. Urology 2008, 71, 9961000.
[6] Desai MM, Aron M, Berger A, et al. Transvesical robotic radical prostatectomy. Br J Urol Int
2008, 102, 16669.
[7] Kaouk JH, Goel RK, Haber GP, et al. Robotic single-port transumbilical surgery in humans: initial
report. Br J Urol Int 2009, 103, 3669.
[8] Konstantinidis KM, Hirides P, Hirides S, et al. Cholecystectomy using a novel Single-site robotic
platform: early experience from 45 consecutive cases. Surg Endosc 2012, 464, 22272.
[9] Escobar PF, Fader AN, Parasio MF, et al. Robotic-assisted laparoendoscopic single-site surgery
in gynecology: initial report and technique. J Minim Invasive Gynecol 2009, 16, 58991.
[10] Nam EJ, Kim SW, Lee M, et al. Robotic single-port transumbilical total hysterectomy: a pilot
study. J Gynecol Oncol 2011, 22, 21706.
Part III: Gynecologic onocology
16 Update on robotic surgery in the management
of cervical cancer
Silvia Agramunt and Pedro T. Ramirez
16.1Introduction
Cervical cancer remains a major health care problem throughout the world, although
its geographical distribution is markedly heterogeneous. In 2008, the incidence of
cervical cancer among women in developed countries was 9.0 cases per 100,000
women per year, making it the 10th most common type of cancer, whereas in develo-
ping countries, the incidence was 17.8 cases per 100,000 women per year [1]. In 2012, it
was estimated that approximately 12,170 women in the United States were diagnosed
with cervical cancer and the overall 5-year survival rate for patients with this disease
will be 69% (ranging from 91% for localized disease at diagnosis to 19% for distant
disease at diagnosis) [2].
Since the approval of the da Vinci robotic surgical system (Intuitive Surgical,
Inc, Sunnyvale, CA, USA) by the Food and Drug Administration for use in gynecologic
procedures in April 2005, numerous publications have explored the role of robotic
surgery in gynecologic malignancies. Worldwide, the number of robotic gynecologic
procedures performed has grown 29% year over year, and approximately 150,000 hys-
terectomies were performed in the United States in 2011 using the da Vinci system.
As of March 2012, there were 1,615 robotic systems in the United States (out of 2,226
worldwide) and 379 in Europe [3].
The benefits of robotic surgery as a minimally-invasive surgical (MIS) are very
similar to those of traditional laparoscopy. However, robotic surgery offers several
advantages over those already documented for laparoscopic surgery, such as
7 degrees of movement, elimination of hand tremors, elimination of the fulcrum effect
of laparoscopy (the robotic arms imitate the movements of the surgeons hand), and
improved visualization (three-dimensional stereoscopic imaging).
16.2Early-stage disease
16.2.1Radical hysterectomy
The optimal treatment for patients with International Federation of Gynecology and
Obstetrics Early-stage Cervical Cancer (stage IA2 to IB1) is radical hysterectomy with
bilateral pelvic lymphadenectomy. In selected patients who desire to preserve ferti-
lity, a radical trachelectomy by either a vaginal [46] or an abdominal [78] approach
is an accepted and oncologically safe procedure. Robotic-assisted surgery has been
198 16 Update on robotic surgery in the management of cervical cancer
demonstrated to be a safe and feasible technique for treating patients with early stages
of cervical cancer and has been demonstrated to produce histopathologic and onco-
logic outcomes similar to those achieved with traditional laparoscopic surgery [910].
Since Sert and Abeler published the first report of robotic-radical hysterectomy
in 2006 [11], several authors have evaluated the safety, efficacy, and feasibility of
robotic radical hysterectomy and pelvic lymphadenectomy to treat early-stage cervi-
cal cancer. After their first published study of robotic radical hysterectomy, Sert and
Abeler compared robotic and laparoscopic radical hysterectomy and bilateral pelvic
lymphadenectomy [12] and found that there was no difference between the two pro-
cedures in operative time, number of lymph nodes excised, or length of parametrial
tissue excised. However, there was significantly less blood loss (median, 71 mL vs.
160 mL, P = 0.038) and shorter length of hospital stay (median, 4 days vs. 8 days,
P = 0.004) in the robotic surgery group.
Over the past 5 years, over 300 robotic radical hysterectomies have been reported,
and the majority of studies have supported the safety and feasibility of the technique.
Initially, Boggess et al [13] published a case-control study in which 51 patients who
underwent robotically-assisted radical hysterectomy were compared to 49 patients who
underwent open type III radical hysterectomy for the treatment of early-stage cervi-
cal cancer. Compared with open surgery, robotic surgery was associated with sig-
nificantly less blood loss (mean SD, 96.5 85.8 mL vs. 416 188.1 mL, P < 0.0001),
significantly shorter operative time (210.9 45.5 min vs. 247.8 48.8 min, P = 0.0002),
and significantly higher number of lymph node retrieved (33.8 14.2 nodes vs. 23.3 12.7
nodes, P = 0.0003). These results confirmed the feasibility of the robotic procedure and
suggested an improved adverse outcomes profile in favor of the robotic group, even with
the limitations of a retrospective study design. Magria et al [14] published the first pros-
pective analysis of robotic radical hysterectomy, in which they compared 27 patients who
underwent this procedure with patients treated by laparoscopy (n = 31) or laparotomy
(n = 35) matched by age, body mass index, and site and type of malignancy, among other
factors. The authors showed that the robotic approach was associated with significantly
lower blood loss (mean, 133.1 mL vs. 208.4 mL vs. 443.6 mL, P < 0.001, for the robotic vs.
laparoscopic vs. laparotomy approaches, respectively), and a shorter length of hospitali-
zation (1.7 days vs. 2.4 days vs. 3.6 days, P = 0.017). Operative time was significantly shorter
for the robotic compared to the laparoscopic approach, although the shortest time was
observed for open radical hysterectomy (mean, 189.6 min vs. 220.4 min vs. 166.8 min, res-
pectively). No significant differences were found among the three groups regarding intra-
operative or postoperative complications, and none of the patients with cervical cancer
had experienced a recurrence at a mean follow-up time of 31.1 months. Recently, Soliman
et al [15] from the University of Texas MD Anderson Cancer Center published a large series
of 95 radical hysterectomy procedures (30 open, 31 laparoscopic, and 34 robotic). Ope-
rative time was significantly shorter in the open surgery group than in the laparoscopic
surgery or robotic surgery groups (median, 265 min vs. 338 min vs. 328 min, respectively,
P = 0.002). Estimated blood loss was significantly lower in the laparoscopic and
16.2Early-stage disease 199
robotic procedures than the open procedures (median, 100 mL vs. 100 mL vs. 350 mL,
respectively, P < 0.001). Median length of hospital stay was significantly shorter in the
robotic procedures than in the laparoscopic or open procedures (median, 1 day vs. 2 days vs.
4 days, respectively, P < 0.01).
To date, there is no completed prospective comparison that is adequately
powered to compare robotic- or laparoscopic-radical hysterectomy to open radical
hysterectomy. A multicenter phase III randomized clinical trial led by MD Anderson
Cancer Center aims to compare robotic or laparoscopic radical hysterectomy with
abdominal radical hysterectomy in patients with early-stage cervical cancer [16].
The goal of this study is to determine whether the MIS approach is equivalent to
the abdominal approach. The protocol aims to determine whether there are differen-
ces between open surgery and MIS as it relates to disease-free survival, treatment-
related morbidity, cost and cost effectiveness, patterns of recurrence, quality of life,
pelvic floor function, feasibility of intraoperative sentinel lymph node sampling, and
overall survival.
Surgical technique
For robotic-radical hysterectomy, the patient is placed in the low lithotomy position
with her arms tucked at her sides. A uterine manipulator is placed. At the MD Ander-
son Cancer Center, the manipulator of choice is the V-Care (Conmed, Utica, NY, USA);
however, numerous other options are available and acceptable. A 12-mm bladeless
trocar (Ethicon Endosurgery, Cincinnati, OH, USA) is placed in the left upper quadrant
under direct visualization. The trocar is placed approximately 2 cm below the left costal
margin in the midclavicular line. This is the trocar for the assistant. Another 12-mm bla-
deless trocar is placed under direct visualization in the midline approximately 20 cm
above the pubic symphysis. The abdominal cavity is insufflated, and the patient is
placed in the steep Trendelenburg position. The robotic system trocars are then placed
as follows: the first robotic trocar is placed 8 cm to the left of and 15 below the assistant
trocar, the second robotic trocar is placed 8 cm to the right of the midline trocar, and the
third robotic trocar is placed 8 cm to the right of and below the second robotic trocar
(Figs. 16.1 and 16.2). Afterwards, the da Vinci robotic system is positioned between the
patients legs and docked (Fig. 16.3). At MD Anderson Cancer Center, the choice of ins-
trumentation is as follows: an EndoWrist (Intuitive Surgical Inc, Sunnyvale, CA, USA)
bipolar grasper on the left hand, an EndoWrist monopolar curved scissors on the right
hand, and an EndoWrist Cadiere forceps in the fourth robotic arm.
The robotic-radical hysterectomy is performed as follows: the round ligaments are
coagulated and transected bilaterally. An incision is then made over the psoas muscle
lateral to the infundibulopelvic ligament. The ureter is localized, and the lymph-
bearing tissue along the pelvis is evaluated to rule out macroscopic metastatic disease.
Any suspicious nodes are sent for frozen section evaluation, and if these are positive,
the procedure is aborted. If there are no suspicious nodes or suspicious nodes are found
Fig. 16.1: Standard trocar placement for robotic surgery in gynecologic oncology
Fig. 16.2: Standard trocar placement for robotic surgery in gynecologic oncology
not to contain cancer, the procedure is continued by developing the paravesical and
pararectal spaces. The uterine artery and vein are identified and transected at the origin
from the iliac vessels. After the bladder is mobilized inferiorly, the ureters are separated
16.2Early-stage disease 201
Fig. 16.3: Robotic system docked on patient prior to procedure
from their medial attachments to the peritoneum. The parametrial tissue is separated,
and the ureters are bilaterally dissected to the point of their insertion into the bladder.
The lateral aspect of the vesicouterine ligament is then divided, and the bladder is mobi-
lized further inferiorly to ensure adequate vaginal margins. The uterus is then ante-
flexed, and the posterior visceral peritoneum is transected to expose the rectovaginal
space. The uterosacral ligaments are transected bilaterally. The infundibulopelvic liga-
ments are transected bilaterally if a bilateral salpingo-oophorectomy is performed. If
the ovaries are preserved, the utero-ovarian ligaments are transected. A circumferential
colpotomy is performed using the EndoWrist monopolar scissors allowing for a 2-cm
margin below the level of the cervicovaginal junction. The specimen is then removed
intact through the vagina. The vaginal cuff is then sutured robotically. Once the vaginal
cuff is closed, bilateral pelvic lymphadenectomy is performed. The margins of dissec-
tion extend from the mid-common iliac vessels proximally to the circumflex iliac vein
distally, and to the internal iliac vessels and the obturator fossa medially.
16.2.2Radical trachelectomy
In patients with stages IA2 to IB1 cervical cancer who are interested in future ferti-
lity, a radical trachelectomy is currently considered standard of care as supported by
the National Comprehensive Cancer Network guidelines [17]. Not all patients should
be offered this procedure; the ideal patients include those with tumors smaller than
2 cm, histologic subtype such as squamous, adenocarcinoma, or adenosquamous
carcinoma, and magnetic resonance imaging findings negative for any evidence of
disease extending to the upper endocervix or to the pelvic lymph nodes. Radical tra-
chelectomy has been proven to be feasible and to be oncologically safe compared
to radical hysterectomy [18]. Although reports of laparoscopic radical trachelectomy
exist [1920], the laparoscopic approach has not been widely accepted because of the
complexity of the procedure and the required advanced skill of the surgeon.
Ramirez et al [21] from the MD Anderson Cancer Center initially published a
small series of robotic-radical trachelectomy and demonstrated the feasibility of this
procedure. In that study, the authors found that the median estimated blood loss
was 62.5 mL (range, 5075 mL), the median length of hospital stay was 1.5 days
(range, 12), the median operative time was 339.5 min (range, 245416 min), and
no patients required conversion to laparotomy or blood transfusions. In the largest
series to date, published by Nick et al [22], outcomes for 37 patients undergoing either
open (25 patients) or robotic (12 patients) radical trachelectomy were retrospectively
analyzed. Five patients (one open and four robotic) underwent conversion to radical
hysterectomy because of close endocervical margins. Robotic radical trachelectomy
was associated with lower blood loss (median, 62.5 vs. 300 mL, P = 0.0001) and
decreased hospital stay (median, 1 vs. 4 days, P < 0.001), but there was no difference
between the groups in operative time or histopathologic outcomes. Rates of serious
morbidities related to surgery were similar between the two groups.
Surgical technique
The surgical technique for robotic-radical trachelectomy is as follows. The patient is
placed in the dorsal lithotomy position with her arms tucked at her sides. A uterine
manipulator is placed. The trocar placement is the same as that described above for
laparoscopic radical hysterectomy. Similar to the procedure for radical hysterectomy,
in a radical trachelectomy, the round ligaments are coagulated and transected. The
paravesical and pararectal spaces are dissected bilaterally, and the ureters are iden-
tified and dissected to the level of their insertion into the bladder. It is important
to note that in a radical trachelectomy, one may safely coagulate and transect the
uterine vessels bilaterally. The blood supply to the uterus will be adequately main-
tained through the infundibulopelvic ligaments bilaterally. The bladder is then mobi-
lized inferiorly. The anterior vesicouterine ligaments are divided. The uterosacral
ligaments are divided bilaterally, and then a circumferential incision is made in the
vagina allowing for at least a 2-cm upper vaginal margin. The uterine manipulator is
then removed, and the EndoWrist monopolar scissor is used to amputate the cervix,
leaving approximately 1 cm of residual cervical stump. The specimen, including the
cervix, parametria, and upper vagina, is removed through the vaginal canal. It is then
16.3Locally advanced disease 203
sent for frozen section evaluation to determine the margin status to the uppermost
section. If the frozen section evaluation shows an endocervical tumor-free margin of
at least 10 mm, the procedure is continued. If the margin is less than 10 mm, one
needs to consider removing an additional margin of tissue or performing a radical
hysterectomy. Some institutions consider a tumor-free margin of 5 mm adequate to
proceed with the surgery.
If the decision is made to proceed with a radical trachelectomy, a Smitt sleeve
(Nucletron, Columbia, MD, USA) is placed in the uterine canal to assure patency of
the canal and avoid stricturing of the lower uterine segment. A cerclage is then placed
using 0-Ethibond suture. The cerclage must be placed approximately 2 cm above the
lower uterine segment margin to minimize the potential for erosion during healing
of the vaginal-uterine anastomosis. The uterus is sutured to the upper vagina using
0-Vicryl suture and an EndoWrist Mega needle driver. The pelvic lymphadenectomy is
performed bilaterally from the level of the mid-common iliac vessels to the circumflex
iliac vein distally.
All patients are considered for discharge on postoperative day 1. Each patient
wears a Foley catheter in her bladder for 7 days and returns for a voiding trial at the
end of this period. The Smitt sleeve is removed after 4 weeks. Patients are encouraged
to refrain from becoming pregnant for a period of at least 6 months after the surgery.
16.3Locally advanced disease
In patients with locally advanced cervical cancer, failure to detect para-aortic nodal
metastases can lead to suboptimal treatment. A recent prospective study by Ramirez
et al [23] from the MD Anderson Cancer Center evaluated 60 patients with locally
advanced cervical cancer who underwent pre-radiotherapy laparoscopic extraperito-
neal para-aortic lymphadenectomy. The investigators found that of 27 patients with
positive pelvic but negative para-aortic lymph nodes on positron emission tomogra-
phy/computed tomography, six (22%) had histopathologically positive para-aortic
lymph nodes. Eleven (18%) of the 60 patients in the study had a treatment modifica-
tion based on surgical findings. Robotic technology provides advantages in addition
to those provided by laparoscopic surgery in terms of instrumentation, particularly
when one is working in a limited surgical field, as is the case during an extraperito-
neal para-aortic lymphadenectomy.
Vergote et al [24] reported the first series of robotic extraperitoneal para-aortic
lymphadenectomy in patients with advanced cervical cancer and concluded that the
robotic procedure was technically easier than the laparoscopic approach. Recently,
a series of 39 patients undergoing isolated robotic para-aortic lymphadenectomy
has been published [25]. The comparison of patients undergoing isolated extra vs.
transperitoneal robotic paraaortic lymphadenectomy did not show any difference in
terms of operative time, postoperative complications, blood loss, lymph node count
or conversion rate. Although feasibility has been demonstrated, further information

about robotic extraperitoneal para-aortic lymphadenectomy is needed for evaluation
of oncologic outcomes and perioperative outcomes.
The surgical technique for extraperitoneal para-aortic lymphadenectomy descri-
bed here has previously been reported by Vergote et al [25]. The operation is started
with a transperitoneal laparoscopy through an umbilical trocar. The peritoneal cavity
is inspected for any evidence of metastatic disease. If none is detected, the robotic
retroperitoneal para-aortic lymphadenectomy is started.
A 12-mm incision is performed just cranial to the left anterior superior iliac spine.
Skin, subcutaneous fat, and fascia are opened sharply. The large muscles are opened
bluntly with opening of the parietal fascia but not of the peritoneal fascia. The surgeon
introduces the right finger into the incision and develops the extraperitoneal space.
Digital dissection is performed until the anterior surface of the left psoas muscle and
the common iliac artery on the left side are identified. Next, a 12-mm blunt-tip balloon
trocar (Tyco Health Care, Princeton, NJ, USA) is introduced, and a zero-angle da Vinci
laparoscope and camera are introduced through this port. The extraperitoneal insuf-
flation pressure is usually 15 mmHg. Two additional robotic trocars are introduced,
one 810 cm distal and medial to the scope trocar and one under the left lowest rib on
the same line as the laparoscopic trocar at a distance of 810 cm from the endoscopic
port. Finally, a fourth trocar (10-mm) (Versaport, Tyco Health Care) is inserted about
1 cm above the right corner of the pubic hair to allow the assistant to lift the perito-
neum with the ureters and ovarian vessels and to remove the lymph nodes.
The da Vinci S robotic system is docked at the patients right side with the robotic
arms reaching over the patient. The third robotic surgical arm is not used in this pro-
cedure because of the limited space in which to place the ports. A bipolar forceps
is introduced through the right port, and a monopolar scissor is introduced through
the left port. The bifurcation of the aorta and the vena cava and the left and the right
ureter are identified, and the lymph nodes are removed. At the end of the procedure,
an incision is made in the peritoneum to avoid lymphoceles. Given that this technique
is in its infancy, we believe that numerous variations of the surgical set-up will be
published until one set-up emerges that produces consistently superior results.
16.4Incidental invasive cervical cancer: robotic-radical

parametrectomy
Unfortunately, some patients with cervical cancer are treated suboptimally with a
simple hysterectomy. Reasons for this suboptimal treatment can include failure to
perform Pap smear screening before surgery, failure to check the findings on Pap smear
screening before surgery, inadequate evaluation of abnormal cytology findings, and
others. In patients who undergo a simple hysterectomy and are subsequently found
to have invasive cervical cancer a radical parametrectomy is the indicated procedure.
16.5Conclusions 205
The first to publish on the safety and feasibility of robotic radical parametrectomy
were Ramirez et al [26] from the MD Anderson Cancer Center. In that series, the authors
reported on five patients with invasive squamous cell carcinoma of the cervix. The
median body mass index was 23.8kg/m2 (range, 17.726.5). The median operative time
was 365min (range, 331430). The median estimated blood loss was 100mL (range,
50175). There were no conversions to laparotomy. There was one intraoperative com-
plication cystotomy. No patient required blood transfusion. The median length of
hospital stay was 1day (range, 12). One patient experienced two postoperative com-
plications, a vesicovaginal fistula and a lymphocyst. No patient had residual tumor
in the parametrectomy specimen, and no patient underwent adjuvant therapy. The
median number of pelvic lymph nodes removed was 14 (range, 616). The median
follow-up time for all patients was 7.5months (range, 1.313.8). There were no recur-
rences. Several other authors have since published on their experience with this pro-
cedure [2728] and have confirmed that it is safe and feasible.
The set-up for radical parametrectomy at the MD Anderson Cancer Center is as
follows. The patient is placed in the dorsal lithotomy position. The arrangement of the
trocar set up is the same as that described for robotic radical hysterectomy above.
The radical parametrectomy is performed as follows. First, an incision is made over
the residual round ligament stump, and the peritoneum lateral to the infundibulo-
pelvic ligaments is opened bilaterally. The paravesical and pararectal spaces are then
developed. A surgical gauze is used on a ring-forcep and placed in the vagina to allow
for traction and manipulation of the upper vaginal cuff. The ureters are then separa-
ted from the peritoneum down to where they enter the lateral parametrial tissue. The
ureters are dissected from the parametria and mobilized completely to the bladder
after division of the anterior and posterior vesico-uterine ligaments. A type III resec-
tion is performed with complete resection of the parametria at the pelvic sidewalls.
The bladder peritoneum is then incised, and the bladder is mobilized inferiorly over
the anterior vaginal wall. This step is facilitated by filling the bladder with saline. The
uterine vessels are transected bilaterally at their origin and dissected over the ureters
bilaterally. The anterior vesico-uterine ligaments are then divided.
The peritoneum over the rectovaginal space is then incised, and the uterosacral
ligaments are divided bilaterally. While upward traction is placed on the vaginal cuff,
a circumferential incision is made approximately 2cm below the vaginal stump. The
specimen is removed through the vagina. The vaginal cuff is then closed using the
EndoWrist mega needle driver and 0-Vicryl sutures.
16.5Conclusions
Robotic radical hysterectomy is safe and feasible for patients with early-stage cer-
vical cancer. Prospective randomized data comparing the open approach to the
minimally-invasive approach will ultimately provide information regarding the best
surgical outcomes. Robotic radical trachelectomy is also a feasible and safe procedure
that should be considered for selected patients with early-stage disease who desire to
preserve their fertility. In patients with locally advanced cervical cancer, the robotics
approach may offer a minimally-invasive option for patients in whom the status of the
para-aortic lymph nodes is to be evaluated.
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[17] http://www.nccn.org/professionals/physician_gls/pdf/cervical.pdf. Accessed on 12/6/2012.
[18] Diaz JP, Sonoda Y, Leitao MM, et al. Oncologic outcomes of fertility-sparing radical
trachelectomy versus radical hysterectomy for stage IB1 cervical carcinoma. Gynecol Oncol
2008, 111, 25560.
[19] Kim JH, Park JY, Kim DY, et al. Fertility-sparing laparoscopic radical trachelectomy for young
women with early stage cervical cancer. Br J Obstet Gynaecol 2010, 117, 3407.
[20] Marchiole P, Benchaib M, Buenerd A, et al. Oncological safety of laparoscopic-assisted vaginal
radical trachelectomy (LARVT or Dargents operation): a comparative study with
laparoscopic-assisted vaginal radical hysterectomy (LARVH). Gynecol Oncol 2007, 106, 13241.
[21] Ramirez PT, Schmeler KM, Malpica A, et al. Safety and feasibility of robotic radical
trachelectomy in patients with early-stage cervical cancer. Gynecol Oncol 2010, 116(3), 5125.
[22] Nick AM, Frumovitz MM, Soliman PT, et al. Fertility sparing surgery for treatment of early-stage
cervical cancer: Open vs. robotic radical trachelectomy. Gynecol Oncol 2012, 124(2), 27680.
[23] Ramirez PT, Jhingran A, Macapinlac HA, et al. Laparoscopic extraperitoneal para-aortic
lymphadenectomy in locally advanced cervical cancer. Cancer 2010, 117(9), 192834.
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lymphadenectomy in cervical carcinoma: first report on the technique used in 5 patients. Acta
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[26] Ramirez PT, Schmeler KM, Wolf JK, et al. Robotic radical parametrectomy and pelvic
lymphadenectomy in patients with invasive cervical cancer. Gynecol Oncol 2008, 111(1), 1821.
[27] Vitobello D, Siesto G, Bulletti C, et al. Robotic radical parametrectomy with pelvic
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17 Robotic-infrarenal aortic lymphadenectomy:
A step-by-step approach
Kristina A. Butler and Javier Magrina
17.1Introduction
Robotic surgery offers many established patient and surgeon advantages, while
advanced ergonomic and optical technology greatly benefits complex upper abdo-
minal procedures, the most common in gynecology being aortic lymphadenectomy.
Enhanced visualization and stability offers ease in intricate dissection and ensuring
hemostasis near the great vessels. Providing the surgeon with four arms enhances
multi-task performance, independence and economy of movement. The challenge
unique to gynecology is that surgery may traverse from within the deep pelvis to
the upper abdomen. Such an expansive operative field presents a unique obstacle
given the limitations of robotics in fully accessing more than two abdominal quad-
rants simultaneously. This has lead to the use of more numerous abdominal trocars
widely dispersed and the undocking of the robot for patient position adjustments or
operative table rotation. The available abdominal surface area and the finite instru-
ment depth of reach dictate trocar placement. Robotic arm restrictions limit extension
from the column and conversely also require a sizeable distance from the patient to
function properly. Patient position changes commonplace to laparoscopic surgery are
not possible once the robot is docked and functional. Strategies to minimize trocar
number and patient repositioning have resulted in various operative techniques to
accomplish robotic aortic lymphadenectomy and other upper abdominal procedures.
Lymphadenectomy techniques vary by operative time, lymph node numbers, and
dissection boundaries [1]. Controversy regarding the confines of the optimal aortic
dissection has resulted in a variety of practice pattern disparities. Herein we aim to
review robotic aortic lymphadenectomy patient selection, operative approaches,
benefits, limitations, and future directions.
17.2Patient selection
Patients with gynecologic malignancy at risk for aortic metastasis are candidates
for robotic lymphadenectomy if a minimally-invasive approach may offer optimal
resection. Gross abdominal disease not amenable to complete resection would be
a contraindication to a minimally-invasive resection approach. Lymphatic enlarge-
ment visualized grossly or radiographically is not a reliable method for confirming
metastasis making tissue extraction the gold standard to exclude nodal dissemina-
tion of disease [2, 3]. Several gynecologic oncology patient groups are candidates for
robotic aortic lymphadenectomy.
210 17 Robotic-infrarenal aortic lymphadenectomy: A step-by-step approach
Endometrial cancer FIGO staging guidelines rely on surgical findings including

the lymph node status of the pelvic and aortic chains to guide prognosis and the use
of adjuvant therapy. Controversy regarding lymphadenectomy has persisted beyond
a decade with conflicting opinion as to which patients are at sufficient risk for lym-
phatic metastasis, to what extent the lymphadenectomy should be completed, and
whether the nodal status should direct adjuvant therapy and benefit patient survi-
val. Randomized trials largely comprised of low-risk patients did not reveal survival
benefit for performing lymphadenectomy when nodal status was not used to direct
adjuvant therapy [4, 5]. Standardizing a subset of at-risk patients would limit over-
treatment morbidity and prevent under treatment of occult disease. The Mayo Clinic
uses an algorithm to select at-risk patients for lymphadenectomy utilizing grade 3
or type 2 histology, tumor diameter greater than or equal to 2 cm and/or myometrial
invasion greater than 50% [6]. Lymph node metastases are the then targeted focally
during radiochemotherapy treatment planning. Lymphadenectomy not including
the infrarenal aortic chains would underscore the actual extent of disease. Among
patients with nodal dissemination, negative pelvic lymph nodes with positive aortic
metastasis may be found in 1617% [7, 8]. When aortic metastases are present, 77% of
the time these nodes are superior to the inferior mesenteric artery, and the left infra-
renal group may be the only positive site [7]. In general, endometrial cancer patients
determined to be at risk for nodal metastasis should undergo systematic pelvic and
infrarenal aortic lymphadenectomy.
Cervical cancer patients with early disease may be surgically staged with aortic
node assessment that may direct treatment with focal radiation in metastatic regions
[9]. Pretreatment radiographic imaging to predict lymphatic dissemination in clini-
cally staged patients with locally advanced disease may be falsely negative in 11%
of patients resulting in under-treatment [10]. Cervical cancer patients with pelvic
lymph node metastasis are at higher risk for aortic metastasis, however the intraope-
rative frozen section nodal analysis had a reported sensitivity as low as 21%. There
is no replacement for pathologic exclusion of disease dissemination. A large series
regarding minimally-invasive lymphadenectomy in locally advanced cervical cancer
revealed isolated infrarenal node positivity in 31% of patients with aortic metastasis
and negative ipsilateral inframesenteric nodes [11]. The use of pretreatment lymph-
adenectomy is controversial with NCCN guidelines suggesting as an option the use of
aortic lymphadenectomy to direct adjuvant therapy [9].
Presumed early stage ovarian cancer patients benefit from minimally-invasive
staging procedures when a thorough abdominal survey can be performed ensuring
no evidence of diffuse gross disease. Most data available are among retrospective
laparoscopy groups. Upstaging occurs in presumed early stage disease at a rate of
1727% for borderline tumors and 2442% among epithelial ovarian cancers [12, 13].
Recurrence rates and overall survival rates among those staged minimally invasively
are similar when compared to laparotomy [12]. The use of minimally-invasive surgery
(MIS) in advanced ovarian cancer is controversial, and some report equivalent survival
17.3Advantages 211
outcomes compared to laparotomy [14, 15]. In a review of retroperitoneal lymph node

metastasis in epithelial ovarian cancer at the Mayo Clinic, 37.5% of patients had iso-
lated infrarenal metastasis with negative inframesenteric nodes [16].
Additionally, retroperitoneal disease recurrence in the thoracolumbar lympha-
tic channels occurs in gynecologic malignancy. Resection of isolated disease recur-
rencemay be performed robotically to facilitate a pathologic diagnosis and reduce the
time to chemoradiotherapy. Only small series reports are available for consideration
in minimally invasive surgery for focal recurrent disease, most of which are laparosco-
pic with promising outcomes [1719].
17.3Advantages
Robotic aortic lymphadenectomy most often accompanies an extensive array of

additional procedures including hysterectomy, parametrectomy, pelvic lymph-
adenectomy, omentectomy, and complex ureterolysis [20]. These procedures often
encompass upper abdominal and deep pelvic dissection. A minimally-invasive
approach is ideal to expedite recoveryand theinitiation of adjuvant chemoradiothe-
rapy. Robotic technology further strengthens technically advanced dissectionwith
unrivaled visualization and delicate stability.
17.4Approaches
Aortic lymphadenectomy upper boundaries of dissection are an area of debate with

some favoring dissection to the inferior mesenteric artery and others the left renal
vein. The extent of the dissection influences trocar placement, operative time, and
patient position changes during surgery. Robotic trocar placement to complete pelvic
surgery can most often accommodate an aortic lymphadenectomy below the inferior
mesenteric artery. Intuitive Surgical Inc (Sunnyvale, CA, USA) initially recommended
caudal docking between the lower extremities for pelvic surgery. Cadaver robotic
experimentation has supported that caudal docking does not allow for an expeditious
and safe approach to the infrarenal aortic nodes gynecologic cancer [21]. Others have
found that with subcostal trocar placement the left and/or right infrarenal nodes may
be removed [2224]. However, it is our opinion that this approach does not allow for
adequate exposure of the infrarenal area, which may contain vessel anomalies at risk
for injury. Given that aortic disease in gynecologic malignancies is found indiscri-
minately up to the renal vessels this area mandates lymph node dissection. Several
transperitoneal and one extraperitoneal robotic technique to access this region safely
have been described and will be discussed in detail. These approaches for robotic
transperitoneal infrarenal lymphadenectomy include: a midline approach with pelvic
trocar placement (with or without operating table rotation), a midline subcostal trocar
method, and a left lateral approach. The extraperitoneal approach utilizes left-sided
trocars with side docking.
17.5Transperitoneal techniques
17.5.1Midline approach, pelvic trocars, no table rotation
Robotic docking over the patients head for robotic infrarenal lymphadenectomy was
first described in 2009 by Fastrez et al on a series of eight patients with cervical cancer.
Three robotic ports were used in the lower pelvis with camera placement to the left of
the pubic symphysis and robotic arms in each iliac fossa. One assistant port was placed
to the right of the symphysis. In the Trendelenburg position the dissection began at
the right common iliac artery by opening the peritoneum toward the aortic bifurca-
tion and suturing it to the anterior abdominal wall. Lymph node removal proceeded
caudal-to-cranial until the renal artery was reached. The inferior mesenteric artery was
preserved. In this series, node positivity prompted termination of the procedure, as
occurred in one of eight subjects. Details may be found in Tab. 17.1. This transperitoneal
approach did not describe performance of concomitant pelvic surgery. While intraperi-
toneal access may lend itself to pelvic surgery, the authors do not specify which trocar
placement was used or if patient position changes were necessary [25].
17.5.2Midline approach, pelvic trocars, 180 table rotation
An operating table rotation system was developed to provide robotic access for
pelvic, upper abdominal and aortic procedures [20]. This technique was designed
using a robotic cadaveric model and subsequently trialed on a 33-patient series. Two
sets of trocars were used, one for pelvic and the other for upper abdominal access.
In some instances, the two robotic arm trocars may be used for both portions thus
reducing the total number of trocars placed (eight to 10 total). This robotic transpe-
ritoneal infrarenal aortic lymphadenectomy involves placing the robotic column
at the patients head for aortic access. A set of five trocars is placed suprapubi-
cally and dispersed laterally in the lower pelvis. The 12-mm optical port resides
on the left, with robotic arms most lateral, and two assistant ports lie equidistant
between. In the Trendelenburg position the robotic column is docked directly over
the patients head and instrument tips directed toward the upper abdomen. The
surgical assistant is positioned between the patients legs and has unobstructed
space with dual access ports. The peritoneum is opened over the right common iliac
and extended toward the aortic bifurcation. This small peritoneal window creates
a tent that can be stabilized to divert the small bowel from the aortic region with a
10-mm fan retractor directed ventrally. The space is opened to the renal vein and
Tab. 17.1: Robotic infrarenal lymphadenectomy techniques and outcomes
Approach N OR time Aortic lymph Blood loss (mL) Hospital stay BMI (kg/m2) Operative complications
(min) node # (days)
Midline, pelvic trocars

Fastrez 2009 [25] 8 138 14 Hgb 0.8 g/dL 4.5 24 None
Magrina 2010 [20] 33 42a 13 45 2.5 26 Conversion n = 1
Midline, subcostal trocars

Boggess 2008 [23]c 103 191b 12 75 1 33 Conversion 3%, bowel injury 1%,
postop complications 5%
Seamon 2009 [22]c 105 242b 10 88 1 34 Conversion 12%, bowel injury n = 3
Holloway 2012 [26]d 291 163b 9 85 1 30 Not stated
Gocmen 2012 [27] 13 224b 26 53 2.8 30 Chylous ascites (diet management)
Left lateral
Jacob 2011 [28] 5 213b 8 150 1 25 Umbilical hernia repair at 8 mos
Extraperitoneal
Magrina 2009 [21] 1 103 5 30 2 27 None
Narducci 2009 [29]e 6 200 12 113 26 Hematoma n = 1
Lambaudie 2012 [30]e 15 202 17 71 2.6 27 Conversion n = 1, Hematoma n = 1
a Console time for aortic lymphadenectomy.
b Time includes additional procedures: pelvic lymphadenectomy/sampling, hysterectomy and/or salpingoophorectomy.
c Left aortic lymphadenectomy was inframesenteric.
d Only 60% had aortic lymphadenectomy and an unknown portion had an infrarenal dissection.
e Left aortic lymphadenectomy alone performed in most patients.
17.5Transperitoneal techniques
213
the right aortic nodes are removed. Then the peritoneal incision is extended from
the bifurcation of the aorta over the left common iliac to provide exposure of the
left aortic area, further increased by retraction of the sigmoid mesentery laterally.
The inferior mesenteric artery is commonly divided to optimize lateralization of
the sigmoid and allow safe and complete evacuation of the left inframesenteric
region and infrarenal nodal groups. The assistant in all procedures used a vessel-
sealing device. Lymphatic tissue from the left infrarenal region is then removed
from caudal to cephalad up to the left renal vein. Additional upper abdominal
procedures performed without difficulty were omentectomy, diaphragm resection,
and liver resection.
The 180 operating table rotation was completed in a mean of 8.8 min between
pelvic and upper abdominal procedures. Ventilatory support was briefly disconti-
nued and resulted in no adverse sequelae. The mean console time was 42 min for
aortic lymphadenectomy. One case was converted to laparotomy due to bleeding
from a lateral branch of the inferior mesenteric artery. The occurrence of major
vessel bleeding was consistent with established rates. Inferior mesenteric artery
ligation did not result in any left colon or sigmoid ischemia. Trocar placement for
pelvic surgery utilizes an umbilical optical trocar and several additional lateral
ports as previously described [20]. Over 3 years, the mean number of aortic nodes
removed robotically increased from 10 to 17 nodes compared to a similar cohort of
laparoscopic infrarenal lymphadenectomies improving from 5.5 to 18.5 nodes over
9 years [31] suggesting that robotic surgery has a steeper learning curve with more
rapid improvement. Challenges of this technique include the need for additional
trocar placement and the need for a well-trained, rehearsed surgical team that can
accommodate the 180 table rotation. This technique provides access of the entire
upper abdomen and the deep pelvis while ensuring patient safety. Visibility of the
left diaphragm surface and spleen is adequate while thorough visualization of the
right diaphragm requires a flexible scope (Olympus, Center Valley, PA, USA) or a
scope with a 120 lens (Storz, Tuttlingen, Germany).
17.5.3Midline approach, subcostal trocars
Several reports of aortic lymphadenectomy with subcostal or supraumbilical optic

trocar placement have been described, most of which do not include homogenous
populations with bilateral infrarenal dissection [26, 23]. Holloway et al reported on a
large series of 291 endometrial cancer patients. The camera port was placed 2327 cm
above the pubic symphysis. Robotic trocars for three robotic arms and two assistant
ports were dispersed laterally in the upper abdominal region. A total of six trocars
were used. Trendelenburg positioning aids bowel retraction. The peritoneum over
the right common iliac artery is opened identifying the ureter safely. Exposure of
the aortic region was developed with retraction of the small bowel peritoneum by
17.5Transperitoneal techniques 215
the assistant, which created a tent. The third robotic arm reflected the duodenum.
Nodal tissue was removed cranial-to-caudal from the right then left aortic chains to
the level of gonadal vein insertion bilaterally. On the left side, lymphadenectomy
from the renal vein to the mid-common iliac artery did not necessitate ligation of the
inferior mesenteric artery. These trocars were then used for pelvic surgery without
the need for additional trocars or patient repositioning. The location of the robotic
column was not clearly described. Operative times including hysterectomy and
pelvic lymphadenectomy and aortic node retrieval improved over a 4-year period
from 173 to 148 min and seven to 11 lymph nodes, respectively (Tab. 17.1). Of note,
60% of all patients underwent aortic lymphadenectomy and an unknown portion
received an infrarenal dissection when possible. Complications and conversions
were not reported [26].
Two additional studies have described a right infrarenal and left inframesen-
teric lymphadenectomy using subcostal trocar placement and a midline approach.
A series of 103 patients utilized five trocars, with the optical trocar positioned
2325 cm suprapubically and the robot docked caudally between the legs. Reason-
able nodal counts were achieved and surgical complications included one each
of bowel injury, hernia, lymphocyst, lymphedema, vaginal leak, and pulmonary
embolism (Tab. 17.1). The robotic approach compared favorably among open and
laparoscopic techniques in this retrospective study [23]. A series of 105 patients
using similar trocar and docking positions reported shorter hospital stays, lower
transfusion rates, and shorter operative times in a robotic cohort with a signifi-
cantly larger mean BMI than a laparoscopic comparison group. The conversion rate
was lower for the robotic group compared to the laparoscopic group (12 vs. 26%).
Women were half as likely to require laparotomy to complete their surgical staging
when approached robotically [22]. Such a conversion rate for laparoscopy is con-
sistent with previous data [32].
An additional series comprised completely of patients undergoing infrarenal
robotic lymphadenectomy with subcostal port placement was described. In this small
series, similar trocar placement included the camera port at least 10 cm above the
umbilicus, right and left upper abdominal robotic arm trocars, the robotic third arm in
the left upper abdomen, and a single 10-mm assistant port in the left subcostal region.
Trendelenburg position, with a 15 right tilt was used and the robot docked caudally
between the legs. Nodal tissue was dissected from the right then left aortic regions
up to the gonadal vein insertion bilaterally. Nodal tissue was placed in separate con-
tainers and removed vaginally prior to culpotomy closure. The authors report that
two additional trocars may be added in the event that deep cuff closure may not be
reached due to high port placement. One patient developed chylous ascites and was
managed with diet adjustment [27]. The strengths of this technique include the ability
to perform pelvic and aortic surgery without position change, while maintaining high
lymph node counts (Tab. 17.1).
17.5.4Left lateral approach
The left lateral approach uses the right lateral decubitus position with gravity dis-
placement of the intestine. The retroperitoneum is opened lateral to the left colon,
over the line of Toldt. The technique for aortic lymphadenectomy utilizes initial
umbilical trocar entry followed by subcostal and suprapubic port sites, for the
left and right robotic arms, respectively. The camera uses a left midclavicular port
and the assistant uses the umbilical port. Six trocars are used for both the aortic
and pelvic dissections. The robot is docked over the left hip. With the patient in
the right decubitus position the dissection begins with medial mobilization of the
descending colon up to the splenic flexure providing exposure of bilateral infrarenal
aortic regions. Gravity aids in downward displacement of the small and large intes-
tine (toward the patients right side). The gonadal vessels are isolated at the pelvic
brim and traced cephalad to the renal vein and caval insertion. Surrounding nodes
are dissected free in a caudal-to-cranial direction bilaterally. The assistant aids in
ureteral lateralization. A transition to pelvic surgery involves rotation of the ope-
rating table less than 90, placing the extremities in low lithotomy stirrups while
maintaining sterility, and robotic docking caudally. The same trocars are used with
the robotic arms rearranged and one additional trocar added on the left, lateral to
the umbilicus (six total trocars). Additional adjustments to this technique without
patient rotation may include lateral docking over the left hip in the lithotomy posi-
tion for pelvic surgery. Operative times shown (Tab. 17.1) include concomitant hyste-
rectomy and pelvic lymphadenectomy. Complications included one umbilical hernia
repair 8 months postoperative [28].
17.6Extraperitoneal technique
Extraperitoneal aortic lymphadenectomy techniques are well-described using lapa-

roscopy and have transitioned similarly with the use of robotic technology. The
retroperitoneal space reduces exposure to intraperitoneal adhesions and intestinal
hindrance. Vergote et al [33] described an initial cervical cancer patient series in 2008,
but lymphadenectomy dissection was limited to the low aortic region [33]. In 2009,
Magrina et al [21] reported on the extraperitoneal approach to the infrarenal and sup-
rarenal aortic nodes developed on a cadaver model and successfully performed on a
patient with advanced cervical cancer. In the semi-lithotomy position a small incision
was created medial to the iliac spine. The retroperitoneal space was developed with
an inflatable balloon. Left flank trocars were placed as follows: robotic camera over
the mid-axillary line, the left robotic trocar at the site of the initial incision, and the
right robotic trocar in a left subcostal position. An assistant port was placed equi-
distant between the camera and the right robotic trocar. The robotic column was
positioned at the patients right side. No complications occurred [21]. Subsequently,
17.7Conclusion 217
Narducci et al reported on a series with dissection up to the left renal vein using right
shoulder docking. Only one of six patients in this series had bilateral aortic lymph-
adenectomy, the others had a left aortic dissection to the renal vein. Complications
included one seroma with hematoma managed with radiologic drainage. While node
counts averaged 12 exclusion of the right aortic chain is not conclusive [29]. This
group described an additional cohort of 15 patients using the same technique with
similar perioperative characteristics (Tab. 17.1, Lambaudie 12).
17.7Conclusion
There are various techniques available to perform robotic infrarenal aortic lymph-
adenectomy. Each affords the patient the opportunity for a minimally invasive
approach to a surgical procedure requiring intricate and advanced dissection. The
gynecologic oncologist must be versed in more than one technique as any of the tech-
niques described here is applicable to all patients. Robotically dissected lymph node
quantities and surgical resection margins maintain the standard of care as in other
surgical modalities. Cost comparison has shown a more expeditious return to normal
activity with reduced postoperative morbidity among robotic versus laparoscopic &
open surgery [34]. Robotic surgery has been shown to improve surgeon technical per-
formance, an advantage appropriate given the degree of difficulty for this procedure
[35]. The importance of providing a minimally invasive approach while not compro-
mising the integrity of the procedure is of utmost concern and is easily recognized in
this robotic surgery appraisal.
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18 Robotic pelvic and aortic lymphadenectomy for
gynecologic malignancies one approach
James E. Kendrick IV, Sarfraz Ahmad and Robert W. Holloway
18.1Introduction
Robotic or computer-enhanced laparoscopic surgery has truly revolutionized

