Robotic-assisted Laparoscopic Repair Research Articles

Robotic-Assisted Laparoscopic Repair of Iatrogenic Vesico-Vaginal Fistula

<h3>Study Objective</h3> This video highlights the principles of robotic assisted laparoscopic repair of iatrogenic vesico-vaginal fistula <h3>Design</h3> Surgical video presentation. <h3>Setting</h3> Academic tertiary care center. <h3>Patients or Participants</h3> We present 2 cases of iatrogenic vesico-vaginal fistula repaired robotically. Case 1 is a 49-year-old patient with a vesico-vaginal fistula after an open supracervical hysterectomy with incidental cystotomy and repair. Case 2 is a 61-year-old patient who was referred for management of a supra-trigonal vesico-vaginal fistula as a complication of vaginal hysterectomy. <h3>Interventions</h3> Case 1 started with cystoscopy and placement of ureteral stents. The peritoneum above the vaginal cuff was incised and an anterior colpotomy was created. The bladder was dissected until the fistula was identified and the injured area was 4 cm away from the colpotomy. The fistulous margins where dissected. The bladder mucosa was repaired in 2 layers in a running fashion. The bladder was retrogradely filled, confirming the repair was watertight. The colpotomy was closed in 2 layers. The repair was reinforced with omental interposition. For case 2, a stent was placed through the vaginal fistulous opening. The stent was identified transvesically with cystoscopy. Bilateral ureteral stents were placed. Similar steps from case 1 were carried out. Cystoscopy was performed confirming an adequate repair. Bilateral ureteral stents were removed. A Foley catheter was inserted to remain in place for 3 weeks. <h3>Measurements and Main Results</h3> Both patients were discharged on post-operative day 1. The patient in case 1 had a voiding cystogram showing no evidence of residual or recurrent fistula on post-operative week 3, and urine leakage was resolved. The patient in case 2 is scheduled for follow up on post-operative week 3. <h3>Conclusion</h3> Robotic assisted repair offers optimal surgical exposure and is ideal for supra-trigonal and complex vesico-vaginal fistulas, affording good outcomes for patients.

Comparing Outcomes of Robotic-Assisted versus Conventional Laparoscopic Hiatal Hernia Repair

Robotic-assisted laparoscopic surgery for anti-reflux and hiatal hernia surgery is becoming increasingly prevalent. The purpose of this study was to compare hospital length of stay and outcomes of robotic-assisted versus conventional laparoscopic hiatal hernia repair. A retrospective review was conducted of 58 patients who underwent robotic-assisted laparoscopic (n = 16, 27.6%) or conventional laparoscopic (n = 42, 72.4%) hiatal hernia repair. Patient characteristics and comorbidities were similar between groups. The robotic-assisted group had a significantly higher use of fundoplication (81.3% vs. 38.1%; p = 0.007). Complications observed between the robotic-assisted and conventional laparoscopic groups were pneumothorax (6.3% vs. 11.9%; p = 1.000), infection (0% vs. 4.8%; p = 1.000), perforation (0% vs. 2.4%; p = 1.000), bleeding (6.3% vs. 2.4%; p = 0.479), ICU admission (31.3% vs. 11.9%; p = 0.119), and mechanical ventilation (18.8% vs. 2.4%; p = 0.60). There were no reported complications of dysphagia, deep vein thrombosis/pulmonary embolus, myocardial infarction, or death in either group. Hospital length of stay was similar for robotic versus conventional patients (3.0 vs. 2.5 days; p = 0.301). Robotic-assisted versus conventional laparoscopic hiatal hernia were compared, which demonstrated similar post-operative complication rates and hospital length of stay. The results showed robotic-assisted or conventional laparoscopic hiatal hernia repair can be performed with similar outcomes.

