Robotic-assisted Total Hysterectomy Research Articles

Hysterectomy Techniques and Outcomes for Benign Large Uteri: A Systematic Review.

To identify the optimal hysterectomy approach for large uteri in gynecologic surgery for benign indications from a perioperative morbidity standpoint. PubMed and Embase databases were searched from inception through September 19, 2022. Meta-analyses were conducted as feasible. This review included studies that compared routes of hysterectomy with or without bilateral salpingo-oophorectomy for large uteri (12 weeks or more or 250 g or more) and excluded studies with any concurrent surgery for pelvic organ prolapse, incontinence, gynecologic malignancy, or any obstetric indication for hysterectomy. The review included 25 studies comprising nine randomized trials, two prospective, and 14 retrospective nonrandomized comparative studies. Studies were at high risk of bias. There was lower operative time for total vaginal hysterectomy compared with laparoscopically assisted vaginal hysterectomy (LAVH) (mean difference 39 minutes, 95% CI, 18-60) and total vaginal hysterectomy compared with total laparoscopic hysterectomy (mean difference 50 minutes, 95% CI, 29-70). Total laparoscopic hysterectomy was associated with much greater risk of ureteral injury compared with total vaginal hysterectomy (odds ratio 7.54, 95% CI, 2.52-22.58). There were no significant differences in bowel injury rates between groups. There were no differences in length of stay among the laparoscopic approaches. For LAVH compared with total vaginal hysterectomy, randomized controlled trials favored total vaginal hysterectomy for length of stay. When rates of blood transfusion were compared between these abdominal hysterectomy and robotic-assisted total hysterectomy routes, abdominal hysterectomy was associated with a sixfold greater risk of transfusion than robotic-assisted total hysterectomy (6.31, 95% CI, 1.07-37.32). Similarly, single studies comparing robotic-assisted total hysterectomy with LAVH, total laparoscopic hysterectomy, or total vaginal hysterectomy all favored robotic-assisted total hysterectomy for reduced blood loss. Minimally invasive routes are safe and effective and have few complications. Minimally invasive approach (vaginal, laparoscopic, or robotic) results in lower blood loss and shorter length of stay, whereas the abdominal route has a shorter operative time. PROSPERO, CRD42021233300.

Robotic-assisted total laparoscopy hysterectomy for the large uterus: size does not matter

Robotic-assisted total laparoscopy hysterectomy for the large uterus: size does not matter

Initial experience and surgical outcomes of robotic-assisted total hysterectomy using the da Vinci SP surgical system.

The da Vinci SP surgical system is a surgical platform capable of implementing robotic-assisted surgery through a single port and was first introduced in Japan at our hospital. In this paper, we describe our experience of the initial introduction of the da Vinci SP surgical system and its surgical outcomes. This is the first report on the surgical outcomes of using da Vinci SP, and its comparison with the conventional system in Japan. After developing an application for a highly difficult new medical technology in-house, we compared the surgical outcomes (median values) of 15 patients who had undergone total hysterectomy at our hospital using the da Vinci SP (1-port) system (SP group) for uterine myoma after March 2023 and of 154 patients who underwent total hysterectomy using the conventional da Vinci Xi (four ports) system (Xi group) for uteri weighing <500 g. The results of the comparison of the characteristics between 15 patients in the SP group and 154 patients in the Xi group were as follows: uterus weight (g): 230 (90-500) versus 222 (55-496) (p = .35); surgical time (minutes): 199 (171-251) versus 198 (88-387) (p = .63); intraoperative blood loss (mL): 13 (5-82) versus 20 (2-384) (p = .17); and rate of surgical complication (%): 0.0 versus 1.3 (p = .66). The data indicated a comparable weight of the resected uterus, surgical time, intraoperative blood loss, and rate of surgical complications between the two groups. Robotic-assisted total hysterectomy using the da Vinci SP surgical system allowed clinicians to safely perform surgeries according to the conventional systems.

