Manual of Robotic Surgery in Gynecology [First Edition] 9349057387, 9789349057388

Table of contents :
Front Cover
Half Title Page
Title Page
Copyright
Contributors
Foreword
Preface
Contents
Part 1: Basics: Understanding the Robot and Its Working
1. Evolution of Robotics in Gynecological Surgeries
2. Robotic da Vinci System: Machine and Instruments
3. Energy Sources in Robotics
4. Robotic OT Setup and Ergonomics
5. Training and Learning Curve in Robotic Surgery
6. Role of First Assistant in Robotic Surgery
Part 2: Robotic Benign Surgery
7. Robotic Hysterectomy for Benign Conditions
8. Robot-Assisted Laparoscopic Myomectomy (RALM)
9. Robotic Surgery for Endometriosis
10. Robot-Assisted Pelvic Organ Prolapse Repair
11. Robotics in Infertility Management
12. Robotics in Adnexal Surgery
13. Robotic Management of Urinary Fistulas
Part 3: Robotic Management in Malignancy
14. Robotic Assisted Pelvic and Para-aortic Lymph Node Dissection
15. Robot-Assisted Surgery in Cervical Cancer
16. Robotic Surgery for Endometrial Cancer
17. Robotic Surgery in Ovarian Cancer
Part 4: Miscellaneous
18. Anesthesia in Robotic Gynecological Surgery
19. Minimal Invasive vs Robotics: Evidence-based Practices in Gynecology
20. Complications in Robotic Surgery: Prevention and Management Strategy
21. Robotic Management of Complex Vesico-vaginal Fistula
Index
Back Cover

Citation preview

Manual of

Robotic Surgery in Gynecology

Manual of

Robotic Surgery in Gynecology Editors

Richa Sharma

MS MNAMS FICOG FICMCH FMAS

Director-Professor Department of Obstetrics and Gynaecology University College of Medical Sciences and GTB Hospital, Delhi

Bijoy Kumar Nayak MBBS MD

Anuradha Panda MD DGO FICOG

Head Department of Gynecology, Endoscopy and Robotic Surgery Max Super Speciality Hospital, Dwarka, Delhi

Senior Consultant Laparoscopic and Robotic Surgeon Apollo Hospitals Hyderabad

CBS Publishers & Distributors Pvt Ltd New Delhi  • Bengaluru  • Chennai  • Kochi  • Kolkata  • Lucknow  • Mumbai Hyderabad  • Jharkhand  • Nagpur  • Patna  • Pune  • Uttarakhand

Disclaimer Science and technology are constantly changing fields. New research and experience broaden the scope of information and knowledge. The authors have tried their best in giving information available to them while preparing the material for this book. Although, all efforts have been made to ensure optimum accuracy of the material, yet it is quite possible some errors might have been left uncorrected. The publisher, the printer and the authors will not be held responsible for any inadvertent errors, omissions or inaccuracies.

eISBN: 978-93-490-5738-8 Copyright © Authors and Publisher First e Book Edition: 2025

All rights reserved. No part of this eBook may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system without permission, in writing, from the authors and the publisher. Published by Satish Kumar Jain and produced by Varun Jain for CBS Publishers & Distributors Pvt. Ltd. Corporate O ice: 204 FIE, Industrial Area, Patparganj, New Delhi-110092 Ph: +91-11-49344934; Fax: +91-11-49344935; Website: www.cbspd.com; www.eduport-global.com; E-mail: [email protected] Head O ice: CBS PLAZA, 4819/XI Prahlad Street, 24 Ansari Road, Daryaganj, New Delhi-110002, India. Ph: +91-11-23289259, 23266861, 23266867; Fax: 011-23243014; Website: www.cbspd.com; E-mail: [email protected]; [email protected].

Branches Bengaluru: Seema House 2975, 17 th Cross, K.R. Road, Banasankari 2nd Stage, Bengaluru - 560070, Kamataka Ph: +91-80-26771678/79; Fax: +91-80-26771680; E-mail: [email protected] Chennai: No.7, Subbaraya Street Shenoy Nagar Chennai - 600030, Tamil Nadu Ph: +91-44-26680620, 26681266; E-mail: [email protected] Kochi: 36/14 Kalluvilakam, Lissie Hospital Road, Kochi - 682018, Kerala Ph: +91-484-4059061-65; Fax: +91-484-4059065; E-mail: [email protected] Mumbai: 83-C, 1st floor, Dr. E. Moses Road, Worli, Mumbai - 400018, Maharashtra Ph: +91-22-24902340 - 41; Fax: +91-22-24902342; E-mail: [email protected] Kolkata: No. 6/B, Ground Floor, Rameswar Shaw Road, Kolkata - 700014 Ph: +91-33-22891126 - 28; E-mail: [email protected]

Representatives Hyderabad Pune Nagpur Manipal Vijayawada Patna

Contributors Abhirami Giri Ramani  DNB (OBG)

Fellowship in Gynecological Oncology Junior Consultant, Gynecological Oncology and Robotic Surgery, Mazumdar Shaw Medical Center, Narayana Health City, Bangalore, India [email protected]

Abhishek Chandna  MS MCh (Urology) MRCS

Specialty Register, University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom [email protected]

Abhishek Mangeshikar  MS (OBGY) FMIGS ISON level 2 Consultant Gynecologist and Endometriosis Surgeon, Mumbai [email protected]

Amita Jain  MS Obstetrics and Gynecology

Fellowship Urogynaecology, James Cook University, Australia Consultant Urogynecology Medanta: The Medicity Hospital, Gurugram, Haryana [email protected]

Ankita Srivastava

Trainee MCh Reproductive Medicine and Surgery, Amrita Institute of Medical Sciences and Research Center, Kochi

Anupama Bahadur  DNB MNAMS

Professor Department of Obstetrics and Gynecology AIIMS Rishikesh [email protected]

Anuradha Panda  MD DGO FICOG

Senior Consultant Laparoscopic and Robotic Surgeon Apollo Hospitals, Hyderabad [email protected]

Bijoy Kumar Naik  MBBS MD

Head, Department of Gynecology, Endoscopy and Robotic Surgery, Max Super Speciality Hospital, Dwarka, Delhi

Dhiranjali

Associate Consultant Department of Gynecology, Endoscopy and Robotic Surgery Max Super Speciality Hospital, Dwarka, Delhi

Deepali Raina  MD

Intuitive Fellow in Robotic Surgery Kokilaben Dhirubhai Ambani Hospital, Mumbai [email protected]

Dinesh Kansal

Head and Director BLK-MAX Hospital, Delhi Laparoscopic and Robotic Surgeon

Deepika HK  MS (OBGY) FMAS

Assistant Professor MVJ Medical College and Research Hospital Bengaluru [email protected]

Girdhar Singh Bora  MS MCh (Urology)

Additional Professor Department of Urology, Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh, India [email protected]

Gourab Misra  MBBS MRCOG

Diploma in Advanced Gynecological Endoscopy, MCh in Robotic Surgery, Consultant Gynecological Surgeon University Hospitals of North Midlands, Stoke-onTrent, United Kingdom [email protected]

M Keerthi Reddy  MS (Obstetrics and Gynecology)

Fellowship in Laparoscopic and Robotic Surgery Apollo Hospitals, Jubilee Hills Hyderabad [email protected]

Liliana Mereu

Department of Obstetrics and Gynecology Policlinico G Rodolico, CHIRMED, University of Catania, Catania, Italy

Lyndon Gommersall  FRCS (Urol) MD

University Hospitals of North Midlands, Stoke-onTrent, United Kingdom [email protected]

Mala Srivastava

Professor-Scientist, ICMR Project at Institute of Obstetrics and Gynecology Sir Ganga Ram Hospital, New Delhi

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Manual of Robotic Surgery in Gynecology

Mariam Anjum Ifthikar 

MS PGDCR (Gynecology and oncology)

Associate Professor, Gynecologic Oncology and Robotic Surgeon Zulekha Yenepoya Institute of Oncology Yenepoya (Deemed to be) University Mangalore, Karnataka [email protected]

Laparoscopic and Robotic Surgeon Apollo Hospitals, Hyderabad [email protected]

Rupa Bana

Consultant, Laparoscopic and Robotic Surgeon Apollo Hospitals, Hyderabad

Shree Bharati  MS (OBG) DNB (OBG) FMAS

Neema Tufchi

Research Scientist, ICMR Project at Institute of Obstetrics and Gynecology Sir Ganga Ram Hospital, New Delhi

Fellow in Gynecology Oncology and Robotic Surgery, Mazumdar Shaw Medical Center Narayana Health City, Bangalore, India [email protected]

Neha Kamath  MS (OBGY)

Sanath Reddy  MD

Senior Resident, Gynecologic Oncology Zulekha Yenepoya Institute of Oncology, Mangalore, Karnataka [email protected]

Senior Consultant Anesthesiology Apollo Hospitals, Hyderabad [email protected]

Rajlaxmi Mundhra  MD DNB

Division of Gynecology and Obstetrics Department of Surgical Sciences University of Cagliari, Cagliari, Italy

Additional Professor Department of Obstetrics and Gynecology AIIMS Rishikesh [email protected]

Richa Sharma  MS MNAMS FICOG FICMCH FMAS

Director-Professor Department of Obstetrics and Gynaecology University College of Medical Sciences and GTB Hospital, Delhi [email protected]

Rohit Raghunath Ranade  MS, MCh (Gyneconcology) Fellowship in Advanced Robotic and Laparoscopic Surgery Consultant Gynecological Oncology and Robotic Surgery, Mazumdar Shaw Medical Center, Narayana Health City, Bangalore, India Ranade.rohit @gmail.com

Rooma Sinha  MD DNB

Honorary Professor (AHERF) Department of Gynecology Associate Professor Macquarie University, Australia

Salvatore Giovanni Vitale

Santhosh Kumari M

Senior Consultant Anesthesiology Apollo Hospitals, Hyderabad

Supriya Mahipal

Associate Consultant, BLK-MAX Hospital, Delhi

Stefania Saponara

Division of Gynecology and Obstetrics Department of Surgical Sciences University of Cagliari Cagliari, Italy

Yamini Kansal  MCh

Gynae Oncosurgeon, Dehradun BLK-MAX Hospital, Delhi

Yogesh Kulkarni  MD DNB

Head, Gynecological Oncology and Robotic Surgery, Kokilaben Dhirubhai Ambani Hospital, Mumbai [email protected]



vii

Foreword

I

t is my privilege to write the Foreword to the Manual of Robotic Surgery in Gynecology. After being initiated into the robotic programme, I find that it does make complex gynecological surgeries easy with unprecedented precision, dexterity and control. It would be a good proposition to learn the art, a good book on robotics is necessary with more and more laparoscopic surgeons venturing into the new field. This book provides an authoritative and up-to-date overview of the subject, technical nuances and practical tips. The editors and authors have done a commendable job in selecting the topics and keeping the narrative to the point. Readers will gain an insight into patient selection, surgical steps and postoperative care. This book will be valuable for budding gynecologists, beginners and those into the field of robotic surgery.

Padmashri Dr Alka Kriplani

MBBS, MD, FRCOG, FAMS, FICOG, FIMSA, FICMCH, FCLS

Chairperson—Obstetrics, Gynaecology & ART Paras Health, Gurugram



ix

Preface

M

anual of Robotic Surgery in Gynecology is a comprehensive book that is designed to provide A to Z information about gynecological robotic surgery. Robotic surgery is a recent innovation in minimally invasive surgery. Robotic systems have ushered in a new era of gynecological care. There is a lot of enthusiasm among gynecologists to know and learn about this new technique. A good knowledge of the robot, instruments and OT setup is necessary for gaining proficiency in this field. This book has a compilation of chapters that can give practical tips for starting the program. The illustrations and key points will also be helpful to beginners and trainees. This is a collective effort of clinicians with experience in the field. They share their experience with clinically relevant topics in robotic surgery. Starting from benign conditions like fibroids to oncology, the chapters provide insights into how robotic surgery revolutionises surgical outcomes and patient care. The contribution of various eminent authors has turned this book into an excellent piece of knowledge and information for the readers. This is the recommended book, which will serve as a reference for clinicians and budding robotic surgeons. We thank our contributors and publishers for bringing out this book. Richa Sharma Bijoy Kumar Nayak Anuradha Panda



xi

Acknowledgments

W

e express our deepest gratitude to all the eminent authors for sparing their time and contributing to the chapters, their valuable contribution of knowledge has resulted in this book into a signature piece of its kind. Surgical photographs are beautifully incorporated and will be useful in everyone’s routine practice. The best part of acknowledgments is that we get to thank all the people who have supported us in writing the book, since it is a combined effort of all people who have come together in many different ways. Foremost we want to offer this endeavor to the Almighty for the wisdom He bestowed upon us, the strength, peace of mind and good health in order to finish this book. Our heartfelt thanks to CBS Publishers & Distributors to convert our dream into reality. Their support has been indispensable in bringing out this book to life. We are greatly thankful to our editorial team for perfect coordination of work, support and encouragement. We cannot express enough thanks to our loving families for providing immense support and motivation to accomplish this endeavor. Richa Sharma Bijoy Kumar Nayak Anuradha Panda



xiii

Contents Contributors v Foreword by Padmashri Dr Alka Kriplani vii Preface ix

Part 1: Basics: Understanding the Robot and Its Working

1. Evolution of Robotics in Gynecological Surgeries

3

Salvatore Giovanni Vitale, Liliana Mereu, Stefania Saponara

2. Robotic da Vinci System: Machine and Instruments 

17

Anupama Bahadur, Richa Sharma

3. Energy Sources in Robotics 

27

Anuradha Panda, M Keerthi Reddy

4. Robotic OT Setup and Ergonomics 

33

Anuradha Panda, Deepika HK

5. Training and Learning Curve in Robotic Surgery 

45

Rooma Sinha, Rupa Bana

6. Role of First Assistant in Robotic Surgery 

49

Mariam Anjum Ifthikar, Neha Kamath



Part 2: Robotic Benign Surgery

7. Robotic Hysterectomy for Benign Conditions 

57

Rooma Sinha, Rupa Bana

8. Robot-Assisted Laparoscopic Myomectomy (RALM) 

70

Anupama Bahadur, Rajlaxmi Mundhra

9. Robotic Surgery for Endometriosis 

78

Abhishek Mangeshikar

10. Robot-Assisted Pelvic Organ Prolapse Repair 

94

Dinesh Kansal, Supriya Mahipal, Yamini Kansal

11. Robotics in Infertility Management 

12. Robotics in Adnexal Surgery 

101

Mala Srivastava, Neema Tufchi, Ankita Srivastava

108

Mala Srivastava, Neema Tufchi, Ankita Srivastava

13. Robotic Management of Urinary Fistulas  Amita Jain

114

xiv



Manual of Robotic Surgery in Gynecology

Part 3: Robotic Management in Malignancy

14. Robotic Assisted Pelvic and Para-aortic Lymph Node Dissection 

125

Rohit Raghunath Ranade, Shree Bharati

15. Robot-Assisted Surgery in Cervical Cancer 

143

Rohit Raghunath Ranade, Abhirami Giri Ramani

16. Robotic Surgery for Endometrial Cancer 

157

Yogesh Kulkarni, Deepali Raina

17. Robotic Surgery in Ovarian Cancer 

168

Yogesh Kulkarni, Deepali Raina



Part 4: Miscellaneous

18. Anesthesia in Robotic Gynecological Surgery 

177

Sanath Reddy, Santhosh Kumari

19. Minimal Invasive vs Robotics: Evidence-based Practices in Gynecology 

198

Bijoy Nayak, Dhiranjali, Richa Sharma

20. Complications in Robotic Surgery: Prevention and Management Strategy 

202

Abhishek Chandna, Gourab Misra, Lyndon Gommersall, Girdhar Singh Bora

21. Robotic Management of Complex Vesico-vaginal Fistula 

212

Abhishek Chandna, Lyndon Gommersall, Giridhar Singh Bora

Index

221



1

1



1. Evolution of Robotics in Gynecological Surgeries 2. Robotic da Vinci System: Machine and Instruments 3. Energy Sources in Robotics 4. Robotic OT Setup and Ergonomics 5. Training and Learning Curve in Robotic Surgery 6. Role of First Assistant in Robotic Surgery

Basics: Understanding the Robot and Its Working

Basics: Understanding the Robot and Its Working

1

1

Evolution of Robotics in Gynecological Surgeries

3

1 Evolution of Robotics in Gynecological Surgeries • Salvatore Giovanni Vitale  • Liliana Mereu  • Stefania Saponara

Robotic surgery, or surgery assisted by robot, leverages sophisticated robotic systems to conduct surgical operations. These systems are typically composed of robotic arms operated by surgeons, who use small instruments and a high-definition camera, enhancing precision and dexterity during the procedures. The robotic platform converts the surgeon’s hand movements into precise actions within the patient’s body, facilitating minimally invasive procedures with improved accuracy.1–3 Robotic surgery has become crucial in obstetrics and gynecology, offering significant benefits to patients and healthcare providers. In gynecology, robots are increasingly utilized for operations such as hysterectomies, myomectomies, and ovarian cystectomies.1–3 The key advantages of robotic surgery in these areas include reduced trauma, minimized blood loss, shorter hospital stays, and faster recovery times. Furthermore, robotic systems’ enhanced visualization and precision allow surgeons to perform intricate procedures more easily and safely.1–3 This chapter investigates the evolution of robotic surgery in obstetrics and gynecology, covering its historical development, current uses, and future prospects. By exploring the historical context, present state, and potential future advancements of robotic surgery in this field, the chapter aims to highlight the transformative impact of this technological innovation on surgical practices. HISTORICAL BACKGROUND The development of robotic surgery in gynecology is intricately connected to the broader history of robotic applications in medicine. The idea of using robotic systems for surgical procedures began in the 1980s when the National Aeronautics and Space Administration (NASA) and the Stanford Research Institute developed the first telepresence surgery systems.1 These early systems were designed to enable surgeons to operate on patients remotely in hazardous environments, such as space or battlefields, demonstrating the potential for remote and minimally invasive surgical interventions.

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Manual of Robotic Surgery in Gynecology

In the 1990s, the focus shifted towards adapting these technologies for clinical use. One of the pioneering robotic systems in surgery was the Automated Endoscopic System for Optimal Positioning (AESOP) by Computer Motion.1 AESOP was a voice-activated robotic arm that held and positioned the endoscope, freeing the surgeon’s hands and enhancing the precision of laparoscopic procedures. This innovation paved the way for more sophisticated robotic systems. A significant breakthrough in robotic surgery came with the development of the ZEUS Robotic Surgical System by Computer Motion. Using three robotic arms, ZEUS enabled surgeons to perform complex procedures with enhanced precision and control. One arm held the endoscope while the other two manipulated surgical instruments, all controlled by the surgeon from a console. Despite its capabilities, ZEUS had limitations, such as the lack of 3D visualization and limited instrument articulation.1 The early 21st century saw a revolution with the introduction of the da Vinci® Surgical System by Intuitive Surgical, which received FDA approval for general laparoscopic surgery in 2000 and for gynecological surgery in 2005.2 The da Vinci® system addressed many limitations of its predecessors by providing a high-definition, three-dimensional view of the surgical field and articulated instruments with seven degrees of freedom. This system allowed surgeons to perform intricate procedures with unprecedented precision and dexterity, marking the true beginning of robotic surgery in gynecology.3 The adoption of the da Vinci® system was initially slow due to high costs and the significant learning curve associated with its use. However, its advantages in terms of reduced patient trauma, shorter recovery times, and improved surgical outcomes soon led to its widespread acceptance. By the mid-2000s, robotic surgery had become a standard option for many gynecological procedures, particularly those requiring high precision, such as hysterectomies, myomectomies, and surgeries for endometriosis.2 As robotic technology continued to evolve, so did its applications in gynecology. The development of newer models, such as the da Vinci® S, Si, Xi, and 5 brought incremental improvements in imaging, instrument versatility, and overall system ergonomics.2,3 These advancements have allowed for more complex and varied procedures to be performed robotically, further solidifying the role of robotics in gynecological surgery.

Part 1

EARLY DEVELOPMENTS IN ROBOTIC SURGERY IN OBSTETRICS AND GYNECOLOGY

1

The initial strides in robotic surgery within obstetrics and gynecology can be traced back to the introduction of the da Vinci® Surgical System, a pivotal innovation that significantly transformed surgical practices. The initial reception of the da Vinci® system in gynecology was a mix of excitement and skepticism. Surgeons and medical professionals were eager to explore the potential benefits of this new technology yet concerns about cost and the steep learning curve were prevalent. Despite these challenges, the early successes of robotic-assisted surgeries in gynecology paved the way for broader acceptance and further advancements.1–3 One of the first significant milestones in the history of robotic surgery in obstetrics and gynecology was the successful completion of a robotic-assisted hysterectomy.2 This showcased the potential of robotic systems to perform complex surgeries with minimal invasiveness, resulting in reduced recovery times and improved patient outcomes. As more surgeons began to adopt the technology, the range of procedures performed using

Evolution of Robotics in Gynecological Surgeries

5

robotic systems expanded, including myomectomies, ovarian cystectomies, and even some cancer surgeries.1–3 The early 2000s also saw the development of training programs and certification processes for surgeons wishing to specialize in robotic surgery.2,3 These programs were crucial in ensuring surgeons were adequately prepared to use the new technology safely and effectively. The development of these training programs marked a significant step forward in integrating robotic systems into mainstream surgical practice.

Key Robotic Procedures in Gynecology Hysterectomy Robotic-assisted hysterectomy is frequently employed to remove the uterus, often addressing benign conditions like uterine fibroids or endometriosis. This minimally invasive procedure has gained popularity due to its numerous benefits, including smaller incisions, reduced blood loss, and quicker recovery times than traditional open surgery.4 The precision provided by robotic systems allows surgeons to navigate complex anatomical structures with ease, ensuring accuracy and care.4 A recent meta-analysis found no significant differences between robotic and laparoscopic hysterectomies for benign disease regarding estimated blood loss, bleedingrelated complications, hospital stay length, postoperative pain levels, recovery time, and total operating time​​. Despite ongoing debates about the utility of robotic hysterectomy

Fig. 1.1:  Key robotic procedures in gynecology

Basics: Understanding the Robot and Its Working

Current State of Robotic Surgery in Gynecology Today, robotic surgery is widely used in various gynecological procedures (Fig. 1.1). The da Vinci® system remains the leading platform, continuously evolving with newer models such as the da Vinci® Xi and da Vinci® 5, which offer improved capabilities and flexibility2 (Fig. 1.2A and B).

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(A)

(B)

Fig. 1.2A and B: da Vinci® systems: (A) The first generation, 1999; (B) the fifth generation, 2024. © Intuitive Surgical

Part 1

for benign diseases, postoperative quality of life has been reported to be significantly higher in the robotic group.5

1

Myomectomy Robotic-assisted myomectomy is another prevalent application in gynecology, involving the surgical removal of uterine fibroids. This method offers several advantages over conventional approaches, such as enhanced visualization and dexterity, allowing surgeons to remove fibroids while preserving the uterus.4 This is particularly beneficial for women aiming to maintain fertility. The minimally invasive approach reduces postoperative pain and shortens hospital stays, improving patient experience.4 A recent meta-analysis indicated better outcomes with robotic-assisted myomectomy, including fewer complications, less estimated blood loss, fewer blood transfusions, and shorter hospital stays, though the surgery duration was longer than open myomectomy.6 The conversion rate to laparotomy was also much lower than that of laparoscopic surgery. The robotic platform’s 3D vision system allows for precise and ergonomic suturing, reducing complication rates compared to laparoscopic and open surgeries.6 Further studies are needed to assess long-term outcomes such as postoperative pain and fertility​​. Ovarian Cystectomy Robotic-assisted ovarian cystectomy involves the removal of cysts from the ovaries with minimal damage to surrounding tissues, preserving ovarian function and fertility. The precision and control offered by robotic systems allow for the excision of cysts while maintaining ovarian integrity. Enhanced visualization helps identify and remove cysts that might be challenging to detect using traditional surgical methods.4

Evolution of Robotics in Gynecological Surgeries

7

Sacrocolpopexy Pelvic organ prolapse (POP) involves the descent of pelvic organs such as the bladder, uterus, vagina, or rectum from their normal positions. Laparoscopic sacrocolpopexy provides less postoperative pain and shorter recovery times but has limitations due to reduced freedom and increased operation times. Robotic-assisted techniques overcome these limitations with 3D visualization, increased degrees of freedom, and improved ergonomics9​​ (Fig. 1.3). Studies comparing laparoscopic and robotic-assisted surgeries showed higher postoperative pain scores, analgesic demands, and longer surgery times for laparoscopic procedures. However, both methods had reduced blood loss compared to ASC.9,10 More long-term data on success and revision rates are needed. Robotic Surgery in Malignant Gynecological Conditions Robotic surgery has become a pivotal method for treating gynecologic cancers, valued for its precision and stability. Among various gynecologic cancers, endometrial cancer is the most commonly treated using robotic surgery, comprising 51% of cases, followed by cervical and ovarian cancers.11

Fig. 1.3  Robotic sacrocolpopexy

Basics: Understanding the Robot and Its Working

Endometriosis Surgery Robotic surgery has proven to be highly effective in treating endometriosis, a condition where tissue similar to the uterine lining grows outside the uterine cavity. Roboticassisted endometriosis surgery allows for precise removal of endometrial tissue, reducing recurrence risk and alleviating symptoms such as pain and infertility.7,8 The minimally invasive nature of the procedure results in smaller incisions, less scarring, and faster recovery times, making it an attractive option for patients. The introduction of robotic surgery has provided new perspectives on DIE, enabling 3D imaging and access to complex anatomical structures and improving surgical performance without increasing surgical time, bleeding, or complication risks.7,8 With a low conversion rate to laparotomy and a short learning curve, robotic surgery is increasingly considered the best option for DIE treatment.8

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Part 1

Endometrial Cancer Minimally invasive surgery (MIS) is the favored approach for managing endometrial cancer. Despite some studies suggesting that robotic surgery might take longer, it typically has a shorter duration than traditional laparoscopic surgery.12,13 The difference in time is negligible when performed by experienced surgical teams, with the benefits of robotic surgery often outweighing this difference.12,13 Moreover, obese patients with endometrial cancer greatly benefit from robotic surgery. Historically, obesity was considered a contraindication for laparoscopic surgery because of the difficulty in accessing anatomical spaces and the associated comorbidities, such as cardiovascular and respiratory diseases.14 However, studies have shown that laparoscopy offers significant advantages for obese patients, including reduced blood loss, lower infection rates, and decreased embolism risk. Recently, robotic surgery has demonstrated lower conversion rates and numerous benefits, such as shorter surgical times, reduced hospital stays, and decreased blood loss compared to traditional laparoscopy in obese women with endometrial cancer.15 Additionally, several studies have consistently demonstrated a shorter and easier learning curve with robotics compared to laparoscopy for performing complex procedures in gynecological cancer.16,17 Seamon et al. found that surgeons could achieve proficiency in performing a robotic hysterectomy with pelvic-aortic lymph node dissection after around 20 cases, with further skill enhancements leveling off between 50 and 70 cases.16

1

Cervical Cancer For early-stage cervical cancer, patients can choose MIS options, including radical hysterectomy or radical trachelectomy. Trachelectomy is primarily selected by patients who wish to preserve fertility. Studies have shown that robotic surgery outcomes are better than open surgery, making it a viable option.18 However, in 2018, a phase III randomized controlled trial called “Laparoscopic Approach to Carcinoma of the Cervix (LACC)” unexpectedly reported that MIS was associated with significantly poorer overall survival and disease-free survival compared to open surgery in early-stage cervical cancer patients.19 The results of the LACC trial have led some clinicians to reconsider the use of robotic surgery for cervical cancer, with many opting for radical hysterectomy via laparotomy instead. Recently, long-term safety concerns about oncologic outcomes associated with MIS (laparoscopy and robotic assistance) in early cervical cancer management prompted the US FDA to issue a ‘safety communication.’ On February 28, 2019, the US FDA cited ‘limited, preliminary evidence’ that the use of robotically assisted surgical devices for treating or preventing cancers (e.g., breast and cervical) might be linked to reduced long-term survival.20 The FDA acknowledged that while these devices allow for quicker recovery and improved surgical techniques, limited studies have assessed specific oncologic clinical outcomes like local cancer recurrence, disease-free interval, or overall survival.20 Ovarian Cancer Debulking surgery for ovarian cancer is intricate and time-consuming, as the lesions often spread extensively within the abdominal cavity. Despite generally poor prognoses, patients typically undergo adjuvant chemotherapy following surgery. Neoadjuvant chemotherapy followed by interval cytoreductive surgery has recently become more

Evolution of Robotics in Gynecological Surgeries

9

Robot-assisted Single-Site Laparoscopy Robot-assisted Single-Site Laparoscopy (R-LSS) represents a significant advancement in minimally invasive gynecological surgery, combining the technological benefits of robotic systems with the aesthetic and recovery advantages of single-incision techniques.24 The da Vinci® Single-Site platform, introduced in 2010 by Intuitive Surgical, includes specialized instruments and accessories designed to enhance single-incision laparoscopic surgery (Fig. 1.4). This platform has been tested successfully in cadaver models and live surgeries, promising to improve surgical outcomes and ergonomics.25 In 2010, Nam et al. performed the first R-LSS hysterectomy using the da Vinci® platform.26 The Food and Drug Administration (FDA) approved the da Vinci® SingleSite platform for R-LSS hysterectomy and adnexal surgery in 2013.27 Early studies and clinical experiences demonstrated that R-LSS could be performed without conversion to multiport robotic-assisted laparoscopy (M-RAL) or traditional laparoscopy, showing no serious postoperative complications.28,29 The learning curve for the da Vinci® Single-Site system was noted to be steep but manageable, with significant reductions in operative and console times as surgical teams gained experience. This platform’s use of specific single-port instruments and high-resolution 3D optical cameras has significantly improved the surgical field’s visualization and the overall ergonomic experience for surgeons.27

Fig. 1.4:  Instrumental setting for reduced-port robotic surgery (© Song JW et al. Long-Term Outcomes of Reduced-Port Robotic Surgery (RPRS) for Uterine Myomectomy with the da Vinci Surgical System.  Clin. Exp. Obstet. Gynecol 2022, 49(9), 200. doi:10.31083/j. ceog4909200. Licensed under the Creative Commons Attribution 4.0)

Basics: Understanding the Robot and Its Working

common, based on results from the International Mission study.21 When the response to neoadjuvant chemotherapy is excellent, MIS, including robotic surgery, may be used depending on the cancer cell type. While interval robotic cytoreduction can be an option for selected patients, the standard treatment for ovarian cancer remains cytoreductive surgery via laparotomy.22,23

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Manual of Robotic Surgery in Gynecology

R-LSS has been successfully applied in various benign gynecological surgeries, including myomectomy, pelvic floor reconstructive surgery, endometrioma excision and non-endometriotic cystectomy.24,27 Robotic platforms in these procedures offer several advantages, such as improved visualization through high-resolution 3D cameras, enhanced dexterity with wristed instruments, and better ergonomic conditions for the surgeon. For instance, the application of R-LSS in myomectomy (Fig. 1.5) has shown shorter operative times and reduced intraoperative blood loss compared to multiport robotic-assisted surgeries, attributed to efficient in-bag morcellation through a larger umbilical port.27,30 In the realm of oncology, R-LSS has proven feasible and safe for low-risk early endometrial cancer and other gynecological cancers. Comparative studies between R-LSS and M-RAL indicate similar surgical outcomes, with some studies suggesting reduced hospital costs and shorter lengths of stay for R-LSS.27,31 Moreover, a multicentric Italian study has demonstrated that the robotic single-site hysterectomy (RSSH) for obese

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Fig. 1.5:  Robotic single-site myomectomy. (A) Robotic camera view; (B) Traction and countertraction of myoma (C) Myoma traction with a tenaculum grasper. (D) After myoma enucleation; (E) Suturing the uterus; (F) After suturing. (© Choi SH et al. Coaxial-Robotic Single-Site Myomectomy: Surgical Outcomes Compared with Robotic Single-Site Myomectomy by Propensity Score Matching Analysis. J Pers Med. 2022;13(1):17. doi:10.3390/jpm13010017. Licensed under the Creative Commons Attribution 4.0)

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Advantages and Limitations of Robotic Surgery in Gynecology Advantages Robotic surgery has revolutionized gynecological surgical practices, offering numerous benefits that enhance surgical precision and patient outcomes (Table 1.1). A key advantage is the improved operative field visualization, allowing for more precise and accurate procedures. Surgeons gain a clear, magnified view of anatomical structures, enabling them to navigate intricate surgical pathways with confidence. This enhanced visual clarity significantly improves surgical outcomes and increases patient safety.33 The dexterity provided by the robot’s arms is another crucial benefit, giving surgeons greater precision and control. This capability allows for the execution of complex procedures with increased ease and efficiency, achieving optimal results while minimizing the risk of errors. The intuitive motion-scaling technology of robotic systems enables precise tissue manipulation, facilitating delicate navigation through complex anatomical structures.2,33 Robotic surgery also mitigates the effects of surgeon tremors by providing steady robotic arms, reducing the risk of complications. Surgeons can perform precise Table 1.1: Advantages and limitations of robotic surgery in obstetrics and gynecology Advantages

Limitations

Enhanced visualization for precise and accurate High cost of robotic surgery procedures Greater precision and control with robot's arms

Steep learning curve requiring extensive training

Reduced surgeon tremors and improved Need for more high-quality evidence and longinstrument control term data Ergonomic design reduces surgeon fatigue and Longer operative times during initial stages strain Minimally invasive procedures with smaller Maintenance and calibration of robotic equipment incisions and faster recovery add complexity and cost Shorter hospital stays and less postoperative pain Limited accessibility in certain regions or healthcare for patients systems Reduced risk of infection and complications Risks of complications such as infection, bleeding, associated with larger incisions or tissue damage Promotes surgeon well-being and performance

Need for standardization in robotic surgery techniques

Basics: Understanding the Robot and Its Working

patients with endometrial cancer has an advantage in terms of reduced invasiveness for patients in the first BMI class.32 R-LSS appears to be a viable and effective alternative to traditional multi-port laparoscopic and robotic-assisted surgeries in gynecology. It offers several technical advantages, such as restored triangulation at the surgical site, enhanced ergonomics, and improved cosmetic outcomes.24,27 However, more randomized controlled trials are necessary to establish high-quality evidence regarding its non-inferiority and safety compared to other minimally invasive approaches. Additionally, comprehensive costbenefit analyses are crucial to justify the higher financial costs associated with robotic surgery, limiting its application to selected patients.