S3567 Bowel in the Chest: Clinical Manifestations of a Type IV Hiatal Hernia

Introduction: Hiatal hernias (HH) result from protrusion of intraabdominal organs into the thoracic cavity through the esophageal hiatus and commonly associated with gastroesophageal reflux disease (GERD). Type IV HH are rare, defined by presence of the stomach and/or other abdominal organs into the thoracic cavity. We report a patient with Type IV HH presenting with atypical pulmonary symptoms caused by mass effect that resolved after surgical operation. Case Description/Methods: 55-year-old female with past medical history of cerebral palsy and GERD presented with vomiting, productive cough with yellow sputum, and hoarseness for 3 days. Review of systems revealed fever and shortness of breath. Physical examination revealed respiratory rate of 25 with oxygen saturation of 89%, end expiratory wheezing in the left lower lobes and absent sounds on the right. CBC showed a WBC of 12,500 K/mm3. Chest and abdominal x-ray indicated possible aspiration and large stool burden. She was admitted for aspiration pneumonitis with ileus and received antibiotics, anti-emetics, and laxative medications. CT chest and abdomen (Figure) revealed a large HH with moderate colonic stool burden exerting mass effect over cardio-mediastinal structures. Upper endoscopy and barium enema showed a large Type IV paraesophageal HH containing a long segment of transverse colon with majority of the stomach extending into the posterior right thoracic cavity with mass effect on narrowed colonic loops. She underwent robotic assisted laparoscopic repair with cruroplasty with mesh, esophagopexy and gastropexy. Intra-operatively, colon and stomach were compressing her cardio-mediastinal structures. Postoperative Upper GI study showed successful repair without evidence of leak. CT abdomen showed resolution of HH and small right sided pleural effusions post-operatively. She tolerated a full diet by POD 3 and discharged on POD 4. Postoperative course was complicated by readmission with chylous leak that was controlled by lymphangiographic embolization. Discussion: This patient presented with pulmonary symptoms leading to a workup for respiratory etiologies. Not uncommonly, paraesophageal HH lead to aspiration and pneumonia, in addition to reflux. Large Type IV HH are unique as they predispose additional organs to strangulation and complications as demonstrated by this case. Heightened awareness for consideration of HHs may promote timely detection and treatment.Figure 1.: CT Abdomen and Pelvis of Type IV Hiatal Hernia (Red) Compressing Mediastinal Structures (Stomach= orange, Colon= green, Lung = blue, Heart = black) [Pre-Operative Axial View (A) with Post-Operative Axial View (B) and Pre-Operative Coronal View (C) with Post-Operative Coronal View (D)].

Less postoperative pain and shorter length of stay after robot-assisted retrorectus hernia repair (rRetrorectus) compared with laparoscopic intraperitoneal onlay mesh repair (IPOM) for small or medium-sized ventral hernias.

The optimal repair of ventral hernia remains unknown. We aimed to evaluate the results after robotic-assisted laparoscopic transabdominal repair with retrorectus mesh placement (rRetrorectus) compared with laparoscopic intraperitoneal onlay mesh repair (IPOM) for patients with small- or medium-sized ventral hernia. This was a retrospective cohort study of consecutive patients undergoing elective rRetrorectus or IPOM repair for small or medium-sized primary ventral or incisional hernias. The primary outcome was the postoperative need for transverse abdominis plane (TAP) block or epidural analgesia, secondary outcomes were length of stay and postoperative complications. All patients were followed for 30days postoperatively. A total of 59 patients were included undergoing rRetrorectus (n = 27) and IPOM (n = 32). Patients in the two groups were comparable in terms of age, sex, comorbidities, smoking status, body mass index (BMI), and type of hernia. The median fascial defect area was slightly larger in the rRetrorectus group (9 cm2 vs. 6.2 cm2, P = 0.031). The duration of surgery was longer for rRetrorectus (median 117.2min. vs. 84.4, P = 0.003), whereas the postoperative need for TAP block or epidural analgesia was less after rRetrorectus compared with IPOM (3.7% versus 43.7%, P = 0.002). There were no severe complications or reoperations after either procedure. The length of stay was shorter after rRetrorectus (median 0 vs. 1day, P < 0.001). rRetrorectus was associated with reduced postoperative analgesic requirement and shorter length of stay compared with laparoscopic IPOM. Registration Clinicaltrial.gov: NCT05320055.