Reducing the Time Before the Console in Robotic-Assisted Laparoscopic Hysterectomy

Robotic-assisted surgery enables precise manipulations with magnified vision, stereoscopic vision, and forceps with multi-joint functions. It requires unique procedures such as position setting, port placement, roll-in, and docking, which lead to prolonged operation and anesthesia time. Five conditions described below were established at our institution to reduce the time to the initiation of console: (1) changing the patients' position from the flat lithotomy position to the spread legs position; (2) attaching a Hasson cone to hold the umbilical cannula stable; (3) changing the cannula's obturator (inner tube) from blunt to bladeless; (4) fixing the team, and (5) conducting regular docking training. These outcomes were examined in this study. The study included 77 patients who underwent robotic-assisted total hysterectomy for benign uterine disease and stage IA uterine cancer at our individual institution between April 2019 and July 2022. We compared the median time from anesthesia to console initiation between the first half group (cases 1-40) and the second half group (cases 41-77). The former required 91.5 (53-131) minutes, whereas the latter required 59 (37-126) minutes. Appropriate equipment selection and team education can reduce the time to console initiation.

First report of robotic-assisted total hysterectomy using the Hugo™ RAS system.

This study describes the first reported treatment of a benign gynecological disease with the Medtronic's Hugo™ RAS System, the first robot-assisted device used in the field of gynecology in Japan. Patients who underwent robot-assisted total laparoscopic hysterectomy with the Hugo™ RAS System at the Tottori University Hospital between March 2023 and June 2023 were included in this study. In the first case, the patient was in her 40s and had uterine fibroids. We describe our experience and compare the device with the conventional da Vinci surgical system. We discuss the key features of the Hugo system (including the independent arms, open console, and pistol-shaped handle), the convenience of robotic surgery, the potential to improve quality of life, and how this technology could revolutionize the field of surgery.

A case of a patient with early-stage endometrial cancer complicated with morbid obesity treated by robotic-assisted total hysterectomy

A case of a patient with early-stage endometrial cancer complicated with morbid obesity treated by robotic-assisted total hysterectomy

Primary Debulking Via Robotic-Assisted Laparoscopy for Stage IIIc Poorly Differentiated Endometrioid Adenocarcinoma of the Ovary.

<h3>Study Objective</h3> It has been demonstrated that minimally invasive surgery (MIS) is feasible and effective for interval cytoreduction after neoadjuvant chemotherapy for advanced ovarian cancer patients. MIS is also widely used to assess resectability in the setting of newly diagnosed advanced ovarian cancer. However, the role of MIS in the primary debulking of advanced ovarian cancer is less clear. Here, we present a case of a patient with stage IIIC high-grade endometrioid ovarian cancer, which was optimally debulked to no gross residual(R0) via robotic-assisted laparoscopy. <h3>Design</h3> This is a presentation of a patient who underwent primary ovarian cancer debulking via robotic-assisted laparoscopy. <h3>Setting</h3> The patient was taken to the operating for a planned robotic left ovarian oophorectomy, myomectomy and resection of endometriosis. Diagnostic laparoscopy revealed peritoneal tumor implants consistent with advanced ovarian cancer. The frozen section confirmed epithelial ovarian cancer. <h3>Patients or Participants</h3> This case involves a 37-yo patient who was found to have advanced ovarian cancer at the time of a planned robotic surgery for a complex left ovarian cyst and resection of fibroids and endometriosis. <h3>Interventions</h3> The patient underwent robotic-assisted total hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, resection of pelvic peritoneal, rectosigmoid, and diaphragmatic tumor nodules, pelvic and paraaortic lymph node dissection as well as pelvic washing. Final pathology showed stage IIIC poorly differentiated endometrioid adenocarcinoma of the ovary. <h3>Measurements and Main Results</h3> Complete gross resection (R0) was achieved. The estimated blood loss was 50 cc. The operative time was 3 hours and 10 mins. She was discharged on postoperative day 1. Her postoperative course was uncomplicated. Adjuvant chemotherapy with IV carboplatin and paclitaxel was initiated three weeks after surgery. <h3>Conclusion</h3> MIS is a feasible option for primary debulking in select cases of advanced ovarian cancer.