the approach to surgical staging for the majority of patients with early-stage gyne-
cologic malignancies. Patients previously considered to be poor candidates for
minimally-invasive laparoscopic surgery (MIS) secondary to body habitus, medical
co-morbidities, or an extensive prior surgical history now routinely benefit from
robotic-assisted laparoscopic procedures. Cervical, endometrial, and even ovarian
cancers have been successfully managed via the robotic approach. Moreover, the
extensive and meticulous dissection required of a comprehensive staging pro-
cedure lends itself to the unique movements and visualization provided by the
robotic platform. In experienced hands, robotic surgery is rapidly becoming the
preferred operative approach for endometrial and cervical cancer staging.
The following chapter deals primarily with the techniques routinely employed
in a thorough and successful robotic aorto-pelvic lymphadenectomy. Uterine cancers
represent the most common gynecologic malignancy, thus a wealth of knowledge and
experience has been gained in developing and honing the robotic techniques utilized
while staging this common female disease. Considerable controversy exists concerning
the merits and rationale for extensive pelvic and aortic lymphadenectomy. Adetailed
review of this topic is beyond the scope and intent of this chapter. For clarity, the
authors subscribe to the commonly held opinion of most US gynecologic oncologists,
that a thorough lymphadenectomy is an essential part of adequate surgical staging,
offering both diagnostic and potentially therapeutic benefit to patients. In addition,
pathologic information gained from complete nodal dissection facilitates proper
adjuvant treatment decision making.
The following chapter will briefly cover the historical rationale of lymphadenec-
tomy for endometrial cancer and the paradigm shift from open to MIS, but the main
focus concerns the techniques and procedures most useful for performing a thorough
and safe robotic staging procedure for endometrial cancer. Burgeoning sentinel
lymph node advancements hold promise for patients in the future, and preliminary
data regarding this topic will be reviewed.
18.2The rationale for lymphadenectomy
In 2008, almost 300,000 cases of endometrial cancer were diagnosed worldwide [1]. The
rising incidence of this disease is particularly evident in the USA, where it represents
222 18 Robotic pelvic and aortic lymphadenectomy for gynecologic malignancies
the most common gynecologic malignancy, accounting for 43,470 new cases in 2010
[www.cancer.gov]. Increasing rates of morbid obesity and the metabolic syndrome
have conspired to increase the prevalence of uterine cancer and complicate its surgi-
cal treatment. Operating on morbidly obese patients, often with a plethora of co-mor-
bidities, presents a host of challenges. The obesity epidemic is particularly germaine
to the minimally-invasive surgeon, as the standard laparoscopic approach to hyste-
rectomy, with or without lymphadenectomy, in obese patients is difficult. The robotic
surgical platform provides instrumentation that facilitates successful MIS for obese
patients that might otherwise be subjected to laparotomy and its attendant peri- and
post-operative morbidities.
In 1988, the International Federation of Gynecology and Obstetrics (FIGO)
changed to a surgical staging system for patients with endometrial cancer [2]. This
entails total hysterectomy, bilateral salpingo-oophorectomy and systemic pelvic
and aortic lymphadenectomy. The FIGO staging categories changed as a direct
result from data produced by the Gynecologic Oncology Group (GOG) Protocol 33
study. This protocol, designed to evaluate the usefulness of surgical staging in pati-
ents with disease clinically confined to the uterus, found that 22% of patients had
extra-uterine disease, including a 9% incidence of positive pelvic nodes, and a 5%
incidence of positive aortic nodes [3, 4]. The diagnostic and therapeutic value of
pelvic and aortic lymphadenectomy is frequently cited in the US literature and sup-
ports our belief that lymph node staging is a critical determinant for risk stratifica-
tion and treatment planning [5, 6]. The overall therapeutic value of surgical staging
continues to be hotly debated however, especially in light of recent European phase
III clinical trials that showed no improvement in progression-free or overall survi-
val for surgically staged patients [7, 8]. These trials have been heavily criticized for
deficiencies in trial design and conduct calling into question the trials conclusions,
and surgical staging continues to remain standard in the opinions of most US
thought leaders [9, 10].
18.3The minimally-invasive shift
In the early 1990s, laparoscopy was first proposed for surgical staging of endo-
metrial cancer [11, 12]. While investigators immediately recognized the benefits of
MIS in terms of recovery and shortened hospital stay, most US surgeons found this
approach difficult for routine clinical use because of increased operating time and
a protracted laparoscopic learning curve. Few centers offered laparoscopic staging
for the majority of their patients with endometrial cancer by 2005 [1315], largely
relegating this technique to non-obese patients with low grade malignancies.
The landmark LAP2 trial from the GOG, comparing laparotomy to laparoscopy for
the surgical management of endometrial cancer, established MIS as a preferred
18.4Operating room set-up and patient preparation 223
approach because of less peri-operative morbidity [16] without substantial increase

in recurrence of disease [17]. As the LAP2 trial was closing to accrual in 2005, the
da Vinci surgical system (Intuitive Surgical Inc, Sunnyvale, CA, USA) was cleared
by the US Food and Drug Administration (FDA) for gynecologic procedures, and
rapidly gained acceptance by surgeons as an effective device for performing hyste-
rectomy with staging lymphadenectomy for patients with endometrial cancer. It is
estimated that more than 50% of such cases were managed with robotic-assisted
surgery in 2011, representing a paradigm shift in the US towards MIS not previously
achieved with traditional laparoscopic surgery.
Often cited technical advantages of robotics over straight-stick laparo-
scopy include wristed instrumentation allowing more precise surgical movements
including knot tying and dissection, improved high-definition stereo-optic vision,
a shorter learning curve, and better surgeon ergonomics. Several single institu-
tion reports have indicated advantages of the da Vinci platform for obese patients
over laparoscopy in terms of blood loss, transfusion, and conversion to laparotomy
compared to laparoscopy [18]. However, performance of aortic lymphadenectomy,
especially to the level of the infra-renal veins, has been described as difficult or
compromised because of the limitations of the robotic systems operative arms
[19, 20]. The following will describe our approach to the set-up, patient preparation,
and surgical technique for robotic-assisted pelvic and aortic lymphadenectomy for
treatment of endometrial cancer utilizing a center-docking approach that has been
developed and modified since 2006.
18.4Operating room set-up and patient preparation
Patients are counseled preoperatively to expect an overnight admission to the hos-

pital following surgery and a less than 3% risk for conversion to laparotomy [21].
A mechanical bowel prep of Mirilax in G-2 Gatorade preceded by two Bisaco-
dyl tablets is prescribed to improve displacement of the bowel thereby improving
visibility for aortic lymphadenectomy. Maximum Trendelenburg positioning to 32
requires special consideration to prevent sliding on the operating table. Washable
gel-pads are placed under the sacrum and shoulders and a tension tape is positi-
oned over towels across the patients clavicles and shoulders. We prefer to avoid
increased risk of brachial plexus injury associated with use of shoulder braces. It
is important to avoid placing the tape or strap below the shoulders over the breasts
and chest, which can result in sliding of the patients torso. Placement of the tape
below the proximal humeri also limits chest expansion during mechanical ventila-
tion, forcing downward movement of the diaphragm that compromises exposure
during infra-renal lymphadenectomy. Other anti-slide alternatives include egg-
crate foam or the vacuum bean-bag mattresses. Arms are padded and tucked
along the torso. For obese patients or patients with cardio-pulmonary disease, we
recommend testing ventilatory performance and security of the chest tape while
in a steep Trendelenburg position prior to prepping and establishing pneumope-
ritoneum. Pressure-controlled anesthesia is required for ventilation in a steep
Trendelenburg, and neuromuscular blockade must be maintained throughout the
procedure. It is helpful to ask the anesthetist to adjust the ventilator with reduced
tidal volumes and increased rate (to maintain minute-ventilation) during the infra-
renal portion of the aortic lymphadenectomy, when exposure is most difficult. For
particularly high-risk patients that may require conversion to laparotomy (suspec-
ted stage IV disease, large uteri, BMI >50 kg/m2), we have open instruments availa-
ble in order to avoid delay should conversion be necessary. Because the arms are
tucked, we recommend patients undergoing lymphadenectomy have two periphe-
ral IVs placed prior to tucking the arms in the event of major bleeding or IV mal-
function, although we have had no need for intra-operative transfusion from acute
blood loss in our 6-year experience with aortic lymphadenectomy.
Robotic hysterectomy is greatly facilitated with the use of a uterine manipulator.
Uterine manipulation improves safety, far outweighing the unlikely and theoretical
risk of dislodging cancer cells from the uterus or cervix [22]. We prefer the V-CARE
disposable uterine manipulator (ConMed, Utica, NY, USA) for its ease of placement
and single piece design. Many surgeons prefer their experience from laparoscopic hys-
terectomy using the ZUMI manipulator, KOH ring, and a separate pneumo-occluder
balloon (Cooper Surgical, Turnbull, CT, USA). Still other surgeons use a metal end-
to-end anastomosis, EEA (US Surgical Corp., Norwalk, CT, USA) rectal sizer as an
obturator to distend the vaginal fornices for colpotomy while using the third da Vinci
operating arm for uterine manipulation. Port sites are anesthetized with 0.5% bupi-
vacaine with the camera port placed 2528 cm above the symphysis pubis, depending
on the individual patients height, torso length, uterine size, and need to perform
infra-renal aortic lymphadenectomy. The S and Si da Vinci models have longer inst-
rument shafts than the original standard model, allowing higher placement of ports
and easier dissection of aortic nodes and hysterectomy from the same port set-up. It
is also helpful to use bariatric-length laparoscopic instruments in order to reach the
pelvis from upper abdominal accessory ports. Placement of the third operating arm
cephalad to the second arm in the left flank at the level of the camera port, allows its
optimal use as a retractor during aortic node dissection as well as obturator space
dissection, and avoids collisions with arm no. 2 during aortic lymphadenectomy.
A 12-mm accessory port is placed between the camera and right robotic ports near
the mid-clavicular line, and a 5-mm port, if necessary, can be placed high in the right
flank, lateral and slightly cephalad to arm no. 1 (Fig. 18.1). We have recognized no
benefit from side docking, but have experienced some difficulties during infra-renal
dissections due to limitations in the arm motion, and therefore recommend routine
center docking for this procedure.
18.4Operating room set-up and patient preparation 225
12mm
assist
camera
5mm
assist
Arm 3
Arm 1 Arm 2
Fig. 18.1: da Vinci port set-up for aortic lymphadenectomy. Camera port is midline 2528 cm above
the symphysis pubis
A zero degree scope is used for most cases; however, a 30 downward facing
lens can afford better visualization of upper abdominal anatomy for infra-renal diss-
ection and omentectomy in the event that the ports were inadvertently placed too
low. Monopolar scissors are used in the right operative arm 1 with the energy set at
38 Watts on fulgarate mode, a fenestrated bipolar grasper is placed in the left arm
2 at 45 Watts, and a double-fenestrated grasper/retractor is preferred for the third
operative arm primarily for use as a retractor. For controlling vascular pedicles, we
prefer the da Vinci fenestrated bipolar grasper, which avoids the cost of an additional
laparoscopic energy device, and is a more efficient grasper than the Maryland bipolar
grasper. Performance of aortic lymphadenctomy to the left renal vein is usually pos-
sible with the da Vinci system, but can be compromised by difficult exposure in mor-
bidly obese patients, especially those with short stature. A Ray-Tec sponge is placed
during port placement at the ligament of Treitz as the omentum and small bowel are
gently folded into the left upper quadrant during port placements. The sponge retards
peristalsis of small bowel into the field of view and can be useful for blotting during
aortic dissection. Prior to docking, it may be necessary to first lyse omental adhesions
using laparoscopic scissors in patients with prior surgeries, so that the omentum and
transverse colon can be optimally displaced above the stomach and liver.
18.5Surgical technique for center-docked robotic-assisted

aortic lymphadenectomy
For patients determined preoperatively to require aortic lymphadenectomy based

on their endometrial pathology, or if pelvic lymphadenopathy is encountered upon
opening the spaces, it is recommended to proceed immediately with the aortic lymph
node dissection prior to hysterectomy. Proceeding with the aortic dissection first
avoids potential difficulties with blood and irrigation fluid that may track cephalad
because of the patients Trendelenburg position, potentially obscuring dissection
planes. Also, small bowel peristalsis into the mid-abdomen during hysterectomy may
be more difficult to repeatedly displace while the robot is docked.
To initiate lymphadenectomy, first open the peritoneum along the right common
iliac artery in a caudal to cephalad direction up the aorta above the inferior mesenteric
artery (IMA). The assistant surgeon grasps the leading peritoneal edge with an atrau-
matic laparoscopic grasper in the 12-mm port, while a suction cannula in the 5-mm
flank port retracts the ureter and gonadal vessels laterally over the psoas muscle.
The third operative arm is positioned over the aorta grasping the recently opened
peritoneum and creating a peritoneal tent with the assistant surgeons grasper,
which effectively creates retroperitoneal exposure. If a redundant sigmoid colon is
encountered, it is useful to suture the tinea coli to the left colic gutter using a 3-0 silk,
displacing it from the lower aorta. Common iliac (CI) lymph nodes are dissected free
from the artery using robotic scissors and short bursts of monopolar cautery, taking
care to avoid injury to the underlying iliac vein and genito-femoral nerve coursing
below the artery along the psoas muscle. It is useful to begin the dissection first on the
artery; then free the nodal bundle from the psoas muscle, lifting it up, and exposing
the genito-femoral nerve and CI vein. Deviation of dissection away from the exposed
artery into nodal fat pads without first exposing the CI vein increases the risk of vas-
cular injury.
Once the CI nodes are removed to the aortic bifurcation, maximum exposure to the
renal veins is achieved by optimizing the assistants grasper and the third operative arm
over the duodenum-peritoneal tent, and by using the suction cannula to gently retract
the duodenum cephalad via the 5-mm right flank port. Dissection planes between pre-
caval, intra-aortic-caval, and infra-renal lymph nodes are created with gentle separa-
tion of adventitia and lymphatics using monopolar cautery. Bipolar cautery is used on
the most cephalad lymphatic borders of the dissection at the left renal vein to potenti-
ally limit lymphatic fluid spill during dissection, and the potential risks of symptomatic
post-operative lymphoceles, and/or chylous ascites. It is prudent to avoid major lym-
phatic channels running between the aorta and vena cava for similar reasons, and use
of laparoscopic clips is advised when they are encountered. The articulating da Vinci
metal clip applicator can be very useful for small vessels occasionally encountered on
the aorta between the IMA and renal vein. Dissect lymph nodes off the aorta and vena
18.5Surgical technique for center-docked robotic-assisted aortic lymphadenectomy 227
cava in a cranial to caudal direction from the duodenum and left renal vein, taking
care to identify and avoid the insertion of the right gonadal artery and vein, as well as
the origin of the IMA from the anterior aortic surface. The IMA is usually encountered
approximately 4 to 5 cm above the aortic bifurcation, and the left renal vein is usually
another 4 to 5 cm above the IMA (Figs. 18.2 and 18.3). Once the anterior lymph nodes
are cleared from the aorta and cava, position the third arm in the left retroperitoneum
retracting the left gonadal vein and ureter laterally to allow dissection of infra-renal
lymph nodes lateral to the aorta and above the IMA. Minor bleeding is controlled with
short bursts of mono- and bi-polar cautery, but great caution must be exercised to avoid
collateral injuries from overzealous or blind use of cautery. Aortic nodes on the right,
below the IMA, are then cleared off the vena cava to the CI vein. Care must be taken
Fig. 18.2: Exposing the left renal vein and infra-renal lymph nodes
Fig. 18.3: View of left renal vein, aorta, and vena cava following the removal of infra-renal lymph nodes
to avoid lifting the nodal bundle off the vena cava. This can result in sheering of the
anterior perforating (fellows) veins and resultant hemorrhage. Careful dissection
and exposure around these veins using bipolar and monopolar cautery is paramount.
Minor vena caval bleeding can be easily managed with pressure and Fibrillar, and The
Ray-Tec sponge already in-situ can be most helpful.
To this point in the dissection, all lymph nodes have been placed in visible, stra-
tegic locations in the pelvis and colic gutters, and are now retrieved with a reusable,
laparoscopic retractable bag system through the 12-mm port. The left infra-mesenteric
aortic and left CI lymphadenectomy are now completed by dissecting below the IMA,
using the third-arms double fenestrated grasper to retract the left ureter laterally
down to the external iliac artery. It is not necessary to routinely sacrifice the IMA
during this dissection, and major lymphatic trunks are sealed with bipolar cautery
or clipped when identified to minimize the risk of lymphoceles or chylous ascites.
The left infra-IMA aortic and CI lymph nodes are removed separately in the re-usable
laparoscopic endo-bag.
18.6Surgical technique for robotic-assisted

pelvic lymphadenectomy
Once the aortic dissection is complete, hysterectomy with bilateral salpingo-oopho-

rectomy is accomplished in the standard robotic-assisted fashion removing the entire
broad-ligament with wide margins on the round and infundibulo-pelvic ligaments. A
modified radical hysterectomy is performed when indicated for clinical suspicion of
disease extension into the cervix.
The formal pelvic lymphadenectomy is initiated on the right side of the pelvis by
using the third operative arm to open the paravesical space and retract the superior
vesical artery medially. The external iliac artery, vein, and obturator spaces are now
exposed (Fig. 18.4). The dissection is best initiated at the right CI artery with the ureter
retracted medially by the bed-side assistant. Lymphatic tissue is dissected free from
the psoas muscle, taking care to separate the genito-femoral nerve and retract it late-
rally. Avoid cautery damage to the nerve bundle during dissection in order to mini-
mize cutaneous anesthesia over the antero-medial thigh. The lymphatic bundle is
dissected laterally to medially off the external iliac artery using traction, short bursts
of monopolar cautery, and cold cutting. The dissection is carried caudally to the
distal circumflex iliac artery and vein, then progresses medially sweeping tissue off
the external iliac vein, in a cephalad direction, back to the right internal iliac artery.
Taking full advantage of the instruments wristed capabilities allows the surgeon to
avoid trauma to the vein with monopolar electrical arcing. Bipolar cautery is used on
the most distal and medial lymphatic pedicles to create a lymphatic seal, minimiz-
ing lymphatic leakage or lymphocele formation. Avoid removing large fat pads distal
to the circumflex vessels. These are rarely involved with tumor, and their removal
18.6Surgical technique for robotic-assisted pelvic lymphadenectomy 229
Fig. 18.4: Left obturator space following lymphadenectomy revealing the external iliac vein (V) above
the grasper, obturator nerve (N), and superior vesical artery (A) near endo-shears
significantly increases the incidence of lymphedema [23]. It is helpful during the

right-sided pelvic dissection for the assistant to use a bariatric length suction cannula
through the 12-mm port as a retractor, and use a laparoscopic grasper through the 5 mm
port to displace the external iliac vein laterally during the obturator space dissection.
Lymph nodes are placed in the posterior cul-de-sac for subsequent retrieval.
The obturator nodal packet is next addressed by first bringing the camera closer
into the pelvis and rotating it slightly to the right. With the superior vesical artery on
medial stretch by the third arm, the obturator space is gently dissected, separating
the nodal fat pad from the underlying obturator nerve. The nerve should be meticu-
lously dissected and visualized to minimize risks of injury. Remain vigilant for the
frequently encountered obturator vein entering the distal external iliac vein, and
dissect the lymph nodes free from the dorsal (or underside) of the external iliac vein
and obturator fascia. Sweep tissue from distal to proximal along the obturator nerve,
avoiding monopolar cautery that may cause obturator muscle twitches. Bleeding in
this area is better handled with bipolar energy, and lymphatic tissue below the nerve
and above the deep branches of the internal iliac system can also be removed. Again,
any bothersome capillary bleeding can be managed with Fibrillar in these spaces,
avoiding potential thermal damage with use of excessive cautery. The external and
obturator lymph nodes are removed separately in the reusable laparoscopic bag ret-
rieval system, while the left paravesical space is opened by the console surgeon. An
identical nodal resection is carried out on the left side of the pelvis using the third
operative arm to displace the ureter medially to inspect the CI dissection and remove
any remaining nodes. Next, position the third arms double-fenestrated grasper to
elevate the distal peritoneal edge at the lateral pelvic sidewall during external iliac
dissection. The same instrument can then be re-positioned to serve as a vein hook
during dissection of the left obturator nodal packet. The bedside assistant holds the
paravesical space open with a grasper in the 5-mm port and uses the suction via the
12-mm port.
18.7Comparative studies
In the 7 years since the US FDA clearance of da Vinci for gynecologic surgery, several
retrospective case-series and comparative studies (either laparoscopy or laparo-
tomy) for endometrial cancer have been published. There have been no prospec-
tive randomized trials completed, but two meta-analyses of observational studies
were published simultaneously in 2010 [2425]. In an analysis of eight comparative
studies [1819, 2631] that included at least 25 robotic cases, [24] identified a cumu-
lative 1,591 patients with endometrial cancer (robotic 589, laparoscopic 396, laparo-
tomy 606). Robotic and laparoscopic cases appeared similar with the exception of
less blood loss for robotic cases (P = 0.001), but no difference in transfusion rates
(OR 0.47, CI 0.102.19, P = 0.22). For the robotic versus laparotomy comparison, lower
transfusion rates approached statistical significance in favor of robotic cases (OR 0.25,
CI 0.051.16, P = 0.06). Operative times for robotic and laparoscopy cases were similar,
but both were greater than laparotomy operative times (P < 0.005). Lymph node yields
were not statistically different for any surgical method. Conversion to laparotomy was
9.9% for laparoscopy compared to 4.9% for robotic, also approaching statistical sig-
nificance (P = 0.06). Reza et al in 2010 [25] also analyzed gynecologic surgery pub-
lications including those for endometrial cancer, and reported that robotic surgery
was associated with reduced blood loss (76 mL, P = 0.03) and fewer transfusions (OR
0.24, CI 0.09 to 0.64) than conventional laparoscopy. In their analysis, conversion to
laparotomy was less for robotic surgery (OR 0.43, CI 0.210.85) and the overall risk of
complications was no different for robotic compared to laparoscopic surgery. Thus,
two systematic reviews of comparative studies suggest that for the management of
endometrial cancer, surgeons may expect less blood loss, fewer transfusions, fewer
conversions to laparotomy, similar operative times, and similar overall complications
for robotic compared to laparoscopic hysterectomy with lymphadenectomy. However,
it is important to recognize the limitations of meta-analyses of retrospective obser-
vational studies, and that their conclusions are not nearly so robust as those from
meta-analyses of prospective randomized trials due to inherent selection biases
encountered in retrospective studies.
18.8Managing obese patients with endometrial cancer
Obesity is associated with a 10-fold increased risk for endometrial cancer, and is often
mentioned as a limiting factor concerning patient selection for MIS procedures.
18.8Managing obese patients with endometrial cancer 231
Obese patients have an increased risk of conversion to laparotomy, and less com-
plete lymph node dissection [16]. Establishment and maintenance of exposure during
aortic lymph node dissection and adequate ventilation with requirements for steep
Trendelenburg positioning can be challenging for both the surgeon and anesthesio-
logist. Gehrig et al in 2008 [18] reported that robotic surgery was preferable to laparo-
scopy for treatment of endometrial cancer in 36 obese and 13 morbidly obese patients
because of shorter operative times, blood loss, hospital stay, and increased lymph
node retrieval. Ninety-two percent of the robotic cases and 84% of the laparoscopic
cases completed both a pelvic and aortic node dissection. While robotic lymph node
yields were greater than those for laparoscopic cases, node counts for morbidly obese
(BMI >40 kg/m2) patients were not greater than laparoscopy, indicating that robotic
aortic lymphadenectomy may still have some limitations for this group of difficult
patients.
Seamon et al in 2009 [19] reported that of 105 patients with endometrial cancer, 13
(12.4%) with BMIs ranging from 47 to 58 and Grade 1 cancer did not undergo a complete
staging: six patients underwent pelvic lymphadenectomy without aortic dissection and
seven had no lymphatic staging. There was a 12.4% rate of conversion to laparotomy.
The mean BMI for those patients requiring conversion to laparotomy was 40 7 kg/m2
compared to 34 9 kg/m2 for those successfully completed robotically. The feasibility
for completing robotic aortic lymphadenectomy was 67% and 35% for BMI 45 and
50 kg/m2, respectively.
Most recently, Subramaniam et al [32] compared outcomes from a group of obese
patients with endometrial cancer undergoing robotic (n = 73, BMI 39.8 kg/m2) and
open hysterectomy (n = 104, BMI 41.9 kg/m2). Lymphadenectomy (total mean node
count 8.0) was performed in 66% of robotic cases and the rate of conversion to lapa-
rotomy was 11%. Transfusions, hospital stay, and complications were all improved
for robotic-assisted surgery. In our experience, height is also very important when
considering patients with an elevated BMI. Short stature and the apple shaped
body habitus, in contrast to a tall patient with pear shaped habitus, portends sig-
nificant difficulty with aortic dissection for patients with BMI in excess of 40 kg/m2.
Pelvic lymphadenectomy can almost always be accomplished for morbidly obese
patients as long as Trendelenburg positioning is tolerated. James et al in 2012 [33]
reported that 72% of 47 patients selected to undergo aortic lymphadenectomy based
on pre-operative histology or intra-operative analysis of the uterine tumor had suc-
cessful infra-renal dissections during the first year attempting this surgical technique
(Figs. 18.2 and 18.3). The mean aortic and pelvic node counts for the 34 patients with
infra-renal dissections were 13.1 and 21.9, respectively, mean BMI 31 kg/m2 (range
2046), mean operative time 178 + 31 min, and there were no conversions to laparo-
tomy. Three (8.8%) patients had isolated aortic metastases that were above and below
the IMA in this study.
In summary, our key recommendations for performing aortic lymphadenectomy
in obese patients include securing the patient carefully to an operating table with
gel pads under the buttocks and shoulders, then taping carefully across the humeri
and chest just below the clavicles (over a thin towel to prevent skin damage). Avoid
taping too low and limiting chest excursion, thus impeding ventilation and increa-
sing diaphragm excursion (which hinders visibility). Place ports as high as possible,
but at least 26 cm above the pubis if infra-renal node dissection is desired. During the
case, the robotic arms can be adjusted externally as needed to improve access and
facilitate easier dissection in difficult areas. Use a bed that will accommodate at least
32 of Trendelenburg. Place the third operative arm above and lateral to arm no. 2,
at the level of the camera for ideal retraction in the left infra-renal space. Keep a clean
sponge in this area to prevent small bowel intrusion, and use it for blotting when
necessary. Avoid excessive trauma to the small bowel and descending colon mesen-
tery to minimize chylous lymphatic leaking. Consider bipolar energy or metallic clips
on major lymphatic trunks for the same purpose. Identify the left renal vein, the inser-
tion of the right and left gonadal veins, and the IMA before dissecting and removing
lymph nodes. A reusable endoscopic bag reduces equipment costs and allows for
serial labeling of node specimens by anatomic location as they are removed.
18.9Future directions
Lymphatic mapping for assessment of sentinel lymph nodes (SLN) is an accepted

practice for breast, melanoma, and vulvar cancers with the primary goal to reduce
morbidity of a complete lymphadenectomy. A secondary goal is to improve detection
of metastatic disease with pathology protocols that utilize ultra-sectioning of SLN and
imunohistochemical (IHC) staining [34]. Bilateral detection of pelvic SLN is reported
in 66 to 86% of cervix and endometrial cancer cases using isosulfan blue (ISB) with or
without Tecnetium-99 (Tc-99) [3538]. Roy et al in 2011 [38] reported a 7.8% increase in
SLN detection utilizing both ISB and Tc-99 compared to ISB alone, achieving a 90.6%
bilateral detection rate in patients with cervical cancer. Recently, other medical dyes
that fluoresce in light at the near-infrared (NIR) spectrum (700900 nm) using lapa-
roscopic imaging systems have been reported for use in lymphatic mapping, of which
indocyanine green (ICG) is considered the most clinically useful fluorescent dye [39].
The da Vinci NIR fluorescence imaging system is FDA cleared for vascular
imaging and is useful for confirming patency of vascular anastamoses in cardiova-
scular surgery [40]. Rossi et al in 2012 [41] described preliminary results with NIR
fluorescence imaging used with robotic-assisted surgery in patients with cervical and
endometrial cancers, recommending that a 1 mg dose of ICG was most efficacious
for lymphatic mapping. Fluorescence imaging with ICG was subsequently shown to
identify more sentinel lymph nodes and identify more metastatic disease than colori-
metric analysis of ISB in a pilot study of 35 patients [42], and all patients had bilateral
SLN detected using combination ISB and ICG with NIR imaging.
18.10Conclusions 233
Intra-operative tumor assessment utilizing gross examination and frozen

section can identify a population of patients with endometrial cancer who have a
low risk for metastasis, also know as Mayo criteria [43]. It may be possible to elimi-
nate complete lymphadenectomy for this group of patients in favor of SLN mapping.
For high-risk tumors, SLN mapping will likely increase the detection of metastatic
lymph nodes through the appropriate use of ultra-staging and IHC staining. Future
multi-institutional prospective trials will be needed to better define the sensitivity
for detection of disease and the negative predictive value of a normal SLN for low-
risk and high-risk populations.
18.10Conclusions
To date, robotic-assisted lymphadenectomy for endometrial cancer is widely accep-

ted as the preferred surgical approach to this disease. Proven benefits of decreased
blood loss, less post-operative pain, faster recovery, and equivalent efficacy regarding
staging ability and lymph node yields serve to bolster this opinion. As technology
increasingly evolves, staging procedures will become even more facile and efficient
in the hands of well-trained minimally invasive surgeons. Compelling research in the
field of sentinel node detection holds tremendous promise for future patients with
early stage disease. Many patients may safely be identified as low risk for metastasis
intra-operatively and may not require an extensive, time consuming, and potentially
morbid complete lymphadenectomy. Staying abreast of the latest technologic advan-
cements, surgical techniques, and provocative data in the field of robotic surgery and
gynecologic cancer is vital to the success of the modern-day robotic surgeon.
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19 Robotic-extraperitoneal lymphadenectomy:
A step-by-step approach
Murat Dede, Mfit Cemal Yenen and Cihangir Mutlu Ercan
19.1Introduction
Today, the incidence of cervical cancers has been decreasing due to effective screen-
ing protocols in developing countries, but it is still the second most common cancer
among women and the most frequent cause of death from gynecological cancers
worldwide [1]. Although most of the cervical cancer cases can be spotted at early
stages through smear screening tests, nearly half of them are beyond the cervix at the
time of diagnosis (locally advanced stage cervical cancer, LACC) [2].
The International Federation of Gynecology and Obstetrics (FIGO) classification
is used to determine the anatomical extent of cervical cancer. FIGO staging for cervical
cancer is an assessment of the size of the tumor and its spread to adjacent and distant
sites; stage IA1 is the earliest and stage IVB the most advanced. Staging is based on
clinical evaluation; the presence or absence of metastatic cancer in the lymph nodes
within the pelvis and abdominal cavity do not contribute to the FIGO staging [3].
Although they do not form part of the assessment of the disease stage, additional
investigations and surgical procedures may be useful in our treatment strategy [4].
The major prognostic factors of the disease are tumor stage and the presence of meta-
static disease in the lymphatic nodes, particularly those at the para-aortic level [5].
It is known that women who present with metastatic para-aortic lymph nodes have
a lower overall survival rate than those who are para-aortic node negative at presen-
tation [6]. The 5-year survival rate for women with FIGO stage IB and IIA disease is
95% as long as the node is negative with only 78% with positive lymph nodes [7]. It
is estimated that para-aortic lymph node metastasis is present in 21% of women with
stage IIB disease, 31% of those with stage III, and 13% of those with stage IVA disease
at presentation [8].
In locally advanced disease (stage IIB to IVA) the treatment of choice is the radi-
ation of primary tumor and pelvic lymph nodes, with concurrent chemotherapy [9].
Accurate detection of involved para-aortic nodes does not alter staging, but it may
result in the modification of treatment plans. Although the use of prophylactic exten-
ded field radiation including the para-aortic nodes in women with LACC is not proven
to improve survival rates, it does increase morbidity due to side effects and complica-
tions of treatment [10]. On the other hand, on local control or survival in cases with
positive para-aortic lymph nodes, extended field radiotherapy does have a positive
effect. In a large, controlled, randomized study of advanced stage cervical cancer
cases, pelvic radiotherapy and pelvic plus para-aortic radiotherapy was compared
and survival at 10 years was found to be higher in the group with additive para-aortic
radiotherapy (44% vs. 55%, respectively) [11]. Thus, accurate knowledge pertaining to
238 19 Robotic-extraperitoneal lymphadenectomy: A step-by-step approach
para-aortic nodal status is an important step to enable treatment planning such that
only those women with confirmed involved para-aortic nodes are given extended field
radiotherapy, with its individualized benefits but concurrent risks [12].
A number of techniques have been used to examine pelvic and para-aortic lymph
nodes. Computed tomography and magnetic resonance imaging have low sensitivity
and specificity in diagnosing lymph node metastasis; these techniques are restric-
ted to assessing the lymph node size [13]. Even though the reported sensitivities
range from as low as 38% to 86%, positron emission tomography, a form of functio-
nal imaging, seems to be more effective in detecting involved para-aortic nodes [12].
Therefore, for patients with LACC many physicians support the surgical assessment
of lymph nodes via performing a para-aortic lymphadenectomy before concomitant
radiochemotherapy [5, 12].
Surgical staging provides better treatment individualization, leading to a better
clinical outcome. Surgical evaluation of para-aortic nodal involvement is more reli-
able than radiological imaging, and it also contributes to treatment by the removal
of large, positive lymph nodes [5, 14]. Surgicopathologic results impact treatment
planning in up to 43% of cases [15, 16]. The surgical evaluation procedure can be
performed via laparotomy or laparoscopy through a transperitoneal or extraperito-
neal approach [1720]. Initially, open transperitoneal surgical staging was used [21].
This involves operating to remove the lymph nodes by opening up the abdominal
cavity. However, when followed by radiotherapy, this approach results in a significant
increase in morbidity with up to 30% of women requiring a second surgical proce-
dure for small bowel complications [22]. More recently, laparoscopic staging has been
proposed [23]. This technique was intended to combine the benefits of laparoscopic
access with those of the extraperitoneal approach, avoiding laparotomy-associated
trauma, preventing blood loss and intestinal adherences, and reducing the recovery
time and the occurrence of radiation enteritis [24, 25]. Finally, lymph node dissection
via the transperitoneal or extraperitoneal laparoscopic approach was developed due
to improvements in endoscopic methods [26, 27]. More recently, robotic surgery with
da Vinci surgical system (Intuitive Surgical Inc, Sunnyvale, CA, USA) that provides a
steady three-dimensional visualization started to be used in LACC patients.
Since 2000, the da Vinci surgical system has enabled the development of a
new, minimally-invasive surgical (MIS) procedure in cardiac, urological, general,
and gynecological surgery. Currently, the increasing availability of da Vinci surgi-
cal system opens up new indications and opportunities for the treatment of gyne-
cological malignancies. The extraperitoneal approach in advanced cervical cancer
staging is one such new indication. According to initial reports, lower para-aortic
lymphadenectomy is feasible in patients with LACC, but the procedures safety and
effectiveness must be demonstrated to be equivalent or better than that of conven-
tional laparoscopy [5, 26, 2831]. In this session, we tried to share our experience
with the robotic extraperitoneal lymphadenectomy procedure in patients with stage
IB2-IVA cervical cancers.
19.2Robotic-assisted retroperitoneal laparoscopic para-aortic lymphadenectomy 239
19.2Robotic-assisted retroperitoneal laparoscopic para-aortic

lymphadenectomy: Technique
Despite improvements in endoscopic surgery, robotic-assisted laparoscopic retrope-

ritoneal para-aortic lymphadenectomy remains a technically challenging operation.
The procedure has been reported in one case with testicular cancer [32] and five pati-
ents with cervical cancer [28]. More recently, a preliminary report with six cervical
cancer cases was published by Narducci et al [31].
Briefly, para-aortic node dissection consists of the resection of nodal tissue
over the distal vena cava from the level of the inferior mesenteric artery to the mid
right common iliac artery and between the aorta and the left ureter from the inferior
mesenteric artery to the left mid common iliac artery [33]. Some experts extend the
para-aortic lymph node dissection superiorly to the level of the renal veins [34].
For a robotic-assisted laparoscopic extraperitoneal para-aortic lymphadenectomy
procedure, these steps must be included: a) inform the patient about the aims and
complications of the procedure and obtain an informed consent; b) examine the
patient under general anesthesia and perform a cystoscopy; c) position the patient;
d) perform a diagnostic laparoscopy; e) enter the extraperitoneal space with intra-
peritoneal laparoscopic guidance; f) place the balloon trocar and form the retrope-
ritoneal space; g) place the surgical trocars into the retroperitoneal space; h) form
the retroperitoneal spaces surgically; i) dissect the left aortic and paracaval nodes;
and j) marsupialize the retroperitoneal space.
19.2.1Informed consent
The initial and most crucial step is informing the patient about the aim, complica-
tions, and expectations of the procedure. The given informed consent form must be
clearly understandable and, according to us, must be given in her own handwriting.
Then the patient may be scheduled for a robotic retroperitoneal lower para-aortic
lymphadenectomy.
19.2.2Examination under anesthesia and cystoscopy
Prior to surgery, the patient will receive a bowel preparation and be injected with
a single dose of 40 mg enoxaparin (BMI >25 kg/m2) the morning of surgery. First,
examination under general anesthesia for parametrial involvement and then cysto-
scopy to exclude any bladder invasion will be performed in a dorsolithotomy posi-
tion. These steps are important for the staging and prediction of advancement of
the tumor.
19.2.3Position of patient
A Foley catheter will be inserted and the patient will be placed in a naturally supine
position [28]. The patient will be positioned with the right arm at 90, left arm tucked
to her side, and her body in a moderate Trendelenburg position with right tilt to avoid
collision between the robotic arms and left arm of the patient. The da Vinci surgical
system will be positioned at the right shoulder of the patient (Fig. 19.1). The nurse and
the assistant will stand at the patients left side [31].
19.2.4Diagnostic laparoscopy
The operation will start with a transperitoneal laparoscopy through an umbilical

10-mm Hassan trocar. An orogastric/nasogastric tube placement will be appropri-
ate for decompression at the beginning of this step. A transperitoneal port is needed
to evacuate leakage of CO2 through the intraperitoneal cavity. Next the abdominal
Fig. 19.1: a) Marked port sites, after diagnostic laparoscopy, before port placement. There must be
810 cm distance between robotic camera and two robotic arms. b) Guidence of a spinal needle
for the placement of trocars. c) Da Vinci S surgical system is positioned at the right shoulder of the
patient in the left extraperitoneal technique. d) Closed port sites with adhesive wound dressing
peds at the end of the procedure
19.2Robotic-assisted retroperitoneal laparoscopic para-aortic lymphadenectomy 241
cavity will be inspected to evaluate any evidence of intraperitoneal involvement with

metastatic disease [3]. If there is evidence of peritoneal carcinomatosis, performing
extraperitoneal approach is not required [31, 35]. Diagnostic laparoscopy will also
allow us to guide a proper entry to the retroperitoneal space by avoiding the disruption
of the peritoneum during the finger dissection and in positioning the balloon trocar.
19.2.5Entering the extraperitoneal space with intraperitoneal laparoscopic

guidance
The robotic retroperitoneal para-aortic lymphadenectomy will start at this step. While
the video screen will be set on the right side at the level of the patients head [28], the
port placement will be performed with the surgeon on the left side of the patient at the
left hip and the assistant on the left side at the upper leg. The extraperitoneal access
will be performed at the level of the left McBurney point through a 15-mm incision.
Skin, subcutaneous fat, and fascia will be opened sharply along the same access. The
large muscles will be opened bluntly with the opening of the parietal fascia but not of
the peritoneal fascia. The surgeons right forefinger will be introduced into the incis-
ion and the extraperitoneal space will be separated from the overlying muscles of the
abdominal wall under laparoscopic monitoring, as described by Querleu et al [29, 36].
The extraperitoneal space may also be developed using a balloon trocar. Digital finger
dissection will be continued until the anterior surface of the left psoas muscle and
the common iliac artery on the left side are identified. Being very meticulous is vital
as the formation of the retroperitoneal space will be prevented if peritoneal rupture
occurs.
19.2.6Placement of balloon trocar and the formation of the retroperitoneal space
After the introduction of a 12-mm blunt-tip balloon trocar (Tyco HealthCare, Prince-
ton, NJ, USA) along the access created by finger dissection, the extraperitoneal space
will be insufflated with a CO2 pressure of 14 mmHg. The zero angle da Vinci lapa-
roscope and camera will be introduced through this port [28]. Following the inser-
tion of the camera into the retroperitoneal space, the psoas muscle, iliac vessels, and
ureter must be identified. At this time, the intraperitoneal pneumoperitoneum will be
emptied.
19.2.7Placement of surgical trocars into the retroperitoneal space
We usually mark the port sites and then perform sufficient incisions for surgical ports.
A spinal needle may be used for guidance under direct vision before placement of the
trocars (Fig. 19.1). In this step, two additional robotic trocars will be introduced, one
810 cm distal and medial to the scope trocar and one under the left lowest rib on
the same line as the laparoscopic trocar at a distance of 810 cm of the endoscopic
port. An assistant port with an 11-mm trocar (Applied Medical Rancho, Santa Marga-
rita, CA, USA) will be inserted at about 1 cm above the right corner of the pubic hair
in order to lift the peritoneum with the ureters and ovarian vessels and to remove
the lymph nodes. As it is described by Vergote et al, the optimum docking of the da
Vinci S robotic system is from the patients right side with the robotic arms reaching
over the patient [28]. Using the third robotic surgical arm is unnecessary due to the
limited space to place the ports. We commonly use Gyrus bipolar forceps (SP Gene-
rator, Gyrus, Maple Grove, MN, USA) through the right port and monopolar scissors
through the left port. Although the 30 scope might be opted for the dissection of the
lateral part of the caval vein to provide a better view on the paracaval area, the 0
Surgical Intuitive endoscope will be used for the dissection of the para-aortic and
pre-aortic region.
19.2.8Formation of the surgical plan at the retroperitoneal space
The steps described by Querleu et al will be followed by the development of the ext-
raperitoneal surgical space and the margins of the para-aortic lymphadenectomy
[29, 36]. The left psoas muscle will be freed cephalad up to the fascia of the left kidney
and the left ureter will be made visible by retracting the peritoneal sac above the
psoas muscle. The dissection plan will include the area between the common iliac
artery and renal vein. The space will be created in the midst of the iliac vessels, aorta,
and ureter by gripping and dissecting with the robotic arms. The final view of the
dissected aortic area will include the common iliac arteries, the aorta, the inferior
mesenteric artery, and the left renal vein [25]. Care must be taken to identify, isolate,
and preserve the inferior mesenteric artery.
19.2.9Left aortic and paracaval nodal dissection
At this point, the left common iliac and aortic lymph nodes will be dissected from
the bifurcation of the common iliac artery caudally to the renal vessels cephalad.
Following this step, we will continue to elevate the peritoneal sac over the sacral
promontory, bifurcation of the aorta, and inferior aspect of the vena cava. The right
common iliac artery will be identified and followed caudally to its bifurcation. Then,
the right ureter will be identified and lifted up together with the overlying peritoneal
sac, thus, separating it from the underlying iliac vessels and psoas muscle. At this
stage, the right lateral common iliac nodes, precaval nodes, and presacral nodes will
19.3Conclusion 243
Fig. 19.2: Robotic assisted laparoscopic-extraperitoneal lymphadenectomy procedure.

a) Para-aortic lymph node dissection and b) paracaval lymph node dissection
be dissected off (Fig. 19.2). This will complete the high para-aortic nodal dissection;
however, some experts prefer a lower retroperitoneal para-aortic lymphadenectomy
as metastases above this level are rare in cases with negative infra-mesenteric lymph
nodes [28, 37]. Hemostasis will be ensured under low pressure. The upper and bottom
limits of the lymph node dissection will be labeled using a 5-mm laparoscopic vascu-
lar clip to guide further radiotherapy. The dissected lymph nodes may be retrieved by
using a laparoscopic extractor (Coelio-extractor) or an endo-bag.
19.2.10Marsupialization of the retroperitoneal space
At the end of the procedure, a hole in the peritoneum will be created anteriorly of the
left ureter to the intra-peritoneal cavity to avoid lymphoceles. Preventive marsupiali-
zation must be performed to avoid the formation of a postoperative symptomatic ret-
roperitoneal lymphocyst by inserting a retroperitoneal drainage via the 10-mm port
above the symphysis.
At the end of the procedure, the fascia of the laparoscopic ports will be closed
with interrupted sutures of Polyglactin 2/0 (Dosan, Turkey) and the skin will be
closed with monofilament polyglycolide 4/0 (Dosan, Turkey) sutures. Then the port
sites will be closed with adhesive wound dressing materials (Fig. 19.1).
19.3Conclusion
Advances in radiochemotherapy has allowed for improved control of the disease

by adjusting radiation fields in accordance with the extent of the disease.
The presence of lymph node metastasis is a major prognosis factor influencing

survival of LACC patients [5, 3840]. Therefore, assessing lymph node involve-
ment at the para-aortic level seems appropriate to adjust radiation fields and to
tailor individualized treatment for every patient. Although imaging modalities
are improving, the gold standard for determining lymph node status is currently
surgical sampling. Retroperitoneal lymphadenectomy via laparotomy is associa-
ted with perioperative morbidity and it delays initiating radiation therapy. In the
extraperitoneal approach, fewer adhesions are observed and the complication risk
due to postoperative radiation is very low. Furthermore many adverse effects could
be prevented by not entering into the peritoneal cavity particularly postoperative
ileus, intraperitoneal adhesion, and intestinal obstruction. Other advantages of
the extraperitoneal approach include faster access to the nodal areas and no need
for adhesiolysis and intestinal mobilization. Moreover, this approach could decre-
ase the risk of inferior epigastric artery injury and rectum hematoma, and the risks
of electrosurgical intestine injury and undetected enterotomy due to dissection
and traction could completely be eliminated [29].
Dargent et al reported success rates of transperitoneal, bilateral extraperitoneal,
and left extraperitoneal para-aortic lymphadenectomy as 78%, 93%, and 95%, res-
pectively. The authors reported that converting to the transperitoneal approach rates
as 24% for the bilateral extraperitoneal and 14% for the left extraperitoneal approach.
The average removed aortic lymph node count was 15, and the mean operation time
was 119 minutes for the extraperitoneal approach. They concluded that operation
time could be decreased by using the left extraperitoneal technique [26].
Although laparoscopy has proven to be feasible, it is still a technically chal-
lenging operation. As the robotic da Vinci surgical system provides a steady, three-
dimensional view, instruments with articulating tips, and less reliance on the
surgeons movements (increasing accuracy and precision), it could facilitate the
retroperitoneal para-aortic lymphadenectomy procedure [41]. Vergote and cowor-
kers reported on the technique and operative results of robotic retroperitoneal
para-aortic lymphadenectomy in five patients with IIB or IIIB disease [28]. From
the authors preliminary experience, robotic para-aortic lymphadenectomy might
be more advantageous than standard laparoscopy. Our early experience on LACC
patients suggests that para-aortic lymphadenectomy up to the left renal vein is
feasible by robotic-assisted laparoscopy.
Our experience is limited in its scope due to the relative newness of the tech-
nique. Further studies with extended follow up periods are needed to confirm that
the robotic extraperitoneal approach is as safe as laparoscopy [42]. Moreover, robotic-
assisted laparoscopy is currently more expensive than the laparoscopic approach.
Therefore, the oncological outcomes and cost effectiveness of this new, MIS approach
needs to be verified through prospectively larger series before reaching any definitive
conclusions.
References 245
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20 Robotic surgery for ovarian cancer
Lyuba Levine and Gwyn Richardson
20.1Introduction
Approximately 22,000 women will be diagnosed with ovarian cancer and more than
15,500 women will die from their disease in 2012 in the USA [1]. Women have a 1 in
72 lifetime risk of developing ovarian cancer. The 5-year survival rate of women diag-
nosed with ovarian cancer in the USA was 43.7% from 2002 to 2008 [1].
A patients survival rate is directly correlated to the stage at diagnosis. About 15%
of patients will have early-stage disease confined to the ovary at the time of diagnosis
[2]. Such patients have a much better outcome, with a 5-year survival rate greater than
90% [2]. Patients with advanced disease have a 5-year survival rate close to 25%.
Most often, early-stage ovarian cancer is identified at the time of oophorectomy
for a presumed benign adnexal mass [3]. The adnexal mass may have been inci-
dentally identified in an asymptomatic patient or discovered in the evaluation of a
symptomatic patient. Prior to surgery, most patients will have undergone a thorough
history, physical examination and evaluation with radiologic imaging and possibly
serum markers such as CA125 [4]. Risk factors for ovarian cancer such as a family
history of cancer, increasing age, nulliparity, endometriosis and infertility, will also
have been evaluated [4]. Particular findings on radiologic imaging such as papillary
projections, solid components or excrescences may raise the index of suspicion for a
malignant process [4]. Similarly, a significantly elevated CA125 in a postmenopausal
patient may also raise concerns.
Most benign-appearing adnexal masses are removed by benign gynecologist and
thus patients may have incomplete staging and suboptimal debulking. When pre-
sumed early-stage ovarian cancer patients undergo comprehensive surgical staging,
almost one-third are upstaged [5].
The International Federation of Obstetrics and Gynecology (FIGO) surgical
staging for ovarian cancer includes hysterectomy, bilateral salpingo-oophorectomy,
omentectomy, pelvic and para-aortic lymph node sampling, peritoneal biopsies and
peritoneal cytologic washings. Comprehensive surgical staging provides important
information to guide treatment planning and patient counseling. Optimal cyto-
reduction confers a significant survival advantage in patients with advanced ovarian
cancer.
Traditionally, a vertical midline abdominal incision is used to stage ovarian
cancer patients. Such an incision affords excellent exposure to the peritoneal cavity
and allows exploration of both the pelvis and upper abdomen. Thorough evaluation
of the peritoneum, diaphragm, bowel and its mesentery in addition to the pelvic and
upper abdominal structures is required to complete surgical staging. Bowel resection
250 20 Robotic surgery for ovarian cancer
and reanastomosis, diaphragmatic stripping and extensive surgery involving upper

abdominal structures including the spleen, pancreas or liver may be required to opti-
mally debulk patients with ovarian cancer.
Because minimally-invasive surgery (MIS) typically has fewer complications
including less blood loss, decreased postoperative pain and quicker recovery, there
has been interest in using minimally-invasive techniques to stage patients with
ovarian cancer, particularly if they have a low-malignant potential tumor or are early-
stage. In patients with diffuse wide-spread metastasis, MIS has not generally been
recommended due to the decreased chance of optimal cytoreduction and increased
risk of vascular and bowel complications intraoperatively [6].
There are no large randomized-controlled trials comparing traditional laparo-
tomy to MIS in patients with ovarian cancer. The available literature is limited to ret-
rospective reviews, case-control studies and case series. The majority of these studies
evaluate traditional laparoscopy [7]. The robotic surgery literature is limited to case
reports, retrospective reviews and case series [8].
This chapter reviews the potential use of robotic surgery in staging low-malignant
potential (LMP) ovarian tumors, early-stage invasive ovarian cancer and a potential
utility for patients with advanced ovarian cancer. The chapter also reviews several
pitfalls of MIS in ovarian cancer including inadequacy of staging, risk of cyst rupture,
port-site metastasis and tumor cell dissemination with carbon dioxide pneumoperi-
toneum. The vast majority of the studies available that involve MIS are laparoscopic
studies. Results from case series, retrospective reviews and case-control studies indi-
cate that ovarian cancer staging for low-malignant potential tumors and early-stage
cancers is both safe and effective.
20.2Benefits of minimally-invasive surgery
When compared to laparotomy, MIS for borderline and early ovarian cancer offers a
number of benefits. Previous randomized and retrospective studies in endometrial
cancer suggest that laparoscopic staging offers shorter hospital stay, less blood loss
and fewer postoperative complications including earlier return of bowel function
when compared to laparotomy [910]. Although no randomized data exists for pati-
ents with early-stage or low-malignant potential ovarian cancer, the bulk of retrospec-
tive data suggests these benefits can be extrapolated to include patients undergoing
comprehensive staging for early ovarian cancer.
20.3Low-malignant potential or borderline ovarian tumors
Low-malignant potential tumors comprise up to 15% of early-stage ovarian cancers.