Robotic-assisted laparoscopic repair of a congenital rectourethral fistula with duplicated urethra

To describe our experience with robot-assisted laparoscopic transperitoneal repair of a congenital rectourethral fistula in a pediatric patient with a urethral duplication. The patient is a 2-year-old male with a past medical history of Tetralogy of Fallot presenting with a febrile urinary tract infection (UTI). He was diagnosed with urethral duplication and a rectourethral fistula by voiding cystourethrogram (VCUG). The parents were counseled on various options and agreed to proceed with a robotic repair. Robotic-assisted transperitoneal rectourethral fistula repair was performed. The procedure time was 229min with an estimated blood loss (EBL) of 15mL. His postoperative course was unremarkable. At his 2-week follow-up, the urethral catheter was removed and the patient was voiding normally and having normal bowel movements. Congenital rectourethral fistula with urethral duplication is a rare anomaly with only a few reports in the literature. Pediatric robotic-assisted transperitoneal rectourethral fistula repair is a technically feasible approach in infants with minimal morbidity that allows for excellent visualization and avoids open repair.

P127 ROBOTIC TRANSABDOMINAL RETRO-RECTUS HERNIA REPAIR VS. LAPAROSCOPIC INTRAPERITONEAL ONLAY MESH REPAIR: IMPROVING POSTOPERATIVE OUTCOMES

Abstract Aim “The optimal repair technique for small and medium-sized ventral hernias in obese patients remains unknown. We aimed to evaluate results after robotic-assisted laparoscopic transabdominal repair with retro-rectus mesh placement (rTARUP) compared with laparoscopic intraperitoneal onlay mesh repair (IPOM).” Material and Methods “Retrospective cohort study of consecutive patients undergoing rTARUP or IPOM repair for small or medium-sized primary ventral and incisional hernias. The primary outcome was postoperative need for transverse abdominis plane (TAP) block or epidural catheter, and secondary outcomes were 30-day complications, and length of stay. All patients underwent elective surgery and were followed for 30 days postoperatively.” Results “A total of 27 patients (rTARUP) and 32 (IPOM) were included. Patients in the two groups were comparable in terms of age, sex, comorbidities, smoking status, body mass index (BMI), and type of hernia. The median BMI was 32.4 kg/m2 and the fascial defect area was comparable (rTARUP median 16.8 cm2 vs. IPOM 11.7 cm2, P = 0.303). The duration of surgery was longer in the rTARUP group (median 117.2 min. vs. 84.4, P = 0.003), whereas the postoperative need for TAP block or epidural analgesics was less in the rTARUP group compared with IPOM (n = 14 vs. n = 1, P = 0.002). There were no severe complications or reoperations in the two groups. The length of stay was shorter in the rTARUP group (median 0 vs. 1 days, P &amp;lt; 0.001).” Conclusions “rTARUP was associated with reduced postoperative analgesic requirement and shorter length of stay compared with laparoscopic IPOM.”

Initial Experience with Robotic Inguinal Hernia Repair in the Adolescent Population.

Purpose: There is no one standard procedure encompassing the needs and differences of the entire pediatric population for inguinal hernia repair (IHR). Several techniques can be used, including open repair, laparoscopic, and robotic-assisted laparoscopic repair. This is a report of a single pediatric hospital's experience performing robotic-assisted IHRs in an adolescent population. Methods: Robotic IHRs performed by the pediatric surgery department were prospectively captured and reviewed. The operation performed was a modified robotic transabdominal preperitoneal approach with ProGrip mesh. Results: Between January 2016 and August 2020, 11 robotic-assisted IHRs occurred. All patients were male, median weight interquartile range (IQR) was 76.6 kg (67.425-90.4 kg) and median age (IQR) was 17 years (17-18.5). All together median (IQR) total operative time was 111 (97.5-126) minutes, median (IQR) total console time was 60 (55.5-75.5) minutes. There were no complications or conversions, with all patients discharged on the day of the operation. Conclusion: This study demonstrates a safe and reliable approach to repairing inguinal hernias using robotics through a small initial case series. Robotic-assisted IHR should be considered a viable technique to optimize the surgical care of adolescents.

