Applications of Robotic Surgery-GynecologyTommaso Falcone, M.D.Professor & ChairDepartment of Obstetrics & Gynecology

Financial Disclosure

I receive no grants/ honoraria / or other financial support from any robotics company

LEARNING OBJECTIVESAt the conclusion of this presentation, the

participant should be able to:Describe the current robotic system that is commercially available and describe the safe strategy for deploymentReview the limitations and advantages of using a robot for a surgical procedureAssess the current clinical data in gynecology for the use of the robotPredict potential future applications of robotics when newer prototypes become available

Robots

Active robots (autonomous)System completes a preprogrammed task with minimal human supervision

Passive robotsComputer-assisted surgery

Cyberknife

Cyberknife

Cyberknife

Navigational devices

Determine the surgical pathComplex technologyRobust and reliable

Target Guidance

Computer-assisted surgical planning

Contrast-enhanced CT or MRI data to reconstruct a model (Fusion technology)Ex. veins and arteries around a tumor

Robot: Surgical Assistant

Laparoscope holderAutomated Endoscopic System for Optimal Positioning (AESOP) 1994Voice activation

Robotics & Medicine-Cleveland Clinic

Neurosurgery (Navigational)General Surgery (Morbid Obesity surgery)

NOT USED AT ALL

Urology ( Radical Prostatectomy)Cardiac surgery ( Coronary bypass surgery & mitral valve surgery)Gynecology

Robot hardwareSurgical Cart

Three-Four robotic arms: one holds the laparoscope; three robotic arms are instrument holders or tissue retractors

Console for the surgeonTwo handles that controls the robot arms

Robot advantages

3 D view of the operative fieldManipulation of the robotic handles is transmitted to a computer that filters, scales and then translates the surgeon’s movements to the robotic arms

Advantages of robotic assistance

Increases dexterityScales surgeon’s movementsFilters natural tremor

Advantages of robotic assistance

Movement can be scaledExample: scaling ratio of 10:1 means that for every 1 cm the surgeon moves the handles at the console, the robotic instruments move 1 mm

Motion scaling:2:1 to 5:12:1 to 5:1

5 cm 1 cm

EndoWristTM Instrumentation

Modeled after the human wrist. Full range of motion

High-strength cable system

Transpose fingers to instrument tips

7 Degrees of freedom instruments

Robotics & Gynecology

Laparoscopic microsuturingMajor challengePrinciple is different from conventional microsurgeryOptically magnified tremorLong operating times results in fatigue for the surgeon & laparoscope holder

First gynecologic procedure: Tubal Reversal using Robotic (Zeus) Assistance

10 mm laparoscopeThree 5 mm portsTwo ends were prepared conventionally6-0 polygalactin for the mesosalpinxTwo layered closure with 8-0 polygalactin7 stitches per side

Results: Fertility & Sterility 2000;73:1040-2

Safe, no injuries occurredEBL 70 mLPatency in all tubes anastomosedHSG 6 weeks post-op 17/19 tubes still patent5/10 patients after follow-up time of 12 months

The da Vinci™ Surgical System

Patient side surgical cartPatient side surgical cart

da Vinci 4th Arm-previous da Vinci 4th Arm-previous modelmodel

Limitations

Requires trainingMost important learning step is port placement

Especially if using the fourth arm

Angle of access may be difficultNeed to adjust the port placementIf convert to traditional laparoscopy ports may be inappropriate

Da Vinci: Limitations

Hard to access the abdomen for accessory portsAssistants have difficulty moving aroundDisengage the system if changing patient position

Laparoscopic Tubal Anastomosis without robotic assistance

Goldberg & Falcone Hum Reprod (2003;)No robot: Procedure time: 190 minutes

– LOS:222 minutes

Zeus robot: Procedure time:284 minutes– LOS:198 minutes

Da Vinci ( Degueldre et al Fertil Steril 2000): Procedure time:181 minutes

Comparative Trial

Compared Robot assisted laparoscopic Tubal reversal surgery with outpatient “mini-laparotomy” using traditional microsurgery techniques (published

Obstetrics & Gynecology 2007)No difference in pregnancy rates or ectopic pregnancy ratesMain differences:

OR time longer with robotReturn to work time shorter with the robot

 Robotic(N=26)

Laparotomy(N=41)

P Value

EBL <100cc 19 (73%) 31 (80%) 0.48

Surgical time (min.) 226 ± 45 186 ± 49 0.001

Anesthesia time (min.) 279 ± 42 209 ± 51 <0.001

Hospitalization (min.) 274 ± 412 381 ± 478 0.14

Costs (difference in median values)

$1446 greater for Robotic95% CI: ($1112 , $1812)

<0.001

Weeks to go back to work 1.5 ± 1.3 2.5 ± 1.5 0.013

Myomectomy

Closure of the uterine defect critical to prevent rupture during laborAdvincula et al ( University of Michigan) JAAGL 2004-35 casesThe mean weight of leiomyomata removed was 223 grams; mean number 1.6; mean diameter 7.9 cmThe mean operative time was 230+ 83 minutes.