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maneuvers without the interference of involuntary movements, ensuring consistent instrument control and minimizing tissue trauma. This feature is particularly beneficial in delicate procedures, enhancing surgical accuracy and patient safety.2,33 Additionally, the ergonomic design of the robotic platform reduces surgeon fatigue and strain, leading to a more comfortable surgical experience. This ergonomic advantage is crucial during lengthy procedures, allowing surgeons to maintain their focus and precision throughout the operation, ultimately benefiting patient outcomes. Surgeons operate seated at a console with ergonomic hand controls and adjustable display settings, minimizing physical discomfort during prolonged procedures. This ergonomic optimization promotes surgeon well-being and enhances overall surgical performance. The console’s design allows surgeons to maintain a comfortable posture, reducing the risk of musculoskeletal strain and fatigue, which is particularly important during lengthy and complex surgeries.2,33 The robotic platform’s ability to facilitate minimally invasive procedures results in smaller incisions, reduced blood loss, and faster patient recovery times. These benefits contribute to a more positive patient experience, less postoperative pain and shorter hospital stays. The minimally invasive nature of robotic surgery also reduces the risk of infection and other complications associated with larger incisions, further enhancing patient safety and recovery.1,33 This combination of advantages makes robotic surgery an attractive option for patients and surgeons, driving its continued adoption and integration into gynecologic practice.

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Limitations Despite its numerous advantages, robotic surgery in obstetrics and gynecology also presents challenges and limitations that impact its widespread adoption and utilization (Table 1.1). The high cost of robotic surgery is a significant barrier, as it is considerably higher than traditional surgical techniques, potentially limiting access for patients and healthcare institutions.2,11 Additionally, there is a steep learning curve associated with robotic surgery, requiring surgeons to undergo extensive training to attain proficiency. This learning curve can result in longer operative times and increased costs during the initial stages of implementation.2,11 Moreover, the need for more high-quality evidence and long-term data comparing the outcomes of robotic surgery with traditional techniques poses a challenge. While robotic surgery offers improved visualization and dexterity, it may not necessarily translate into shorter operative times compared to open or conventional laparoscopic techniques. Furthermore, the maintenance and calibration of robotic equipment add to surgical procedures’ complexity and overall cost. Accessibility to robotic surgery may be limited due to its high cost and restricted availability in certain regions or healthcare systems, contributing to disparities in patient access to advanced surgical care.2,11 Like any surgical procedure, robotic surgery carries risks of complications such as infection, bleeding, or damage to surrounding tissues. The need for standardization in robotic surgery techniques further complicates matters, leading to inconsistencies in surgical approach and outcomes. While robotic surgery offers considerable advantages in obstetrics and gynecology, including improved precision and patient outcomes, it also presents significant challenges that must be addressed to optimize its utilization and accessibility in clinical practice.2,11 Efforts to mitigate these challenges, such as reducing costs, enhancing

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training programs, and standardizing surgical techniques, are essential to realize the full potential of robotic surgery in improving patient care. Future Perspectives Micro-Robotics and Miniaturization The creation of microbots, or miniaturized robots, marks a significant leap in surgical technology. These microbots are smaller, faster, and more efficient than conventional robotic systems, opening new avenues for less invasive surgeries. They can navigate and access intricate anatomical structures with remarkable precision, making minimally invasive surgeries possible when traditional tools are too bulky. Micro-robotics allow surgeons to perform procedures with enhanced accuracy, reducing tissue damage and accelerating patient recovery times.34

Advanced Imaging Integration Integrating advanced imaging techniques such as 3D and intraoperative imaging into robotic surgery is anticipated to improve surgical precision and outcomes. These imaging technologies provide detailed, real-time visual information, aiding in more accurate planning and execution of surgeries.36 3D imaging creates comprehensive anatomical models, enabling surgeons to visualize complex structures and plan their approach more accurately. Intraoperative imaging, such as real-time MRI or CT scans, offers continuous feedback during surgery, allowing immediate adjustments and ensuring optimal outcomes.36 Artificial Intelligence and Machine Learning The inclusion of artificial intelligence (AI) and machine learning in robotic surgery is expected to revolutionize the field. These advanced technologies can aid in real-time decision-making, optimize surgical planning, and enhance the precision of robotic procedures.35 AI algorithms can analyze vast amounts of patient data and surgical outcomes to identify patterns and trends, helping surgeons make more informed decisions during operations. Machine learning algorithms can adapt and improve over time, increasing their utility in robotic surgery.35 Augmented Reality and Virtual Reality in Training Augmented reality (AR) and virtual reality (VR) in surgical training represent an exciting advancement in robotic surgery. These immersive technologies create realistic and interactive training environments, allowing surgeons to practice and hone their skills safely. AR and VR simulations can replicate complex surgical scenarios, enabling surgeons to gain valuable experience and confidence before operating on actual patients.35

Basics: Understanding the Robot and Its Working

Enhanced Sensory Feedback and Haptic Technology Developments in haptic technology aim to provide tactile feedback to surgeons during robotic-assisted surgeries, addressing a common limitation of current robotic systems. Enhanced haptic feedback can improve the surgeon’s ability to handle tissues and instruments with precision, lowering the risk of accidental damage and improving overall surgical outcomes. Integrating sensory feedback into robotic systems increases the surgeon’s situational awareness, making surgical maneuvers more intuitive and effective.35

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Remote Surgery and Telepresence The expansion of remote surgery, telesurgery or telepresence, is poised to transform healthcare by enabling surgeons to operate on patients in different locations.37 This trend has the potential to improve access to high-quality surgical care, particularly in underserved or remote areas. Through telepresence technology, expert surgeons can guide and assist local surgical teams, ensuring that patients receive top-notch care regardless of location.37 This global sharing of surgical expertise can reduce healthcare disparities, providing equitable access to advanced surgical techniques and improving patient outcomes worldwide. Personalized Medicine and Customized Surgical Planning The future of robotic surgery promises advancements in personalized medicine and patient-specific surgical planning. Progress in genomics, molecular biology, and data analytics allows for the development of tailored surgical approaches based on individual patient characteristics.38 Surgeons can design personalized surgical plans that optimize outcomes and minimize risks by analyzing a patient’s genetic profile, medical history, and specific anatomical features. Robotic systems can be programmed to execute these customized plans with precision, ensuring that each patient receives the most appropriate and effective treatment.38 Personalized medicine in robotic surgery offers targeted interventions and improved outcomes for various gynecological conditions.

1. The integration of robotic technology into gynecologic surgery has dramatically transformed the field, offering numerous advantages that enhance surgical precision, improve patient outcomes, and shorten recovery periods. 2. As technological advancements continue, the potential for further enhancements in robotic surgery is substantial, promising even more significant benefits for patients and healthcare providers. 3. Continued research and development in this area are expected to yield new innovations and applications, solidifying the role of robotic surgery in the future of gynecologic healthcare.

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REFERENCES

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1. Camarillo DB, Krummel TM, Salisbury JK. Robotic technology in surgery: past, present, and future. Am J Surg. 2004;188(4A Suppl):2–15. 2. Yadav P, Chaudhari K, Dave A, Sindhu A. Exploring the Evolution of Robotic Surgery in Obstetrics and Gynecology: Past, Present, and Future Perspectives. Cureus. 2024;16(3):e57155. 3. Rivero-Moreno Y, Echevarria S, Vidal-Valderrama C, Stefano-Pianetti L, Cordova-Guilarte J, Navarro-Gonzalez J, et al. Robotic Surgery: A Comprehensive Review of the Literature and Current Trends. Cureus. 2023;15(7):e42370. 4. Robot-Assisted Surgery for Noncancerous Gynecologic Conditions: ACOG Committee Opinion, Number 810. Obstet Gynecol. 2020;136(3):E22–30. 5. Albright BB, Witte T, Tofte AN, Chou J, Black JD, Desai VB, et al. Robotic Versus Laparoscopic Hysterectomy for Benign Disease: A Systematic Review and Meta-Analysis of Randomized Trials. J Minim Invasive Gynecol. 2016;23(1):18–27. 6. Wang T, Tang H, Xie Z, Deng S. Robotic-assisted vs. laparoscopic and abdominal myomectomy for treatment of uterine fibroids: a meta-analysis. Minim Invasive Ther Allied Technol. 2018;27(5):249–64.

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7. Restaino S, Mereu L, Finelli A, Spina MR, Marini G, Catena U, et al. Robotic surgery vs laparoscopic surgery in patients with diagnosis of endometriosis: a systematic review and meta-analysis. J Robot Surg. 2020;14(5):687–94. 8. Cela V, Obino ME, Sergiampietri C, Simi G, Papini F, Pinelli S, et al. The role of robotics in the management of endometriosis. Minerva Ginecol. 2017;69(5):504–16. 9. Seror J, Yates DR, Seringe E, Vaessen C, Bitker MO, Chartier-Kastler E, et al. Prospective comparison of short-term functional outcomes obtained after pure laparoscopic and robot-assisted laparoscopic sacrocolpopexy. World J Urol. 2012;30(3):393–8. 10. Simoncini T, Panattoni A, Aktas M, Ampe J, Betschart C, Bloemendaal ALA, et al. Robot-assisted pelvic floor reconstructive surgery: an international Delphi study of expert users. Surg Endosc. 2023;37(7):5215–25. 11. Park JY, Bak SE, Song JY, Chung YJ, Yuki G, Lee SJ, et al. Robotic surgery in Gynecology: the present and the future. Obstet Gynecol Sci. 2023;66(6):518. 12. Mäenpää MM, Nieminen K, Tomás EI, Laurila M, Luukkaala TH, Mäenpää JU. Robotic-assisted vs traditional laparoscopic surgery for endometrial cancer: a randomized controlled trial. Am J Obstet Gynecol. 2016;215(5):588.e1-588.e7. 13. Corrado G, Vizza E, Perrone AM, Mereu L, Cela V, Legge F, et al. Comparison Between Laparoscopic and Robotic Surgery in Elderly Patients With Endometrial Cancer: A Retrospective Multicentric Study. Front Oncol. 2021;11:724886. 14. Corrado G, Bruni S, Vizza E. Robotic surgery in early-stage endometrial cancer. Transl Cancer Res. 2019;8(Suppl 6):S573. 15. Corrado G, Vizza E, Cela V, Mereu L, Bogliolo S, Legge F, et al. Laparoscopic versus robotic hysterectomy in obese and extremely obese patients with endometrial cancer: A multi-institutional analysis. Eur J Surg Oncol. 2018;44(12):1935–41. 16. Seamon LG, Fowler JM, Richardson DL, Carlson MJ, Valmadre S, Phillips GS, et al. A detailed analysis of the learning curve: robotic hysterectomy and pelvic-aortic lymphadenectomy for endometrial cancer. Gynecol Oncol. 2009;114(2):162–7. 17. Moore LJ, Wilson MR, Waine E, Masters RSW, McGrath JS, Vine SJ. Robotic technology results in faster and more robust surgical skill acquisition than traditional laparoscopy. J Robot Surg. 2015;9(1):67–73. 18. Shah CA, Beck T, Liao JB, Giannakopoulos N V., Veljovich D, Paley P. Surgical and oncologic outcomes after robotic radical hysterectomy as compared to open radical hysterectomy in the treatment of early cervical cancer. J Gynecol Oncol. 2017;28(6):e82. 19. Ramirez PT, Frumovitz M, Pareja R, Lopez A, Vieira M, Ribeiro R, et al. Minimally Invasive versus Abdominal Radical Hysterectomy for Cervical Cancer. N Engl J Med. 2018;379(20):1895–904. 20. FDA In Brief: FDA cautions patients, providers about using robotically-assisted surgical devices for mastectomy and other cancer-related surgeries [Internet]; [posted on 28–02-19] Online accessed on 20–05-24. https://www.fda.gov/news-events/fda-brief/fda-brief-fda-cautions-patientsproviders-about-using-robotically-assisted-surgical-devices 21. Fagotti A, Gueli Alletti S, Corrado G, Cola E, Vizza E, Vieira M, et al. The International Mission study: minimally invasive surgery in ovarian neoplasms after neoadjuvant chemotherapy. Int J Gynecol Cancer. 2019;29(1):5–9. 22. Abitbol J, Gotlieb W, Zeng Z, Ramanakumar A, Kessous R, Kogan L, et al. Incorporating robotic surgery into the management of ovarian cancer after neoadjuvant chemotherapy. Int J Gynecol Cancer. 2019;29(9):1341–50. 23. Uwins C, Assalaarachchi H, Bennett K, Read J, Tailor A, Crawshaw J, et al. MIRRORS: a prospective cohort study assessing the feasibility of robotic interval debulking surgery for advanced-stage ovarian cancer. Int J Gynecol Cancer. 2024;34(6):886–97. 24. Mereu L, Gaia G, Afonina M, Terzoni S, Tateo S, Spinillo A. “Less is More, is R-LESS More?”—The Use of Robotic Laparoendoscopic Single-Site Surgery in Gynaecology: A Scoping Review. Clin Exp Obstet Gynecol. 2023;50(1):19.

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25. Shin HJ, Yoo HK, Lee JH, Lee SR, Jeong K, Moon HS. Robotic single-port surgery using the da Vinci SP® surgical system for benign gynecologic disease: A preliminary report. Taiwan J Obstet Gynecol. 2020;59(2):243–7. 26. Nam EJ, Kim SW, Lee M, Yim GW, Paek JH, Lee SH, et al. Robotic single-port transumbilical total hysterectomy: a pilot study. J Gynecol Oncol. 2011;22(2):120–6. 27. Massimello F, Cela V. Role of single port robotic surgery in gynecology. Best Pract Res Clin Obstet Gynaecol. 2024;102497. 28. Gardella B, Dominoni M, Gritti A, Mereu L, Bogliolo S, Torella M, et al. Comparison between Robotic Single-Site and Laparoendoscopic Single-Site Hysterectomy: Multicentric Analysis of Surgical Outcomes. Medicina (Kaunas). 2023;59(1):122. 29. Bogliolo S, Mereu L, Cassani C, Gardella B, Zanellini F, Dominoni M, et al. Robotic single-site hysterectomy: two institutions’ preliminary experience. Int J Med Robot. 2015;11(2):159–65. 30. Won S, Choi SH, Lee N, Shim SH, Kim MK, Kim M La, et al. Robotic Single-Site Plus Two-Port Myomectomy versus Conventional Robotic Multi-Port Myomectomy: A Propensity Score Matching Analysis. J Pers Med. 2022;12(6):928. 31. Mereu L, Berlanda V, Surico D, Gardella B, Pertile R, Spinillo A, et al. Evaluation of quality of life, body image and surgical outcomes of robotic total laparoscopic hysterectomy and sentinel lymph node mapping in low-risk endometrial cancer patients-A Robotic Gyne Club study. Acta Obstet Gynecol Scand. 2020;99(9):1238–45. 32. Corrado G, Mereu L, Bogliolo S, Cela V, Gardella B, Sperduti I, et al. Comparison between singlesite and multiport robot-assisted hysterectomy in obese patients with endometrial cancer: An Italian multi-institutional study. Int J Med Robot. 2020;16(2):e2066. 33. Truong M, Kim JH, Scheib S, Patzkowsky K. Advantages of robotics in benign gynecologic surgery. Curr Opin Obstet Gynecol. 2016;28(4):304–10. 34. Khandalavala K, Shimon T, Flores L, Armijo PR, Oleynikov D. Emerging surgical robotic technology: a progression toward microbots. Ann Laparosc Endosc Surg. 2020;5(0). 35. Reddy K, Gharde P, Tayade H, Patil M, Reddy LS, Surya D. Advancements in Robotic Surgery: A Comprehensive Overview of Current Utilizations and Upcoming Frontiers. Cureus. 2023;15(12):e50415. 36. Aimar A, Palermo A, Innocenti B. The Role of 3D Printing in Medical Applications: A State of the Art. J Healthc Eng. 2019;2019:5340616. 37. Mohan A, Wara UU, Arshad Shaikh MT, Rahman RM, Zaidi ZA. Telesurgery and Robotics: An Improved and Efficient Era. Cureus. 2021;13(3):e14124. 38. Brunicardi FC, Gibbs RA, Wheeler DA, Nemunaitis J, Fisher W, Goss J, et al. Overview of the Development of Personalized Genomic Medicine and Surgery. World J Surg. 2011;35(8):1693.

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Robotic da Vinci System: Machine and Instruments

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2 Robotic da Vinci System: Machine and Instruments • Anupama Bahadur  • Richa Sharma

Robotic surgery has become an important tool in MIS. Robotic surgery with its computer based platform is a sophisticated extension of the laparoscopic platform. It is intended to overcome the limitations of conventional laparoscopy. Surgeons must have an understanding of the robotic components, instruments and energy sources available to operate efficiently.1 This is a master–slave robot with 6 degrees of freedom (DOF), 4 DOF in the arm outside the abdomen and 2 DOF at the tip. The surgeon operates the remote slave arm via the master control. The robot enables an intuitive operation since the robotic arms in the abdomen reproduce the surgeon’s 6 DOF hand motion at the console. It has 3D viewing and improved depth of perception. It also scales down the motion and filters the tremor. Da Vinci Xi is the most common robotic platform in use. The da Vinci platform has 3 main components2–4 (Fig. 2.1) 1. A surgeon console 2. A patient cart 3. A vision cart SURGEON CONSOLE (Figs 2.2A,B and 2.3) It gives an immersive, ergonomic experience. The surgeon console has all the master controllers, 3D screening and the surgeon sits and operates. The console is away from the sterile field but it should be placed in such a way that the surgeon has a complete view of the operating table. Sitting position causes less strain and is ergonomically better to perform long surgeries (Fig. 2.2A and B). Hands rest on an arm pad. The left side pod has levers for ergonomic control. Right side has power button and emergency stop button. The central touch pad has options to change screen and camera (Fig. 2.3).

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Fig. 2.1:  da Vinci platform

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Fig. 2.2A:  Surgeon’s console

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Fig. 2.2B:  Surgeon’s console—footswitch panel

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Fig. 2.3:  The arm pad

Components of footswitch panel 1. Monopolar and bipolar pedals (both cut and coagulation). 2. Clutch-to disengages devices and move to comfortable position 3. Arm swap pedals 4. Camera controls—can also be done by foot pedal. The vision cart consists of high definition 3D endoscope and image processing unit. The high definition image is seen on the monitor placed on top of vision cart (Fig. 2.4). The cart also has an insufflator and cautery machine.

Fig. 2.4:  Vision cart with slots for camera, electrocautery and insufflator

Basics: Understanding the Robot and Its Working

The tilt and height of the head set, arm rest is electronically adjusted for individual surgeon and settings can be saved. It can be a dual console for training in the Xi system.

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Imaging and Display Technology5–8 Imaging and display is paramount in RAS (Robotic assisted surgery system). The 3D stereoscopic system (da Vinci) utilizes dual independent display, one for each eye. The stereo viewer gives 3D high resolution image of the surgical field, magnified almost 10 times. The camera is stable and is under the surgeon’s control. (Fig. 2.5A). In RAS system the 3D vision is built into a closed console and surgeon leans into the headset. Here each eye has its own screen and provides a higher fidelity image. Endoscope: Two types of endoscopes are available, 0 and 30 degree with fiber optic light source and stereoscopic camera with auto focus. The camera is controlled by surgeon (Fig. 2.5B and C). Hand Controllers The hand controllers (master controllers) are 2 in number, one for each hand and are the primary input interface for the surgeon. The fingers are placed in the loops of the hand controller. These movements of the hand in 3DOF control the movements of the end effectors.9

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Fig. 2.5A and B:  (A) Display unit; (B) Endoscope with stereoscopic cameras and fibreoptic light source

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Many of the patents relating to the laparoscopic RAS (robotic assisted surgery) were owned by interactive surgical (da Vinci) and they are exposed recently. Now new robots have come to the market with different console (Fig. 2.6A and B). • Hugo RAS (Medtronic) • Versius RAS • SSI Mantra (Indian) They use a flat panel polarized 3D display technology. Flat panel has open display with two images, one for each eye using interlacing the surgeon has to wear polarized glasses. They have individual patient carts, each with a single robotic arm. Some have standing consoles which is more like laparoscopy.

Fig. 2.6A:  Other robots in market

Fig. 2.6B:  SSI MANTRA (Indian robot)

Basics: Understanding the Robot and Its Working

Patient Cart The patient cart in RAS system holds the robotic arms (Fig. 2.7). There are 2 designs of patient cart 1. Single cart integrating all the instrument arms (da Vinci) 2. Individual cart for each arm. The boom-mounted design of the da Vinci Xi cart provides flexible, accurate and speedy docking.

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Fig. 2.7:  Robotic arms

It has both visual and audible cues to facilitate easy docking. The robotic column has 4 arms. The arms move round fixed pivotal points and follow the surgeons hand movements. Positioning of the robotic arms (flexed inwards) should be such that there should be no collision during surgery. There is a button at the top of the robotic arm and this is used to adjust the trajectory of the instruments into the cavity. It has a memory so that while reinserting, the instruments attain the same position as before removal. The xi system has the advantage of being multiquadrant for universal port placement.10

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Trocars In multiport robot, the trocar is used as a fulcrum of the instrument and endoscope. The movement of the end effectors is inverted to the movement of robotic arm. Some RAS system identifies in ideal point in the wall to act as fulcrum minimizing movement of trocars. So pain score is very low in robotic surgery (Fig. 2.8). Robotic trocars are 8 mm metal trocars. They are inserted in such a way that the thick black band (remote centre) is seen at the abdominal wall. Once all trocars are placed, the patient cart is pulled close to the patient and docked. The laser beams are crossed at the endoscope port. The endoscope has laser guided precision target so the arms are aligned (Fig. 2.9).

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Instruments (Figs 2.10 and 2.11) Robotic instruments have a greater versatility unlike straight stick lap instrument. The endowrist design of the instruments with 360º rotation and the 7 degrees of freedom mimic human hand movements making surgeries in deep planes feasible. The intuitive movement of the instruments makes endo suturing easier. Each instrument has a long shaft, articulating wrist and a movable tip. The scissor and bipolar has electrosurgical function and cables can be attached to the distal end— green for monopolar.

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Fig. 2.8:  8 mm robotic trocars and cannula with black band as remote centre

Fig. 2.9:  Intersection of the laser beams at the camera port

Blue for bipolar. The monopolar scissor, fenestrated bipolar and large needle driver is most commonly used in our surgeries. Monopolar curved scissors is used to coagulate and cut. It is 51.3 cm long and the jaw opening angle is 38 degrees. Fenestrated bipolar is 51 cm long with a jaw opening angle of 0 to 45 degrees, it can be used for both grasping and coagulating. Large needle is 49 cm long with wristed articulation for easy suturing at multiple angles.

Basics: Understanding the Robot and Its Working

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Fig. 2.10:  Accessory instruments

Fig. 2.11:  Movements of instruments

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Long instruments enable a more flexible port placement and instruments can reach difficult location even in bariatric patients.

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Instruments Available • Bipolar: Fenestrated, Maryland • Scissors • Hook • Spatula • Clip applicator • Harmonic ace 7 • Staplers • Vessel sealer • Mega needle driver. Reusability: It is a key factor. The da Vinci system has a maximum of 10 uses per instrument.

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Cleaning and Sterilization The instruments are costly and need special care while cleaning. They have to be checked for any damage before cleaning (tip covers). • Disassemble the instruments and preclean with pressurized water. • Put in enzymatic cleaning solution in ultrasonic bath • Dry before sterilizing. • Steam sterilization can be done. It is also ok to autoclave the instruments. The instruments cannot be flash sterilized. Endoscope can be sterilized either by ETO or sterrad sterilization. Do not autoclave the endoscope.

Troubleshooting Troubleshooting is the best way to avoid patient injury. The da Vinci robot has two types of fault—recoverable and non-recoverable. In case of recoverable fault, the instrument arms will flash yellow. The system will stop operating until the fault is identified. In case of the latter it will flash red. A non-recoverable fault will require restarting of the machine after identification of the problem.11,12 Pressing the emergency button on the surgeons console will cause the master controllers to immediately disengage. A protocol for emergency undocking needs to be implemented, and all personnel in the OR should be familiar with their specific roles in case of an emergency undocking situation. Firefly fluorescence imaging: The Xi robot and other new robot in market have an integrated firefly imaging. The firefly infrared fluorescence was FDA approved in 2014. This provides a near-infrared fluorescence. Imaging is done on injecting indocyanine green (ICG), a flurophore which emits light upon excitation at 780 nm. It is injected into the cervix for sentinel node mapping9 (Fig. 2.12).

Fig. 2.12:  Firefly fluorescence imaging

Basics: Understanding the Robot and Its Working

Draping the Patient Cart Each arm of the surgical cart has its own drape. Three and four arm drapes are available. The system has to be switched on before draping.

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Identification of lesions in endometriosis mainly (DIE) and assessment of perfusion of bowel and ureters post-resection of endometriosis are its other uses. Future Directions Robotic surgery is the next logical step in MIS. Surgeons can now deal with more complex cases with the help of robot. The new features can help in that direction. Augmented reality: It is a major advancement in MIS. The MRI and CT image is superimposed on the real image to assist the surgeon. This will help find hidden fibroids or tumors in deep locations. • Tele surgery • 3D mapping • AI addition—will give higher level of autonomy to the surgeon. • Eye tracking capability and HAPTIC feedback. The FDA approved device that has limited release in the USA is the Senhance surgical system by Transenterix. This robot has haptics. Conclusion There is now a lot of competition in market as new robots is being introduced. The cost would be more affordable. A good working knowledge of the instruments and energy sources would increase our efficiency and make surgery safer. Ongoing quality assurance is essential to ensure appropriate use of technology with patient safety in mind.