Robotic Assisted Laparoscopic Repair with Acell Extracellular Matrix Reinforcement of Recurrent Trans-Mural Isthmocele

Study Objective To illustrate the use of robotic surgery in repairing a recurrent trans-mural isthmocele using Acell extracellular matrix as reinforcement following treatment of a cesarean scar ectopic pregnancy. Design N/A Setting 36 year old G4P1031 with a history of cesarean scar ectopic managed with intramuscular and intragestational sac methotrexate presented with a full thickness transmural isthmocele. She underwent a robotic assisted laparoscopic repair of the isthmocele. Office hysteroscopy following the surgery demonstrated resolution of the uterine defect. A recurrence of the full thickness defect in the anterior uterine wall resulting in a diverticulum was noted on hystosalpingogram and confirmed with pelvic MRI during her infertility workup. Patients or Participants N/A Interventions Patient underwent a combined hysteroscopic guided via transillumination and robotic assisted laparoscopic trans-mural isthmocele repair with Acell extracellular matrix reinforcement. Measurements and Main Results N/A Conclusion The initial cesarean scar ectopic pregnancy was treated with methotrexate with trans-mural isthmocele as a sequela. Without a clearly defined gold standard in the literature for repairing recurrent trans-mural isthmocele, laparoscopy provides a minimally invasive approach. However, the recurrence rate of isthmocele following laparoscopic repair is unknown. Acell extracellular matrix has been used for other gynecologic procedures because of its ability to optimize the strength of the repair where scarring would be expected by promoting and facilitating the body's ability to remodel functional native tissue while minimizing the risk of foreign body response. The use of Acell in robotic assisted laparoscopic application for the reinforcement of isthmocele repair has not been previously described.

Safety of robotic assisted laparoscopic recurrent paraesophageal hernia repair: insights from a large single institution experience.

Laparoscopic repair of recurrent as opposed to primary paraesophageal hernias (PEHs) are historically associated with increased peri-operative complication rates, worsened outcomes, and increased conversion rates. The robotic platform may aid surgeons in these complex revision procedures. The aim of this study was to compare the outcomes of patients undergoing robotic assisted laparoscopic (RAL) repair of recurrent as opposed to primary PEHs. Patients undergoing RAL primary and recurrent PEH repairs from 2009 to 2017 at a single institution were reviewed. Demographics, use of mesh, estimated blood loss, intra-operative complications, conversion rates, operative time, rates of esophageal/gastric injury, hospital length of stay, re-admission/re-operation rates, recurrence, dysphagia, gas bloat, and pre- and post-operative proton pump inhibitor (PPI) use were analyzed. Analysis was accomplished using Chi-square test/Fischer's exact test for categorical variables and the Mann-Whitney U test for continuous variables. There were 298 patients who underwent RAL PEH repairs (247 primary, 51 recurrent). They were followed for a median (interquartile range) of 120 (44, 470) days. There were no significant differences in baseline demographics between groups. Patients in the recurrent PEH group had longer operative times, increased use of mesh, and increased length of hospital stay. They were also less likely to undergo fundoplication. There were no significant differences in estimated blood loss, incidence of intra-operative complications, re-admission rates, incidence of post-operative dysphagia and gas bloat, and incidence of post-operative PPI use. There were no conversions to open operative intervention or gastric/esophageal injury/leaks. Although repair of recurrent PEHs are historically associated with worse outcomes, in this series, RAL recurrent PEH repairs have similar peri-operative and post-operative outcomes as compared to primary PEH repairs. Whether this is secondary to the potential advantages afforded by the robotic platform deserves further study.

