Robotic-assisted 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.

Robot-Assisted Surgery of an Iliac Artery Aneurysm: A Case Report.

Robot-assisted surgery has not yet been able to establish itself for vascular surgery. However, the preconditions for robot-assisted vascular interventions have changed fundamentally over the past years because of technological advances and extensive experience in other surgical disciplines. Hence, we describe a robot-assisted repair of an iliac artery aneurysm using a late-generation robotic platform. A 63-year-old male patient was diagnosed with an asymptomatic 30 mm aneurysm of the right common iliac artery. The operation was performed with the Da Vinci Xi system (Intuitive Surgical, Inc., Sunnyvale, CA, USA) using a direct transperitoneal approach to repair the aneurysm by interposition of a Dacron vascular prothesis. The total operating duration was 304 minutes without perioperative need for blood transfusion. The patient was discharged on the eighth postoperative day after an uneventful postoperative course. The case presented shows that robot-assisted surgery in the iliac axis can be performed safely with reasonable operating times.

Robotic-assisted repair of post-esophagectomy hiatal hernia: case report and review of technique

Robotic-assisted repair of post-esophagectomy hiatal hernia: case report and review of technique

Functional outcomes of hybrid hiatal hernia repair.

Gastroesophageal reflux disease (GERD) results in a total healthcare cost of 12.3 billion dollars to the United States annually. GERD is often seen with hiatal hernias. Our study aims to compare short-term functional outcomes and postoperative symptom relief afforded by hiatal hernia repair with transoral incisionless fundoplication (TIF), together known as hybrid repair, to those of hiatal hernia repair with surgical fundoplication (conventional repair). We performed a retrospective chart review on 112 consecutive patients who underwent robot assisted laparoscopic hiatal hernia repair at a community hospital by a single surgeon. We found that the short-term functional results and symptom relief with hybrid repair were no superior to those with conventional repair. We did not find a significant difference between hybrid and conventional repair in terms of in 30day complications, ER visits or inpatients admissions. The number of patients who were symptomatic at delayed follow-up was not significantly different between both the groups. As such, short-term functional outcomes and symptom relief with hybrid hiatal hernia repair are no superior to those with conventional repair. Therefore, surgical repair of hiatal hernia with surgical fundoplication remains the standard of care until further data is available on long-term outcomes of the hybrid approach.

Robotic versus hybrid assisted ventral hernia repair: a prospective one-year comparative study of clinical outcomes

Background Laparoscopic ventral hernia repair (LVHR) may be associated with chronic pain, seroma formation, bulging and failure to restore abdominal wall function. These outcomes are risk factors for hernia recurrence and poor quality of life (QoL). Our study evaluates whether robotic-assisted ventral hernia repair (rVHR) diminishes these complications compared to LVHR with primary closure of the defect (hybrid). Methods Thirty-eight consecutive patients undergoing incisional ventral hernia operation with fascial defect size from 3 to 6 cm were recruited between November 2019 and October 2020. Nineteen patients underwent rVHR and nineteen underwent hybrid operation. The main outcome measure was postoperative pain, evaluated with a visual analogue scale (VAS: 0–10) at 1-month and at 1-year. Hernia recurrence was evaluated with ultrasound examination and QoL using the generic SF-36 short form questionnaire. Results At the 1-month control visit, VAS scores were significantly lower in the rVHR group; 2.5 in the hybrid group and 0.3 in the rVHR group (p < 0.001). At the 1-year control, the difference in VAS scores was still significant, 2.8 vs 0.1 (p = 0.023). There was one hernia recurrence in the hybrid group (p = 0.331). QoL did not differ significantly between the study groups when compared to preoperative physical status at 1-year follow-up (p = 0.121). However, emotional status (p = 0.049) and social functioning (p = 0.039) improved significantly in the rVHR group. Conclusions Robotic-assisted ventral hernia repair (rVHR) was less painful compared to hybrid repair at 1-month and at 1-year follow-up. In addition, improvement in social functioning status was reported with rVHR. Trial Registration ID 5200658.