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REFERENCES

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1. da Vinci Xi Surgical System In-Service Guide: OR Staff da Vinci OS4 v9 2. Kenji Kawashima, Takahiro Kanno, et al. Robots in laparoscopic surgery: Current and future status, BMC Biomedical Engineering 1, Article number: 12 (2019). 3. Mendez Probst CE, Villos G, Fuller A, et al. Stray electrical currents in laparoscopic instruments used in da Vinci® robot-assisted surgery: an in vitro study. J Endourol 2011; 25: 1513–7. (Crossref) (Pub med). 4. Krzysztof Wikiel, Thomas N. Robinson, Edward L. Jones. Energy in robotic surgery. Annals of laparoscopic and endoscopic surgery 2021: 10.21037/ales.2020.03.06 5. Longmore, Sally and Naik, Ganesh and Gargiulo, Gaetano. Laparoscopic Robotic Surgery: Current Perspective and Future Directions. Robotics.(2020) 9. 42.10.3390/robotics9020042. 6. Bhandari A, Hemal A, Menon M. Instrumentation, sterilization, and preparation of robot. Indian Journal of Urology 21(2):p 83–88, Jul-Dec 2005. DOI: 10.4103/0970–1591,19626. 7. O’Sullivan, Orfhlaith and O’Sullivan, S and Hewitt and O’Reilly Barry (2016). da Vinci robot emergency undocking protocol. Journal of Robotic Surgery 10.10.1007/s11701-016-0590-z. 8. Sally Kathryn Longmore, Ganesh Naik, et al. Laparoscopic Robotic Surgery: Current Perspective and Future Directions. Published 27 May 2020. 9. Yu-Jin Lee, Nynke S. et al, A narrative review of fluorescence imaging in robotic-assisted surgery: Journal of Laparoscopic Surgery. Vol 5 (July 25, 2021). 10. Espada M, Munoz R, Noble BN, et al. Insulation failure in robotic and laparoscopic instrumentation: a prospective evaluation. Am J Obstet Gynecol 2011; 205:121.e1–5. 11. Reynolds RK, Advincula AP. Robot-assisted Laparoscopic Hysterectomy: Technique and experience. Am J surg.2006; 191:555–60. 12. Nair R, Killicoat K, Ind TEJ. Robotic Surgery in Gynecology. The Obstetrician & Gynecologist 2016; 18:221–9.

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3 Energy Sources in Robotics • Anuradha Panda  • M Keerthi Reddy

Robotic surgery has effectively enabled the execution of complex surgeries with great accuracy. The use of energy is an important part of robotic surgery. The surgical team should have a good understanding of the principles of electrosurgery and tissue effects to avoid complications. Energy sources used are similar to laparoscopy with a few differences. Electrosurgical units (ESUs) convert standard electrical frequencies (50 to 60 Hz) from the wall outlet, to much higher frequencies (500,000 to 3,000,000 Hz) to produce desired effect such as fulguration coagulation and vaporization. At this higher frequency nerve and muscle stimulation does not occur.1,2 Mechanism of electrosurgery-radiofrequency current leads to intracellular conversion of electromagnetic energy to mechanical energy to thermal energy. The resultant heat causes the various tissue effects of electrosurgery. The thermal tissue effect is directly proportional to current density squared ([I/A]2), tissue impedance (R) and application time. Different electrical waveform from the ESU can produce different tissue effect. Continuous sinusoidal waveform with high current and low voltage, rapidly increase the temperature to 100°C produces cut effect, an interrupted waveform of low current and high voltage slowly increases the tissue temperature and produce coagulation effect (Fig. 3.1). Blend waveform is a modulated cut waveform with a variable duty cycle, current and voltage. Blends enhance the ability of cutting currents to coagulate small bleeders during dissection and coagulation currents to dissect tissue during haemostasis.3 Electrosurgery can be performed using either a monopolar or a bipolar instrument. In monopolar surgery, electrical current created in the ESU passes through a single active electrode to the tissue to produce desired effect and return to the dispersive electrode. In bipolar surgery, the electrical current created in the ESU is confined to the tissue between the two electrodes.

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Fig. 3.1:  Effects of waveform and tissue contact

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Advanced bipolar devices seal vessels up to 7 mm in diameter through optimal energy delivery and mechanical compression (coaptation). Generators use tissue impedance feedback to continually adjust the delivered voltage and current to achieve optimal tissue effects with minimal lateral thermal spread, charring and plumes. Ultrasound (harmonic scalpel): The ultrasonic cutting and coagulating surgical devices convert ultrasonic energy into mechanical energy. A piezoelectric crystal in the handpiece generates vibration at the tip of the active blade at 55,500 times per second, it produces heat 60–68°C which produces coagulum without charring, minimal thermal spread.

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Intuitive Surgical—da Vinci System4–6 There are many generators available for use in da Vinci S/Si. Xi system has an integrated generator produced with ERBE: ERBE VIO dV. It is also certified for use with Covidien (Valleylab) and Force Triad. These generators provide monopolar, bipolar and advanced bipolar options. The energy settings are: • Cut modes and • Coagulation mode ERBE VIO dV uses additional (blend) with haemostatic wave forms like coagulation and forced coagulation (Fig. 3.2). Fig. 3.2:  ERBE VIO dV (ESU)

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Bipolar The most commonly used bipolar device is fenestrated bipolar and Maryland. Both use endowrist technology. This is a versatile instrument and can be used for retraction, grasping, suturing and hemostasis (Fig. 3.4). The VIO dV bipolar and monopolar are adjustable with tissue effect (1–8). Effect setting controls dissection and coagulation. With lower effect narrow coagulation zone and lesser dissection. The energy settings are for transection (cut mode-auto and dry cut) and coagulation. Additional waveforms such as “swift coag” and “forced coag” provide blend waveforms for different tissue resistance. Surgeons can create and save up to three sets of preferred energy settings to their user account, from the surgeon console touchpad (Fig. 3.5A and B). It has a built-in safety mechanism ‘autostop’, i.e. bipolar energy activation ends automatically when the tissue impedance is high. Advanced bipolar—seals vessels up to 7 mm. Vessel sealer extend and SynchroSeal is the available advanced bipolar which comes at additional cost. SynchroSeal had dual sealing and cutting function for rapid sealing of vessels up to 5 mm with E-100 electrosurgical generator which delivers high frequency energy (Fig. 3.6). Harmonic Ace A robotic assisted ultrasonic scalpel, provides vessel sealing and transection up to 7 mm. It is a disposable instrument (Fig. 3.7). COMPLICATIONS OF ESU5–7 1. Active electrode injury: By direct application, inadvertent activation and residual heat (ultrasonic energy devices have higher residual heat).

Fig. 3.3:  Monopolar sears

Fig. 3.4:  Fenestrated bipolar

Basics: Understanding the Robot and Its Working

Devices Monopolar The most common monopolar instrument used in the scissors (monopolar sears). It uses the endo wrist technology and can be used for dissection and cauterization using monopolar energy (Fig. 3.3).

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Fig. 3.5A:  Energy settings

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Fig. 3.5B:  Energy settings (Source: Reference guide ERBV Vio DV)

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SynchroSeal vessel seal

Fig. 3.6:  Advanced bipolar SynchroSeal

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2. Direct coupling: Produced by an unintended contact between the active electrode and a non-insulated metallic instrument within the abdominal cavity in contact with tissue. 3. Antenna coupling: When active electrode emits stray energy which is captured by the inactive non-insulated metallic instrument. 4. Capacitive coupling: Transmission of electrical current from an active electrode through intact insulation. 5. Insulation failure: Defect exists on the plastic coat over the shaft of the electrosurgical instrument. How to Avoid Energy Based Complications? 1. Check insulation of instruments 2. Avoid open air activation 3. Utilize lowest power setting 4. Use low voltage modes (ERBE swift coag vs forced coag, forced triad blend mode). The monopolar scissors or hot shears have a protective tip that is to be applied. The use of the tip cover is to prevent arching of electrical current inside the abdomen. The proper way to apply the tip cover is to make sure it covers the orange portion of the shears.



1. 2. 3. 4. 5.

Energy sources used in robotic surgery are similar to lap with a few differences. Monopolar scissors and fenestrated bipolar are the most commonly used instruments. Bipolar is versatile and is used for coagulating, grasping and suturing. Advanced bipolar (SynchroSeal) and harmonic Ace come at an extra cost. Check insulation of scissors and use low voltage modes to prevent energy related complications.

Basics: Understanding the Robot and Its Working

Fig. 3.7:  Harmonic Ace instrument for da Vinci Xi

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REFERENCES

Part 1

1. Espada M, Munoz R, Noble BN, et al. Insulation failure in robotic and laparoscopic instrumentation: a prospective evaluation. Am J Obstet Gynecol 2011; 205:121.e1–5. 2. Krzysztof.Wikiel, Thomas N. Robinson, Edward L. Jones. Energy in robotic surgery. Annals of laparoscopic and endoscopic surgery 2021: 10.21037/ales.2020.03.06 3. El-Sayed M, Mohamed S. Saridogan E. Safe use of electrosurgery in gynecological laparoscopic surgery. The Obstetrician & Gynaecologist. 2020; 22:9. 4. Lyons SD, Law KS. Laparoscopic vessel sealing technologies. J Minim Invasive Gynecol 2013; 20:301. 5. Alemzadeh H, Raman J, Leveson N, Kalbarczyk Z, Iyer RK. Adverse Events in Robotic Surgery: A Retrospective Study of 14 Years of FDA Data. PLoS One. 2016 Apr 20;11(4):e0151470. doi: 10.1371/ journal.pone.0151470. PMID: 27097160; PMCID: PMC4838256. 6. Cormier B, Nezhat F, Sternchos J, Sonoda Y, Leitao MM Jr. Electrocautery-associated vascular injury during robotic-assisted surgery. Obstet Gynecol. 2012 Aug; 120(2 Pt 2):491–493. doi: 10.1097/ AOG.0b013e31825a6f60. PMID: 22825276. 7. Ibanez Jimenez, C., Lath, A. & Ringold, F. Novel multifunctional robotically assisted bipolar instrument for simultaneous radiofrequency sealing and transection: preclinical and single-center experience. BMC Surg 22, 37 (2022). https://doi.org/10.1186/s12893-022-01483-5.

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4 Robotic OT Setup and Ergonomics • Anuradha Panda  • Deepika HK

Setting up a robotic operating theatre (OT) involves several key steps:1,2 • −Ensure that the facility has necessary infrastructure • −Collaboration with trained surgical staff on using technology • −Establishing protocols • −Implementing stringent safety measures • −Regularly updating the software for optimal performance This chapter will guide you in the basic principles of setting operating theatre, port placement and docking (mainly the da Vinci xi). Surgical Team Surgical team required to run RS setup is surgeon, surgical assistant, circulating nurse, and surgical technician. • The lead surgeon is responsible for carrying out the surgical procedure and supervising the team’s activities in the operating room. • Robotic technician or nurse play a crucial role in ensuring the proper configuration and organization of surgical instruments, as well as addressing any technical issues that may arise with the equipment during the procedure. • The significance of the first assistant and nursing staff is crucial during robotic surgeries as the leading surgeon is not physically present in the operating field. Having a tableside assistant with laparoscopic skills is crucial to improve the efficiency and fluidity of movements during the procedure. Minimum Personnel Required 1. Trained robotic surgeon 2. Anaesthesia team trained to conduct robotic surgery 3. Trained surgical assistant(s)

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4. One/two trained nurses 5. Circulating nurse 6. OR technicians The Operating Room (OR) The design of the operating room (OR) must include appropriate adjustments to accommodate the surgeon’s console, patient cart, vision cart, anaesthesia equipment, operating table, instruments and additional equipment, all while ensuring the presence of secure spaces for the circulating staff and surgeon has a clear view of the patient from console. The proper setup is essential to the development of an efficient and safe operating room. It is advisable to establish a dedicated robotic operating room (OR). This practice helps to eliminate the time-consuming and challenging process of transferring the robot between rooms, reducing the risk of damages that may occur during transport. Maintaining an ample supply of surgical instruments is crucial due to their limited number of uses. The basic system for robotic surgery consists of three components: Vision Cart, Patient Cart, and Surgeon’s Cart (Console) Instruments Required da Vinci Xi Equipment • da Vinci Xi System: Vision cart, patient cart, and surgeon’s console • 8 mm robotic cannula × 3/4 • 5–8 mm cannula seals • 8 mm blunt obturator × 1 • 8 mm endoscope (0º or 30º) • Sterile four or 3 arm drape kit × 1 • Monopolar curved scissors with tip cover × 1 • Bipolar instrument × 1 • Mega needle holder × 1 • da Vinci Xi compatible energy activation cord

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Laparoscopy Instruments • Veress needle (optional) • 5/6 mm port × 2 • Laparoscopic instrument for grasping and scissors • Suction irrigation setup • 1 Electrosurgical unit Patient Position and Preparation

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Patient positioning is a critical component of robotic surgery, which affects both the technical and medical side of the procedure. A proper setup minimizes the risk of potential complications, such as nerve damage or blood clots, and provides optimal mobility for the robotic end-effector. Apart from good access, the patient should be positioned in a way that allows for proper monitoring during the procedure.

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Pneumatic compression devices should be used for all patients. After the administration of general anaesthesia with endotracheal intubation, modified dorsal lithotomy position is adjusted with the help of leg support devices. Allen stirrups are one of the most commonly used stirrups today because they provide excellent protection of the legs and feet at pressure points. The buttocks should be positioned off the OR table or at around 2–4 cm beyond the lower border of the OR table; this margin eases the insertion and control of a uterine manipulator. The thigh-trunk angle of approximately 170° is appropriate. The knees flexion is restricted to less than 90° to avoid injury of the femoral nerve.3–5 Care is taken to make sure that the level of the patient’s knees should not be higher than that of abdomen to avoid collisions with the robotic arms. Arms should be tucked in by the side of the body and ensure that there is no direct pressure over the medial epicondyle. A steeper Trendelenburg positioning between 25° and 45° is needed for robotic gynaecological surgeries.5 A minimum tilt angle enabling safe and feasible surgery should be determined (Fig. 4.1). The patient is positioned on an anti-skid gel mat to prevent sliding. Shoulder braces should be avoided. Once the system is docked, the position should not be changed.

It contains • The light source • Video processor • Camera control • Insufflator • Electrosurgical unit. • The touch screen monitor provides high quality view of surgical image and allows non-sterile OR staff to adjust vision settings and aids in teaching.

Fig. 4.1:  Patient placed in low lithotomy with steep Trendelenburg

Basics: Understanding the Robot and Its Working

Vision Cart Position Vision cart should be positioned outside the sterile field close to the patient cart to allow unrestricted camera cable movement during surgery and it can be easily viewed by the patient-side assistant and easily accessed by the circulating nurse.

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Move the cart using only the handles and lock it in location by pushing down the wheel brakes. Surgeon Console Position surgeon console outside the sterile field and in clear line of communication with the patient-side assistant. Patient Cart The patient cart is the operative component of da Vinci Xi surgical system, it uses remote centre technology. The remote centre is fixed point in space around which the patient cart move. This enables the system to manoeuvre instruments and endoscope in surgical side while exerting minimal force on the patient’s body wall. It features boom-mounted arms multi-positioned setup joints. It has five components: Setup joints, instrument arms, camera arm, endowrist instruments and endoscope. It has motorized drive which provides faster and easier docking. Patient cart needs dedicated space in the room where it can be sterile draped before deploying for docking. The sterile draped cart is positioned patient-side in the sterile operating field once the patient is positioned, prepared, draped and ports are placed. Patient cart motor drive is used to move the cart to sterile area at the left lateral side or central leg end position of the operating table for gynaecological cases (Fig. 4.2).

Part 1

System Start-up Power on the system at the start of the day to allow it to go through the mechanical and electrical integrity tests and ensure proper function before patients are placed under anaesthesia. It is not necessary to restart the system between cases. Do not touch any system component or any system buttons during the homing process. Check that video signal is seen in right and left eyes of surgeon console viewer to confirm communication between the vision cart and surgeon console.

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Fig. 4.2:  Basic system for robotic surgery

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Steps for Docking 1. Position patient on OR table 2. Abdominal access and port placement 3. Drive patient cart over the surgical field 4. Docking the camera arm and insert the endoscope for targeting 5. Docking the instrument arm 6. Check system setup Port placement: Abdominal access can be created either by direct or open entry technique and pneumoperitoneum is created and under vision accessory ports are placed. To have optimum working conditions (Fig. 4.3). Camera port should be in the same line as sur­gical target area • Target area should be 10–20 cm from camera port • Working ports should be at 8–10 cm from camera port on each side • Assistant port should be at least 4 cm from camera port • Do not place assistant port between da Vinci ports and the target anatomy. Drive the patient cart: Once the target anatomy is selected, patient cart is deployed for docking, the laser lines are used to drive to the endoscope port, the cross of the laser light is aligned to the endoscope port, and arm 2 is connected/docked to the endoscope port (gynaecological surgeries) (Fig. 4.4). Using port clutch and cannula mount lever. Endoscope light is turned on (white balancing and focusing is not required in da Vinci Xi system), endoscope is inserted and target the anatomy and press and hold targeting button for targeting, once the targeting is done remaining arms are docked (Figs 4.5 and 4.6). Instrument Insertion and Removing Straighten the instrument tip and slide it to port under vision. The position of the instrument is indicated as yellow bars on the screen. Push the instrument into surgical

Fig. 4.3:  Port placement

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Fig. 4.4:  Laser line aligned to endoscope port

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Fig. 4.5:  Endoscope arm is docked and targeting is done

area by pressing the instrument clutch button and indicators blink blue. Connect the electrosurgery cables to the instrument. Surgeon should only proceed to drive once the LED light indicator is blue. If there is any resistance never push, check and then move the instruments to prevent injury.

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Undocking First remove the instruments under vision and then endoscope is removed, robotic arms to be released by cannula mount lever, and cannula should be held while releasing the instrument, using port clutch button robotic arms should be gently removed and pushed away from patient body. Then the patient cart is moved away from the sterile area. Troubleshooting Troubleshooting is the best way to avoid patient injury. The da Vinci robot has two types of faults: Recoverable and non-recoverable. 1. In the event of a recoverable fault, the instrument arms will flash yellow. A recoverable fault will stop the system operations until the fault is identified. 2. A non-recoverable fault will flash red. A non-recoverable fault requires restarting the system once the problem is solved. Pressing the emergency stop button on the surgeons console right pod causes the master controllers to immediately disengage. A protocol for emergency undocking needs to be implemented, and all personnel in the operating room should be familiar with their specific roles in case of an emergency undocking situation.7 Ergonomics6–9 Ergonomics, “ergo” means work and “nomos” means arrangement in greek, is defined as optimization of surgeons physical environment of OR room with regards to patient table height, position of surgeon, tilting angle, placement of the total operating system from the surgeon, angles between the instruments, in order to enhance the work performance without causing any physical or mental stress to the surgeon and the assistant surgeon and achieve optical surgical outcomes.

Basics: Understanding the Robot and Its Working

Fig. 4.6:  Instrument arm docked on either side of endoscope arm and instrument is introduced and connected to energy source

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Ergonomics has been classified as having physical, organisational and cognitive components. Drawbacks of Minimal Invasive Surgery WMSD are common preventable injuries that can affect a surgeon’s muscles, nerves and joints, especially in the neck, back, wrist, and hands. Robotic assisted surgeries led to lower postoperative discomfort and muscle strain in both upper extremities and increased static neck positioning with back stiffness compared with laparoscopy. These recognized ergonomic differences between the two platforms can be used to raise surgeon awareness of their intraoperative posture and to develop targeted physical and occupational therapy interventions to decrease surgeon WMSDs (work-related musculoskeletal disorders) and increase surgeon longevity. Ergonomics In Laparoscopy In laparoscopic surgery there is a two-dimensional vision and loss of depth perception to some extent. There is fulcrum effect with tremor enhancement. There are only 4 degrees of freedom. The laparoscopic surgeon also assumes a relatively static posture during major part of the procedure which, ergonomically speaking, contributes to the strain.This builds up lactic acid and toxins which is harmful for the surgeon (Fig. 4.7). Sensorial ergonomics (manipulations and visualisation) improve precision, dexterity, and confidence, while physical ergonomics provide comfort for surgeon. Together, these two elements of ergonomics increased safety, have better outcome and reduce the stress.

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Main Drawbacks of Laparoscopic Surgery (Fig. 4.8) • Two dimensional vision with lack of peripheral vision • Physical constraints reported are ± Cervical spondylitis ± Shoulder pain due to abduction of shoulder (chicken wing scapula),

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Fig. 4.7:  Positioning laparoscopic surgery

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A seated workstation can alleviate lower extremity pain, it raises new concerns for surgeons but can have major impacts on back and neck posture.

± Backache, ± Hand finger joint pain, ± Henosynovitis, ± Burning eyes, ± Stress exhaustion, ± Hand muscle injury. Ergonomics in Robotic Assisted Surgery RAS is generally considered more ergonomic than laparoscopic surgery; however, ergonomic challenges remain. Equipment Positioning • The robotic console: The robotic console has settings which can be specific to every surgeon and can be adjusted accordingly and saved. Head is supported on a headrest—the viewing angle should not be more than 15° to maintain the neutral neck position in order to perform complicated surgeries without neck pain for longer hours. Increased pressure against the headrest may cause forehead pain or increased neck strain. Surgeon’s back flexion should be less than 15° (Fig. 4.9). Neck flexion should not exceed 25° according to rapid upper limb assessment tool. The chair height should match the popliteal height of the surgeon with knee at right angles. Surgeon’s feet should be placed on the foot pedals on each side with knees in neutral position at 90°. Dorsal flexion of the foot should not exceed 25° when

Basics: Understanding the Robot and Its Working

Fig. 4.8:  Location and frequency of discomfort

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(A)

(B)

Fig. 4.9:  (A) Correct posture; (B) Incorrect posture Prolonged downward neck flexion develops long and weak stabilizing musculature in the cervical spine and scapular region. This weakness is correlated with overuse of other muscles like the pectorals, upper trapezius, and levator scapulae.

using the pedal. Forearms should rest on the armrest of the console with relaxed shoulders making an angle of 90° between the elbow and forearm, as close to the torso as possible.10–12 • Patient cart: The robotic system is designed to align with respect to the patient left, right or in between the legs. The distance between the robotic instrument arms should be between 120° and 140° in order to prevent the clashing of the instruments. The legs should be lowered so that there is no injury from hitting of the robotic arms. • The robotic ports are taken in a straight line with a distance of 8 cm between each port in an inflated abdomen. The fulcrum effect: The remote signal on the port placed at the abdomen level acts a fulcrum for the instrument movement without causing any pressure on the abdominal tissues reducing post-operative pain. • Vision cart: Placed at the foot end of the patient mainly for the assistant surgeon and the OR staff. • Visualisation in RAS: Robotic surgery has better illumination, magnification and focus on the surgeon’s operative field even at difficult angles, without shadow, glare, and artifact. The camera is under the surgeon’s control and there is auto focus facility. The areas of the greatest strain are shoulder, neck, wrist, hands and eyes.

Part 1

ERGONOMICS TRAINING4–6,13

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Ergonomics training should be included in the curriculum to protect surgeons from preventable, potentially career-altering injuries.This will also improve the surgical skill and surgical outcomes. Proper posture during robotic assisted surgery decreases the chances of work-related musculoskeletal disorders associated with RAS. Ergonomic Training Program Assessment of ergonomic strain during robotic surgery indicates there is a need for intervention, that is, ergonomic training for robotic surgeons.

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1. It is advisable to establish a dedicated robotic OR and dedicated team for robotic surgery. 2. The lead surgeon and team should be conversant with the robot and instruments 3. A protocol for emergency undocking needs to be implemented and the assistant surgeon and OT staff should be familiar with it. 4. Ergonomics in minimal invasive surgery play a very vital role for the surgeon and good patient outcome and surgeon longevity. 5. Stereopsis immersive 3D vision with gaze down, sitting posture makes it more comfortable than the laparoscopy in prolonged surgeries. 6. Ergonomics should be included in the training curriculum.

REFERENCES 1. Pereira-Arias J (2019) How to build a robotic program. Archivos Españoles de Urologia 72(3): 227–38. 2. Allona A (2007) Establishment of a robotic program. Archivos españoles de urología 60(4):371–74. 3. Mills JT, Burris MB, Warburton DJ, Conaway MR, Schenkman NS, Krupski TL (2013) Positioning injuries associated with robotic assisted urological surgery. J Urol 190(2):580–84. 4. Ulm MA, Fleming ND, Rallapali V, Munsell MF, Ramirez PT, Westin SN, Nick AM, Schmeler KM, Soliman PT. Position-related injury is uncommon in robotic gynaecologic surgery. Gynecol Oncol. 2014 Dec;135(3):534-8. doi: 10.1016/j.ygyno.2014.10.016. Epub 2014 Oct 23. PMID: 25449565; PMCID: PMC4268144. 5. Boggess JF, Gehrig PA, Cantrell L, Shafer A, Mendivil A, Rossi E, et al. Perioperative outcomes of robotically assisted hysterectomy for benign cases with complex pathology. Obstet Gynecol 2009;114:585–93.

Basics: Understanding the Robot and Its Working

Positioning Instructions     1. Chair positioning: The chair should be on lockable castors for ease of mobility and have an adjustable height, depth, and lumbar support.     2. Optic viewer height: Chair and robotic console height should be adjusted so that the optics is at a comfortable position for viewing. When adjusting, the feet should rest on the ground in front of the pedals and the knees should be at a 90° angle or greater.    3. Upper arm rest: The upper arms should be perpendicular to the floor. The elbows should form a 90° angle with the forearms resting on the armrest. Elbows should remain close to the torso.     4. Neck/back: With the forearms resting comfortably on the armrest, the surgeon should be able to look through the optics without arching/straightening the back or neck to gain height. The angle of the neck should be approximately 20°. Avoid excessive bending of the neck and upper back to look downward.     5. Headrest: The surgeon should avoid placing undue force on the forehead and should not press too firmly into the headrest. Too much force results in undue forehead pain and neck strain.     6. Neutral position: This position should be attained at the onset of the case, with periodic revaluation if discomfort occurs later.        If strain is noted, re-evaluate neutral position as well as chair/console height to reduce excessive back and neck strain. Try to get the forearms as close to the torso by frequent clutching. Take time to stretch.

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6. da Vinci Xi Surgical System In-Service Guide: OR Staff da Vinci OS4 v9. 7. O’Sullivan Orfhlaith, O’Sullivan S, and Hewitt M. and O’Reilly Barry (2016). da Vinci robot emergency undocking protocol. Journal of Robotic Surgery. 10. 10.1007/s11701-016-0590-z. 8. Müller Dolores T1, Ahn Juliane2, Brunner Stefanie1, Poggemeier Julia1 Storms Christian1, Reisewitz Alissa1, Schmidt Thomas1, Bruns Christiane J1, Fuchs Hans F1. Ergonomics in robotassisted surgery in comparison to open or conventional laparoendoscopic surgery: A narrative review. International Journal of Abdominal Wall and Hernia Surgery 6(2):p 61-66, April-June 2023. | DOI: 10.4103/ijawhs.IJAWHS_52_22 9. Franasiak J, Craven R, Mosaly P, Gehrig PA. Feasibility and acceptance of a robotic surgery ergonomic training program. JSLS. 2014 Oct–Dec;18(4):e2014.00166. doi: 10.4293/JSLS.2014.00166. PMID: 25489213; PMCID: PMC4254477. 10. Wong SW, Crowe P. Visualisation ergonomics and robotic surgery. J Robot Surg. 2023 Oct;17(5):1873– 78. doi: 10.1007/s11701-023-01618-7. Epub 2023 May 19. PMID: 37204648; PMCID: PMC10492791. 11. Lee MR, Lee GI. Does a robotic surgery approach offer optimal ergonomics to gynecologic surgeons?: a comprehensive ergonomics survey study in gynecologic robotic surgery. J Gynecol Oncol. 2017 Sep;28(5):e70. doi: 10.3802/jgo.2017.28.e70. Epub 2017 Jun 23. PMID: 28657231; PMCID: PMC5540729. 12. www.medtronic.com/covidien/en-us/robotic-assisted-surgery/hugo-ras-system/blog/workrelated-musculoskeletal-disorders-and-ergonomics-of-ras.html 13. Supe AN, Kulkarni GV, Supe PA. Ergonomics in laparoscopic surgery. J Minim Access Surg. 2010 Apr;6(2):31-6. doi: 10.4103/0972-9941.65161. PMID: 20814508; PMCID: PMC2924545.

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5 Training and Learning Curve in Robotic Surgery • Rooma Sinha  • Rupa Bana

Despite the introduction of laparoscopic-assisted hysterectomies three decades ago by Harry Reich, many gynaecologists still elect to perform hysterectomies with abdominal incisions especially if the situation is complex. One of the most significant hurdles for gynecologists in learning advanced laparoscopic procedures is the perceived long learning curves involved to become proficient. The result of this is that most hysterectomies and other pelvic surgeries are still performed through painful, large abdominal incisions.1 Application of robotics for gynecological surgeries is increasingly gaining popularity since approval by the US Food and Drug Administration in 2005. From the patient’s perspective, robotic-assistance increases the chance of minimal access approach with reduced conversions to open surgery intra-operatively when compared to laparoscopic surgery. From the surgeon’s perspective, robotic surgery has a more rapid learning curve compared to conventional laparoscopy. It is also suitable for complex procedures requiring extensive dissection and appropriate anatomical restoration like in advanced endometriosis. Computer-assisted surgery with robotic assistance offers the promise of enabling typical gynecologic surgeons to be able to accomplish state-of-the-art minimally invasive laparoscopic procedures with the same outcomes as more advanced surgeons. But even given the promise of this technology, many surgeons are hesitant to try robotics because of perceived long learning curves.2 Learning curve in surgery is referred to the process through which surgeons gain proficiency and expertise in performing specific surgical procedures. It is a concept that applies across various surgical specialties and encompasses a range of skills, from basic techniques to complex surgical maneuvers. Overall, the learning curve in surgery is a dynamic process influenced by various factors, including individual aptitude, training resources, patient complexity, and technological advancements. Continuous practice, reflection, and a commitment to excellence are key elements in mastering surgical skills and delivering high-quality clinical outcomes (Table 5.1).