Most of these tumors are confined to the ovary and patients have a greater than
20.3Low-malignant potential or borderline ovarian tumors 251
95% 5-year survival rate [11]. Low-malignant potential tumors frequently occur in
premenopausal women aged 30 to 50 years with up to 85% of patients diagnosed
with stage I cancers [12]. A prior study of over 300 patients of varying histologic
subtypes found up to 30% of patients diagnosed with low-malignant potential
tumors at the time of frozen section were subsequently found to have invasive
ovarian cancer on final pathology [13].
Low-malignant potential tumors are most commonly serous and mucinous his-
tologic subtypes. Up to 30% of serous tumors are bilateral with concurrent perito-
neal involvement in 35% of cases [14]. Almost 42% of patients with serous tumors had
nodal involvement in one study [15]. In contrast, very few mucinous low-malignant
potential tumors have lymph node involvement [16]. Frequently appendiceal prima-
ries are identified in patients with mucinous low-malignant potential ovarian tumors,
so appendectomy is recommended [11].
Because many patients with low-malignant potential tumors desire future ferti-
lity, efforts have been made to use minimally-invasive techniques to decrease adhe-
sion formation and theoretically improve fertility [17]. The literature involving staging
of patients with low-malignant potential tumors using minimally-invasive techniques
shows promising results but is limited to case series and retrospective analysis.
Several case series have been published analyzing the clinical outcome of pati-
ents undergoing laparoscopic staging of low-malignant potential ovarian tumors.
The largest retrospective cases series to date suggested that laparoscopy had a
higher rate of incomplete staging and cyst rupture [18]. In this study, Fauvet et al
analyzed data from 358 women who underwent surgery for low-malignant poten-
tial tumors at multiple institutions in France. One hundred and forty-nine (41%)
of women underwent laparoscopy were compared to 209 women who underwent
laparotomy. Forty-two women underwent conversion from laparoscopy to lapa-
rotomy because of suspected ovarian cancer or large tumor volume. Women who
underwent laparoscopy were more likely to have undergone conservative surgery
(unilateral cystectomy, bilateral cystectomy and unilateral salpingoophorectomy)
than the laparotomy group (68.9% vs. 31.6%, respectively), which likely explains
the lower rate of complete surgical staging. Mean followup was 27.5 months with
100% survival and only four patients with evidence of disease. A later retrospective
study compared 61 patients who underwent laparotomy vs. 52 patients who under-
went laparoscopy and did not find a difference in progression-free survival with a
mean follow-up of 44 months [19].
Additional studies support laparoscopic surgical staging of low-malignant poten-
tial tumors (Tab. 20.1).
Lenhard et al reported on their long-term followup of patients who underwent
staging via laparotomy (n = 95) or laparoscopy (n = 18) [20]. The mean follow-up was
9.6 years and the recurrence rate was similar in women who underwent conservative
surgery (10.5%) and those who underwent traditional surgical staging (10%), which
is in contrast to the study by Fauvet.
Tab. 20.1: Laparoscopic management of borderline ovarian tumors
Author No. of Conversions Complications Mean Recurrences Survival n

patients to laparotomy (n) follow-up n (%) (%)
n (%) (months)
Darai et al 25 7 (28) 0 41 3 (12) 23 (92)

1998 [21]
Querleu et al 30 0 3 29.1 1 (3.2) 30 (100)
2003 [22]
Camatte et al 34 0 0 45 6 (17.7) 34 (100)
2004 [23]
Fauvet et al 149 42 (28.2) 0 27.5 13 (12.1) 107 (100)
2005 [18]
Romagnolo et al 52 0 44 7 (13.5) 51 (98.1)
2006 [19]
Lenhard et al 18 0 115.2 1 (5.5) 18 (100)
2009 [20]
The overall survival rate of patients undergoing laparoscopic staging for border-
line tumors of the ovary approaches 98%. Continued evaluation of long-term outcome
should occur but initial studies show promise for minimally-invasive techniques to
stage low-malignant potential tumors.
20.4Early-stage invasive ovarian cancer
Approximately 15% of women will have early-stage ovarian cancer at diagnosis. The
diagnosis of early ovarian cancer is frequently made incidentally at the time of surgery
for another indication. In such cases, complete surgical staging provides important
prognostic information, avoids understaging patients and guides treatment recom-
mendations. Traditionally, patients undergo total abdominal hysterectomy, bilateral
salpingo-oophorectomy, omentectomy, peritoneal biopsies, pelvic and paraaortic
lymph node dissection and peritoneal washings. If complete staging is not performed
at the time of initial surgery, a restaging procedure via laparaoscopy or laparotomy is
recommended.
As MIS has become more prevalent, recent studies have sought to address its
appropriateness for patients with early ovarian cancer. Staging for early ovarian
cancer requires careful inspection of the peritoneum, pelvic and abdominal structu-
res and lymph node dissection. To determine whether MIS is feasible to stage early
ovarian cancers several issues must be addressed: the frequency of complications,
the frequency of conversion to laparotomy and the recurrence rate after minimally-
invasive staging [6]. Due to the rarity of early-stage ovarian cancer and difficulty in
early diagnosis, a randomized controlled trial has not been possible. However, several
case reports and series have been published.
20.4Early-stage invasive ovarian cancer 253
The first case report of laparoscopic restaging in early-stage invasive ovarian

cancer was published in 1994. The retrospective report included complete pelvic and
paraaortic lymph node dissection in a case series of nine patients undergoing resta-
ging procedures for either fallopian tube or ovarian cancer [24]. Patients in this study
had a mean blood loss of 300 mL and a hospital stay of 2.8 days.
A prospective study published in 1995 of 14 patients undergoing primary or res-
taging early ovarian cancer confirmed a shorter hospital stay and suggested similar
accuracy rates between laparoscopy and laparotomy based on an upstaging rate of
57% (8/14), which was slightly greater than the published laparotomy rate at the time
[25]. In particular, the authors found that the magnification of the hemidiaphragm
using laparoscopy might yield a higher detection rate than palpation used at laparo-
tomy.
Studies published since then have sought to address potential complications,
conversion to laparotomy and survival data.
Three case control series were published by 2008 that compared laparotomy and
laparoscopy. Chi et al reported 20 laparoscopic patients with 30 laparotomy patients
who underwent primary surgery or restaging procedures [26]. Nodal counts, rate of
upstaging, complication rate and omental specimen size were similar between the
two groups. Hospital stay and blood loss were less in patients undergoing laparo-
scopy but the mean surgery time was 321 min compared to 276 min in the laparotomy
group. Ghezzi et al compared 17 patients undergoing laparoscopy with 17 patients
undergoing laparotomy and found no difference in nodal count, complication rate
or likelihood of metastatic disease [27]. Park et al reported on a more rapid return of
bowel function with less postoperative complications in patients undergoing laparo-
scopic procedures [28].
The Gynecologic Oncology Group evaluated the feasibility of laparoscopic com-
pletion of surgical staging in patients with incompletely staged ovarian, fallopian
tube, endometrial and primary peritoneal cancer in Protocols 9,302 and 9,402 [29].
Seventy-four of 84 eligible patients had ovarian, fallopian tube or primary peritoneal
cancers. Fifty-eight patients underwent complete laparoscopic staging, confirmed
with photographic documentation. Nine patients were incompletely staged laparo-
scopically secondary to lack of bilateral lymph nodes, cytology or peritoneal biopsies.
Seventeen patients underwent laparotomy: 13 because of extensive adhesive disease,
three because of complications and one because of macroscopic metastatic disease.
Among patients treated laparoscopically, five patients had a bowel injury, one had a
cystotomy, one developed a small bowel obstruction, one had a venotomy and two
required a blood transfusion. Compared to patients undergoing laparotomy, patients
who underwent laparoscopic staging had a significantly shorter hospital stay, less
blood loss and comparable nodal counts.
Most recently, Ghezzi et al published the results of a multi-institutional cohort eva-
luating laparoscopic staging of early ovarian cancer [30]. No patients were converted
intraoperatively to laparotomy. Only one patient had an intraoperative hemorrhage
requiring transfusion. One patient did require a reoperation that included a laparotomy
for a retroperitoneal hematoma identified 7 hours after her initial surgery. Thirty-four
of 82 women had reached or exceeded 3-year follow-up with a 97% 3-year survival rate
and 91.2% disease free survival rate.
Table 20.2 summarizes the laparoscopic literature for early ovarian cancer staging.
20.5Advanced-stage invasive ovarian cancer
Given the multiple complicated surgeries typically involved in cases of advanced

ovarian cancer, MIS has not generally not been recommended [6].
Magrina et al recently reported a retrospective case-control study of 25 patients
who underwent primary surgical debulking via robotic approach, 27 patients who
underwent debulking via laparoscopic approach and 119 patients who were surgi-
cally debulked via laparotomy [31]. Sixty and 75 percent of patients had stage III or
IV disease in the robotic and laparoscopy groups, respectively, and 87 percent of the
laparotomy group patients were stages III and IV. The rest of the patients had stage I
and II disease. Patients were categorized based on the extent of surgery and number
of procedures required to achieve optimal cytoreduction. Complete cytoreduction was
defined as no remaining visible disease at the end of the procedure. The robotics group
took significantly longer (315 min) compared to the laparoscopy (254 min) or laparo-
tomy (261 min) groups. However, the robotics group had less blood loss and a shorter
hospital stay than either the laparoscopy or laparotomy group. Optimal debulking was
achieved in 84% of patients in the robotic group, 93% of patients in the laparosco-
pic group and 56% of the laparotomy group (P < 0.001). After 3 years, there was no
difference in the overall survival among the three groups. Among patients requiring
one major additional surgical procedure, the authors recommend robotic or laparosco-
pic approach for primary tumor debulking. If patients require more than two or major
surgical procedures, then the authors recommend an open procedure. Because of the
inherent patient selection bias in choosing patients for each surgical method and the
retrospective nature of the data, the results must be interpreted and used with caution.
20.6Considerations
The use of robotic surgery in ovarian cancer has been primarily recommended for
borderline tumors and an early-stage ovarian cancer. MIS has not been recommended
for advanced ovarian cancer with gross metastatic disease due to low likelihood of
optimal tumor debulking and increased risk of surgical complications especially with
liver involvement [32].
Port-site metastasis are still of concern as well as effect of CO2 pneumoperito-
neum on tumor growth, tumor rupture and associated peritoneal seeding. The risk of
port-site metastasis has been evaluated in several retrospective series and reported to
be 1 to 2%.
Tab. 20.2: Laparoscopic literature for early ovarian cancer staging
Author No of patients Operative time Blood Length of Complications Upstaged Follow-up Current
(min) loss (mL) stay (%) (months) status
Querleu et al 1994 9: all 227 <300 2.9 1 Postoperative ecchymosis n/a n/a n/a
[24] restaging
Childers et al 1995 14: 5 restaging n/a n/s 1.6 1 IVC injury 40 n n/a
[25] 1 abdominal ecchymosis
Chi et al 2005 [26] 20: 13 312 235 3.1 0 n/a n/a n/a
restaging
Ghezzi et al 2007 [27] 15: 5 restaging 377 n/a 3 1 retroperitoneal hematoma, 27 16 20 NED
requiring exploration with
laparatomy
1 lymphedema
Park et al 2007 [28] 17: 6 restaging 303.8 231.2 8.9 1 thermal ureteral injury 5.8 19 1D
treated with stent 1 external 16 NED
iliac vessel laceration repaired
laparoscopically
Nezhat et al 2009 36: 9 restaging 229 195 2.37 1 intraoperative transfusion 17.6 55.9 34 NED
[33] for preoperative anemia 1
SBO managed conservatively
2 lymphoceles managed
conservatively 1 lymphocyst
requiring drainage
Ghezzi et al 2012 [30] 82 263 100 n/a 1 Hemorrhage requiring 25.6 34 78 NED
transfusion
1 retroperitoneal hematoma
20.6Considerations
requiring laparotomy
5 febrile morbidity
5 lymphorrhea 1 lymphocyst
requiring drainage
255
1 lymphedema
Two large retrospective series from Memorial Sloan-Kettering [34] and from the
MD Anderson [35] cancer centers reported similar incidence of 1.18% and 1.1%, res-
pectively. Use of CO2 or CO2 dilution with O2 did not affected risk of port-site metastasis
[36] . Laparoscopy has found to be associated with higher incidence of intra-operative
cyst rupture. This potentially could lead to patient being upstaged and require adju-
vant chemotherapy. It was reported that intra-operative cyst rupture in stage I ovarian
cancer has been associated with decreased progression free survival [37]. Appropriate
patient selection, use of endobag and meticulous techniques are imperative in these
cases.
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21 Risk-reducing bilateral salpingo-oopherectomy in
BRCA mutations career
Ibraham Alanbay, Banu Arun and Fatih Sendag
21.1BRCA1/2 mutations
Breast and ovarian cancer are the second and fifth causes of cancer death, respectively,
especially in Western countries [1]. The majority of ovarian cancers are sporadic, and
only 710 % are due to mutations in hereditary genes and the majority of these are due
to germline mutations in the BRCA1 and BRCA2 genes [1]. Women who have inherited
mutations in the BRCA1 or BRCA2 mutation are at high risk to develop both breast
and ovarian cancer. While a womans lifetime risk of developing ovarian cancer in the
general population is about 1 in 70, or 1.4% [2]; women who have a germ-line BRCA1 or
BRCA2 mutation, have an estimated risk of ovarian cancer ranging from 36% to 46%
and 10% to 27%, respectively [35].
Cumulative breast and ovarian cancer risks have been found (up to an age of 70
years) to be up to 65 and 40%, respectively, for BRCA1 carriers; and up to 49 and 18%,
respectively, for BRCA2 carriers [2, 6, 7]. Ovarian cancer risks are low before the age
of 40 and 50 years in BRCA1 and BRCA2 mutation carriers, respectively. The ovarian
cancers associated with BRCA mutations usually are diagnosed at a younger age as
high-grade, advanced-stage serous carcinomas, surgical and pathological character-
istics similar to sporadic cancers. Women with BRCA1/2 mutations also have increa-
sed risk for fallopian cancer and primary peritoneal carcinomas [810]. The lifetime
risks of fallopian and primary peritoneal cancer in BRCA1 and BRCA2 mutation car-
riers has been reported to be 0.6% and 1.3%, respectively [10]. A study suggest that
primary peritoneal papillary serous carcinoma risk amongst BRCA2 carriers is lower
than amongst BRCA1 carriers [11].
BRCA1 mutation carriers also have a risk for uterine serous papillary carcinoma,
however, the occurrence rate is very rare;only 12 cases/1,000 BRCA mutation carriers
[1214].
This article will review BRCA mutations and BRCA- associated gynecologic cancer
and risk management. In this article, the rationale and efficacy of risk reducing
salpingo-oophorectomy (RRSO), timing of surgery, pathologic review of RRSO, cont-
roversies regarding hysterectomy with RRSO, new surgical methods of surgery will be
discussed.
21.2Risk-reducing strategies
The recommended strategies for reducing the risk of ovarian cancer in women with
BRCA mutations include prophylactic bilateral salpingo-oophorectomy (RRSO: risk
260 21 Risk-reducing bilateral salpingo-oopherectomy in BRCA mutations career
reducing salpingo-oopherectomy), chemoprevention with oral contraceptives, and

regular screening of ovaries with annual pelvic examination, ultrasound and serum
CA-125 [15]. The combination of a pelvic examination, CA125, and transvaginal ultra-
sonography should start by age 35 years or 5 to 10 years before the earliest age of first
diagnosis of ovarian cancer in the family [16].
The RRSO is important due to ovarian cancer screening tests that mainly based
on pelvic examination, serum CA125, and transvaginal ultrasound are inefficient to
detect early ovarian cancer, which substantially influences survival in BRCA1/2 muta-
tion carriers [1721]. In a retrospective study, with a consecutive number of 241 women
with BRCA1/2 mutation evaluated screening methods included annual pelvic exami-
nation, transvaginal ultrasound and serum CA125 measurements, showed that the
effectiveness of those methods in detecting ovarian cancer was disappointing, with
low sensitivities and very low positive predictive values. Furthermore, all detected
cancers were found in an advanced stage. A positive predictive value (PPV) of strate-
gies are 20%, 33%, and 6% for pelvic examination, TVU, and CA125, respectively [22].
21.3Risk reducing salpingo-oopherectomy (RRSO)
Because of limitations in the efficacy of screening in BRCA mutations career, RRSO

has become an important choice of the management options in hereditary breast-ova-
rian cancer syndrome. Surgical removal of the fallopian tubes and ovaries is the most
effective method of prevention in high-risk women for breast and ovarian cancer.
RRSO can eliminate future development of ovarian cancer risk and also significantly
reduce breast cancer risk due to the ablation of ovarian hormones and therefore their
negative effects on breast tissue. Bilateral prophylactic salpingo-oopherectomy (elec-
tive salpingo-oophorectomies) is the removal of the ovaries for the potential benefit
of preventing long-term morbidity and mortality that describes the removal of ovaries
with tuba prior to the occurrence of clinically apparent ovarian or fallopian cancer at
the time of removal [2, 23].
RRSO can reduce ovarian cancer risk by 8595% and breast cancer risk by
5060% in BRCA1 and BRCA2 mutation carriers if surgery is performed before meno-
pause [2426]. A study showed that RRSO is the most effective option for prevent-
ing ovarian/tubal cancer in women at high risk for the disease, with a hazard ratio
(HR) for ovarian cancer of 0.21 (95% CI 0.120.39) in BRCA1/BRCA2 carriers [27]. In a
large, retrospective analysis of 551 BRCA carriers, RRSO was found to reduce the risk
of ovarian cancer by 96% and breast cancer by 53% at a mean follow-up of 9 years
[25]. Similar findings have been observed in a prospective study of 170 BRCA carriers
during a mean follow-up of 2 years, the incidence of ovarian or peritoneal cancer and
breast cancer was significantly greater in women who were selected for surveillance
than in those who underwent RRSO [26].
21.3Risk reducing salpingo-oopherectomy (RRSO) 261
Recently, Rebbeck et al carried out a meta-analysis of ten studies which

investigated breast or gynecologic cancer outcomes in BRCA1/2 mutation carri-
ers who had undergone PBSO. The authors subsequently concluded that PBSO
was associated with a statistically significant reduction in breast cancer risk in
BRCA1/2 mutation carriers. Similar risk reductions were observed in BRCA1 muta-
tion carriers and in BRCA2 mutation carriers. Furthermore, PBSO was associated
with a statistically significant reduction in the risk of BRCA1/2-associated ovarian
or fallopian tube cancer; however, data were deemed insufficient to obtain sepa-
rate estimates for ovarian or fallopian tube cancer risk reduction. Moreover, PBSO
was strongly associated with reductions in the risk of breast, ovarian, and fallo-
pian tube cancers, and should provide guidance to women in planning cancer
risk-reduction strategies [27].
A study including 1,079 women with BRCA1 or BRCA2 has shown that RRSO was
associated with an 85% reduction in BRCA1-associated gynecologic cancer risk [hazard
ratio (HR) = 0.15; 95% CI, 0.04 to 0.56] and 72% reduction in BRCA2-associated breast
cancer risk (HR = 0.28; 95% CI, 0.08 to 0.92) during a 3-year follow-up. However, neither
the reduction of BRCA1-associated breast cancer nor BRCA2-associated gynecologic
cancer reached statistical significance [28]. In addition, a retrospective short-term
follow-up study confirmed that RRSO was associated with a 90% reduction in breast
cancer-specific mortality, a 95% reduction in gynecologic cancer-specific mortality,
and a 76% reduction in overall mortality [28].
Although several studies demonstrate that RRSO decreased the risk of both breast
and ovarian cancers in BRCA1/2 mutation carriers, these studies were heterogeneous
and used different study designs, inclusion criteria and definitions are confounding
factors that may interfere with results. For example, while some studies included
unaffected mutation-positive women and followed them up; others included ovarian
cancer risk-women with breast cancer.
There are no randomized controlled trials evaluating the potential benefits
or harm of prophylactic surgery. Because of the small number of BRCA mutations
studies, multi-center studies are needed. However, such studies are complicated
by the fact that there is no standardization in regards to surgical risk-reducing
techniques.
The decision to proceed with prophylactic surgery is largely patient driven
depending on the patients perception of risk and how she values the psychosexual
function of the breast and ovaries. It is observed that many women who undergo
BRCA testing use these results to choose risk-reducing surgery within months of
receiving BRCA-positive results. Predictors of risk-reducing surgery uptake are: age
below 60 years, prior breast cancer, and utilization of another risk-reducing surgery.
A prospective study of unaffected BRCA1/2 carriers (n = 244) by using multivariate
Cox proportional hazard modeling has shown that time to surgery is shorter when
the psychological impact of BRCA1/2 result disclosure is stated to be higher. The
study also revealed that uptake of risk-reducing salpingo-oophorectomy is quicker

in the older women and those with at least two children. Time to surgery is shorter
when there is a first-degree relative with ovarian/breast cancer. The authors conclu-
ded that time to prophylactic surgery depends on the stated psychological impact
of disclosure and on womens cognitive anticipation of surgery after adjusting for
sociodemographic characteristics [29].
21.4Time of RRSO
Ovarian cancer diagnoses is rare before the age of 40 years in women with hereditary
breast and ovarian cancer. The average age of ovarian cancer diagnosis is 52 years
for women with BRCA1 mutations and 60 years for those with BRCA2 mutations [30,
31]. The optimal age to perform RRSO in BRCA1 and BRCA2 carriers is uncertain.
The National Comprehensive Cancer Network (NCCN) and Society of Gynecologic
Oncology (SGO) guidelines recommend that women with BRCA1/2 mutations should
undergo RRSO to reduce their cancer risk, generally by age 40 or after the comple-
tion of childbearing [32]. However, there are wide-ranging implications of this surgery
for a womans well-being, particularly for women who elect to have surgery prior to
menopause.
21.5Primary peritoneal carcinoma after RRSO
Despite the significant risk reducing effect of RRSO, it has been demonstrated that
this procedure does not completely eliminate cancer risk. Case reports of high-risk
women developing primary peritoneal carcinoma after RRSO have been reported
numerous times over the past 30 years, but the overall risk is difficult to precisely
quantify. Primary peritoneal cancer has been reported in women with BRCA1/2
mutations following RRSO, with an estimated frequency of 25%, and may occur
more frequently in BRCA1 compared to BRCA2 carriers [24, 28]. After salpingo-
oophorectomy, women still remain at risk of primary peritoneal carcinoma. Find-
ings of a large registry study indicated a 4.3% risk of primary peritoneal cancer at
20 years after risk-reducing salpingo-oophorectomy in BRCA mutation carriers. Many
cases of primary peritoneal cancer occur within 2 years of risk-reducing salpingo-
oophorectomy, suggesting that an occult cancer may have been missed at the time
of risk-reducing salpingo-oophorectomy [24]. Primary peritoneal cancer risk appears
to be higher after risk-reducing salpingo-oophorectomy when salpingectomy is not
performed, suggesting that occult cancer in fallopian tubes may seed the peritoneal
cavity [11]. Nevertheless, prophylactic BSO has been shown to be effective in spite of
a 35% residual risk of primary serous peritoneal carcinomatosis. In addition, occult
adnexal carcinomas can be detected thanks to RRSO [5, 19, 28, 33]. However, many of
21.6Occult cancer at the time of RRSO 263
the primary peritoneal cases occurred within 2 years, suggesting that an occult cancer
may have been missed at the time of surgery, and the real risk would be much lower
[24]. There is insufficient evidence to warrant monitoring these women postopera-
tively with serial CA125 measurements which may play a role in screening for perito-
neal cancer after RRSO [34]. The Gynecologic Oncology Group is conducting just such
a trial to explore the role of CA125 in BRCA carriers before and after RRSO (Protocol
199) that may highlight screening after RRSO.
Another author suggested that after RRSO cases of peritoneal carcinoma might
occur in women who had an occult malignancy that was not detected at the time of
surgery, or possibly had incomplete operations with remnants of the infundibulopel-
vic ligament or fallopian tube left in situ [35].
21.6Occult cancer at the time of RRSO
Both clinical and occult ovarian and tubal cancers have been found at the time of
risk-reducing procedures. The detected occult cancer rate after RRSO has a wide
range (range 017%, mean 4.7%) [3640]. A recent study compared women with
BRCA mutations (n: 117) to women who unknown BRCA muations (n = 191), those
who underwent risk-reducing surgery have shown that the overall occult invasive
cancer rate was 5.1% (95% CI 1.910.83) in BRCA1/BRCA2 carriers and 1.05% (95% CI
0.133.73) in untested women. When tubal in situ cancers were included, the overall
rate was 4.55% (95% CI 2.57.5). The authors concluded that the occult invasive/
in situ cancer rate for both BRCA1/BRCA2 carriers (8.55%) was significantly higher
than that of women with unknown mutation status [41]. Another study showed that
the risk of occult neoplasia was 9.7% (6/62) in BRCA1/2 carriers over age 45 and
the risk of occult neoplasia was 18.8 %. Those data demonstrated that older age is
a significant risk factor for premalignant or malignant lesions at RRSO specimen
[38, 42]. The large series evaluated 647 BRCA1/2 mutation carriers from 18 centers
(PROSE Consortium) detected occult cancer in 16 of 647 women (2.5%) [42]. The
variation of occult cancer rate might be due to several reasons. While low rate might
reflect missed ovarian tumors due to inefficient pathological examination of the
surgical specimen or the sample involved women who were relatively young in age,
the high level may represent an extensive pathologic review, biases due to sample
selection, or have involved women who were relatively older in age [42]. As older age
at the time of RRSO is associated with increased probability of finding an occult car-
cinoma, pathologists should be more aware of doing meticulous pathologic exami-
nations. For example, Powell et al have reported a rigorous post- RRSO pathologic
assessment including cytology of peritoneal washings, serial sectioning of ovaries
and fallopian tubes, peritoneal and omental biopsies in 67 RRSO procedures, seven
(10.4%) occult malignancies were found in the ovaries and fallopian tubes [43].
However, the role of peritoneal washing or random peritoneal biopsies is uncertain.
21.7Health proplems after RRSO
The benefit of RRSO needs to be weighed against its impact on of quality of life [44].
A study evaluated patients who underwent prophylactic surgery who completed
questionnaires before and 1 year after surgery. The findings of study revealed that
subjects who were premenopausal at the time of surgery (n = 75) experienced a
significant worsening of vasomotor symptoms (hot flashes, night sweats and swea-
ting) and a decline in sexual functioning (desire, pleasure, discomfort and habit).
The increase in vasomotor symptoms and the decline in sexual functioning were
mitigated by HRT, but symptoms did not return to pre-surgical levels. HRT decreased
vaginal dryness and dyspareunia; however, the decrease in sexual pleasure was not
alleviated by HRT. Satisfaction with the decision to undergo prophylactic salpingo-
oophorectomy remained high regardless of increased vasomotor symptoms and
decreased sexual function.
21.8Technique of RRSO
Risk-reducing surgery should include careful inspection of the peritoneal cavity and
surfaces, pelvic washings, and ligation of the ovarian vessels at least 2 cm away from
the end of visible ovarian tissue, approximately at the level of the pelvic brim [2].
Performing risk-reducing salpingo-oophorectomy in women at an increased risk of
ovarian cancer necessitates complete removal of the ovaries and fallopian tubes. If
hysterectomy is not performed, care must be taken to completely remove the fallopian
tubes to the level of the corpus, because most of the earliest microscopic neoplasms
originate in the fallopian tube [38, 43]. A study re-evaluated 14 consecutive hysterec-
tomy specimens complete cross-sections with a 3-mm interval of the tubal lumen from
the outside of the uterus at the cutoff point of the current BSO procedure to the uterine
cavity and examined for the presence or absence of tubal type (ciliated) epithelium
and subepithelial endometrial stroma. This remaining section of the tube shows a
lumen that is mainly lined with unilayered tubal type (ciliated) epithelial cells. This
finding indicates that in almost all cases at least about 1 cm of risk-bearing epithelium
is left behind at both sides of the uterus after prophylactic surgery [45].
21.9RRSO with/without hysterectomy
The role of hysterectomy as part of the prophylactic surgical procedure is controver-

sial. When salpingo-oophorectomy is performed primarily for prevention of ovarian
cancer or for the hormonal therapy of breast cancer, hysterectomy is not required.
Theoretically, hysterectomy allows more complete removal of the fallopian tube,
however, the interstitial component of the fallopian tube is not a known location of
21.10Radical fimbriectomy: As a new temporary risk reducing surgery 265
tubal cancer [46]. A large clinical-pathological study revealed that 92% of 105 tubal
carcinomas developed in the distal-or mid-portion of the tuba [47]. There are no
data to suggest that uterine preservation results in higher cancer risks in BRCA1 or
BRCA2 mutation carriers. However, careful consideration should be made regarding
the benefits and risks of elective hysterectomy in each woman, including individual
risk factors for endometrial and cervical cancer. However, hysterectomy can be taken
into consideration for other reasons, such as the reduction of endometrial cancer risk
associated with tamoxifen treatment for a previous breast cancer [48], or the elimi-
nation of the low risk of uterine serous papillary carcinoma [1213]. However, studies
from both Canada and the USA have not been able to demonstrate that serous cancer
of the endometrium is more common in mutation carriers than the general popula-
tion [49]. Also, additional morbidity due to a higher rate of infections, hematomas
and blood loss should be taken into consideration.
21.10Radical fimbriectomy: As a new temporary risk reducing

surgery
Prophylactic BSO can be associated with significant adverse effects. Although poorly
documented, morbidity from laparoscopic BSO is low but not nil and postoperative
climateric symptoms might be severe [50, 51]. Some young BRCA mutation carri-
ers, especially those with a history of breast cancer may be reluctant to undergo
prophylactic BSO despite their awareness that oophorectomy is associated with
a significant reduction in both ovarian and breast cancer risk [52]. Leblanc et al
recently suggested a novel surgical concept, called the radical fimbriectomy. The
technical principle is based on a complete removal of both fallopian tubes and
the fimbrio-ovarian junction. This procedure intends to protect those women who
decline to undergo prophylactic BSO and wish to preserve part of their ovaries for
hormonal or fertility functions, until they either reach menopause or undergo BSO
at a later date [52]. Briefly, the procedure is performed using a classical 4-trocar
laparoscopy and radical fimbriectomy consists of resecting the fallopian tube from
the uterine level to the ovary, resecting the totality of the terminal part of tube or
fimbria along with its attachment to the underlying ovary. The tube is then dissected
free from mesosalpinx to the fimbria, by simple sharp dissection. The authors con-
cluded that radical fimbriectomy is safe temporary choice of risk-reducing surgery
in BRCA mutation.
21.10.1Laparoendoscopic single-port surgery (LEES) for RRSO
Risk-reducing salpingo-oophorectomy (RRSO) with or without hysterectomy is per-

formed usually a minimal-invasive approach. Robotic approach is allowed for a
three-dimensional view, dexterity and ergonomics with laparoscopic surgery. Further-

more, to overcome disadvantages of the minimal-invasive approach either laparo-
scopy or robotic surgery such as requirements of more ports, large trocar port inci-
sions, a more less-invasive technique called laparoendoscopic single-port surgery
(LEES) has been developed [53].
A recent study has evaluated surgical outcomes and learning curve analysis asso-
ciated with laparoendoscopic single-site (LEES) with and without hysterectomy in
BRCA carriers, women with breast cancer, and others at high risk for breast, ovarian,
and/or endometrial cancer. Briefly port systems are placed manually into the perito-
neal cavity under direct visualization at a single 1.5- to 2-cm umbilical incision that
is performed via an open Hasson approach in the low lithotomy position. After inser-
tion of the port and insufflation of the abdomen with CO2 gas, either a 30 bariatric
length rigid laparoscope, or a Visera EndoEye flexible laparoscope (Olympus America
Inc, Center Valley, PA, USA) is introduced through the port. The retroperitoneal space
is developed by using a roticulating grasper and infundibulopelvic ligament is ske-
letonized and transected at least 2 cm below the ovarian tissue, fallopian tube and
mesosalpinx are dissected, and the utero-ovarian ligament is transected. The speci-
men is removed using an endobag through the umbilicus after initial removal of the
port device. In the study, 58 LESS RRSO were performed. There were no need for open
conversion and intraoperative complications. The mean operative time for those who
underwent a RRSO alone was 35 min, range 1680 min, and the mean time for those
undergoing RRSO with a hysterectomy was 42 min, range 2273 min. The authors con-
cluded that a single-port approach may be the preferable surgical route in this group
of patients as it may lead to shorter convalescence and fewer interruptions of active
cancer treatment [53].
21.11Pathologic examination of tuba
Pathologists have improved the accuracy of specimen examinations and reports

since the observations of tubal carcinomas in prophylactic BSO specimens. Using
a new protocol of sectioning and extensively examining the fimbriated end of the
tubes (SEE-FIM) [54, 55] and multistep sectioning method [44] can detect more
serous tubal carcinomas or precancerous abnormalities [from p53 signature to
serous intraepithelial tubal carcinoma (STIC) in BRCA-mutated specimens of
salpingo-oophorectomy].
There is a high rate of occult ovarian and fallopian tube malignancies discovered
on rigorous tissue examination. Earlier reports focused mainly on occult carcinoma
in the ovary, and in the last decade, the fallopian tube has become recognized as
an important site of occult disease in these patients. Because of high occult cancer
detection in the fallopian tube, the distal fallopian tube (fimbria) is examined tho-
roughly by SEE- FIM, tubes and ovaries are sectioned at 2- to 3-mm intervals before
21.12 Complication of RRSO 267
analysis [55]. This modification entailed amputation of the fimbriated end with
serial sagittal rather than cross sections of this segment. This resulted in an incre-
ase in the surface area examined by approximately 60%. A retrospective case series
study found in five (11%) cases of occult neoplasia that all cases of primary neopla-
sia were in the fimbrial end of the fallopian tube suggesting the importance of com-
plete removal of the fallopian tubes and ovaries and the rigorous systematic patho-
logical examination of these specimens [35]. Fallopian tubes from women with and
without BRCA1/2 mutations have recently been found to contain clusters of epithe-
lial cells with immunostaining for p53, called p53 signatures. These foci of p53
positive cells have been hypothesized to be precursor lesions to high-grade serous
carcinomas. A study observed a significant increase in the frequency of p53 foci in
those with BRCA1/2 mutations compared to controls, particularly in BRCA1/2 muta-
tion carriers with overt or occult gynecologic carcinoma [56]. Another study showed
that the prevalence of a non-invasive tubal lesion [p53-signature] tubal intra-epi-
thelial carcinoma (TIC) increased with age; e.g., an abnormality was present in 5%
of women who had surgery before the age of 40 (one of 12) and in 56% of women
who underwent surgery at age 60 or above [57].
The recommendations for RRSO procedure are examination of total bilateral
salpingo-oopherectomy specimen and removal of entire fallopian tube, cytologic exam-
ination of peritoneal washings (instill 50 mL of normal saline into peritoneal cavity
and withdraw immediately) and serial sectioning of entire fallopian tubes and ovaries
at 2-mm intervals and microscopic examination of all sections [35, 58].
21.12 Complication of RRSO
RRSO is usually performed by a minimal-invasive technique as laparoscopy and lapa-

roscopic surgery of the ovaries is accompanied by a low complication rate. Only a
few studies has reported data about surgical outcome after a prophylactic salpingo-
oophorectomy in a hereditary breast-ovarian cancer population. From the literature
the complication rates of RRSO have been reported at 3.111% [59].
A recent study showed the low intraoperative (0.6%) and postoperative compli-
cation rate (3.1%) and short median hospital stay (1 day) reflect the safety of this pro-
cedure [59].
21.13Surveilance
Diagnosis of hereditary cancer risk and early intervention to prevent cancer develop-
ment has resulted in a new cohort of cancer survivors. The long-term surveillance
of women with BRCA1/2 mutations career who underwent RRSO is not yet clear.
Because most women with BRCA mutations had surgical intervention 10 to 15 years
earlier than natural menopause, these women will experience premature surgical
menopause and are susceptible to heart disease, metabolic syndrome and osteopo-
rosis [60]. In addition to the risks of surgical menopause, BRCA1/2 mutation carriers
continue to have post-RRSO cancer risk for the development of primary peritoneal
cancer and require continued post-operative surveillance. The National Cancer Care
Network (NCCN) 2010 practice guielines concluded that limited information is
available regarding management of women following risk-reducing salpingo-oopho-
rectomy [61]. A study evaluated post-surgical menopause symptoms and sequelae
surveillance and the treatment BRCA1/2 mutation carriers receive with respect to
primary peritoneal cancer, bone loss and menopausal symptoms revealed that an
estimated 60% of those patients cohort continues to receive care after RRSO in terms
of serum CA-125, bone densitometry, and screening primary peritoneal carcinoma
those is accepted standard screening [60].
21.14Cost analysis
A study evaluated the cost effectiviness of the prevention strategies in women with
BRCA1/2 mutations. The study which included tamoxifen, oral contaceptives, RRSO,
bilateral prophylactic mastectomy, RRSO with bilateral prophylactic mastectomy
showed that the most cost effective strategy is RRSO [62].
In conclusion, RRSO is a safe procedure with a low incidence of complications
and conversions. RRSO is the only effective preventive option which can be safely per-
formed laparoscopically, and with single-port minimally-invasive techniques. There-
fore, RRSO should be offered to all BRCA1/2 carriers after child bearing age. Large
studies are required to confirm of effectiveness and safety of new surgical techniques
such as radical fimbriectomy.
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22 Robotic surgery for uterine cancer
Dan-Arin Silasi and Masoud Azodi
22.1Epidemiology
Uterine cancer accounts for 6% of all cancers in women. It is the most common gyne-
cologic malignancy in the USA, with an estimated 47,130 cases and 8,010 deaths
expected in 2012 [1]. Endometrial cancer ranks eighth in cause of cancer deaths for
women. Although it has been described to occur as early as age 16 years, it is primarily
a disease of the postmenopausal woman. Only 25% of the cases occur in premenopau-
sal patients.
22.2Presentation
The majority of patients with uterine cancer present with abnormal vaginal bleeding.
For most women, postmenopausal bleeding prompts them to seek medical attention,
and this accounts for the diagnosis at stage I in 75% of the patients. For menstruating
women, a change in the bleeding pattern, including absence of bleeding, requires
investigation. Metastatic disease, with spreads to and beyond the pelvic organs, can
manifest with pelvic pressure, pain, or urinary and bowel symptoms.
22.3Surgical treatment
Uterine cancer is staged surgically. In 2009, the Committee on Gynecologic Oncology

of the International Federation of Gynecology and Obstetrics revised the 1988 staging
system [2].
Surgery can be performed by laparotomy and laparoscopy. A large body of lite-
rature exists that recognizes minimally-invasive surgery (MIS) as a better treatment
option where applicable. A Gynecologic Oncology Group (GOG) study has shown that
the number of lymph nodes retrieved and the incidence of lymph node metastases
were similar to both operative approaches [3, 4].
Since the FDA approved the da Vinci surgical system (Intuitive Surgical Inc,
Sunnyvale, CA, USA) for gynecologic surgery in 2005, the robotic system has been
widely adopted and incorporated into practice by gynecologic oncologists [5].
We have shown that, when compared to open surgery, robotic surgery for endo-
metrial cancer does not compromise the adequacy of the procedure, has shorter ope-
rative times, less postoperative complications, and shorter hospital stay [6].
Controversy exists regarding the necessity and extent of lymph node dissection,
especially for type I cancers confined to the corpus. There is consensus, however, that
274 22 Robotic surgery for uterine cancer
the most accurate evaluation for lymph node involvement is by lymphadenectomy

and pathologic review [7, 8].
22.4Preoperative evaluation
Our routine preoperative evaluation includes taking a complete history and perfor-
ming a physical examination. Aspects to consider are the size and mobility of the
uterus and the vaginal caliber as the specimens will be delivered transvaginally.
Occasionally, a uterus too large to be delivered transvaginally intact can be contained
in a laparoscopic bag, the mouth of the bag eversed at the vaginal introitus and the
uterus cored or spirally sliced to fit in the vagina and be delivered without intraperi-
toneal spillage.
Imaging studies for evaluation of the pelvic anatomy are not routinely ordered
unless very large pelvic masses are identified. Masses up to 20 cm are not a contrain-
dication for robotic surgery if they have a cystic component. This will allow the mass
to be contained in a bag similarly to the technique described above and to be partially
drained without any spillage and contamination to the peritoneal cavity.
Preoperatively, the patients are given instructions for mechanical bowel prepara-
tion. This consists of a clear liquid diet the day before the procedure and administra-
tion of a 295 ml bottle of magnesium citrate at noon. Fleet enemas can be prescribed
but are not necessary.
Current clinical data offer no evidence to support the claim that preoperative
colon cleansing reduces the risk of anastomotic leaks or infectious complications. On
the contrary, doing so may increase the rate of anastomotic complications. However,
during laparoscopy, preoperative bowel preparation is used by many surgeons
because it adds to the ease of bowel handling, allows better exposure and visualiza-
tion, and potentially reduces operative time.
22.5Surgical staging
Comprehensive surgical staging for carcinoma of the corpus uteri includes explora-
tion of the peritoneal cavity, total hysterectomy, resection of ovaries and fallopian
tubes, and pelvic and para-aortic lymph node dissection. At the beginning of each
operation, a cytologic evaluation of the abdominal cavity is performed. In addition to
these procedures, the authors perform an omentectomy and peritoneal biopsies for
endometrioid tumors with architectural grade 3, clear cell carcinoma, serous carci-
noma, as well as carcinosarcomas. When intraperitoneal metastases or bulky lymph-
adenopathy are encountered, resection of all masses to no visible residual disease
is indicated. For grossly metastatic disease, the approach most often chosen is to
convert the procedure to laparotomy. However, depending on the distribution of the
22.6Patient positioning 275
tumors as well as the individual skill of the operator, we believe that optimal tumor
debulking can be accomplished in many cases without opening the abdomen. Ope-
rations requiring stripping of the pelvic peritoneum, resection of bulky lymphadeno-
pathy, recto-sigmoid colon resection, or resection and re-anastomosis of an intestinal
loop can be performed safely with the robotic system. In our experience, procedures
such as resection of well-defined tumors in the upper abdomen can also be accom-
plished by a minimally-invasive approach.
22.6Patient positioning
The patients are positioned on a gel pad over a bean bag (Vac-Pac Olympic Medical,
Seattle, WA, USA) and then placed in a dorsal low lithotomy position using Yellofin
stirrups (Allen Medical Systems, Acton, MA, USA). Alternatively, an egg-crate foam
pad and padded shoulder braces can achieve the same stabilization of the patient.
The disadvantage of using the bean bag is that a Bookwalter retractor cannot be
placed in case of conversion to laparotomy.
The operating table cannot be in flexion of the patients thorax over the
abdomen. This will affect significantly the exposure and visualization for most but
the very thin patients. Wedge shaped foam utilized by the anesthesia team to hyper-
extend the neck and facilitate intubation will be removed from under the patients
shoulders.
22.7Pneumoperitoneum, port placement, and instruments
Pneumoperitoneum was created with the direct insertion of the Verres needle with
a maximum insufflation pressure of 15 mmHg. It is unusual to place the camera port
into the umbilicus when para-aortic lymphadenectomy and/or omentectomy is con-
templated; most often it is placed midline or left paramedian above the umbilicus.
When the patient had several prior surgeries or an umbilical hernia is suspected,
it may be prudent to place the insufflation needle at Palmers point. Commonly
we place the ports symmetrically, in an arch centered by the camera port (sunrise
distribution). To the left of the camera port, at the same level or slightly below it,
is the port for arm 2. Opposite and symmetrical is the port for the assistant. At the
ends of the imaginary arch we insert the port for arm 1 on the right and arm 3 on the
left. Additional ports may need to be inserted during difficult cases, mostly to assist
with bowel retraction and exposure of the operative field. However, these are only
guidelines and, depending on the torso length and width of the patient as well as
the goals to be achieved during the surgical procedure, the ports should be logically
placed so as to maximize maneuverability and visualization.
Vaginally, a Koh Colpotomizer System (CooperSurgical, Trumbull, CT, USA) in

