Robotic Assisted Laparoscopic Myomectomy-5 Modifications at Apollo Hospital Hyderabad, India

Abstract

Study Objective To make Robotic Assisted Laparoscopic Myomectomy (RALM) feasible and cost effective. Design We discuss 5 modifications over 7 years. Setting Apollo Hospital using DaVinci SI system. Patients or Participants 158 cases who underwent RALM were included. Interventions The first modification was a preoperative MRI in each case, for accurate myoma mapping, differentiated myomas from adenomyosis and helped plan precise incisions. Reducing the number of robotic instrument was the next step. Laparoscopic myoma screw via 5 mm assistant port instead of robotic tenaculum. The fenestrated bipolar during suturing instead of prograsp or second needle holder. Instead of SIX instruments, we now use only THREE instruments. The third modification was to reduce the number of ports by Rail Road technique. We have one 12 mm port for the camera, one 8 mm on right side for scissors and on the left side we combine the 8mm over 11mm as one port by a rail road technique. The fourth modification was to use a single 30 or 45 cm barbed suture. This is contrary to what is taught during laparoscopy to use a length of 8-10 cms for effective non entangled suturing. A single suture was sufficient for hysterotomy closure, reducing the time needed for multiple needle pass and cost. The last modification was to do away with the electro mechanical morcellator & predesigned bags. Cold knife morcellation in an indigenous plastic bag via either umbilicus, vaginal or rarely suprapubic. Measurements and Main Results Over 7 years we have reduced OR time by 7% and instruments cost by 14.9%. Conclusion Using these modifications, we have made Robot Assisted Myomectomy feasible and cost effective in Indian Scenario. This has enabled us to offer this surgery to women and reduce incidence of open myomectomy in all types of myomas.