Same-day discharge after robotic hysterectomy for gynecologic malignancy: a study of cost analysis and resource utilization

Objectives: To determine impact and cost savings of a quality intervention involving enhanced patient, provider, and staff education focused on same day discharge after robotic assisted total hysterectomy, and/or bilateral salpingo-oophorectomy with sentinel and/or additional lymph node dissection. Methods: A quality project was undertaken at our institution to improve the rate of same day discharge after robotic assisted hysterectomy and to assess the resource utilization savings of such an intervention. Literature supports feasibility and safety of same day discharge for robotic assisted hysterectomies alone or with other procedures for benign and malignant indications. Complex robotic assisted hysterectomies include bilateral salpingo-oophorectomy plus sentinel or additional lymph node resection. We collected historical data via chart review for the 12 months of 2018 (Group A) to determine our baseline same day discharge rate for complex robotic hysterectomies. Faculty, outpatient clinic and perioperative clinic staff were provided with education regarding the same day discharge goal for complex robotic assisted hysterectomies for patients from a single institution in our gynecologic oncology practice. We then prospectively collected the outcome data on patients undergoing complex robotic hysterectomies for the subsequent 12 months in 2019 (Group B). We compared demographic, clinical factors, and factors of resource utilization such as time in surgery and recovery and length of admission. Descriptive statistics and t-test were utilized to compare the groups. Results: One hundred three patients underwent complex robotic assisted hysterectomy in 2018, and 5% (5 patients) were discharged home on the day of surgery (Group A). One hundred twelve patients underwent complex robotic assisted hysterectomy in 2019 (Group B), and 32% (36 patients) were discharged home on the day of surgery. There was no significant difference between mean age (62 vs 64) or BMI (37 vs 36) in the two cohorts, respectively. Median length of stay was 21 hours for patients that were not discharged on day of surgery and 3.5 hours for patients discharged day of surgery. Of the 41 total patients undergoing same day discharge (Group A + Group B), there was one urgent care visit, one ER visit and and no readmissions in 30 days post procedure. A savings of approximately $1975 per case when patient discharged day of surgery. By promoting same day discharge after robotic assisted hysterectomy, 648 in-patient care hours were saved during the 12 months post intervention. Conclusions: A low cost patient and provider education initiative to increase same day discharge after robotic hysterectomy in gynecologic oncology patients positively impacted cost and resource utilization without negatively impacting readmission rates and ER utilization. In 12 months, the same day discharge rate in one facility was increased from 5% to 32% of robotic hysterectomy cases.

1885 Robotic-Assisted Hysterectomy and Bilateral Salpingo-Oophorectomy with Uterine Artery Ligation in a Case of Tubo-Ovarian Abscess with Severe Pelvic Adhesion

Video Objective Surgeries for tubo-ovarian abscess (TOA) may be very challenging due to severe adhesions from the abscess to the surrounding inflamed tissue. Treatment was often limited to drainage of the abscess due to the difficulty of more extensive surgery. This video demonstrates successful robotic-assisted total hysterectomy with bilateral salpingo-oophorectomy and uterine artery ligation with adhesiolysis for treatment of a case with tubo-ovarian abscess. Techniques of visualizing surgical anatomy and localizing the uterine artery will also be demonstrated. Setting A 41 year-old G3P2SA1 female patient presented to our out-patient clinic with lower abdominal pain with fever for 1 month. She had undergone cesarean delivery twice 17 and 18 years ago with no other significant gynecologic history. On pelvic examination, lifting tenderness with moderate odorous discharge was noted. Transvaginal ultrasound showed bialteral adnexal mass, measuring 5 × 2 cm and 5 × 3 cm. She was then admitted to our department under the tentative diagnosis of tubo-ovarian abscess. Interventions Robotic-assisted total hysterectomy with bilateral salpingo-oophorectomy, uterine artery ligation and adhesiolysis was performed on the second day of hospitalization. Conclusion Total hysterectomy with bilateral salpingo-oophorectomy may be feasible in the treatment of tubo-ovarian abscess by using robotic-assisted instruments. Due to the greater precision, better visualization, and higher dexterity of robotic-assisted surgeries.