conjunction with a RUMI Uterine Manipulator (CooperSurgical) is inserted after
obtaining the peritoneal cytology. The Koh Colpotomizer System includes the Koh
Cup Vaginal Fornices Delineator (we prefer the Ultem polymeric resin product)
and the Colpo-pneumo Occluder balloon. Another manipulator frequently used by
our group is the VCare Uterine Manipulator/Elevator (ConMed Endosurgery, Utica,
NY, USA). When a uterine manipulator is not used because of a physicians preference
or too narrow vaginal caliber, a sponge stick with the Colpo-pneumo OccluderTM
balloon is placed in the vagina.
We perform all operations using the four-arm da Vinci surgical system with a five-
port technique.
After insertion of the laparoscopic ports the patients are tilted in a steep Trende-
lenburg position and the da Vinci system is docked. The robot is most often positi-
oned between the patients legs. The EndoWrist instruments used are Hot Shears
(monopolar curved scissors) with tip cover accessory and power setting 4550 W for
arm 1, fenestrated bipolar forceps with power setting 4565 W for arm 2, and Cadiere
or ProGrasp forceps for arm 3.
Vascular pedicles are coagulated and transected by the scrubbed assistant with
an advanced energy device such as LigaSure sealer/divider (Valleylab, Boulder, CO,
USA) or Thunderbeat (Olympus America Inc, Southborough, MA, USA). The assistant
also performs suction and irrigation (Suction Irrigator, Vital Concepts, Grand Rapids,
MI, USA) and retraction to expose the operative field. The 30 laparoscope was also
used at times during the procedure to assist with visualization.
Suturing is performed by switching the monopolar cautery in arm 1 with the
Mega Needle Driver. A second needle driver can be used in arm 2 but we prefer to
keep the bipolar forceps.
22.8Anesthesia concerns
For pelvic surgery, the patient is in the steep Trendelenburg position and this can
interfere with ventilation. Inspiratory pressures can be adversely affected, especially
in obese and morbidly obese patients. These patients also require to be placed in the
steepest Trendelenburg position which further impairs ventilation. If the diaphragma-
tic excursions interfere with exposure in the operative field, most commonly during
para-aortic lymphadenectomy, the tidal volume needs to be decreased and the ven-
tilation frequency increased, even if temporary. Intraoperative infusion of fluids is
limited because of the positioning. Urine production will be decreased because of
the preoperative fluid deficit, the positioning during surgery, and the intrabdomi-
nal pressure from the pneumoperitoneum. The operative time should be kept to a
minimum.
Another concern is the intraocular pressure with the patient positioned
head-down. Our practice is to routinely monitor the intraocular pressure by the
22.9Pelvic lymphadenectomy 277
anesthesia team at the beginning and throughout the case using a portable
tonometer. A dorzolamide and timolol ophthalmic solution can be used to decrease
the pressure (normal 1020 mmHg). Undocking the robotic system and placing the
patient in a reverse Trendelenburg position decreases the intraocular pressure to
normal within 10 to 15 min.
22.9Pelvic lymphadenectomy
Pelvic lymphadenectomy consists of removing the lymphatic tissue surrounding the

external iliac vessels and the lymphatic tissue located in the obturator fossa. In most
but the very thin patients, resection of the lymphatic structures involves removal of
intermingled adipose tissue as well. In very thin patients, the individual lymph nodes
are distinct and the magnification of the robotic optical system allows visualization
of some lymphatic vessels. However, the majority of patients are overweight or obese,
and the lymphatic tissue is thickly covered by adiposity.
The authors have no preference regarding whether the pelvic or para-aortic
lymph nodes dissection is performed first. However, it is easier to perform the pelvic
lymphadenectomy before approaching the hysterectomy part. Throughout the case,
the exposure of the para-aortic area to be dissected varies. It is mostly dependent
on the bowel being collapsed or not, the peristalsis of the small intestine, and the
amount of adipose tissue in the mesentery of the terminal ileum and mesentery of the
sigmoid colon. In the authors opinion, the timing of para-aortic lymph node dissec-
tion is dictated by exposure. If the exposure of the para-aortic area at the beginning
of the case is less than optimal but improves when the pelvic lymphadenectomy is in
progress, the pelvic portion of the surgery can be interrupted and resumed after com-
pletion of the para-aortic lymphadenectomy. In morbidly obese patients, especially
the ones with truncal obesity (androgenetic distribution of fat, apples) the aid of a
laparoscopic retractor (fan or paddle) can help with retracting the bowel and expo-
sing the area to be dissected. In difficult cases, with BMIs ranging from 60 to above
90, we have used more than one assistant port and more than one assistant. More
than one retracting device can then be used to expose the surgical field. Other ways to
improve exposure is temporary decreasing of the tidal volume and the use throughout
the entire case of oro-gastric suction.
This section describes the transperitoneal approach, were access to the retrope-
ritoneally located lymph nodes requires incision of the peritoneum, usually on the
posterior leaf of the broad ligament.
The landmarks for the external iliac dissection are the following: laterally the
psoas muscle, medially the anterior division of the hypogastric artery and the supe-
rior vesical artery, distally the deep circumflex iliac vein and proximally the bifurca-
tion of the common iliac artery and the crossing of the ureter over or above to the
bifurcation. Most commonly, the resection of the obturator fossa lymphatics is limited
to tissue located above the obturator nerve. In this case, the landmarks are: laterally
the obturator internus membrane, medially the anterior division of the hypogastric
artery and the superior vesical artery, distally the paravesical space, and proximally
the hypogastric artery and vein. If the dissection is carried out below the obturator
nerve, the structures to be identified laterally are the arcuate line, proximally the
roots of the sacral nerve and inferiorly the pelvic floor.
The surgeon needs to identify and can preserve in most cases the following ana-
tomical structures:
The genito-femoral nerve is located over the psoas muscle or over the external
iliac artery. It may split in its two components, the genital and the femoral branch
while over the psoas muscle.
The obturator nerve and vessels bundle has the N-A-V configuration.
When the dissection commences distally, arm 3 grasps the round ligament,
places it under tension and elevates it. With arm 3 locked, arm 2 puts traction on the
infundibulo-pelvic ligament and arm 1 with the monopolar cautery incises the perito-
neum. A T-shaped incision of the broad ligament peritoneum affords adequate access
for the lymph node dissection. This is accomplished by an incision which is parallel
and immediately posterior to the round ligament followed by a perpendicular incis-
ion parallel and lateral to the infundibulo-pelvic ligament.
The fat under the round ligament is grasped and placed under traction with
arm 2 while arm 1 frees sharply and bluntly the lymph nodes from their attachments
to the underlying vessels. The deep circumflex iliac vein should be visible as it crosses
over the external iliac artery. If the superficial circumflex iliac artery is identified, the
dissection was carried too far.
The external iliac lymph nodes are eight to ten in number and lie along the
external iliac vessels.
They are arranged in three groups, one on the lateral, another on the medial,
and a third on the anterior aspect of the vessels; the third group is, however, someti-
mes absent. They are arranged in three chains, medial, lateral and one on top of the
artery. It is the authors preference to leave the most lateral chain undissected if no
gross lymphadenopathy is encountered. With this approach we had no lymphedema
formation in 500 cases of uterine cancer staging.
Once the lymphatic tissue under the round ligament has been mobilized, arm
3 shifts from traction on the round ligament to medial traction on the infundibulo-
pelvic ligament. This provides wide exposure to the dissection field. The ureter can
be visualized on the medial leaf of the broad ligament, as it crosses the iliac vessels
medial to the infundibulo-pelvic ligament. The lymphadenectomy of the external
iliac vessels is now completed using arms 1 and 2.
The genito-femoral nerve is spared. If a complete lymphadenectomy is pursued,
additional lymphatic tissue is located in between the external iliac artery and
psoas muscle. If this approach is chosen, mobilization of the external iliac artery
away from the psoas muscle will also allow access to the obturator fossa and its
structures.
22.10Para-aortic lymphadenectomy 279
The more common approach, dissection of the obturator lymph nodes from
medial to lateral, starts by developing the plane between the medial/inferior aspect
of the external iliac vein and the lymphatic tissue. Medial oriented traction to the
lymphatic tissue is applied by arm 2 and arm 1 develops this plane. The dissection
arm will insinuate itself under the external iliac vein and along the obturator memb-
rane and obturator muscle. The superior vesical artery is the medial dissection border
and it is easily freed from the specimen to be resected. Visualization of the obturator
nerve is imperative before amputating the lymph node specimen. If not easily visible,
longitudinal dissection of the obturator fat pad along the presumed trajectory of the
obturator nerve will expose it. The obturator artery and vein need not be sacrificed.
Precise dissection allows the cleaning of fat and lymph nodes off these structures
and their preservation. Caution should be exercised when dissecting the lymph node
located at the bifurcation of the common iliac vein, especially on the right since the
attachments of the lymph node to the vein are on the underside of the vessel and
exposure of a tear is difficult.
On the left side of the pelvis a physiologic adhesion of the sigmoid colon obscures
partially or totally the infundibulo-pelvic ligament. Traction is placed with arm 3 on
the round ligament, arm 2 pushes the colon and its mesentery medially and the sur-
gical plane is exposed and incised. The mobilization of the colon medially will help
also with identification of the left ureter.
The specimens are deposited in laparoscopic bags (Endo Catch Gold 10 mm
specimen pouch, Covidien, Mansfield, MA, USA) and delivered transvaginally after
the hysterectomy is completed. The dissection bed is assessed for hemostasis. Hemo-
static adjuncts such as oxidized cellulose polymers, thrombin-, gelatin-, or fibrin-
based can be used alone or combined if clinically necessary.
Excessive lymphatic dissection carries the risk of postoperative lymphedema for-
mation. On the left, May-Thurner syndrome is characterized by compression of the
left common iliac vein by the overlying right common iliac artery. Postoperatively,
this can be identified by CT scan and placement of intravenous stents is often suc-
cessful treatment.
22.10Para-aortic lymphadenectomy
The peritoneum overlying the distal aorta is grasped and elevated with arm 3 and
incised vertically with the monopolar cautery exposing the retroperitoneum. The inci-
sion can be prolonged up to the 3rd portion of the duodenum. The duodenum is easily
recognizable as it crosses the aorta at a 90 angle. If dissection is required above the
3rd portion of the duodenum, the duodenum can be elevated and the para-aortic
lymph node chain followed to the renal vessels.
With the exception of the very thin patient, some adipose tissue is enveloping the
aorta and vena cava. In morbidly obese patients the fat deposition is so prominent that
the great vessels cannot be visualized, not even the pulsations. If the fat deposition
is too abundant and the great vessels cannot be recognized, an excellent landmark is
the sacral promontory. Care needs to be taken when the aortic bifurcation is located
higher than usual. An initial incision below the aortic bifurcation can lead to unne-
cessary dissection below the aortic crotch where the lymph node yield is low. This
area contains the presacral plexus and resection of nerve fibers obscured by retrope-
ritoneal fat is usually without consequence. The bifurcation of the vena cava is some-
what protected by the overlying aorta. It is easier and safer to initially dissect the fat
left paramedian, i.e., over the aorta, because the vena cava wall is paper thin and an
injury is difficult to repair without adequate exposure.
One of the anatomical structures that need to be avoided on the left is the infe-
rior mesenteric artery (IMA). This artery emerges left paramedian approximately
34 cm above the aortic bifurcation. The 3rd arm grasps the left leaf or side of the
now incised peritoneum and elevates and places traction on it to expose the retrope-
ritoneal tissues. The elevation will create a dam that will keep the redundant sigmoid
colon away from the operative field. It is unlikely to avulse the IMA or one of its bran-
ches by applying too much traction since the peritoneum tears at the grasping point
before the vessels. However, this is a high-risk area and handling of the tissues with
care is required.
Once the peritoneum overlying the aorta is incised and the retroperitoneum
exposed with help from arm 3 and possibly the assistant, the interaorto-caval lym-
phatic tissue is dissected by grasping it with arm 2, placing it under traction and
this exposes the loose areolar tissue that connects it to the great vessels walls. This
dissection plane is incised with the monopolar cautery. To the right of the vena
cava, the monopolar cautery should be used after the trajectory of the right ureter
is identified.
Dissection to the left of the aorta identifies the ureter approximately 23 cm
lateral from the emergence of the inferior mesenteric artery. Sometimes the left ureter
is very close to the aorta and use of energy should be applied only after its location
is evident. The surgeon should be aware that both the inferior mesenteric artery and
vein can have many normal configurations, with unexpected branches.
It is easier to resect the left-sided para-aortic lymph nodes in two groups: below
and above the inferior mesenteric artery. Dissection with longitudinal moves of arm
1, along the axis of the aorta, will free the lymphatic bundle. The lumbar vessels are
at the bottom of the area to be dissected and emerge at a 90 angle from the aorta and
the direction of the dissection. Brisk bleeding from this area may require tamponade
with the sponge inserted previously. The lymph nodes located posterior to the aorta
can be easiest accessed from the left side. Exposure is facilitated by the assistant who
pushes the aorta to the right with a blunt instrument. The fascia on top of the verte-
bral bodies is visualized and the lymphatics posterior to the aorta can be retrieved.
Operating on or around the largest vessels in the body can be potentially life-
threatening and adequate exposure is key. This is difficult to obtain in a short
22.10Para-aortic lymphadenectomy 281
abdomen with truncal obesity. The small intestines are crowded into the upper
abdomen, difficult to contain, and keep rolling into the operative field. In addition,
the omentum is abundant and further obscures the operative field. If the exposure
is inadequate after placing the patient in the steep Trendelenburg position, several
maneuvers can be tried. Resection of the infracolic omentum and depositing it in
the pelvis frees additional space for the intestines. A large uterus pushes up a red-
undant sigmoid colon. Performing the hysterectomy first followed by transvaginal
delivery of the specimen can free up the para-aortic area when a redundant recto-
sigmoid colon can take its place in the pelvis. When the mesentery of the sigmoid
colon is extremely thick and heavy from fat deposition and the epiploica is excep-
tionally hypertrophic, the sigmoid colon will keep rolling into the operative field.
This can be prevented by tacking the sigmoid colon at the point of maximum redun-
dancy to the left sidewall using a single stitch through one of the epiploic appendi-
ces. TLift is a laparoscopic tissue retraction system (Vectec, Warren, RI, USA) that
can be used for difficult cases.
When operating in the para-aortic area, if only one assistant port is used and
this is occupied with a fan or paddle retractor, we recommend the introduction of a
sponge in the peritoneal cavity.
It is the authors preference to insert a surgical sponge through the assistants
port prior to the para-aortic dissection. The sponge can be used in many ways: gentle
dabbing of the dissection bed, extra support for retraction, and tamponade in case
of significant hemorrhage. The exchange of the paddle with another instrument, i.e.,
a suction device can be tedious and it cannot meet the demands of sometimes brisk
bleeding associated with impaired exposure when the intestines keep rolling into the
operative field. The sponge can be grasped and utilized to blot the area or to apply
pressure to a dissected and bleeding area until hemostasis ensues, usually in less
than 1 min. It can be also useful in the event of inadvertent injury to the aorta or vena
cava, to tamponade the area. The vascular defect can then be repaired by applying
hemostatic clips or suturing.
In case of vessel injury, the grasping instrument of arm 2 or 3 will approximate the
defect in the vessel wall. If the bleeding is contained, the vessel can be easily repaired
with the other two arms as suturing is facilitated by the wrist instruments and the
optical magnification. If the bleeding is impossible to control after repeat instrumen-
tal applications, manipulations, suctioning, laparotomy is warranted. Laparoscopic
bulldog clamps are inadequate for the aorta, common iliac arteries and even external
iliac arteries. They can be used for smaller arteries. The large veins can be compressed
but tear easily.
In these situations, the presence of a skilled assistant is imperative. Suctioning
indiscriminately will drop the intraperitoneal pressures with collapsing of the ante-
rior abdominal wall and prolapse of the bowel from the upper abdomen, obstructing
the surgical site. In addition, the intrabdominal pressure exerts a hemostatic effect
which will also be lost, further compounding the problem.
22.11Omentectomy
The omentum is a very large organ spanning over the entire upper abdomen. The
greater omentum is the largest peritoneal fold. It consists of a double sheet of perito-
neum, folded upon itself so that it is made up of four layers.
The two layers which descend from the greater curvature of the stomach and com-
mencement of the duodenum pass in front of the small intestines, sometimes as low
down as the pelvis; they then turn upon themselves, and ascend again as far as the
transverse colon, where they separate and enclose that part of the intestine.
These individual layers may be easily demonstrated in the young subject, but
in the adult they are more or less inseparably blended. The left border of the greater
omentum is continuous with the gastro-lienal ligament; its right border extends as far
as the commencement of the duodenum.
The right and left gastro-epiploic vessels provide the sole blood supply to the
greater omentum. Both are branches of the celiac trunk. The right gastro-epiploic is
a branch of the gastro-duodenal artery, which is a branch of the common hepatic
artery, and this in turn is a branch of the celiac trunk. The left gastro-epiploic artery
is the largest branch of the splenic artery, which is a branch of the celiac trunk. The
right and left gastro-epiploic vessels anastomose within the two layers of the anterior
greater omentum along the greater curvature of the stomach.
The greater omentum is usually thin, presents a cribriform appearance, and
always contains some adipose tissue, but in obese people it accumulates in conside-
rable quantity.
There is no consensus as to extent of staging for type II uterine cancers. Some
authors advocate for omentectomy while others found no additional value for this
procedure [911].
We routinely perform at least sampling of the omentum, most commonly infra-
colic omentectomy. The term omentectomy has been loosely applied to a variety of
procedures, including as little as amputation of the omental tip.
While the omental biopsy is a fast and easy procedure performed by applying an
advanced energy device across the tip of the omentum and amputating it, true infra-
colic and total omentectomy can be time-consuming, especially in the obese patient.
For omental biopsy, the distal aspect of the omentum is grasped, elevated off the
intestines, and placed under traction. An advanced energy device is used to amputate
the distal end.
The infracolic omentectomy is technically more challenging. Unless the trans-
verse colon is unusually long and its belly descends with or without traction all the
way into the pelvis, placement of the camera port into the umbilicus will often not
provide adequate visualization. A simple but time-consuming solution is re-docking
of the robotic system at the patients left or right shoulder and positioning of the
patient in the reverse Trendelenburg position. In this case, the port setup can be the
same as for the pelvic part of the surgery, in a sunrise distribution, with the camera
port into the umbilicus.
22.11Omentectomy 283
This port setup is very convenient for combined upper abdominal and pelvic pro-
cedures because only the docking of the robot needs to be changed. The omentectomy
is then performed as the last procedure in the case, so resulting blood and fluids do
not pool into the pelvis and obstruct visualization of the surgical planes.
If re-docking is not contemplated, we recommend placement of the robotic
system in between the patients legs. With side docking, adequate access into both
the pelvis and upper abdomen up to the diaphragm is not possible in this configu-
ration. It is virtually impossible to correct complications in the high upper abdomen
with side docking. The gastro-colic ligament has an abundant blood supply and is in
close relationship with the transverse colon mesentery. Achieving exposure and/or
hemostasis can become difficult at this level if the robotic arms do not have adequate
range of motion.
With midline docking, the camera port needs to be placed in the epigastrium and
the ports for the robotic arms at least at the level of the umbilicus.
To commence the infracolic omentectomy, arm 3 places traction on the omentum
after grasping its distal end. Since the patient is in the Trendelenburg position, the
omentum will keep sliding into the upper abdomen if it is released from traction.
Counter traction is provided by arm 2 and in most cases this facilitates exposure of
the attachments of the omentum to the transverse colon at the level of the taenia
omentalis. It is easiest to start in the center third of the transverse colon. The line of
reflection of the omental leaves on the transverse colon is easily recognized as a clear
space between the omentum and the colonic wall and it is divided with the mono-
polar cautery. The middle, right, and left omental arteries are the only vessels that
need to be secured. To the left, the transverse colon ascends towards the spleen and
it is occasionally difficult to follow all the way to the splenic flexure. Uncontrolled
traction can avulse the splenic attachment of the lieno-colic or lieno-diaphragmatic
ligaments but this is unusual. While in open surgery strong traction on the left side of
the omentum can cause tears of the spleen or its capsule via the phrenico-colic liga-
ment, the robotic forceps, while strong, has a small grasping area and the omentum
tears at the grasping site. The infracolic omentectomy is completed by resecting the
attachments of the omentum to the right side of the transverse colon. The specimen
is deposited in the upper abdomen and delivered transvaginally after the hysterec-
tomy. In some cases, the transverse colon distends substantially after omentectomy
and obstructs the view.
A total omentectomy requires more operative time. When performing a total
omentectomy and the patient is in the Trendelenburg position, we recommend a dif-
ferent approach than in open surgery. In open procedures, the easiest technique is to
start at mid-transverse colon, lyse the attachments of the infracolic omentum to the
taenia omentalis and enter and develop the lesser omental sac. In a robotic approach
we start at the gastro-epiploic vascular arcade and develop the lesser omental sac in
a retrograde manner, from the stomach down. The clear spaces between the short
gastric vessels are developed and the vessels coagulated starting at the middle third
of the greater gastric curvature. The lesser omental sac is entered to the left of the
midline and developed. To the right, the attachments of the gastro-colic ligament
to the transverse colon mesentery are identified and transected. It is imperative to
enter the correct surgical plane in order to avoid erroneously dissecting the transverse
colon mesentery containing the vessels. If the omentum is exceptionally large, resec-
tion can be done in two stages: infracolic, then gastro-colic.
22.12Extrafascial hysterectomy
The uterus is elevated out of the pelvis by grasping and placing traction on the mid-
round ligament with arm 3. A common mistake is to grasp the round ligament to close
to the uterine corpus; it can tear at the grasping site and retracts, making hemostasis
and re-grasping difficult. This maneuver also places the infundibulo-pelvic ligament
under tension and elevates it away from the ureter. If the ureter is not visualized
transperitoneally, we recommend identifying it in the retroperitoneum before secu-
ring the ovarian vessels. The ureters are located medial to the adnexal pedicle and
the dissection of the retroperitoneum is from lateral to medial. The right ureter can
be accurately identified as it dives into the pelvis, crossing medial to or on top of the
bifurcation of the common iliac artery. On the left side, a physiologic adhesion of
the colon frequently obscures the ovarian pedicle all the way up to the ovary. Cepha-
lad and medial traction on the sigmoid colon permits visualization of the avascu-
lar tissue between the mesentery and ovarian pedicle. Traction on the colon and its
mesentery can be accomplished with arm 2 or arm 3 and it should be pushing motion
towards the sacral promontory rather than grasping the mesenteric fat which easily
bleeds. Once this physiologic adhesion is identified, it can be incised with the mono-
polar cautery along the infundibulo-pelvic ligament.
Mobilization of the mesenteric fat allows transection of the ovarian pedicle at
23 cm from the ovary after the left ureter is identified.
The round ligaments are coagulated and transected then arm 3 places cephalad
traction on the uterus. Arm 2 grasps the peritoneum below the incision and applies
counter-traction. The incision in the round ligament is prolonged with the monopolar
cautery on the anterior leaf of the broad ligament and it is oriented medially slightly
below the reflection of the bladder serosa on the lower uterine segment until it meets
with the contralateral incision. The traction on the bladder peritoneum allows the
intrabdominal gas to dissect the foamy areolar tissue of the vesico-uterine space. The
curved incision between the bladder pillars should be performed 3 to 5 mm distal to
the bladder serosa reflection to avoid unnecessary bleeding which obscures the sur-
gical planes. The bladder is mobilized distally with a combination of sharp dissection
with the monopolar cautery and blunt dissection with the backhand of the scissors.
All the while, arm 2 applies traction on the bladder serosa facilitating the dissection.
The bladder is mobilized from the lower uterine segment, cervix, and superior vagina.
The critical aspect of this procedure is pushing the ureters laterally via the vesico-
cervical ligaments. These ligaments are flanking the curved incision of the bladder
22.13Closure of the vaginal apex 285
peritoneum and lateral mobilization of these bladder pillars will displace the ureters
laterally as they are curving around the cervix to insert at the level of the bladder
trigone. An adequate lateral mobilization of the ureters will place them at 2 to 2.5 cm
from the vascular pedicles of the uterus and will prevent thermal injury to these struc-
tures when securing the uterine vessels. Also, if hemostasis is not accomplished with
the first application of energy, re-grasping and re-application of heat to the bleeding
and now retracted pedicle can be safely achieved. Arm 3 places the uterus under trac-
tion via the round ligaments and exposes the vascular pedicles. The uterine vessels
are coagulated and transected at the level of the cervico-uterine junction, followed
by the cardinal and utero-sacral ligaments. Once the level of the dissection is below
the level of the cervix in the vagina, the specimen is amputated circumferentially and
delivered transvaginally. Pushing the uterine manipulator or sponge stick from below
delineates better the vaginal fornices, increases the distance from the cautery appli-
cation to the distal ureters, and stretches and thins the vaginal tissue thus minimizing
the thermal injury.
22.13Closure of the vaginal apex
Our preference is to close the vagina vertically using a running suture. For the first
bite, arm 3 grasps the anterior lip of the vagina, arm 2 pushes the bladder away and
arm 1 now carrying a needle driver places the suture. For the subsequent throws of
the running suture, arm 3 will suspend the suture vertically, while arms 1 and 2 will
complete the closure. The last 1 or 2 throws incorporate the distal stumps of the utero-
sacral ligaments, plicating them and suspending the vagina in the pelvis.
References
[1] Siegel R, Naishadham D, Jemal A. Cancer statistics. CA Cancer J Clin 2012, 62, 1029.
[2] FIGO Committee on Gynecologic Oncology. Revised FIGO staging for carcinoma of the vulva,
cervix, and endometrium. Int J Gynecol Obstet 2009, 105, 1034.
comprehensive surgical staging of uterine cancer: Gynecologic oncology group study LAP2. J Clin
Oncol 2009, 27, 53316.
[4] Fader AN, Seamon LG, Escobar PF, et al. Minimally invasive surgery versus laparotomy in women
with high grade endometrial cancer: A multi-site study performed at high volume cancer centers.
[5] Brudie LA, Backes FJ, Ahmad S, et al. Analysis of disease recurrence and survival for women with
uterine malignancies undergoing robotic surgery. Gynecol Oncol 2013, 128, 30915.
[6] ElSahwi KS, Hooper C, De Leon MC, et al. Comparison between 155 cases of robotic vs. 150 cases
of open surgical staging for endometrial cancer. Gynecol Oncol 2012, 124, 2604.
[7] The writing committee on behalf of the ASTEC study group. Ecacy of systematic pelvic
lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study. Lancet 2009,
373, 12536.
[8] Chan JK, Urban R, Cheung MK, et al. Lymphadenectomy in endometrioid uterine cancer
staging. How many lymph nodes are enough? A study of 11,443 patients. Cancer 2007, 109(12),
245460.
[9] Giuntoli RL, Gerardi MA, Yemelyanova AV, et al. Stage I noninvasive and minimally invasive
uterine serous carcinoma: comprehensive staging associated with improved survival.
Int J Gynecol Cancer 2012, 22, 2739.
[10] Chan JK, Loizzi V, Youssef M, et al. Significance of comprehensive surgical staging in
noninvasive papillary serous carcinoma of the endometrium. Gynecol Oncol 2003, 90, 1815.
[11] Gehrig PA, Van Le L, Fowler WC. The role of omentectomy during the surgical staging of uterine
serous carcinoma. Int J Gynecol Cancer 2003, 13, 2125.
23 Compartment-based radical surgery: The TMMR,
FMMR and PMMR family in uterine cancer
Rainer Kimmig, Bahriye Aktas and Martin Heubner
23.1Introduction
Tumor growth seems to be confined to ontogenetically permissive compartments

derived from a common primordium in embryonic development. Based on this
theory compartment-based radical surgery has been developed intending to exert
tumor control by surgery alone due to complete removal of the tissue at risk [1].
This chapter introduces the robotic translation of the surgical technique based
on this new approach in surgical oncology with respect to uterine cancer. Basi-
cally, it represents a review of three recently published papers; with respect to
robotically-assisted surgery, these describe in detail, principles and techniques for
therapeutic pelvic and periaortic lymphadenectomy (rtLNE), total mesometrial resec-
tion (rTMMR) and peritoneal mesometrial resection (rPMMR) as newly developed
techniques of radical hysterectomy on the basis of compartmental surgery [24].
For fertility preserving mesometrial resection (FMMR) extraction of the description of
this technique from [5] has also been included.
Tumor permeation may be facilitated in the permissive ontogenetic compartment
but is suppressed at the compartment borders [1]. The existence of developmental
compartments was shown first in Drosophila [6] and recently reviewed by Dahmann
et al [7]. In surgery, it was first described for total mesorectal excision (TME) in the
treatment of rectal cancer [8, 9]. Hckel and Fritsch investigated embryonic develop-
ment of the female reproductive tract with respect to embryological different com-
partments [1012] and were able to define three different primordial tissue complexes
(anlagen) from cranial to caudal: The paramesonephric-mesonephric-complex, the
sinusal tubercle-deep urogenital sinus (UGS) complex and the superficial UGS-genital
folds and tubercle complex [1]. Convincing evidence for the functionality of this theory
concerning the paramesonephric-mesonephric-complex in cervical cancer has been
shown for cervical cancer with respect to local tumor control following TMMR without
any adjuvant radiotherapy [13, 14] but also with respect to pattern analysis of local
tumor spread in advanced and recurrent disease [15].
With respect to regional spread data TMMR and therapeutic pelvic lymphadenec-
tomy were also systematically analyzed and assigned to the ontogenetic iliac lympha-
tic compartments which may be subclassified in external iliac nodes, paravisceral
nodes, common iliac nodes and presacral nodes [13].
The da Vinci surgical system (Intuitive Surgical Inc, Sunnyvale, CA, USA)
was used for robotically-assisted minimally-invasive surgery (MIS) of cervical and
288 23 Compartment-based radical surgery
endometrial cancer. Preparation of the patient, in principle, was identical to clas-

sical laparoscopy. Trendelenburg positioning was at least 2530. Side docking of
the patient cart was used in most instances. Positioning of the trocars: camera trocar
about 10-cm supraumbilically (i.e., 25 cm above the symphysis), two lateral robotic
trocars about 510 cm above the upper anterior iliac spine on both sides, i.e., one
additional robotic trocar on the left between camera trocar and left lateral trocar, one
assistant trocar of 10-mm diameter on the right side between camera trocar and right
lateral trocar. The space in between the trocar-incisions should be at least 10 cm to
ensure adequate free mobility (Fig. 23.1).
23.2Therapeutic-pelvic and periaortic lymphadenectomy (rtLNE)
The principle of ontogenetically derived surgical compartmental resection may be

defined for each organ system. In the following, we will focus on lymphatic basins
of the uterus. As outlined by Hckel et al [1], the lymphatic downstream compart-
ments of the uterine cervix may be divided in the mesenteric system, correspon-
ding to the intercalated lymph nodes in the vascular mesometrium (mm) and in
the parietal system corresponding to the paravisceral (pv) and external iliac (ei)
basins as primary and the common iliac (ci) and presacral (ps) basins as secondary
basins. Tertiary and quarternary basins of the cervix are located along the aorta
and vena cava inframesenterically (im) and supramesenterically/infrarenally (sm)
(Fig. 23.1bd).
Whereas in cervical cancer skip metastases in periaortic tertiary and quaternary
basins are extremely uncommon, they occur in endometrial cancer due to the diffe-
rent lymph drainage (Fig. 23.1d). Whereas cervical lymph drainage runs downstream
along the vascular and fibrofatty (ligamentous) mesometria, drainage of uterine
(a)
optics
assistant
da Vinci 2
da Vinci 1
da Vinci 3
Fig. 23.1a: Positioning of trocars for rTMMR and rrLNE in uterine cancer
23.2Therapeutic-pelvic and periaortic lymphadenectomy (rtLNE) 289
(b)
According to Reiffenstuhl
According to Hckel
(d)
(c)
According to Reiffenstuhl
(modified)
According to Hckel (modified)
Fig. 23.1bd: b) Pelvic lymph drainage in cervical cancer adopted from Hepp H [18] with permission
of Urban&Schwarzenberg and from Hckel M with permission from Elsevier. c) and d) The structures
of the female genital tract with reference to the embryologic Muellerian compartment to be resected
(green) and the corresponding primary and secondary lymph basins (adapted from Hckel M [16]
and Hepp H [18]) with permission from Elsevier and Urban & Schwarzenberg
corpus involves vascular mesometrium and ovarian vessels. This implicates that in
endometrial cancer tertiary "cervical" and quaternary basins have also to be regarded
as primary basins in contrast to cervical cancer. Following this concept, the following
lymph nodes have to be removed in cervical cancer: In addition to mesometrial nodes
which are included in the TMMR/PMMR specimen the Lnn. iliaci externi, interni and
communes, Lnn. obturatorii, gluteales superiores et inferiores, pudendales, recta-
les, praesacrales and subaortici corresponding to the primary and secondary basins.
In the case of proven node metastases in the secondary basins, the inframesenteric
periaortic and pericaval nodes ought to be removed; as should the inferenal periaortic
and pericaval nodes if lower periaortic nodes are involved.
In the case of high-risk endometrial cancer without cervical involvement no meta-
stases may be present in the deep gluteal, pudendal and rectal nodes. However, all
other nodes of level 14 have to be removed complemented by the intercalated nodes
in the infundibulopelvic ligaments due to the risk of involvement.
The following steps will illustrate the surgical anatomy and operative technique
of robotically-assisted therapeutic pelvic and periaortic lymphadenectomy (rtLNE).
Therapeutic-pelvic lymphadenectomy
First, the robotically-assisted pelvic therapeutic lymphadenectomy will be described:
Step 1: Inspection of the topography, exposition of preaortic/precaval region
and incision of peritoneum lateral to the right common iliac artery (Fig. 23.2a). Deve-
lopment of the retroperitoneum from the inframesenterial periaortic region to the
branching of internal and external iliac vessels and presacrally down to S2. The left
common iliac artery can be followed dorsally of the sigmoid mesenterium into the
sigmoid tunnel (Fig. 23.2a).
Step 2: Separation of the retroperitoneal lymph basins from the mesenteries of the
rectosigmoid (Fig. 23.2b) and ascendant colon (Fig. 23.2c) and the plexus hypogastri-
cus superior (Fig. 23.3) should define the ventral and lateral borders of common iliac
and subaortic/presacral lymph basins.
Step 3: Preparation of the infundibulopelvic ligaments, ureters, genito-femoral
nerves, psoas muscles on both sides to define the dorsal borders laterally as shown
on the left (Fig. 23.2d).
Step 4: Mobilization of the lymphatic tissue en bloc starting from laterally,
right to medially dissecting vessel anastomoses to the infundibulopelvic ligament
and the caval vein, less frequently the aorta; cranially starting from the level of aortic
branching, caudally to the iliac branching, usually located at the level of crossing
the ureter. Laterodorsally mobilization of obturator nerve and lumbosacral trunk and
removing all lymphatic tissue.
Step 5: Dissection of the lymphatic basin and separation from the medial border
of the common iliac vessels down to the branching of the internal iliac artery into its
anterior and posterior branches, medially down to S2. Mobilization from caudally to
(a)
(b)
Uterus Mesosigma
A. mesenterica
Sigmoid
inferior
colon
Subaortic/
Aortic presacral basin
bifurcation Right common iliac artery
A. iliaca communis sinistra A. iliaca communis dextra
(d) Mesocolon
Ureter sinister ascendens
(c)
M. psoas
Ureteral bridging vessels
N. genito-femoralis
Right ovarian Right ureter

A. Iliaca communis sin. vessels
Fig. 23.2: a) Inspection of the situs. Due to Trendelenburg positioning of the patient, the common
iliac arteries and the aortic bifurcation are exposed. b) After incision of the parietal peritoneum, the
common iliac vessels are exposed. Thesigma and mesosigma can be elevated in order prepare the left
iliac vessels further distally. c) Preparation of the left upper iliac retroperitoneum (ci). d) Preparation of
the right iliac retroperitoneal space. Preparation of the left upper iliac retroperitoneum (ci)
Aortic bifurctaion
LN
Plexus hypogastricus superior
Fig. 23.3: Identification of the hypogastric superior plexus at the aortic bifurcation
cranially by exposing the promontory, the median sacral artery and the back bone
(Fig. 23.4c, d). Laterodorsally mobilization of obturator nerve and lumbosacral trunk
removing all lymph tissue (Fig. 23.4a).
Step 6: The same preparation on the left side from medially to laterally. The pre-
paration of the branches of the internal vessels may be performed down to the left
uterine artery due to the excellent access via the sigmoid tunnel. Now the mobi-
lized tissue of the secondary compartment (level II) may be resected and stored in an
endobag or left en bloc.
Step 7: Exposition of the right external iliac region and again preparing the
genito-femoral nerve and the psoas muscle laterally (Fig. 23.4b) down to the A. and
V. circumflexa ilium profunda and the level of the femoral channel. Mobilization of
lymph tissue from laterally to medially by exposing the external iliac vessels. Opening
the paravisceral basin from lateral by dissecting the nodal tissue from the obturator
fascia down to the arcus tendineus retracting the iliac vessels medially. Dissecting the
lymph tissue at the level of the femoral channel preserving the Vasa circumflexa ilium
profunda and the inferior epigastric vessels medially (ei).
Step 8: Identification of the obliterated umbilical artery (medial umbilical
ligament) and preparation from the anterior abdominal wall to its origin from the
internal iliac artery. Development of the paravisceral basin starting from the vesical
(b) Os pubis N. genito-femoralis

(a) M. psoas
V. iliolumbalis N. genito-femoralis
N. obturatorius
N. obturatorius
V. iliolumbalis
Vasa iliaca
communia
Vasa iliaca externa dextra Truncus lumbosacralis Truncus lumbosacralis
Promontorium
(d)
(c)
Promontorium
A. sacralis media
Spine
Ureter
V. Iliaca communis sinistra A. Iliaca communis dextra Aortic bifurcation V. cava inferior Ureter dexter
Fig. 23.4: a) Preparation of the lateral part of upper paravisceral basin (pv) and lower common iliac
basin (ci), dissecting all lymphatic tissue. b) Preparation of lateral part of paravisceral basin (exposition
of obturator nerve). c) Exposition of the promontorium and the presacral region (subaortic nodes, ps).
d) Lymphadenectomy of the upper iliac region exposing the aortic bifurcation (ci, ps)
mesenteric septum dorsally to the umbilical artery and performing the dissection
down to the endopelvic fascia (Fig. 23.5a). Removal of the medial nodes located in
front of the femoral channel and exposition of the Pecten ossis pubis. By preparing
down along the obturator muscle from lateral until the endopelvic fascia is reached
again. Now the obturator nerve/vessel bundle can be identified, freed completely
from lymph tissue and preserved. The lateral and medial part of paravisceral basin
can be joined and totally be cleaned down to the pubococcygeal and ileococcygeal
muscles and up to the internal iliac vessels (pv, caudally) (Fig. 23.5b).
Step 9: In the case of removal of the lymphatic tissue along the branches of iliac
vessels in cervical cancer, first the prespinal tissue will be removed exposing the A.
pudenda interna reentering the pelvis via the foramen ischiadicum minus (Fig. 23.5c).
Step by step first the arterial branches of the Aa. glutea superior, inferior, iliolumba-
lis, rectalis media and pudenda interna and the corresponding veins will be freed
from lymphatic tissue, completely. Concomitantly the lumbosacral trunk, the roots of
S1S4 of sacral plexus, the ischiadic and pudendal nerve are exposed and preserved
(Figs. 23.5d and 23.6 shown on the left) (pv, cranially).
(a) (b) Os pubis V. Iliaca externa

A. iliaca externa dextra
N. obturatorius
M. obturator internus
Paravisceral
basin Arcus tendineus
m. levatoris ani
A. umbilicalis
A. umbilicalis dextra
(c) V. Iliaca externa (d) Vasa iliaca externa sinistra N. obturatorius
N. obturatorius dexter
A. glutea superior
L5
A. pudenda interna
A. iliolumbalis
S1
Regio praespinalis
Ramus anterior A. iliacae internae
Fig. 23.5: a) Development of the paravisceral space by medialisation of the vesical mesenteric
septum and dissection down to the endopelvic fascia (pv). b) Clearing of the lateral and medial
partof the paravisceral basin down to the pubococcygeal and iliococcygeal muscles and up to the
internal iliac vessels (pv). c) Preparation of the right prespinal region with corresponding lymph
basins (pv). d) Exposition of the superior gluteal artery and pelvic nerval roots (pv) on the left
N. obturatorius N. ischiadicus (Foramen infrapiriforme f. ischiadici maioris)
Spina
Regio praespinalis
L5
S4 Vasa pudenda interna
A. glutea superior
S1
S2 S3
A. glutea inferior
Fig. 23.6: Visualization of the N. ischiadicus (L5S4), superior and inferior gluteal vessels and the
vasa pudenda (upper paravisceral basin)
(b) A. mesenterica inferior

(a) A. Iliaca externa
A. Iliaca interna
A. Iliaca communis
M. psoas
Spine
Aorta
Ureter sinister
Fig. 23.7a, b: a) Left iliac bifurcation, border to common iliac basin (ci, line). b) Preparation of the
lower periaortic region exposing the inferior mesenteric artery (im)
Steps 1012 correspond to steps 79 on the left side.

