Best practice

Robotic Uterine Myomectomy

Robotic uterine myomectomy is a minimally invasive surgical procedure used to remove uterine fibroids (leiomyomas) with the aid of robotic technology. It is performed using a robotic surgical system which enhances the surgeon's precision, dexterity, and visualization. Robotic uterine myomectomy is particularly beneficial for women seeking fertility preservation, as it allows precise removal of fibroids while maintaining the structural integrity of the uterus.

Indications

Robotic myomectomy is indicated for patients with symptomatic uterine fibroids, which may cause:

• Heavy menstrual bleeding.
• Pelvic pain or pressure.
• Infertility or recurrent pregnancy loss.
• Urinary or bowel dysfunction due to fibroid pressure.

Procedure Steps

1. Preparation:
   • The patient is placed under general anesthesia.
   • The abdomen is insufflated with carbon dioxide gas to create space for surgical instruments.
   • Several small incisions are made in the abdominal wall.
2. Docking the Robot:
   • The robotic arms are docked to the trocars inserted through the incisions.
   • Instruments, such as scissors, graspers, and a camera, are attached to the robotic arms.
3. Excision of Fibroids:
   • The surgeon controls the robotic arms from a console, which provides a 3D, high-definition view of the surgical field.
   • The fibroids are identified, and incisions are made in the uterus to expose them.
   • The fibroids are excised while preserving the surrounding uterine tissue.
4. Repair of the Uterus:
   • The uterine incisions are meticulously sutured in multiple layers to restore the uterine integrity and minimize the risk of future complications, such as uterine rupture during pregnancy.
5. Specimen Removal:
   • The excised fibroids are removed from the abdomen, often using a specimen retrieval bag to avoid spillage.
6. Closure:
   • The robotic arms are undocked, and the incisions are closed with sutures or surgical glue.

Advantages

• Precision: Robotic technology allows for fine movements and enhanced suturing.
• Reduced Blood Loss: The minimally invasive approach results in less bleeding compared to open surgery.
• Faster Recovery: Patients typically experience shorter hospital stays and faster return to daily activities.
• Aesthetic results: Smaller incisions result in less scarring.
• Postoperative outcomes: fewer postoperative complications such as surgical wound infections and shorter recovery times compared to laparotomy

 

Robotic Sacrocolpopexy

Robotic sacrocolpopexy is a minimally invasive surgical procedure used to correct pelvic organ prolapse (POP), specifically apical prolapse (prolapse of the vaginal vault or uterus). The procedure involves attaching the vaginal apex (or uterus, if present) to the sacrum using a mesh, providing support and restoring normal anatomy. Robotic assistance enhances the surgeon’s precision and visualization, making it a preferred option for complex prolapse repairs.

Indications

Robotic sacrocolpopexy is indicated for:

• Apical Pelvic Organ Prolapse: Vaginal vault prolapse post-hysterectomy or uterine prolapse.
• Severe Prolapse Symptoms: Including pelvic pressure, vaginal bulging, urinary incontinence, or bowel disorders
• Desire for Durable Repair: Especially in younger or active patients who prefer a long-term solution.

Procedure Steps

1. Preparation:
   • Preoperative Evaluation: Includes imaging (e.g., pelvic ultrasound, MRI) and urodynamic studies if urinary symptoms are present.
   • Anesthesia: The procedure is performed under general anesthesia.
2. Positioning and Incision:
   • The patient is placed in the lithotomy position with steep Trendelenburg positioning.
   • Several small abdominal incisions are made to insert robotic trocars.
3. Docking the Robot:
   • The robotic system is docked, and instruments (e.g., graspers, scissors, needle drivers) are attached to the robotic arms.
4. Dissection and Preparation:
   • The surgeon dissects the vaginal apex and the anterior and posterior vaginal walls to expose the prolapsed tissues.
   • The peritoneum over the sacral promontory is opened, exposing the anterior longitudinal ligament of the sacrum.
5. Mesh Placement:
   • A Y-shaped surgical mesh is used:
     • The arms of the mesh are sutured to the anterior and posterior vaginal walls using permanent or delayed-absorbable sutures.
     • The base of the mesh is anchored to the sacral promontory using sutures or surgical tacks.
6. Peritoneal Closure:
   • The peritoneum over the mesh is closed to prevent bowel contact with the mesh, reducing the risk of complications such as adhesions or erosion.
7. Completion:
   • The robotic arms are undocked, and the small incisions are closed with sutures or adhesive.

Advantages of Robotic Sacrocolpopexy

• Enhanced Visualization: The 3D, magnified view allows for precise dissection and suturing.
• Minimally Invasive: Smaller incisions result in less pain, reduced blood loss, and quicker recovery compared to open surgery.
• Durable Results: High success rates and long-term durability.
• Faster Recovery: Shorter hospital stay and quicker return to normal activities.