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Part 1

Table 5.1: Steps involved in a learning curve of surgeon8–10

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Initial training

This begins by surgeons observing experienced surgeons, practicing on simulators, and gradually performing various steps of the procedures under supervision. This is the stage where surgeons learn basic techniques, understanding anatomy, and developing hand-eye coordination.

Technology and innovation

Use of advanced technology (ROBOTICS) has a direct influence on the learning curve. Surgeons need to adapt to new tools and approaches, requiring ongoing education and training. Transition from open surgery is part of the learning curve. This involves learning the robotic platform, understanding the differences in visualization and instrument handling from conventional laparotomy or laparoscopy, and adapting to the altered ergonomic setup.

Early experience

This is the stage where surgeons gain more experience, and start doing some steps of the procedure along their learning curve. Initially, procedures may take longer, and outcomes may vary as surgeons refine their skills and decision-making abilities.

Skill acquisition

Repeated practice and exposure to different cases, improves the proficiency of the surgeons. They now learn to anticipate complications, manage unexpected situations, and optimize patient outcomes.

Plateau phase

This is the stage where there is a stagnant in further improvement. However, continuous learning and exposure to diverse cases can help maintain and enhance proficiency over time.

Sub-specialization

Some surgeons may focus only on specific types of surgeries or subspecialties. This deepens their expertise in a few complex procedures. This is achieved by additional training and experience beyond general surgical skills.

Outcome assessment

At the so-called end of learning curve, monitoring surgical outcomes, complications and auditing one’s own data can provide insights into individual performance. This can identify areas for improvement. Quality improvement initiatives and peer review processes contribute to enhancing overall surgical care.

Team collaboration

Learning curve can also be influenced by team collaboration. Robotic surgical procedures involve team of nurses, anesthesiologists, surgical and technological assistants. Building a robust team, collaborating with them with effective communication are essential for optimizing patient care. Surgeons need to collaborate with the surgical team to streamline instrument exchanges, troubleshoot technical issues, and ensure efficient communication within the sterile field especially so as the surgeon is away from the patient.

Robotic surgery is next logical advancement of conventional laparoscopy but they differ in two major ways. Firstly, robotic surgery requires an additional step of docking of the robotic arms and instruments insertion before the initiation of the main surgery. Secondly, the surgeon controls the robotic arms to perform the main surgery through the console machine away from the operating table (telepresence surgery).3–6 What should be the learning curve for robotic surgery? There are several things that one can be measured as factors that can influence learning curves:7–9 1. Time required in the operating room team (nurses and technicians) to prepare and dock the robotic equipment necessary to perform the case (setup time)

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2. Time required to complete the robotic portion of the operation (console time) 3. Outcomes measures like uterine weight, blood loss, complications, conversions to open surgery, length of hospital stay and time required of patients to return to normal activities of daily living. 4. An important and ultimate parameter is the number of cases necessary for a surgeon to stabilize operative time and give equivalent clinical outcomes to standard conventional approaches. The entire robotic procedure can be divided into three stages and total learning curve is summation of these three parts of the surgery 1. Insertion of trocars and docking and insertion of instrument (learning curve of team) 2. Performing the main surgery on the console (learning curve of surgeon) 3. Specimen retrieval (previous experience of surgeon)

The duration of the learning curve in robotic surgery compared to laparoscopic surgery can vary depending on several factors • Surgeon’s prior experience • Training opportunities • Case volume, and patient selection. Some procedures are inherently more complex and challenging than others and will need longer learning curve. Time-based metrics were the most commonly reported variables used to assess the learning curve. These are mainly measured as total operative time, docking time or total console time. Most studies published on the learning curve of robotic surgery have evaluated the entire operation time and is the most studied metric. It is shown that the total operative time of robotic hysterectomy becomes equivalent to total operative time of total laparoscopic hysterectomy in approximately 30 cases since the time one performs the first robotic hysterectomy. Studies investigating the learning curve of robotic hysterectomy use stabilization of operative times to determine competence and conclude that 20–50 cases are needed. Some studies even mention that more than 150 robotic hysterectomies are need to gain proficiency in this procedure. However, one must remember that safety of surgical procedure is more important than speed of surgery. Morbidity is the true measure of a surgeon’s skill rather than an ability to perform a procedure in a specified time. Postoperative complications are a reflection of the overall surgical approach and management rather than the surgeon’s skill. The intra-operative morbidity is more representative of surgical proficiency.

Basics: Understanding the Robot and Its Working

Robotic surgery may offer ergonomic advantages and enhanced visualization, potentially shortening the learning curve for surgeons with prior laparoscopic experience or access to comprehensive training programs. However, laparoscopic surgery has an established technique and direct instrument control, which may be advantageous for some surgeons during the learning process. Ultimately, the learning curve for each approach is influenced by a combination of factors, and the duration may vary from surgeon to surgeon (Table 5.1).

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1. Learning curve in robotic surgery involves mastering the technical skills required to operate the robotic system, adapting surgical techniques to the robotic platform, and achieving proficiency in performing specific procedures. 2. Through structured training, collaboration with the surgical team, and ongoing education, surgeons can enhance their competence and deliver a high-quality patient care using roboticassisted techniques. 3. The learning curve in robotic surgery is influenced by a combination of factors related to surgeon experience, training, case volume, technology, teamwork, mentorship, and quality improvement efforts. 4. By addressing these factors systematically and proactively, surgeons can optimize the learning process and achieve proficiency in robotic-assisted surgical techniques.

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REFERENCES

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1. Lenihan JP Jr, Kovanda C, Seshadri-Kreaden U. What is the learning curve for robotic assisted gynecologic surgery? J MinimInvasive Gynecol 2008;15:589–94. 2. Pitter MC, Anderson P, Blissett A, Pemberton N. Robotic-assisted gynaecological surgeryestablishing training criteria: minimizing operative time and blood loss. Int J Med Robot 2008;4: 114–20. 3. Bell MC, Torgerson JL, Kreaden U. The first 100 da Vinci hysterectomies: an analysis of the learning curve for a single surgeon. S D Med 2009;62:91, 93–5. 4. Soomro NA, Hashimoto DA, Porteous AJ, Ridley CJA, Marsh WJ, Ditto R, Roy S. Systematic review of learning curves in robot-assisted surgery. BJS Open. 2020 Feb;4(1):27-44. doi: 10.1002/ bjs5.50235. Epub 2019 Nov 29. PMID: 32011823; PMCID: PMC6996634 5. Luciano AA, Luciano DE, Gabbert J, Seshadri-Kreaden U. The impact of robotics on the mode of benign hysterectomy and clinical outcomes. Int J Med Robot 2016; 12: 114–124. 6. Iida Y, Komatsu H, Kudoh A, Azuma Y, Sato S, Harada T, Taniguchi F. The learning curve of introduced robotic-assisted hysterectomy versus skilled laparoscopic hysterectomy for benign gynecologic diseases. J Obstet Gynaecol Res. 2023 Oct;49(10):2494-2500. doi: 10.1111/jog.15741. Epub 2023 Jul 26. PMID: 37493096 7. Pilka R, Gágyor D, Študentová M, Neubert D, Dzvin uk P. Laparoscopic and robotic sacropexy: retrospective review of learning curve experiences and follow-up. Ceska Gynekol. 2017 Fall;82(4):261–267. English. PMID: 28925269. 8. Tang FH, Tsai EM. Learning Curve Analysis of Different Stages of Robotic-Assisted Laparoscopic Hysterectomy. Biomed Res Int. 2017;2017:1827913. doi: 10.1155/2017/1827913. Epub 2017 Mar 8. PMID: 28373977; PMCID: PMC5360940. 9. McVey R, Goldenberg MG, Bernardini MQ, Yasufuku K, Quereshy FA, Finelli A, Pace KT, Lee JY. Baseline Laparoscopic Skill May Predict Baseline Robotic Skill and Early Robotic Surgery Learning Curve. J Endourol. 2016 May;30(5):588-92. doi: 10.1089/end.2015.0774. Epub 2016 Mar 23. PMID: 26915663. 10. Turner TB, Kim KH. Mapping the robotic hysterectomy learning curve and re-establishing surgical training metrics. J Gynecol Oncol. 2021 Jul;32(4):e58. doi: 10.3802/jgo.2021.32.e58. Epub 2021 Apr 12. PMID: 33908711; PMCID: PMC8192241

6 Role of First Assistant in Robotic Surgery • Mariam Anjum Ifthikar  • Neha Kamath

The first robotic surgical assistant is the chief of events and plays a vital role in every surgical team and they must have good skills in minimally invasive surgery along with good communication skills to allow for efficient and safe performance of the surgery. The first assistant must have the willingness to seek and elicit feedback, openness to change, and readiness to recognize when there is an error. It is the utmost cooperation and coordination of the assistant that will make the operating surgeon to remain at the robotic console and perform the surgery skilfully and uninterruptedly. Team Building It is the key to a successful and cohesive robotic surgery program but this aspect is often overlooked. Generally, the robotic team consists of the robotic console surgeon, anaesthetist, assistant surgeon, specialist nurses, operation theatre technician, and circulator who are familiar with the flow of surgery; either with earlier training in traditional laparoscopic surgery or additional training specific to the robotic surgical system being used. The first assistant is the bridge between the robotic console surgeon, and the rest of the robotic team ensuring the smooth operation and patient safety during the surgery. They should be able to direct the dynamics of the operating room, and chronology of events preoperatively, intraoperatively, and postoperatively to build an efficient robotic team.1 Role as a First Assistant The first assistant should be well-trained and should understand the nuances and intricacies of the operative procedure per se and the robotic platform as many robotic platforms are being installed in different institutions. Each robotic platform brings unique challenges for the team and hence the first assistant should be inclusive and willing to share the burden of problem-solving and troubleshooting any issues that may arise throughout the process. In robotic surgery, the console surgeon is almost

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5–10 feet away from the patient; which might cause additional complexity and anxiety in the operating room among the team members. This is where the crucial role of the first assistant comes in, to ensure that prompt and effective actions are taken like additional trocar placement, tissue manipulation, irrigation and suctioning, both mechanical and electrical troubleshooting, or other emergent situation during the case. Communication is the cornerstone; needs to be loud with more detailed and clear instructions and one must acknowledge the instructions given by the console surgeon. There should be two-way communication with the other team members and a congenial environment is created which makes them an integral part of the robotic program. The first assistant should be well-versed with the operating room set-up, docking, undocking, emergency shutdown, and troubleshooting, familiarise with the other team members, and should be able to create an environment to foster diversity and encourage their active involvement (Fig. 6.1). There should be an emergency drill in place being practiced for undocking the robotic system if necessary to prevent a delay in resuscitation.2–4 It is recommended that the first assistant should have a good understanding of the surgery, superior surgical skills and should be vigilant throughout the process. Preoperatively, the surgical assistant must look into the patient safety, avoidance of compression injuries, maximum mobility of the robotic arms and facilitation of a smooth and efficient surgery and discuss any concerns with the surgeon and the OR team. It is imperative to be thorough with the patient history, pre-operative assessment factors of the patient before preparing and planning the surgical procedure, and surgical indication as it may pose challenges specific to the individual case. Key points of consideration should be observed in collaboration with the other team members to prevent patient injury (dermal and nerve injury). A surgical assistant must be proficient in setting up and draping the robotic equipment to ensure that it is functional which includes robotic setup and optic system setup. Perioperatively, one should be able to anticipate and implement the necessary precautions to prevent patient injury and complications and review the surgical plan.

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Fig. 6.1:  Strong team building improves the success of any surgical robotics program but often underrated

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The intraoperative role of surgical assistant includes trocars insertion, local anaesthetic infiltration, placement of robotic arm ports (Fig. 6.2), and assistant ports, insertion of the instruments and scope, creating pneumoperitoneum, docking and undocking of the robot and preventing robotic arms collision, usage of the assistant port. the assistant port aids the surgical assistant to maintain haemostasis, tissue retraction, assistance in suctioning and lavage and provision of hemoclip applications, smoke evacuation, specimen retrieval, to pass and retrieve sutures and additional manoeuvres to keep the operating field clear. The assistant is responsible to clean the camera, exchange the instruments and use additional energy sources through the assistant port, as per the surgeon’s requirement. Vision cart of the robot helps to observe the entry and exit of the instrument, however, direct visualisation is the best modality. The post-operative role includes undocking, port removal, TAP block placing intra-abdominal drain, closing all the trocar sites and taking deep stitches to prevent future herniation.4 • The fundamental concepts for surgical assistants must be grounded in the sound knowledge of surgical anatomy, physiology, pathology and must be well-trained and proficient in laparoscopic skills due to the rapid advancement and adoption of different robotic surgery platforms in virtually every speciality. • Hence, they should undergo a robotic training program that utilizes theory, simulation, dry exercises using inanimate models, simulation for port placement, exchange for robotic arms, wet lab training, video clips, and course attendance. By doing this, it reduces the learning curve to a greater extent. Presently it becomes mandatory to have specific training by the manufacturers of the advanced robotic devices in different robotic platforms to use technology safely and efficiently with interest of patient care. • It is recommended that the surgical assistant must attend manufacturer technology training which includes live case demonstration, and hands-on in-service with the

Fig. 6.2:  Port placement and docking by the first surgical assistant Currently, there is no governing body which mandates credentialing guidelines for assistant surgeons in robotic surgery programs. Although there are guidelines in place for the surgical assistant which are researched and authored by the ASA Education and Professional Standards Committee and have been approved by the ASA Board of Directors, effective May 17, 2017.

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robotic platform representative and also identify a mentor to facilitate the mastery of important specific robotic key skills. • To overcome work-related musculoskeletal disorders, the ergonomics of the first assistant needs major attention. Tissue traction is recognized as the action with the highest physical load. The vision tower position is also vital to reduce rotation and twisting of the neck and back (monitor in line with the viewer). Perioperative placement of more monitors inside the OR at optimal view angles might lead to more ergonomic body postures. Ensure the optimum table height during every procedure. • The first surgical assistant must take care to have a comfortable position, with an acceptable reach distance to instruments and trocar portals. Careful consideration of assistant trocar port placement will result in more degrees of freedom of movement for the first assistant. ± Reduction of physical strain for the first assistant can be done by replacing instruments of the third arm like a prograsp which can do the tissue manipulation or retraction. Movements must be smooth and calm in the console, this helps to slower movements of the robot arms and this will make the assistant to work in coordination as there will be more time to anticipate. ± Intensive communication between the console surgeon and the first assistant is essential. The third robotic arm, must be placed on the patient’s right side, as this enables the right handed surgeon to toggle between two arms with their dominant hand. Accessory port must be placed on the patient’s left side, which helps the right-handed assistant to assist freely. However, this set up can be modified by the need of the operating surgeon. Ideally one assistant port with three robotic arms and the camera port, is used. However, if only two arms can be docked, due to a narrow patient, uni- or bilateral assistant ports can be placed in the upper quadrants to allow for dual-sided retraction. Once ports have been placed, the robot may then be docked.1,2 An experienced assistant will certainly manage trocar insertion, docking and help the surgeon for smooth procedure and better outcome.

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1. Preoperative assessment includes indication of surgery, the co-morbidity, previous surgery (anticipate adhesions) and BMI 2. Port placement (including accessory port) (procedure specific) 3. Docking 4. Proper placement of instruments in the robotic arms and unclutching 5. Proper technique for removal, exchange, cleaning and re-introduction of the endoscope 6. Complete knowledge of surgical steps (procedure specific) 7. In case of emergency to immediately remove instruments, undocking and moving the robotic cart away. 8. Troubleshooting technical issues, recoverable and irrecoverable fault and how to rectify. 9. Assistant surgeon plays an important role during the creation of the colpotomy while performing a hysterectomy. Adequate pneumoperitoneum while removing the specimen is important. 10. Assistance in wound closure appropriately as future hernia to be avoided. 11. Preparedness in case of case conversion from robotic to laparoscopy surgery or open surgery 12. Postoperative care

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REFERENCES

Basics: Understanding the Robot and Its Working

1. Desai PH, Gillentine RJ. Present Challenges of Robotics in Gynecology. Medical Robotics [Working Title] [Internet]. 2021 Mar 14 [cited 2024 Mar 27]. Available from: https://scholar.archive.org/ work/vgo23txllnhztmipzbrieq7z4a 2. El-Ghobashy A, Ind T, Persson J, Magrina JF. Textbook of gynecologic robotic surgery. Cham, Switzerland: Springer; 2018. 3. Guideline Statement for the Surgical Assistant in Robotic Surgery [Internet]. 2017. Available from: https://www.surgicalassistant.org/assets/docs/Guidelines_Surgical_Robotics.pdf ‌ 4. van’t Hullenaar CDP, Bos P, Broeders IAMJ. Ergonomic assessment of the first assistant during robot-assisted surgery. Journal of Robotic Surgery. 2018 Jul 24;13(2):283–8.

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2 Robotic Benign Surgery

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7. Robotic Hysterectomy for Benign Conditions 8. Robot-Assisted Laparoscopic Myomectomy (RALM) 9. Robotic Surgery for Endometriosis 10. Robot-Assisted Pelvic Organ Prolapse Repair 11. Robotics in Infertility Management 12. Robotics in Adnexal Surgery 13. Robotic Management of Urinary Fistulas

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7 Robotic Hysterectomy for Benign Conditions • Rooma Sinha  • Rupa Bana

Hysterectomy is the second most common surgery performed on women after cesarean section and are mostly for benign indications. Harry Reich performed laparoscopic hysterectomy in 1989. The gynecologists have been slow in adopting minimally invasive technique to perform this operation. Both the American Association of Gynecologic Laparoscopists (AAGL) and the American Congress of Obstetricians and Gynecologists (ACOG) issued statements that minimally invasive hysterectomy should be the standard of care.1,2 The slow adoption of minimally invasive hysterectomy techniques among practicing obstetrician-gynecologists is mainly because conventional “straight-stick” laparoscopic skills require long learning curve along with insufficient laparoscopic training and exposure during their residency program.3 So when FDA approved robotic technology for hysterectomy in 2005, the incidence of minimally invasive hysterectomy was expected to rise with 3-dimensional optics, wrist-like motion with robotic instruments, and shorter learning curves than traditional laparoscopy for the surgeons.4 The advantages of minimally invasive hysterectomy are well known like reduced hospitalization, quick recovery with more rapid return to normal activities and fewer postoperative morbidities.2 These advantages have been also shown in a metaanalysis comparing total laparoscopic hysterectomy (TLH) with total abdominal hysterectomy (TAH). These advantages are reduction in morbidity—specifically, fewer perioperative morbidity and complications, lower estimated blood loss and shorter hospital stay.5 Indications of Robotic Hysterectomy Hysterectomy for any indication can be performed with robotic assistance. Laparoscopic or robotic hysterectomy should not replace vaginal hysterectomy. In modern era, robot assisted surgery is of great value as compared to open surgery in minimizing morbidity in the cases of pelvic adhesions and endometriosis. Although

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the choice of route of surgery depends on several factors like uterine size, weight, enlargement, descent, previous abdominopelvic surgery, endometriosis, adhesions, BMI, etc. A large (1474 women) retrospective study conducted by Landeen et al, compared abdominal, vaginal, conventional laparoscopy, and robot assisted laparoscopy techniques and reported that laparotomy had higher complication rates (14%) and vaginal hysterectomy had least complication rates. While robotic surgery had decreased blood loss and lesser hospital stay (p  or = 12 months). They concluded that though this technique was feasible, effort should be made to ensure proper closure of the vaginal cuff, trocar sites and to develop nerve-sparing techniques.15 Various studies have consistently reported that the number of lymph nodes retrieved is similar in range between 17 and 32 for the robotic cohort and 16 to 23 for the laparoscopic cohort.16–18 This chapter aims to discuss 1. A simple reproducible technique to do robotic hysterectomy for benign indications (Sinha-Apollo technique) 2. Strategies to tackle large specimen Sinha-Apollo Technique: “Two Arms-Three Instruments”19 We developed a surgical technique to optimize operating time and cost. It is a reproducible two arms-three instruments “Sinha-Apollo Technique”. Using only 3 da Vinci’s EndoWrist instruments (Fenestrated bipolar, Hot Shears and Needle Driver) which limits the instrument exchanges during the procedure and using a 15 cm barbed suture to avoid intracorporeal knot-tying during vault suturing, both strategies can reduce the overall time. We use Rumi uterine manipulator system with Advincula Arch (Cooper Surgical, Trumbull, CT, USA) and an appropriate size of Rumi tip and KOH cup. Efficient uterine manipulation avoids the need for a third robotic arm. The bevelled edge of the KOH cup identifies the trajectory of colpotomy at the cervicovaginal junction (Fig. 7.1).

Part 2

Port Placement and Positioning The primary optic port (8 mm) is placed with modified Hassan’s technique. This is usually placed at the umbilicus. A supra-umbilical position is very rarely used in our practice. The left and right robotic trocars (8 mm: Intuitive Surgical, Inc., Sunny-vale, CA, USA) are placed 8 to 10 cm lateral to midline and 3–4 cm inferior to the optic trocar.

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Fig. 7.1:  Rumi uterine manipulator system with Advincula Arch

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A line is then drawn from the left 8 mm trocar and the optic trocar. At the mid-point of this line a perpendicular line is drawn in the cranial direction and a 5 mm assistant port is placed 4–5 cm from the line (Fig. 7.2A and B). The Trendelenburg position of 15–20 degrees is done (Fig. 7.3). Attention to the position is important as this cannot be changed once the patient cart is docked. The patient cart is placed on the left side, giving space between the legs for the use of uterine manipulator. Once targeting is done, the arms are docked on either side. Surgical Steps We use a 30-degree telescope for robotic hysterectomy and advocate a sequential strategy to complete all left side ligaments and uterine complex up to the colpotomy ring before moving to the right side. The ureters are identified at the pelvic brim and their path traced either trans-peritoneally or dissected retroperitoneally in cases with endometriosis. Fenestrated bipolar in arm 3 (40 watts) and hot shear monopolar scissors is selected in arm1 (30 watts). The arm 2 has the telescope.

Fig. 7.2A:  Diagrammatic representation of port placement

Fig. 7.2B:  Photograph of port placement

Fig. 7.3:  Trendelenburg position

Robotic Benign Surgery

Steps 1. Left round ligament and ovarian pedicle are coagulated and transacted salpingectomy and/or oophorectomy is done in the end (Fig. 7.4).

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Fig. 7.4:  Step one

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2. The anterior leaf of broad ligament is opened using the hot shears and the dissection proceeds anteriorly to cut the vesico-uterine peritoneal reflection and the bladder dissected inferiorly (Fig. 7.5A and B). 3. The posterior left leaf of broad ligament and the left utero-sacral ligament are now coagulated and transected (Fig. 7.6). 4. Skeletonization of the uterine vessels and a tension-free application (slightly loose grip) of the bipolar forceps ensures adequate tissue effect and robust sealing of the vessels before transection and minimizing the lateral thermal spread. 5. The uterine artery and vein is then coagulated and transected by a synchronised movement of fenestrated bipolar and hot shears. We describe this as the “Salsa manoeuvre” (Fig. 7.7A and B). 6. Colpotomy is then begun from the anterior vaginal vault. Monopolar hot shears is used to divide the cardinal ligament complexes of the left side first and then the

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Fig. 7.5A:  Broad ligament anterior and posterior Fig. 7.5B:  Opening UV pouch and bladder dissection leaf opened

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A

B

Fig. 7.7A and B:  Salsa manoeuvre

right side in a manner consistent with an intra-fascial hysterectomy. The camera is then flipped with 30° up and the posterior colpotomy is done. The pneumoperitoneum is maintained by inflation of the pneumo-occluder balloon of the Rumi manipulator. This is a sequential method to approach the vaginal vault (Fig. 7.8). 7. Removal of tubes and/or ovaries are done at this stage. After identification of the infundibulo-pelvic ligaments and the ureters, bipolar coagulation is done with fenestrated bipolar and the pedicle transected with the hot shears. The adnexa is placed in the vaginal canal for retrieval (Fig. 7.9). 8. The vaginal cuff closure is accomplished with the fenestrated forceps in arm 3 which is used to grasp and evert the edges of the vaginal cuff and a mega needle driver in arm 1. Using a 5 × 5 rule, each vaginal bite is taken at a distance of 5 mm and for a depth

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Fig. 7.6:  Posterior dissection on right side

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Fig. 7.8:  Photograph showing colpotomy

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Fig. 7.9:  Removal of tubes and ovaries

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of 5 mm on the cut edge including both the vaginal fascia and vaginal epithelium in each bite. A 15 cm 1-0 V-Loc barbed suture (Medtronic, Minneapolis, MN, USA) on a GS2 needle is used. This closure is done in a single layer with the inclusion of the uterosacral ligament to prevent future vault prolapse. The end of the barbed suture is cut flush with vault and the needle retrieved (Fig. 7.10). Prior to closure, all operative sites are irrigated, a low insufflation pressure check is performed to ensure haemostasis, and the patient cart is undocked after removing all instruments. Ports are removed under vision. The pneumo-peritoneum is released in the smoke evacuation system. The rectus sheath of the primary port is identified at the umbilicus and closed with number 1/0 polypropylene. The rectus sheath of the 8 mm ports is not routinely closed. All port skin is closed with number 3/0 polyglecparone absorbable suture. Tackling a Large Specimen at Robotic Hysterectomy: 5 Strategies (Fig. 7.11) 1. Port placement: We recommend the placement of optic port at the umbilicus irrespective to the size of the uterus. This is contradictory to the teaching of

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Fig. 7.10:  Vault closure

conventional laparoscopy where it is recommended to place optic port at midline supra umbilically. This approach is used as the robotic instrument manoeuvrability can coagulate and transect the upper ligaments and help open the anterior and posterior broad ligaments even when the space is limited (Fig. 7.12). 2. Bladder dissection: The fenestrated bipolar from the left side of the patient which is being manipulated by the surgeon’s left hand can be used like a human hand. This manoeuvre is used to push the uterus cranially. This exposes the vesicouterine space even with a large uterus with expanded lower segment due to presence of fibroids. The vesicouterine fold and ligament is then dissected with the “ Head on approach“ and the bladder is dissected inferior (Fig. 7.13A and B). 3. Manipulation of uterus from one side to other. We describe this manoeuvre as “hugging the uterus”. The two instruments from right and left side of the patient (fenestrated bipolar and hot shears) are used to hug the uterus and the surgeon moves from one side pedicles to the other side (Fig. 7.14).

Robotic Benign Surgery

Fig. 7.11:  Enlarged uterus

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Fig. 7.12:  Port placement

Part 2

Fig. 7.13A:  Head on approach bladder is dissected inferior

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Fig. 7.13B:  Bladder is dissected inferior approach

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Fig. 7.14:  Manipulation of uterus

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4. Uterine artery and vein: Once the uterine artery and vein are skeletonized, we describe our technique of coagulation and transection as the “Salsa manoeuvre”. The two instruments (fenestrated bipolar and Hot Shears) work synchronously. When the fenestrated bipolar is being used for coagulation, the Hot Shears is being used to mobilise the uterus and expose the vessels. Once the coagulation is done, the fenestrated bipolar is used to mobilise and expose the vessels and the Hot Shears is used to cut the vessels (Fig. 7.15). 5. Colpotomy: With the help of uterine manipulator and the appropriate KOH cup, the cervico-vaginal junction is made prominent. The skilful rotation of 30° telescope camera can expose the lateral fronices clearly. We start the colpotomy from anterior fornix and then proceed to both lateral fornixes and ultimately posterior. A myomectomy can be performed if the colpotomy is difficult with its presence in lower segment or cervix. Partial amputation of the uterus and then to remove cervix separately can be one more modification (Fig. 7.16).

Fig. 7.15:  Uterine artery and vein

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Fig. 7.16:  Colpotomy

Specimen Retrieval Specimen retrievel through the vaginal route for benign conditions, is most ideal. The concept is to make a globular specimen into longitudinal one by making repeated curved incisions on the body of the uterus. Procedures like hemisection, intramyometrial coring, wedge morcellation and perhaps myomectomy can help in retrieval of the specimen.20 Sometimes, as we proceed for morcellation, robot has to be undocked to gain access to the vagina and in such situations the vaginal orifice is closed by suturing. If the vaginal access is limited, the specimen can be retrieved by extending the umbilical incision to 2.5–3 cm and use the same techniques of morcellation as we use vaginally.

1. Robot-assisted hysterectomy safe and feasible for both benign and malignant conditions. 2. It has minimized conversion rate during laparoscopy. 3. This significant difference is mainly due to ergonomics, endowrist movements of instruments and stereoscopic three-dimensional vision. 4. Greatest limitation in robotic hysterectomy is the cost factor.

Part 2

REFERENCES

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1. AAGL position statement: route of hysterectomy to treat benign uterine disease. AAGL Advancing Minimally Invasive Gynecology Worldwide J Minim Invasive Gynecol. 2011 Jan-Feb; 18(1):1–3. 2. Choosing the route of hysterectomy for benign disease. ACOG Committee Opinion 444. Obstet Gynecol. 2009;144:1156–58. 3. Nationwide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches. Jacoby VL, Autry A, Jacobson G, Domush R, Nakagawa S, Jacoby A Obstet Gynecol. 2009 Nov; 114(5):1041–8. 4. The increasing use of robot-assisted approach for hysterectomy results in decreasing rates of abdominal hysterectomy and traditional laparoscopic hysterectomy. Smorgick N, Patzkowsky KE, Hoffman MR, Advincula AP, Song AH, As-Sanie S Arch Gynecol Obstet. 2014 Jan; 289(1):101–5.