Resident training experience with robotic assisted transabdominal preperitoneal inguinal hernia repair

BackgroundGeneral surgery is the fastest growing field in the adoption of robotic assisted laparoscopic surgery. Here, we present the results of one institution’s experience in training surgical residents in robotic assisted transabdominal preperitoneal inguinal hernia repairs. MethodsData were prospectively collected on patients undergoing robotic assisted laparoscopic inguinal hernia repair with residents. Data points included patient age, gender, complications, hernia difficulty, resident technical competency as measured by GEARS, Zwisch scores, operative time, and the number of robotic console cases reported by residents as primary surgeon. ResultsResidents who performed >30 robotic cases had significantly higher mean modified GEARS scores (p ≤ .002). Residents who completed 10 or fewer robotic cases achieved significantly lower mean modified GEARS and Zwisch scores than those who completed 11 or more (p < .001). ConclusionsResident competency and autonomy improve with increasing total robotic case load. Attending surgeons grant more autonomy to residents with higher competency scores.

Robotic Assisted Laparoscopic Repair of Isthmocele

Video Objective This video demonstrates the technique for a Robotic assisted laparoscopic repair of a large Isthmocele. Setting A 41-year-old G1P1 woman presented with secondary infertility and postmenstrual spotting. Her first spontaneous pregnancy ended by cesarean section delivery 5 years ago. She has a 3 years history of secondary infertility and failed Intracytoplasmic sperm injection (ICSI). Transvaginal ultrasound showed a wedge-shaped hypoechoic area in the myometrium at the level of the previous cesarean scar and Pelvic MRI confirmed the diagnosis of Isthmocele. Interventions Diagnostic hysteroscopy done prior to the Robotic assisted Laparoscopy for endometrial cavity assessment and localization of the cesarean scar defect showed an endometrium studded with black hemosiderin-like lesions, biopsy was taken. Then a Robotic assisted Laparoscopic surgery started with dissection of the vesicovaginal plane and resection of the isthmocele pouch. Complete excision of fibrotic tissues performed and a Hegar dilator was placed to maintain cervico-uterine patency. The defect was then repaired in 3 layers. For the first two layers 0-polyglactin (Vicryl®) was used for faster absorption of the suture material in contact with the endometrial cavity. The third layer was closed using 2-0 delayed absorbable barbed sutures (V-LocTM). An adhesion barrier was placed overlying the suture line. The operative time was 150 minutes and the patient had an uneventful postoperative recovery. Conclusion The pathology of the endometrial biopsy showed the unusual finding of endometrial glands filled with blood.The postoperative vaginal ultrasound confirmed a well re-approximated uterine wall, a myometrial thickness of 14 mm and a continuous and intact endometrial lining at 6 weeks postoperatively. At 3 months a flexible office hysteroscopy showed excellent repair, complete healing of the lower uterine defect and a normal endometrial cavity with resolution of the abnormal lesions.Post-operatively, the patient denied any post-menstrual spotting and conceived spontaneously 4 months after the repair. This video demonstrates the technique for a Robotic assisted laparoscopic repair of a large Isthmocele. A 41-year-old G1P1 woman presented with secondary infertility and postmenstrual spotting. Her first spontaneous pregnancy ended by cesarean section delivery 5 years ago. She has a 3 years history of secondary infertility and failed Intracytoplasmic sperm injection (ICSI). Transvaginal ultrasound showed a wedge-shaped hypoechoic area in the myometrium at the level of the previous cesarean scar and Pelvic MRI confirmed the diagnosis of Isthmocele. Diagnostic hysteroscopy done prior to the Robotic assisted Laparoscopy for endometrial cavity assessment and localization of the cesarean scar defect showed an endometrium studded with black hemosiderin-like lesions, biopsy was taken. Then a Robotic assisted Laparoscopic surgery started with dissection of the vesicovaginal plane and resection of the isthmocele pouch. Complete excision of fibrotic tissues performed and a Hegar dilator was placed to maintain cervico-uterine patency. The defect was then repaired in 3 layers. For the first two layers 0-polyglactin (Vicryl®) was used for faster absorption of the suture material in contact with the endometrial cavity. The third layer was closed using 2-0 delayed absorbable barbed sutures (V-LocTM). An adhesion barrier was placed overlying the suture line. The operative time was 150 minutes and the patient had an uneventful postoperative recovery. The pathology of the endometrial biopsy showed the unusual finding of endometrial glands filled with blood.The postoperative vaginal ultrasound confirmed a well re-approximated uterine wall, a myometrial thickness of 14 mm and a continuous and intact endometrial lining at 6 weeks postoperatively. At 3 months a flexible office hysteroscopy showed excellent repair, complete healing of the lower uterine defect and a normal endometrial cavity with resolution of the abnormal lesions.Post-operatively, the patient denied any post-menstrual spotting and conceived spontaneously 4 months after the repair.