V04-08 ROBOT-ASSISTED REPAIR OF BENIGN DISTAL URETEROENTERIC STRICTURES FOLLOWING RADICAL CYSTECTOMY

You have accessJournal of UrologyCME1 May 2022V04-08 ROBOT-ASSISTED REPAIR OF BENIGN DISTAL URETEROENTERIC STRICTURES FOLLOWING RADICAL CYSTECTOMY Victoria Maxon and Alvin Goh Victoria MaxonVictoria Maxon More articles by this author and Alvin GohAlvin Goh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002560.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This video aims to provide a step-by-step approach for robot-assisted repair of benign distal ureteroenteric strictures (UES) following radical cystectomy (RC). METHODS: We demonstrate the feasibility and safety of robotic repair through three clinical scenarios after different forms of diversion and open primary surgery. UES repair is performed in the setting of an open RC and neobladder (NB), an open Indiana pouch and a repeat repair after RC and ileal conduit (IC). The RC/IC and Indiana pouch patients were placed in the modified lateral position with right side up. Port placement was directed at the right lower quadrant. The RC/NB patient was placed in the supine position and port placement was similar to that of RC. The operation consists of extensive lysis of adhesions, mobilization of the diversion and ureter, identification of the UES, excision of ureteral scar tissue and spatulation, assessment of ureteral perfusion using indocyanine green (ICG) fluorescence and the creation of a tension-free and watertight anastomosis. RESULTS: All cases were completed successfully without the need for open conversion. There were no intraoperative complications. Operative times ranged from 174-273 minutes. Estimated blood loss ranged from 10-50ml. Patients were discharged on postoperative day 1. No major complications occurred within 90 days of discharge. Renal function remained stable in all three patients at 6 weeks postoperatively. Patients were followed with functional renal imaging at 3 months postoperatively. CONCLUSIONS: Robot-assisted repair of UES is feasible and safe, even in the setting of extensive prior open abdominal surgery. This is the ideal approach for UES repair because it requires less mobilization of surrounding structures, allows for intraoperative ureteral assessment with ICG fluorescence and can successfully create a tension-free and watertight anastomosis. Our patients recovered quickly and without complications. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e369 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Victoria Maxon More articles by this author Alvin Goh More articles by this author Expand All Advertisement PDF downloadLoading ...

Robot-Assisted Repair of Atrial Septal Defect: A Comparison of Beating and Non-Beating Heart Surgery.

BackgroundRobot-assisted repair of atrial septal defect (ASD) can be performed under either beating-heart or non-beating-heart conditions. However, the risk of cerebral air embolism (i.e., stroke) is a concern in the beating-heart approach. This study aimed to compare the outcomes of beating- and non-beating-heart approaches in robot-assisted ASD repair.MethodsFrom 2010 to 2019, a total of 45 patients (mean age, 43.4±14.6 years; range, 19–79 years) underwent ASD repair using the da Vinci robotic surgical system. Twenty-seven of these cases were performed on a beating heart (beating-heart group, n=27) and the other cases were performed on an arrested or fibrillating heart (non-beating-heart group, n=18). Cardiopulmonary bypass (CPB) was achieved via cannulation of the femoral vessels and the right internal jugular vein in all patients.ResultsComplete ASD closure was verified using intraoperative transesophageal echocardiography in all patients. Conversion to open surgery was not performed in any cases, and there were no major complications. All patients recovered from anesthesia without any immediate postoperative neurologic symptoms. In a subgroup analysis of isolated ASD patch repair (beating-heart group n=22 vs. non-beating-heart group n=5), the operation time and CPB time were shorter in the beating-heart group (234±38 vs. 253±29 minutes, p=0.133 and 113±28 vs. 143±29 minutes, p=0.034, respectively).ConclusionRobot-assisted ASD repair can be safely performed with the beating-heart approach. No additional risk in terms of cerebral embolism was found in the beating-heart group.