2081 Robot-Assisted Laparoscopic Hysterectomy vs Traditional Laparoscopic Hysterectomy for Benign Gynecologic Disease: Clinical Results at a University Hospital

Study Objective To describe and analyze our first 42 robot-assisted laparoscopic total hysterectomy vs 42 traditional laparoscopic hysterectomy for benign gynecologic disease. Design Ambispective Observational Study, between 2015 to 2018 Setting University Hospital at Mexico City. Patients or Participants Patients undergoing robotic-assisted total hysterectomy or traditional laparoscopic hysterectomy performed for benign disease between 2015 and 2018. Interventions We reviewed 84 clinical data of patients undergoing robotic-assisted total hysterectomy and traditional laparoscopic hysterectomy, the criteria evaluated was: age, body mass index, surgical time, anesthesia time, intraoperative blood loss, laparotomy conversion rate, uterine weight, days of hospitalization and postoperative complications. We use T- test and ANOVA to perform the statistical analysis, In all circumstances, p ≤ 0.05 was used to define statistical significance. Measurements and Main Results A total of 84 surgeries were registered, the mean age of patients (total laparoscopic hysterectomy 47.25 years; robotic hysterectomy 44.4 years; p= 0.007), mean body mass index (total laparoscopic hysterectomy 24.5 Kg/m2; robotic hysterectomy 25.4 Kg/m2; p= 0.04), the surgical time (total laparoscopic hysterectomy 216.3 minutes; robotic hysterectomy 222.8 minutes; p= 0.7), for total anesthesia time (total laparoscopic hysterectomy 237 minutes; robotic hysterectomy 256 minutes; p= 0.3), blood loss (total laparoscopic hysterectomy 238.7 ml; robotic hysterectomy 145.4 ml; p= Conclusion We confirmed the finding that the estimated blood loss is lower in robotic hysterectomy in comparison to total laparoscopic hysterectomy. The findings in our study suggest both techniques can be performed safely and in similar operative time, we found a longer hospitalary stay in robotic approach since it was the first experience with robotic surgery from our clinic this was due to standard protocol and not to adverse patient conditions.

Roboto asistuojama totalinė histerektomija: pirmoji patirtis

[straipsnis ir santrauka lietuvių kalba; santrauka anglų kalba]&#x0D; Straipsnyje retrospektyviai analizuojamos Klaipėdos universitetinėje ligoninėje atliktos pirmosios 23 totalinės histerektomijos, naudojant Senhance® robotinę sistemą. Pacientės operuotos dėl gimdos vėžio, miomatozės, endometriozės, profilaktiškai po krūties vėžio gydymo ir atskirais atvejais esant gimdos kaklelio patologijų ar nustačius gerybinį kiaušidžių naviką. Aptariama operacijų atlikimo technika, pateikiami rezultatai. Išvados. Roboto asistuojama totalinė histerektomija – metodas, saugus pacientėms ir komfortiškas chirurgui.

Robotic total pancreatectomy with splenectomy for multifocal intraductal papillary mucinous neoplasm

Objective: In this video, we describe a systematic approach to a robotic total pancreatectomy for multifocal intraductal papillary mucinous neoplasm (IPMN) involving the entire pancreas. Methods: The patient is a 61-year-old female with a history of stage I endometrial cancer post robotic assisted total hysterectomy and salpingo-oophorectomy who was diagnosed with multifocal IPMN. Endoscopic ultrasound with fine needle aspiration of a complex cyst at the pancreas neck was significant for a CEA of 2080. She is a type 1 diabetic on an insulin pump. Results: A total of 6 robotic ports were placed and the da Vinci Xi robotic system was used with the patient supine. The approach entailed: (i) Diagnostic laparoscopy (ii) Entry into the lessec sac (iii) Division of the short gastric vessels (iv) Exposure and dissection of the inferior pancreas border (v) Dissection and transection of the splenic artery (vi) Mobilization of the spleen (vii) Exposure of the splenic vein-superior mesenteric vein confluence and transection of the splenic vein (viii) Kocher maneuver (ix) Release of the Treitz and transection of proximal jejunum (x) Transection of the distal stomach (xi) Portal lymphadenectomy (xii) Dissection and transection of the gastroduodenal artery (xiii) Hepaticojejunostomy (xiv) Cholecystectomy (xv) Gastrojejunostomy. Conclusion: Robotic total pancreatectomy with splenectomy offers a minimally invasive approach to a major abdominal operation and is feasible in a stepwise, reproducible technique.