Following preparation of the branches of the anterior internal iliac artery the
mesometrial nodes are usually removed concomitantly with resection of vascular meso-
metrium by TMMR in cervical or PMMR in endometrial cancer and will be described
later. Finally, the connection to the left common iliac region has to be established to
guarantee complete node dissection also dorsally of the sigmoid colon (Fig. 23.7a, b).
Thus, the therapeutic pelvic lymphadenectomy is completed.
Therapeutic-periaortic lymphadenectomy
In the case of indication for periaortic lymphadenectomy three different situations
have to be addressed: primary tumor involves uterine corpus and/or adnexa or the
cervix only or both.
In the first situation lymph drainage follows the vascular mesometrium and the
infundibulopelvic ligament: therefore primary lymph basins are pelvic and periaortic,
simultaneously and therefore have to be removed entirely. In the second situation
periaortic lymph basins are of third or fourth order and may be maintained in case of
histologically proven negative pelvic nodes. If involvement of the uterine corpus and
cervix is simultaneously present both pathways have to be addressed.
In the case of tumor involvement of the uterine corpus or the adnexa in addition to
the vascular mesometrium also the network for vascular and lymphatic anastomoses
between uterus and adnexa has to be removed, best covered by the peritoneal leaves
of the broad ligament (PMMR). The vascular and lymphatic drainage system along the
ovarian vessels has to be removed in analogy to the vascular mesometrium up to its con-
nection to the periaortic and pericaval lymph basins. Whereas the vascular anastomoses
to the mesenteric vessel system (ascendant and descendant colon) are dissected the con-
nections to the periaortic lymph basins are preserved and removed together en bloc.
However, if a tumor is located in the uterine corpus, exclusively, the deep gluteal,
pudendal and rectal nodes may be preserved, as usually there will be no upstream
drainage in such situations except for clinically suspicious nodes. On the other
hand, if it is located in uterine cervix only, periaortic lymphadenectomy has only to
be performed in the case of positive pelvic nodes and resection of the ovarian vessel
system is not mandatory.
Step 13: In the case of cervical cancer inframesenteric periaortic lymphadenec-
tomy may be performed following elevation of the superior hypogastric plexus, the
inferior mesenteric artery and the sigmoid colon ventrally, thus continuing lymph-
adenectomy from the common iliac vessels (Fig. 23.7b, c). It has to be ascertained
whether to also remove the interaortocaval nodes and the posterior chains dorsally of
the aorta and vena cava.
Step 14: In any case in endometrial or ovarian cancer the infundibulopelvic liga-
ments have to be resected first, and the aorta, vena cava, the right ureter and the
right infundibulopelvic ligament are identified. Mobilization of the right colic mesen-
tery allows to identify vessel anastomoses to the ovarian vessel system which should
be divided. Following the ovarian vein the lateral border of the ovarian lympho-
vascular drainage bundle can be followed until the right angle between the vena cava
and right renal vein is reached. Thus all anastomoses to the periaortic lymph basin
should be kept intact (outlined in PMMR Figs. 23.3123.34). The duodenum usually is
loosely attached to the preaortic region and has to be mobilized (Fig. 23.7d).
(c) A. mesenterica inferior (d) V. ovarica dextra
Lymph node
Vena cava
Vasa vertebralia V. cava inferior Duodenum
Fig. 23.7c, d: c) Interaortocaval region with vertebral vessels (ir and im). d) Upper periaortic region;
mobilization of the duodenum
Step 15: The right ovarian vein is isolated at the level of the vena cava and
dissected (Fig. 23.8a). Now the lymphatic channels may be dissected cranially along
the right renal vein and dorsally to the right pericaval region to expose the back bone.
The lymphatic periaortic system may now be pulled to the left and the interaortocaval
region will be exposed. The vertebral vessels will be freed from the lymphatic tissue
and the vena cava now is cleaned all around 360. Care has to be taken to remove the
dorsolateral lymph node chain draining from deep right pelvis, which is not directly
connected to the ventral chain. The right ovarian artery will be exposed, sealed and
divided (Fig. 23.8b). The left renal vein will now be identified at its angle to the vena cava
and followed laterally and again the lymph channels will be dissected along the left
renal vein until the left ovarian vein can be identified. The left ovarian vein is coagu-
lated and cut (Fig. 23.8c). Now we move downward using the left infundibulopelvic
ligament as lateral border and the aorta as medial border. For mobilization and resec-
tion of left periaortic lymphatic basin the left ovarian artery will be identified appro-
ximately at the level of right ovarian artery, sealed and cut (Fig. 23.8d).
Step 16: The left periaortic lymphatic tissue together with the left infundibulopel-
vic ligament can be separated from the inferior mesenteric system (Fig. 23.9) and the
(a) (b) Left Vena cava inferior

Aorta
Vena cava inferior
Vena ovarica dextra

Arteria ovarica dextra
Right infundibulopelvic ligament

and periaortic nodes
(c) Vena ovarica sinistra

(d)
Aorta
Arteria ovarica sinistra

Left
Vena renalis sinistra
Fig. 23.8: a) Preparation and dissection of the right ovarian vein (ir). b) Exposition of the right
ovarian artery at its origin (ir). c) Preparation of the left ovarian vein (ir) at the level of the left renal
vein. d) Exposition of the left ovarian artery (ir)
23.3Total mesometrial resection (rTMMR) 297
Left colon mesentery
Plexus mesentericus inferior
Left periaortic supramesenteric

lymph basin Plexus aorticus
Aorta
Fig. 23.9: Fibers of the inferior mesenteric and superior hypogastric plexus are clearly visible, they
are mobilized together with the mesosigma (ir). Fibers of the aortic plexus may remain in touch with
the aortic wall
superior hypogastric plexus. The mesenteric vessels are elevated ventrally together
with the nerve bundles and the lymphatic tissue is mobilized and pushed through
the paraaortic tunnel posterior to the mesenteric artery caudally (Fig. 23.33). Atten-
tion has to be paid to preserve the nerve fibers of the inferior mesenteric plexus and
the aortic plexus which can be separated from the lymphatic tissue (Fig. 23.9). The
right part, especially the right sided connecting nerve fibres to the right sympathe-
tic chain, however, for our experience cannot entirely be preserved in the case of
therapeutic-periaortic lymphadenectomy.
Step 17: The left infundibulopelvic ligament and periaortic lymph tissue is mobi-
lized inframesenterically using the left aortic wall, the back bone, the sympathetic
chain and the left ureter as border, medially, dorsally and laterally. It may be develo-
ped en bloc from caudally through the sigmoid channel.
If resection of the ovarian vessel drainage system is not necessary in case of
cervical cancer the procedure can be performed identically following the dissec-
tion of the connecting vessels to the periaortic drainage system and lateralization and
preservation of the ovarian vessels.
During the preparation care should be taken to mobilize the entire lymphatic
basins at risk and concomitantly preserve the autonomic nerve fibers and the ureteral
supplying vessels as thoroughly as possible.
23.3Total mesometrial resection (rTMMR)
Having done rtLNE, all regional nodes at risk are removed, except for intercalated
mesometrial nodes located predominantly in the vascular mesometrium. Prior to
the standardized description of rTMMR for treatment of cervical cancer the prin-
ciples and nomenclature of Hckels method should be recalled. As shown in
Fig. 23.1b the Mllerian compartment consists of the uterus, the fallopian tubes, the
vascular mesometria and the fibrofatty (ligamentous) mesometria and mescolpia and
the proximal vagina. The vascular mesometria correspond to the tissue surrounding
and accompanying the uterine vessels to the iliac vessels and along their anastomo-
ses to the vesical vessel system anteriorly. The fibrofatty (ligamentous) mesometria/
mesocolpia correspond to the sacrouterine and rectouterine/vaginal ligaments,
posteriorly, which insert dorsally medially at the mesorectum and laterally along the
pubo- and ileococcygeus muscles. All these structures have to be removed comple-
tely; the vagina only, belonging also to the Mllerian system with its upper 2/3 should
not be removed completely for functional reasons; consequently, the resection at the
level of the vagina should have clear margins confirmed by histology. With respect to
all other resection borders clear margins are achieved by removal of the total Mlle-
rian compartment irrespective of the distance to the resection border as long as the
tumor does not transgress the compartment.
The removal of the uterus, the fallopian tubes, the vascular and ligamentous
mesometria and part of vagina starts dorsally.
Step 1: First, the peritoneum is incised pararectally to the pouch of Douglas from
right to the left and rectum is mobilized medially from the vaginal wall. Rectovaginal
and rectouterine ligaments which form the medial part of ligamentous mesometrium
are lateralized until their insertion to the perirectal tissue is reached (Fig. 23.10).
Step 2: Now, the ureter is identified and will be kept intact together with the
mesureter and the adjacent inferior hypogastric plexus and nerve. Thus, the avas-
cular plane between the lateral part of ligamentous mesometrium (i.e., sacrouterine
ligament) may easily be developed and the nerve plane can be dissociated laterally
from the mesometrium (Fig. 23.11).
Step 3: The medial and lateral part of the ligamentous mesometrium may now be
completely exposed and resected first laterally, pararectally towards the coccygeal
muscles (sacrouterine part, Fig. 23.12) and then, prerectally along the descending
branch of the rectal artery (rectouterine/vaginal part, Fig 23.13), starting on the right,
finalizing on the left.
Step 4: To separate the vesico-uterine attachment the anterior surface of the
uterus has to be exposed and put under tension to facilitate incision of the perito-
neum at the vesico-uterine fold. The peritoneum has to be incised in the direction to
the lateral part of the round ligaments to divide these at the entrance to the inguinal
channel. The looseconnective tissue is dissected until the ureters are identified ente-
ring the vesical wall (Fig. 23.14). The preparation is extended laterally and the border
of the vesical and Mllerian compartments is identified.
Step 5: Now, the umbilical artery is identified and completely dissected to its
origin from the internal iliac artery. Thus branching of uterine artery and one or more
superior vesical arteries can now be easily identified.
Uterus Right ligamentous mesometrium

lateral aspect (sacrouterine part)
Left ligamentous mesometrium

medial aspect (recto-vaginal part)
Vagina
Rectum
Plexus
hypog.
inferior
Fig. 23.10: Overview following preparation of ligamentous mesometria with simultaneous demonstration
of the medial (recto-vaginal, on the left) and the lateral aspect (sacro-uterine on the right)
A. vesicalis superior
A. uterina dextra
Plexus hypogastricus inferior
Cervix Ureter
Mesureter
Ligamentous mesometrium
(sacrouterine part)
Promontorium
Rectum
Fig. 23.11: Preparation of the lateral part of ligamentous mesometria on the right. Developing of the
avascular space between the ureter, the mesureter and the inferior hypogastric plexus laterally/
ventrally and the ligamentous mesometrium medially/dorsally (sacrouterine ligament)
Step 6: At this time the vascular mesometrium can be exposed first by developing
the avascular space between its anterior surface and the bladder mesentery containing
the superior vesical artery and secondly, by developing the avascular space between
the posterior surface and the plain of the ureter, mesureter and hypogastric plexus
(Fig. 23.15). The caudal border of the vascular mesometrium is marked by the deep
uterine vein, which should also be removed.
right
Ureter
Plexus
hypogastricus
Ligamentous mesometrium inferior
(sacrouterine part)
Rectum
Fig. 23.12: Lateral resection line of ligamentous mesometrium on the right starting from the ridge
pararectally, following the dorsal/lateral rim of the inferior hypogastric plexus to the insertion along
the iliococcygeal and pubococcygeal muscle and the fascia endopelvina
Cervix uteri
Right ligamentous mesometrium

medial (recto-vaginal) part
Descendant branch
A. rectalis media
Rectum
Fig. 23.13: Medial resection of ligamentous mesometrium on the right starting from the ridge
dissecting the connective tissue junction along the descendant branch of the rectal artery to
separate the mesorectum
Step 7: Complete resection of the vascular mesometrium including all paracervi-

cal/mesometrial intercalated nodes. Starting with coagulation and division of uterine
artery and superficial veins at their origin from the iliacal vessels; this step should
done without separating the vessels in order to remove all the tissue in between
as shown on the left side; the deep uterine vein will be identified and coagulated
separately (Fig. 23.16).
Bladder Arterial vesicouterine anastomoses

(ligamentum vesicouterinum, anterior part
Vagina
Right ureter
A. uterina dextra
Fig. 23.14: Separation of Mllerian compartment from the bladder compartment anteriorly,
preparing ureteral entrance to the bladder wall from medially exposing the vesicouterine arterial
vessels connecting the Mllerian with the bladder compartment (anterior part of vesicouterine
ligament) shown on the right
A. Iliaca externa
Bladder and vesical mesentery
Cervix
N. obturatorius
A. umbilicalis
Uterus
Vascular mesometrium
A. uterina
Rectum Plexus hypogastricus

inferior
Ligamentous mesometrium Ureter dexter
Fig. 23.15: Preparation of the vascular mesometrium (upper ridge marked by the uterine artery) on
the right dissecting the avascular plane dorsally with separation of the ureter, the mesureter and
the inferior hypogastric plexus dorsally/medially
Step 8: Dissection of the ureteral branch of the uterine artery (and vein) following
elevation of the uterine bundle to mobilize the ureter in its tunnel (Fig. 23.17).
Sealing and dissection of vesicouterine/vaginal vessel anastomoses in the anterior
part of vesicouterine ligament to separate the Mllerian and the vesical compart-
ment ventrally (Fig. 23.18).
left
A. umbilicalis sinistra
Bladder wall
A. uterina
Plexus hypogastricus
Deep uterine vein inferior
Ureter
Fig. 23.16: Identification of deep uterine vein and dissection of vascular mesometrium at the level of
the origin from internal iliac vessels shown on the left
left
A. umbilicalis
A. uterina sinistra
Bladder
Ureteral branch
Uterus
Ureter
Fig. 23.17: Elevating of the dissected vascular mesometrium and dissection of the ureteral branches
of the uterine vessels to separate the ureter from the vascular mesometrium on the left
Step 9: Dissection of the uterine nerve fibers at the lateral posterior aspect of the
cervix (Fig. 23.19); following that inferior hypogastric vesical nerve branches can be
mobilized and pushed off laterally together with the ureter to preserve them.
Step 10: Dissection of the ladder-like arranged vesicovaginal venous anasto-
moses below the level of the ureter (Fig. 23.20), if not already done during separation
of the ventral aspect of vascular mesometrium from the bladder mesentery (so-called
posterior leaf of vesicouterine ligament).
A. and V. iliaca externa sinistra Arterial vesicouterine anastomoses

(lig. vesicouterinum), anterior part
N. obturatorius Bladder
Bladder
Ureter
A. uterina
dissected
Uterus
Fig. 23.18: Now, the vascular mesometrium can be pulled dorsally without elevating the ureter and
the vesicouterine vascular junction can be exposed from laterally on the left (vesicouterine ligament).
The connecting vessels and the accompanying connective tissue are dissected in its free part close
to its junction to the bladder vessels
Le
A. Iliaca externa Vascular

mesometrium
Cervicovaginal juncon
Arteria umbilicalis
N. obturatorius
Le uterine branch of plexus
hypogastricus inferior
Vagina
Ureter Plexus hypogastricus Ligamentous

inferior mesometrium
Fig. 23.19: To separate the complex of inferior hypogastric plexus, mesureter and ureter definitely
from the Mllerian compartment the uterus supplying nerve fibers have to be dissected at their
branching laterodorsally of the cervix as shown on the left
Step 11: Defining the resection plane of the vaginal wall and further dissection of
mesocolpium, if necessary. Incising the vagina from dorsally and resection of vaginal
cuff with sufficiently clear margins confirmed by frozen section.
A. umbilicalis sinistra
Bladder wall
Plexus hypogastricus inferior
Vesicouterine venous anastomoses

(lig. vesicouterinum) posterior part
Ureter sinister
Uterus
Fig. 23.20: Finally, the vesicouterine/vesicovaginal venous anastomoses representing the

posterior part of vesicouterine ligament have to be dissected to complete the dissection of
vascular mesometrium as shown on the left
Step 12: Following saving of all resected tissue, bags and sponges, and confirma-
tion of clear margins, the vagina is closed by running suture.
Finally, all the tissue of the Mllerian compartment (except for distal vagina) has
been removed completely, but adjacent structures such as the ureter, mesureter, hypo-
gastric plexus, mesorectum and vesical mesentery are entirely preserved (Fig. 23.21).
Resection lines ligamentous mesometria Bladder

su (sacrouterine), rv (recto-vaginal), l/r
A. umbilicalis
Vagina
Rectum
rvl
rvr sur
sul
Ureter Mesureter Plexus hypogastricus inferior
Fig. 23.21: Pelvic topography following TMMR demonstrating complete resection of the Mllerian
compartment including the vascular and ligamentous mesometria except for the healthy part of
vagina. Mind the completely intact plane of ureter, mesureter and inferior hypogastric nerve plexus
on both sides
23.4Fertility-preserving mesometrial resection (rFMMR) 305
Fig. 23.22: Specimen of TMMR and therapeutic pelvic lymphadenectomy en bloc with vascular and
ligamentous mesometria
Thus, this procedure may be performed identically for all compartment-defined

cervical cancers ensuring maximum radicalness with respect to tumor resection
without increasing morbidity by extending the radicalness to neighboring structures.
Surgery does not have to be adapted any longer with respect to tumor size and extent
to prevent unnecessary morbidity. Finally, the specimen removed is demonstrated
with adhering intact mesometria and regional lymph basins (Fig. 23.22).
In contrast to Hckel we do not readapt the natural sigma adhesions represen-
ting the sole difference to the original method described for open surgery; however,
this may be easily implemented if desired.
23.4Fertility-preserving mesometrial resection (rFMMR)
At present there is some debate whether radical trachelectomy is necessary in early

cervical cancer, on the one hand, or may be not sufficient in more advanced tumors,
on the other hand [18]. In the situation of more advanced tumors, however, not all the
tissue at risk will be removed by radical trachelectomy, as lateral parts of vascular
and ligamentous mesometria are not resected. Thus, the fertility preserving meso-
metrial resection (FMMR) may represent the logical consequence from compartment-
defined surgery with respect to cervical cancer for these tumors. In this operation the
uterine cervix will be removed with clear margins together with the vascular and liga-
mentous mesometria and the proximal part of vagina including the regional lymph
basins. The only difference to TMMR is the preservation of the uterine corpus and a
small part of uterine isthmus and cervix, if clear margins can be achieved.
In node-negative disease, radical trachelectomy and pelvic LNE seems to be asso-
ciated with a very low recurrence rate; it may be assumed, with respect to oncological
safety, that FMMR and tLNE may perform at least equally or even better. However, in
more advanced disease and especially in node-positive tumors, it may be an alterna-
tive to TMMR and tLNE to preserve fertility; provided that locoregional control with
respect to the pelvis without any adjuvant irradiation is similar to TMMR and tLNE,
risk of locoregional recurrence will be primarily determined by risk of recurrence in
the preserved uterus itself. As there are no data available with respect to this situa-
tion, it cannot be recommended to perform FMMR and tLNE in such situations rou-
tinely. However, if a patient declines a hysterectomy definitely for personal reasons,
FMMR may be safer, compared to radical trachelectomy.
Technique of fertility-preserving mesometrial resection (rFMMR)

Step 1: Prior to FMMR, an adequate vaginal cuff has to be formed and closed vaginally
either before starting the operation or immediately before opening the vagina for defi-
nitive removal of the specimen.
Step 2: Performance of pelvic rtLNE as already described above and in [2].
Step 3: Opening of the vesicouterine and rectouterine peritoneum and prepara-
tion of vascular and ligamentous mesometria exactly in the same way as described
for rTMMR above and in [3].
Note: In contrast to rTMMR the infundibulopelvic and round ligaments will be
kept intact (Fig. 23.23).
Step 4: Vascular and ligamentous mesometria will be resected completely as in
rTMMR with the difference that the uterine arteries should be skeletonized and pre-
served if adequate (as shown in Figs. 23.24 and 23.26 for right uterine artery).
Step 5: Following the opening of the vagina the level of resection in the upper
cervix is defined and the tumor bearing cervix is removed together with the mesomet-
ria and the closed vaginal cuff followed by the endobags containing the lymph nodes.
Clear margins have to be achieved at the vaginal and the cervical resection margin. To
guarantee for tumor free margins a safety slice of tissue may be resected for histo-
logy from the remaining cervix as shown in Fig. 23.24.
Step 6: A permanent cerclage (e.g., prolene 1/0) will be applied to support the
cervical tissue and a transient catheter will be fixed in the cervical channel by suture
for the first 5 days (Fig. 23.25).
Step 6: Exposition of the vaginal vault (Fig. 23.26) and adaptation to the cervix
in such a way that the cervix will be located centrally and no vaginal stenosis will
occur. Final control of the topographical situation as shown in Figs. 23.27 and 23.28.
The resection lines of the insertions of the ligamentous mesometria can be identified
on the left; the uterine artery was skeletonized and preserved on the right (Fig. 23.27).
23.4Fertility-preserving mesometrial resection (rFMMR) 307
Left
Uterus
Lig. rotundum
External iliac vessels
A. umbilicalis
N. obturatorius
Adnexa
Rectum
Infundibulopelvic ligament
Fig. 23.23: Topography in FMMR following therapeutic lymphadenectomy with preservation of round
and infundibulopelvic ligaments
Left Resected slice
Vasa iliaca externa
A. uterina
Uterine corpus
Fig. 23.24: Topography in FMMR following TMMR of the cervix with preserved part of the uterus
and slice from the proximal uterine cervix for documentation of clear margins
When considering the aim of fertility preservation it has to be controlled for risk
of recurrence and also for preterm birth: Thus, free margins should be at least 10 mm,
better at 15 mm and if possible at least 10 mm of proximal cervix should be preserved.
There is some evidence that neoadjuvant chemotherapy may support to achieve these
goals in more advanced tumors [18].
Right
Bladder
Transient Cervical
Catheter
Lig. rotundum
Permanent Cerclage
Uterus
Fig. 23.25: Cerclage at the cervico-isthmic junction and with permanent suture and fixation of
a cervical catheter
Vagina
A. uterina
Uterus
Fig. 23.26: The vagina prior to adaptation of the preserved uterus with intact uterine artery on the right
Left
Uterus
A. uterina
Ureter Plexus hypogastricus Rectum

inferior
Fig. 23.27: Final topography of FMMR following adaption of the uterus to the vagina (posterior aspect)
23.5Peritoneal mesometrial resection (rPMMR) 309
Left Ligg. rotunda
Nn. obturatorii
Aa. umbilicales
Bladder
Uterus
Vs. Iliaca externa
Fig. 23.28: Final topography of FMMR following adaption of the uterus to the vagina (anterior
aspect)
23.5Peritoneal mesometrial resection (rPMMR)
In close cooperation with Hckel the method of rPMMR has been developed
modifying TMMR according to the topography of endometrial cancer and surgical
steps with respect to removal of ontogenetically-derived compartments of permissive
tumor progression were defined. Although, endometrial cancer also arises within the
Mllerian compartment, there are two important differences to cervical cancer with
respect to tumor site in compartment-related tumor progression.
First, there is additional downstream lymphatic drainage along the mesonephric
derived ovarian vessel system into periaortic nodes.
Second, there is no drainage into the deep preischiadic nodes via the ligamentous
(fibrofatty) mesometria, as long as there is no distal cervical stromal infiltration.
On the other hand, the drainage along the vascular mesometrium is almost iden-
tical compared to cervical cancer using the same lymph channels along the uterine
vessels into the external, internal and common iliac nodes.
Thus, with respect to type of radical hysterectomy, vascular mesometrium has to
be resected in endometrial cancer almost identically to cervical cancer; the ligamentous
mesometrium as well as the rectovaginal septum, i.e., sacrouterine and rectovaginal
ligaments, however, may be left in situ. Furthermore, it is important to remove all the
vascular anastomoses between the uterine and ovarian vessel system to guarantee
for the clearance of the whole Mllerian and mesonephric compartment at risk. This
can be achieved by intact resection of the content of the broad ligament together
with the peritoneum covering this tissue region. With respect to loco-regional spread
bilateral complete resection of adnexa and infundibulpelvic ligaments including
intercalated lymph nodes is mandatory. With respect to parietal lymphadenectomy

pelvic and periaortic nodes represent primary basins, thus implying a complete bila-
teral pelvic and periaortic lymphadenectomy in case of therapeutic intent as already
described in detail (rtLNE, [2]). As a consequence of the lacking lymph drainage via
the ligamentous mesometria in endometrial cancer the deep preischiadic nodes may
be left in situ. The resulting technique of rPMMR has been described in detail step
by step in [4]. For identical steps of rTMMR will be referred to this procedure and [3].
Concomitantly to the removal of lymph nodes, infundibulopelvic ligaments
containing lymph vessels and intercalated nodes will be completely exposed and
totally resected; the anastomoses to the periaortic lymphatic system at the level of
aorta, caval vein and renal veins should kept intact and mobilized without separa-
tion. Following that, all regional nodes are removed, except for intercalated meso-
metrial nodes located predominantly in the vascular mesometrium. Prior to the
standardized description of rPMMR the principles and nomenclature of the technique
of Hckel should be kept in mind again. As already described for rTMMR in rPMMR all
structures of the Mllerian compartment have also to be removed completely except
for ligamentous mesometria and the vagina (but wide tumor-free margins have to be
ensured; Fig. 23.1c); nevertheless, the inferior hyopgastric plexus should be identified
in order to safely separate it from the vascular mesometrium. Additionally the inter-
calated tissue between the Mllerian derived uterine vessel system and the ovarian
vessel system of mesonephric origin has to be removed entirely together with ovary
and the ovarian vessel system due to the lymphatic drainage of uterine corpus fol-
lowing this way (Fig. 23.1d).
The procedure of rPMMR and rtLNE starts by opening the peritoneum lateral to
the right infundibulopelvic ligament at the level of right common iliac artery.
Step 1: First, the peritoneum will be incised lateral to the right iliac common artery
and the right infundibulopelvic ligament and will be divided cranially to expose the
anterior aspect of vena cava, the right ureter, the right infundibulopelvic ligament
and the right colon mesentery. Usually lymphatic anastomoses between the infundi-
bulopelvic ligament and low right periaortic nodes can be identified (Fig. 23.29).
Step 2: Now, the border between the mesonephric compartment of infundibu-
lopelvic ligament and the right colon mesentery is identified and the structures are
separated; anastomosing vessels have to be identified and sealed (Fig. 23.30).
Step 3: The infundibulopelvic ligament will be elevated and dissected from late-
rally to medially keeping the connections to the periaortic lymphatic system intact
and separating it from the right ureter and mesureter dorsally (Fig. 23.31).
Step 4: Resection of the right infundibulopelvic ligament following dissection of
ovarian vessels at their origin together with periaortic lymphadenectomy (Fig. 23.8a, b).
The right infundibulopelvic system is now completely mobilized together with
adherent right periaortic nodes (Fig. 23.32).
Step 5: Together with left periaortic node dissection left ovarian vein and artery
are also resected at their origin (Fig. 23.8c, d) mobilized laterally and dorsally to the
Right ureter
Vena cava inferior

Lymph
vessels Colon mesentery
A. ovarica dextra
Periaortic V. ovarica dextra

lymph node
Fig. 23.29: Right infundibulopelvic ligament (mesonephric ovarian pathway) with A. and
V. ovarica, the border to right colon mesentery and the lymphatic anastomosis to the right
inframesenteric periaortic lymph nodes (arrows)
A. Iliaca communis Ureter
Colon mesentery
Psoas
A. and V. ovarica dextra
V. cava inferior Ramus communicans V. colica dextra
Fig. 23.30: Separation of right infundibulopelvic ligament from right mesocolon and dissecting the
connecting vessels
left colon mesentery and the left ureter identically to the right (Fig. 23.33) and pulled
through retrosigmoidally to the left pelvis at the level of the left common iliac artery
together with the adherent infra-renal periaortic nodes (Fig. 23.34).
Step 6: Completion of therapeutic pelvic lymphadenectomy as described for
endometrial cancer in rtLNE and [2].
Ovarian vessels with intercalated nodes

Colon mesentery
M. psoas
A. Iliaca
communis
Right ureter
Fig. 23.31: Mobilization of right infundibulopelvic ligament from lateral to medial and resection
together with adherent periaortic nodes ventrally of the vena cava; preparation and mobilization of
the ureter and preserving the supplying vessels to the mesureter
Ligamentum infundibulopelvicum dextrum Right
Uterus
Ureter
Sigmoid colon
Right
periaortic
nodes
(mobilized) A. Iliaca communis dextra
Fig. 23.32: Mobilized right infundibulopelvic ligament following dissection of ovarian artery at the
aortic and ovarian vein at the cava level; right periaortic nodes are left attached as first draining
nodes (compare Fig. 23.1c)
Step 7: Incision of the peritoneum covering the round ligament, the ovarian
vessels, the utero-ovarian junctions, and the vascular mesometrium in that way to
guarantee a complete resection of both regions together with the ovaries and there
connecting structures (Figs. 23.35a, b).
Left Lig. infundibulopelvicum sinistrum
Ovarian vessels
Sigma mesentery
A. mesenterica inferior
Left periaortic nodes

(mobilized) Aorta
Fig. 23.33: Same preparation of the left side. Following dissection of the ovarian vessels at their
aortic and renal origin the left infundibulopelvic ligament will be dissected from the left mesocolon
and followed to the sigmoid tunnel. Left infrarenal periaortic nodes also were kept in continuity to
the ovarian vessel system as it has been show on the right
Left Left fallopian tube
Ligamentum infundibulopelvicum sinistrum
Uterus
23.
Ovary
Left periaortic
nodes (mobilized)`
A. Iliaca communis sinistra
Ureter
Fig. 23.34: Following complete mobilization left infundibulopelvic ligament can be pulled through
the sigmoid tunnel to the pelvis together with left infrarenal periaortic nodes to guarantee
complete resection of the mesonephric ovarian pathway by avoiding division of the ligament
Step 8: Radical hysterectomy with complete resection of the vascular mesomet-

rium as described in detail for rTMMR and [3], however without separating it from its
conjunction with the adnexa and infundibulopelvic ligaments. For rPMMR in endo-
metrial cancer without cervical infiltration in contrast to cervical cancerresection
(a) Right
Bladder
Uterus
Ligamentum rotundum dextrum
(b) Right ovary and

fimbria
Cervix
Vagina
Rectum
Fig. 23.35: a) Incision line ventrally to preserve the peritoneum covering the uterine and ovarian
vessel system to guarantee for complete resection. b) Incision line dorsally which should be
caudally of the uterine vessels being identified through the intact peritoneum
of ligamentous mesometria is not required; therefore, this part of rTMMR may be

omitted.
Step 9: Same procedure on the left side. As in endometrial cancer the tumor also
arises primarily in the Mllerian compartment it has to be proven that the vaginal
wall (belonging to the same ontogenetic compartment) at the level of resection pre-
sents definitely clear margins. Closure of vagina may be done by running suture.
A postoperative specimen following rPMMR and rtLNE in high-risk endomet-
rial cancer stage I is shown in Fig. 23.36a, b. The complex of vascular mesometrium
connected to the mesonephric infundibulopelvic vessel system responsible for the
(a)
Periaortic mesonephric Periaortic mesonephric
ovarian pathway right ovarian pathway left
Pelvic Mllerian Pelvic Mllerian

uterine pathway right uterine pathway left
(b) Left infundibulopelvic ligament Right infundibulopelvic ligament

and periaortic nodes
Ovarian vessels Right Adnexa
Uterine vessels
Left pelvic nodes Right pelvic nodes
Fig. 23.36: a) PMMR: Specimen of the uterus (ventrally) following rPMMR and tLNE showing the
complete resected uterine and ovarian vessel system without separating the connecting vessels and
surrounding tissue. The uterine and ovarian pathways of lymph drainage are indicated by arrows.
b) PMMR: Same specimen dorsally together with pelvic nodes kept in continuity with the uterine
drainage system
different pelvic and periaortic pathways to the primary lymph basins can easily be
identified (Fig. 23.36a). Not detaching the overlaying peritoneum facilitates complete
and intact removal of these connections (Fig. 23.36a, b). Connections to pelvic and
periaortic lymph basins may also preserved when intended.
This chapter summarized the technique for compartmental-based radical
surgery in uterine cancer based on basic research reporting on mechanisms of tissue
border control [1, 7] and clinical data obtained for surgery of rectal [8, 9] and cervi-
cal, vaginal and vulvar [1012] cancer in open surgery. Our own data with respect
to translation of compartmental surgery developed in open surgery to robotic
suggest that it is feasible, may reduce morbidity and may achieve comparable results
with respect to locoregional tumor control [24]. This, however, has to be confirmed
by larger trials. If this holds true, compartment-based robotically-assisted endoscopic
surgery could become the surgical treatment of choice in the future. It would combine
an excellent chance for standardization of surgical technique and thus a high degree
of reproducibility with reduced morbidity due to the mimimally-invasive approach.
Also, the technique can be learnt easily step by step by trainees, who could be cont-
rolled on the other hand by the trained surgeon using the HD teaching monitor.
Acknowledgments
We thank Michael Hckel, Head of the Department of Gynecology and Obstetrics and
Head of Leipzig School of Radical Pelvic Surgery, University of Leipzig, Germany, for
his intensive and steady support in understanding ontogenetically-derived compart-
ment based radical surgery in lower genital tract cancer; moreover, we thank him
especially for helping us translating his method from open to robotically-assisted
laparoscopic surgery.
References
[1] Hckel M. Cancer permeates locally within ontogenetic compartments: clinical evidence and
implications for cancer surgery. Future Oncol 2012, 8(1):2936.
[2] Kimmig R, Iannaccone A, Buderath P, et al. Definition of compartment based radical surgery
in uterine cancer. I. Therapeutic pelvic and periaortic Lymphadenectomy by Michael Hckel
translated to robotic surgery (rtLNE). ISRN Obstet Gynecol 2013, 297921.
[3] Kimmig R, Wimberger P, Buderath P, et al. Definition of compartment based radical surgery
in uterine cancer. II. Radical hysterectomy in cervical cancer as Total Mesometrial Resection
(TMMR) by Michael Hckel translated to robotic surgery (rTMMR). World J Surg Oncol 2013,
11(1), 211.
[4] Kimmig R, Aktas B, Buderath P, et al. Definition of compartment based radical surgery in
uterine cancer. III. Modified radical hysterectomy in intermediate/high risk endometrial cancer
as Peritoneal Mesometrial Resection (PMMR) by M. Hckel translated to robotic surgery
(rPMMR). World J Surg Oncol 2013, 11(1), 198.
[5] Kimmig R. Fertilitatserhaltende Mesometriale Resektion (Kap. 13, S. 129136) In: Wagner U,
Hoffmann R, Bartsch DK (eds). Operationsatlas Gynkologische Onkologie, Springer Verlag
Berlin Heidelberg 2013.
[6] Garcia-Bellido A, Ripoli P, Morata G. Developmental compartmentalization on the wing disk of
Drosophila. Nat New Biol 1973, 245, 2513.
[7] Dahmann C, Oates AC, Brand M. Boundary formation and maintenance in tissue development.
Nature Rev 2011, 12, 4355.
[8] Heald RJ, Rayan DRH. Recurrence and survival after total mesorectal excision for rectal cancer.
Lancet 1986, 327, 147982.
References 317
[9] Quirke P, Dixon MF, Durdey P, et al. Local recurrence of rectal adenocarcinoma due to
inadequate surgical resection. Lancet 1986, 328, 9968.
[10] Hckel M, Horn LC, Fritsch H. Association between the mesenchymal compartment of
uterovaginal organogenesis and local tumour spread in state 1B-2B cervical carcinoma: a
prospective study. Lancet Oncol 2005, 6, 7516.
[11] Hckel M, Schmidt K, Bornmann K, et al. Vulvar field resection: Novel approach to the surgical
treatment of vulvar cancer based on ontogenetic anatomy. Gynecol Oncol 2010, 119, 106113.
[12] Hckel M, Horn LC, Illig R, et al. Ontogenetic anatomy of the distal vagina: Relevance for local
tumor spread and implications for cancer surgery. Gynecol Oncol 2011, 122, 31318.
[13] Hckel M, Horn LC, Hentschel B, et al. Total mesometrial resection: high resolution
nerve-sparing radical hysterectomy based on developmentally defined surgical anatomy.
Int J Gynecol Cancer 2003, 13, 791803.
[14] Hckel M, Horn LC, Manthey N, et al. Resection of the embryologically defined uterovaginal
(Mllerian) compartment and pelvic control in patients with cervical cancer: a prospective
analysis. Lancet Oncol 2009, 10, 68392.
[15] Hckel M, Kahn T, Einenkel J, et al. Local spread of cervical cancer revisited: a clinical and
pathological pattern analysis. Gynecol Oncol 2010, 117, 4101408.
[16] Hckel M. Do we need a new classification for radical hysterectomy? Insights in surgical
anatomy and local tumor spread from human embryology. Gynecol Oncol 2007, 107(1 Suppl 1):
106112.
[17] Hepp H, Scheidel P, Monaghan JM. Lymphonodektomie in der gynkologischen Onkologie.
Indikationen, Technik und Konsequenzen fr die Therapieplanung. Urban & Schwarzenberg
Mnchen, 1988.
[18] Ribeiro Cubal AF, Ferreira Carvalho JI, Costa MF, et al. Fertility-sparing surgery for early-stage
cervical cancer. Int J Surg Oncol 2012:936534.
Part IV: Urogynecology
24 Robotic surgery for urogynecologic diseases
Omer Burak Argun, Can Obek and Ali Riza Kural
24.1Introduction
Robot-assisted laparoscopic surgery is becoming increasingly important in the

surgical care of patients with both urological and gynecological diseases. The intro-
duction of the da Vinci robotic surgical system (Intuitive Surgical Inc, Sunnyvale,
CA, USA) into the field urology has dramatically changed the surgical management of
urologic diseases. In 2005, the da Vinci robotic surgical system was approved for use
in gynecologic procedures in the USA by the Food and Drug Administration [1]. Since
then, robotic techniques are increasingly being used for gynecologic and urologic sur-
gical procedures including malignant and benign diseases.
The main use of robot-assisted laparoscopic surgery in the field of urogynecology
is for reconstructive procedures such as sacrocolpopexy due to its ability to permit
dexterous suturing. A robotic surgical system provides a less invasive technique with
the advantages of laparoscopic surgery and seems to be next generation surgery for
the surgical treatment of sacrocolpopexy. Urogenital fistulas may also be treated with
this technique.
24.2Robotic-vesicovaginal fistula repair
Vesicovaginal fistula (VVF) is one of the complications of childbirth and usually

occurs during prolonged obstetric labor. The predominant complaint is usually
continuous urine leakage [2].
Vesicovaginal fistulas (VVF) may become apparent 16 weeks after surgery,
and recurrent fistulas can occur within 3 months of primary repair [3]. VVFs can be
repaired either via the transvaginal or transabdominal route. Although transvaginal
repair was introduced to decrease operative morbidity [4], it has been reported to have
a lower success rate than transabdominal repair [5]. In 1953, Couvelarie explained the
key points for successful repair of the VVF as good visualization, good dissection,
good approximation of the margins and good urine drainage [6].
Efforts in looking for a new technique with a better success rate brought about lapa-
roscopic repair of VVF. Although the laparoscopic approach showed similar outcomes
compared to the open technique, it did not gain popularity because of its technical dif-
ficulties [7]. The most challenging part of the procedure was intracorporeal suturing.
The robotic system provided better ergonomic maneuverability of the instru-
ments, with three-dimensional vision, which has helped to overcome these technical
difficulties [8]. Smaller cystotomy and dissection and suprapubic catheter insertion
are the advantages of the robotic approach during VVF repair [9].
322 24 Robotic surgery for urogynecologic diseases
Surgical technique includes five major steps:

1. Vaginoscopy, urethrocystoscopy, bilateral ureteric jj stenting or catheterization
2. Trocar placement
3. Robotic dissection of the vesicovaginal fistula
4. Robotic repair of the fistula
5. Interposition of the tissue (flap) between the suture lines
Melamud et al performed the first robot-assisted VVF repair in 2005. They described
a technique in which the dissection and resection of the fistula are completed with con-
ventional laparoscopy. They used the robotic system only for suturing in their cases.
Operation time and EBL were 280 min and 50 mL, respectively. A urethral catheter was
left in place for 2 weeks. The patient was free of symptoms at 16-weeks follow-up [10].
Gupta et al reported a retrospective analysis of open- and robotic-assisted repairs
of VVFs. In this study, robot-assisted repair was associated with shorter LOS and
decreased EBL compared to the open counterpart [11].
24.3Robotic ureteral reconstructive surgery
The treatment of VVF with robotic approach continues to evolve, although, long-term
follow-up and more trials are required, early results are encouraging.
The use of robotic assistance in adult genitourinary surgery has been successful in
many other fields. Schimpf et al reported their robot-assisted laparoscopic distal ure-
teral re-implantation series. This series included ureteral reimplantation for ureteral
cancer and benign conditions [12]. It was the largest robotic distal ureterectomy series
to date for urothelial carcinoma of the ureter. The mean operation time, console time,
LOS and EBL were 189 min, 157 min, 2.4 days and 82 mL, respectively. They conclu-
ded that, robot-assisted laparoscopic distal ureterectomy is an acceptable procedure
in select patients. Several authors for different indications have published the use of
robot-assisted laparoscopy for ureteral surgery. These case reports includes the opera-
tions like uretero-pyelostomy, nephroureterectomy, uretero-ureterostomy, ureterolysis,
uretero-calicostomy and psoas hitch reimplantation of the distal ureteral [1315].
A multi-institutional study including 12 patients was published by Patil et al [16].
They compared their robotic ureteral reimplantation with open and laparoscopic
series. The endpoint of the study was decreased blood loss and length of stay with
laparoscopic approach.
Thus, the robotic approach may be useful for ureteral surgery facilitating intracor-
poreal suturing; however, larger volume randomized controlled studies are needed to
establish its definitive role in this setting.
The results of robotic surgery for the treatment of urogynecologic diseases are
encouraging and may have a much larger role in the near future. As more surgeons
embrace this new technology, more results and hopefully long-term data of some
24.4Robot-assisted laparoscopic sacrocolpopexy (RALS) 323
randomized trials will be available. This would help to define the ultimate role of this
new technique.
24.4Robot-assisted laparoscopic sacrocolpopexy (RALS)
Pelvic floor disorders such as pelvic organ prolapses (POP) and urinary fistulas affect
millions of woman worldwide. Nearly one of every three women suffers from at least
one of these disorders during their lifetime [17]. Pelvic reconstructive surgery is the
most common sub-specialty in urogynecologic cases. Sacrocolpopexy is one of the
most ideal procedures for robotic surgical application, because of the necessity of
complex suturing (Fig. 24.1). Because of the morbidity of open sacrocolpopexy, there
was a need for a minimally-invasive technique, which can mimic the principles of
open repair. Although laparoscopy was initially thought to be the ideal surgical tech-
nique, technical difficulty on suturing and need for the advanced surgical skill has
limited its acceptance.
Di Marco et al were the first to describe robot-assisted laparoscopic sacrocolpopexy
in 2004 with a mean operative time of 212 min [18, 19]. Same authors reported similar
results in terms of operative time with a subsequent series on 31 women [20] (Tab. 24.1).
Geller et al published the only study comparing RALS with abdominal sacrocol-
popexy (ASC) [21]. The study included 178 patients (73 RALS and 105 ASC). There was
a slight improvement in POP quantification (POP-Q) scale for RALS, but it was not sta-
tistically significant. Secondary outcomes with significant differences between RALS
and ASC were estimated blood loss (EBL) (103 vs. 255 mL), operative time (328 vs. 225
min), length of stay (LOS) (1.3 vs. 2.7 days) and postoperative fever (4.1 vs. 0%). They
concluded that RALS has improved EBL and LOS but had a longer operative duration.
In 2005 Ayav et al published their robot-assisted laparoscopic colpohysteropexy
and rectopexy series [22]. At 12 months follow-up, patients were satisfied with the
results and they did not report any recurrence.
Promontorium
Mesh
Vagina
Fig. 24.1: Demonstration of sacrocolpopexy

Akl et al published the largest sacrocolpopexy series to date [23]. Their study
included 80 patients with a mean operative time of 198 min. The EBL and LOS were
96.8 mL and 2.6 days, respectively. Four cases were converted to laparotomy. They had
two bladder injuries, one small bowel injury, one ureteral injury, one pelvic abscess,
one postoperative ileus and five mesh erosions. All the erosions were managed with
either vaginal estrogen or transvaginal excision and repair. There were four recurrent
prolapse cases and one was at the apical region.
Sierra and colleagues reported outcomes of their most recent series in 2011. In
their series there was no conversion to laparoscopy. The mean LOS was 4.6 days.
Interestingly, in one patient, syncopal episode was reported due to the mesh tension.
Symptoms were resolved after re-surgery [24].
Geller et al compared the RALS and ASC in terms of operative and functional
outcomes. Their study included 178 patients (73 RALS and 105 ASC). Even though there
was a slight improvement in POP-Q stage in the favor of RALS, it did not reach stati-
stically significance. The EBL, operative time and length of stay were 103 vs. 255 mL,
Tab. 24.1: Outcomes of robotic sacrocolpopexy series
Patient Mean age Mean OT Mean LOS Success Mean

(n) (year) (min) (days) rate (%) follow-up
(months)
Elliot et al 30 67 186 1 95% 24

(2006) [26]
Geller et al 73 60 328 1.3
(2008) [27]
Kramer et al 21 66 194 1.1 95% 25
(2009) [28]
OT: operation time.
LOS: length of hospital stay.
Tab. 24.2: Advantages and disadvantages of the robotic surgery
Advantages Disadvantages
Three-dimensional vision system Cost

Maintenance and purchase
Ergonomic positioning of the surgeon Patient positioning
Steep Trendelenburg position
Limited vaginal access with docking of the
robot
Wristed instrumentation
Complete control of the camera
Use of a fourth arm for retraction
No tremor
References 325
328 vs. 225 min and 1.3 vs. 2.7 days, respectively. They concluded that RALS was asso-
ciated with decreased EBL and LOS, but longer operative time [25].
Despite the widespread use of the robotic system in urogynecology, there is still a
lack of randomized controlled trials comparing its efficacy and safety in comparison
with other surgical approaches. There are advantages and disadvantages of robotic-
assisted surgery compared with standard laparoscopy (Tab. 24.2). The evolving litera-
ture on robot-assisted surgery in urogynecology suggests that the surgical limitations
of conventional laparoscopy can be overcome and the skill level of the surgeon may
be enhanced.
References
[1] Nezhat C, Saberi NS, Shahmomhamady B, et al. Robotic-assisted laparoscopy in gynecological
surgery. J Soc Laparoendosc Surg 2006, 10, 31720.
[2] Latzko W. Postoperative vesicovaginal fistulas: Genesis and therapy.Am J Surg1942, 58, 21128.
[3] Zimmern PE, Hadley HR, Staskin DR, et al. Genitourinary fistulae. Vaginal approach for repair of
vesico-vaginal fistulae.Urol Clin North Am1985, 12, 3617.
[4] Latzko W. Postoperative vesicovaginal fistulas.Am J Surg1942, 58, 211.
[5] Hilton P, Ward A. Epidemiological and surgical aspects of urogenital fistulae: A review of 25
years experience in southeast Nigeria.Int Urogynecol J Pelvic Floor Dysfunct1998, 9, 18994.
[6] Couvelaire R. Reflections on a personal statistics of 136 vesicovaginal fistulas.J Urol Medicale
Chir1953, 59, 15060.
[7] Sotelo R, Mariano MB, Garcia-Segui A, et al. Laparoscopic repair of vesicovaginal fstula. J Urol
2005, 173, 16158.
[8] Sundaram BM, Kalidasan G, Hemal AK. Robotic repair of vesicovaginal f stula: Case series of
five patients. Urology 2006, 67, 9703.
[9] Hemal AK, Kolla SB, Wadhwa P. Robotic reconstruction for recurrent supratrigonal vesicovaginal
fistulas. J Urol 2008, 180(3), 9815.
[10] Melamud O, Eichel L, Turbow B, et al. Laparoscopic vesicovaginal fistula repair with robotic
reconstruction. Urology 2005, 65, 1636.
[11] Gupta NP, Mishra S, Hemal AK, et al. Comparative analysis of outcome between open and
robotic surgical repair of recurrent supra-trigonal vesicovaginal fistula. J endourol 2010, 24,
177982.
[12] Schimpf MO, Wagner JR. Robot-Assisted Laparoscopic Distal Ureteral Surgery. J Soc
Laparendosc Surg 2009, 13, 444.
[13] De Naeyer G, Van Migem P, Schatteman P, et al. Pure Robot-assisted psoas hitch ureteral
reimplantation for distal-ureteral stenosis. J Endourol 2007, 21, 61820.
[14] Duchene DA, Theil DD, Winfield HW. Robotic-assisted laparoscopic ureteropyelostomy for
treatment of prostatitis secondary to ectopic ureteral insertion of a completely duplicated
collecting system. J Endourol 2007, 21, 4557.
[15] Nanigian DK, Smith W, Ellison LM. Robot-assisted laparoscopic nephroureterectomy. J Endourol
2006, 20, 4636.
[16] Patil NN, Mottrie A, Sundaram B, et al. Robotic-assisted laparoscopic ureteral reimplantation
with psoas hitch: a multi-institutional, multinational evaluation. Urology 2008, 72(1), 4750.
[17] Thomas TM, Plymat KR, Blannin J, et al. Pre-valence of urinary incontinence. Br Med J 1980,
281(6250), 12435.
[18] Di Marco DS, Chow GK, Gettman MT, et al. Robotic-assisted laparoscopic sacrocolpopexy for
treatment of vaginal vault prolapse. Urology 2004, 63, 3736.
[19] Elliott DS, Frank I, Dimarco DS, et al. Gynecologic use of robotically assisted laparoscopy:
Sacrocolpopexy for the treatment of high-grade vaginal vault prolapse. Am J Surg 2004, 188
(4A Suppl), 52S6S.
[20] Elliott DS, Chow GK, Gettman M. Current status of robotics in female urology and gynecology.
World J Urol 2006, 24, 18892.
[21] Geller EJ, Siddiqui NY, Wu JM, et al. Short-term outcomes of robotic sacrocolpopexy compared
with abdominal sacrocolpopexy. Obstet Gynecol 2008, 112, 12016.
[22] Ayav A, Bresler L, Hubert J, et al. Robotic-assisted pelvic organ prolapse surgery. Surg Endosc
2005, 19, 12003.
[23] Akl MN, Long JB, Giles DL, et al. Robotic assisted sacrocolpopexy: technique and learning
curve. Surg Endosc 2009, 23, 23904.
[24] Moreno Sierra JM, Ortiz Oshiro E, Fernandez Prez C, et al. Long-term outcomes after robotic
sacrocolpopexy in pelvic organ prolapse: prospective analysis. Urol Int 2011, 86, 4148.
[26] Elliott DS, Krambeck AE, Chow GK. Long-term results of robotic assisted laparoscopic
sacrocolpopexy for the treatment of high grade vaginal vault prolapse. J Urol 2006, 176, 6559.
[28] Kramer BA, Whelan CM, Powell TM, et al. Robot-assisted laparoscopic sacrocolpopexy as
management for pelvic organ prolapse. J Endourol 2009, 23, 6558.
25 Robotic sacrocolpopexy for the management
of uterine and vaginal vault prolapse
Sami Gokhan Kilic, Ibrahim Alanbay and Fikret Fatih Onol
25.1Introduction
Pelvic organ prolapse (POP) is a common womens health problem which tends to
increase with advanced age. The prevalence of uterine prolapse is 14.2% among
women, and the prevalence of vaginal vault prolapse varies from up to 42% [1, 2].
A forecast study calculated that by the year 2050, 43.8 million women would be affec-
ted by POP in the US alone [3]. Consequently, repair surgery of prolapse has become
increasingly common [4].
Although surgical repair of POP includes a variety of different techniques,
such as transvaginal repair and placement of graft material via a vaginal approach,
abdominal sacrocolpopexy (ASC) has been considered the gold standard technique
for repairing apical prolapse with durable success rates that range from 78% to 100%
[4, 5]. Suspension of the vaginal apex is the keystone of surgical repair for pelvic organ
prolapse. Good suspension of the apex protects the anterior and posterior vaginal
walls from transabdominal forces that push these tissues toward the introitus. Uterine
and posthysterectomy vault prolapse results from weakening of the uterosacral-cardi-
nal ligament complex supporting the vaginal apex. Conventional open ASC involves
dissecting the vesicovaginal plane a few centimeters towards the bladder neck and
the rectovaginal septum (which may be carried down to the levator plate), then fixing
of the mesh (most commonly polypropylene mesh) at the anterior/posterior vaginal
apex and at the anterior longitudinal ligament of the sacrum.
However, the invasive nature of ASC, which requires laparotomy, has led to the
utilization of laparoscopic sacrocolpopexy (LSC), which offers reduced morbidity,
shorter hospitalization, and decreased postoperative pain. The disadvantages of
the laparoscopic approach include longer operating time and the need for advanced
laparoscopic skills, especially laparoscopic suturing and knotting skills. Robotic sur-
gical systems have been developed with the goal of facilitating technically difficult
procedures.
With the introduction of the da Vinci surgical system (Intuitive Surgical Inc,
Sunnyvale, CA, USA), robotic surgery has become popular for pelvic prolapse surgery.
The da Vinci robotic device has enabled surgeons to overcome obstacles associated with
LSC, such as the dissection of presacral and rectovaginal spaces and the steep learning
curve for attaining laparoscopic suturing and knot-tying skills. In addition, robotic
surgery has the advantages of a 3-dimensional vision system, wristed instrumentation,
tremor filtering, and dexterity [4]. The first robotic-assisted sacrocolpopexy (RASC)
328 25 Robotic sacrocolpopexy for the management of uterine and vaginal vault prolapse
was described in 2004 by Di Marco et al [6]. Since then, several case series have been
published reporting good short- and medium-term results [79].
In this chapter we describe the robotic-assisted approach to sacrocolpopexy,
focusing on indications, technique, complications, and outcomes.
25.2Evaluation and surgical indications
Clinical evaluation of the patient with apical prolapse includes a complete history
and physical examination as well as a limited number of additional tests. Conside-
rations, such as symptomatology, associated organ prolapse, urinary incontinence,
reproductive status, and sexual function, all influence the choice of management.
A careful examination with the patient sitting at a 45 angle or standing often produ-
ces the abdominal pressure needed to expose the apical defect. Apical prolapse rarely
occurs in isolation. Therefore, the anterior, posterior, and apical vaginal walls should
be examined separately with the aid of a half-speculum. Speculum examination is
useful to address other types of prolapse, such as cystocele, rectocele, or enterocele,
and also to assess the presence of urethral hypermobility. The size of the introitus and
vaginal canal must be noted, as this may limit transvaginal delivery of an enlarged
uterus. Rectal and pelvic floor tones are also assessed.
Just as with other conditions that affect quality-of-life without threatening life,
surgical correction of uterine or vault prolapse must be a balance between risk and
benefit. Attention must be given to the degree to which the patients quality-of-life is
impaired. The surgeon must individualize management based on the unique clinical
presentation of each patient, taking into account age, comorbidities, previous surge-
ries, and level of physical and sexual activity [10, 11]. RASC is best suited for young
(<50 years) and middle-aged (5065 years) patients with reduced vaginal capacity
and when ongoing sexual function is important. It can also be indicated in recur-
rent prolapse and when fertility and future pregnancies are desired. As with general
laparoscopy, several issues with RASC need to be addressed: severe chronic obstruc-
tive pulmonary disease (COPD), morbid obesity, extensive prior abdominal or pelvic
surgery, organomegaly, large hernias, and aneurysms.
Preoperative evaluation will also be influenced by the absence or presence of
the uterus. If the uterus is present and will be preserved, history of any unexplained
vaginal bleeding or any abnormal Pap smear needs to be evaluated before surgery. In
general, unless postmenopausal bleeding can be explained by such factors as regular
withdrawal from progesterone as part of hormone replacement therapy, an endomet-
rial biopsy should be performed prior to RASC. For pre- or perimenopausal women,
any abnormal uterine bleeding needs to be evaluated similarly: bleeding more often
than every 21 days, bleeding 7 days or longer, or excessive menstrual bleeding, espe-
cially in women at high risk for uterine cancer, such as obese or nulliparous women.
25.3Technique and concomitant procedure 329
A bimanual exam should be performed as part of the preoperative assessment to

exclude any adnexal enlargement or a pelvic mass.
A urinalysis and postvoid residual urine volume are obtained for all patients.
For patients with uterine prolapse and no history of stress or urge incontinence with
normal residual urine, routine urodynamic evaluation is not advocated. However, for
patients with the above symptoms or with elevated residual urine, we recommend
assessment of the lower urinary tract with urodynamic studies. An ultrasound imaging
of the upper urinary tract is also recommended, as patients with uterine prolapse are
more likely compared to other vaginal prolapse to have associated hydronephrosis
that may be severe enough to cause renal failure.
25.3Technique and concomitant procedure
25.3.1Preoperative preparation
All patients should have a vaginal exam before the surgery and, in cases of bacte-
rial vaginosis, should be treated accordingly. Pretreatment atrophic vaginitis should
also be treated with local estrogen treatment 6 weeks to 3 months before the surgery.
Fasting starts at midnight before surgery. Thromboprophylaxis is implemented with
good hydration, placement of compressive elastic stockings on the lower extremities,
and low-molecular-weight heparin that is initiated as needed on the first day after
surgery and continued until the patient is discharged. Patients also receive antibiotic
prophylaxis with a single preoperative dose of intravenous second-generation cepha-
losporin (in case of planned concomitant hysterectomy), unless they are allergic to
penicillin. Blood type and cross match are determined.
25.3.2Patient positioning and initial preparation
The surgery is performed under general anesthesia. The patient is positioned in the
modified dorsal lithotomy position with the lower limbs in abduction, allowing the
robotic dock to be moved toward the patient and intraoperative access to the peri-
neum. The upper limbs are tucked comfortably alongside the body to avoid the risk of
stretch injuries to the brachial plexus and to allow for free movement of the operative
team (refer to Chapter 8 for more details).
The patient is prepped from the nipples to proximal thigh, including the vagina.
An 18-Fr Foley catheter with 10 mL normal saline in the balloon is introduced after
placement of the sterile drapes. A nasogastric or orogastric tube is placed by the
anesthesiologist, and the stomach is decompressed to allow additional space for
placement of the small bowel above the promontory. This stomach decompression
also facilitates the prevention of stomach trocar injury when Palmers point is used.
The patient position is Trendelenburg to allow the robotic arms to have a proper
surgical approach without interference by the bowel.
When combined surgeries are performed, trocar placement, patient positioning,
and the number of trocars should be discussed beforehand between the surgeon who
is involved with the sacrocolpopexy and the surgeon performing the hysterectomy. In
this case, the sacrocolpopexy surgeon should join the hysterectomy surgery no later
than the cuff closing to be well oriented for the bladder and rectal dissections. We also
recommend for combined procedures that the hysterectomy surgeon is well experi-
enced in robotic surgery so that long surgical times associated with the hysterectomy
learning curve do not prolong the overall combined surgery time.
25.3.3Access and port placement
There are different approaches for robotic sacrocolpopexy, most of them adapted
from laparoscopy sacrocolpopexy cases. The robot is docked either centrally, with
the robotic column placed between the patients legs, or to the side, with the robotic
column positioned outside the leg and arms positioned at a 45 oblique angle to the
patient dorso.
Depending on the surgeons discretion, the number of trocars varies from four to
six trocars (Figs. 25.1 and 25.2) including camera, robotic arms, and an assistant port.
Many studies describe port placement for RASC as either pyramid or triangle confi-
gurations. The 12-mm robotic camera port is placed in the midline. Two options are
Fig. 25.1: Six-trocar entry