2960 An Overview of Uterine Scar Defects Post Cesarean Section

Study Objective Using a patient's obstetrical history, symptomatology, and radiologic findings of cesarean scar defects (CSD) to establish criteria to triage patients who require surgical repair. Additionally, to outline surgical technique for successful Robotic-assisted laparoscopic repair of CSDs. Design Comprehensive overview of diagnosis, radiological findings and repair of CSD. Setting Two large tertiary care academic medical centers. Patients or Participants Patients with previous cesarean section who are referred for possible surgical intervention for CSD. Interventions Robotic-assisted laparoscopic approach after proper multidisciplinary planning with Radiologist, Maternal fetal medicine specialist, and minimally-invasive gynecologic surgeon. Measurements and Main Results Cesarean scar defects are readily visible on ultrasound evaluation, and is a finding in many patients following cesarean section. Currently, there are no accepted guidelines to aid in the decision for when surgical management is required. The study will combine obstetrical history, symptomatology, and, most importantly, radiologic findings to aid clinicians in designing a treatment plan. Radiologic findings include degree of myometrial thinning and presence/width of the serosal dehiscence. If surgical intervention is necessary, outline the steps to robotic assisted laparoscopic repair of CSD. Included in this analysis are radiographic images of defects and video of surgical repairs. Conclusion There are numerous reports of the minimally invasive repair of CSD; however, it remains unknown in the obstetrical literature when interventions are required. Patients with minimal myometrial thinning and without evidence of serosal dehiscence may not require repair of the defect. More evidence is needed to observe obstetrical outcomes with or without repair.

Robotic-assisted Laparoscopic Repair of Scrotal Inguinal Hernias

Scrotal inguinal hernias represent a challenging surgical pathology. Although some advanced laparoscopists can repair these hernias through a minimally invasive approach, open repair is considered the technique of choice for most surgeons. The purpose of this study is to show our results of robotic-assisted laparoscopic repair of scrotal inguinal hernias. We reviewed the charts of 14 patients with inguinoscrotal hernias who underwent robotic-assisted transabdominal preperitoneal (TAPP) hernia repair. Mean follow-up was 7 months. The European Registry for Abdominal Wall Hernia Quality of Life score, a 90-point scale, was utilized to quantify patient reported outcomes. Robotic TAPP repair was successful in all 14 patients. Average case duration was 100 minutes (78 to 140 min) for unilateral hernias and 208 minutes (166 to 238 min) for bilateral hernias. Trainees were involved in 93% (13/14) of cases. There were no recurrences. Three patients developed postoperative seromas. The mean European Registry for Abdominal Wall Hernia Quality of Life score was 3.7 (0 to 10). Scrotal hernias can be safely repaired using robotic-assisted TAPP methods with low morbidity and favorable patient reported outcomes.

Robotic-assisted laparoscopic repair of ureteral injury: an evidence-based review of techniques and outcomes.

