Robotic Single-Site Myomectomy: A Step-by-Step Tutorial

Abstract

Objective To provide a step-by-step description of our published technique of single-site robot-assisted laparoscopic myomectomy with the goal of promoting its safe adoption. Design Surgical video tutorial. Setting University medical center. Patient(s) Ten women undergoing single-site robot-assisted laparoscopic myomectomy between November 2014 and March 2015. Intervention(s) A 2.5-cm vertical incision is made within the umbilicus, through which a multilumen single-site port (da Vinci Single-Site; Intuitive Surgical) is seated. An 8.5-mm 0-degree laparoscope is introduced, and the teleoperator (da Vinci Si Surgical Platform; Intuitive Surgical) is docked, allowing subsequent placement of two curved 5-mm instrument cannulae. Two wristed, semirigid needle drivers are loaded onto robotic arms 1 and 2. An 8-mm assistant cannula is also placed through the multilumen single-site port; a flexible 2-mm CO 2 laser fiber and all conventional 5-mm laparoscopic instruments are introduced through this cannula as needed. Intramyometrial dilute vasopressin is injected, and fibroid enucleation is performed. The hysterotomy is repaired in layers with unidirectional barbed suture (Stratafix; Ethicon). The teleoperator is undocked. The single-site port is exchanged for a self-retaining wound retractor with gel-sealed cap. An endoscopic pouch is placed in the abdomen, and the specimen is placed within the pouch. The edges of the pouch are exteriorized. Extracorporeal tissue extraction is performed with a scalpel. A running mass closure of the fascia and peritoneum is performed, followed by a subcuticular closure of the skin. Main Outcome Measure(s) Median number and size of fibroids removed, specimen weight, operative time, estimated blood loss, and perioperative complications. Result(s) The technique described in our video was successfully employed in our first 10 patients. The median number of fibroids removed was 2.5 (range: 1–8); the median size of the largest myoma was 6 cm (range: 4–8 cm); the median specimen weight was 70 g (range: 26–154 g); the median operating time was 202 minutes (range: 141–254 minutes); the median blood loss was 87.5 mL (range: 10–300 mL). No conversions to multiport robotic or open myomectomy occurred. No major complications occurred, and no patients required blood transfusion. Conclusion(s) Robot-assisted laparoscopic single-site myomectomy employing a multilumen port and wristed, semirigid needle drivers is a safe and reproducible technique. Our technique allows surgeons to offer myomectomy and contained, extracorporeal tissue extraction via a single 2.5-cm umbilical incision in select patients with low tumor burden.