Outcomes

Robotic sacrocolpopexy has high success rates, with studies reporting durable anatomical and symptomatic improvements. It is especially effective for apical prolapse and is considered the gold standard for uterine or vaginal vault prolapse in suitable candidates.

 

Robotic Endometriosis Surgery

Endometriosis surgery is performed to diagnose and treat endometriosis, a condition in which endometrial-like tissue grows outside the uterus, causing pelvic pain, infertility, and other symptoms . The surgery aims to remove or destroy endometriotic lesions, restore normal anatomy, and alleviate symptoms.

Minimally invasive surgery is the gold standard due to lower complication rates, less bleeding and faster recovery.

Robotic-assisted surgery systems in particular offer several advantages:

1. Enhanced Precision

• Improved Dexterity: Robotic arms mimic the natural movements of a surgeon's hands but with a greater range of motion, including the ability to perform fine, tremor-free movements.
• Micro-suturing: Ideal for procedures requiring delicate suturing in confined spaces

2. Superior Visualization

• 3D High-Definition View: Provides a magnified, three-dimensional image of the surgical field, enhancing the surgeon's ability to identify structures and perform dissections.
• Stable Camera Control: The robotic system maintains a steady camera view, controlled directly by the surgeon, eliminating the need for a human assistant to handle the camera.

3. Minimally Invasive Approach

• Smaller Incisions: Robotic surgery typically uses small incisions, reducing trauma to surrounding tissues.
• Reduced Blood Loss: Precision and minimal tissue manipulation lower the risk of bleeding during surgery.
• Lower Infection Risk: Smaller incisions reduce the risk of wound infections compared to open surgery.

4. Ergonomic Benefits for Surgeons

• Comfortable Operating Position: The surgeon operates from a console, reducing physical strain associated with traditional surgery.
• Reduced Fatigue: Ergonomic controls and an optimized operating environment enable surgeons to perform lengthy procedures more comfortably.

5. Faster Recovery for Patients

• Shorter Hospital Stays: Patients often go home sooner compared to open surgery.
• Quicker Return to Activities: Minimally invasive techniques result in less postoperative pain and faster recovery times.
• Reduced Scarring: Smaller incisions result in better cosmetic outcomes.

6. Increased Surgical Access

• Complex procedures : Robotic systems allow surgeons to operate in anatomically challenging locations and in case of obese patients. Useful for surgeries requiring meticulous dissection and reconstruction.

Indications for Surgery

Endometriosis surgery is indicated for:

• Chronic Pelvic Pain: Severe pain unresponsive to medical treatments.
• Infertility: Endometriosis-associated infertility where surgery may improve outcomes.
• Severe Disease: Deep infiltrating endometriosis (DIE) affecting organs like the bladder, bowel, or ureters.
• Endometriomas: Large ovarian cysts caused by endometriosis.
• Failure of Medical Therapy: Persistent symptoms despite hormonal or other medical treatments.

Goals of Surgery

1. Diagnosis: Confirming endometriosis through direct visualization and histological biopsy.
2. Excision or Ablation: Removing or destroying endometriotic lesions.
3. Adhesiolysis: Releasing pelvic adhesions to restore organ mobility.
4. Preservation of Fertility: Conserving reproductive organs where possible.
5. Symptom Relief: Reducing pain and improving quality of life.

Types of Surgical Procedures

1. Diagnostic procedures:
   • Used to confirm the presence of endometriosis.
   • Lesions are inspected and biopsied for definitive diagnosis.
2. Operative procedures:
   • Involves excision or ablation of endometriotic lesions.
   • Adhesions are lysed to restore normal pelvic anatomy.
   • Endometriomas are removed through cystectomy procedures
3. Deep Infiltrating Endometriosis Surgery:
   • Specialized surgery for lesions infiltrating the bladder, bowel, or ureters.
   • May involve segmental bowel resection, ureterolysis, or bladder reconstruction.
4. Hysterectomy (with or without Oophorectomy):
   • Reserved for severe, refractory cases where childbearing is not a concern.
   • May involve removal of the uterus (hysterectomy) and ovaries (oophorectomy) to reduce estrogen stimulation of residual disease.

Surgical Techniques

1. Excision vs Ablation:
   • Excision: Complete removal of lesions, preferred for thorough treatment and histopathological analysis.
   • Ablation: Use of energy (e.g., laser, electrosurgery) to destroy superficial lesions. Less effective for deep lesions.
2. Adhesiolysis:
   • Involves cutting or removing scar tissue to restore normal organ function.
3. Treatment of Endometriomas:
   • Ovarian cystectomy to remove the cyst wall and preserve ovarian function (ovarian stripping, ablative procedures or combined techniques)

Outcomes

• Symptom Relief: Most patients experience significant improvement in pain and quality of life.
• Fertility: Surgery may enhance fertility, particularly in cases of mild to moderate endometriosis.
• Recurrence: Endometriosis can recur in 20-40% of cases, emphasizing the importance of follow-up care and medical management by experienced professionals