Fig. 25.2: Five-trocar entry
commonly used for the camera placement: either at the umbilicus with the camera
at 30 to reach the sacral part of the surgery or above the umbilicus using a 0 scope
throughout the surgery. Initial port placement begins by creating a pneumoperitoneum
either with a Veress needle placed at the umbilical or via optic trocar insertion into
the abdominal cavity. The peritoneal cavity is then insufflated with carbon dioxide.
If an optic trocar is placed at a different point than the camera port, the camera port
is placed by guiding via the optic trocar visualization. Depending on the surgeons
discretion, two or three robotic ports can be introduced. In our experience, the choice
of a third arm is useful for sigmoid colon mobilization during suture placement in the
sacral area and for grabbing the peritoneal edges during the peritoneum closing.
If the surgeon decides to use three robotic arms, two of the robotic arms would
be on the same side of the patient, usually on the patients right side (Fig. 25.3).
Eight-millimeter specially designed robotic trocars are placed bilaterally, usually
10 cm lateral at the umbilicus level, at least one handbreadth distance from the
camera on each side to prevent robotic arm collision during maneuvering. When
using three 8-mm robotic arms, the third port is placed on the patients lateral left
side below the umbilical level and usually above the left anterior superior iliac spine.
One or two assistant (accessory) ports are placed. A 10- or 12-mm assistant port for
the surgeons assistance is placed on either the patients left upper quadrant, usually
the Palmers point, or between the umbilical port and left lateral port. If additional
assistance is required, the other assistant port is placed on either the patients right
upper quadrant side between the umbilical and right robotic port or on the right side
just above the iliac crest. This second assistant trocar is usually used for tunneling
in the peritoneum rather than opening the entire peritoneum (Fig. 25.1). An assistant
Fig. 25.3: Robotic arm docking
port is usually used for introducing the needle and the mesh to the abdominal cavity
during mesh placement, for retraction, and for suction irrigation. The assistant port
should reach all the way to the perineal body and not be limited to only the vaginal
cuff area; otherwise, this port will not be very efficient for the dissection and suturing
part of the sacrocolpopexy.
In our clinic, we use two robotic arms. One is on the right upper quadrant, and
another is on the left upper quadrant so that the position of both robotic arms is 10 cm
lateral to the umbilicus. However, if the hysterectomy is going to be done by another
surgeon, it is critical to measure the Palmers point to assure the assisted arm can
easily reach the pelvic area. As two robotic arms and one assistant arm are usually
sufficient to perform simple hysterectomies, sacrocolpopexy can be performed in
two ways, either by placing an extra trocar (a second assistant arm) or by placing a
third robotic arm. While monopolar scissors are attached on the right robotic hand,
either a bipolar grasper or a plasma kinetic (PK) dissector is attached on the left
robotic hand.
25.3.4Surgical technique
The abdominal cavity is explored after all port placement, and the sacral promontory
access should be confirmed before surgery to lyse any adhesions. Also, any small bowel
in the pelvis overlying the vaginal apex or uterus can be brought into upper abdominal
cavity with a bowel grasper before placing the patient in the Trendelenburg position.
In cases of redundant sigmoid colon, two to three retraction sutures by 2/0 polyglycolic
acid suture (Vicryl polyglactin 910, Ethicon, USA) can be placed continuously next to
each other through the sigmoid tenia. The continuous suturation can help to gain suf-
ficient traction and to prevent tearing of the sigmoid tenia. The ends of the sutures
are captured by the Carter Thomason (CT) (Carter Thomason Closure System, CT, USA)
needle, which is inserted through the skin into the abdominal cavity from the left lower
quadrant. Both ends of the strings are brought out of the abdominal cavity and through
the skin, where they are held by a small Kocher clamp at the skin for retraction. Adjus-
ting traction of the sigmoid colon is done by moving it over to the left upper quadrant
in order to maintain better exposure for the sacral dissection. Suture needles can be
removed from the abdominal cavity through the assistant port.
25.3.5Sacral dissection
We prefer to start from the sacral area dissection, which is the most critical part of the
dissection, to avoid wasting further time if problems occur that necessitate aborting
the procedure. Before starting the sacral dissection, the anatomy should be delinea-
ted well. The sigmoid colon is removed from the area either as previously described
by using sutures to retract it over to the patients left side or by using the third robotic
arm with a Cadiere grasper.
The third robotic arm should not be in the field of dissection. Position the third
arm positioned extended parallel to the rectus muscle with close proximity to the left
side after grasping the perineal edge of the sigmoids reflexion with an acute angle.
The camera view will not be interrupted by the third arm in this position.
The anatomical landmarks in this area should include the sacral promontory,
aortic bifurcation, right and left common iliac vessels, and right ureter (Fig. 25.4).
Fig. 25.4: The anatomical landmarks in this area: common iliac vessel and right ureter
The sacral promontory is fairly prominent in most cases, and peritoneal dissection
should be started this area. However, in case of anatomic difficulties encountered
due to fatty tissue or anything else that compromises the visualization, the aortic
bifurcation should be identified first. Another useful landmark is the right ureter for
sacrocolpopexy (Fig. 25.5). A study evaluated the location of the ureters in relation
to the sacral promontory at the level of the pelvic brim. Female patients who had
undergone indicated computed tomographic (CT) urograms were selected. Among 38
patients, the left ureter was 35.9 4.9 mm lateral to the midsacral promontory, and
the right ureter was 29.7 6.2 mm lateral to the sacral promontory. On average, the
sacral promontory is located 29.7 mm medial to the right ureter at the level of the
pelvic brim. The study concluded that the right ureter may be a useful landmark for
choosing the proper location for dissection toward the anterior longitudinal ligament
during robotic sacrocolpopexy [12].
The dissection starts with an incision of the lifted peritoneum and extends care-
fully from 2 cm above the sacral promontory caudally, which will be away from the
aortic bifurcation and right ureter. This will prevent injury to the middle sacral vessels
and, more importantly, the left common iliac vein. The dissection continues deeper
until reaching the longitudinal ligament. This dissection area should be large enough
to place at least two sutures. Along the way, if there are some apparent sacral vessels
branching aberrantly toward the patients right side where planned sacral sutures
will be placed, they should be coagulated to avoid needle suturing injuries later on.
The most important thing during the dissection is to know where left common iliac
vein traces. Sacral dissection is performed until the periosteum is exposed. When
Fig. 25.5: Proximity of the right ureter to the sacral promontory

the sacral dissection is completed, begin the peritoneal incision in between the right
ureter and the sigmoid colon reflexion, extending it caudally to the vaginal apex
area. In some cases, a tunneling approach is performed at this point. A laparoscopic
suction irrigator can usually be placed into the space, and then hydrodissection is
used to create the tunnel. This additional trocar provides an ergonomic advantage for
hydrodissection; however, the total number of trocar-related incisions is increased.
25.3.6Anterior dissection
A vaginal probe is used during anterior dissection for identification of the cuff or
the cervix. The overlying peritoneum is incised longitudinally, including the planes
between the bladder and the vagina anteriorly, and between the rectum and vagina
posteriorly (Fig. 25.6). Anterior dissection is usually based on the patients require-
ment for correction of pelvic prolapse. Anterior dissection may be challenging due to
patients surgical histories, especially previous C-sections, for whom the peritoneum
is adhered to the lower uterine segment, or patients who have had a supracervical
hysterectomy. If a hysterectomy is going to be performed by the same surgeon, this
part of the dissection will be facilitated by the creation of a dissection plane earlier
during the hysterectomy.
Filling the bladder with sterile milk or methylene blue/indigo carmine can
help to get a better delineation of the bladder boundaries. As the adhesions from a
C-section occur mostly in the lower uterine segment, the surgeon should create an
Fig. 25.6: Anterior dissection between vaginal cuff and bladder

anterior plane just underneath the adhesions, which will allow the surgeon to create
small bands on both sides of the adhered tissue during the hysterectomy. This can
provide better visualization of the adhesions both anteriorly and posteriorly. If the
patient underwent supracervical hysterectomy before, the cervix can be held by a
single-tooth laparoscopic tenaculum to create traction during the anterior and pos-
terior dissection. This technique is useful for proper dissection. The third robotic arm
can provide a tenaculum option as well. The supracervical hysterectomy naturally
prevents vaginal cuff mesh exposure later on. However, supracervical hysterectomy
should not be a regular choice just for the convenience if a full hysterectomy is requi-
red and should be carried out. Throughout the anterior dissection, an EEA (end-to-end
anastomosis probe) sizer is placed into the vagina for traction purposes (Fig. 25.7). In
posthysterectomy cases, the peritoneum over the vaginal apex is thinnest and should
be carefully avoided during dissection to prevent inadvertent vaginotomy. Identifying
the anatomical border between bladder and vagina can help lead to a bloodless dis-
section. If bleeding is encountered during dissection, the probability of dissection of
the bladder wall should be kept in mind [4].
25.3.7Posterior dissection
Posterior dissection is carried out with the EEA sizer placed into the vaginal cuff area,
and traction is created by pushing the EEA sizer caudally and anteriorally toward the
Fig. 25.7: Various vaginal and rectal probes used: EEA sizers, blunt probe, and Navratile Brzezinski
retractor
rectus muscle. At this stage, if the rectum is not very well defined, another smaller
EEA sizer can be placed into the rectum. Pushing it cephalad and posteriorally
toward the sacrum creates a triangle shape between the vaginal cuff and rectal axis.
The traction between the rectum and the vagina creates optimum visualization for
creating the posterior rectal vaginal plane (Fig. 25.8). Both the posterior and anterior
initial dissection incisions are made 1 cm away from the vaginal cuff closing area to
decrease the risk of mesh exposure later when hysterectomy is performed at the same
time as sacrocolpopexy. Although a 0 or 30 lens can be used depending on surgeon
preference, a 30 lens, especially in an upward configuration, can be useful for visua-
lization of posterior dissection, if needed.
Posterior dissection is carried out based on the patients posterior defect; it can
extend all the way to the perineal body if needed.
To check the integrity of the rectum after completing the posterior dissection, the
pelvic cavity can be filled with normal saline. Air is given through the rectum, and the
pelvic cavity is watched for air bubbles that might indicate bowel injury.
25.3.8Mesh preparation
Wide-pore polypropylene mesh, pre-packaged and Y-shaped (Intel Pro, American

Medical Systems, Minnetonka, MN, USA ), is most commonly used in RASC. This mesh
is introduced through the accessory port. The right robotic instrument is changed to
a needle driver, and the Y-shaped mesh is sutured to the apex of the vagina ante-
riorly and posteriorly. The end of the mesh should be trimmed to a rounded shape
Fig. 25.8: Posterior dissection between vagina and rectum

Fig. 25.9: Mesh preparation
prior to surgery instead of being left square to prevent the edges of the mesh from
being folded during suturing (Fig. 25.9). Following anterior and posterior vaginal area
dissection, the positioned mesh should be measured after being sutured at either
the vaginal apex or sacral promontory. Durng measurement, the surgeon should be
careful to avoid placing any tension on the mesh. Redundant mesh at the promontory
site should be removed. Paying attention during the anterior and posterior vaginal
mesh suturing will prevent mesh clumping, which can be achieved by suturing both
the anterior and posterior vaginal areas with small bites and not synching too much
during the suturing.
During the anterior mesh placement, permanent or long acting suturing is pre-
ferred. Currently, we prefer V-Loc (V-Loc Absorbable Wound Closure Device, Covi-
dien, Mansfield, MA, USA) 3/0 or 2/0 long acting barbed suture. The vaginal ret-
ractor, such as an EEA sizer, is placed in the vagina, and protraction cephalad and
slightly toward the sacral cavity to visualize the entire anterior vaginal space helps
to facilitate this maneuver. The first bite of suturing should be placed at the distal
corner end of the mesh. Continuous sutures start from one end of the mesh and
move toward the other side of the mesh horizontally. Once the sutures have reached
to the corner of mesh, the suturing turns 11.5 cm cephalad and continues to the
other side of mesh corner. Finally, the continuous turn of suturing loop at each
mesh corner will create an S-shaped suturation. The sutures are placed through the
entire thickness of the vaginal wall, sparing the vaginal epithelium. The suturing
should be finished 1 cm from the vaginal cuff closing area. The suture should be cut
short after being locked.
During posterior mesh placement, the EEA sizer can be replaced with a Navratile
Brzezinski retractor, facilitating more convenient suturing to create a concave space
at the posterior vaginal wall. Retractors should be pushed cephalad and toward
the bladder to visualize the complete posterior dissection area. The posterior tail of
the Y-shaped mesh can be tailored before inserting it into the abdominal cavity by
measuring the size of the dissection. The first bite of suturing for the posterior vaginal
mesh should be started in one corner of the vaginal wall by using the same V-Loc 2/0
or 3/0 barbed suture. Continuous suturing can be made across to the other end of the
mesh. Once the sutures have reached the other end of the mesh, the suture turns ver-
tically toward the patients head. After a 11.5-cm vertical suture advance, the suture
turns transversely again. Continuous suturing can advance until reaching within 1 cm
of the vaginal cuff closing area, and, finally, this technique will create an S-shaped
suture placement similar to the anterior mesh placement. After locking the end of the
barbed suture, the suture should cut with a small amount of slack to prevent touching
the peritoneum and bowel.
After completing posterior vaginal wall mesh suturing, the tail of Y-shaped mesh
is sutured to the sacral area. At this point, the mesh can be pulled toward the sacrum,
and vaginal exam (apical lifting up) can help to achieve the optimum apical cuff cor-
rections. At this point, the decision can be made where to attach the mesh to the
sacrum, and excess mesh can be cut away and removed from the abdominal cavity.
The sacral area suturing can be achieved primarily by two separate permanent or
long-acting sutures (Fig. 25.10). The Gore-tex (PTFE: nonabsorbable expanded polyte-
trafluoroethylene suture) is the most commonly used suture for sacral mesh suturing.
A mega needle holder should be used on the right hand, and the suture needle should
be grabbed in the middle of the needle mid-hub. This can help overcome having the
needle turn and losing direction inside the longitudinal ligament. The first sacral
suture is placed 1 cm below the sacral promontory, avoiding injury to the special
external iliac vein, midsacral vessel, and right ureter. After tying the Gore-tex suture
eight times, the second suture should be placed slightly above the first suture, toward
the promontory. Following this order for the two suture placements will allow better
visualization during the second suture placement.
Fig. 25.10: Sacral suture placement in a cadaver

Placement of mesh within the sacral area first, which is the most critical part
of the surgery, prior to placement of the vaginal mesh is another option for mesh
placement. This option can allow the surgeon to tailor the mesh at the last moment
depending on the patients cuff prolapse.
Peritoneal closing starts after assuring good homeostasis. The peritoneum is
reapproximated over the mesh using a running 2/0 absorbable suture (Fig. 25.11).
In order to obtain correct peritoneal closing, the peritoneum of the vaginal cuff area
should first be closed transversely by continuous suturing. The second phase of
peritoneal closing should start with the sacral area and move to the vaginal area.
The critical point about closing the sacral peritoneum is that the right ureter should
always be under direct visualization to make sure the ureter is not pulled over to
the midline, which may cause ureteral bleeding later on. A second point to consider
during sacral area peritoneal closing is that either the retracting sutures or the robotic
third arm for retraction of the sigmoid colon should be loosened to make an accurate
reapproximation.
As exposed sutures have a potential risk for grabbing the bowel, it is important
to be careful during peritoneal closing by V-Loc barbed suture, which must be embed-
ded toward the retroperitoneum. Before closing the peritoneum, cautiously control
bleeding in the sacral promontory, especially venous area, by using bipolar energy or
homeostatic agents. A Halban procedure or Moschcowitz culdoplasty can be perfor-
med at this stage at the surgeons discretion.
Cystoscopy can be considered to evaluate the right ureter opening and rule out
bladder injuries from the dissection. The robot should be undocked and the patients
Trendelenburg position must be reversed for cystoscopy. Indigo carmine (5 mL) is
given intravenously in the free arm without a blood pressure cuff; otherwise, indigo
Fig. 25.11: Closing peritoneum

carmine under pressure can cause local spreading in the arm. During the cystoscopy,
before indigo carmine reaches the bladder, the bladder should be examined under
cystoscopy with a 30 scope. Once the blue dye has reached the bladder, the right
ureter should be examined to assure good efflux.
In case any complication is discovered, the trocars should be left in place to
repair it through a minimally invasive technique. When cystoscopy is completed, a
laparoscopic scope should be introduced into the abdominal cavity, and abdominal
pressure should be dropped 5 mmHg to assure good hemostasis, especially for venous
bleeding. In case retroperitoneal hematoma is noticed during this process, the perito-
neum would be re-entered to obtain a good venous hemostasis.
After completion of surgery, the robotic arms are disengaged, the robot is
undocked, and all ports are removed under direct visualization. The facial layer of all
12-mm port sites (as well as 12- or 11-mm assistant trocars and camera ports) should
be closed at the level of fascia. If the fascia cannot be visualized from outside, the
fascia can be closed by internally using laparoscopic techniques. The most preferred
method is using the Carter Thomason closing system to create an internal loop to
assure the full thickness of fascial closing. In a patient with a BMI of less than 30,
external closing of the fascia by O vicryl may be preferred.
25.3.9Follow-up
All drains are removed, and the urethral catheter is removed as soon as the patient
walks, provided that no inadvertent entry to the bladder occurred during the proce-
dure. A light diet can generally be resumed on the day of surgery.
The patient is discharged on the first postoperative day and scheduled for a
follow-up visit 1 week later. The patient can be followed over the phone by a nurse on
post-op the third day to discover whether the patient has fever, any spontaneous mic-
turition, or bowel movement problems. One week after surgery, the patient should be
seen in the clinic for trocar healing as well as bowel sounds and an abdominal exam.
In case of bladder injury during the sacrocolpopexy procedure, leaving the Foley
catheter for good sealing is recommended after the intraoperative bladder repair. In
this case, the Foley catheter can be removed and the voiding trial performed at the
1 week post-op exam. If the residual volume is less than 100 mL, there will not be any
need to replace the Foley catheter. If a patient does not pass the voiding trial, The
Foley catheter should be replaced and the trial repeated in 4 h. A patient who fails
the voiding trial again will be discharged home with the catheter in place until the
1 week clinical visit.
The patient should be seen at 6 weeks and again at 3 months post-op to check
vaginal cuff and mesh erosions. Patients who have atrophic vaginitis should continue
to be treated with local vaginal estrogen starting 6 weeks after surgery. It has been
our experience that the vaginal applicator for local estrogen treatment is a risk in the
first 6 weeks. For the first 3 months, the patient will gradually be allowed to increase
physical activity. The patient would be allowed to be sexually active in 6 weeks. If
the patient had a hysterectomy at the same time, sexual activity should not resume
for 3 months.
25.4Outcomes and complications
25.4.1Anatomical and functional outcomes of RASC
The current literature is limited about long-term follow-up of RASC compared to

open or laparoscopic sacrocolpopexy and mainly depends on cohort series [4]. RASC
has gained rapid popularity with promising outcomes reported for the short- and
long-term. For example, Elliott et al reported 95% success with RASC for the apical
compartment in 30 women at a minimum follow-up of 1 year (mean follow-up:
2 years) [7]. All patients but 1 were discharged from the hospital after an overnight
stay. The study reported a mean operative time of 186 min. They found a decreased
hospital stay, low complication rates, and high patient satisfaction with a minimum
of 1-year follow-up.
Akl et al published the outcomes of one of the largest case series, including
80 RASC patients, of whom 76 completed RASC and 4 (5%) cases required conversion
to laparotomy. Two (2.5%) patients had injury to the bladder, and one had injury to
the right ureter with subsequent urinoma. Three (3.7%) patients developed recurrent
prolapse at a mean follow-up of 4.8 months. They also addressed the learning curve
associated with RASC. Mean operative time was 197.9 min; however, they reported
that after completion of the first 10 cases, mean operative time was decreased by 25%
(64 min) [13].
Despite the profound advantages of enhanced view, articulating instruments,
and better ergonomics, few comparative studies have investigated the outcomes of
RASC vs. conventional LSC or ASC (Tab. 25.1) [1419].
One study with 73 RASC and 105 open-mesh sacrocolpopexy cases compared
surgical features and short-term results. Comparing robotic to open sacrocolpopexy,
estimated blood loss and length of hospital stay were significantly less; however, ope-
rative time was significantly longer for robotic surgery. The overall complication rates
were 17.8% and 11.4% for robotic and open surgery, respectively. When patients were
evaluated based on POP-Q, significant improvement of the all preoperative POP-Q
points was found in the robotic group compared to open group [14].
Recently, it has been documented that RASC and abdominal sacrocolpopexy
(ASC) have equivalent POP-Q-based anatomical success and similar quality-of-life
improvement assessed at 1 year [15] and at 44 months [16]. There was less blood
loss and shorter hospitalization with RASC compared to ASC; however, operative
time was longer for RASC [14, 15]. A retrospective study by Geller et al showed
Tab. 25.1: Summary of currently available data comparing robotic-assisted sacrocolpopexy with open and laparoscopic sacrocolpopexy
Author Number of Mean Outcome Complications Conclusions

patients follow-up
Geller et al 2008, 73 RASC 6 weeks No difference in POP-Q points 1 conversion to open Similar apical support in short-
Comparative 105 ASC 6 weeks improvement 5.5% and 1.9% postop. ileus in term with longer operative time,
cohort study Operative time: 328 vs. 225 RASC and ASC, respectively less EBL and LOS with RASC
min (P < 0.001)
Siddiqui et al 2012, 125 RASC 18.3 months No difference in anatomical Significantly higher postope- Comparable improvement in
Comparative 322 ASC 11.7 months outcome and validated rative febrile morbidity and ileus pelvic floor symptoms and
cohort study quality-of-life measures with ASC compared to RASC. quality-of-life assessment
between ASC and RASC
Geller et al 2012, 23 RASC 44 months No difference in all POP-Q Mesh erosion: 8% in RASC and RASC demonstrates similar long-
Comparative 28 ASC 44 months measures, quality of life and 7% in ASC arm term anatomical and functional
cohort study sexual function scores outcomes with ASC.
Collins et al 2012, 30 RASC 10 days No faster return to preoperative Not reported Pain control is not improved in
Prospective 22 ASC 10 days baseline physical activity with the early postoperative period
non-randomized study RASC after RASC compared to ASC
Paraiso et al 2011, 40 RASC 12 months Similar success rates Cystotomy: 6% in each arm RASC resulted in increased pain
Prospective 38 LSC 12 months Longer operative time and Small bowel obstruction: 6% in and costs compared with LSC
randomized study inferior pain control at RASC
36 weeks with RASC
Seror et al 2011, 20 RASC 15 months Similar operative times No difference in Clavien grade RASC is equivalent to LSC in
Prospective 47 LSC 18 months Similar success rates IIII complications terms of operative time and
non-randomized study Less EBL with RASC than LSC functional outcome
(55 vs. 220 mL)
(ASC: abdominal sacrocolpopexy, LSC: laparoscopic sacrocolpopexy, RASC: robotic-assisted sacrocolpopexy, LOS: length of stay, EBL: estimated blood loss).
25.4Outcomes and complications
343
comparable short-term efficacy between open and robotic sacrocolpopexy, with

significantly decreased length of hospital stay in the robotic group (1.3 0.8 vs.
2.7 1.4 days, P < 0.001) [14].
Another study compared 125 women with RASC and 322 women with ASC, retro-
spectively, regarding vaginal bulge symptoms or repeat surgery for prolapse. The
study showed that there were no significant differences between the RASC and ASC
groups in terms of symptoms and repeat surgery prolapse, with low proportions of
surgical failure for both groups. The study also showed there were no statistical diffe-
rences for anatomical failures, mesh erosion, postoperative pelvic floor, and quality-
of-life between the two groups [15].
The benefit of RASC over ASC in terms of decreased postoperative pain and faster
return to physical activity was tested in a recent trial. Collins et al prospectively allo-
cated 22 women to ASC and 30 women to RASC groups and assessed postoperative
pain with quantitative measures of return to baseline physical activity and with vali-
dated questionnaires [17]. Within 10 days after surgery, women who underwent RASC
did not return to their preoperative level of physical activity faster than women who
underwent this procedure via laparotomy, and pain control was not improved after
RASC compared to ASC.
Two recent trials have questioned whether RASC provided better outcomes than
LSC. Paraiso et al randomized 38 women to LSC and 40 women to RASC for posthys-
terectomy vaginal apex prolapse surgery by experienced surgeons in each study arm
[18]. Although operating time was the primary outcome of this study, surgical pain
scales, return to normal activities, and pelvic organ prolapse quantitative measure-
ment were also evaluated. The authors found significantly longer operative times
in the RASC group compared with the LSC group in several parameters measured
(sacrocolpopexy, sacrocolpopexy suturing, operating room, anesthesia, and total
time). The total surgical times were 265 50 vs. 199 46, P < 0.001, for robotic sac-
rocolpopexy and laparoscopic surgery, respectively. Robotic assistance is advocated
mainly to facilitate the more difficult surgery steps; however, this study showed,
interestingly, that the suturation time took an additional 31 min in the robotic group
[18]. There was no statistical significance in terms of intraoperative and postoperative
complications, narcotic use, return to normal activity, and activity assessment. Non-
steroidal anti-inflammatory drug use was significantly longer in the robotic group
compared to the laparoscopic group. Furthermore, pain scores were significantly
higher with RASC between postoperative weeks 3 and 6. Postoperative POP-Q stage
and quality-of-life were evaluated, and this study showed that there was no difference
between robotic and laparoscopic groups in terms of anatomical success at 6 months
and 1 year after surgery.
Another study that included 47 laparoscopic and 20 robotic sacrocolpopexy
cases has shown that strict operative time was significantly shorter in RASC compa-
red to LSC (mean 128 vs. 231 min, P < 0.0001), whereas there was no difference in the
overall length of time the patient was in the operating room (mean 217 vs. 231 min,
P = 0.4) [19]. There was also no difference regarding the use of analgesics or length of
25.4Outcomes and complications 345
hospitalization between the two groups. However, RASC was superior in terms of
blood loss (median 55 mL vs. 280, P = 0.03). With a median follow-up of 16 months,
the study also showed the overall anatomic repair rate was 98.5%, and there was no
difference between the two surgical approaches.
25.4.2Complications
Although the potential complications of laparoscopic approaches and open surgery

already described are similar to those of robotic surgery, use of the da Vinci robot
does have specific complications. The steep Trendelenburg position in the robotic
set-up might cause difficult ventilation for morbidly obese patients or those with
underlying pulmonary disease. In addition, although it is rarely described, technical
failure of the robotic set-up can force conversion from robotic surgery to laparoscopy
or open [4].
Possible perioperative complications of RASC include subcutaneous emphysema,
bleeding, and bladder, bowel, or ureteric injury, which may necessitate conversion to
laparotomy. Closing the peritoneal incisions over the retroperitoneal mesh should be
performed to reduce the risk of bowel complications, which may risk ureteral injury,
hematoma, or inadvertent bowel injury. The incidence of these complications has
been generally reported as less than 5% [8, 13, 15, 18, 19]. Paraiso et al reported that
intraperitoneal adhesiolysis longer than 45 min was required in 40% of their patients
during RASC [18]. Subsequently, ileus developed in 6% of their patients. Considering
that the average RASC takes at least 23 h, the prolonged duration of steep Trende-
lenburg position (especially during the initial phase of the learning curve) may result
in severe respiratory acidosis [20]. The incidence of further complications related
to increased cardiopulmonary, intracranial, and intraocular pressures, as well as
neurapraxia, are yet to be established.
Postoperative complications of RASC include wound infections, port-site hernias,
small bowel obstruction and ileus, and mesh erosion [15, 18]. While wound- and
port-site-related complications are relatively uncommon, postoperative ileus has
been reported in up to 6% of the patients due to the transperitoneal nature of the pro-
cedure [9, 15, 18]. Most patients with postoperative ileus resolved with conservative
management, whereas some required explorative laparotomy to relieve the intestinal
obstruction. Vaginal mesh erosion after RASC has ranged from 0% to 8% [7, 13, 15, 18, 21].
25.4.3Disadvantages
One of the most common arguments against robotic surgery is the cost. The cost of
robotic surgery depends mainly on purchase of the surgical system, annual main-
tenance costs, and robotic instrument costs since instruments can be only used for
a finite number of cases before disposal. A randomized controlled study analyzing
the cost of both robotic and laparoscopic sacrocolpopexy showed that the mean cost
of robotic sacrocolpopexy ($16,278 $3,326) was more than laparoscopic ($14,342
$2,941), with a mean difference of $1,936. The study explained this cost discrepancy
was mainly due to the difference in operating room costs [18].
In a different study evaluating a decision model developed to compare the costs of
robotic and laparoscopic sacrocolpopexy [22], robotic surgery cost $2,008 more than
laparoscopic. The model included factors, such as operative time, risk of conversion,
risk of transfusion, and length of stay (LOS) for each method, which were taken from
the literature. Respective baseline estimates for robotic, laparoscopic, and abdominal
sacrocolpopexy procedures included operative time (328, 269, and 170 min, respec-
tively), conversion (1.4%, 1.8%, and 0%, respectively), transfusion (1.4%, 1.8%, 3.8%,
respectively), and LOS (1.0, 1.8, and 2.7 days, respectively). Two models were used,
one a model using existing robot equipment, and the other a model factoring in the
purchase of robotic equipment. The study showed that for the existing robot model,
robotic sacrocolpopexy was the most expensive at $8,508 per procedure compared
with laparoscopic sacrocolpopexy at $7,353 and abdominal sacrocolpopexy at $5,792.
The addition of robotic purchase and maintenance costs resulted in increases of $581,
$865, and $1,724 per procedure when these costs were distributed over 60, 40, and 20
procedures per month, respectively.
25.5Conclusion
The primary advantages of robotic sacrocolpopexy are dexterity, three-dimensional

vision, certainty of wrist movement, easy suturing and knotting, decreases in blood
loss, length of hospital stay, and convalescence. More studies and long-term follow-
up are necessary to know exactly how useful robotic sacrocolpopexy is compared to
open surgery.
References
[1] Hendrix SL, Clark A, Nygaard I, et al. Pelvic organ prolapse in the Womens Health Initiative:
gravity and gravidity. Am J Obstet Gynecol 2002, 186, 11606.
[2] Beer M, Kuhn A. Surgical techniques for vault prolapse: a review of the literature. Eur J Obstet
[3] Wu JM, Hundley AF, Fulton RG, et al. Forecasting the prevalence of pelvic floor disorders in U.S.
Women: 2010 to 2050. Obstet Gynecol 2009, 114, 127883.
[4] Gilleran JP, Johnson M, Hundley A. Robotic-assisted laparoscopic mesh sacrocolpopexy. Ther
Adv Urol 2010, 2, 195208.
[5] Nygaard IE, McCreery R, Brubaker L, et al. Abdominal sacrocolpopexy: a comprehensive review.
References 347
[6] Di Marco DS, Chow GK, Gettman MT, et al. Robotic-assisted laparoscopic sacrocolpopexy for
treatment of vaginal vault prolapse. Urology 2004, 63, 3736.
[7] Elliott DS, Krambeck AE, Chow GK. Long-term results of robotic assisted laparoscopic
sacrocolpopexy for the treatment of high grade vaginal vault prolapse. J Urol 2006, 176, 6559.
[8] Daneshgari F, Kefer JC, Moore C, et al. Robotic abdominal sacrocolpopexy/sacrouteropexy
repair of advanced female pelvic organ prolaspe (POP): utilizing POP-quantification-based
staging and outcomes. Br J Urol Int 2007, 100, 8759.
[9] Kramer BA, Whelan CM, Powell TM, et al. Robot-assisted laparoscopic sacrocolpopexy as
management for pelvic organ prolapse. J Endourol 2009, 23, 6558.
[10] Cvach K, Dwyer P. Surgical management of pelvic organ prolapse: abdominal and vaginal
approaches. World J Urol 2012, 30, 4717.
[11] Maher CM, Feiner B, Baessler K, et al. Surgical management of pelvic organ prolapse in women:
the updated summary version Cochrane review. Int Urogynecol J 2011, 22, 144557.
[12] McCullough M, Valceus J, Downes K, et al. The ureter as a landmark for robotic sacrocolpopexy.
Female Pelvic Med Reconstr Surg 2012, 18, 1624.
[13] Akl MN, Long JB, Giles DL, et al. Robotic-assisted sacrocolpopexy: technique and learning
curve. Surg Endosc 2009, 23, 23904.
[15] Siddiqui NY, Geller EJ, Visco AG. Symptomatic and anatomic 1-year outcomes after robotic and
abdominal sacrocolpopexy. Am J Obstet Gynecol 2012, 206, 435.
[16] Geller EJ, Parnell BA, Dunivan GC. Robotic vs abdominal sacrocolpopexy: 44-month pelvic floor
outcomes. Urology 2012, 79, 5326.
[17] Collins SA, Tulikangas PK, OSullivan DM. Effect of surgical approach on physical activity and
pain control after sacral colpopexy. Am J Obstet Gynecol 2012, 206, 4386.
[18] Paraiso MF, Jelovsek JE, Frick A, et al. Laparoscopic compared with robotic sacrocolpopexy for
vaginal prolapse: a randomized controlled trial. Obstet Gynecol 2011, 118, 100513.
[19] Seror J, Yates DR, Seringe E, et al. Prospective comparison of short-term functional outcomes
obtained after pure laparoscopic and robot-assisted laparoscopic sacrocolpopexy. World J Urol
2012, 30, 3938.
[20] Fitzgerald MP, Mueller ER, Edelstein S. Severe acidosis during laparoscopic repair of pelvic
organ prolapse and incontinence. Female Pelvic Med Reconstr Surg 2011, 17, 2602.
[21] Osmundsen BC, Clark A, Goldsmith C, et al. Mesh erosion in robotic sacrocolpopexy. Female
Pelvic Med Reconstr Surg 2012, 18, 868.
[22] Judd JP, Siddiqui NY, Barnett JC, et al. Cost-minimization analysis of robotic-assisted,
laparoscopic, and abdominal sacrocolpopexy. J Minim Invasive Gynecol 2010, 17, 4939.
26 Robotic retropubic urethropexy
Sami Gokhan Kilic, Pooja R. Patel and Mostafa A. Borahay
26.1Introduction
With the aging population in the USA, pelvic organ prolapse (POP) and urinary inconti-
nence have become common indications for surgery, resulting in an estimated lifetime
risk of surgery equal to 11% [1]. This, however, is likely an underestimate of the general
population, as it is based on hospital data. Among the various forms of urinary incon-
tinence is stress urinary incontinence (SUI), the involuntary leakage of urine during
activities that increase intra-abdominal pressure, such as laughing, coughing, sneez-
ing, and jumping. Unfortunately, conservative management is limited, and treatment
usually involves pessary use or surgery, with many patients opting for surgery due to
the inconvenience associated with the former [2, 3].
26.2Midurethral sling vs. robotic retropubic urethropexy
Currently, the primary forms of surgical management are midurethral slings and
retropubic urethropexy. Both have disadvantages: the former being a blind procedure
associated with the use of mesh, and the latter requiring an intra-abdominal incis-
ion. The midurethral sling gained popularity initially because it provided a vaginal
approach and allowed patients to go home the same day [4]. However, with the advent
of robotic-assisted surgery, the retropubic urethropexy is becoming an attractive option
given that patients can avoid a blind procedure with possible mesh-related problems
and simultaneously enjoy the advantages of a short postoperative course [5].
Robotic surgery has quickly gained popularity in the field of gynecology since it
was introduced a little over a decade ago [6]. The readiness to adopt robotic surgery
results from the disadvantages of traditional options coupled with the advantages
robotic surgery has to offer. For example, the learning curve associated with laparosco-
pic surgery is very long [7]. Second, the hand movement associated with laparoscopic
surgery is counterintuitive and difficult to adopt, unlike with robotic surgery. The long
instruments associated with laparoscopic surgery also limit range of motion and fine
motor control, contributing to surgeon fatigue and frustration, which impact perfor-
mance. Robotic surgery, however, allows the surgeon to sit comfortably at the console
and use natural hand and wrist motions that mimic movements performed in open
surgery. Due to these advantages, the robotic platform allows for a quick learning curve
in performing more complex surgeries, such as the retropubic urethropexy.
When deciding between a midurethral sling and a retropubic urethropexy, the
surgeon may prefer an abdominal approach for certain patients. For example, patients
350 26 Robotic retropubic urethropexy
who have failed a previous midurethral sling have less success with a repeat synthetic
midurethral sling procedure [8]. In addition, an attempt to remove scarred mesh in
order to replace it would expose these patients to increased risks of injuring surround-
ing structures. Patients who are undergoing a concomitant abdominal surgery would
not incur additional risks from another abdominal procedure, thus presenting as good
candidates for a retropubic urethropexy. Frequently, patients who undergo incon-
tinence procedures are also scheduled to undergo hysterectomies. In these patients,
the benefit of undergoing a vaginal colposuspension would be moot. Finally, patients
who previously received pelvic radiation therapy will face a potentially increased risk
of tissue weakening and mesh erosion. These patients would benefit from a mesh-free
retropubic urethropexy rather than a midurethral sling. For the reasons already enume-
rated, a robotic approach would clearly serve these patients and the surgeon better than
an open or laparoscopic approach.
The two types of retropubic urethropexy procedures are the Marshall-Marchetti-
Krantz (MMK) colposuspension and the Burch colposuspension. The former involves
tacking the periurethral tissue to the pubic bone, while the latter involves tacking the
periurethral tissue to the Coopers ligament just below the pubic bone. In this chapter,
we review the evolutionary history of the robot-assisted retropubic Burch colposuspen-
sion and a step-by-step description of the procedure.
26.3Evolution of the robotic Burch colposuspension
The Burch colposuspension was first described in 1961 and was considered the gold
standard for SUI. Initially, Burch described attaching the periurethral tissue to the
arcus tendineus; however, he changed the attachment to the Coopers ligaments, as
this would create a more secure fixation and have less chance of infection as seen
with the prior MMK procedure [9]. In 1991, Vancaille and Schuessler described the
first laparoscopic colposuspension [10]. Although gynecologic laparoscopy was pre-
valent at that time, few reports of laparoscopic Burch colposuspensions exist in the
literature, as this approach did not gain much momentum due to the cumbersome
nature of laparoscopic dissection and suturing [1113]. In order to perform these pro-
cedures comfortably, surgeons had to spend excessive time training and developing
an advanced skill set, leading many to abandon the procedure.
Robotic surgery was first described in the 1980s and was initially adopted by uro-
logists to perform prostate surgery [14]. The robotic approach did not begin to migrate
into other fields until the early 21st century [14, 15]. The first gynecologic robotic
surgery, a tubal anastomosis, was performed in 2000 [16]. Since then, the frequency of
robotic surgery has increased drastically in many institutions, while frequency of tra-
ditional approaches has decreased [17, 18]. The popularity of robotic surgery is fueled
by the fact that a robotic approach includes better ergonomics, three-dimensional
magnification resulting in improved visualization of the anatomy (in this case of the
26.4Step-by-step description of the robotic-assisted Burch colposuspension 351
retropubic space of Retzius), shorter postoperative recovery, less blood loss, and more
precise control of surgical instruments [5].
The literature has few descriptions of robotic Burch colposuspension, as it is in its
early stages of use. Partin et al reported brief experiences with two robotic Burch col-
posuspensions as part of a cohort studying 17 patients who underwent robot-assisted
urologic procedures [19]. Payne et al described results in eight patients treated with
robotic Burch procedures at the time of robotic hysterectomy; however, as their aim
was to compare perioperative outcomes between patients undergoing total laparosco-
pic hysterectomy and robotic hysterectomy, they did not report specifically on outco-
mes of the Burch portion of the procedure [20]. The only article we were able to find
that focused on robotic Burch colposuspensions was a description of two successful
procedures published in 2007 by Khan et al [21]. In our experience, on a case series
of six patients who underwent successful robotic Burch colposuspensions, most
were discharged from the hospital the day after surgery, none sustained postopera-
tive complications, and all reported improvement in incontinence symptoms. These
preliminary outcomes suggest that robotic Burch colposuspension is critical in our
armament of surgeries for urinary incontinence.
26.4Step-by-step description of the robotic-assisted Burch

colposuspension
26.4.1Preoperative planning
Prior to performing the operation, the surgeon must have a clear plan of how to
approach the surgery. A Burch colposuspension has the potential to create a posterior
compartment defect, as it elevates the anterior vaginal wall, thus changing the axis
of the vagina and making the posterior compartment vulnerable [22, 23]. Therefore,
perform a thorough pelvic exam preoperatively to determine if a posterior enterocele
or rectocele is already present. Also, the alignment of the Burch sutures is critical
and can easily be disrupted with excessive manipulation during another procedure
(i.e., culdoplasty). Therefore, if the surgeon plans to perform multiple procedures
during the operation, he or she should complete all other procedures prior to
performing the Burch colposuspension.
26.4.2Positioning the patient and Foley insertion
Refer to the Chapter 5, Positioning the patient section 5.3
26.4.3Docking
Refer to the Chapter 5, Docking section 5.6

