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Thus far I have only discussed conventional laparoscopy or “straight stick” laparoscopy as it is known in the USA. The instruments used in conventional laparoscopy have a long rigid shaft. The operating end consists of a rigid instrument tip such as scissors, needle driver, spade diathermy etc. These tips are inflexible and do not bend at the wrists compared with robotic instruments. For exceedingly complex cases, the straight instruments are suboptimal because of their lack of flexibility. This makes access into hard to reach spaces within the pelvis difficult. Surgeons learn to compromise by ensuring a good surgical assistant is at hand. Even for the experienced and accomplished surgeons, long operations are tiring. Suturing can be quite challenging and good approximation of tissue not always satisfactorily achieved. Also for long operations, the arms, shoulders, back or legs of the surgeon tire and the quality of the surgery will be affected.

Da Vinci robotic system is the only platform available commercially at the moment. It has undergone numerous updates and enhancement. The latest is the generation three SI system, much smaller, easier to set up and quicker to be docked on to the patient. Superior surgeon ergonomic and 3-D view of the operating field decrease operator fatigue and improve surgeon concentration for longer operations. The surgeon sits at the operating console positioned a few meters from the patient. The sitting position of the surgeon is ideal. The surgeon looks down into the visual eyepiece and sees a 3-D stereoscopic view of the operating field. 3-D perception is superior than 2-D. What we see out of our eyes is a 3-D stereoscopic landscape of the outside world. 3-D view allows for superior depth perception. Subtle topographical undulation of the operating field can be perceived more easily and important anatomical structures such as ureters, blood vessels and nerves situated deeper below the surface can be recognized and avoided much more readily. The surgeon has full control of the camera unlike at conventional laparoscopy where the assistant handles and moves the camera or laparoscope. Unless the assistant is similarly well trained and experienced it is not always easy to second guess the surgeon. A well trained assistant is few and far between.

The multimedia cart is the visual optic centre of the system. It connects the surgeon console and the robotic sidecart together. At the surgeon console there are two master controllers, one for each hand. The movement of the controllers in turn moves the operating arms of the robotic sidecart. Robotic arm movements are more delicate and cause less pain and trauma at the port sites. This is seen afterwards with less post operative pain. The operating ports are slightly longer and generally inserted much higher on the abdomen. This is because the surgical cases are usually more difficult with uterine sizes frequently at or above the navel. The camera port is situated midline but positioned about 5-10 cm above the navel. The robotic instruments are longer and most importantly wristed. It has seven degrees of movement, one more than the human hand. Hard to reach places in the pelvis are less of an issue. Operating in tight anatomical confines is not as stressful with flexible and endowristed instruments. The quality of dissection improves noticeably. Suturing in multiple layers without sacrificing good tissue approximation becomes a lot easier. In fact, the system is far more intuitive than conventional laparoscopy and the time taken for a surgeon to achieve proficiency is less than half.

Preparation for robotic surgery is similar to conventional laparoscopy. Bowel preparation is often required as cases tend to be more complex. Incisions for the operating ports are slightly larger 8-12 mm and located higher on the abdomen. The patient is positioned on the operating table at a tilt of 25 – 29 degrees from horizontal. Uterine manipulators are inserted vaginally to help move pelvic structures therefore allowing greater accessibility. The operation time is similar to conventional laparoscopy. Depending on the complexity of the case it could take 2-3 hours. Post operatively, the patient may have to be admitted overnight into a high dependency unit if the operation time exceeds four hours. The bed tilt increases the risks of swelling of the face and windpipe. Hence the patient may need to be monitored for breathing issues immediately post operation. Otherwise the patient is kept watch on the normal gynaecology ward and expected to be discharged from hospital 36 – 48 hours post operation. Post operative analgesia usually comprises of paracetamol (e.g. panadol) or non-steroidal anti-inflammatory medications (e.g. voltaren). Recovery from robotic assisted laparoscopic gynaecology surgery is similarly swift barring any major complications. Depending on the operation and the nature of the patient’s employment, she could return to work one to two weeks post surgery.

Complication and adverse risks from robotic surgery are similar to conventional laparoscopy.

The cost of robotic laparoscopic surgery is high because it is a fairly new technology and the equipment is expensive. Government and health insurance fundings in Australia for this type of surgery are still lacking and this is the main reason for the high out-of-pocket costs. If costs were not an issue then robotic surgery should be considered for all advanced laparoscopic surgical cases.