Wound Infiltration With Extended-Release Versus Short-Acting Bupivacaine Before Laparoscopic Hysterectomy: A Randomized Controlled Trial

Study ObjectiveTo evaluate if preincision infiltration with extended-release liposomal bupivacaine provides improved overall pain relief compared with 0.25% bupivacaine after laparoscopic or robotic-assisted hysterectomy. DesignA single-center double-masked randomized controlled trial (Canadian Task Force Classification I). SettingA tertiary-care community hospital. PatientsPatients recruited from July 2015 through January 2016. Sixty-four patients were randomized, and 59 were analyzed for the primary outcome. InterventionsWomen scheduled to undergo multiport laparoscopic or robotic-assisted total hysterectomy for benign indications were randomized to receive preincision infiltration with undiluted liposomal bupivacaine or 0.25% bupivacaine. Measurements and Main ResultsThe primary outcome was overall average pain intensity by numeric rating scale (0–10) using the Brief Pain Inventory (BPI) via telephone survey on postoperative day (POD) 3. A sample size of 28 per group (N = 56) was planned to detect a 30% change in pain scores. Secondary outcomes were overall average and worst numeric pain scores on PODs 1, 2, and 14; pain scores in hospital; BPI pain interference scores; and total opioid use. There were no demographic differences between the 2 groups. For the primary outcome, we found a decrease in the average (p = .02) pain scores on POD 3 in the liposomal bupivacaine group. We also found a decrease in worst pain scores on POD 2 (p = .03) and POD 3 (p = .01). There were no differences in pain scores while in the hospital or on POD 1 or POD 14. There were no differences in BPI pain interference scores, opioid use, or reported adverse effects. ConclusionFor laparoscopic and robotic-assisted multiport hysterectomies, there is evidence of decreased average postoperative pain with liposomal bupivacaine compared with 0.25% bupivacaine for port-site analgesia on POD 3, but no difference in opioid use or measures of functioning.

Perioperative and Postoperative Outcome of Robotic-Assisted Total Hysterectomy for Extremely Large Uterus Compared with Adequate Size Uterus

Perioperative and Postoperative Outcome of Robotic-Assisted Total Hysterectomy for Extremely Large Uterus Compared with Adequate Size Uterus

Robotic versus abdominal hysterectomy; metabolic and inflammatory responses and subsequent recovery. A randomised controlled study

Objectives: The aim was to study if robotic assisted total hysterectomy (RTLH) would induce less insulin resistance than abdominal hysterectomy (AH). In addition, inflammatory response and clinical recovery were compared. Methods: We conducted a randomised controlled study at the Department of Obstetrics & Gynaecology, Örebro University Hospital; Sweden. Twenty women scheduled for a planned total hysterectomy with or without salpingo-oophorectomy, between October 2014 and May 2015, were randomly allocated to robotic assisted laparoscopic hysterectomy or abdominal hysterectomy. Insulin resistance after surgery was measured by the hyperinsulinemic normoglycemic clamp method. Inflammatory response was measured in blood samples and clinical recovery outcomes registered. Results: There were no differences in development of insulin resistance (mean ± SD) for robotic group (39±22%) vs abdominal group (40±19%; p=0.948). The robotic group had a significantly shorter hospital stay (median 1 vs. 2 days, p=0.005). Inflammatory reaction differed in form of significantly greater increase in serum interleukin 6 levels and white blood cell count, from preoperative value to postoperative peak value, in abdominal group compared with robotic group. Conclusion: Robotic assisted hysterectomy reduced inflammatory responses and recovery time but these changes were not accompanied by less insulin resistance. Disclosure of interest: None declared.