Robot-assisted repair of cervical fixation elongation recurrence after laparoscopic sacrocolpopexy in two cases

Robot-assisted repair of cervical fixation elongation recurrence after laparoscopic sacrocolpopexy in two cases

Durable Treatment of Refractory Vesicourethral Anastomotic Stenosis via Robotic-assisted Reconstruction: A Trauma and Urologic Reconstructive Network of Surgeons Study

BackgroundRefractory vesicourethral anastomotic stenosis (VUAS) after radical prostatectomy poses challenges distinct from bladder neck contracture, due to close proximity to the sphincter mechanism. Open reconstruction is technically demanding, risking de novo stress urinary incontinence (SUI) or recurrence. ObjectiveTo demonstrate patency and continence outcomes of robotic-assisted VUAS repair. Design, setting and participantsPatients with VUAS underwent robotic-assisted reconstruction from 2015 to 2020 in the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) consortium of institutions. The minimum postoperative follow-up was 3 mo. Surgical procedureThe space of Retzius is dissected and fibrotic tissue at the vesicourethral anastomosis is excised. Reconstruction is performed with either a primary anastomotic or an anterior bladder flap-based technique. MeasurementsPatency was defined as either the passage of a 17 French flexible cystoscope or a peak flow on uroflowmetry of >15 ml/s. De novo SUI was defined as either more than one pad per day or need for operative intervention. Results and limitationsA total of 32 patients met the criteria, of whom 16 (50%) had a history of pelvic radiation. Intraoperatively, 15 (47%) patients had obliterative VUAS. The median length of hospital stay was 1 d. At a median follow-up of 12 mo, 24 (75%) patients had patent repairs and 26 (81%) were voiding per urethra. Of five men with 30-d complications, four were resolved conservatively (catheter obstruction and ileus). In eight patients, recurrent stenoses were managed with redo robotic reconstruction (in two), endoscopically (in four), or catheterization (in two). Of 13 patients without preexisting SUI, 11 (85%) remained continent at last follow-up. No patients underwent urinary diversion. ConclusionsRobotic-assisted VUAS reconstruction is a viable and successful management option for refractory anastomotic stenosis following radical prostatectomy. The robotic transabdominal approach demonstrates high patency and continence rates. Patient SummaryWe studied the outcomes of robotic-assisted repair for vesicourethral anastomotic stenosis. Most patients, after the procedure, were able to void per urethra and preserve existing continence.

V01-06 ROBOTIC ASSISTED REPAIR OF A PERINEAL BLADDER HERNIA

You have accessJournal of UrologyIncontinence & Female Pelvic Medicine/Reconstructive Surgery (V01)1 Sep 2021V01-06 ROBOTIC ASSISTED REPAIR OF A PERINEAL BLADDER HERNIA Dmitry Volkin, and Christopher Tarnay Dmitry VolkinDmitry Volkin More articles by this author , and Christopher TarnayChristopher Tarnay More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001970.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Perineal hernias are relatively uncommon but certainly may be encountered by the urologist or pelvic reconstructive surgeon. Diagnosis and management of these unusual hernias is limited to case reports in the literature. Our aim was to provide a video guide demonstrating our technique of how to successfully repair such a hernia. METHODS: This is a video presentation of a 70 year old female patient who developed lower urinary tract symptoms and a palpable mass in her right buttocks. Imaging confirmed a bladder hernia in the right ischiorectal fossa. She underwent repair of her hernia via a robotic assisted abdominal approach, which confirmed a large defect in the levator muscle bordered medially by the vagina and bladder. We also perform a brief review of the literature on perineal hernias and review possible sites of herniation of the bladder. RESULTS: The patient underwent a patch repair of the hernia with soft polypropylene mesh cut to approximately the size of the defect but she recurred 6 weeks later. Repeat operation revealed a medial detachment of her mesh patch. A second repair was performed utilizing a larger piece of mesh, anchoring it more broadly to the levator musculature laterally and pubic bone anteriorly. The patient’s immediate post-operative course was complicated by a retroperitoneal hematoma that was managed conservatively. She was free of hernia recurrence 1 year after her second operation. CONCLUSIONS: Perineal hernias are within the scope of practice of the urologist and pelvic reconstructive surgeon. They can successfully be repaired with reduction of the hernia and application of a broad mesh patch. Source of Funding: Not applicable © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e63-e63 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dmitry Volkin More articles by this author Christopher Tarnay More articles by this author Expand All Advertisement Loading ...