The evolution of surgery
The evolution of surgery
Masters controller for each hand
Masters controller for each hand
da vinci Si Dual Console
Operating theatre layout for da Vinci robotic surgery

da Vinci Si overview
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da Vinci surgery robotic origami
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Robotic total laparoscopic hysterectomy

Robotic laparoscopic hysterectomy is an ideal operation for the large and difficult uterus. Most small to moderate size fibroid uterus can be dealt with via the conventional laparoscopic approach because conventional laparoscopy is more cost effective at this point in time. If cost is not an issue then robotic laparoscopic hysterectomy is recommended for all difficult and large multifibroid uteri. Otherwise open surgery is the other option. The large multifibroid uterus with co-existing endometriosis presents a real challenge to the surgeon. Due to the many advantages outlined earlier, robotic surgery makes the laparoscopic approach possible even for cases where many would consider it impossible to perform using conventional laparoscopy. In other words, almost all cases can now be performed one way or the other using conventional or robotic laparoscopy.

Post operative recovery is much quicker compared with open surgery and comparable to conventional laparoscopy. Post operative pain is anecdotally less than conventional laparoscopic approach. Complication rates are similar to conventional laparoscopic hysterectomy and far lower than open surgery in terms of infection risks, scar formation, blood loss and requirement for blood transfusion and post operative venous thrombosis.

It is recommended that you seek a second opinion regarding the possibility of laparoscopic hysterectomy even when your doctor thinks it is impossible.

Comparison of incisions for open vs robotic surgery for hysterectomy
Comparison of incisions for open vs robotic surgery for hysterectomy
Robotic laparoscopic hysterectomy - at start of operation. Note the wristed instrument
Robotic laparoscopic hysterectomy - at start of operation. Note the wristed instrument
Robotic laparoscopic hysterectomy - Note the previously seen uterus removed. What is left is the sewn vagina cuff
Robotic laparoscopic hysterectomy - Note the previously seen uterus removed. What is left is the sewn vagina cuff

Robotic Laparoscopic Hysterectomy
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Robotic laparoscopic myomectomy

Myomectomy (the surgical removal of fibroid) is another operation that is performed so much better using the robotic assisted laparoscopic approach. Many solitary fibroids up to 7 cm in diameter or multiple fibroids fewer than four in number could be removed using conventional laparoscopy. Fibroids greater than 7 cm and more than four in total are best removed using the da vinci robotic system. In fact if cost is not an issue, the robot is the ideal platform for myomectomy. Myomectomy using laparoscopy causes less bleeding, infection rates and scarring. It also results in much quicker hospital discharge and recovery. The wristed instruments make suturing ideal and result in superior tissue approximation. Multiple layer closure is also the norm and replicate what normally happens during open surgery. This results in a stronger scar and is thought to reduce the risk of scar rupture during pregnancy. Scar rupture almost never occurs after open myomectomy and there have been a few reported cases of scar rupture after conventional laparoscopic myomectomy. Whilst there may be many reasons to explain this, the most notable one is due to a deficient scar from a lack of good tissue approximation resulting from a deficient closure of the muscle wall. For a deep defect, a minimum of three if not more layers of closure is important. Straight stick instrument does not tend to allow good multiple layer closure even with the use of the new barbed sutures.

After myomectomy, six to eight weeks of healing is generally required before attempting pregnancy. However, twelve weeks of healing may be required before trying to conceive if the myomectomy is performed for large multiple fibroids.

Comparison of incisions for open vs robotic surgery for myomectomy
Comparison of incisions for open vs robotic surgery for myomectomy
Robotic myomectomy - fibroid detached (foreground). Uterus without fibroid (background)
Robotic myomectomy - fibroid detached (foreground). Uterus without fibroid (background)
Robotic myomectomy - enucleated 10 cm fibroid
Robotic myomectomy - enucleated 10 cm fibroid
Robotic Myomectomy - suturing of uterus post enucleation of fibroid
Robotic Myomectomy - suturing of uterus post enucleation of fibroid
Robotic myomectomy - completion but before anti adhesion barrier
Robotic myomectomy - completion but before anti adhesion barrier
Robotic myomectomy - completion with anti adhesion barrier applied
Robotic myomectomy - completion with anti adhesion barrier applied

Robotic laparoscopic endometriosis surgery

Stage 4 (most severe) endometriosis is difficult surgery because of the loss of tissue plane from endometriosis. Often important structures are adherent to each other making tissue recognition a challenge and increasing the risk of inadvertent damage to vital tissues. The wristed robotic instruments allow for safer tissue dissection. The 3-D vision of the operating field becomes very useful and permits good visualization of what one is dissecting. Because of the inflammation and loss of tissue plane associated with severe endometriosis, dissection close to vital structures such as blood vessels, nerves, ureters and bowels is common place. Seeing what you are cutting is obviously very important. Laparoscopic surgery for severe endometriosis is often protracted and could sometimes take 3-4 hours. Operating for that long is tiring especially with conventional laparoscopic approach. Robotic laparoscopy has good ergonomics because the surgeon sits and looks down into the height adjustable eyepiece and visualizing the operating field that is three dimensional. This helps to prevent operator fatigue and maintain a good level of mental alertness for longer. Conventional laparoscopy is still the mainstay approach for most endometriosis surgery because of ease of set up and the lower cost involved. For the most severe disease, robotic surgery has an increasing role to play.

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