26.4.4Trocar insertion
Refer to the Chapter 5, Trocar placement section 5.4. Of note, for the Burch colposus-
pension, a total of four ports are used: 12-mm camera trocar at midline, two 8-mm
robotic arm trocars lateral to the rectus abdominis muscles, and an assistant trocar
through which forceps can be used for retraction and passing sutures to the abdomi-
nal cavity.
26.4.5Concomitant procedures
Complete all other scheduled procedures (i.e., hysterectomy, culdoplasty) at this time.
26.4.6Repositioning the patient
After completion of additional procedures, undock the robot and decrease the angle
of Trendelenburg to 0 to 10, if needed. As the focus will be directed to the anterior
pelvis, steep Trendelenburg is no longer needed. By decreasing the angle of Trende-
lenburg, the potential risks of this nonphysiologic positioning are diminished (refer
to Chapter 30).
26.4.7Retrograde filling of the bladder
At this time, insert 500 mL of normal saline into the Foley to distend the bladder. This
facilitates dissection in that it allows delineation of the initial incision site (Fig. 26.1).
Fig. 26.1: Filling the bladder to delineate the site for the initial incision
Fig. 26.2: Entering the Retzius space using the bladders weight as a retractor
26.4.8Dissection to create the retropubic space of Retzius
Decrease the 500 mL of saline to 200 mL in the bladder before starting the dissection.
Five hundred milliliters will overinflate the bladder and block the view of the Retzius
space. However, the weight of the 200 mL distended bladder will allow the bladder
to fall as the dissection proceeds, opening up the retropubic space of Retzius using
gravity in its favor (Fig. 26.2). An EndoWrist monopolar curved scissors is preferred
on the right, and a bipolar grasper or PK forceps (Robotic Gyrus PK 400) is preferred
on the left. If a third arm used, a forceps is preferred, usually a Prograsp or Cadiere
grasper, while an atraumatic grasper (alligator grasper) or a suction irrigator is prefer-
red for the assistant arm as needed.
26.4.9Identification of urethro-vesicular junction (UVJ) using hand

in the vagina
With one hand in the vagina, manipulate the Foley to identify the UVJ (Fig. 26.3). This
will help identify the location for suture placement as described in the next step.
26.4.10Suturing
Identify the Coopers ligament (Fig. 26.4). Using a total of four 2/0 Prolene or PDS
stitches, suspend the periurethral endopelvic fascia to the Coopers ligament. Place
two stitches 2 cm bilateral to the UVJ and two stitches bilateral to the proximal third
of the urethra again, 2 cm from urethra. Tie all sutures using air knots to prevent
Fig. 26.3: Identification of urethro-vesicular junction using hand in the vagina
Fig. 26.4: Identifying Coopers ligaments
postoperative bladder retention (Fig. 26.5). At this point, hemostatic agents can be
used if needed in the Retzius space (Fig. 26.6). If the surgeon chooses to close the
peritoneum, 2/0 polyglactin 910 running suture is appropriate (Fig. 26.7).
26.4.11Cystoscopy
Inject indigo carmine into the IV by the anesthesiologist 15 min prior to cystoscopy.
Carefully examine the bladder for injuries during dissection and for stitches that
could have passed through the bladder wall. Initiate cystoscopy after passing the
Fig. 26.5: Burch sutures in place
Fig. 26.6: Hemostatic agent injected
four sutures but before tying them. This gives the surgeon an opportunity to easily
remove them in case sutures are visualized in the bladder mucosa. In addition,
examine bilateral ureteral orifices to confirm efflux jets of indigo carmine. The
patient will complete a voiding trial in the recovery room before being discharged
home.
Fig. 26.7: Peritoneum closed
References
[1] Takacs EB, Kobashi KC. Minimally invasive treatment of stress urinary incontinence and vaginal
prolapse. Urol Clin North Am 2008, 35, 46776, ix.
[2] Oliphant SS, Wang L, Bunker CH, et al. Trends in stress urinary incontinence inpatient
procedures in the United States, 19792004. Am J Obstet Gynecol 2009, 200, 5216.
[3] Wu JM, Gandhi MP, Shah AD, et al. Trends in inpatient urinary incontinence surgery in the USA,
19982007. Int Urogynecol J 2011, 22, 143743.
[4] Richter HE, Albo ME, Zyczynski HM, et al. Retropubic versus transobturator midurethral slings
for stress incontinence. N Engl J Med 2010, 362, 206676.
[5] Estey EP. Robotic prostatectomy: The new standard of care or a marketing success? Can Urol
Assoc J 2009, 3, 48890.
studies. Curr Opin Obstet Gynecol 2011, 23, 2838.
[8] Stav K, Dwyer PL, Rosamilia A, et al. Repeat synthetic mid urethral sling procedure for women
with recurrent stress urinary incontinence. J Urol 2010, 183, 2416.
[9] Burch JC. Urethrovaginal fixation to Coopers ligament for correction of stress incontinence,
cystocele, and prolapse. Am J Obstet Gynecol 1961, 81, 28190.
[10] Vancaillie TG, Schuessler W. Laparoscopic bladderneck suspension. J Laparoendosc Surg 1991,
1, 16973.
[11] Moehrer B, Ellis G, Carey M, et al. Laparoscopic colposuspension for urinary incontinence in
women. Cochrane Database Syst Rev 2002, CD002239.
References 357
[12] Hong JH, Choo MS, Lee KS. Long-term results of laparoscopic Burch colposuspension for stress
urinary incontinence in women. J Korean Med Sci 2009, 24, 11826.
[13] Rehman J, Landman J, Kerbl K, et al. Laparoscopic repair of diaphragmatic defect by total
intracorporeal suturing: clinical and technical considerations. JSLS 2001, 5, 28791.
CT guided stereotactic brain surgery. IEEE Trans Biomed Eng 1988, 35, 15360.
[15] Kappert U, Schneider J, Cichon R, et al. Development of robotic enhanced endoscopic surgery
for the treatment of coronary artery disease. Circulation 2001, 104, I1027.
anastomosis: a case report. J Laparoendosc Adv Surg Tech A 1999, 9, 10713.
[17] Paley PJ, Veljovich DS, Shah CA, et al. Surgical outcomes in gynecologic oncology in the era of
robotics: analysis of first 1000 cases. Am J Obstet Gynecol 2011, 204, 5519.
[18] Matthews CA, Reid N, Ramakrishnan V, et al. Evaluation of the introduction of robotic
technology on route of hysterectomy and complications in the first year of use. Am J Obstet
Gynecol 2010, 203, 4995.
[19] Partin AW, Adams JB, Moore RG, et al. Complete robot-assisted laparoscopic urologic surgery: a
preliminary report. J Am Coll Surg 1995, 181, 5527.
2008, 15, 28691.
[21] Khan MS, Challacombe B, Rose K, et al. Robotic colposuspension: two case reports.
J Endourol 2007, 21, 10779.
[22] Nichols DH. Vaginal prolapse affecting bladder function. Urol Clin North Am 1985, 12, 32938.
[23] Langer R, Ron-El R, Neuman M, et al. The value of simultaneous hysterectomy during Burch
colposuspension for urinary stress incontinence. Obstet Gynecol 1988, 72, 8669.
Part V: Specialties
27 Pediatric gynecology for robotic surgery
Gustavo N. C. Inoue and Hiep T. Nguyen
27.1Introduction
Since the U.S. Food and Drug Administration (FDA) approval of the da Vinci surgical
system (Intutitive Surgical Inc, Sunnyvale, CA, USA) in 2000, the number of robotic pro-
cedures has dramatically increased annually [1]. The potential to overcome the limita-
tions of conventional videoendoscopic surgery has been used worldwide to improve
the application of minimally-invasive surgery (MIS) to many surgical specialties. Three-
dimensional visualization, tremor filtration and high amplitude of movements are the
main features that provide considerable advantages to the surgeons during a minimally-
invasive procedure. Although there are still many contradictory studies, the direct costs of
this technology seem to be decreasing [2].
In April 2005, da Vinci surgical system was FDA-approved for gynecologic proce-
dures, based on preliminary evidence of safety and efficacy in performing myomec-
tomy and hysterectomy at the University of Michigan [3]. Since then, many studies
have demonstrated that robotic-assisted laparoscopic surgery was associated with
equivalent, if not better, operative time, comparable surgical outcomes, shorter
hospital stay, and fewer major complications compared to conventional open sur-
geries [45]. While there are many gynecological applications for this technology in
the adult population, its use in children is limited. In this chapter, we will review in
detail some of the applications of robotics in pediatric gynecological surgery.
27.2Sling procedure for bladder outlet

incompetence
Bladder outlet incompetence is uncommon in children but may be seen in patients

with neurogenic bladder, with bladder exstrophy-epispadias complex, and primary
pelvic floor laxity. While the former two conditions are well-recognized conditions
in pediatric urology, the latter is a rare condition that is primarily observed in pre-
pubertal females and in particular, athletes. Although there are no reliable medical
treatments for bladder outlet incompetence, the sling procedure is a relatively effec-
tive option for its management [6]. Typically, the sling procedure is performed via
an open surgery. However, the application of the robotic approach to this procedure
has allowed for improved access to structures deep in the pelvis and to anterior and
posterior aspects of the bladder neck.
362 27 Pediatric gynecology for robotic surgery
After cystocopic evaluation, with the patient in the extended dorsal lithotomy posi-
tion, the robot is positioned between the subjects leg. The camera port is inserted
at the umbilicus. Two ports are placed in the right and left lower quadrants in the
mid-clavicular line approximate 1 cm below the camera port (Fig. 27.1). A 12 French
Foley catheter is placed sterilely; manipulation of the catheter will be needed during
the procedure. The patient is then placed in the Trendelenburg position to facilitate
displacement of the intestines from the pelvis. After all the ports are placed and the
robotic instruments are engaged, the peritoneum overlying the bladder is incised
transversely from the right to left median umbilical ligaments. The peritoneum is then
bluntly dissected off the posterior aspect of the bladder.
The bladder is first mobilized posteriorly away from the uterus in females or the
sigmoid colon in males, all the way down to the bladder neck and urethra. A hitch
stitch (a suture that is placed through the anterior abdominal wall, through the dome
of the bladder and back out again) may be used to elevate the superior portion of
the bladder to allow for deep pelvic dissection of its posterior aspect. Tugging on the
bladder catheter helps to identify the bladder neck and urethra. The endopelvic fascia
lateral to the bladder neck and urethra is then identified by blunt dissection (Fig. 27.2).
Bladder Neck Sling
1
Robotic System
X 3
1: 8 mm working port, mid-clavicular line

810 cm
2: 12 mm camera port, midline
2 160
3: 8 mm working port, mid-clavicular line
810 cm X: 10 mm port for sutures and stapler
Fig. 27.1: Port placement and positioning of the Robotic System for RAL Bladder Neck Sling
27.2Sling procedure for bladder outlet incompetence 363
Fig. 27.2: Exposure of the bladder neck
Pubic bone
Bladder
Fig. 27.3: Development of the space of Retzius
Next, the dissection is carried out anteriorly between the pubic bone and the
bladder (exposing the space of Retzius) to the level of the bladder neck and urethra
(Fig. 27.3). Again the endopelvic fascia is then identified laterally. With one robotic
instrument on the posterior aspect of the endopelvic fascia and the other on the supe-
rior aspect, the lateral border of the bladder neck and urethra can be developed by
incising through the endopelvic fascia (Fig. 27.4). After performing this on the right
and left side, a surgical umbilical tape can be placed around the bladder neck. Cys-
toscopy is then performed to ensure proper positioning and integrity of the bladder
neck and proximal urethra.
Fig. 27.4: Creation of the lateral border of the bladder neck
Fig. 27.5: Placement of the umbilical tape around the bladder neck
The sling [e.g., anterior rectus fascia, small intestine submucosa (SIS) or processed
pericardium] is then sutured onto one end of the umbilical tape and pulled through into
position, replacing the umbilical tape. The sling is then cinched around the bladder
neck and secured in place with non-absorbable sutures (Fig. 27.5). Next, two small
puncture incisions are made through the rectus fascia on either side of the midline and
each end of the sling is brought through the fascial incision. With upward traction on
the ends of the sling, the bladder neck/urethra complex is then lifted (Fig. 27.6). Cysto-
scopy is used again to check the elevation and coaptation of the bladder neck. The sling
is then sutured in position on the anterior abdominal wall and the incisions are closed.
A suprapubic tube is recommended for drainage and the foley catheter removed.
The suprapubic tube is left indwelling for 24 weeks. Once voiding and complete
emptying has been documented, the suprapubic tube can be removed. The patient is
27.3Vaginoplasty 365
Fig. 27.6: Replacement of the umbilical tape with SIS sling
then placed on a strict voiding schedule. Urodynamic re-evaluation is recommended

39 months following surgery. Potential complications of the procedure include inju-
ries to the bladder neck and to the surrounding structures such as the vagina and
rectum. In general, the robotic procedure provides sufficient visualization of the
pelvic structures and these complications are uncommon.
27.3Vaginoplasty
Vaginal agenesis or atresia is caused by a failure in the canalization of the vaginal

plate during the proliferation of the cells between the mllerian tubercle and the uro-
genital sinus. It is commonly seen in patients with Mayer-Rokitansky-Kuster-Hauser
syndrome (MRKH), with an incidence of approximately 1:4,00010,000 female births.
There are many treatment of options for the creation of a functional vagina, including
progressive dilatation, rectovesical space dissection and vaginal molds, bowel inter-
position and myocutaneous or free flaps. Vaginal replacement with bowel is preferred
by some clinicians because of a lower incidence of stenosis and its self-lubricant pro-
perties [15]. Traditionally, this surgery is performed via a combined transperitoneal
and perineal approach. The use of robotic-assisted laparoscopic approach provides
an alternative to the traditional approach. Although it is not a common surgery, this
technique is similar to the conventional laparoscopy, which seems to has satisfactory
anatomical and functional results [7].
A bowel preparation with clear liquids and enemas is generally recommended. The
patient is placed in a modified lithotomy, rotated right side down 30o, and the robot is
positioned on patients left side. This arrangement may allow a more natural exposure
of the sigmoid colon and easy repositioning of the small bowel. Four ports are utilized.
The 12-mm camera port is placed infra-umbilically; a 8-mm robotic ports is positioned
in the left upper quadrant along the anterior axial line and in the right lower quadrant
below the inferior epigastric vessels. The fourth port, used as an accessory port, can be
placed below the umbilicus and lateral to the inferior epigastric vessels.
After all the ports have been placed and the robotic instruments are engaged,
a segment of sigmoid colon is isolated. The proximal and distal ends of resection
can be marked with a 5-cm silk suture. The next step is to expose the mesentery and
the vascular supply using one robotic and one laparoscopic bowel grasper placed
through the accessory port to move the sigmoid colon. The other robotic arm which
is armed with a hook cautery, is used to dissect the sigmoid mesentery from the
bowel wall. Once the bowel segment is isolated on its pedicle, a laparoscopic endo-
vascular stapler can be used to divide the bowel segment (it can be introduced by
the camera port, with temporary visualization with a 5-mm laparoscopic camera
through the accessory port). A side-to-side anastomosis is then performed to
re-establish bowel continuity.
Next, the bowel segment should berotated 180 on its mesentery and brought
to the perineum. The proximal staple line is excised and sutured with two layers of
an absorbable material. If the patient has a normal distal segment of the vagina,
a dilator is placed into it to extend the segment into the pelvis where it can be
sutured to the isolated sigmoid segment. If, however, the patient does have an
inadequate distal vagina, the bowel segment may be anastomosed to skin flaps
extending from the perineum. In this situation, to identify the best route to pass
through the rectovesical space, pressure can be applied to the patients perineum
to demarcate the exiting site. An omega-shape skin flap is developed, and an
opening is then created and expanded. The sigmoid segment can be grabbed with
a forceps brought on to the perineum. Creating ample space that can easily accom-
modate the bowel and supports a well-vascularized and tension-free anastomosis
is crucial in the success of the surgery. Finally, the sigmoid segment is anasto-
mosed to the perineal skin flap with full thickness, interrupted sutures.
27.4Hysterectomy
Robotic-assisted laparoscopic hysterectomy is performed increasingly in the US for

both benign and malignant indications [8]. In children, its indication is limited to the
correction of specific mllerian anomalies, which are present in 24% of the female
population. Although hysterectomy can be performed using conventional laparosco-
pic technique, it has been demonstrated that the robotic approach offers an advan-
tage over other surgical approaches with shorter operative time, less blood loss, and
shorter hospital stay [9]. In addition, the robotic approach allows for improved visua-
lization and dissection of structures deep in the pelvis.
27.5Surgical management of endometriosis 367
The robotic and ports are positioned in a similar manner as described for the sling
procedure. The peritoneum can be accessed via the Hassan technique (incision of
the peritoneum followed by placement of the trocar under direct vision) or via direct
placement of an insufflation-needle or a trocar. Some surgeons recommend the use
of a balloon trocar for incision site 10 mm or greater to prevent accidental dislodge-
ment. An additional accessory 58-mm port placed in midline below the camera port
is helpful to provide additional retraction during the procedure. Placing the patient
in the Trendelenburg position help to move the intestines from the pelvis and allow
better visualization of the uterus.
The procedure begins with obtaining access to the extraperitoneal space around
the rectum by incising the parietal peritoneum lateral to the infundibulopelvic (IP)
ligaments. The ureters can be identified on each side of the IP ligaments. The IP liga-
ments are then ligated, and the round ligaments are divided near the pelvic wall. The
bladder is dissected away in the usual manner. The vascular pedicle to the uterus is
then isolated and divided at the level of the isthmus. Next, a colpotomy is created,
and the incision extended with monopolar curved scissors. The intact uterus can be
removed through the vagina. Finally, the colpotomy is closed with a continuous vicryl
running suture.
Complications such as significant bleeding and injuries to the surrounding struc-
tures and organs are uncommon. The robotic approach has similar peri-operative out-
comes when compared to other minimally-invasive surgeries in an adult population
[10, 11].
27.5Surgical management of endometriosis
Endometriosis is the presence of tissue similar to the lining of the uterus located
outside its normal location. The ectopic implants may occur on the ovaries, the fal-
lopian tubes, the vagina, the cervix, the uterosacral ligaments or the rectovaginal
septum. Signs and symptoms of endometriosis include severe dysmenorrhea, infer-
tility and chronic pelvic pain. Interestingly, evidence of endometriosis may be found
during laparoscopy in 2050% of asymptomatic women [12]. Althoughpelvic endo-
metriosis typically occurs in women aged 2530 years, it seems to be the cause of
chronic pelvic pain in 45% of the adolescent female population. Treatment for endo-
metriosis is directed to the relief of pain, the control of endometriosis progression
and the preservation of fertility. Minimally-invasive surgical therapy is a good treat-
ment option to preserve endometriosis-associated infertility, but this treatment is not
as effective at eliminating pain. Robotic laparoscopic single-site surgery (LESS) and
single-port laparoscopy (SPL) are the most recent techniques available in the gyneco-
logical field for endometriosis surgery [13].
With the patient in the dorsal lithotomy position, a uterine manipulator and a Foley
catheter are placed. The robot is positioned between the patients legs. Four ports are
utilized: one 12-mm umbilical port for the camera; two 5-mm ports located in the right
and left mid-clavicular line midlateral; and one 5-mm or 12-mm suprapubic port, used
by the assistant to provide laparoscopic instruments as needed by the surgeon [14].
The abdomen is then carefully inspected for the ectopic implants. Once identified,
the peritoneum surrounding the implants are dissected; removal of the endometriosis
can be done by en block excision or by electrocauterization.
27.6Conclusion
Admittedly, the use of robotic-assisted laparoscopic surgery is limited in pediatric

gynecology currently, with only a few numbers of selected institutions able to perform
such procedures. Consequently, this prevents a more complete analysis of its effec-
tiveness and outcomes. However, the advantages of this technology, specifically the
more detailed visualization and the dexterous instrument manipulation will increase
its use in the future. These advantages will likely allow more complex gynecological
procedures (in particular reconstructive ones) to be performed laparoscopically.
References
[1] Dulan G, et al. Content and face validity of a comprehensive robotic skills training program for
general surgery, urology, and gynecology. Am J Surg 2012, 203(4), 5359.
[2] Rowe CK, et al. A comparative direct cost analysis of pediatric urologic robot-assisted
laparoscopic surgery versus open surgery: could robot-assisted surgery be less expensive?
J Endourol 2012, 26(7), 8717.
[3] Reynolds RK, Advincula AP. Robot-assisted laparoscopic hysterectomy: Technique and initial
experience. Am J Surg 2006, 191, 55560.
[4] Yu HY, Hevelone ND, Lipsitz SR, et al. Use, costs and comparative effectiveness of robotic
assisted, laparoscopic and open urological surgery. J Urol 2012, 187(4), 13929.
[5] Yim GW, Kim YT. Robotics and gynecologic oncology: review of the literature. Curr Opin Obstet
Gynecol 2012, 24(1), 1423.
[6] Labrie J, Fischer K, van der Vaart CH. Health-related quality of life. The effect of pelvic floor
muscle training and midurethral sling surgery: a systematic review. Int Urogynecol J 2012,
23(9), 115562.
[7] Davies MC, Creighton SM. Vaginoplasty. Curr Opin Urol 2007, 17(6), 4158.
[8] Advincula AP. Surgical techniques: robot-assisted laparoscopic hysterectomy with the da Vinci
surgical system. Int J Med Robot 2006, 2, 30511.
[9] Renato S, Mohamed M, Serena S. Robot-assisted radical hysterectomy for cervical cancer:
review of surgical and oncological outcomes. ISRN Obstet Gynecol 2011, 872434.
References 369
[10] Burke WM, Wilde ET. Comparative effectiveness of robotic versus laparoscopic hysterectomy
for endometrial cancer. J Clin Oncol 2012, 30(8), 78391.
[11] Paraiso MF, Ridgeway B, Park AJ, et al. A randomized trial comparing conventional and
robotically assisted total laparoscopic hysterectomy. Am J Obstet Gynecol 2013,
208(5), 368. e17.
[12] Williams TJ, Pratt JH. Endometriosis in 1,000 consecutive celiotomies: incidence and
management.Am J Obstet Gynecol 1977, 129(3), 24550.
[13] Escobar PF, Fader AN, Paraiso MF, et al. Robotic-assisted laparoendoscopic single-site surgery
in gynecology: initial report and technique. J Minim Invasive Gynecol 2009, 16(5), 58991.
[14] Nezhat C, Lewis M, Kotikela S, et al. Robotic versus standard laparoscopy for the treatment of
endometriosis. Fertil Steril 2010, 94(7), 275860.
[15] Hensle TW, Reiley EA. Vaginal replacement in children and young adults. J Urol 1998,
159(3), 10358.
28 Robotic-assisted surgery advances benefit
patients
Courtney M. Townsend, Jr.
In all my years as a physician, I have seen many advances that benefit patients. As a
surgeon, I can tell you one of the most remarkable developments has been the incre-
asing use and sophistication of minimally-invasive surgery (MIS).
MIS is changing the way doctors and patients think about surgery. Instead of a
large open incision, surgeons operate through a series of small incisions.
This method results in better outcomes, less pain, quicker recovery times and
less scarring. Some incisions are so small they are barely visible once they fully heal.
So, how did we get here? The concept of minimizing the damage to human tissue
through small cuts has been around for at least a 100 years but it has taken a surgical
perfect storm of technological advances to propel these procedures into the surgical
mainstream.
The development of the computer chip television camera that projected a real-
time magnified view onto a monitor is considered by many in the medical profession
to be the final piece that fell into place.
In most procedures, a surgeon makes several small incisions and inserts trocars.
In some cases, carbon dioxide gas is used to inflate the area, creating a dome between
organs and skin.
A miniature camera is inserted into one of the trocars, and the image from the
camera is viewed on a TV monitor. This is only a 2-dimensional view. Surgical instru-
ments are inserted through the other trocars to perform the procedures.
Using the minimally-invasive approach, we perform a variety of these surgeries,
some of them with the da Vinci robotic system. In robotic-assisted surgery proce-
dures, the surgeon is seated at a console a few feet away from the patient.
The surgeon looks through a viewfinder that provides a true 3-D view of the area
being operated on. Using hand and foot controls, the surgeon is able to reposition the
camera, zoom in or out, move the field up, down, left, right or even completely rotate
the camera for a better image.
The surgeons hands are placed into the surgical console. Then, with hand controls,
the surgeon uses the same skills and motions used during traditional surgery.
The da Vinci surgical system transfers every movement the surgeon makes to
robotic arms, which mimic the surgeons movements and actually perform the surgi-
cal procedure on the patients body.
The robotic surgical system offers several advantages over traditional laparo-
scopic surgery. The instruments are designed to provide a wide range of motion,
allowing the surgeon to rotate instruments more than 360.
372 28 Robotic-assisted surgery advances benefit patients
The system also is intuitive, which means as the surgeon twists the controls
clockwise, the robots instruments move clockwise. In standard laparoscopic surgery,
the movement of the instruments is counterintuitive, which is similar to doing surgery
while looking into a mirror.
Finally, the robotic system enhances accuracy by correcting and compensating
for any tremor in the surgeons hand.
We are able to perform MIS for a variety of general surgical, urologic, thoracic,
gynecologic and otolaryngological procedures, including cholecystectomy, gastric
bypass, colectomy, hernia repair, biliopancreatic diversion, prostatectomy, lung
resection, hysterectomy, salpingo-oophorectomy, sacrocolpopexy and tonsillectomy.
Especially dual console future provides a great advantage to do interdisciplinary com-
bined surgeries. Under these given circumstances all surgeons involved with the case
should communicate beforehand to address with the patient the order of steps that
will be taken: positioning, trocar placement, procedure order, specimen removal and
postoperative care. This new technique also demands new sets of approach to intra-
operative consultations. All surgical members of the team should work in parallel to
help to each other. This can be done only by providing combined training sessions
from different departments on a regular basis.
While the technology such as the da Vinci is a game-changer in the operating
room, we should never lose sight that the patients well-being is still in the hands of
the surgeon and the surgical team.
And, as beneficial as these procedures are, they are not for everyone and not for
all procedures. So, check with your doctor and surgeon.
People who have MIS usually recover faster, meaning a shorter stay in the hospi-
tal and getting back to work much sooner.
29 Gynecology-related general surgery
Ilknur Erguner and Ismail Hakki Hamzaoglu
Robotic surgery is one of the newest branches of advanced laparoscopy, and gyneco-
logic procedures have been performed using robotics for nearly 20 years.
Complications can occur during any type of operation, even if open, laparoscopic
or robotic. Smith et al reported that overall complication rates for laparoscopic and
robotic cases were 6% and 2.5% (P = 0.201), respectively [1]. Most of the recent liter-
ature reported that the complication rates were similar between women that were
treated using conventional laparoscopic or robotic methods [14].
Ureter, bladder, small bowel, colon and vascular system are all at risk of injury
during all types of gynecologic operations [5]. Several factors can effect these injuries,
such as close proximity to these organs, distortion of the anatomy, previous abdomi-
nal and pelvic surgeries, advanced malignancies, preoperative radiotherapy, delayed
mechanical and energy effects. According to several studies, the incidence of gastro-
intestinal injury (GI) during gynecologic surgery is between 0.05% and 0.33% [59].
The mortality rate related with intraoperative GI injuries was reported as 3.6% [6].
29.1How do gastrointestinal injuries occur?
Gastrointestinal injuries are not uncommon during gynecologic surgery. Most of the
reasons that causes injury are listed below.
Veress needle or trocar replacement
Adhesiolysis and tissue dissection
Devascularization of the bowel mesentery
Electrosurgical injury (thermal injury)
The most common sites that are injured, respectively, the small intestine, large bowel,
rectum and occasionally stomach and duodenum [5, 913]. The important thing is
to recognize this and treat intraoperatively [12]. If the diagnoses of GI injuries are
delayed, the morbidity and mortality rates increase [5, 10, 12].
29.2Management of the gastrointestinal injuries
29.2.1Bowel injuries
The incidence of intraoperative bowel injury during gynecologic operations is

reported to be between 0.2% and 1.5% [9, 14]. Bowel injuries can range from simple
serozal tears and lacerations, to complete transection of the bowel. Recognition is
374 29 Gynecology-related general surgery
the first important step in bowel injury. The injured segment should be isolated to
prevent the contamination of the abdomen [10, 11]. The injury can be repaired with a
robotic arm or after undocking it can be repaired laparoscopically. Also, the surgeon
decides whether laparotomy is necessary or not. Seromuscular defects do not usually
require repair. However, if they are extensive, the surgeon can decide to repair them.
Transmural injuries, on the other hand, always require repair [1114]. Treatment
of all gastrointestinal injuries should include peritoneal lavage and appropriate
antibiotherapy [5, 10, 15].
29.2.2Small bowel injuries
Treatment options differ according to the type of injury. These are simple repair,
resection and anastomosis, small bowel stoma (Tab. 29.1).
Technique
Primary repair
If the defect is less than 50% of the circumference of the injured segment, it can be
primarily repaired with continued or interrupted 3/0 or 4/0 silk or absorbable suture
[5, 11, 14]. The layers are closed one or two layers depending on the surgeons prefe-
rence. The suture line should always be perpendicular to the lumen of the bowel to
avoid stricture [10, 11, 14].
Resection and anastomosis

If the defect is bigger than 50% of the circumference of the injured segment or the
simple repair narrows the lumen resection, anastomosis is done. Also, grade III, IV,
and V injuries require resection and anastomosis [5, 11, 14, 16]. In case of thermal
injury, resection with a wide margin around the injury site is required because thermal
damage may extend for a considerable distance from the site of thermal contact
[5, 10, 11, 17]. After resection, anastomosis can be done side to side, or end to end, with
Tab. 29.1: Smal bowel injury scale
Grade Injury Treatment
I (a) Contusion of hematoma without devascularization Primary repair

(b) Partial thickness laceration
II Laceration 50% of circumference Primary repair
III Laceration >50% of circumference without transection Resection + anastomosis
IV Transection of the small bowel Resection + anastomosis
V (a) Transection of the small bowel with segmental Resection + anastomosis
tissue lost (resection should be continued
(b) Devascularized segment until the well-perfused edge are
obtained)
29.2Management of the gastrointestinal injuries 375
one layer or two layer suture, with silk or absorbable suture. Also, the GIA stapler or
the Endo-GIA stapler can be used for anastomosis.
Small bowel stoma

If the injury site was radiated and after resection anastomotic sides were located in
the radiation field, or there is a doubt about the bowel vascularization, it can be safer
to perform a temporary or protective ileostomy or jejunostomy. It can be closed 2 or 4
months after surgery. If after resection, non-radiated segments come together in ana-
stomosis then primary anastomosis can be safer [11].
Intestinal anastomotic healing depends on a good blood supply, a tension-
free suture or staple line, an adequate lumen, a water tight closure, and no distal
obstruction [16].
29.2.3Large bowel injuries
There is no other organ injury that has higher septic complication than the colon.
The treatment options are similar to small bowel (primary repair, resection and
anastomosis, stoma). The American Association for the Surgery of Trauma (AAST)
developed a colon injury scale (Tab. 29.2) [15]. According to this scale, in grade I and II
(non-destructive) injuries primary repair is sufficient. There is no other data that
showed colostomy has better results [14, 15]. After the injury is repaired, irrigation
with saline should be done.
Technique of repair
Primary repair
This is similar to small bowel repair. But the large bowel lumen is larger than the
small bowel, so the suture line may not be perpendicular to the lumen of the colon.
The defect is over sewn with continuous or interrupted 3/0 or 4/0 silk or absorbable
suture.
Tab. 29.2: AAST colon injury scale
Grade Injury Treatment
I (a) Contusion of hematoma without devascularization Primary repair

(b) Partial thickness laceration
II Laceration 50% of circumference Primary repair
III Laceration >50% of circumference Resection + anastomosis
IV Transection of colon Resection + anastomosis
(a) Transection of the colon with segmental tissue lost (resection should be continued
(b) Devascularized segment until the well-perfused edge are
obtained)
Resection and anastomosis

In grade III and IV (destructive) injuries, resection to normal and well-perfused edges
should be performed, and the anastomosis should be tension free. One or two layer
anastomosis can be done with continuous or interrupted 3/0 or 4/0 silk or absorbable
suture. Also GIA and Endo-GIA staples can be used.
Colostomy
Until recently, several guidelines suggest that patients who have had blood transfu-
sions >6 units, delays of operations >6 h, shock at admission and destructive colon
injury (scale 34) resection and colostomy occurs [11, 12, 18, 19]. The American Society
of Colon and Rectal Surgeons (ASCRS) suggest, however, that the only indications for
colostomy are the presence of severe colon edema or a questionable blood supply of
the colon [15].
29.2.4Rectal injury
Rectal injury is more common during vaginal surgeries. The rate of the iatrogenic
rectal injury during gynecologic operation is reported between 1.4% and 2.1% [11].
29.2.5Stomach Injury
Stomach injuries are relatively lower than bowel injuries. It is reported 1 in 3,000
cases [5, 20].
Prior to upper abdominal surgery, a distended stomach may increase the risk
of injury. An orogastric or nasogastric tube should be placed before Veress or trocar
insertion.
The defect can be over sewn with a interrupted or continuous delayed absorb-
able suture by robotic arms or laparoscopically or laparotomy. The abdominal cavity
should be irrigated and antibiotherapy should be given. The nasogastric tube usually
stays in place until bowel movements begin [21].
Management of undiagnosed injury

In the postoperative period if the patient has signs of sepsis, gastrointestinal inju-
ries should be always suspected. On the postoperative third or fourth day the patient
generally presents with abdominal pain, high temperature, nausea, and anorexia
(Tab. 29.3). Usually, the patients bowel movements decrease. White blood cell count
increases or decreases. Radiograms reveal multiple air and fluid levels or air under
the diaphragm. Further radiologic examinations may be needed, e.g., ultrasonogra-
phy or abdominopelvic computerize tomography (CT) with a contrast agent. If rectal
injury is suspected, a water soluble contrast enema with CT should be used. The
patient should be hydrated well and antibiotic therapy should be started promptly.
29.3Prevention of gastrointestinal injury 377
Tab. 29.3: Symptoms of undiagnosed injury
Abdominal pain
Abdominal distention
Trocar pain
Leukopenia/Leucytosis
Diarrhea
Ileus
Fever
Nausea
Vomiting
The patient should be operated upon immediately [5, 10, 13, 14, 17]. Exploration can
be done laparoscopically or by laparotomy. The injured bowel should be excised with
or without diversion. All necrotic tissues should be resected. The abdomen should be
irrigated with copious saline [9, 12, 22].
Oral regimen should not be started until the bowel movements begin.
29.3Prevention of gastrointestinal injury
There are some precautions that can prevent injuries [10, 17, 22].
1. If the patient has abdominal surgery history, the first port should be placed with
an open-entry technique.
2. Inspection of the bowel under the entry site can prevent undiagnosed injury.
3. Gentle and careful tissue dissection is very important.
4. Using atramatic instruments for bowel handling decreases bowel injury.
5. If bowel injury is suspected, exploration of all the bowel beginning from the treizt
ligaman should be done.
6. Electrothermal devices should be used carefully.
References
[1] Smith AL, Krivak TC, Scott EM, et al. Dual-console robotic surgery compared to laparoscopic
surgery with respect to surgical outcomes in a gynecologic oncology fellowship program.
Gynecol Oncol 2012, 126(3), 4326.
Obstet and Gynecol Int 2011, 852061.
[3] Backes FJ, Brudie LA, Farrell MR, et al. Short- and long-term morbidity and outcomes after
robotic surgery for comprehensive endometrial cancer staging. Gynecol Oncol 2012, 125(3),
54651.
[4] Cho JE, Shamshirsaz AH, Nezhat C, et al. New technologies for reproductive medicine:
laparoscopy, endoscopy, robotic surgery and gynecology. A review of the literature. Minerva
Gynecol 2010, 62(2), 13767.
[5] Sharp HT, Swenson C. Hollow viscus injury during surgery. Obstet Gynecol Clin North Am 2010,
37(3), 4617.
[6] van der Voort M, Heijnsdijk EA, Gouma DJ. Bowel injury as a complication of laparoscopy.
Br J Surg 2004, 91(10), 12538.
[7] Chapron C, Pierre F, Harchaoui Y, et al. Gastrointestinal injuries during gynaecological
laparoscopy. Hum Reprod 1999, 14(2), 3337.
[8] Brosens I, Gordon A, Campo R, et al. Bowel injury in gynecologic laparoscopy. J Am Assoc
Gynecol Laparosc 2003, 10(1), 913.
[9] Lam A, Kaufman Y, Khong SY, et al. Dealing with complications in laparoscopy. Best pract Res
Clin Obstet Gynaecol 2009, 23(5), 63146.
[10] Nezhat CR, Nezhat FR, Nezhat C, et al. Complications. In: Operative Gynecologic Laparoscopy
Principles and Techniques. Second Edition edn. Edited by CR N. New York: McGraw Hill Medical
Publishing Division, 2000, 365386.
[11] Mendez LE. Iatrogenic injuries in gynecologic cancer surgery. Surg Clin North Am 2001, 81(4),
897923.
[12] Sweeney KJ JM, Geraghty JG. Management of intra-operative bowel injuries. CME J Gynecol
Oncol 2002, 7, 17882.
[13] Bishoff JT, Allaf ME, Kirkels W, et al. Laparoscopic bowel injury: incidence and clinical
presentation. J Urol 1999, 161(3), 88790.
[14] Winter WE, Cosin JA. Management of intraoperative injuries to the gastrointestinal tract in
radical gynecologic surgery. CME J Gynecol Oncol 2002, 7, 18793.
[15] Hoyt DB LM. Trauma of the colon and rectum. In: The ASCRS Textbook of Colon and Rectal
Surgery. Second Edition edn. Edited by Beck DE, Roberts PL, Saclarides TJ, Senagore AJ, Stamos
MJ, Wexner SD. New York: Springer, 2011.
[16] LN D. Stomach and small bowel. In: Trauma. 6th Edition. edn. Edited by Feliciano DV MK, Moore
EE. New York: McGraw-Hill, 2008, 682700.
[17] Li TC, Saravelos H, Richmond M, et al. Complications of laparoscopic pelvic surgery:
recognition, management and prevention. Hum Reprod Update 1997, 3(5), 50515.
[18] Pasquale M, Fabian TC. Practice management guidelines for trauma from the eastern
association for the surgery of trauma. J Trauma 1998, 44(6), 94156, discussion 95647.
[19] Chappuis CW, Frey DJ, Dietzen CD, et al. Management of penetrating colon injuries. A
prospective randomized trial. Ann Surg 1991, 213(5), 4927, discussion 4978.
[20] Taylor R, Weakley FL, Sullivan BH, Jr. Non-operative management of colonoscopic perforation
with pneumoperitoneum. Gastrointest Endosc 1978, 24(3), 1245.
[21] Sharp HT, Dodson MK, Draper ML, et al. Complications associated with optical-access
laparoscopic trocars. Obstet Gynecol 2002, 99(4), 5535.
[22] Nezhat F, Nezhat CH, Admon D, et al. Complications and results of 361 hysterectomies
performed at laparoscopy. J Am Coll Surg 1995, 180(3), 30716.
30 Ophthalmology and steep Trendelenburg position
Giovanni Taibbi and Gianmarco Vizzeri
30.1Introduction
Robotic-assisted gynecological surgery is conducted in a steep Trendelenburg

position for several hours. As head-down tilt is not a physiological posture, questions
related to the safety of this surgical approach on the visual system may arise. In fact,
data from bed-rest studies and reports from different surgical specialties indicate that
ophthalmological changes may occur when the body is placed in a recumbent posi-
tion.
In this chapter, we describe the effects of head-down tilt on the ocular structures
and the possible complications that may arise when surgery is performed in a steep
Trendelenburg position.
30.2Posture-induced ocular changes
Posture-induced ocular changes are largely described for different angles of tilt and
time lengths. The majority of data derive from bed-rest studies designed to inves-
tigate the relationship between body position and intraocular pressure (IOP). For
example, short-duration (from 2 min to 48 h) bed-rest studies indicate that IOP
immediately increases when the body is placed in a recumbent position, with a rise
in IOP that ranged from 2 to 5 mmHg for body angles between 0 and 50 [16]. In
general, the amount of IOP elevation correlates with the angle of tilt. In addition,
posture-induced IOP changes may be more pronounced in patients with glaucoma
[7]. Although the underlying mechanisms need to be fully elucidated, cephalad
shifts of body fluids in response to tilt may increase episcleral venous pressure,
causing an increased resistance to aqueous humor outflow [8]. Moreover, head-
down tilt causes choroidal vascular engorgement. This expansion against the rigid
sclera (the outermost ocular layer), leads to ocular compression and subsequent
IOP elevation [5, 9, 10].
Quick Hit: Elevated IOP may be harmful in predisposed individuals. There is con-
sensus that the risk of developing glaucoma increases substantially with the degree of
IOP elevation [11]. However, there is conflicting evidence with regard to the effects of
short-term IOP fluctuations (i.e., IOP changes occurring within the same day), and
glaucoma development or progression [12].
Bed-rest studies suggest that increased IOP may be associated with a drop in
heart rate and a significant gradual reduction in blood pressure [3, 4, 6].
A limited number of experiments have been conducted to evaluate the effect of
postural changes on ocular perfusion pressure (OPP, defined as mean blood pres-
sure minus IOP) and choroidal blood flow (ChBF) [3, 4, 6]. Although there is no direct
380 30 Ophthalmology and steep Trendelenburg position
evidence, it is conceivable that, after a possible initial increase, both OPP and ChBF
may subsequently decrease in response to head-down tilt with the presence of limited
or no autoregulatory mechanisms. OPP increased in response to 2, 21 and 30 min
of body tilt at 8 [3], 15 [4], and 0 [6], respectively. In one study, there was an 11%
increase in ChBF after 2 min at 8 head-down tilt [3]. However, in another study,
Kaeser et al reported a 12% decrease in ChBF after 30 min in a supine position;
ChBF plotted against OPP demonstrated that both variables decreased uniformly
[6]. The disparate findings can be partially explained by differences in study design
and data collection at various time points and by difficulties in obtaining accurate
and reproducible measurements. Further studies are required to better characterize
posture-related changes in ocular blood flow.
In summary, head-down tilt position may cause an increase in IOP associated with
a reduction in blood pressure. This finding may be particularly relevant for patients
with cardiovascular risk factors undergoing robotic-assisted surgical procedures, since
their optic nerves may suffer an acute ischemic insult, likely due to insufficient blood
supply coupled with elevated IOP. As discussed below, ischemic optic neuropathy is
a cause of permanent perioperative vision loss (POVL) after nonocular surgeries [13].
30.3Postoperative ophthalmological complications
To our knowledge, there are no available reports of ophthalmological complications

after robotic-assisted gynecological surgery. This may be due to the fact that gyneco-
logical robotic surgery is a relatively novel surgical approach and such reports are not
yet available. It is possible that this surgical approach may be safe and well tolerated
with little or no ophthalmological complications. However, to date no studies have
been performed to test the safety of surgery conducted in steep Trendelenburg posi-
tions on ocular structures and visual function.
A case of unilateral anterior ischemic optic neuropathy possibly associated with
gynecological surgery has been recently described [14]. The patient complained of
monocular vision loss upon awakening from a laparotomy performed 36 h apart from
a previous hysterectomy that was complicated by substantial abdominal hemorrhage.
The hysterectomy was conducted in the Trendelenburg position for an unspecified
period of time. Of note, on ophthalmological exam the patient was found to have
small optic discs, an anatomical feature possibly associated with an increase in the
incidence of ischemic optic neuropathy. At 3-year follow-up, visual acuity in the affec-
ted eye had further decreased from 20/25 to 20/32, there was a superior altitudinal
visual field defect and the optic disc appeared diffusely pale on ophthalmoscopic
examination.
Quick Hit: Anterior ischemic optic neuropathy (AION) is classified in non-
arteritic (NA-AION) AND arteritic (A-AION). NA-AION is caused by transient ischemia
or, in rare cases, by an embolism to the arterial vessels feeding the anterior segment of
the optic nerve. The degree of visual impairment depends on the extent and duration
30.4Ophthalmological patient management 381
of the ischemic event. There is no established treatment for postoperative NA-AION

and prognosis varies, with mild improvement in visual function over time still possi-
ble in some cases. A-AION is primarily caused by giant cell arteritis. It left untreated,
it rapidly leads to blindness. High doses of systemic corticosteroid therapy must be
immediately established when there is a reasonable index of suspicion of A-AION.
Robotic-assisted surgery is not limited to gynecology. It is being increasingly used
in other surgical specialties, such as urology. Weber et al described two cases of poste-
rior ischemic optic neuropathy after minimally-invasive prostatectomy, one of which
was robotic-assisted [15]. Both surgeries were performed in the steep Trendelenburg
position for a prolonged time (>6.5 h). Given the similarities between gynecology and
urology with regard to the use of robotic technology and patient positioning, it is pos-
sible that similar complications may occur after gynecological procedures.
Ocular complications following non-ophthalmic conventional surgery are well
described. As discussed below, the cornea is most commonly involved, usually
without permanent visual impairment [16]. However, in rare cases, permanent POVL
resulted from ischemic optic neuropathy (anterior or posterior), retinal vascular
occlusion (central artery or vein), pituitary apoplexy, or cortical infarction [13, 1719].
Several factors, including prone head-down positioning, operative time, direct exter-
nal compression of the eye, substantial blood loss, anemia, decreased blood pres-
sure, systemic vascular risk factors, ocular/cerebral microemboli, or small optic
disc size, have been suggested to explain the occurrence of POVL. Given the rare
incidence of POVL (from 0.002% among all nonocular surgeries to 0.2% of cardiac
and spine surgeries) [13], prospective controlled studies aimed at evaluating specific
risk factors for POVL are not available, and current knowledge mainly derives from
retrospective chart reviews or case reports. For the interested reader, more detailed
discussions pertaining to POVL after nonocular surgery are referenced at the end of
this chapter.
30.4Ophthalmological patient management
Based on currently available evidence, following are recommendations that might help
prevent ocular complications in patients undergoing robotic-assisted gynecological
surgery.
30.4.1Preoperative evaluation
A pre-operative ophthalmological evaluation should be performed to assess the risk