Robotic transthoracic diaphragmatic hernia repair.

Robotic transthoracic diaphragmatic hernia repair.

Robot-assisted vs. laparoscopic repair of complete upside-down stomach hiatal hernia (the RATHER-study): A prospective comparative single center study

Abstract Objective Complete upside-down stomach (cUDS) hernias are a subgroup of large hiatal hernias characterized by high risk of life-threatening complications and technically challenging surgical repair including complex mediastinal dissection. In a prospective, comparative clinical study, we evaluated intra- and postoperative outcomes, quality of life and symptomatic recurrence rates in patients with cUDS undergoing robot-assisted, as compared to standard laparoscopic repair (the RATHER-study). Methods All patients with cUDS herniation requiring elective surgery in our institution between July 2015 and June 2019 were evaluated. Patients undergoing primary open surgery or additional associated procedures were not considered. Primary endpoints were intra- and postoperative complications, 30-day morbidity, and mortality. During the 8-53 months follow-up period, patients were contacted by telephone to assess symptoms associated to recurrence, whereas quality of life was evaluated utilizing the Gastroesophageal Reflux Disease–Health-Related Quality of Life (GERD-HRQL) questionnaire. Results A total of 55 patients were included. 36 operations were performed with robot-assisted (Rob-G), and 19 with standard laparoscopic (Lap-G) technique. Patients characteristics were similar in both groups. Median operation time was 232 min. (IQR: 145-420) in robot-assisted vs. 163 min. (IQR:112-280) in laparoscopic surgery (p &amp;lt; 0.001). Intraoperative complications occurred in 5/36 (12.5%) cases in the Rob-G group and in 5/19 (26%) cases in the Lap-G group (p = 0.28). No conversion was necessary in either group. Minor postoperative complications occurred in 13/36 (36%) Rob-G patients and 4/19 (21%) Lap-G patients (p = 0.36). Mortality or major complications did not occur in either group. Two asymptomatic recurrences were observed in the Rob-G group only. No patient required revision surgery. Finally, all patients expressed satisfaction for treatment outcome, as indicated by similar GERD-HRQL scores. Conclusion While robot-assisted surgery provides additional precision, enhanced visualization, and greater feasibility in cUDS hiatal hernia repair, its clinical outcome is at least equal to that obtained by standard laparoscopic surgery.

Safety of perioperative period in robot-assisted atrial septal defect repair under hyperkalemic arrest

BackgroundVarious attempts have been made to meet patient desires, especially among younger and otherwise healthy individuals, for cosmetically satisfying incision with atrial septal defect (ASD) repair. One of procedures was a robotic-assisted totally endoscopic ASD repair via only two ports under hyperkalemic arrest without aortic cross-clamping. This study investigated perioperative management and safety for robotic-assisted total endoscopic ASD repair surgery under hyperkalemic arrest.MethodsWe retrospectively reviewed perioperative management of thirty patients who underwent total endoscopic robot-assisted ASD repair under hyperkalemic arrest. All procedures were performed under general anesthesia using robotic-assisted total endoscopic for ASD repair via two or three ports under hyperkalemic arrest without aortic cross-clamping.ResultsA total of 30 patients (mean age 45 ± 17 years, 8 male, 22 female) underwent successful ASD repair with the total endoscopic robotic-assisted procedures under hyperkalemic arrest.Hyperkalemic arrest was achieved and maintained by intravenous administration of mean potassium dose of 91±32 mEq (1.4±0.6 mEq/kg) with the lowest bladder temperature was 31.9±1.4 °C during hyperkalemic arrest.In all cases, serum potassium concentration was <5.0 mEq/L after weaning from cardiopulmonary bypass, although two cases who developed hyperkalemia >6 mEq/L after operation. At other time points, no patient exceeded 6 mEq/L of serum potassium concentration. At admission to the intensive care unit, mean serum creatine phosphokinase-MB level was 32±7mg/dL. There were no cases of arrhythmia or other cardiac complications during recovery.ConclusionsPerioperative management of robotic-assisted total endoscopic ASD repair under hyperkalemic arrest is safe and is not associated with fatal arrhythmia due to hyperkalemia.