Iatrogenic ureteral injuries represent a common surgical problem encountered by practicing urologists. With the rapidly expanding applications of robotic-assisted laparoscopic surgery, ureteral reconstruction has been an important field of recent advancement. This collaborative review sought to provide an evidence-based analysis of the latest surgical techniques and outcomes for robotic-assisted repair of ureteral injury. A systematic review of the literature up to December 2017 using PubMed/Medline was performed to identify relevant articles. Those studies included in the systematic review were selected according to Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria. Additionally, expert opinions were included from study authors in order to critique outcomes and elaborate on surgical techniques. A cumulative outcome analysis was conducted analyzing comparative studies on robotic versus open ureteral repair. Thirteen case series have demonstrated the feasibility, safety, and success of robotic ureteral reconstruction. The surgical planning, timing of intervention, and various robotic reconstructive techniques need to be tailored to the specific case, depending on the location and length of the injury. Fluorescence imaging can represent a useful tool in this setting. Recently, three studies have shown the feasibility and technical success of robotic buccal mucosa grafting for ureteral repair. Soon, additional novel and experimental robotic reconstructive approaches might become available. The cumulative analysis of the three available comparative studies on robotic versus open ureteral repair showed no difference in operative time or complication rate, with a decreased blood loss and hospital length of stay favoring the robotic approach. Current evidence suggests that the robotic surgical platform facilitates complex ureteral reconstruction in a minimally invasive fashion. High success rates of ureteral repair using the robotic approach mirror those of open surgery, with the additional advantage of faster recovery. Novel techniques in development and surgical adjuncts show promise as the role of robotic surgery evolves.

38: Robotic assisted laparoscopic vesicovaginal fistula repair

The objective of this video is to present the surgical steps for a robotic assisted laparoscopic vesicovaginal fistula repair. In this video we present the steps of a robotic assisted laparoscopic vesicovaginal fistula repair, beginning with placement of ureteral stents as well as stenting the tract itself for improved identification during dissection. The steps of tract excision, dissection, and a tension free closure are illustrated. Various techniques for vesicovaginal fistula repair have been described, traditionally completed via a vaginal approach. However, in patients with limited vaginal access vesicovaginal fistula repair performed with robotic assistance is a reasonable alternative.

Feasibility of Transvesical Robotic VVF Repair in Porcine Model.

Extraperitoneal transvesicoscopic vesicovaginal fistula (VVF) repair has received limited use because of its narrow working space, longer operation time, and technical difficulty. The present study describes the feasibility of robotic-assisted transvesicoscopic VVF repair in an animal model. Two Yorkshire swine underwent robotic-assisted laparoscopic (RAL) VVF repair. With the 4 trocars, an artificial VVF was made in the supratrigonal area and VVF repair was performed in 3 layers as in open VVF repair methods. The mean operation time was 108 minutes. The operation time was prolonged in 1 case due to weak fixation of bladder to anterior abdominal wall. Equipment interference did not occur. Tissue manipulation and suturing were easy. The results of this study suggest that extraperitoneal RAL procedures for VVF repair may be an effective minimally invasive modality with reduced morbidity. A shorter operation time and easy suturing technique were the distinct merits of the extraperitoneal RAL technique.

Robotic repair of vesicovaginal fistula - initial experience.

ABSTRACTObjective The most common acquired fistula of the urinary tract is Vesicovaginal fistulae (VVF) (1) posing social stigmata for the patient as well as a surgical challenge for the urologist. Here we present our initial experience with Robotic assisted laparoscopic repair of VVF, its safety and efficacy.Materials and Methods Seven out of eight fistulas were post hysterectomy; five had undergone abdominal while two had laparoscopic hysterectomy while one was due to prolonged labour. Two had associated ureteric injury. All underwent robotic assisted laparoscopic trans abdominal extravesical approach. Three 8 mm ports for robotic arms, one 12 mm port for camera and another 12 mm for assistant were used in a fan shaped manner. All had preoperative ureteric catheter placed. Bladder was closed in two layers and vagina in one layer. Omental flap placed in all cases except two where it was not possible. Drain and per urethral catheter placed in all cases. Double J stents were placed in two cases requiring ureteric implantation additionally.Results The mean age of presentation was 39.25 years (26-47 range) with mean BMI being 26.25 kg/m2 (21-32 range). Mean duration between insult and repair was 9.37 months (3-24 months). Only in single case there was history of previous repair attempt. On cystoscopy four had supratrigonal VVF and four were trigonal with mean size of 13.37 mm (7-20 mm). Mean operative time was 117.5 minutes (90-150). There were no intraoperative/postoperative complications or need for open conversion. Mean haemoglobin drop was 1.4 gm/dL (0.3-2 gm). Drain was removed once 24-48 hours output is negligible. One patient had post-operative urinary leak at 2 weeks which ceased with continuation of catheterisation for another 2 weeks. Catheter was removed after voiding cystourethrogram showed no leak at 2-3 weeks postoperatively. Mean duration of drain was 3.75 days (3-5) and per urethral catheterisation (which was removed after voiding cystourethrography) was 15.75 days (9-28). Mean hospital stay was 6.62 days (4-14). Post-operative bladder capacity was 324.28 cc (280-350) on voiding diary. Follow up ranged from 3-9 months. At 3 months of follow-up, these patients continued to void normally and there was no evidence of recurrence of VVF.Conclusion Robotic repair of VVF is safe and feasible and has additional advantages in the form of precise suturing under 3D vision and certainly a more striking and effective option especially in complex VVF repair associated with ureteric injuries (2).