of POVL and to evaluate the presence of glaucoma or ocular hypertension. Atten-
tion should be paid to history of ocular ischemic events and potential risk factors
for POVL such as a small optic disc size and small cup to disc ratio [18]. Surge-
ons should adequately inform patients with regard to possible ophthalmological
changes, including vision loss, along with other complications associated with
steep Trendelenburg positions. This is particularly important in cases in which a
longer operation is expected or when significant blood loss is anticipated.
Patients should be informed that IOP will likely increase intraoperatively as a
result of the steep Trendelenburg position. The amount of change in IOP is depen-
dent on multiple factors, such as the angle of tilt or the time spent in the recumbent
position, and cannot be accurately predicted. Although at present the relationship
between short-term IOP fluctuations and glaucoma onset or disease progression
has not yet been fully characterized, there is strong evidence in support of elevated
IOP as a risk factor for the development and progression of glaucoma [11].
Therefore, in patients with a diagnosis of glaucoma or ocular hypertension, the
risk of glaucoma progression associated with robotic-assisted surgery should not be
ignored, although it is not quantifiable at this time.
30.4.2Intraoperative period
During a surgical procedure, the eyes should be periodically evaluated to ensure that
corneas are adequately protected. Corneal abrasions are the most common ocular
complication of non-ophthalmic surgery [16]. The American Society of Anesthesio-
logists Closed Claim Project reports that the corneal abrasions account for 35% of
general anesthesia ocular injuries [20]. Damage to the ocular surface is generally
caused by incomplete eyelid closure leading to tear film evaporation and corneal
drying, though accidental trauma caused by the operating room staff and the surgical
instrumentation has also been implicated. General anesthesia predisposes patients
to corneal injury. Under general anesthesia, tear production is significantly decreased
and the eyelids usually are not completely closed, particularly in the steep Trendelen-
burg position. Applying paraffin-based or methylcellulose ointments on the cornea
and taping the eyelid closed for the duration of the operation are preventive measures
used to minimize the likelihood of corneal abrasion postoperatively.
Monitoring the systemic arterial pressure may be a useful measure to minimize
the intraoperative risk of ocular hypoperfusion and optic nerve ischemia. The Task
Force on Perioperative Vision Loss established by the American Society of Anesthe-
siologists emphasizes the importance of continuous blood pressure monitoring in
high-risk patients undergoing spine surgery, which is frequently performed in a prone
position under some degree of head-down tilt [21].
30.4.3Postoperative assessment
Patients complaints of vision loss postoperatively should never be underestima-

ted or ignored. Vision should be first evaluated upon awakening from anesthesia
(e.g., in the recovery room or intensive care unit). Particular attention should be
30.5Conclusions 383
given to those patients who lost a significant amount of blood and/or underwent
prolonged procedures. Prompt ophthalmological consult is warranted when ocular
changes (e.g., decreased vision, altered color perception, red eyes) are noticed by
the patient and/or the medical staff. Finally, clinicians should be aware that ocular
signs/symptoms may be delayed up to 710 days postoperatively [19, 22]. Therefore,
patients need to be advised to seek additional care should they experience decrea-
sed vision or other ocular symptoms upon discharge.
30.5Conclusions
There is evidence that IOP increases when the body is placed in a recumbent posi-
tion. It is unclear whether head-down tilt may produce other ocular structural
and functional changes.
At present, there are no studies that have evaluated the ocular safety of surgery
performed in steep Trendelenburg positions.
POVL is a rare, vision-threatening complication of general non-ophthalmological
surgery. Although there are no reports of POVL after robotic-assisted gynecologi-
cal surgery, some cases of POVL after procedures conducted in the steep Trende-
lenburg position have been described.
It is advised that a pre-operative ophthalmological evaluation be performed
to assess the risk of POVL and evaluate the presence of glaucoma or ocular
hypertension.
30.6Acknowledgements
The authors wish to thank Thomas Jennings, MD for his thoughtful suggestions during
the preparation of this chapter.
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invasive prostatectomy. J Neuroophthalmol 2007, 27(4), 2857.
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31 The future of telesurgery and new technology
Emilio Ruiz Morales, Stefano Gidaro and Michael Stark
31.1Introduction
Ephraim McDowell in Kentucky was the first to perform a successful laparotomy at

the beginning of the 19th century [1]. Just before the beginning of the 20th century
Johannes Pfannenstiel described the transverse abdominal incision which improved
the surgical outcome [2]. As tradition prevails, the first known comparison of the two
methods was done not before 1971 [3].
At the beginning of the 20th century Georg Kelling in Germany [4] introduced
the experimental endoscopy which was developed throughout the century along with
the introduction of endotracheal intubation [5], and the development of other instru-
ments, the insufflators and light sources [6].
At the end of the 20th century it looked as if most the abdominal operations had
endoscopic alternatives [7], such as nephrectomies [8], cholecystectomies [9], appen-
dicectomies [10] and splenectomies [11]. It was shown that patients undergoing endo-
scopic procedures present decreased morbidity with shorter hospital stay and need
less postoperative analgesics [12].
Two new developments emerged during the last years with the intention to
improve surgical outcomes, namely natural orifice surgery and telesurgery. Gastroen-
terologists started to perforate the stomach as an entry into the abdominal cavity and
had already performed experimentally various procedures such as partial hysterec-
tomy [13], oophorectomy [14] and tubal ligation [15]. This approach however implies
technical difficulties such as the small given size of the possible instruments used due
to the limited diameter of the esophagus as well as pharmacological problems due
to the acidity of the stomach, as well as technical problems concerning the closure
of the perforated stomach. The use of the pouch of Douglas as an entry to the abdo-
minal cavity is another potential approach [16]. Due to the lack of abdominal scars
these developments seem promising, and prospective comparative studies will prove
if these methods will improve surgical outcome.
The development of telesurgery is supported by the fast progress in mechanics
and electronics in the last years. The term robotic used by many to refer to these
systems is questionable. These systems are not equipped with artificial intelligence,
although it is probable it will be added in the future, and therefore in this chapter the
more preferred descriptive term is telesurgery. In 1988 the PUMA system was used
for the first time in a neurosurgical biopsy guided by computer tomography [17].
386 31 The future of telesurgery and new technology
Other systems in use today or in the past are the PROBOT [18], ROBODOC [19], ZEUS [20]
and the da Vinci system (Intutitive Surgical Inc, Sunnyvale, CA, USA) [21].
The usage of todays telesurgical systems proved beneficial in certain procedu-
res, and questions are raised as to the added value of using these systems in certain
operations like radical hysterectomy or sacrocolpopexy. It seems that the outcome is
equivalent to endoscopy and laparotomy, but it shows that the procedures increase
the operation time and costs [22].
The advantages of the existing telesurgical systems are 3D stereo-vision with aug-
mented reality, accuracy, filtration of the surgeons hands tremor, improved ergono-
mics, and the potential of operating from remote sites.
The main disadvantages of the existing systems are lack of haptic feedback,
restriction to specific indications next to long docking time and high initial invest-
ments and maintenance costs. In some systems the access to the patient is limited,
and the trans Douglas access is not possible.
Haptic sensation is an integral part of any surgical procedure, including laparo-
tomy. The surgeon can use the tips of his/her fingers to palpate anatomical or patho-
logical findings, looking for lymph glands, and control the traction force exerted on
the suture material. Haptic sensation during surgery should be part of an optimal
telesurgical system, despite claimed similarities between visual force feedback and
haptic feedback [23]. Physiologically, fingertips are one of the most sensitive areas in
the human body, making palpation a useful characteristics in surgery. Musicians use
their fingertips to produce sounds and when playing strings can feel the vibrations
through their fingers. Most of the delicate craftsmanships professions activities are
performed through the fingertips. In surgery it was the same until the introduction
of endoscopy, when the fingertips were abandoned in favor of the fists, and indeed,
most of todays endoscopic tools are controlled with the fists or the proximal part of
the fingers.
Todays telesurgical systems proved beneficial in a limited number of procedu-
res. In a recent review article, the question was raised what was the added value of
use of telesurgical systems in certain gynaecological operations (radical hysterec-
tomy and sacrocolpopexy). It was shown that the outcome is equivalent to endo-
scopy and laparotomy. It was stressed that the procedures increase the time of the
operation as well as the costs [22]. Longer operation times and higher costs were
shown also in hysterectomies [24]. In ophthalmological operations, a telesurgical
system proved to be less sufficient for standard operations compared to an ophthal-
mic microscope [25].
Telesurgical systems were found however to be optimal for procedures like baria-
tric operations in extremely obese patients [26].
Obviously, the next telesurgical systems should provide benefits in a wide range
of procedures, as there is no sense in high investments in procedures where there is
no added value to traditional systems.
31.2Technical description 387
31.2Technical description
To meet these demands, the Joint Research Centre (JRC) of the European Commission
in collaboration with SOFAR S.p.A. in Milan, Italy under the scientific supervision of
the New European Surgical Academy (NESA) in Berlin, initiated a novel telesurgical
system, the Telelap Alf-x, based on a new concept, integrating haptic sensation into a
system combining todays technical and software know-how with a system which offers
the advantages both of laparotomy (concerning the tactile feedback) and endoscopy
(concerning precision, lack of big abdominal scars and better outcome) (Fig. 31.1).
The system is characterized by the following features:
1. Modular system consisting of three or four manipulator arms and one or two con-
soles, according to the needs; each extendable manipulator arm is an indepen-
dent movable unit. This system enables free access to the patient throughout the
operation;
2. Introducing the arms from any given angle. The system enables direct access
to the abdominal cavity through the abdominal wall or, in women, through the
pouch of Douglas;
3. Quick docking of instruments to access ports: the system detects within seconds
the optimal pivot point of each inserted instrument. This point becomes the axis
of the arm movement, preventing extension of the incision in the fascia;
4. Immediate exchange of instruments. The instruments are attached to the arms
through magnets;
5. Uninhibited view and easy access to the surgical area when working through
auxiliary surgical ports (Fig. 31.2);
6. A console with an unobstructed view onto the screen with 3D vision and an ergo-
nomic seat enabling a comfortable position (Fig. 31.3);
7. One or two surgeons consoles for cooperative work or training purposes;
Fig. 31.1: The Telelap Alf-x system

Fig. 31.2: The assistant during a procedure using the Telelap Alf-x system
Fig. 31.3: The eye-tracking system
8. Haptic (1:1) sensation and newly designed handles enabling manipulation of the
instruments with the fingertips. Sensed forces can be amplified when necessary;
9. Avoidance of tremor, advanced control and limitation of applied forces, thus
avoiding the risk of breaking suture threads during knot tying;
10. The console features an eye-tracking system that is adjusted to any surgeon within
a short time by him/herself following instructive icons on the screen. The camera
is controlled by the movements of the surgeons eyes, and any point looked at on
the screen will automatically move to the centre of the screen. By approaching or
retracting his/her head to or from the screen, the zoom function is activated.
The Telelap Alf-x system can be applied to any surgical discipline where an anatomi-
cal cavity exists or can be produced.
31.3 First preclinical studies 389
31.3First preclinical studies
Despite extensive work, telesurgery is probably still in its infancy. The main reason
for the long operative time is the lack of haptic sensation and the reliance on visual
force feedback.
In order to find whether the Telelap Alf-x brings added value to existing systems
or traditional endoscopy, an experimental operation room was installed at the Uni-
versity of Lodi, Italy. In experimental surgeries the average time for cholecystectomy
using the Telelap Alf-x was 31.75 min as compared to 91 min using a conventional
telesurgical system [27]. Haptic sensation probably contributed to the self-confidence
of the surgeon, who was not dependent on visual force feedback only.
With the combination of haptic sensation, 3D vision, and universality, the Telelap
Alf-x provides all the advantages of laparotomy along with those of endoscopy.
References
[1] Ellis H. Ephraim McDowell and the first successful elective laparotomy. Br J Hosp Med (Lond)
2009, 70(2), 107.
[2] Pfannestiel J (1897) ber die Vorteile des suprasymphysren Faszienquerschnitt fr
die gynkologischen Koliotomien, zugleich ein Beitrag zu der Indikationsstellung der
Operationswege. Samml Klin Vortr Gynkol 6898 (Klin Vortr NF Gynk 1900, 97, 268).
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anesthesia, its mechanism and inherent (though not peculiar) complications and to effective
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Laparoendoscopic Surgeons 2004, 8(2), 1012.
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Community Health 2007, 61(3), 1824.
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for gastrotomy closure in experimental transgastric surgery. Surg Endosc 2007, 21, 186265.
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[18] Harris SJ, Arambula-Cosio F, Mei Q, et al. The Probot--an active robot for prostate resection.
Proc Inst Mech Eng H 1997, 211(4), 31725.
[19] Hananouchi T, Nakamura N, Kakimoto A, et al. CT-based planning of a single-radius femoral
component in total knee arthroplasty using the ROBODOC system. Comput Aided Surg 2008,
13(1), 239.
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with conventional laparoscopic cholecystectomy. Hepatobiliary Pancreat Dis Int 2006, 5(1),
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[21] Kang CM, Kim DH, Lee WJ, et al. Conventional laparoscopic and robot-assisted spleen-preserving
pancreatectomy: does da Vinci have clinical advantages? Surg Endosc 2011, 25(6), 20049.
[22] Swan K, Advincula AP. Role of robotic surgery in urogynecologic surgery and radical
hysterectomy: how far can we go? Curr Opin Urol 2011, 21(1), 7883.
[23] Reiley CE, Akinbiyi T, Burschka D, et al. Effects of visual force feedback on robot-assisted
surgical task performance. J Thorac Cardiovasc Surg 2008, 135(1), 196202.
studies. Curr Opin Obstet Gynecol 2011, 23(4), 2838.
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Index
absorbable polyglyconate 104 big uterus 111

adhesion prophylaxis 138, 141, 142 bladder 8, 45, 76, 77, 101, 102, 112, 113, 117,
Advincula Arch 40, 137 118, 120, 123, 125, 126, 128, 162, 163,
Allen stirrup 38, 69, 95, 120, 135 166168, 170, 172, 173, 182, 192, 200203,
American Association for the Surgery 205, 239, 284, 285, 299, 301303, 324,
of Trauma (AAST) 375 327, 330, 335, 336, 338, 340342, 345,
American Association of Gynecologic 352357, 361363, 367, 373
Laparoscopists (AAGL) 18, 20, 34, 89, neck 327, 361365
111, 117 neck sling 362
anastomotic leak 274 neurogenic 361
anesthesia 40, 42, 68, 71, 83, 95, 118, 119, 176, blood loss 7, 23, 24, 74, 90, 91, 93, 94, 107,
182, 189, 224, 228, 239, 275277, 329, 108, 111, 124, 133, 143, 146, 147, 155, 156,
344, 382, 384, 389 159, 179, 183, 184, 192, 198, 202, 203, 205,
antibiotic 117, 120, 189, 329, 376 213, 223, 224, 230, 231, 233, 238, 250,
anticipation 41, 54, 262 253255, 265, 322, 323, 342, 343, 345,
aorta 80, 112, 204, 214, 226, 227, 239, 242, 346, 351, 366, 381, 382
279, 280, 281, 288, 290, 295, 296, 310 body mass index (BMI) 93, 106, 118, 121, 127,
appendix 162, 164, 165 179, 213, 215, 224, 231, 239, 341
artery bowel preparation 119, 239, 274, 365
common iliac 204, 212, 214, 215, 226, 239, bulldog clamp 281
241, 242, 277, 279, 284, 290, 310, 311 Burch 8, 350, 351, 352, 355357
hypogastric 277, 278 business plan 14
inferior mesenteric 210212, 214, 215, 226,
239, 242, 280, 294, 295 camera 41, 42, 96, 97, 105, 176, 190, 191, 216,
superior rectal 165 240, 330
ASC 323, 324, 327, 342, 343, 344 computer chip television 371
assistant 9, 17, 28, 4045, 4965, 67, 95, cancer
96, 98, 99, 105, 112, 113, 123, 124, 139, cervical 8, 12, 78, 79, 106, 126, 197199, 201,
182184, 188, 190, 192, 199, 204, 212, 203207, 210, 212, 216, 218, 221, 232, 234,
214216, 226, 228230, 240242, 235, 237239, 245247, 265, 287290,
275277, 280, 281, 288, 330333, 341, 293, 295, 297, 298, 305, 309, 313, 316,
352, 353, 368, 388 317, 368
robotic surgical 4957, 5964 endometrial 8, 12, 2629, 47, 53, 68, 7880,
attentive passiveness 54 8385, 130, 210, 214, 217219, 221223,
audible feedback 113 230235, 246, 250, 256, 265, 266, 271,
273, 285, 288, 290, 294, 309, 310, 311,
bag 313, 314, 369, 377
Anchor 115 extraperitoneal approach 238
laparoscopic 115, 229, 274, 279 hereditary ovarian 269, 271
basin high risk endometrial 79, 290, 314, 316
paravisceral 292294 locally advanced stage cervical (LACC) 237
pelvic and periaortic lymph 315 ovarian 8, 85, 210, 211, 218, 221, 249257,
periaortic lymph 294, 295, 315 259261, 262, 264, 267271, 295
periaortic lymphatic 296 uterine 85, 219, 221, 222, 234, 273, 278, 282,
bifurcation, aortic121, 130, 204, 212, 214, 226, 285288, 315, 316, 328
227, 242, 280, 291, 292, 333, 334 Carter Thomason 333, 341
392 Index
Centers of Excellence in Minimally Invasive credentialing 1416, 3135, 57, 129

Gynecology (COEMIG) 18, 20 C-section 335
cerclage 181185, 203, 306, 308 cuff 38, 70, 81, 86, 92, 93, 96, 103105, 114,
abdominal 181184 126, 128, 166, 201, 205, 215, 303, 306, 330,
robotic-assisted laparoscopic 181, 184 332, 335341
cervical insufficiency 181, 183 dehiscence 81, 85, 86, 93, 105, 114, 126
chromopertubation 178 cystoscopy 76, 77, 84, 118, 166, 167, 239, 322,
chyloperitoneum 79 340, 341, 354, 363, 364
collision 37, 42, 43, 46, 187, 191, 224
colostomy 75, 375, 376 database 14, 15, 17, 18, 20, 21, 29, 80, 84, 108,
colposuspension 350352, 357 130, 159, 170, 171, 193, 217, 356
laparoscopic 350, 356 da Vinci surgical system 7, 10, 11, 13, 14, 130,
communication 9, 10, 12, 15, 20, 54, 59, 60, 62, 189, 238, 240, 244, 276, 361, 368, 371, 390
68, 82 diaphragm 70, 162, 168, 169, 173, 174, 214, 218,
compartment 223, 232, 249, 250, 253, 276, 283, 357, 376
mesonephric 309, 310 diaphragmatic lesions 168
Mllerian 289, 298, 301, 303, 304, 309, diathermy 126, 128, 164, 168
310, 314 dissection
ontogenetic 287, 314, 316 posterior 336338
ontogenetically permissive 287 sacral 333335
complication 9, 17, 20, 22, 24, 27, 33, 37, 38, docking 7, 9, 37, 40, 41, 4547, 5054, 59, 60,
54, 67, 68, 7076, 78, 81, 82, 84, 85, 91, 6265, 91, 95, 97, 98, 106, 109, 121, 123,
92, 94, 107, 109, 124, 131, 132, 142, 149, 124, 135, 138, 140, 143, 149, 167, 168, 176,
150, 155, 164, 172, 178, 183, 191, 198, 203, 177, 189, 211, 212, 215218, 223225, 242,
205, 213, 215217, 230, 231, 237239, 250, 282, 283, 288, 324, 332, 351, 386, 387
252255, 266, 268, 273, 274, 283, 321, side 46, 47, 52, 60, 65, 98, 124, 135, 138, 167,
328, 342345, 351, 357, 361, 365, 367, 373, 177, 212, 224, 283, 288
378382, 389 straight 46, 47
gastrointestinal 75 drive
configuration dry 16
3-arm 4143 wet 16
4-arm 41, 42, 44 dual console 17, 21, 129, 372
M 112 duodenum 215, 226, 227, 279, 282, 295, 373
W 112
console training 56 economics 21, 25
corneal abrasion 382, 384 education
cost 9, 11, 1315, 1719, 2129, 40, 45, 46, 90, in robotic assistance 56
91, 95, 108, 122, 133, 136, 143, 155, 158, structured 63
161, 175, 179, 184, 199, 217, 219, 225, 232, efficiency 14, 18, 19, 27, 37, 38, 58, 68, 156
234, 268, 317, 324, 343, 345347, 361, electrosurgery (ES)
368, 386 bipolar 73
caregiver 26 monopular 71
effectiveness 11, 14, 15, 19, 21, 22, 2426, 29, endometriosis 8, 12, 77, 90, 111, 113, 118120,
180, 199, 244, 271 124126, 134, 149, 150, 161174, 249,
fixed 21, 27 367369
inpatient hospital 26 hepatic 169, 174
of robotic surgery 23, 345 thoracic syndrome (TES) 168
robotic 26 ureteral 167, 170, 173
variable 21 endoscopy 7, 377, 385387, 389
Index 393
end-to-end anastomosis 168, 336 heparin 329

enterocele 328, 351 hydrodissection 163165, 167, 169, 335
epiploica 281 hypothermia 39
estrogen 133, 161, 324, 329, 341 hysterectomy 7, 8, 1113, 21, 22, 25, 26, 28,
evolving program phase 13 29, 42, 46, 47, 53, 55, 57, 76, 81, 84, 85,
exposure 37, 41, 70, 95, 126, 140, 141, 143, 145, 8996, 99, 106109, 111, 115, 117, 119, 124,
162, 168, 187, 211, 214, 216, 223226, 228, 125, 129131, 138, 151, 162, 166, 187, 191,
231, 249, 274281, 283, 333, 336, 337, 192, 193, 204, 207, 211, 213, 215, 216, 218,
363, 365 222224, 226, 228, 230, 231, 234, 235,
extraperitoneal 47, 65, 80, 85, 123, 165, 203, 249, 252, 256, 259, 264266, 269, 271,
204, 207, 211213, 216, 218, 219, 274, 277, 279, 281, 283, 306, 327,
237246, 367 329, 330, 332, 335337, 342, 344, 352,
356, 357, 361, 366, 369, 372, 380, 385, 390
femoral 37, 38, 68, 278, 292, 293, 390 complex 117
fibrin 279 difficult 118120, 122124
financial analysis 15, 21, 23 extrafascial 284
fistula 8, 12, 164, 174, 321323, 325 laparoscopic (LH) 89, 9194
vesicovaginal 76, 205, 321, 322, 325 radical 8, 12, 78, 81, 93, 106, 126, 134, 135,
fistulization 77 197199, 202, 203, 205, 206228, 245,
fleet enema 274 287, 309, 313, 316, 317, 368, 386, 390
Foley catheter 39, 40, 76, 77, 203, 240, 329, robot-assisted 9294, 97
341, 362, 364, 368 robot-assisted laparoscopic (RALH) 11, 94,
109, 130, 368
genito-femoral 68, 290, 292 robotic 21, 26, 29, 77, 80, 81, 83, 86, 91, 94,
glaucoma 71, 379, 381384 97, 106, 108, 111, 117, 118, 120, 122124,
gonadotropin-releasing hormone (GnRH) 119, 127, 129, 224, 247, 351
130, 170 single-port total (R-SPH) 106, 107
agonists 131133, 146, 147, 158, 161, 166 supracervical 109, 112, 131, 170, 335, 336
Gore-tex 339 total laparoscopic 25, 28, 84, 108, 193, 256,
grasper 351, 357, 369
alligator 99, 353 vaginal (VH) 81, 89, 90, 93, 107, 109, 234
Cadiere 99, 188, 333, 353
gynecologic malignancy 83, 85, 197, 211, 221, ileus 75, 244, 324, 343, 345, 377
234, 235 iliac crest 44, 184, 331
gynecologic operation 373 implant 162165, 168, 169, 367, 368
gynecology 7, 11, 12, 16, 18, 20, 23, 24, 28, implementation phase 13, 14, 18
3133, 35, 64, 65, 67, 73, 87, 90, 109, 158, incision 7, 23, 50, 55, 67, 74, 77, 79, 80, 82, 85,
159, 170, 180, 193, 197, 209, 222, 233, 237, 103, 106, 114, 115, 117, 121, 125, 127, 128,
249, 269, 273, 316, 319, 321, 325, 326, 349, 130, 136, 138, 140, 145, 149, 152, 157, 163,
356, 361, 368, 369, 373, 377, 381 164, 166, 178, 187193, 199, 202, 204, 205,
214, 216, 241, 245, 249, 266, 277280,
haemostatic activity 63 284, 288, 290, 291, 298, 312, 314, 334,
Halban 340 335, 337, 345, 349, 352, 364, 367, 371,
haptic sensation 386, 387, 389 385, 387
hematoma 40, 80, 81, 191, 213, 217, 244, 254, incontinence 328, 329, 347, 349, 350, 351,
255, 265, 341, 345, 374, 375 356, 357
hemostasis 55, 72, 133, 136, 140, 141, 143, 148, urinary 325, 328, 349, 351, 356, 357
164, 169, 178, 190, 209, 243, 279, 281, 283, indigo carmine 76, 77, 178, 335, 340, 341,
284, 285, 341 354, 355
394 Index
infertility 156, 157, 161, 170, 249, 367 lesser omental sac 283
informed consent 31, 33, 149, 239 ligament
infundibulopelvic (IP) 101, 367 anterior longitudinal 327, 334
injury Coopers 350, 353, 354
bowel 37, 75, 80, 84, 213, 215, 253, 324, 337, gastro-colic 283, 284
345, 373378 lieno-diaphragmatic 283
electrosurgical 7173, 84, 373 longitudinal 334, 339
gastrointestinal 75, 373, 374, 376378 phrenico-colic 283
nerve 37, 82 round 99101, 124, 199, 202, 205, 278, 279,
prevention of gastrointestinal 377 284, 285, 298, 306, 312, 367
rectal 376 utero-ovarian 101, 201
small bowel 374 uterosacral 112, 162, 201, 202, 205,
stomach 70, 376 285, 367
thermal 7577, 285, 373, 374 linear stapling 165, 166
undiagnosed 376, 377 lithotomy 39, 68, 69, 82, 135, 199, 216, 239,
ureteral 76, 77, 84, 345 266, 275, 365
vascular 74, 80 dorsal 38, 95, 176, 202, 205, 329, 362, 368
instrument 4, 7, 9, 17, 18, 21, 22, 25, 38, lobectomy 168, 173
4042, 44, 46, 49, 5255, 57, 6264, 72, lower uterine segment 77, 101, 203, 284, 335
74, 79, 84, 89, 9597, 104, 106, 111, 113, lumbosacral trunk 290, 291, 293
115, 117, 119, 123, 127, 135, 136, 141143, lung 70, 168, 372, 389
145, 157, 161, 165, 169, 177, 182, 187189, lymphadenectomy 12, 29, 68, 78, 79, 83, 85,
191, 224, 244, 275, 276, 281, 321, 342, 345, 127, 197, 198, 201, 203, 206, 207, 209213,
349, 351, 362, 366, 368, 371, 372, 377, 385, 215219, 221224, 226, 228234, 237,
387, 388 238, 243, 244, 246, 274, 277, 278, 285,
interdisciplinary 14, 15, 372 286, 290, 292, 295, 307, 310
intraocular pressure 40, 71, 84, 276, 277, 345, aortic 8, 47, 78, 83, 203, 207, 209219,
379, 383, 384 221226, 231, 235, 246
ischemic optic neuropathy 380, 381, 384 inframesenteric periaortic 295
anterior (AION) 380 infrarenal aortic 209, 210, 212, 217219
para-aortic 41, 46, 85, 203, 204, 207, 218,
Jackson-Pratt 77 219, 233, 234, 238, 239, 241244, 246,
junction 275277, 279
cervico-uterine 285 pelvic and periaortic 287, 288, 290,
urethro-vesicular (UVJ) 101, 353, 354 310, 316
periaortic 287, 288, 290, 294, 295, 297,
landmark 45, 123, 124, 277, 333 310, 316
large fibroid 120, 123, 125 robotic-assisted retroperitoneal laparoscopic
lateral femoral 68 para-aortic 239
lead surgeon 13, 14, 16, 62 therapeutic pelvic 287, 290, 294, 305, 311
leak test 75, 166 therapeutic pelvic and periaortic (rtLNE) 287,
learning curve 9, 13, 14, 16, 18, 24, 25, 29, 32, 288, 290, 297, 306, 310, 311, 314316
39, 45, 62, 63, 67, 8991, 93, 106, 108, therapeutic periaortic 294, 297
117, 129, 130, 132, 161, 170, 175, 179, 187, lymphedema 78, 79, 215, 229, 255, 278, 279
191, 214, 222, 223, 266, 271, 326, 327, 330, lymphadenopathy 226, 274, 275, 278
342, 345, 347, 349 lymphocyst formation 78, 79
legal issue 31, 3335
Lehey 114 magnesium citrate 274
length of stay (LOS) 155, 255, 322324, 343, 346 malpractice 33, 34
Index 395
mapping of the pelvic anatomy 146 node

marketing 14, 15, 1722, 356 infra-renal periaortic 311
Marshall-Marchetti-Krantz (MMK) 350 intercalated 290, 300, 310
May-Thurner syndrome 279 intercalated mesometrial 297, 310
mescolpia 298 preischiadic 309, 310
mesh 168, 324, 327, 332, 336347, 349, 350 novice surgeon 31, 32, 37
polypropylene 327, 337
mesocolpium 303 obese 43, 70, 80, 83, 90, 93, 108, 109,
mesometria 118123, 126, 127, 130, 142, 222225,
fibrofatty (ligamentous) 288, 298 230, 231, 234, 235, 276, 277, 279, 282,
ligamentous (fibrofatty) 298, 299, 304306, 328, 345, 386, 390
309, 310, 314 obesity 18, 40, 41, 46, 67, 83, 91, 122, 123, 130,
ligamentous 298300, 309 222, 230, 277, 281, 328
vascular 288, 290, 294, 295, 297304, 309, octreotide 79
310, 312314 ocular hypertension 381383
mesureter 298, 299, 301, 303, 304, 310, 312 ocular perfusion 379, 383
metastatic disease 199, 204, 232, 235, 237, 241, omentectomy 8, 211, 214, 225, 249, 252, 274,
253, 254, 273, 274 275, 282, 283, 286
microsurgical 9, 117, 175, 177180 infracolic 282, 283
midurethral sling 349, 350, 356, 368 total 282, 283
Monopolar EndoWrist 99 omentum 142, 162, 169, 225, 281284, 350
monopolar hook 163, 164 oncological tourism 28
monopolar scissor 99104, 136, 167, 182, 201, onion peel 115
225, 242, 332 open-entry 121, 377
morbidity 14, 20, 23, 67, 75, 78, 83, 84, 95, 108, operating
111, 175, 181, 199, 210, 217, 223, 232, 237, table 9, 17, 49, 5053, 55, 60, 62, 120, 122,
238, 244, 255, 260, 265, 305, 316, 321, 211, 212, 214, 216, 223, 231, 275
323, 327, 343, 373, 377, 385 time 37, 58, 70, 91, 94, 155, 156, 175, 222,
Moschcowitz 340 327, 344
myoma operative time 67, 91, 178, 193, 215, 216, 230,
localization of 134 231, 273, 343, 344
multiple 131, 137, 145148, 153, 157 Optiview 41
uterine 131134, 148, 159
myomectomy 8, 11, 42, 54, 112, 113, 118, Palmer point 97
130138, 140143, 145, 146, 148153, palsy
155160, 170, 187, 193, 361 Erbs 69
robot-assisted (RALM) 131143, 148152, Klumpkes 69
155158 paper roll 114, 115
patient load 28
narcotic use 344 peer review 14, 20
Navratile Brzezinski 336, 338 pelvic
negligent 34 brim 77, 216, 264, 334
nephroureterectomy 167, 322, 325 desensus 90
nerve 68, 290, 380 floor laxity 361
cutaneous 68 pain 89, 118, 151, 153, 170, 171, 367
genito-femoral 226, 228, 278 radiation 350
hypogastric vesical 302 periaortic lymphatic system 310
obturator 68, 83, 229, 277279, 290293 perineal body 332, 337
peroneal 37, 68 peritoneal closing 340
396 Index
peritoneum 7, 4143, 52, 53, 70, 76, 79, 81, 83, probe
97, 103, 101, 115, 118, 121, 123, 125, 128, blunt 336
138, 148, 162, 163, 165, 166, 182, 201, 204, vaginal 118, 183, 335
205, 212, 214, 216, 224, 226, 227, 241243, proctor 3235
249, 250, 252, 254, 257, 270, 275280, robotic 34, 35
282, 284, 285, 290, 291, 298, 306, 309, ProGrasp 99, 127, 136, 276, 353
310, 312, 314, 315, 331, 334336, 339341, prolapse 12, 29, 89, 281, 323, 324, 326,
354, 356, 362, 367, 368 327329, 335, 340, 342, 344, 346, 347,
permanent perioperative vision loss 380 349, 356, 357
pessary 349 apical 327, 328
PK forceps 353 pelvic organ (POP) 323, 326, 327, 344, 346,
planning phase 1315 347, 349
PlasmaJet 165 pelvic organ prolapse quantification (POP-Q)
plasma kinetic 332 323, 324, 342344, 347
pleura 168, 173 uterine 89, 327, 329
plexus vault 12, 326328, 346, 347
aortic 297 psoas hitch 77, 322, 325
brachial 37, 38, 69, 83, 126, 135, 154, pubic bone 350, 363
223, 329
hypogastric 295, 297301, 303, 304 quality of life 67, 91, 94, 191, 199, 264, 271,
hypogastricus superior 290 328, 342344, 368
inferior hypogastric 298301, 303
inferior mesenteric 297 radical trachelectomy 197, 201203, 206, 207,
S1S4 of sacral 293 305, 306
pneumoperitoneum 41, 42, 70, 81, 83, 97, 103, real-time magnified view 371
115, 123, 128, 224, 241, 250, 254, 275, 276, rectocele 93, 328, 351
331, 378 rectosigmoid 118, 164, 166, 167, 172,
polyglactin 910 106, 332, 354 281, 290
port placement 4046, 106, 177, 215, 225, 240, rectovaginal 125, 162, 170, 172, 173, 201, 205,
241, 275, 330332, 362 298, 309, 327, 367
positioning 4, 9, 11, 28, 37, 38, 40, 50, 52, 53, rectovaginal septum 162, 165, 172, 309,
55, 60, 6870, 73, 8284, 95, 96, 119, 120, 327, 367
122, 134, 135, 137, 149, 161, 176, 187, 209, remote center 43, 190
214, 215, 223, 231, 241, 275, 276, 282, 288, resection 374376
291, 324, 329, 330, 351, 352, 357, 362, 363, fertility preserving mesometrial (FMMR) 287,
366, 372, 381, 390 305307, 309
patient 37, 38, 46, 50, 6870, 119, 120, 122, peritoneal mesometrial (rPMMR) 287, 290,
134, 176, 275, 324, 329, 330, 381 294, 295, 309, 310, 313316
Trendelenburg 83, 119, 214, 223, 231, segmental 76, 172
288, 291 total mesometrial (rTMMR) 287, 288, 290,
postoperative pain 7, 23, 38, 43, 90, 96, 250, 294, 297, 298, 304307, 309, 310, 313,
327, 344 314, 316
postoperative specimen 314 retraction 53, 55, 96, 112, 114, 121, 123, 127,
pregnancy rate 150, 157, 175, 178, 179 162, 187, 214, 232, 275, 276, 281, 324, 332,
presentation 24, 53, 64, 78, 80, 140, 142, 145, 333, 340, 352, 367
151, 152, 164, 172, 237, 273, 328, 378 retroperitoneal 38, 4446, 77, 80, 113, 118, 126,
pressure points 39, 120 162, 166, 173, 204, 207, 211, 216, 219, 226,
primary repair 172, 321, 374, 375 239, 241244, 246, 254, 255, 266, 277,
private healthcare system 27 280, 290, 291, 341, 345
Index 397
retroperitoneum 165, 216, 227, 279, 280, 284, 197199, 202204, 206, 207, 209212,
290, 291, 340 214218, 221, 223, 230235, 238, 239,
retropubic urethropexy 349, 350 249254, 256, 259267, 269271, 273,
return on investment 13, 14, 25 274, 276, 277, 282, 283, 287, 305, 315317,
Retzius space 353, 354 321332, 338, 340342, 344346,
revenue 15, 21 349351, 356, 357, 361, 365369,
robotic program 1222, 57, 58, 108 371373, 375386, 389, 390
robotic team 14, 1618, 56, 58, 63 compartment based radical 287, 316
RUMI 40, 96, 103, 112, 122, 137, 276 feasibility of robotic 25
laparoendoscopic single-site (LESS) 106, 367
sacral promontory 165, 242, 280, 284, minimally-invasive (MIS) 4, 6, 7, 9, 10, 23, 25,
332334, 338340 34, 49, 6769, 7375, 7782, 89, 90, 106,
sacrocolpopexy 8, 12, 26, 29, 42, 44, 46, 47, 114, 134, 155, 164, 169, 171, 176, 184, 187,
321, 323, 324, 326, 327, 328, 330, 332, 197, 199, 210, 211, 218, 221223, 230, 244,
334, 337, 341344, 346, 347, 372, 386 250, 252, 254, 257, 273, 285, 287, 361,
abdominal (ASC) 323, 324, 327, 342344, 346 371, 372
laparoscopic (LSC) 327, 342, 343, 346 robotic 4, 6, 813, 1517, 2129, 33, 34, 37,
robotic-assisted (RASC) 327, 328, 330, 337, 38, 41, 57, 62, 64, 65, 67, 68, 70, 78, 81,
342345 83, 8991, 93, 105109, 129, 130, 155, 156,
robot-assisted laparoscopic (RALS) 323, 159, 163, 176, 178181, 184, 187, 191, 192,
326, 347 197, 198, 200, 206, 209, 214, 217, 221, 230,
sexual activity 328, 342 231, 233, 235, 238, 247, 249, 250, 254, 256,
sexual function 261, 264, 270, 328, 343 257, 266, 273, 274, 285, 316, 321, 322, 324,
shoulder block 38 327, 330, 342, 345, 346, 349, 350, 356,
sigmoid colon 68, 75, 124, 164, 165, 226, 275, 361, 373, 377, 380, 390
277, 279, 280, 281, 284, 294, 295, 331, robotic-assisted 8, 12, 27, 29, 47, 64, 109,
332, 333, 335, 340, 362, 366 160, 178, 191, 197, 218, 223, 231, 232, 234,
simulation 16, 21, 22, 32, 57, 58, 62, 64, 107 325, 349, 371, 381, 382
single-port robotic platform 106, 109 single-port robotic 41, 187, 192
single-site port 106 video-assisted thoracoscopic (VATS) 168
sling procedure 350, 356, 361, 367 surgical
spatial distance 54, 60 anatomy 290, 317
spleen 45, 214, 250, 283, 390 instructor 33
sponge 38, 90, 104, 225, 228, 232, 276, 280, mal-occurrences 33
281, 285, 304 staging 28, 84, 85, 215, 217219, 221, 222,
egg-crate 38 233235, 238, 245247, 249, 251253, 257,
steering committee 1419, 22 274, 285, 286
stoma 374, 375 Surgical Review Corporation (SRC) 20, 22
primary repair, resection and suture
anastomosis 375 barbed 81, 86, 114, 141, 338, 339, 340
sunrise distribution 275, 282 barbed running 141
superficial epigastrics 80 of the myometrium 132
supraumbilical 139, 149, 214, 288 sacral 334, 339
surgery 3, 4, 613, 1517, 2129, 3135, 3743, sweet spot 46, 98
46, 49, 50, 52, 5458, 6265, 6771, 73,
7578, 8185, 8992, 9498, 105109, tamponade 73, 80, 81, 280, 281
112, 117119, 122, 123, 126, 127, 129, 130, technique 11, 12, 20, 23, 24, 28, 31, 3739,
132135, 141, 146150, 152, 155164, 41, 47, 49, 55, 57, 65, 72, 74, 81, 84, 86,
168171, 173181, 184, 187, 189, 191193, 90, 94, 100, 101, 106109, 112, 114, 115,
398 Index
117, 119123, 125, 126, 129, 130, 141143, tumor

149, 150, 157159, 162164, 167, 168, borderline 210, 252, 254, 256
170, 172, 175182, 184, 185, 189, 192, debulking 254, 275
193, 198, 199, 202, 204, 206, 207, 209,
211219, 221223, 226, 228, 231, 233, 234, ulipristal acetate 131133, 146148, 158
238240, 244247, 250252, 256, 261, umbilicus 41, 44, 96, 112, 121, 123, 130, 139,
264, 266268, 274, 276, 283, 287, 290, 176, 181, 182, 187, 189, 215, 216, 266, 275,
306, 310, 315, 316, 321323, 326329, 332, 282, 283, 331, 332, 362, 366
336, 339, 341, 346, 347, 362, 365369, undocking 37, 46, 50, 55, 62, 63, 105, 140, 143,
372, 374, 375, 377, 378, 389 165, 209, 277, 374
of repair 375 emergency 55
tenaculum 113, 127, 135137, 140, 153, 336 ureter 12, 53, 77, 101, 112, 113, 118, 120,
laparoscopic 113, 336 124126, 142, 162, 163, 165168,
thermal trauma 77 172, 173, 199202, 204, 205,
thrombin 279 214, 216, 226229, 239, 241243,
thromboembolic 78, 120 255, 277280, 284, 285, 290, 295,
tidal volume 70, 83, 224, 276, 277 297299, 301304, 310312, 322,
tilt test 40 324, 325, 333335, 339342, 345,
tissue border control 315 347, 367, 373
tLNE 306, 315 ureteral
transperitoneal 80, 203, 204, 211, 212, 218, reimplantation 167, 322, 325
219, 235, 238, 240, 244, 246, 247, 284, 365 stent 54, 77, 167
transperitoneal approach 78, 176, 212, 244, 277 ureterectomy 167, 322
transvaginal delivery 281, 328 uretero-calicostomy 322
tremor 9, 24, 57, 140, 143, 175, 176, 189, 191, ureterolysis 167, 168, 211, 322
192, 197, 324, 327, 361, 372, 386, 388 uretero-pyelostomy 322
Trendelenburg 17, 40, 6971, 95, 106, 120, 121, uretero-ureterostomy 77, 167, 173, 322
126, 224, 232, 330, 352 urodynamic 329, 365
position 38, 40, 45, 47, 6971, 81, 83, 84, 115, uterine manipulation 54, 96, 118, 122124, 135,
118123, 126, 135, 142, 148, 149, 165, 176, 137, 153, 224
177, 190, 199, 212, 215, 224, 226, 231, 240, uterine manipulator 40, 41, 52, 95, 96, 101103,
276, 277, 281283, 324, 332, 340, 345, 112114, 122, 134, 137, 138, 199, 202, 224,
362, 367, 379383 234, 276, 285, 368
trocar
bariatric 43 vaginal apex 285, 327, 332, 335, 336,
optical 96, 214, 215 338, 344
placement 37, 41, 42, 46, 52, 62, 75, 96, 112, vaginally morcellate 114
122, 123, 135, 138, 139, 200, 202, 209, 211, vaginoplasty 365, 368
212, 214, 215, 322, 330, 352, 372 vaginotomy 336
troubleshooting 17, 53, 55 vascular pedicle 124, 225, 276, 285
tubal VCare 40, 96, 112, 122, 137, 199, 224, 276
patency 135, 137, 138, 149, 177179 vein
reanastomosis 8, 175, 177180 gonadal 215, 227, 232
sterilization 7, 67, 175, 178, 180 left renal 211, 214, 217, 219, 225227, 232,
tubal reversal 175179 242, 244, 246, 296
robot-assisted 177, 178 vena cava 204, 226228, 239, 242, 279, 280,
tube 281, 288, 295, 296, 310, 312
nasogastric 40, 75, 120, 240, 376 Veress needle 41, 75, 80, 96, 112, 121, 122, 162,
orogastric (OG) 40, 70, 112, 329 331, 373
Index 399
vessel 214, 221, 225, 238, 266, 274277, 279,

iliac 80, 124, 200, 201, 203, 241, 242, 277, 282284, 294, 321, 331, 334, 336, 337,
278, 290293, 295, 298, 302, 333 339, 340, 341, 350, 361, 365368
middle sacral 334 V-LocTM 104, 141, 338, 339, 340
uterine 77, 99, 102104, 113, 114, 123, 125,
140, 142, 181, 183, 202, 205, 285, 298, waiters tip 69
302, 309, 314 watertight 76, 167
visualization 9, 23, 24, 4043, 45, 68, 74, 76,
80, 96, 97, 106, 112, 113, 117, 119, 123, 124, Y-shaped 337, 339
127, 142, 162, 165, 167, 168, 175177, 182,
183, 187, 189, 191, 192, 197, 199, 209, 211, ZUMI 40, 122, 137, 224

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Sami G. Kilic, Kubilay Ertan, M. Faruk Kose (Eds.

Endoscopic Mitral Valve Surgery:

Biomedical Engineering/Biomedizinische Technik

Practical Examples in Gynecology

Library of Congress Cataloging-in-Publication data

Bibliographic information published by the Deutsche Nationalbibliothek

2014 Walter de Gruyter GmbH, Berlin/Boston

Typesetting: Compuscript Ltd, Shannon, Ireland

Knowing is not enough, we must apply

Sami G. Kilic, Kubilay Ertan and M. Faruk Kose

Silvia Agramunt Ibrahim Alanbay

Eralp Baer Alexander di Liberto

Jeffrey M. Fowler Ismail Hakki Hamzaoglu

Stefano Gidaro Martin Heubner

Sami G. Kilic Eric Lambaudie

Camran Nezhat Pooja R. Patel

Can Obek John Y. Phelps

Gwyn Richardson Dan-Arin Silasi

Courtney M. Townsend, Jr. Mfit Cemal Yenen

1 Robotic gynecologic surgery introduction 3

2 Launching a successful robotic program 13

3 Financial analysis of robotic surgery in gynecology 23

3.4 Coverage of robotic surgery by health systems 27

4 Training and credentialing in robotic gynecologic surgery

5 Patient positioning, trocar placement, and docking for robotic

6 Role of the robotic surgical assistant 49

6.2.2 Tasks of the robotic surgical assistant between beginning

7 Strategies for avoiding complications from robotic

Part II: General gynecology 87

8 Robotically-assisted simple hysterectomy 89

9 Approach to the big uterus for hysterectomy 111

10 The difficult robotic hysterectomy 117

10.5.6 Trocar placement 122

11 Robot-assisted laparoscopic myomectomy (RALM) 131

11.8 Case studies 150

12 Endometriosis: robotic-assisted laparoscopic surgical

13 Robotic-assisted tubal reanastomosis 175

14 Robotic-assisted abdominal cerclage 181

15 Single-port robotic surgery 187

15.3 Discussion 191

Part III: Gynecologic onocology 195

16 Update on robotic surgery in the management of

17 Robotic-infrarenal aortic lymphadenectomy: A step-by-step

18 Robotic-pelvic and aortic lymphadenectomy for gynecologic

18.5 Surgical technique for center-docked robotic-assisted aortic

19 Robotic-extraperitoneal lymphadenectomy: A step-by-step

20 Robotic surgery for ovarian cancer 249

21 Risk-reducing bilateral salpingo-oopherectomy in BRCA

22 Robotic surgery for uterine cancer 273

23 Compartment-based radical surgery: The TMMR, FMMR

Part IV: Urogynecology 319

24 Robotic surgery for urogynecologic diseases 321

25 Robotic sacrocolpopexy for the management of uterine

25.5 Conclusion 346

26 Robotic-retropubic urethropexy 349

Part V: Specialties 359

27 Pediatric gynecology for robotic surgery 361

28 Robotic-assisted surgery advances benefit patients 371

29 Gynecology-related general surgery 373

30 Ophthalmology and steep Trendelenburg 379

31 The future of telesurgery and new technology 385

There is no excuse today for the surgeon to learn on the patient.

Tab. 1.1: Asimovs Laws of Robotics [8]