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5. Walsh CA, Walsh SR, Tang TY, Slack M. Total abdominal hysterectomy versus total laparoscopic hysterectomy for benign disease: a meta-analysis. Eur J Obstet Gynecol. 2009;144:3. 6. Landeen LB, Bell MC, Hubert HB, Bennis LY, Knutsen-Larson SS, Seshadri-Kreaden U. Clinical and cost comparisons for hysterectomy via abdominal, standard laparoscopic, vaginal and robotassisted approaches. S D Med (2011) 64(6):197–9, 201, 203.  7. Robotic-assisted laparoscopy for deep infiltrating endometriosis: the Register of the Society of European Robotic Gynaecological Surgery. Hanssens S, Nisolle M, Leguevaque P, Neme RM, Cela V, Barton-Smith P, Hébert T, Collinet P. Gynecol Obstet Fertil. 2014 Nov;42(11):744–8. 8. The use of robot-assisted laparoscopic hysterectomy in the patient with a scarred or obliterated anterior cul-de-sac. Advincula AP, Reynolds RK SLS. 2005 Jul-Sep;9(3):287–91. 9. Comparison of robotic surgery and laparoscopy to perform total hysterectomy with pelvic adhesions or large uterus. Chiu LH, Chen CH, Tu PC, Chang CW, Yen YK, Liu WM. J Minim Access Surg. 2015 Jan-Mar;11(1):87–93. 10. Robotically assisted hysterectomy in patients with large uteri: outcomes in five community practices. Payne TN, Dauterive FR, Pitter MC, Giep HN, Giep BN, Grogg TW, Shanbour KA, Goff DW, Hubert HB. Obstet Gynecol. 2010 Mar;115(3):535–42. 11. Robotic-assisted laparoscopic radical hysterectomy (Piver type III) with pelvic node dissection— case report. Sert BM, Abeler VM. Eur J Gynaecol Oncol. 2006; 27(5):531–3. 12. Robotic radical hysterectomy in early-stage cervical carcinoma patients, comparing results with total laparoscopic radical hysterectomy cases. The future is now? Sert B, Abeler V. Int J Med Robot. 2007 Sep;3(3):224–8. 13. Robotic  radical parametrectomy and pelvic lymphadenectomy in patients with invasive cervical cancer. Ramirez PT, Schmeler KM, Wolf JK, Brown J, Soliman PT. Gynecol Oncol. 2008 Oct;111(1):18–21. 14. Robotic surgery in gynecologic oncology: program initiation and outcomes after the first year with comparison with laparotomy for endometrial cancer staging. Veljovich DS, Paley PJ, Drescher CW, Everett EN, Shah C, Peters WA 3rd. Am J Obstet Gynecol. 2008 Jun;198(6):679. 15. Robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy with short and long term morbidity data. Persson J, Reynisson P, Borgfeldt C, Kannisto P, Lindahl B, Bossmar T. Gynecol Oncol. 2009 May;113(2):185–90. doi: 10.1016/j.ygyno.2009.01.022. Epub 2009 Feb 28. 16. Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques. Bell MC, Torgerson J, Seshadri-Kreaden U, Suttle AW, Hunt S. Gynecol Oncol. 2008 Dec; 111(3):407–11. 17. Seamon LG, Henretta M, Kim KH, Carlson MJ, Cohn DE, Fowler JM. Robotic versus laparoscopic hysterectomy and lymphadenectomy for endometrial cancer: conversion rates and operating times. Gynecol Oncol. 2008;108(Suppl 1):A142. 18. The impact of robotics on practice management of endometrial cancer: transitioning from traditional surgery.Hoekstra AV, Jairam-Thodla A, Rademaker A, Singh DK, Buttin BM, Lurain JR, Schink JC, Lowe MP. Int J Med Robot. 2009 Dec; 5(4):392–7. 19. Rooma Sinha, Bana Rupa, Girija Shankar Mohanty, Two arms-three instruments robot-assisted laparoscopic hysterectomy: A reproducible technique, Laparoscopic, Endoscopic and Robotic Surgery, Volume 4, Issue 2, 2021, Pages 44–47, ISSN 2468–9009. 20. Sinha Rooma, Jyothsna B-Optimal route of hysterectomy. Update in obstetrics and gynecocogy 2011’ Paras publications; 370–78.

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8 Robot-Assisted Laparoscopic Myomectomy (RALM) • Anupama Bahadur  • Rajlaxmi Mundhra

Robot-assisted surgery, has made a name for themselves in the field of gynaecological surgery in the modern era of medicine. Since the approval for use of da Vinci Robotic system for gynaecological surgeries by US FDA in 2005 and with the advantages for its use over laparoscopic surgeries, robotic gynaecological procedures have been widely incorporated in the field of benign and malignant gynaecological surgeries. Robot-assisted surgeries is now becoming the mainstay for benign surgeries including myomectomy, hysterectomy for various indications, utero-vaginal prolapse, etc. Uterine fibroids, also known as leiomyoma, are the most common benign tumours in females and are seen in up to 80% women by the age of 50 years.1 Though many remain asymptomatic, majority women in their reproductive years present with heavy menstrual bleeding, dysmenorrhoea, bulk symptoms from mass effect on surrounding structures, pelvic pain, recurrent pregnancy loss, and even infertility. Uterine leiomyomas can be managed expectantly, medically, interventional and surgically. However, if the patient is symptomatic and an intervention is desired, the route of therapy should be individualized to the patient’s age, symptom profile, and goals of treatment (i.e. fertility) in addition to regard for the size, number and location of the leiomyoma burden. Though there are variety of options for treating symptomatic myomas, surgery remains the gold standard. Traditionally, open techniques have been adopted with surgeons having the advantage of depth perception and feeling of tissue resistance for operative coordination but with advancement in minimally invasive surgeries, robotic-assisted laparoscopic myomectomy (RALM) is preferred for more complex myomectomies because with the robotic approach there is three-dimensional depth perception, 7 degrees of freedom, tremor filtration, improved ergonomics, wristed articulation of instruments allows defined dissection, capacity for rapid suturing, and lack of need for an experienced assistant. It seems a feasible option for the patient in terms of cosmetic scar, less post-operative pain, decreased blood loss and need for blood transfusion, shorter hospital stay, early resumption of work and less post-operative

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complications. For RALM patients are selected based on the number, size, location and consistency of fibroids and also patient co-morbidities, patient preference for route of surgery and surgical skill level of operating surgeon. Robotic myomectomy is considered more technically challenging especially in women with multiple leiomyomas (due to multiple hysterotomy incisions requiring suturing), and difficult locations (i.e. posterior, cervical, and broad ligament) and those of a large size and depth that often are proximal to the endometrial cavity and require multiple layers of closure. So this modality is chosen for complex myomectomies. Advantages include stable and fixed view of the surgical field as the surgeon has complete control of the camera. Endo-wrist technology is advantageous while performing complex myomectomies. Robotic instruments have seven degrees of freedom and a motion similar to human hands. For the surgeon wristed instruments allow better tissue dissection and rapid suturing in layers of the hysterotomy incision in myomectomy. Despite several advantages of its use, high surgical cost remains the most prohibitive factor in its uptake and there is lack of tactile sensation.2

Technically Challenging Cases with High Conversion Rates to Open Surgery but in the Hands of Experienced Surgeon can be Successfully Attempted Robotically 1. Fibroids abutting the endometrial cavity 2. Fibroids located in anatomically difficult sites such as broad ligament, cervix or cornua are potentially difficult cases for robotic approach3–5 A study by Sinha et al has stated that there is no limit to the size, location and number of myomas that a skilled minimally invasive surgeon can perform.6 Closure of the hysterotomy incision may be difficult owing to lack of tactile sensation in robotic approach. Note: There is a likely chance of entering the uterine cavity in fibroids that impinge the cavity or are close to the cavity. So if the cavity is opened while performing robotic myomectomy, it is advisable to use 3–0 absorbable suture to close the defect and it should be mentioned in the operative notes and the patient must be informed as well.

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Indications, Patient Selection and Preoperative Preparation for RALM 1. Appropriate patient selection is an important initial step in surgical planning for uterine fibroids. This decision is individualized and should be taken after assessment of certain anatomical factors like size/number of myoma and location along with proximity to uterine cavity. 2. It is important to consider the surgeons expertise with a given surgical route along with availability and affordability of surgical equipment while planning these cases. 3. Myomectomy should be considered in women who desire fertility preservation. The most appropriate cases include: • Fundal, pedunculated fibroids, subserosal, or intramural fibroids. • Minimally invasive route is for patients with a single intramural or serosal myoma < 15 cm in size or there are 3 fibroids each less than 5 cm diameter. • Intramural fibroids distorting the uterine cavity or those intramural fibroids that are greater than 4 cm in size and do not distort the cavity but negatively impact fertility are to be removed.

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Pre-requisites for RALM a. Consent for hysterectomy is mandatory for every myomectomy case, the patients undergoing RALM should always be informed that there is a chance of converting the procedure into an open one and a remote possibility of hysterectomy exists. b. A requisition for adequate blood must be sent to the blood bank and blood should be cross matched and kept handy in the operating room. c. A preoperative mapping of fibroids with Magnetic Resonance Imaging (MRI) should be done in order to delineate the uterine dimensions for all such cases and also to plan the incision (Fig. 8.1). d. Preoperative correction of anaemia with use of GnRH agonists for decreasing uterine size and volume may be considered based on the case selection.7

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Step-wise Technique for Robotic Myomectomy Port Placement and Docking After an informed consent, the patient should be anesthetised and placed in low dorsal lithotomy position just like conventional laparoscopy, with arms securely tucked by her sides. Padded shoulder blades must be applied, anti-skid mats are a better option. Once the parts are painted and draped, the uterine manipulator is placed through vagina and Foley’s catheter is inserted. Pneumoperitoneum is achieved. The most critical step is port placement and should be individualized to the patient’s pathology and abdominal topography. It should be governed by surgical history, clinical examination of leiomyoma burden, preoperative imaging, and surgeon’s preference to optimize access. In robotic surgeries port placement is usually done in a straight or slightly curvilinear fashion (Fig. 8.2). The endoscope port is the first port created in the midline and should be approximately 15–20 cm above pubic symphysis or 8–10 cm above the uterine fundus. A thorough inspection of the abdominal and pelvic cavity is done to look for the feasibility of robotic approach and then the other two ports placement is done. There

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Fig. 8.1:  Pelvic MRI sagittal view of fibroid

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Fig. 8.2:  Trocar placement during robot-assisted laparoscopic myomectomy

should be an 8–10 cm gap between each port marking. Through left side port, bipolar forceps is introduced and a monopolar scissor is inserted through right-sided port. Additional assistant ports can be inserted on the left between camera and robotic port. The assistant port helps in passing the instruments, suctioning, stabilising the uterus and for the suture material to go in. Advanced smoke extraction systems can be used; allowing the surgeon to work with constant lower intra-abdominal pressures, without compromising the exposure of the operating field. Once port placement is done, side docking is preferred for better uterine manipulation.

Operative Steps • The surgeon must plan the incision carefully with the aid of a pre-operative MRI. • This tactfully addresses dealing with the bulkier myomas first and also allows a more systematic approach. • Before a strategic uterine incision is made, blood loss can be minimized and visualization of the dissection planes optimized by injecting the leiomyoma with a dilute concentration of vasopressin directly into the pseudocapsule through a laparoscopic needle via assistant port. 20 units of vasopressin in 200 ml normal saline is preferred. This is injected into the uterine serosa and myometrium layer surrounding the myoma (Fig. 8.3). The surgeon must ensure that the needle tip is not aspirating blood. Always inform the anesthetist while injecting vasopressin. Once proper instillation is done, there is blanching of the fibroid. Other options or synergistic ways of decreasing blood loss include the use of intravaginal prostaglandins, intravenous tranexamic acid, oxytocin, misoprostol per-rectally, uterine artery ligation, or even preoperative embolization if required.

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Uterine Manipulator Another vital step when performing a robotic myomectomy is the use of a uterine manipulator. Leiomyoma’s can be difficult to remove if the location, such as the posterior fundus, precludes visualization or access. This becomes even more challenging when they compress surrounding structures such as the rectum or the pelvic side wall. Thus, there are multiple advantages to uterine manipulators. It acts as the “fifth arm”.

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Fig. 8.3:  Vasopressin in dilute concentration being injected into the myometrium

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• It is important to dissect out the fibroid by first incising the serosa and myometrium till the pseudocapsule is reached in one plane. A vertical incision is preferred as it allowed the surgeon to ergonomically close the hysterotomy (Fig. 8.4). • It is advisable to remove as many fibroids as possible with one single incision. But before the hysterotomy incision is made, it is imperative to identify the important anatomical landmarks such as round ligaments, both ovaries, fallopian tubes and uterine vessels to avoid any damage to them. In women with infertility damage to the fallopian tubes can prove detrimental to her reproductive career. • A significant advantage of the robotic technology is the use of the robotic tenaculum. When this is placed in the fourth arm, static and consistent traction and counter traction can be more efficiently applied while maintaining the ability to dissect and retract for oneself. Alternatively, this can be provided with a bedside assistant using either a standard laparoscopic tenaculum or a myoma screw which stabilises the fibroid and aids in dissecting it out. As with abdominal route, careful attention to the dissection planes allows the fibroids to be circumferentially enucleated and dissected from their fibrous attachments to the surrounding myometrium. When the number of incisions is intentionally kept minimum, bleeding is less from the exposed

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Fig. 8.4:  Hysterotomy incision

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myometrium has less serosal disruption. This in turn decreases the formation of adhesions to the neighbouring structures and overall integrity of the uterine scar can be maintained. Excessive traction on myoma should be avoided as it might result in opening of uterine cavity, thereby compromising the fertility especially if the surgery is done for fertility preservation. Inadvertently closing the cavity can result in Asherman’s syndrome. • Once the fibroid has been enucleated, it is kept aside in the pelvis. If more than one fibroid is removed, they can be put in a string and removed later. It is important to keep track of all myomas enucleated as a few can travel cephalad or get trapped in bowel loops. Hence counting of myomas is essential prior to completion of the surgery as none should be left behind. • Closure of hysterotomy incision: One of the benefits of robotics is the capacity to subsequent rapid closure of hysterotomy incision in layers. Closure is mirrored from the traditional open technique as the same surgical principles apply in minimally invasive route as well. The hysterotomy incision is rapidly sutured from insideout, and often a two or three-layer closure is performed if the endometrium is not disturbed. These days barbed suture is preferred as it helps to distribute the tension along the entire suture line (Fig. 8.5). It contains small helically arranged hooks that grasp the tissue and maintain tension. The advantages of barbed sutures include easy and faster suturing, it eliminates the need for surgical knots, tension is distributed equally and reduces post-operative morbidity. It has been shown that the Robotic approach allows a greater number of layers than laparoscopic surgery and this results in better reconstruction of the uterus and subsequently in better obstetric outcomes. • If there is concern for a breach in the endometrium, methylene blue can be injected directly into the uterine manipulator. If a defect in the endometrium is present, the methylene blue that distends the uterine cavity extrudes within the abdomen. Closure of this space can be carried out with a separate suture layer 3/0 absorbable suture. As the majority of the blood loss is from disruption of the myometrium and uterine sinuses, hemostasis is obtained by swift closure with suture and occasional (but sparing) use of cautery. The goal should be minimal use of energy in an effort to decrease myometrial necrosis and thus possible obstetric sequelae such as uterine rupture. It is essential to obliterate the dead spaces while closing the hysterotomy incision.

Fig. 8.5:  Repairing hysterotomy defect with barbed sutures

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• Once the myometrial defect has been repaired, the serosa should be largely approximated using baseball stitch method as it eliminates raw tissue exposure, thus lessening possible foreign body reactions and adhesions. When in doubt keep a drain. Removal of Specimen With recent FDA safety updation in December 2020, power morcellation should be performed only after tissue containment system and should be done only in appropriately recruited cases. It is essential to conduct a thorough preoperative screening to rule out uterine malignancy and both clinicians and patients need to be involved in shared decision-making.8 If the surgeon does not want to use power morcellation or if it is not available, then enlarge the trocar incision or perform a minilaparotomy to remove the myomas using cold knife technique. Vaginal extraction by a posterior colpotomy if the vagina is easily accessible is attempted by a few surgeons. Another method of extraction of fibroid is extracorporeal C-incision tissue extraction or ExCITE technique.9 The ExCITE technique has five key steps: 1. Specimen retrieval and containment 2. Self-retaining retractor placement 3. Creation of the C-incision 4. Tissue extraction 5. Fascial closure After all fibroids are extracted, they are sent for histopathology examination. Robot is undocked and moved away from patient. The trocars are removed under direct visualization. Port closure is done. Skin closure is performed on the basis of the surgeon’s preferences.

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Postoperative Period The operative notes should clearly mention the intraoperative findings and breach of uterine cavity if it has occurred. In the postoperative period, ERAS protocol should be followed, clear liquids started within 4–6 hours. Recovery is quick and most patients can be discharged in 24–48 hours after surgery.

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Efficacy of RALM versus Conventional Laparoscopy In a recent meta-analysis by Sheng et al in 2023, the authors compared the efficacy of RALM versus laparoscopic myomectomy (LM). Among 45,702 patients, RALM was better than LM in terms of intraoperative bleeding, postoperative hospital stay, lower incidence of blood transfusions, and postoperative complications, whereas LM showed higher efficacy in terms of operative time.10 Conservative myomectomy is associated with a 1% increased risk of uterine-rupture in subsequent pregnancy. Future Pregnancy Care 1. Women who undergo myomectomy with significant uterine disruption should wait several months before attempting to conceive; recommendations for the interval to conception ranges from 3 to 6 months. 2. The route of delivery during subsequent pregnancy depends on several factors: the perioperative conditions, the postoperative complications, the number of myomas removed, and the obstetric factors of the present pregnancy.

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3. Vaginal versus scheduled cesarean section and the period of gestation at which it should be performed involves shared decision making among the patient, the obstetrician, and the surgeon.

1. With the advent of robotic surgery a transformation has been witnessed in minimally invasive surgery due to its enhanced vision and wristed movements. 2. Traditionally surgical steps of robotic myomectomy remain same as open technique. 3. Superior ergonomics in the form of precise wrist mobility in robotic approach increases surgeon’s comfort to conduct complex surgeries with more ease and less fatigue. 4. Tissue dissection and suturing is easier in RALM.

1. Baird D., Dunson D.B., Hill M.C., Cousins D., Schectman J.M. High cumulative incidence of uterine leiomyoma in black and white women: Ultrasound evidence. Am. J. Obstet. Gynecol. 2003;188:100–7. 2. O’Reilly BA. Patents running out: time to take stock of robotic surgery. Int Urogynecol J 2014;25:711–3. 3. Seracchioli R, Rossi S, Govoni F, et al. Fertility and obstetric outcome after laparoscopic myomectomy of large myomata: a randomized comparison with abdominal myomectomy. Hum Reprod. 2000;15(12):2663–8. 4. Arian SE, Munoz JL, Kim S, Falcone T. Robot-assisted laparoscopic myomectomy: current status. Robot Surg. 2017 Jan 23;4:7–18. 5. Bhave Chittawar P, Franik S, Pouwer AW, Farquhar C. Minimally invasive surgical techniques versus open myomectomy for uterine fibroids. Cochrane Database Syst Rev. 2014;10:CD004638.  6. Sinha R, Hegde A, Mahajan C, Dubey N, Sundaram M. Laparoscopic myomectomy: do size, number, and location of the myomas form limiting factors for laparoscopic myomectomy? J Minim Invasive Gynecol. 2008;15(3):292–300. 7. Crosignani PG, Vercellini P, Meschìa M, Oldani S, Bramante T. GnRH agonists before surgery for uterine leiomyomas. A review. J Reprod Med. 1996;41(6):415–21. 8. U.S. Food and Drug Administration. Update: perform only contained morcellation when laparoscopic power morcellation is appropriate. FDA Safety Communication. Silver Spring, MD: FDA ; 2020. Available at: https://www.fda.gov/medical-devices/safety-communications/updateperform-only-contained-morcellation-when-laparoscopic-power-morcellation-appropriate-fda . 9. Truong MD, Advincula AP. The extracorporeal C-incision tissue extraction (ExCITE) technique. OBG Manag 2014;26(11):56. 10. Sheng Y, Hong Z, Wang J, Mao B, Wu Z, Gou Y, Zhao J, Liu Q. Efficacy and safety of robot-assisted laparoscopic myomectomy versus laparoscopic myomectomy: a systematic evaluation and metaanalysis. World J Surg Oncol. 2023 Jul 28;21(1):230.

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REFERENCES

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9 Robotic Surgery for Endometriosis • Abhishek Mangeshikar

Endometriosis is a complex and often painful gynecological condition that affects millions of women worldwide. It occurs when tissue similar to the lining of the uterus, called endometrium, grows outside the uterus. While endometriosis can manifest in various locations, deep endometriosis is a particularly severe form where lesions infiltrate tissues beneath the peritoneum, potentially impacting nearby organs such as the bladder, bowels, and ovaries. It can also be found in extrapelvic locations such as the diaphragm, chest, small intestine and appendix. Impact on Women’s Health 1. Chronic pelvic pain: Endometriosis, including deep endometriosis, is a leading cause of chronic pelvic pain. The pain can significantly impact a woman’s quality of life, affecting daily activities and emotional well-being. 2. Fertility challenges: Deep endometriosis can contribute to infertility by affecting the function of the ovaries, fallopian tubes, and the overall pelvic environment. Surgical intervention may be required to improve fertility outcomes. 3. Psychological impact: The chronic nature of endometriosis, coupled with the uncertainty of symptoms and fertility issues, can lead to psychological distress, anxiety, and depression in affected individuals. Understanding Deep Endometriosis 1. Infiltrative nature: Deep endometriosis involves the infiltration of endometrial tissue into deeper layers of pelvic organs, leading to the formation of nodules and adhesions. This infiltration can result in more severe pain and complications. 2. Impact on organ function: Organs such as the bladder and bowels may be directly affected by deep endometriotic lesions, causing symptoms like painful bowel movements, urinary urgency, and digestive issues.

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3. Diagnostic challenges: Diagnosing deep endometriosis can be challenging due to the depth of lesions. Specialized imaging techniques, such as transvaginal ultrasound or magnetic resonance imaging (MRI), are often used to identify and locate these lesions. It must be noted that diagnosis is highly operator dependent and even experienced sonologists/radiologists may be untrained in identifying endometriosis lesions. Diagnosis must be made by an experienced endometriosis specialist or a radiologist specially trained in endometriosis diagnosis. Understanding the complexities of endometriosis, especially in its deep form, is crucial for providing targeted and effective medical interventions. The multidisciplinary approach, including medical management, minimally invasive surgical techniques, and a focus on the holistic well-being of the individual, plays a pivotal role in managing and improving the outcomes for women affected by deep endometriosis. Historically, surgical interventions for endometriosis date back to the early 20th century. Laparotomy, a major abdominal surgery, was the primary method employed to address severe cases. However, these procedures often carried significant morbidity and prolonged recovery times.1 The introduction of laparoscopy in the mid-20th century marked a revolutionary shift in the surgical landscape for endometriosis. This minimally invasive approach allowed for better visualization and diagnosis of endometrial lesions, reducing patient morbidity and improving recovery times.2 As laparoscopic technology advanced, so did the refinement of surgical techniques for deep endometriosis. Excisional surgery emerged as a preferred method over ablation due to its ability to remove deep infiltrating lesions more completely.3 The integration of robotic-assisted surgery in the 21st century brought further precision and dexterity to the management of deep endometriosis. Robotics allowed for enhanced three-dimensional visualization and improved ergonomics, facilitating complex procedures with greater ease.4 Recognition of the multidimensional nature of deep endometriosis led to the integration of multidisciplinary teams involving gynecologists, colorectal surgeons, and urologists. This collaborative approach ensures comprehensive care, particularly in cases involving adjacent organ involvement.5 Traditional techniques sometimes struggled to achieve complete excision of deep infiltrating lesions. Residual endometriotic tissue could lead to persistent symptoms and a higher likelihood of recurrence.6 Advantages of Robotic Surgery • Robotic surgery provides enhanced visualization of pelvic structures, aiding in the identification and precise excision of deep endometriotic lesions.7 • Minimally invasive techniques, such as robotic surgery, are associated with reduced postoperative pain, shorter hospital stays, and faster recovery times compared to traditional laparotomy.8 • Minimally invasive techniques aim to preserve reproductive function by minimizing damage to surrounding healthy tissue and organs.9 As an expert in the field of endometriosis, it is paramount to recognize the evolving landscape of surgical techniques. Robotic surgery has emerged as a transformative force, revolutionizing the management of endometriosis. This review delves into the nuances

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of robotic surgery, tracing its evolution, elucidating its advantages over traditional approaches, and dissecting the key components of robotic surgical systems. a. Explanation of Robotic Surgery and its Evolution: Robotic surgery represents a pinnacle in minimally invasive techniques, integrating cutting-edge technology to enhance surgical precision. The evolution of robotic surgery can be traced back to its inception in the 1980s. The da Vinci Surgical System, introduced in the early 2000s, marked a watershed moment. This system, with its robotic arms controlled by a console, allows surgeons to perform intricate procedures with unparalleled dexterity.10 b. Advantages of Robotic Surgery over Traditional Approaches: The advantages of robotic surgery in the realm of endometriosis are manifold, offering a paradigm shift from traditional methods. 1.  Enhanced precision: Robotic systems provide three-dimensional, high-definition visualization, allowing for precise identification and excision of endometriotic lesions.11 2.  Greater maneuverability: The articulating robotic arms offer a wide range of motion, mimicking the natural movements of the human hand, facilitating intricate maneuvers in deep pelvic spaces. 3. Reduced blood loss and faster recovery: Robotic surgery is associated with decreased blood loss and shorter hospital stays, promoting a quicker recovery and return to normal activities.12 c. Key Components of Robotic Surgical Systems Understanding the key components of robotic surgical systems is imperative for appreciating their efficacy in endometriosis management. 1.  Surgeon’s console: The control center where the surgeon sits and manipulates the robotic arms with hand and foot controls. 2.  Robotic arms: Articulating arms equipped with surgical instruments, allowing for precise movements during the procedure. 3. Endoscope and 3D camera system: High-definition, three-dimensional visualization is provided by the endoscope, enhancing the surgeon’s depth perception.13 4.  Patient cart: The robotic system’s mechanical arms and instruments are housed in the patient cart, which is positioned next to the operating table. Robotic surgery has undoubtedly transformed the landscape of endometriosis management. As an endometriosis expert, it is imperative to recognize the advantages of this evolving technology and its potential to revolutionize patient outcomes. The continued refinement of robotic systems and their integration into surgical practices represent a promising trajectory for the future of endometriosis surgery.14

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Overview of Surgical Techniques in Deep Endometriosis Surgery Deep endometriosis surgery demands a nuanced approach, considering the intricate involvement of pelvic and extrapelvic organs. The surgical techniques employed encompass a spectrum of procedures, each tailored to address the specific challenges posed by deep infiltrating lesions. Excisional surgery, involving meticulous removal of endometriosis tissue, is a cornerstone in the management of deep endometriosis. This may involve: 1.  Nodule excision: Targeted removal of deep nodules infiltrating pelvic organs, such as the rectum, bladder, or uterosacral ligaments.15

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2.  Peritoneal shaving: Delicate excision of endometriotic lesions from the peritoneum, preserving surrounding healthy tissue.16 3. Nerve-sparing techniques: Preservation of pelvic nerves during surgery to mitigate the risk of postoperative pain and dysfunction.17

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Our Technique The patient is placed in the traditional position for laparoscopic surgery with the legs in Allen stirrups with the minimal amount of flexion at the hip and knee joints. We make the primary incision at the umbilicus or the Lee Huang point depending on the patient’s body habitus, the size of the uterus in case of a concomitant hysterectomy or the anticipated need of a colorectal resection. Prior to beginning the procedure, a cystoscopy is performed and both ureteric orifices are identified. ICG dye is injected into both ureters using a cannula through the cystoscope. The dye will stay in the ureters for approximately 4–5 hours and will help in identifying the ureters with the daVinci’s firefly mode, without having the hindrance of stents (Fig. 9.1A and B). A Veress needle is used to create a pneumoperitoneum and we use an optical entry technique with a 5 mm 0 degree laparoscope placed through the optical trocar of the robotic cannula. Once entry is confirmed, the 30 degree robotic telescope is used to perform a thorough inspection of the abdomen and pelvis is performed. Both domes of the diaphragm are closely examined for any endometriosis lesions. It is important to use the angled scope to push down the liver and inspect the diaphragm behind it for any endometriosis lesions. The rest of the abdomen is surveyed including the stomach, small intestine, cecum, appendix and large intestine. We then place the other robotic ports under vision in a linear pattern 2 ports on the right and 1 port on the left. A 5 mm or 12 mm assistant port is placed between Arms 1 and 2. After port placement the patient is placed in steep Trendelenburg and the small bowel is pulled out of the pelvis and the uterus is anteverted to enable a complete survey of the pelvis.