Combined Robotic-Assisted Bio-absorbable Mesh Placement and Gluteal Fasciocutaneous Flap Reconstruction: a Novel Technique for the Repair of a Symptomatic Perineal Hernia Following Extralevator Abdominoperineal Resection for Rectal Cancer

Extralevator abdominoperineal resection for rectal cancer has predominated over the common technique during recent years providing better oncologic results. However, extralevator abdominoperineal resection has been associated to a higher incidence of wound complications and perineal hernia. Several risk factors including preoperative pelvic radiotherapy, laparoscopic abdominoperineal resection, women, previous hysterectomy, obesity, coccygectomy, long small bowel mesentery, postoperative wound infection, and open pelvic peritoneum have been correlated to increased perineal hernia rate. Despite the minor clinical manifestation of a perineal hernia, its effect on the quality of life remains remarkable. Therefore, the surgical management of a perineal hernia after abdominoperineal resection is still a challenge for colorectal surgeons. Several techniques have been used including biologic meshes and myocutaneous flaps. Nevertheless, the ideal technique has not yet been proved. During last years, colorectal surgeons have utilized minimally invasive techniques such as robotic repair of perineal hernias. We presented the first case in the literature of a combined approach of robotic-assisted repair using a bio-absorbable mesh and a gluteal fasciocutaneous flap reconstruction.

Comparisons of abdominal wall reconstruction for ventral hernia repairs, open versus robotic

The surgical complexities of our current population have pushed the technological limits of healthcare, urging for minimally invasive approaches. For ventral hernias, in particular, robotic assisted laparoscopic repairs have been met with conflict. Cost and longer operative times are among the arguments against robotic surgery, although thorough evaluation of patient outcomes could potentially advocate for use of this tool. We attempted to approach this by retrospectively reviewing our own data. We reviewed charts between September 2016 and February 2017 of patients receiving complex hernia repairs, either a standard open repair (SOR) or robotic-assisted repair (RAR). Data collected included preoperative, perioperative, and postoperative care. Of the 43 patients reviewed, 16 were SOR, versus 27 RAR. Patients were comparable in age, gender, BMI, diabetes as a comorbidity; average hernia defect size was similar between the two groups. Although operative times were longer in the RAR group, estimated blood loss (EBL) was less. Hospital stay was also shorter in the RAR group, at 3.0 ± 1.9 days versus 9.6 ± 8.4 days for the OAR group. Of those requiring critical care management, only one patient had a robotic assisted repair, versus half of the patients who received an open repair. Of the patients who presented to the emergency department within 30 days of surgery, each group had four patients, and two from the OAR group required admission. Our data is consistent with other literature supporting shorter lengths of stays. Although the robotic approach did required a longer operative time, the resulting improved patient outcomes support this technique for complex ventral hernia repairs.

ROBOTIC TRANS-ABDOMINAL PREPERITONEAL APPROACH (TAPP) APPROACH FOR LATERAL INCISIONAL HERNIAS.

ABSTRACT Background: Lateral incisional hernias arise between the linea alba and the posterior paraspinal muscles. Anatomical boundaries contain various topographic variations, such as multiple nearby bony structures and paucity of aponeurotic tissue that make it particularly challenging to repair. Aim: To describe a robotic assisted surgical technique for incisional lumbar hernia repair. Methods: Retrospective data was collected from four patients who underwent robotic-assisted repair of their lumbar hernias after open nephrectomies. Results:Age ranged from 41-53 y. Two patients had right sided flank hernias while the other two on the left. One patient had a recurrent hernia on the left side. The patients were placed in lateral decubitus position contralateral to the hernia defect side. A trans-abdominal preperitoneal approach was used in all cases. Each case was accomplished with two 8 mm robotic ports, a 12 mm periumbilical port, and a 5 mm assistance port that allowed docking on the ipsilateral hernia side. The hernias were identified, a preperitoneal plane was created, and the hernia sac completely dissected allowing for complete visualization of the defect. All defects were primarily closed. Polypropylene or ProGripTM mesh was applied with at least 5 cm overlap and secured using either #0 Vicryl® transfacial sutures, Evicel® or a combination of both. The peritoneal space was closed with running suture and the ports were removed and closed. The average surgical length was 4 hr. The post-operative length of stay ranged from 0-2 days. Conclusion: The robotics platform may provide unique advantages in the repair of lateral incisional hernias and represents a safe, feasible and effective minimally invasive approach for the correction of lateral incisional hernias.

