Applications of Robotics in
Gyn Surgery: Mayo Clinic AZ
Experience
Rosanne M Kho, MD
Asst Professor
Gyn Surgery
Mayo AZ
Kauai April 2009
“ home computer in 2004”
Objectives
• History of robotics in gynecology
• Applications in gynecology
• Lessons learned from over 1000
procedures
•
•
•
•
series of 1st rob hyst cases
Endometrial cancer
Cervical cancer
Complications
• Ideal cases: videos
AESOP
Mayo AZ 1997
Zeus
Mayo AZ 2003
da Vinci
Conventional Robotic
Scope
Control
Instruments
Manual
Mechanical
Rigid
Articulated
Movement
Direct
Downscaled
Haptics
opposite
Yes
‘intuitive’
No
Tremor
Yes
No
Video
2D
3D
Surgeon
Standing
Sitting
Mayo Clinic AZ Experience
Mar 2004 – July 2007
Giles et al. Presented at SGS (Georgia. April 2008)
• Patients:
• Procedures:
• Indications:
• Benign
• Urogyn
• Oncology
• * to 6/08
552
1676
85%
6%
15%
826 *
Benign
• Adn cystectomy
• Adnexectomy
• Appendectomy
• Myomectomy
• Hysterectomy
• Excision inv endo
25
43*
355
543
150
36
62
275
413
133
158
• * to 06/08
Urogynecology
• Colposuspension
• Burch
• PVDR
• Sacrocolpopexy
• VV fistula repair
• RV fistula repair
14
5
11
7
13
27
54
2
4
5
Gyn Oncology
• Mod/rad hyst
• Upper vaginectomy
• Omentectomy
• Sigmoid resection
• Mod post exent
• Pelvic LND
• Para-aortic LND
31
59
13
25
28
37
14
25
1
2
73
110
42
69
Lessons Learned
Robotic hysterectomy: technique
and initial outcomes
RM Kho, WS Hilger, JG Hentz*, PM Magtibay, JF Magrina
AJOG July 2007;197: 112.e1
surgical video available online
Robotic Hysterectomy
• Patient selection
• Candidate for the laparoscopic
approach
•
•
•
•
Narrow pelvis
Limited vaginal access
Suspicious adnexal mass
Pelvic pain/known endometriosis
• Uterus undoubtedly requiring
morcellation – Vaginal approach
Methods
• 91 patients
• daVinci Surgical System (Intuitive
Surgical, Sunnyvale, CA)
• from Mar 2004 to Dec 2005
Methods
• Inclusion
• ± USO/BSO
• ± appendectomy
• ± lysis of adhesions
• Exclusion
• lymphadenectomy
Methods
• Surgical times:
• total operating time
• skin incision to skin closure
•
•
(cystoscopy)
docking time
• time to advance the robot to
bedside and attach the robotic
arms to the patient
console time
• time to perform the procedure
with robotic assistance
Results
• Mean docking time (SD)
• 2.9 (1.8) min
• (range, 1 – 9 min)
Results
Docking time for sequential groups of 10 patients
decreased over time
Results
Console
Mean (SD)
Range
min
min
73 (30)
30 - 191
129 (35)
51 - 271
(N = 81)
Operating
(N = 91)
Results
• Console time was not significantly affected
by
• BMI
• Mean BMI : 28 kg/m²
kg/m² (range: 18 – 49)
Results
• Console time was significantly affected by
• uterine weight
• Mean uterine weight: 135 g (range: 18 – 366g)
Results
• No conversions
• Intra-operative complication
• Enterotomy - repaired robotically
Results – 1st 6 weeks post-op
• Postoperative complication
• ICU admission - congestive heart
•
failure
Re-admissions (w/in 6 wks p-op)
• ileus – 1
• pneumonia - 1
• vaginal cuff abscess - 1
• C. difficile colitis - 1
• need for pain control - 2
Summary
• Robotic hysterectomy can be performed
with acceptable operating times and
surgical outcomes
• Comparison study with conventional
laparoscopic hysterectomy
Trocar placement
video
IDEAL Robotic Case
• Obese
IDEAL Robotic Case
• Obese
• Complex gynecologic procedure
• Invasive endometriosis
• video
video
Ideal Robotic Case
• Obese
• Complex surgery
• invasive endometriosis
• Extensive dissection
• Case requiring extensive suturing
• Sacrocolpopexy
• Myomectomy
Ideal Robotic Case
• Obese
• Extensive suturing
• Complex gynecologic procedure
• Complex oncologic procedure
Robotic Hysterectomy in the Treatment of
Uterine Cancer
Giles, Magrina, Magtibay. Presented WAGO (June 2007)
• Compared to Laparotomy
• Decreased EBL
• Decreased LOS
• Decreased post-op transfusions
• Decreased number of major postop complications
Robotic Radical Hysterectomy:
Comparison to Laparoscopy and
Laparotomy
Magrina, Kho et al. Gyn Onc 2008. April; 109 (1): 86.
Robotic
n=27
Laparoscopy Laparotomy
n=31
n=35
p value
OR,min
189.6
220.4
166.8
<0.001
EBL,ml
133.1
208.4
443.6
<0.001
LNs
26.0
25.0
26.0
0.50
1.7
2.4
3.6
Hospital, d
<0.001
What benefit does the robot provide
the advanced laparoscopist?
• Simple
• ‘spring board’
• Complex cases
• Obese
• Suturing (urogyn)
• Extensive dissection
• Invasive endometriosis
• Oncology
Riding on robotic technology: move to the
NEXT level of complex pelvic surgeries
[email protected]