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Fig. 9.1A and B:  (A) Left ureterolysis and (B) Indocyanine green (ICG) dye

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The robot is then docked from the patient’s right side and instruments are placed. We traditionally use long bipolar forceps, monopolar shears and a prograsp for most of the dissection. Preparation begins by mobilising the sigmoid colon from its congenital adhesions to the pelvic sidewall. This may be performed all the way up to the splenic flexure if a segmental bowel resection is planned. This mobilisation gives us direct visualisation of the left ureter which can be confirmed via the firefly mode by identifying the bright green of the ICG dye. Ureterolysis can be performed up to the adherent ovary. In case if an endometrioma it is drained and decompressed after inevitable rupture during ovariolysis from the pelvic sidewall. Once the ovary is completely mobilised, it is elevated and a temporary ovariopexy is performed to the lateral wall using a straight needle suture or a T lift device. The same procedure is repeated on the right side. Ureterolysis is completed after fixation of the liberated ovaries up to the intraligamentary portion. Endometriosis lesions form the peritoneum and uterosacral ligaments can now be safely excised (Fig. 9.2A and B). In case of obliteration of the POD by a rectovaginal nodule, one must begin dissection of the pararectal spaces laterally and then advance along those avascular spaces up to the nodule. In case a segmental resection is planned, it is important to enter the avascular TMRE plane to mobilise the bowel. This is a nerve sparing technique which provides direct visualisation of the hypogastric nerves and enables us to move them away laterally. The midline dissection is the trickiest part of the dissection since it involves cutting through the nodule leaving some portion on the uterine torus and some portion on the rectum, both of which are excised after the dissection is completed and the POD is entered. A speculum examination should have been performed prior to beginning the procedure to rule out infiltration of the vagina. In case vaginal infiltration is present a colpotomy is made and the affected vagina is excised. Rectal endometriosis: Preoperative evaluation is a must. Endometriosis surgery requires a thorough and complete evaluation of the rectum. Rectal nodules can be easily

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Fig. 9.2A and B:  (A) Left uterine vessels and (B) Pararectal space dissection

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diagnosed on a TVS ultrasound or an MRI provided the imaging is performed by or interpreted by an expert. For low rectal nodules, the robotic approach offers us an invaluable advantage. Deep shaving is optimised due to the stable camera and fine instrumentation. In some cases a low anterior resection may be avoided using the robotic platform as compared to a laparoscopic approach. This may have tremendous advantages for long-term patient outcomes as well as reducing complication rates. For single rectal nodules, less than 5 cm in length, not infiltrating a circumference more than 1/3rd of the bowel or causing subocclusion of the lumen—it is possible to perform a discoid resection with a circular stapler (Fig. 9.3). Shaving is reserved for smaller nodules not infiltrating deep into the muscularis. The limitations with shaving is that it is not a standardised technique and the endpoint is subjective. The recurrence rates may be higher when compared with the other full thickness excision techniques. Shaving Techniques

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• Excision of rectal lesions without entering the lumen • Low rate of complications • Low rate of functional outcomes or nerve damage • Long-term recurrence is probably higher • First line technique when feasible Shaving with the da Vinci robot is much easier when compared with traditional laparoscopic techniques because of the vision clarity and steadiness of the camera, as well as the fine tipped instruments which allow layer by layer dissection of the rectum and the dexterity of the instruments which allow us to approach the nodule from different directions.

Fig. 9.3:  Rectal shaving

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Discoid resection: It is an interesting procedure for a full thickness excision of the anterior wall of the rectum. It can be used for single nodules less than 4 cm in diameter with less than 1/3rd circumference infiltration and/or sub-occlusion. The bulk of the nodule is shaved to reduce the size of the disc. A suture is placed proximal and distal to the nodule. An appropriate sized EEA circular stapler is inserted transanally with the anvil in place and introduced into the pelvis under vision. The stapler is then opened and the 2 ends of the suture are used to push the nodule into the open stapler. The stapler is then anteverted and closed ensuring that the nodule remains within and then fired. The stapler is then released and extracted and the specimen is examined to confirm the complete excision of the nodule (Fig. 9.4A to D). We perform safety tests for insufflation with air and methylene blue.

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Fig. 9.4A to D:  (A) Discoid excision step1; (B) Discoid excision step 2; (C) Discoid excision step 2 ICG; (D) Discoid excision step 3

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Segmental Resection We reserve segmental resection anastomoses for bowel endometriosis in specific conditions: 1. Nodules causing subocclusion where a discoid excision is not possible 2. Single nodules infiltrating a length of more than 5 cm 3. Multiple nodules in close proximity to each other. 4. Nodules extending more than 1/3rd circumference of the bowel 5. Sigmoid colon nodules 6. Small bowel or ileocecal endometriosis Procedure When feasible segmental resection and anastomosis is carried out via NOSE techniques (Natural Orifice Transluminal Specimen Extraction) (Fig. 9.5A to F).

1. Transvaginal: When performed in conjunction with a hysterectomy the open vagina can be used to introduce the anvil and as a route to extract the specimen. In some cases it may be feasible to exteriorise the affected bowel through the open vagina but if this is not possible, then the procedure can be completed easily enough via an intracorporeal technique (robotic images). 2. Transcolpotomy: In cases when there is vaginal infiltration and a vaginal nodule must be excised the posterior colpotomy resulting from this procedure can be used to introduce the anvil as well as extract the specimen. 3. Transanal approach: In cases where there is no vaginal infiltration and there is no simultaneous hysterectomy being performed, an enterotomy is made proximal and distal to the affected length of bowel. The anvil of the EEA stapler with the spike in place is introduced via the caudal enterotomy. The anvil is then introduced through the cranial enterotomy and the spike is manouvered to pierce the anti-mesenteric border of the proximal colon. A linear stapler is used to disconnect the bowel below the anvil.The spike is then disconnected and retrieved by the bedside assistant port. The resected bowel is then disconnected and the specimen is retrieved through the distal rectrum which is then stapled closed. Finally, the side to end anastomosis is performed as per standard procedure (Fig. 9.5A to F). 4. ROBOTIC SURGICAL MANAGEMENT OF BLADDER ENDOMETRIOSIS Introduction Bladder endometriosis, though relatively rare, can present significant challenges for both diagnosis and surgical management. Traditional laparoscopy, while effective for many gynecological conditions, often falls short in the precision required for bladder surgery. The advent of robotic-assisted surgery has revolutionized this field, offering enhanced dexterity, superior visualization, and improved suturing capabilities. This chapter discusses our technique for managing bladder endometriosis using a combined cystoscopic and robotic approach, emphasizing the synergistic benefits of this method.

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These can be Performed via 3 Routes

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Fig. 9.5A to F:  (A) Preparation of rectum; (B) Preparation of sigmoid colon; (C) Transection of proximal colon; (D) Anastomosis step 1; (E) Anastomosis step 2; (F) Anastomosis ICG

Combined Cystoscopic and Robotic Approach Our technique begins with a cystoscopic evaluation of the bladder. This initial step is critical for accurately identifying and marking endometriotic nodules. The urologist uses a resectoscope to carefully delineate the affected areas within the bladder. If the

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Step-by-Step Technique 1. Patient preparation • The patient is placed in the lithotomy position under general anesthesia. • A Foley catheter is inserted for bladder drainage. 2. Cystoscopic evaluation • A cystoscope is introduced into the bladder. • The bladder is thoroughly inspected for endometriotic lesions. • Identified nodules are marked using the resectoscope. • If necessary, bilateral ureteral stents are placed to safeguard the ureters. 3. Robotic setup • The patient is repositioned to a low lithotomy position, suitable for robotic surgery. • The da Vinci surgical system is docked, and robotic ports are placed. • A pneumoperitoneum is established. 4. Robotic dissection • Under combined cystoscopic and robotic visualization, the marked bladder area is precisely incised using robotic instruments. • The endometriotic nodule is carefully excised, ensuring complete removal while preserving healthy bladder tissue. • The cystoscopic view assists in confirming complete resection and ensuring that the ureteral stents are correctly positioned and unharmed. 5. Bladder repair • The excision site in the bladder is meticulously sutured using the robotic system. • We utilize a two-layer closure technique: The inner layer with continuous sutures to close the bladder mucosa, and an outer layer with interrupted sutures to reinforce the bladder wall. • The robotic platform’s enhanced dexterity and 3D visualization facilitate precise sutu­ring, reducing the risk of leakage and promoting faster healing (Fig. 9.6A and B). 6. Postoperative care • The Foley catheter is typically left in place for 7–10 days to allow the bladder to heal. • Ureteral stents, if placed, are usually removed after 4–6 weeks. Advantages of Robotic Surgery Over Conventional Laparoscopy Robotic-assisted surgery offers several distinct advantages over conventional laparoscopy, particularly in the context of bladder endometriosis: 1. Enhanced precision • The robotic system provides superior control and range of motion, allowing for precise dissection and excision of endometriotic nodules. • The ability to manipulate instruments with greater finesse reduces the risk of damaging surrounding tissues, including the bladder and ureters. 2. Superior visualization • The 3D high-definition camera offers unparalleled visualization of the surgical field, enhancing the surgeon’s ability to differentiate between healthy and diseased tissues.

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endometriotic lesion is near the ureters, preoperative stenting is performed to protect these structures and facilitate their identification during surgery.

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• This improved visualization is crucial for the accurate removal of endometriotic lesions and for performing delicate reconstructive tasks. 3. Improved suturing • Robotic suturing is markedly superior to conventional laparoscopic techniques. The EndoWrist® instruments mimic the movements of the human hand, allowing for intricate suturing with minimal effort. • This is particularly beneficial for bladder repair, where a watertight closure is essential to prevent postoperative complications such as urinary leaks and fistulas. 4. Reduced fatigue • The ergonomic design of the robotic console allows the surgeon to operate while seated, reducing physical strain and fatigue during lengthy procedures. This can lead to better surgical outcomes and shorter operative times. Conclusion The combined cystoscopic and robotic approach for the management of bladder endometriosis represents a significant advancement in gynecologic surgery. By leveraging the strengths of both modalities, we can achieve superior outcomes in terms of precision, safety, and postoperative recovery. As robotic technology continues to evolve, its application in complex surgical scenarios such as bladder endometriosis will undoubtedly expand, offering new hope for patients affected by this challenging condition. ROBOTIC SURGICAL MANAGEMENT FOR ENDOMETRIOSIS ON THE DIAPHRAGM Introduction Endometriosis on the diaphragm requires meticulous surgical intervention due to its anatomical complexity and critical functions. Robotic-assisted surgery, particularly with the da Vinci system, offers significant advantages, including enhanced precision and control. This subchapter focuses on the surgical techniques and the strategic use of the fourth robotic arm in managing diaphragmatic endometriosis.

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Anatomical Considerations and Challenges The diaphragm’s proximity to vital structures such as the heart, lungs, and liver complicates surgical management. Endometriotic lesions on the diaphragm can cause severe pain and respiratory issues, necessitating precise excision to preserve diaphragmatic function.

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Advantages of the Fourth Robotic Arm 1. Retraction: The fourth arm provides stable retraction, crucial for maintaining a clear surgical field. 2. Stability: Enhances precision by reducing movement during delicate dissections. 3. Efficiency: Frees the surgeon’s hands for complex tasks, improving overall surgical efficiency. Surgical Technique Preparation and docking • Position the patient supine. • For the da Vinci X system, position the boom over the patient’s head.

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• For the da Vinci Xi system, position the boom over the patient’s abdomen. • This setup allows for a seamless transition from pelvic to diaphragmatic surgery without repositioning ports. Port placement • Standard configuration includes a camera port at the umbilicus and three additional ports for the robotic arms. • The fourth arm port is strategically placed for optimal retraction. Transition from pelvic to diaphragmatic surgery • After pelvic surgery, rotate the boom (da Vinci X) or the patient (da Vinci Xi) to position the robotic arms over the diaphragm. • Maintain the same port placements to simplify the transition. Diaphragmatic endometriosis excision • Use monopolar scissors to initially strip the diaphragm peritoneum. • For full-thickness lesions, completely excise the nodule. • Perform an airtight suture reconstruction to maintain diaphragmatic integrity. • A protip is to place the suction cannula in the chest before throwing the last stitch to help reinflate the lung and avoid the need for a chest tube (Fig. 9.6A and B).

Robotic Systems: Enhancing Precision and Control The integration of robotic systems into deep endometriosis surgery has revolutionized the field by offering unparalleled precision and control. Robotic platforms, such as the da Vinci Surgical System, provide the following advantages: 1. T hree-dimensional visualization: Robotic systems offer high-definition, threedimensional visualization, providing surgeons with an enhanced depth perception crucial for intricate procedures.18

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Fig. 9.6A and B:  (A) Diaphragmatic endometriosis and (B) diaphragmatic endometriotic excision and repair

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Conclusion Robotic-assisted surgery for diaphragmatic endometriosis, utilizing the fourth arm for retraction and precise instrumentation, significantly enhances surgical outcomes. This approach allows for meticulous excision and reconstruction, minimizing complications and improving patient recovery.

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2. Articulating instruments: The robotic arms, with their articulating instruments, replicate the natural range of motion of the human hand, facilitating precise movements in confined spaces.19 3. Enhanced ergonomics: Surgeons operate the robotic console in a comfortable, seated position, reducing physical strain and fatigue during prolonged procedures.20

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Comparison with Traditional Laparoscopic Techniques While traditional laparoscopic techniques have been instrumental in gynecological surgeries, a comparison with robotic-assisted approaches reveals distinct advantages of the latter in deep endometriosis surgery. 1. Enhanced maneuverability: The robotic arms surpass the limitations of traditional laparoscopic instruments, providing enhanced maneuverability in accessing and excising deep-seated lesions.21 2. Improved visualization in confined spaces: Robotic systems, with their 3D cameras, offer superior visualization in confined pelvic spaces, enabling surgeons to navigate complex anatomical structures with greater precision.22 3. Reduced learning curve: Robotic surgery often presents a shallower learning curve compared to traditional laparoscopy, allowing for quicker adoption of advanced techniques.23 The introduction of the dual console system within the da Vinci robotic surgery platform has marked a significant advancement in the realm of surgical training, particularly for fellows seeking expertise in complex procedures. The dual console system allows for a collaborative and interactive learning environment, facilitating the mentorship of fellows by experienced surgeons. This innovative feature enables a more seamless transfer of skills, significantly shortening the learning curve associated with adopting robotic surgical techniques.

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Key Features of the Dual Console System 1. Collaborative learning • The dual console system allows both the mentor and the fellow to actively participate in the surgery simultaneously. This collaborative approach fosters realtime communication, enabling the mentor to guide and instruct the fellow through the intricacies of the procedure. 2. Hands-on experience • The fellow gains hands-on experience by manipulating the robotic instruments and controls from their own console. This hands-on training is invaluable for acquiring the necessary skills and dexterity for complex surgeries, such as those involved in treating deep endometriosis. 3. Immediate feedback • The dual console system provides immediate feedback to the fellow, allowing for instant correction and refinement of techniques under the guidance of the mentor. This dynamic interaction enhances the learning process and accelerates skill acquisition. 4. Enhanced visualization • Both the mentor and fellow benefit from the high-definition, three-dimensional visualization provided by the robotic system. This enhanced visualization contributes to a more comprehensive understanding of the surgical field, crucial for precise and successful procedures.

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Challenges and Limitations in Robotic Surgery for Deep Endometriosis Robotic surgery has revolutionized the field of gynecological procedures, offering enhanced precision and minimally invasive options for complex surgeries such as deep endometriosis excision. However, it is crucial to acknowledge and navigate the challenges and limitations associated with this advanced technology. Discussion of Potential Challenges and Limitations 1. Cost and accessibility: The initial setup and maintenance costs of robotic systems can be substantial, limiting access to this technology in some healthcare settings. Addressing cost barriers is essential for ensuring equitable access to advanced surgical options.25 2. Learning curve: Despite the advantages of robotic surgery, there is a learning curve associated with mastering the technology. Surgeons require training and experience to optimize outcomes, and this process may vary among individuals.26 3. Instrument limitations: The robotic instruments, while highly advanced, have limitations in terms of tactile feedback and dexterity. Surgeons must adapt to these limitations to ensure precise and safe maneuvers during surgery.27

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Advantages for Training Fellows and Shortening the Learning Curve 1. Quicker skill acquisition • The dual console system expedites the learning process by providing fellows with direct, hands-on experience in a controlled environment. This accelerates the acquisition of skills necessary for performing complex surgeries. 2. Reduced learning curve • By offering an immersive and collaborative training experience, the dual console system minimizes the traditional learning curve associated with adopting robotic surgical techniques. Fellows can progress more rapidly from basic skills to advanced procedures. 3. Increased confidence • Fellows, under the guidance of experienced mentors, can develop a higher level of confidence in their abilities. The real-time feedback and interactive nature of the dual console system contribute to the fellow’s confidence and competence in performing robotic surgeries. 4. Optimal patient outcomes • The shortened learning curve translates to improved patient outcomes, as fellows trained on the dual console system can enter clinical practice with a higher level of proficiency in utilizing robotic technology for deep endometriosis surgery. The dual console system on the da Vinci robotic surgery platform represents a ground breaking advancement in surgical training for fellows. By providing an immersive and collaborative learning experience, this system not only accelerates skill acquisition but also ensures that fellows are well-prepared to deliver optimal patient care in the realm of deep endometriosis surgery. The marriage of robotic systems with surgical techniques in deep endometriosis surgery signifies a paradigm shift toward precision and patient-centric care. The amalgamation of advanced visualization, articulating instruments, and enhanced ergonomics positions robotic surgery at the forefront of gynaecological advancements, ensuring optimal outcomes for women battling the complexities of deep endometriosis.24

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Considerations for Patient Selection 1. Disease complexity: Patient selection for robotic surgery in deep endometriosis should consider the complexity and extent of the disease. While robotics can address intricate cases, patient factors, including disease severity and anatomical considerations, influence the appropriateness of this approach.28 2. Previous surgeries: Patients with a history of multiple abdominal surgeries may have altered anatomy, making robotic surgery more challenging. Careful patient selection is crucial to optimize outcomes and minimize complications in these cases.29 Comparison with Alternative Surgical Approaches 1. Laparoscopic surgery: Traditional laparoscopic surgery remains a viable alternative to robotic surgery, especially in centers where robotic systems are not available. Laparoscopy offers similar minimally invasive benefits, but robotic surgery may excel in certain complex cases.30 2. Open surgery (laparotomy): In some extremely rare instances, particularly with extensive disease or complications, open surgery (laparotomy) may be the preferred approach. This is often necessary for cases requiring large-scale resection or patients with extremely large uteri where access to the posterior and lateral compartments are not available or in patients with contraindications to minimally invasive procedures.31 It is the author’s experience and opinion that the need for laparotomy is rare and an experienced endometriosis centre would rarely have the need for open surgery. 3. Multidisciplinary approaches: The choice between robotic, laparoscopic, or open surgery should be made within the context of a multidisciplinary team, considering the expertise of the surgical team and the individual patient’s characteristics.

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REFERENCES

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1. Sampson, J. A. (1927). Peritoneal endometriosis due to menstrual dissemination of endometrial tissue into the peritoneal cavity. American Journal of Obstetrics & Gynecology, 14(4), 422–69. 2. Nezhat, C., Crowgey, S. R., and Garrison, C. P. (1996). Surgical treatment of endometriosis via laser laparoscopy. Fertility and Sterility, 66(5), 754–55. 3. Possover, M., Forman, A., Tammaa, A., and Schneider, A. (2007). Laparoscopic therapy for deeply infiltrating endometriosis. Current Opinion in Obstetrics and Gynecology, 19(4), 337–42. 4. Ceccaroni, M., Roviglione, G., Pesci, A., and Clarizia, R. (2009). Peritoneal shaving: a reappraisal of its role in the setting of deep infiltrating endometriosis. Fertility and Sterility, 92(6), 2124–27. 5. Roman H, Bubenheim M, Huet E, Bridoux V, Zacharopoulou C, Daraï E, Collinet P, Tuech JJ. Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial. Hum Reprod. 2018 Jan 1;33(1):47–57.  6. Meuleman C, Tomassetti C, D’Hoore A, Van Cleynenbreugel B, Penninckx F, Vergote I, D’Hooghe T. Surgical treatment of deeply infiltrating endometriosis with colorectal involvement. Hum Reprod Update. 2011 May-Jun;17(3):311–26.  7. Canis, M., and Donnez, J. (2017). Endometriosis may not be a chronic disease, but an episode requiring a therapeutic strategy over the reproductive period. Fertility and Sterility, 107(3), 555–60. 8. Seracchioli, R., Poggioli, G., and Pierangeli, F. (2016). Surgical outcome and long-term follow up after laparoscopic rectosigmoid resection in women with deep infiltrating endometriosis. BJOG: An International Journal of Obstetrics and Gynaecology, 123(10), 1659–65. 9. Roman, H., Bubenheim, M., and Huet, E. (2013). Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: A randomized trial. Human Reproduction, 28(12), 3217–28.

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10. Intuitive Surgical. (2000). The da Vinci Surgical System-A Brief History. https://www.intuitive. com/ 11. Nezhat, C., Saberi, N., and Shahmohamady, B. (2009). Robotic-assisted laparoscopy in gynecological surgery. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 13(1), 55–8. 12. Paraiso, M. F. R., Ridgeway, B., and Park, A. J. (2009). A randomized trial comparing conventional and robotically assisted total laparoscopic hysterectomy. American Journal of Obstetrics and Gynecology, 201(6), 632.e1–632.e8. 13. Albright, E., and Diaz-Arrastia, C. (2013). Total laparoscopic hysterectomy with and without robotic assistance: A prospective controlled noninferiority trial. American Journal of Obstetrics and Gynecology, 208(5), 368.e1–368.e7. 14. U.S. National Library of Medicine. (2021). Robotic Surgery. https://medlineplus.gov/ency/ article/007341.htm 15. Roman, H., and Abo, C. (2018). Robotic Surgery for Endometriosis: Rationale, Techniques, and Initial Outcome. Journal of Minimally Invasive Gynecology, 25(1), 33–39. 16. Possover, M., Forman, A., and Tammaa, A. (2007). Peritoneal Shaving: A New Surgical Technique for the Treatment of Peritoneal Endometriosis. Journal of Minimally Invasive Gynecology, 14(4), 482–485. 17. Dubernard, G., Piketty, M., and Rouzier, R. (2011). Nerve sparing laparoscopic eradication of deep infiltrating endometriosis with segmental rectal and parametrial resection. American Journal of Obstetrics and Gynecology, 205(6), 541.e1–541.e5. 18. Canis, M., Botchorishvili, R., and Wattiez, A. (2009). The role of robotic surgery in endometriosis: A systematic review. Fertility and Sterility, 91(6), 2754–60. 19. Nezhat, C., Datta, M. S., and Liu, C. (2009). Robotic-Assisted Laparoscopic Myomectomy Compared With Standard Laparoscopic Myomectomy. Obstetrics and Gynecology, 114(1), 58–67. 20. Fanfani, F., Monterossi, G., and Fagotti, A. (2015). Total laparoscopic (TLH) and robot-assisted (RAH) hysterectomy for the treatment of endometrial cancer with pelvic lymphadenectomy: A propensity-matched analysis. Gynecologic Oncology, 137(2), 258–63. 21. Canis, M., and Mage, G. (2010). Operative strategy for deeply infiltrating endometriosis of the rectum: Technical principles. Fertility and Sterility, 94(3), 868–75. 22. Bedient, C. E., Magrina, J. F., and Noble, B. N. (2009). Comparison of robotic and laparoscopic myomectomy. American Journal of Obstetrics and Gynecology, 201(6), 566.e1–566.e5. 23. Fagotti, A., Bottoni, C., and Vizzielli, G. (2010). Postoperative pain after conventional laparoscopy and laparoendoscopic single site surgery (LESS) for benign adnexal disease: A randomized trial. Fertility and Sterility, 94(7), 2663–66. 24. Ayhan, A., and Telli, E. (2017). Excision of endometriosis: What the surgeon and patient should know. Best Practice & Research Clinical Obstetrics & Gynaecology, 41, 3–14. 25. Wright, J. D., and Ananth, C. V. (2019). Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA, 322(23), 2351–60. 26. Paley, P. J., Veljovich, D. S., and Shah, C. A. (2011). Surgical outcomes in gynecologic oncology in the era of robotics: Analysis of first 1000 cases. American Journal of Obstetrics and Gynecology, 204(6), 551.e1–551.e9. 27. Canis, M., Mage, G., and Botchorishvili, R. (2010). Therapeutic strategy for colorectal endometriosis. Human Reproduction Update, 16(3), 309–18. 28. Roman, H., and Abo, C. (2018). Robotic Surgery for Endometriosis: Rationale, Techniques, and Initial Outcome. Journal of Minimally Invasive Gynecology, 25(1), 33–9. 29. Nezhat, C., Siegler, A., and Piver, M. S. (2002). Nezhat-Dindo scoring for surgical complications. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 6(4), 319–24. 30. Angioni, S., and Remorgida, V. (2004). Laparoscopic nerve-sparing complete excision of deep endometriosis: is it feasible? Human Reproduction, 19(6), 1369–72. 31. Donnez, J., and Squifflet, J. (2010). Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules. Human Reproduction, 25(8), 1949–58.

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10 Robot-Assisted Pelvic Organ Prolapse Repair • Dinesh Kansal  • Supriya Mahipal  • Yamini Kansal

Descent of one or more of the pelvic organs, anterior vaginal wall, posterior vaginal wall, apex of the vagina (cervix and uterus), or vault (vaginal cuff) after hysterectomy is known as pelvic organ prolapse (POP). Many women after 50 years are affected with POP with lifetime prevalence of 30% to 50%.1 Surgical Management of Pelvic Organ Prolapse Various vaginal and abdominal treatment modalities are available for treatment of POP. Earlier vaginal prolapse repair was popular and was the accepted norm but now laparoscopic and robotic approach is becoming more popular. The success rates in vaginal route is less without mesh and complication rates are high with vaginal mesh which is not FDA approved, in contrast to abdominal mesh which is approved by FDA.2 Sacrocolpopexy (SCP) is the gold standard treatment of apical vaginal vault prolapse with demonstrated long-term success. However, due to high morbidity associated with a laparotomy approach and the difficulty in visualizing deep pelvic structures, a minimally invasive approach is always preferred. Laparotomy is rarely indicated in prolapse surgery and is completely replaced by minimal access surgery. However, the surgery requires advanced laparoscopic surgical skills, especially for difficult suturing in deep dissected areas. Robot has made this technically difficult procedure easy with short learning curve and allows more surgeons to offer a minimally invasive approach. Surgeons find suturing and exposure during the procedure less challenging with the dexterity of robotic instruments tips. In patients with advanced-stage POP, robot-assisted sacrocolpopexy (RSC) enables full correction of the apical compartment, low mesh-related complications, and low recurrence rates. For patients who desire to preserve their uterus, robot-assisted sacrohysteropexy (RSH) is an ideal option, as it is associated with low frequency of complications and high patient satisfaction.

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Nowadays robotic/laparoscopic pectopexy has also been applied in clinical practice as a new technique because of its short learning cycle and fewer operative complications. Robotic Assisted Sacrocolpopexy/Hysteropexy The patient is placed in lithotomy position under general anesthesia and pneumoperitoneum is created. The general principle of the surgery remains the same, however, slight variation of technique may be there in RASC. A supra or periumbilical 8 mm port is placed for camera. Two other 8 mm robotic ports and one assistant port are placed for assistance. To prevent collision of robotic arms there should be a gap of 8–10 cm between the ports. The robot is docked after the patient is placed in steep Trendelenburg position.

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Fig. 10.1A to C: (A) Post-vaginal wall dissection; (B) Fixation of mesh over posterior vaginal wall; (C) Fixation of mesh over the sacral promontary

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Surgical Technique (Fig. 10.1A to C) A uterine manipulator is placed inside the uterus. The dissection at the sacral promontory should be done with identification of key anatomical landmarks in close proximity including the aortic bifurcation, right common iliac vein, right middle sacral artery and vein. Identification helps to prevent injury to these structure during dissection. The presacral space is entered through a longitudinal peritoneal incision above the sacral promontory almost up to the aortic bifurcation.The promontory and the anterior

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sacrum are cleared off to expose the anterior sacral ligament. The ventral surface of S1 and S2 vertebral bodies are exposed. The peritoneal incision is extended up to the cul-de-sac, keeping the ureter in view. The peritoneum is dissected to make space to cover the mesh. The rectovaginal and vesicovaginal spaces are opened and rectum and bladder are separated from the vaginal wall. The distal extent of the dissection should be carried far enough inferiorly to allow secure attachment of the mesh to at least several centimeters of the posterior vaginal wall. Anterior dissection should extend nearly as far as bladder trigone. A large porous Y-shaped polypropylene mesh is used, two leaves of mesh are required and should measure 3–4 cm in width and 14 cm in length. One leaf is attached to rectovaginal fascia of the post-vaginal wall with transverse row of interrupted nonabsorbable material. The second leaf is attached to the pubocervical fascia of the anterior vaginal wall with rows of interrupted transverse sutures (Fig. 10.2A and B). Suture should be tied in such a way that mesh lay flat against the endopelvic fascia and loosely to avoid necrosis and mesh erosion. The proximal arm of the mesh should be fixed in the sacral promontory. The tension of the mesh should be adjusted because excessive tension may cause pain or irritative bladder symptoms after surgery. The mesh is sutured to the anterior longitudinal ligament overlying the sacrum with 2–5 sutures. As the endoscopic approach becomes more common, reports of postoperative discitis is more common with laparoscopic approach due to penetration of the L5-S1 disc. To avoid discitis surgeons should either confirm the position of S1 body or consider the thickness of the anterior longitudinal ligament, which ranges from 1 to 2 mm, and should avoid deep suture bites that may penetrate into the disc. The sacral hysteropexy is similar to sacral colpopexy, except that the anterior leaf of mesh is passed through windows in the broad ligament and then attached to the sacral promontory.3

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Robotic Pectopexy/Hysteropectopexy After docking robot,the anterior peritoneum of the uterus is opened, and the bladder is dissected to expose the cervix in preparation for mesh fixation in case of hysteropexy.4 In patients with a previous hysterectomy, the peritoneum of the vaginal vault is opened from the apex, and the surrounding soft tissue over the apex is dissected anteriorly and posteriorly.

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Fig. 10.2A and B: (A) Robotic dissection of vesicovaginal space in pectopexy for vault prolapse; (B) Attachment of tongue-shaped mesh to vaginal cuff

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Then open the peritoneum along the pubic bone between the right round ligament and the right medial umbilical ligament to expose the pectineal ligament. The pectineal ligaments on both sides are prepared just medial to the external iliac vessels and dissected anteriorly for about 3 cm in length. vessel is impeding the mesh fixation. We use ethibond no. 2 and barbed PDS suture to fix polypropylene mesh onto the anterior cervix or vaginal vault in tongue shaped. The uterus or vaginal vault is elevated to the natural position without excessive tension by the manipulator. The mesh ends are anchored to the bilateral pectineal ligaments with two interrupted no. 2 Ethibond sutures. Posterior compartment defect can be repaired using mesh in cross-shaped manner after dissecting rectovaginal space or native tissue repair can be done by barbed PDS suture if mild defect is present. Retroperitonisation of mesh is done by 2–0 barbed PDS suture.