Reparación de hernias paraesofágicas gigantes asistida por robot en un hospital de cuarto nivel en Bogotá, Colombia, Clínica Shaio: serie de casos y revisión de la literatura.

Giant paraesophageal hernias have a surgical indication in case of symptoms. Since twenty years ago robot-assisted repair was incorporated to overcome the limitations of the laparoscopic surgery, and to offer new advantages. To report the experience on repairing giant paraesophageal hernias assisted by robot in a fourth level hospital in Bogotá, Colombia, Shaio Clinic. Retrospective and descriptive study of five cases of giant paraesophageal hernia type III or IV, taken to robotic correction during August 2016 to June 2018. Evaluation of post-surgery outcomes. Five paraesophageal robot-assisted repair were performed. Mean surgical time was 146 minutes, one conversion to open surgery, the average intraoperative bleeding was 100 mL, hospital stay time of 2.2 days. Morbidity, mortality and recurrence percentages in the short time were equal to 0%. Robot-assisted repair of giant paraesophageal hernias, has shown advantages that overcome the limitations of the laparoscopic approach such as dissections in difficult-to-reach angles, increased accuracy, ergonomics, three-dimensional, and closer view of the workspace. In addition, robot-assisted repair promotes better surgical and postoperative outcomes; these advantages have been demonstrated mainly in the repair of giant paraesophageal hernias.

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.

ROBOTIC MITRAL VALVE REPAIR: SINGLE INSTITUTION EXPERIENCE

The purpose of this study is to share the initial experience at our institution using the Da Vinci Xi surgical system for mitral valve robotic assisted repair, as well as the evolution of our program from minimally invasive surgery to a robotic approach.

Robot-assisted Repair of Complex Vesicovaginal Fistulae: Feasibility and Outcomes

OBJECTIVETo share our experience and techniques of robot-assisted repair of complex vesicovaginal fistulae. METHODSProspectively maintained data of patients undergoing robot-assisted repair of complex vesicovaginal fistula (VVF) from December 2014 to October 2019 were analyzed. Patient characteristics, operative data, postoperative events, and follow-up outcomes were noted. All cases underwent preoperative cysto-vaginoscopy and upper tract imaging. The procedure was completed in a standard fashion. Additional procedures included Boari flap reimplantation, Burch-colposuspension, ureteric reimplantation and Vaginal flap incorporation. On follow-up, successful repair was defined as no urine leak after removal of catheter. RESULTSOut of 73 patients undergoing robot-assisted VVF repair at our institute, 33 were classified as complex VVF. Mean age was 42.7 ± 7.2 years. The most common cause of VVF was posthysterectomy (81.8%) with 21 (63.1%) recurrent VVFs. Thirty patients (90.0%) had supratrigonal fistulae; multiple fistulae were present in 3 cases. Two patients underwent Boari flap ureteric reimplantation for concomitant ureteric stricture and ureteric neocystostomy was required in another patient. One patient underwent our novel technique of vaginal flap incorporation and a Burch colposuspension was performed simultaneously in one patient with stress incontinence. The median follow-up was 35 months (interquartile range 8.5months). Successful outcome was noted in 31 (93.9%) patients; recurrence requiring further repair in 2 patients. CONCLUSIONThe current series presents the largest number of complex VVFs repaired by robotic assistance. Robot-assisted repair can be considered as one stop procedure for such complex and vexing problems.