Incidental Small Ovarian Surface Serous Carcinoma With Miliary Abdominal Seeding During Robotic-Assisted Total Hysterectomy

Incidental Small Ovarian Surface Serous Carcinoma With Miliary Abdominal Seeding During Robotic-Assisted Total Hysterectomy

Combined robotic and vaginal approach in radical hysterectomy for the patient with bulky cervical cancer

Objectives: Robotic surgery is gradually being incorporated into gynecologic oncology. Robotic radical hysterectomy offers some advantages over other surgical approaches with respect to operative time, blood loss, and hospital stay. Due to the necessary location of the robot docking system, however, there is not enough space to enable the performance of vaginal procedures. Therefore, robotic-assisted total radical hysterectomy is in the mainstream for early-stage cervical cancer treatment. In bulky cervical cancer, however, intrauterine manipulation is difficult to install and increases the risk of intra-abdominal tumor seeding. Especially difficult is determination of the level of vaginal cutting. For this reason, the vaginal approach is preferred for robot-assisted radical hysterectomy in bulky cervical cancer.

Obesity and older age as protective factors for vaginal cuff dehiscence following total hysterectomy.

Studies have shown an increased risk of vaginal cuff dehiscence following total laparoscopic hysterectomy (TLH). Patient variables associated with dehiscence have not been well described. This study aims to identify factors associated with dehiscence following varying routes of total hysterectomy. This is a retrospective, matched, case-control study of women who underwent a total hysterectomy at a large, urban, university-based teaching hospital from January 2000 to December 2011. Women who underwent a total hysterectomy and had a dehiscence (n = 31) were matched by surgical mode to the next five total hysterectomies (n = 155). Summary statistics and conditional logistic regression were performed to compare cases to controls. Obese women (BMI ≥ 30) were 70 % less likely than normal weight women (BMI < 25) to experience a dehiscence (p = 0.02). When stratified by hysterectomy route, obese women were 86 % less likely to have a dehiscence following robotic-assisted total hysterectomy (RAH) and TLH than normal weight women (p = 0.04). Further, increasing age was protective of dehiscence in this subgroup of women (p = 0.02). Older age and obesity were associated with a decreased risk of dehiscence following RAH and TLH but not following other routes. Increased risk of dehiscence following TLH observed in previous studies may be partially due to patient characteristics.

Leiomyosarcoma of the Vagina: An Exceedingly Rare Diagnosis

Background. Primary leiomyosarcoma of the vagina is an exceedingly rare diagnosis. Current estimates are that this tumor could at most represent a mere 0.062% of malignant neoplasms in the female genital tract, although in actuality it is likely far less common. Case Presentation. A 70-year-old female gravida 3 para 2 with new onset palpable vaginal mass and pink vaginal discharge is diagnosed with primary leiomyosarcoma of the vagina. Chemotherapy is complicated by acute Lyme disease, and the patient requires a robotic-assisted total hysterectomy with bilateral salpingo-oophorectomy and partial vaginectomy. The patient remains without recurrence 18 months after surgery. Conclusion. Vaginal leiomyosarcoma is exceedingly rare with an aggressive course, high recurrence, and undetermined ideal treatment regimen. Its diagnosis can be delayed and its presentation varied. Information on this rare tumor type is predominantly through rare case reports with collective consensus on management lacking. The gynecologic oncologist must exercise prudence in individualizing treatment regimens for this rare yet aggressive malignancy.

Incidental ureteral injury and repair during robotic-assisted total laparoscopic hysterectomy.

To show a surgical educational video in which an incidental ureteral injury was recognized intraoperatively and was repaired during robotic-assisted total hysterectomy for a very large uterus. Step-by-step demonstration of ureterolysis and repair of ureteral injury via a ureteroureterostomy technique using an educational video and schematic pictures. Ureteral injuries are estimated to occur with a frequency of approximately 0.02% to 0.4% during laparoscopic hysterectomy. When compared with bladder injuries, ureteral injuries are much less likely to be recognized intraoperatively, and in some cases can be missed despite the use of intraoperative cystoscopy. The sequelae from ureteral injury are not insignificant, which can easily be prevented by intraoperative recognition and immediate repair. Minimally invasive surgery using the robotic system has led to a paradigm shift in the management of urinary tract injuries, which has been traditionally approached with open surgery. Robotic total hysterectomy and repair of incidental ureteral injury via ureteroureterostomy using standard end-to-end anastomosis technique and intracorporeal retrograde double J stent placement. Robotic repair of ureteral injury during gynecologic surgery was associated with good outcomes, appeared safe and feasible, and saved the patient and the physician significant morbidity and medicolegal implications, respectively.