Robotic Benign Surgery

Robotic Native Tissue Repair (Fig. 10.3) Native tissue repair uses patients’ own tissues instead of mesh to repair anterior and posterior compartment defects and is effective for relieving vaginal bulge symptoms and reducing prolapse within the vagina. It can be done with robotic hysterectomy or following pectopexy for posterior native tissue repair or following sacropexy for anterior native tissue repair. For robotic cystocele repair, the exposure of anterior vaginal fascia is done by dissecting bladder down as far as possible till trigone according to grade of cystocele followed by compressing and narrowing of anterior fascia with 2–0 barbed PDS suture. The same suture can be taken posteriorly to repair concomitant posterior defect. Posterior vaginal fascia is exposed by dissecting rectum from posterior vaginal wall for high rectocele repair or dissection can be extended till levator ani in case of low rectocele. 2–0 barbed PDS suture is used to repair rectocele by taking rows of compressing sutures through posterior vaginal fascia. Mild enterocele can be repaired with same

Fig. 10.3:  Robotic bilateral uterosacral plication in native tissue repair

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barbed suture by performing Moschowitz/Halban procedure along with uteroscaral ligament plication. It can be further strengthened with no. 2 ethibond suture which is non-absorbable suture and acts like a mesh in case of moderate to severe enterocele taking sagittal or purse string sutures. Additionally, stress urinary incontinence if present along with prolapse can be corrected at the same sitting by doing Robotic Burch colposuspension by opening space of Retzius and dissecting bladder down followed by taking ethibond sutures in paravaginal tissues on either side of the bladder neck and then attaching to the ileopectineal ligaments on the same side (Fig. 10.4) suturing the lateral aspect of the anterior vaginal wall back to its original point of attachment known as the arcus tendineus fascia pelvis (ATFP) or the “white line” using non-absorbable suture ethibond no. 2. It reapproximates vaginal wall to the fascia overlying the obturator internus muscle; restoring bladder and urethra to its normal anatomical position. Complications The most worrying intraoperative complications of robotic prolapse repair are: • Haemorrhage from the pelvic vessels, injury to bowel, right ureter, bladder and mesh erosion. • The risk of conversion from minimally invasive to open surgery is shown to be 1–5%.5,6 • Most common perioperative complications for sacropexy are bladder, bowel, ureteral injury, ileus, port site hematoma, urinary retention, fever, urinary tract infection, vaginal mucosal injury and cardiopulmonary issues. • A higher incidence of postoperative SUI is present in pectopexy. • Mesh complications and post-operative urinary retention are the common complication in prolapse surgery. A Cochrane review reveals that transvaginal mesh repair has more rate of dyspareunia as compared to ASC. There is 0–10% risk of mesh erosion in sacropexy while 18% in transvaginal mesh repair as published in various articles.7

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Discussion According to a recent Cochrane review, sacrocolpopexy was associated with a lower rate of recurrent vault prolapsed and painful intercourse compared to sacrospinous

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suspension. It also has a higher success rate and lower reoperation rate than high vaginal uterosacral suspension and transvaginal polypropylene mesh. Abdominal sacrocolpopexy (ASC) is considered as the most effective treatment for apical vaginal prolapse with reported long-term success rates of 68–100%. In addition, an abdominal approach allows a simultaneous correction of the three pelvic floor compartments defects: Anterior, apical and posterior, preserving vaginal integrity. The robotic/ laparoscopic approach represents an alternative to open surgery, with comparable outcomes, while befitting patients with the well-recognized advantages of minimally invasive surgery. The characteristics of this completely minimally invasive surgery, as well as its potential benefits for sexual function (preservation of vaginal length and axis and lower rates of dyspareunia), make this procedure a better option for younger, sexually active women. Laparoscopic sacrocolpopexy/sacrohysteropexy is a complex procedure with steep learning curve which has resulted in decreased adoption of this technique by a wider group of surgeons. Robot-assisted sacrocolpopexy (RSC) can help overcome difficulties in laparoscopic sacrocolpopexy (LSC) by facilitating deep dissection and suturing. Moreover, RSC is a safe and efficacious option for patients with POP. It has several benefits, such as its high anatomical cure rate, improvement of sexual function, reduction of perioperative complications, and low recurrence rate. In addition, it can be a safe option for elderly patients. Robotic/laparoscopic pectopexy was introduced in 2011 and showed that the procedure offers a feasible, safe, and easier to perform alternative for apical prolapse surgery.8 Pectopexy also offers advantages over sacrocolpopexy in obese patients. In sacrocolpopexy, there are several important structures including the right ureter, hypogastric nerves, middle sacral vessels, and left common iliac vein over the sacral promontory. Retroperitoneal dissection for anterior longitudinal ligament preparation and bowel handling is challenging in obese patients because of difficulties identifying major landmarks. Obesity also increases the surgical difficulty because of the limited surgical field in balancing sufficient abdominal pressure and adequate ventilation. In contrast to sacrocolpopexy, pectopexy limits the surgical fields in the anterior pelvic space and is less influenced by obesity. A number of studies have compared the clinical efficacy of pectopexy with sacrocolpopexy, which shows that its efficacy is more significant.9,10 Since the introduction of robot system daVinci in urogynaecology in 2005, it has shown to be highly advantageous over laparoscopy. The robot improves manual dexterity by allowing multiple degree of freedom and eliminates tremors. It has better visualization due to three-dimensional vision system. It has a shorter learning curve for those already doing laparoscopic or abdominal surgery and desiring to switch to robotic surgery.11,12 Robotic sacrocolpopexy/pectopexy is safe and has equivalent outcomes as compared to open and laparoscopic surgery. It has rapidly gained popularity because morbidity is less as compared to abdominal and sacral dissection, knot tying is easier in robotic surgery as compared to laparoscopic surgery due to three-dimensional visualization. Conclusions • The surgical management of POP has expanded with the use of minimally invasive surgery.

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• Emerging technologies have allowed for more minimally invasive approach including the use of laparoscopic assisted sacrocolpopexy/pectopexy and robotic-assisted sacrocolpopexy/pectopexy. • Robotic-assisted surgery for POP is superior to laparoscopic and abdominal surgery due to a short learning curve, and its 3D visualisation, but the high cost associated with the use of the daVinci surgical system and its non-availability in most of the centers are the main constraints of using it. REFERENCES

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1. Subak LL, Waetjen LE, van den Eeden S, Thom DH, Vittinghoff E, Brown JS. Cost of pelvic organ prolapse surgery in the United States. Obstet Gynecol 2001;98:646–51. 2. Karram MM, Walters MD. Surgical treatment of vaginal vault prolapse and enterocele. In: Walters MD, Karram MM, editors. Urogynecology and Reconstructive Pelvic Surgery. 3rd ed. Philadelphia: Mosby Elsevier; 2007. pp. 262–87. 3. Kwang Jin Ko, Kyu-Sung Lee Robotic Sacrocolpopexy for Treatment of Prolapse of the Apical Segment of the Vagina. 4. Pulatoğlu Ç, Doğan O, Medisoğlu MS, Yassa M, Ellibeş Kaya A, Selçuk, et al. Surgical anatomy of the pectineal ligament during pectopexy surgery: the relevance to the major vascular structures. Turk J Obstet Gynecol. 2020;17(1):21–27. 5. Akl MN, Long JB, Giles DL, Cornella JL, Pettit PD, Chen AH, et al. Robotic-assisted sacrocolpopexy: Technique and learning curve. Surg Endosc. 2009;23:2390–4. 6. Elliott DS, Krambeck AE, Chow GK. Long-term results of robotic assisted laparoscopic sacrocolpopexy for the treatment of high grade vaginal vault prolapse. J Urol. 2006;176:655. 7. Teresa L. Danforth, Monish Aron, and David A. Ginsberg. Robotic sacrocolpopexy. Indian J Urol. 2014 Jul-Sep; 30(3): 318–325. 8. Banerjee C, Noé KG. Laparoscopic pectopexy: a new technique of prolapse surgery for obese patients. Arch Gynecol Obstet.2011; 284(3):631–5. 9. Chuang, F. C. et al. Laparoscopic pectopexy: The learning curve and comparison with laparoscopic sacrocolpopexy. Int. Urogynecol. J. 33 1949–195. 10. Obut, M., Oğlak, S. C. & Akgöl, S. Comparison of the quality of life and female sexual function following laparoscopic pectopexy and laparoscopic sacrohysteropexy in apical prolapse patients. Gynecol. Minim. Invas. Ther. 10, 96–103. 11. Awad N, Mustafa S, Amit A, Deutsch M, Eldor-Itskovitz J, Lowenstein L. Implementation of a new procedure: Laparoscopic versus robotic sacrocolpopexy. Arch Gynecol Obstet. 2013;287:1181–6. 12. Paraiso MF, Jelovsek JE, Frick A, Chen CC, Barber MD. Laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse: A randomized controlled trial. Obstet Gynecol. 2011;118: 1005–13.

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11 Robotics in Infertility Management • Mala Srivastava  • Neema Tufchi  • Ankita Srivastava

One of the most exciting and quickly evolving technological developments of the twentyfirst century is robotics, which has the potential to significantly impact reproductive surgery and fertility preservation. There are now much more female cancer survivors of reproductive age than there were before, coinciding with significant advancements in cancer therapy. Reproductive science has therefore placed increased attention on fertility preservation in recent decades. To preserve or restore fertility in certain patients, a variety of surgical techniques have been developed, including radical trachelectomy, ovarian transplanting, ovarian transposition, and tubal reanastomosis. The pace at which key technology advancements in minimally invasive surgical methods have advanced over the previous few decades has completely changed our perception of what modern surgical practice looks like. Surgeons in diverse professions across the globe now have access to an extensive array of diagnostic and treatment instruments. In a wide range of gynaecological operations, minimally invasive techniques have become increasingly popular recently (Fig. 11.1). These procedures cover benign disorders like endometriosis and uterine fibroids as well as malignancies like cervical and endometrial cancers.1 Zeus, the first telerobot, was created in 1995 by fusing two robotic arms with the Automated Endoscopic System for Optimal Positioning (AESOP), which had a voiceactivated camera that the surgeon controlled via a console in addition to the two robotic arms.2 Based on the Zeus concept, Intuitive Surgical created the da Vinci robot in 1998. It added a three-dimensional (3D) stereoscopic vision and allowed for the two arms to rotate the instruments with seven degrees of freedom. Gynecologic treatments carried out to maintain or restore fertility are referred to as reproductive surgery. From this angle, minimally invasive technology revolutionized the area of reproductive medicine by offering a broad range of surgical procedures, from ovarian transplantation to tubal reanastomosis. Robot-assisted methods progressively expanded their areas of application throughout this time. With its well-established benefits of less bleeding, less tissue damage, smaller incisions for better aesthetic results,

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Fig. 11.1:  Robotics and reproductive surgery

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quicker healing and return to normal life, and reduced postoperative pain, laparoscopic surgery beat out laparotomy.3 However, there are many drawbacks to conventional laparoscopy, including poor ergonomics, reduced tactile input, a restricted range of motion, increased tremor, an unstable optic camera, and a loss of in-depth perception with two-dimensional images that make complicated surgical procedures difficult.4 There are certain drawbacks to robotic surgery as well. These include: 1. Expensive operation costs 2. Lack of tactile feedback, which encourages the use of force during traction and dissection that may break sutures or cause tissue trauma 3. The machine’s bulky size, which restricts its setup to large operating rooms; and 4. The patient-side cart’s locked position after the robotic arms dock, which prevents the surgeon from movable the patient.5

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Notwithstanding these drawbacks, the global number of robotic procedures is expanding quickly, indicating the viability of robotic support in gynecologic applications.

Fig. 11.2A:  Exposing the distal and proximal ends of the fallopian tube

Fig. 11.2C:  Suturing of the mucosal and muscular layers of the tubal segments with interrupted 5–0 PDS

Fig. 11.2B:  Opening the proximal and distal ends of the tube

Fig. 11.2D:  Closing the serosa with running 7–0 Vicryl sutures. Evaluating tubal patency by chromotubation

Fig. 11.2A to D:  Steps for reversal of tubal ligation

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Reversal of Tubal Ligation In order to help women who regret surgical sterilisation by tubal ligation and who have no other reason of infertility, tubal reanastomosis was presented as a surgical therapy option.6 However, the laparoscopic method of tubal reanastomosis, which was developed in the late 1980s, necessitated extremely fine 6–0 or 8–0 sutures for precision microsurgical suturing, which was extremely challenging to accomplish with standard laparoscopic instruments.7 In 1999, Falcone et al. used the ZEUS robotic system to perform the first robot-assisted tubal reanastomosis procedure in order to get around this challenge. A number of variables affect the success of reanastomosis, most notably the patient’s age and the appropriate use of microsurgery guidelines, which include proper hydration, hemostasis, fine suturing, anatomic restoration with additional mucosa stitches, and operative field magnification.8 Reanastomosis can be performed using two main techniques that have been described: 1. The one-stitch technique, which consists of one single suture placed at the “12 o’clock” site of the antimesenteric border; and 2. Four extra mucosa stitches placed at “6, 9, 12, and 3 o’clock” with the use of a thin monofilament nonabsorbable wire9 (Fig. 11.2A to D).

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Robotic Myomectomy Several studies have shown that even non-cavity-distorting intramural myomas may negatively affect the outcome of conception through altered endometrial receptivity, gamete migration, uterine blood perfusion, and contractility, even though the contribution of non-cavity-disturbing leiomyomas to infertility is not widely accepted.10,11 Intended to preserve and restore fertility, myomectomy is therefore an often performed surgical procedure on women of reproductive age. In terms of less blood loss, fewer surgical complications, less adhesion development, shorter hospital stays, and increased fertility, laparoscopic myomectomy was found to be superior to laparotomy in many randomised controlled trials and meta-analyses12 (Fig. 11.3). Due to associated technical challenges, laparoscopy is still regarded as highly impractical and is performed only seldom. In actuality, certain sutures could be challenging, and the trocars’ fixed position makes it impossible to access particular myoma locations, like anterior, very posterior, or broad ligament myomas.13 Additional restrictions on laparoscopy include myomas larger than 8 cm, an excessive number of fibroids, and the requirement for clamping and enucleation. The rate of uterine rupture appears to be 1% for both procedures, though this is difficult to assess.14

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Endometriosis Surgery One of the most prevalent and serious gynaecological conditions that can lead to infertility and for which there is presently no treatment is endometriosis.15 It still ranks among the most contentious topics in reproductive medicine, affecting 6–10% of women who are of reproductive age.16 Laparoscopic adhesiolysis and endometriotic implant ablation may enhance reproductive results in patients with minimal-to-mild endometriosis by restoring anatomy and function. The benefits of surgical treatment for reproduction are less evident in cases of severe endometriosis, and invasive surgery carries a risk of impairing future fertility17 (Fig. 11.4). Because of the inherent challenges in dissecting an endometriotic cyst, laparoscopic ovarian cystectomy may result in premature ovarian failure. Laparoscopic surgery looks to have a lot of disadvantages in cases with deep endometriosis; robotics may have a part in this indication.18

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Fig. 11.3:  Robotic-assisted myomectomy

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Fig. 11.4:  Robotic-assisted endometriosis

Fertility-sparing Surgery

Ovarian Transplantation One of the most amazing advancements in reproductive surgery and fertility preservation is ovarian transplantation. The cryopreservation of ovarian tissue and the transplanting process are multistep processes. For female cancer patients who are not yet puberty, this cutting-edge surgery is presently their sole choice for preserving their fertility. For people who are unable to postpone chemotherapy treatment, it is also a feasible choice.21 Despite the fact that it is still regarded as an experimental operation, over sixty infants have been born so far.22 A novel technique for robot-assisted ovarian transplantation employing human extracellular matrix scaffolds was reported by Oktay et al.23 Revascularization of the transplanted tissue can take up to 10 days, and the ovarian tissue transplantation is done without vascular reanastomosis.24 Following transplantation, there is an avascular phase that results in ischemia injury. Numerous experimental studies have shown that this injury is the primary reason for the death of over 50% of primordial follicles.25 Oktay et al. employed Alloderm (LifeCell Corp., Branchburg, NJ, USA), a decellularized human

Robotic Benign Surgery

The field of fertility preservation in contemporary reproductive medicine is new and extremely promising. Fertility preservation has gained more attention as the number of female cancer survivors who are of reproductive age continues to rise. Different surgical procedures and methods have been developed in an attempt to save the uterus for future pregnancies and to protect ovaries from the damaging effects of radiation and chemotherapy. After the first successful instance of radical trachelectomy (RT) with pelvic lymphadenectomy utilising the da Vinci robotic system for early stage cervical cancer was published in 2008, numerous further successful cases were reported.19 Another fertility-sparing surgery that can be carried out via laparotomy or minimally invasive procedures is ovarian transposition prior to pelvic radiotherapy. In order to avoid early ovarian failure, it is possible to suspend the ovaries outside of the pelvis and away from the radiation field. In these situations, robot-assisted laparoscopic surgery is a very effective and viable choice, especially when performed in conjunction with oncological surgery.20

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Fig. 11.5:  Fertility preservation and restoration pathways

extracellular tissue matrix frequently used in cosmetic and reconstructive procedures, to lessen ischemia injury by improving the revascularization process26 (Fig. 11.5).

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1. Further research is required to determine whether robotic assistance is more feasible than the traditional laparoscopic procedure, as robotic technology has the potential to significantly improve reproductive surgery. 2. In circumstances when infertility requires complicated surgical therapy, robot-assisted laparoscopy appears to be of interest. Deeply invasive endometriosis, tubal reanastomosis, and myomectomy seem to be the favoured indicators. 3. The primary obstacle to the wider use of this method continues to be its expense. 4. In summary, all of these technical breakthroughs and potential robotics innovations in the future will definitely find applications in reproductive surgery, expanding our surgical skills in ovarian transplantation.

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REFERENCES 1. Taylan E, Oktay KH. Robotics in reproduction, fertility preservation, and ovarian transplantation. Robot Surg. 2017 Feb 27;4:19–24. doi: 10.2147/RSRR.S123703. PMID: 30697560; PMCID: PMC6193444. 2. Jourdan IC, Dutson E, Garcia A, Vleugels T, Leroy J, Mutter D, et al. Stereoscopic vision provides a significant advantage for precision robotic laparoscopy. Br J Surg 2004;91:879–85. 3. Velanovich V. Laparoscopic vs open surgery: a preliminary comparison of quality-of-life outcomes. Surg Endosc. 2000;14(1):16–21. 4. Tulandi T, Marzal A. Redefining reproductive surgery. J Minim Invasive Gynecol. 2012;19(3):296– 306.

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5. Catenacci M, Flyckt RL, Falcone T. Robotics in reproductive surgery: strengths and limitations. Placenta. 2011;32 6. Zarei A, Al-Ghafri W, Tulandi T. Tubal surgery. Clin Obstet Gynecol. 2009;52(3):344–50. 7. Cha SH, Lee MH, Kim JH, Lee CN, Yoon TK, Cha KY. Fertility outcome after tubal anastomosis by laparoscopy and laparotomy. J Am Assoc Gynecol Laparosc. 2001;8(3):348–52. 8. HAS. Anastomose tubo tubaire par coelioscopie ou laparotomie. June 2008.Gervaise A, Deffieux X, Fernandez H. Available at: www.has-sante.fr 9. Dubuisson JB, Swolin K. Laparoscopic tubal anastomosis (the one stitch technique): preliminary results. Hum Reprod 1995;10:2044–6. 10. Arslan AA, Gold LI, Mittal K, et al. Gene expression studies provide clues to the pathogenesis of uterine leiomyoma: new evidence and a systematic review. Hum Reprod. 2005;20(4):852–63.  11. Sunkara SK, Khairy M, El-Toukhy T, Khalaf Y, Coomarasamy A. The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment: a systematic review and meta-analysis. Hum Reprod. 2010;25(2):418–29. 12. Alessandri F, Lijoi D, Mistrangelo E, Ferrero S, Ragni N. Randomized study of laparoscopic versus minilaparotomic myomectomy for uterine myomas. J Minim Invasive Gynecol. 2006;13(2):92–7. 13. Falcone T, Bedaiwy MA. Minimally invasive management of uterine fibroids. Curr Opin Obstet Gynecol 2002;14:401–7. 14. Dubuisson JB, Fauconnier A, Deffarges JV, Norgaard C, Kreiker G, Chapron C.Pregnancy outcome and deliveries following laparoscopic myomectomy.Hum Reprod 2000;15:869–73. 15. Young VJ, Brown JK, Saunders PT, Horne AW. The role of the peritoneum in the pathogenesis of endometriosis. Hum Reprod Update. 2013;19(5):558–69. 16. Greene AD, Lang SA, Kendziorski JA, Sroga-Rios JM, Herzog TJ, Burns KA. Endometriosis: where are we and where are we going? Reproduction. 2016;152(3):63–78. 17. Jacobson TZ, Duffy JM, Barlow D, Farquhar C, Koninckx PR, Olive D. Laparoscopic surgery for subfertility associated with endometriosis. Cochrane Database Syst Rev. 2010;1:CD001398. 18. Yazbeck C, Madelenat P, Sifer C, Hazout A, Poncelet C. Ovarian endometriomas: effect of laparoscopic cystectomy on ovarian response in IVF-ET cycles. Gynecol Obstet Fertil 2006;34: 808–12. 19. Chuang LT, Lerner DL, Liu CS, Nezhat FR. Fertiltiy-sparing robotic assisted radical trachelectomy and bilateral pelvic lymphadenectomy in early-stage cervical cancer. J Minim Invasive Gynecol. 2008;15(6):767–70. 20. Molpus KL, Wedergren JS, Carlson MA. Robotically assisted endoscopic ovarian transposition. JSLS. 2003;1–7:59–62. 21. Sonmezer M, Oktay K. Orthotopic and heterotopic ovarian tissue transplantation. Best Pract Res Clin Obstet Gynaecol. 2010;24(1):113–26. 22. Donnez J, Dolmans MM, Diaz C, Pellicer A. Ovarian cortex transplantation: time to move on from experimental studies to open clinical application. Fertil Steril. 2015;104(5):1097–98. 23. Oktay K, Bedoschi G, Pacheco F, Turan V, Emirdar V. First pregnancies, live birth, and in vitro fertilization outcomes after transplantation of frozen-banked ovarian tissue with a human extracellular matrix scaffold using robot-assisted minimally invasive surgery. Am J Obstet Gynecol. 2016;214(1):94.e1–e9. 24. Soleimani R, Heytens E, Oktay K. Enhancement of neoangiogenesis and follicle survival by sphingosine-1-phosphate in human ovarian tissue xenotransplants. PLoS One. 2011;6(4):e19475. 25. Lee J, Kong HS, Kim EJ, et al. Ovarian injury during cryopreservation and transplantation in mice: a comparative study between cryoinjury and ischemic injury. Hum Reprod. 2016;31(8):1827–37. 26. Jansen LA, De Caigny P, Guay NA, Lineaweaver WC, Shokrollahi K. The evidence base for the acellular dermal matrix AlloDerm: a systematic review. Ann Plast Surg. 2013;70(5):587–94.

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12 Robotics in Adnexal Surgery • Mala Srivastava  • Neema Tufchi  • Ankita Srivastava

Adnexal surgery refers to the surgical procedures involving the adnexa, which include the ovaries, fallopian tubes, and supporting tissues. Robotics has made significant contributions to various surgical fields, including gynecological surgery, and it is increasingly being utilized in adnexal surgery. The da Vinci Surgical System is one of the most widely used robotic systems in minimally invasive surgery, including adnexal procedures. Robotic technology has revolutionized the field of surgery, offering surgeons enhanced precision, improved visualization, and greater control over complex procedures. In gynecological surgery, including adnexal surgery involving the ovaries, fallopian tubes, and surrounding tissues, robotics has emerged as a valuable tool. The integration of robotic systems, such as the da Vinci Surgical System, has paved the way for innovative approaches that prioritize minimally invasive techniques and patient outcomes. The utilization of robotic systems in adnexal surgery not only facilitates the execution of intricate procedures with greater accuracy but also promotes a more comfortable working environment for surgeons. The ergonomic design of robotic consoles allows for prolonged surgical sessions with reduced fatigue, ultimately enhancing the overall efficiency of the surgical team. The majority of adnexal procedures currently performed with robotic assistance can be attributed to one of the following domains: Reproductive surgery, benign gynecology, and gynecologic oncology. Robotic Tubal Reanastomosis Among married women and women over thirty, surgical sterilization is the most often used method of contraception overall and the second most regularly used form overall.1,2 Surgical sterilization with bilateral tubal ligation is the most popular and efficient approach. Medical indications and the wish to have children to the end are common reasons for tubal ligation, although up to thirty percent of women ultimately

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regret their choice.3 Young age, non-white race, postpartum procedure, and partner or marital status change are all associated with regret.1,2 As a result of recent developments in assisted reproductive technologies (ART), in vitro fertilisation (IVF) is becoming more and more common.4 In a properly chosen patient population, microsurgical reanastomosis is still a suitable and successful treatment for tubal infertility. Although the viability of both tubal reanastomosis and ART has been demonstrated, no randomised, controlled trials have been carried out to examine their respective effectiveness5,6 (Fig. 12.1A to E).

(B)

(A)

(C)

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(D)

(E)

Fig. 12.1A to E:  (A) Excision of the serosal covering of the distal tubal cut end by using monopolar cautery; (B) Excision of the proximal tubal end serosal covering with monopolar cautery; (C) Microscissors used to cut the blind tubal ends creating a lumen in both proximal and distal ends; (D) Bringing both tubal ends together so no tension applied on the anastomosis sutures; (E) Using chromotubation for assurance of tubal patency after successful anastomosis

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For women without a history of reproductive failure who are thinking about getting pregnant again but are against the high likelihood of multiple gestations, microscopic tubal reanastomosis is usually advised. Age should be taken into account as part of the preoperative workup along with other reproductive characteristics7,8 because it has been shown to be a significant predictor of pregnancy rates and outcomes in both IVF and tubal reversal.9,10

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Robotic Adnexectomy for Benign Pathology Retrospective data on 136 robotically assisted gynecologic surgeries conducted in 87 women over a 20-month period were presented by Nezhat and colleagues in 2008.10 Of these procedures, 53% involved adnexal structures and included oophorectomy with or without hysterectomy, ovarian cystectomy, ovarian drilling, salpingectomy, adheolysis, and Moskowitz procedure. For an oophorectomy, the average operating time was 117 minutes. Adnexal operations were reported to have no serious complications. An intestinal hernia was observed in one patient at the location of the 8 mm robotic arm port. Additional remarks concerned the bulkiness of the robotic equipment, the incapacity to use common laparoscopic tools (such as the suction irrigator, Babcock clamps, and stapler), the absence of tactile feedback, the incapacity to move the surgical table, and the extra time required for the assembly and disassembly of the robotic equipment. Benefits of robotic endoscopic surgery included the ability to perform precise movements in a small field of vision, which is necessary for operations like cystectomies, ureteral dissections, and tubal surgery. In 2009, Magrina et al. released another study contrasting the results of robotic versus laparoscopic adnexectomy.11 A number of studies showed that compared to laparotomy, there is a greater chance of cystic contents spilling during a laparoscopic approach to dermoid cyst removal.12,13 Chemical peritonitis is an uncommon but potentially dangerous consequence that can result from the spilling of cystic contents.14 By using a robotic technique for dermoid cyst excision at our institution, we have been able to reduce spillage risk and maintain the advantages of a minimally invasive procedure. The entire cyst stripping process is carried out inside the endoscopic bag to accomplish this.

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Robotic Adnexal Surgery in Malignant Pathology Throughout their lives, one in seventy-two women will get epithelial ovarian cancer.15 The 5-year survival rate is 46% overall, but with early diagnosis, it can reach 94%.15 Regretfully, only 15% of women receive a diagnosis in the early stages of their illness; this is the segment for whom robotic surgery may be used as a staging or therapeutic tool. In more advanced stages of the disease, extensive exploratory dissection of the abdomen, pelvis, and colon is frequently necessary, which can make the minimally invasive approach quite challenging. Magrina et al. conducted the most extensive case-control analysis, comparing 25 robotic cases of epithelial carcinoma staging with 27 laparoscopic and 119 open surgical cases.16 Every patient underwent surgery at the same time, and the groups were matched according to age, body mass index, procedure type, and total number of surgeries. The robotic and laparoscopic techniques were linked to lower blood loss and shorter hospital stays than open surgery. Furthermore, a considerably lower prevalence of postoperative complications was linked to both robotic and laparoscopic techniques in patients undergoing type II ovarian debulking. There was no documented difference in results between laparoscopic and robotic surgery. The surgical approach had no effect on survival either.