Myomectomy

Conversion to laparotomy-3Pneumonia-1Port site infection-1Cardiogenic shock (from vasopressin)-1Length of stay-median=1 day (0-5 days)

Robot versus Laparotomy

Advincula et al 2007N=58 (29 in each group)2 conversionsUterine weight: robot (227+247g) and laparotomy (223+228 g )OR time: Robot (231+85 minutes) and laparotomy (154+43 minutes)LOS: robot (1.5 days) and laparotomy (3.6 days)

Technical considerationsUterine manipulator8-10 cm between the endoscope and the top of the elevated uterusAccurate myoma “mapping”

No tactile feedback

Keep your instruments in viewYou may have 2 energy sources at one time

Use your wrist often

15°

10 cm

45°

8-10 cm

Hysterectomy video

Robot-assisted laparoscopic hysterectomy

7 case series reported 2002-2007Total-94 patients in 6 case series & 91 cases in 1 ( Mayo clinic-Arizona)Age-median 38-55BMI-26-28Indications-Mostly non-malignant conditions (uterine weights-30-327 g)

Robot-assisted laparoscopic hysterectomy: Operative Time

1. 270-600 minutes2. 148-277 minutes3. 170-368 minutes (Median=254 min)4. 43-315 minutes (Median=185 min)5. 170-432 min ( Median= 242 minutes )6. 110-290 min (Median= 192 minutes )

Robot-assisted laparoscopic hysterectomy

Hospital stay-US study=1-2 daysFrench study=8 days

Robot-assisted laparoscopic hysterectomy: Operative Time

Mayo Clinic experienceUterine weight 135 g (67)53 % menometrorrhagia or pelvic painSurgery time 127 + 35 minutes

Ochsner Clinic Experience (Baton Rouge, Louisiana)

AAGL-2007 Washington) abstract“Robotic equivalence to laparoscopic skin to skin times was achieved after 75 cases”

Robot-assisted laparoscopic hysterectomy: Complications

Conversion to open surgery- 5 cases12 operative/postoperative

Hemorrhage-3Vaginal cuff/pelvic hematoma-3Cystotomy-1Thermal bowel injury-1Pneumonia/UTI/Venous phlebitis/lymph collection

Robot-assisted cancer procedures

2005-Reynolds et al JSLS 7 patients ( 4 endometrial/2 ovarian/1 tubal cancer)• Mean OR time 257 minutes, median lymph

node count 15/ EBL 50 mL/LOS 2 days

Kim et al Gynecol Oncol 200710 patients-radical hyst 1A2-1B1 cervix• Mean OR time 207 minutes

Robot-assisted cancer procedures

Sert & Abeler Int J Med Robotics & Computer Assisted Surgery 2007

7 patients-robotic (Stage 1A & 1 B cases)• 3 robotic & 2 conventional ports• Mean console time 241 (160-445) minutes• Docking time was 25 minutes

7 patients-laparoscopic• Mean OR time 300 ( 225-375) minutes

Robot-assisted cancer procedures

Boggess JF Am J Obstet Gynecol 2008Robotic versus open radical hysterectomy

Boggess JF Obstet Gynecol 2008Robotic versus conventional laparoscopy for cervix cancer

Boggess JF Obstetr Gynecol 2008Robotic versus conventional laparoscopy for endometrial cancer

Sacrocolpopexy

Suture of a mesh to the vagina and sacral promontoryMultiple interrupted 1.0 Gore-Tex sutures were used to secure the mesh to the vagina and sacral promontory. The average operative time was 3 hours 42 minutes.

Ovarian Transposition:Molpus et al JSLS 2003

Ovarian Transplantation

Autologous transplant to orthotopic site

Small ovarian tissue piecesSutured with 6-0 PDS to ovarian bed

Next phase in computer aided surgery

Tactile & Force feedback (Science of Haptics)Automation of surgical Tasks

Autonomous knot tying ( Bauerschmitt et al Germany)