Robotic-assisted repair of a duodenal diaphragm in a child

Abstract The retroperitoneal location of the duodenum and the small volume of the peritoneal cavity in pediatric patients make the laparoscopic repair of congenital duodenal anomalies challenging. As a result, robotic-assisted repair of duodenal atresia in a pediatric patient has been reported only once in the literature. This report describes the robotic-assisted laparoscopic repair of a congenital duodenal diaphragm in a 2-year-old, 8 kg patient who presented with vomiting and failure to thrive. An upper gastrointestinal series revealed partial obstruction at the second part of the duodenum with proximal dilatation. These findings are consistent with a duodenal diaphragm. Traditional laparoscopy was utilized to kocherize the first and second parts of the duodenum and to identify a loop of proximal jejunum for the proposed anastomosis. A duodeno-jejunal anastomosis was then performed using intra-corporeal suturing with a daVinci SI robotic system. The patient had a quick and uneventful post-operative course. At 6 month follow-up, she was asymptomatic and the surgical incisions had healed with excellent cosmetic appearance. A combination of laparoscopic and robotic techniques offers a promising alternative to open or purely laparoscopic repair of congenital duodenal anomalies.

Robotic-assisted laparoscopic removal of cesarean scar ectopic and hysterotomy revision

A 38-year-old gravida 6 para 2042 woman presented in consultation regarding management of a uterine defect, or "niche," following resolution of a cesarean scar ectopic pregnancy. She had 3 prior losses, followed by invitro fertilization that resulted in 2 healthy births, both delivered by cesarean. A third invitro embryo transfer resulted in the cesarean scar ectopic. After consideration of treatment options, she underwent multiple-dose parenteral methotrexate with eventual termination of the ectopic. Magnetic resonance imaging demonstrated a uterine defect, suspected to contain residual pregnancy tissue. Questions considered in her consultation included whether the defect should be repaired and, if so, from a hysteroscopic or laparoscopic approach, as well as her risk of intrauterine scarring, when, or if, it would be safe to pursue another pregnancy, and her subsequent risk of uterine rupture. Literature review regarding cesarean niche was helpful, but did not seem to completely inform this particular clinical scenario. She elected to proceed with robotic-assisted laparoscopic repair. The vesicovaginal space was opened to expose the defect. Dilute vasopressin was injected circumferentially around the defect to help minimize the use of electrosurgery in opening the hysterotomy. Scar overlying the defect was resected and pregnancy tissue removed. The hysterotomy was closed with delayed-absorbable barbed suture, extrapolating technique from laparoscopic myomectomy. The first layer was imbricated with a second, similar to a 2-layer closure in cesarean delivery. Follow-up magnetic resonance imaging revealed resolution of the defect. After several failed attempts at repeat invitro fertilization, spontaneous pregnancy was achieved 18 months postoperatively. The pregnancy was uncomplicated and she underwent scheduled cesarean delivery of a healthy neonate at 37 weeks' gestation. The lower uterine segment was thick and developed, with no evidence of a dehiscence.

Obstetric Outcomes after Robotic-Assisted Laparoscopic Repair of Cesarean Scar Defect

Obstetric Outcomes after Robotic-Assisted Laparoscopic Repair of Cesarean Scar Defect