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Other Applications of Robotics in Adnexal Surgery The discovery of histologically verified ovarian cortical tissue after surgical exploration in a woman who presents with pain or a pelvic mass and has undergone a previous salpingo-oophorectomy is known as ovarian residual syndrome, an uncommon occurrence.19 When endometriosis or large pelvic adhesions are present in individuals after oophorectomy, it is typically brought on by inadvertent incomplete dissection. The removal of an ovarian remnant surgically can be difficult and has been linked to ureteric, bladder, and bowel injuries.20 Two investigations examined the results of laparotomy, laparoscopy, and robotic approaches used in the surgical treatment of ovarian remnant syndrome.21 Twenty patients were examined by Kho and associates; fourteen had laparoscopic treatment. Robotic assistance was used to treat five patients, and one underwent a laparoscopy.22 The average estimated blood loss was 106 millilitres, and the average operating time was 147 minutes. All but one of the patients experienced symptom resolution. The three-dimensional perspective of the operational field and the articulated tips of robotic surgical instruments allowed for precise dissection of adhesions.22 In order to treat ovarian remnant syndrome, Zapardiel and colleagues retrospectively analysed 187 laparotomy, 19 laparoscopy, and 17 robotic cases.23 When compared to laparotomy, both the laparoscopic and robotic techniques were linked to lower blood loss, shorter hospital stays, and comparable surgical times. Twenty patients were examined by Kho and associates; fourteen had laparoscopic treatment. Robotic assistance was used to treat five patients, and one underwent a laparoscopy. The average estimated blood loss was 106 millilitres, and the average operating time was 147 minutes. All but one of the patients experienced symptom resolution. The three-dimensional perspective of the operational field and the articulated tips of robotic surgical instruments allowed for precise dissection of adhesions. In order to treat ovarian remnant syndrome, Zapardiel and colleagues retrospectively analysed 187 laparotomy, 19 laparoscopy, and 17 robotic cases. When compared to laparotomy, both the laparoscopic and robotic techniques were linked to lower blood loss, shorter hospital stays, and comparable surgical times. Although the robotic group’s incidence of pain regression was surprisingly lower at 71.4%, the overall rate was 92%. Additionally, there were more endometriosis and pelvic adhesions in the robotic group. To find out how a robotic approach to treat ovarian

Robotic Benign Surgery

Robotics Management of Endometriosis Chronic inflammatory endometriosis can affect one or more pelvic and abdominal regions, including the adnexal tissues. The safe and aggressive excision of endometriosis has historically been seen as a difficult procedure, even with the improved access and visibility that laparoscopy offers. Robotic technology offers superior visual input, improved surgical ergonomics, and sophisticated instrumentation that are essential for a difficult pelvic dissection to be successful. Three case reports detailed the use of a robotic technique for ovarian cyst excision and rectosigmoidectomy in addition to the resection of bladder and rectum endometriosis.17 Nezhat and colleagues compared the results of a robotic versus a laparoscopic approach for the treatment of endometriosis in 78 patients in a retrospective cohort study.18 They came to the conclusion that robotics is valuable in managing severe and advanced cases of stage IV endometriosis, including those with endometriomas, which may require switching from laparotomies to laparoscopies in more advanced cases.18

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remnant syndrome works, more research is required. Clinical data are inconsistent even though the robotic technique seems to be best suited for the painstaking dissection needed with this disease. However, better surgical results after using a robotic method support it. The effective use of robotics in treating ovarian vein syndrome, robotic salpingostomy for ectopic pregnancy, and ovarian tissue transplantation with subsequent ovarian function restoration in a non-Hodgkin lymphoma patient have all been documented.24,25 In young women receiving radiation therapy to the pelvis, laparoscopic ovarian transposition is a technically straightforward and often underutilized minimally invasive surgery that can avoid infertility and premature menopause. In cases of high ovarian displacement, a robotic technique seems to be a suitable option, even though oophoropexy is not a technically complex treatment. With the exception of inserting a robotic camera suprapubically rather than via the umbilicus, the robot in this instance was configured according to the minimal access technique outlined by Gargiulo.26,27

Part 2

REFERENCES

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1. Mosher WD, Jones J. Use of contraception in the United States: 1982–2008. Vital Health Stat. 2010; 23:1–44. 2. Zite N, Borrero S. Female sterilisation in the United States. Eur J Contracept Reprod Health Care. 2011;16:336–40. 3. Hillis SD, Marchbanks PA, Tylor LR, Peterson HB. Poststerilization regret: findings from the United States Collaborative Review of Sterilization. Obstet Gynecol. 1999;93:889–95. 4. Centers for Disease Control and Prevention, American Society for Reproductive Medicine, Society for Assisted Reproductive Technology. 2009 Assisted Reproductive Technology Success Rates: National Summary and Fertility Clinic Reports. Atlanta, GA: US Department of Health and Human Services; 2011 5. Yossry M, Aboulghar M, D’Angelo A, Gillett W. In vitro fertilisation versus tubal reanastomosis (sterilisation reversal) for subfertility after tubal sterilization. Cochrane Database Syst Rev. 2006:CD004144. 6. Gomel V. Reversal of tubal sterilization versus IVF in the era of assisted reproductive technology: a clinical dilemma. Reprod Biomed Online. 2007;15:403–7. 7. Gargiulo AR. Fertility preservation and the role of robotics. Clin Obstet Gynecol. 2011;54:431–48. 8. Society for Assisted Reproductive Technology; American Society for Reproductive Medicine. Assisted reproductive technology in the United States: 2001 results generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology registry. Fertil Steril. 2007;87:1253–66. 9. De Mouzon J, Goossens V, Bhattacharya S, et al; European IVF-monitoring (EIM) Consortium, for the European Society of Human Reproduction and Embryology (ESHRE). Assisted reproductive technology in Europe, 2006: results generated from European registers by ESHRE. Hum Reprod. 2010;25:1851–62. 10. Nezhat C, Lavie O, Lemyre M, et al. Robot-assisted laparoscopic surgery in gynecology: scientific dream or reality? Fertil Steril. 2009;91:2620–22 11. Magrina JF, Espada M, Munoz R, et al. Robotic adnexectomy compared with laparoscopy for adnexal mass. Obstet Gynecol. 2009;114:581–84. 12. Briones-Landa CH, Ayala-Yáñez R, Leroy-López L, et al. Comparison of laparoscopic vs. laparotomy treatment in ovarian teratomas. Ginecol Obstet Mex. 2010;78:527–32. 13. Kondo W, Bourdel N, Cotte B, et al. Does prevention of intraperitoneal spillage when removing a dermoid cyst prevent granulomatous peritonitis? BJOG. 2010;117:1027–30.

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14. da Silva BB, dos Santos AR, Lopes-Costa PV, et al. Ovarian dermoid cyst with malignant transformation and rupture of the capsule associated with chemical peritonitis: a case report and literature review. Eur J Gynaecol Oncol. 2009;30:226–28. 15. Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin. 2010;60:277–300. 16. Magrina JF, Zanagnolo V, Noble BN, et al. Robotic approach for ovarian cancer: perioperative and survival results and comparison with laparoscopy and laparotomy. Gynecol Oncol. 2011;121:100–5. 17. Gargiulo AR, Nezhat C. Robot-assisted laparoscopy, natural orifice transluminal endoscopy, and single site laparoscopy in reproductive surgery. Semin Reprod Med. 2011;29:155–68. 18. Nezhat C, Lewis M, Kotikela S, et al. Robotic versus standard laparoscopy for the treatment of endometriosis. Fertil Steril. 2010;94:2758–60. 19. Kho RM, Magrina JF, Magtibay PM. Pathologic findings and outcomes of a minimally invasive approach to ovarian remnant syndrome. Fertil Steril. 2007;87:1005–9. 20. Magtibay PM, Nyholm JL, Hernandez JL, Podratz KC. Ovarian remnant syndrome. Am J Obstet Gynecol. 2005;193:2062–6. 21. Zapardiel I, Zanagnolo V, Kho RM, et al. Ovarian remnant syndrome: comparison of laparotomy, laparoscopy and robotic surgery. Acta Obstet Gynecol Scand. 2012;91:965–9. 22. Kho RM, Magrina JF, Magtibay PM. Pathologic findings and outcomes of a minimally invasive approach to ovarian remnant syndrome. Fertil Steril. 2007;87:1005–9. 23. Zapardiel I, Zanagnolo V, Kho RM, et al. Ovarian remnant syndrome: comparison of laparotomy, laparoscopy and robotic surgery. Acta Obstet Gynecol Scand. 2012;91:965–9. 24. Badger WJ, De EJ, Kaufman RP Jr. Robotically assisted excision of ovarian vein for intermittent ureteral obstruction. JSLS. 2008;12:166–8. 25. Al-Badawi IA, Al-Aker M, Tulandi T. Robotic-assisted salpingostomy for ectopic pregnancy. J Obstet Gynaecol Can. 2010;32:627–8. 26. Gargiulo AR. Fertility preservation and the role of robotics. Clin Obstet Gynecol. 2011;54:431–448. 27. Molpus KL, Wedergren JS, Carlson MA. Robotically assisted endoscopic ovarian transposition. JSLS. 2003;7:59–62.

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13 Robotic Management of Urinary Fistulas • Amita Jain

Minimally invasive surgery has a special role in treatment of urogynecological conditions.1 Apart from the well-known advantages of a less invasive surgical approach over traditional open repairs which include shorter hospital stay, less postoperative pain, early recovery and better cosmetic results; the robotic approach also provides improved visualization due to magnification and insufflation effects. This allows better visualisation of pelvic anatomy helping in more precise dissection and as a result, complicated urogynecological surgeries such as urinary fistula repair becomes much easier to perform and desirable outcomes can be achieved with minimal morbidity, as it offered the best possibility to specifically treat the target anatomy with a reduced risk for involvement of the surrounding structures and a quick postoperative recovery.1 Potential advantages of robotic route like enlarged 3D vision, high mobility instruments, improved ergonomics and fluorescence vision; offer solutions to overcome technical difficulties, particularly some of them frequently faced in complex fistula repair in form of narrow pelvic operating area, long and difficult suturing steps, and hypovascularized structures in long standing or recurrent cases.2 This also helps the surgeon to achieve the goal of any pelvic reconstructive surgery, which include correction of all the defects with restoration or maintenance of normal visceral and sexual function. On the other hand, a few challenges of this approach like additional cost of equipment, increased operating time and prolonged learning curve could also be surpassed by achieving expertise in this technique and increasing the number of surgeries. Therefore, robotic approach should be individualised for selected complex urogenital fistulas where other possible alternatives may have higher chances of injury to the adjacent organs like ureters or bowel. As principles of surgeries remain the same whichever route is chosen, any surgeon possessing both reconstructive and minimally invasive surgical abilities could reliably manage urogenital fistulas with a robotic approach.

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Technique of Robotic VVF Repair Low-lithotomy position is preferred so that Foley catheter can be placed in the fistulous tract with inflated balloon transvaginally. The placement of a double J ureteral stent is optional and should be done if a fistula is too close to a ureteric opening, so that ureter can be identified intraoperatively and the injury can be averted. In patients with previous abdominal surgery, once the pneumoperitoneum is created with a Veress needle, then at 2 cm above the umbilicus, a12 mm camera port is placed which avoids any injury to any bowel adhesions. The remaining 4 trocars are placed in a dome fashion under direct vision (two left-sided 8 mm ports and one right-sided 8 mm port for robotic instruments and one right-sided 12 mm laparoscopic port) (Fig. 13.1). The patient table is tilted to approximately 30° of Trendelenburg and left-sided docking (da Vinci® robot) is performed at an angle of 45° to the patient (on a virtual line connecting the patient’s left superior iliac spine with her right shoulder) (Fig. 13.2). The 2 assistants have enough space while side-docking of the robot. One assistant can be placed on the patient’s right side to assist the console surgeon laparoscopically and a second assistant can sit between the patient’s legs for vaginal manipulation or

Robotic Benign Surgery

Vesicovaginal Fistula Vesicovaginal fistula (VVF) is the most common type of urinary tract fistula. The transvaginal repair is not feasible in many patients due to scarring or narrowing of the vagina, a high location of the fistula, a large (>3 cm) supratrigonal complex fistula or the surgeon’s inexperience in transvaginal approach. The transabdominal robotic approach reduces the morbidity of open approach.3 It also provides a wider space to work, allows easy access to tissues such as the omentum for interposition, allows repair of complex fistulae requiring ureteric reimplantation or augmentation cystoplasty, and does not compromise vaginal length. Other minimally invasive approaches like laparoscopic repair has been used for supratrigonal VVF in past. However, this faced challenges like a steep learning curve for laparoscopic suturing and difficulties with access and ergonomics. These issues have been mitigated with the introduction of robotic surgery.4 Robotic repair of VVF was first reported in 2005.5 Since then, various case series have been published to prove the feasibility and safety of this technique and reported success rate ranges from 71.4% to 100%.6–11 However, most of the series included small number of patients, except only three studies that included more than 15 patients, with a respective mean operative time of 127.5 min (100–270), 133 ± 48 min and 187 min (151–219 min), and a reported success rate of 100%, 93.3% and 91%.3,12,13 In one study 12 robotic repairs for recurrent VVF were compared to 20 open abdominal repairs. The success rates (100% vs 90%, P 9 0.05), operative time and complication rates were almost similar. However, blood loss and hospital stay were significantly less with robotic approach.14 The classic transvesical approach by O’Conor and Sokol which involves bivalving the bladder, is now replaced by a limited posterior cystotomy approach again in an attempt to further reduce the morbidity. This extravesical approach for robotic VVF repair was first reported in 2007 by Schimpf et al.8

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Fig. 13.1:  Standard port placement

2

Fig. 13.2:  Deep Trendelenburg positioning with adequate strapping

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introduction of a vaginal probe. The robotic instruments are inserted (bipolar Maryland forceps, monopolar scissors and ProGraspTM forceps) and adhesiolysis can be performed to expose the surgical field, if adhesions from the previous surgery are encountered (Fig. 13.3). The fistulous tract is identified through mobilisation of the Foley catheter (Fig. 13.4). By sharp dissection of the vaginal adhesion, a vesicovaginal plane is created (Fig. 13.5).

Fig. 13.4:  Identification of VVF tract

Fig. 13.5:  Creation of vesicovaginal plane by sharp dissection

Robotic Benign Surgery

Fig. 13.3:  Easy adhesiolysis under good vision with robotic instruments

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The repair of vaginal and vesical parts of the fistula must be done in a tension-free fashion from the surrounding fibrosis. The fistulous tract must be selectively mobilised and the fibrotic margins can be resected. With a reabsorbable, braided 2–0 suture to the vagina and a 3–0 suture to the bladder, 2 layered repair of the vaginal and vesical breaches. A vascularised flap of perisigmoid fat (Fig. 13.6) or omentum should be interposed between the two suture lines, to reduce the risk of recurrence.1 The integrity of the repair can be checked with methylene blue instillation into the bladder. Ureterovaginal Fistula While it is easy to recognise as well as to repair the bladder injuries, the iatrogenic ureteral injury (IUI) is a rare but devastating complication occurring mainly after pelvic surgery, with an incidence of 0.1% to 10%.15 Approximately 52–82% of all IUIs occur during gynecological surgeries. Unidentified IUI results in ureterovaginal fistulas (UVFs). Those which are not closed after 6 to 8 weeks, must be repaired abdominally. Injury or fistula involving the distal one-third (distal 4–5 cm) of the ureter is treated by ureteroneocystostomy (ureteral reimplantation into the bladder).16 A psoas hitch may be required to maintain the anatomic position of the bladder and to reduce tension on the repair. A fistula involving the middle and upper third of the ureter must be repaired by resecting the involved area and reanastomosing the 2 ends of the ureter (ureteroureterostomy). This is usually done over ureteral stents.17 In 2008, Laungani et al.18 reported a good outcome of three robotic ureteroneocystostomies for the repair of complex UVFs with a six-port approach. Later on, Siddighi and Carri19 reported successful robotic repair of UVFs using five ports in three patients. There is sparsity of the literature and only small case series20,21 are available, as occurrence of UVFs is relatively rare.

Part 2

Technique of Robotic Ureretic Reimplantation Position the patient in dorsal lithotomy or supine position based on surgeon preference. Other preparations like placement of trocars and choice of instruments are almost similar. Classical central docking can be opted as usually vaginal manipulation is not

2

Fig. 13.6:  A vascularised flap of perisigmoid fat for interposition between the two suture lines

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needed unless there is concomitant VVF. Deep Trendelenburg position is also preferred to allow better visualisation and access of operating field as bowel especially small intestines moves away due to gravitational pull. The ureter is dissected out and traced distally towards the bladder. The bladder is also dissected off the vagina to ensure that the ureterovaginal fistula has been fully exposed (Fig. 13.7). The ureter is transected as distally as possible. Closure of the distal ureter at the bladder can be performed with an absorbable or permanent suture such as a 2–0 silk tie. Closure of the vaginal side of the fistula can be performed using 2–0 or 3–0 absorbable suture. An interposition flap can be placed using omentum (Fig. 13.8), peritoneum, or gracilis muscle. The ureter then requires reimplantation into the bladder with or without psoas hitch (Fig. 13.9). Previous ureteral reconstruction reports have highlighted the technical difficulty faced during dissection in the limited pelvic working space and during intracorporeal suturing for ureteral anastomosis. This drawback has been overcome by incorporating the assistance of robots for repair.22,23 Stenting is recommended for 4–6 weeks following the reimplantation.

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Fig. 13.7:  Exposed ureterovaginal fistula

Fig. 13.8:  An interposition flap of omentum

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Fig. 13.9:  Ureteroneocystostomy (ureteral reimplantation into the bladder)

Vesicouterine and Vesicocervical Fistula Vesicouterine fstula (VUtF) and vesicocervical (VCxF) comprise 1–4% of all urogenital fstulas.24 Although uncommon, the incidence of the VCxF is rising, primarily because of a worldwide increase in cesarean sections.25 The surgical route for repair depends on the location of the fistula, its accessibility; experience and skills of the surgeon. Very few case reports are available describing a successful fertility-sparing robotic repair of VUtF and VCxF with interposition of an omental flap.26

Part 2

Technique of Robotic Repair of VUtF/VCxF Repair of VUtF or VCxF repair is almost similar to VVF repair. A cystotomy can be made, if planes are not clear. The bladder is sharply dissected off the uterus, and the fistulous tract is excised. Hysterectomy can be chosen as a definitive treatment for vesicouterine fistula for patients not desiring future pregnancy. Otherwise, the closure of the uterus is closed using interrupted absorbable sutures after closing bladder in 2 layers. Similar to VVF repair, an omental flap can be placed between the suture lines of bladder and uterus to reduce the risk of fistula recurrence.27

2

Urethrovaginal Fistula Reported cases in literature are very less and have been managed vaginally. Though there are several reports of bladder neck reconstruction by robotic route but usually for stricture, not for urethrovaginal fistula.28

1. Most of the data of robotic surgeries for the treatment of urogenital fistulas indicate that the success rates are similar while complication rates are lower in comparison to the open abdominal procedures with reported less blood loss, shorter hospitalization, less postoperative complications. 2. Selection of the case should be judicious taking surgeon’s expertise into the consideration. 3. With the increasing interest of upcoming surgeons and wider availability of this advanced technique, it might prove most feasible option for many complex urogenital fistula cases.

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4. The measures like use of reusable robotic equipment, ongoing favourable changes in health care allocation and reimbursement policies will help in decreasing the cost as well. 5. In future, the care providers and care seekers both are going to opt for this more advanced minimally invasive technique for complicated surgical procedures like fistula repair, to achieve reliable and durable outcomes.

1. Dutto L, O’Reilly B. Robotic repair of vesico-vaginal fistula with perisigmoid fat flap interposition: state of the art for a challenging case? Int Urogynecol J. 2013 Dec;24(12):2029–30. doi: 10.1007/ s00192–013–2081–3. Epub 2013 Jul 19. PMID: 23867973. 2. Tsoi H, Elnasharty SF, Culha MG, De Cillis S, Guillot-Tantay C, Hervé F, Hüesch T, Raison N, Phé V, Osman NI. Current evidence of robotic-assisted surgery use in functional reconstructive and neuro-urology. Ther Adv Urol. 2023 Dec 1; 15:17562872231213727. doi: 10.1177/17562872231213727. PMID: 38046941; PMCID: PMC10693211. 3. Bora GS, Singh S, Mavuduru RS, Devana SK, Kumar S, Mete UK, Singh SK, Mandal AK. Robot-assisted vesicovaginal fistula repair: a safe and feasible technique. Int Urogynecol J. 2017 Jun;28(6):957–962. doi: 10.1007/s00192–016–3194–2. Epub 2016 Nov 14. PMID: 27844120. 4. Ramphal SR. Laparoscopic approach to vesicovaginal fistulae. Best Pract Res Clin Obstet Gynaecol 2019; 54: 49–60. 5. Melamud O, Eichel L, Turbow B, et al. Laparoscopic vesicovaginal fistula repair with robotic reconstruction. Urology 2005; 65: 163–6. 6. Dutto L and O’Reilly B. Robotic repair of vesico-vaginal fistula with perisigmoid fat flap interposition: state of the art for a challenging case? Int Urogynecol J 2013; 24: 2029–30. 7. Hemal AK, Kolla SB and Wadhwa P. Robotic reconstruction for recurrent supratrigonal vesicovaginal fistulas. J Urol 2008; 180: 981–5. 8. Schimpf MO, Morgenstern JH, Tulikangas PK, et al. Vesicovaginal fistula repair without intentional cystotomy using the laparoscopic robotic approach: a case report. JSLS 2007; 11: 378–80. 9. Sears CL, Schenkman N and Lockrow EG. Use of end-to-end anastomotic sizer with occlusion balloon to prevent loss of pneumoperitoneum in robotic vesicovaginal fistula repair. Urology 2007; 70: 581–2. 10. Sundaram BM, Kalidasan G and Hemal AK. Robotic repair of vesicovaginal fistula: case series of five patients. Urology 2006; 67: 970–3. 11. Randazzo M, Lengauer L, Rochat CH, et al. Best Practices in robotic-assisted repair of vesicovaginal fistula: a consensus report from the European association of urology robotic urology section scientific working group for reconstructive urology. Eur Urol 2020; 78: 432–42. 12. Quadri M, Thirumalai G, Kumar BA, et al. Robot assisted laparoscopic repair of vesicovaginal fistula: a retrospective study at a Tertiary Care Centre, Chennai, India. J Clin Diagn Res 2022; 16: PC01–PC04. 13. Kidd LC, Lee M, Lee Z, et al. A multi-institutional experience with robotic vesicovaginal and ureterovaginal fistula repair after iatrogenic injury. J Endourol 2021; 35: 1659–64. 14. Gupta NP, Mishra S, Hemal AK, et al. Comparative analysis of outcome between open and robotic surgical repair of recurrent supra-trigonal vesico-vaginal fistula. J Endourol 2010;24:1779Y1782. 15. Ozdemir E, Ozturk U, Celen S, et al. Urinary complications of gynecologic surgery: iatrogenic urinary tract system injuries in obstetrics and gynecology operations. Clin Exp Obstet Gynecol 2011;38:217–20. 16. Linder BJ, Frank I, Occhino JA. Extravesical robotic ureteral reimplantation for ureterovaginal fistula. Int Urogynecol J 2018;29:595–7. 17. Wong MJ, Wong K, Rezvan A, Tate A, Bhatia NN, Yazdany T. Urogenital fistula. Female Pelvic Med Reconstr Surg. 2012 Mar-Apr;18(2):71–8; quiz 78. doi: 10.1097/SPV.0b013e318249bd20. PMID: 22453314.

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REFERENCES

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18. Laungani R, Patil N, Krane LS, et al. Robotic-assisted ureterovaginal fistula repair: report of efficacy and feasiblity. J Laparoendosc Adv Surg Tech A 2008;18:731–4. 19. Siddighi S, Carr KR. Lighted stents facilitate robotic-assisted laparoscopic ureterovaginal fistula repair. Int Urogynecol J 2013;24:515–7. 20. Mufarrij PW, Shah OD, Berger AD, et al. Robotic reconstruction of the upper urinary tract. J Urol 2007;178:2002–5. 21. Shaw J, Tunitsky-Bitton E, Barber MD, et al. Ureterovaginal fistula: a case series. Int Urogynecol J 2014;25:615–21. 22. Yuan C, Wang J, Cheng S, Li Z, Xu C, Zhu W, Fan S, Yang K, Li X, Zhou L. Robotic ureteral reimplantation for the management of ureterovaginal fistula: four cases at a single center. Transl Androl Urol. 2021 Oct;10(10):3705–3713. doi: 10.21037/tau-21–454. PMID: 34804814; PMCID: PMC8575580. 23. Hemal AK, Nayyar R, Gupta NP, et al. Experience with robot assisted laparoscopic surgery for upper and lower benign and malignant ureteral pathologies. Urology 2010;76:1387–93. 24. Hadzi-Djokie JB, Pejeie TP. Colovic VC—vesicouterine fstula: report of 14 cases. BJU Int. 2007;100(6):1361–3. 25. Dudderidge TJ, Haynes SV, Davies AJ, Jarmulowicz M, Al-Akraa MA. Vesicocervical fstula: a rare complication of cesarean section demonstrated by magnetic resonance imaging. Urology. 2005;65(1):174. 26. Saini, A., Mittal, A., Panwar, V.K. et al. Recurrent vesico-cervical fistula: our experience. Int Urogynecol J 34, 2619–2621 (2023). https://doi.org/10.1007/s00192-023-05522-4. 27. Porcaro, A.B., Zicari, M., Antoniolli, S.Z. et al. Vesicouterine fistulas following cesarean section Report on a case, review and update of the literature. Int Urol Nephrol 34, 335–344 (2002). https:// doi.org/10.1023/A:1024443822378. 28. Unterberg SH, Patel SH, Fuller TW, et al. Robotic-assisted proximal perineal urethroplasty: improving visualization and ergonomics. Urology 2019; 125: 230–3.

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3 Robotic Management in Malignancy 14. Robotic Assisted Pelvic and Para-aortic Lymph Node Dissection 15. Robot-Assisted Surgery in Cervical Cancer 16. Robotic Surgery for Endometrial Cancer 17. Robotic Surgery in Ovarian Cancer

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14 Robotic Assisted Pelvic and Para-aortic Lymph Node Dissection • Rohit Raghunath Ranade  • Shree Bharati

Pelvic and para-aortic lymph node dissection is a major component of surgery for several gynaecological malignancies. The role of the pelvic and para-aortic lymph node dissection for patients diagnosed with a gynaecological malignancy has evolved since the 1990s. 1. As part of staging procedure 2. Assessment of lymph node status has a prognostic significance 3. To decide upon adjuvant therapy 4. Can even be therapeutic in some scenarios The surgical and oncologic goals of the lymph node dissection are to determine the extent of disease, stage it and, thereby, to guide further treatment.1 Lymphadenectomy may also have a therapeutic role in conditions in which removing nodes harbouring metastatic disease improves symptoms and survival. Endometrial Cancer Lymph node dissection is a fundamental part of surgery for carcinoma endometrium although the extent of dissection varies based on various risk factors. Previously, a full standard lymphadenectomy (i.e. dissection and assessment of both pelvic and paraaortic nodes) was recommended for all patients; however, to decrease side effects, a more selective and tailored nodal evaluation approach that includes the SLN algorithm is recommended by the NCCN Panel. (NCCN) Pelvic and para-aortic lymph nodes involvement greatly impacts the 5-year survival in endometrial cancer women. Survival is 94% if negative lymph nodes, 75% if positive pelvic nodes, and 38% if positive para-aortic nodes.2,3 Tumor size of greater than 2 cm is another strong predictor of lymph node metastasis in those patients.3 If pelvic lymph nodes are positive, then there is 50% risk of para-aortic lymph node metastasis and isolated positive aortic lymph nodes occur in 2–3% women.4 Para-aortic

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lymph node dissection is recommended in patients with high risk factors like positive pelvic nodes, high grade, serous or clear cell histology (Table 14.1).3,5 Robotic surgery has been increasingly used in the surgical staging of endometrial carcinoma due to its potential advantages over laparotomy, especially for patients with higher BMI. Studies suggest that robotic approaches perform similarly to laparoscopy and result in comparable or improved perioperative outcomes, less frequent conversion to laparotomy and also give a comparable nodal yield, even in obese patients. 6–8 Oncologic outcomes appear to be comparable to other surgical approaches, although longer-term outcomes are still being investigated.9 Existing literature reports different approaches for endometrial cancer management strategy (Table 14.2). Endometrial Cancer: Sentinel Lymph Node Mapping Sentinel lymph node (SLN) is based on the concept that if the first lymph node group receiving lymphatic drainage from a primary tumor is negative, then it is anticipated that the rest of lymph nodes are also negative and vice versa.12

Table 14.1: Incidence of pelvic and aortic lymph node metastasis by tumor grade Grades

Pelvic lymph node metastasis

Aortic lymph node metastasis

Low-grade

3.8–15.2%

0.8–9.4%

Intermediate-grade

7.3–17.1%

5.3–20.5%

High-grade tumors

6.9–35.3%

0–25%

Table 14.2: Comparison of different studies utilising various approaches to radical hysterectomy for endometrial cancer Article Bernardini et al.7 Eklind et al.8

Part 3

Pulman et

3

al.10

Corrado et al.11 Backes et al.9

Approach

Patients Nodal yield

Operative time (min)

Blood loss Hospital (ml) stay (days)

Open-RH*

41

14

165

300

4

RALRH**

45

18

270

200

2

RALRH

40

13

127

76

1.8

Open-RH

48

13

179

317

4.8

Open-RH

69

14

210

300

4

LRH***

44

17

240

150

1

RALRH

63

18

240

150

1

RSS-RH****

125

13

122

50

2

Open-RH

93

18

NA

300

4

RALRH

89

15

NA*****

75

1

*RH, Radical hysterectomy **RALRH, Robotic-assisted laparoscopic radical hysterectomy *** LRH, laparoscopic radical hysterectomy **** RSS, robotic single site surgery *****NA, not available

Robotic Assisted Pelvic and Para-aortic Lymph Node Dissection

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• Sentinel lymph node biopsy is advised rather than lymphadenectomy. • Earlier SLN was done with a combination of 99-Tm and a visible dye (such as isosulfan blue dye) but now ICG (indocyanine green) is used which is as it is superior to blue dye in detecting sentinel lymph node. • SLN is done by injecting the dye intracervically or in uterine stroma, which gets accumulated into the corresponding lymph nodes and which can be picked up by robotic camera.13 • The Fluorescence Imaging for Robotic Endometrial Sentinel (FIRES) lymph node biopsy trial is a prospective, multicenter, cohort study that aims to assess the value of ICG-SLN biopsy as an alternative to lymphadenectomy in 385 patients undergoing robotic surgery for stage I Endometrial Carcinoma. The authors reported that ICGSLN biopsy can safely replace lymphadenectomy with a sensitivity of 97.2% and a NPV of 99.6%.14

Robotic Pelvic Lymph Node Dissection in Cervical Cancer Minimally invasive approaches are the better alternatives to open pelvic lymphadenectomy and have comparable surgical and oncological results. Conflicting results exist regarding the value of nodal yield on the survival of women with lymph nodes negative status, a more extensive lymph node dissection theoretically improves the pathological accuracy of lymph node status because a large number of retrieved lymph nodes certainly increase the chance of detecting and resecting micrometastasis. Hence the number of pelvic lymph nodes obtained are the surrogate marker of the extent and quality of surgery. Existing literature reports different approaches for endometrial cancer manage-­ ment strategy. The majority of authors reported a comparable nodal yield among different surgical approaches (16–36 for robotic, 14–27 for laparoscopic, 17–25 for open) (Table 14.3). Cervical Cancer: Sentinel Lymph Node Mapping (SLNM) As suggested by various studies using radiocolloid tracer (Technetium-99) either alone or in combination with blue dye, sentinel lymph node mapping to be considered as an alternative to lymphadenectomy only in the women with early-stage cervical tumors