Robotics in Gynecology 2 LR

Labib Riachi, M.D. Chief Division of Robo4cs and Urogynecology Chairman Dept of Ob/Gyn at Trinitas Regional Medical Center Robo$c Surgery Market
Gynecologic Condi$ons
  Pre-­‐cancer Fallopian Tube   Cancer Ovary Uterus   Pelvic masses   Abnormal bleeding   Endometriosis   Fibroids   Pelvic floor disorders   Infer4lity Pubic Bone Bladder Rectum Urethra Vagina Cancer of the Female Reproduc$ve Organs
Malignant growth or tumor ✓  Uterus or endometrium ✓  Cervix ✓  Ovary Ovarian Cancer Endometrial Cancer Cervical Cancer Surgical Staging for Endometrial Cancer
Para-Aortic Lymph Nodes
Fallopian Tube
Ovary
Uterus
Pelvic Lymph Nodes
Cervix
• The most common gynecologic cancer • Usually detected in an early stage • Almost always treated with surgery Radical Hysterectomy for Cervical Cancer
Fallopian Tube
Pelvic
Lymph
Nodes
Ovary
Uterus
Parametrium
Cervix
Upper Third of Vagina
• Can be detected by an abnormal PAP smear • Early stages are usually treated with surgery • Advanced stages are treated with radia4on/chemotherapy Surgical Approaches to Gynecologic Condi$ons
  Open (abdominal) surgery   Minimally invasive surgery (MIS) ✓  Vaginal surgery ✓  Conven4onal laparoscopic surgery ✓  da Vinci® Hysterectomy (robo4c-­‐assisted surgery) Benefits of Minimally Invasive Surgery (MIS)
  Reduced blood loss   Fewer complica4ons   Shorter LOS   Faster recovery   Less scarring   Less risk of infec4on   Significantly less pain   Improved cosmesis Circa. 1991 MIS – Laparoscopic Surgery ▪  Minimally invasive surgery (MIS) ▪  Ability to operate through small keyhole incisions ▪  The camera and instruments fit through the keyhole incisions ▪  BeXer visualiza4on than open surgery Drawbacks with Conven$onal Laparoscopic Surgery
  Surgeon operates from a 2D image   Straight, rigid instruments (limited range of mo4on)   Instrument 4ps controlled at a distance   Reduced dexterity, precision and control   Unsteady camera controlled by assistant   Dependent on assistant for surgical support through an accessory port   Greater surgeon fa4gue   Makes complex opera4ons more difficult How to overcome these drawbacks? ▪  Improve visualiza4on ▪  Improve instrument control ▪  Enhance dexterity for technically challenging aspects of the procedure ▪  Decrease surgeon fa4gue , and hand tremor History  Robot derived from the Czech word robota  1917 , 1921 , the Capek brothers  1958 GM introduced the Unimate  1985 robo?c arm perfomed a brain biopsy  1992 Robodoc for use in hip replacement surgery  1994 AESOP/Hermes telerobo?c manipulators system  1997 Da Vinci system performed a Cholecystectomy  1999 Zeus system and the surgeon’s worksta?on  2005 approved for gynecological surgery Robo$c Hysterectomy for Early Stage Cancer
Poster Presenta$on: S. DeNardis, R. Holloway et al (Florida Hospital)
Robo4c-­‐assisted laparoscopic hysterectomy (RALH) versus total abdominal hysterectomy (TAH) with pelvic + aor4c lymphadenectomy (LA) for staging endometrial cancer RALH + LA (n=56)
da Vinci
TAH + LA (n=106)
Open
p-value
Age (years)
58.9
62.5
0.05
BMI (kg/m2)
28.5
34.0
0.0001
Severe medical co-morbidity (%)
5.4
8.5
NS
Estimated blood loss (ml)
105
241
<0.0001
OR time (mins)
177
79
0.0004
Total lymph nodes
18.6
18.0
NS
Hospital stay (days)
1.0
3.2
<0.0001
Transfusion rate (%)
0%
8.5%
0.005
Major peri-operative comps (%)
3.6%
20.8%
0.007
Source: Poster presentation by Dr. Robert Holloway (Florida Hospital) at SGO in March 2008.
Booth Presenta$on: The UNC Experience Dr. John Boggess (UNC)
Type III Radical Hysterectomy with Pelvic Lymph Node Dissec?on for Treatment of Early Stage Cervical Cancer: Robo?c vs. Open da Vinci (n=50)
Open (n=50)
p-value
Age (years)
47.4
41.9
0.029
BMI (kg/m2)
28.6
26.1
0.08
Estimated blood loss (ml)
95.4
416.8
<0.0001
OR time (mins)
210.8*
247.8
0.0002
Total lymph nodes
33.8**
23.3
0.0003
Hospital stay (days)
1.0
3.2
<0.0001
Post-operative complications
8.0% (4)
16.0% (8)
0.35
*Opera4ve 4mes of last 12 cases was 193 mins. **Improved lymph node yield due to improved dissec4on boundaries with da Vinci. Source: Oral presentation by Dr. John Boggess (UNC) at SGO in March 2008.
Robo$c assisted Hysterectomy
▪  BeXer access and visualiza4on enable more precise dissec4on ▪  Precise, controlled dissec4on around arteries, veins and nerves ▪  Access to pelvic and aor4c lymph nodes allows replica4on of open surgical techniques Video courtesy of Labib Riachi, M.D. Pelvic Node sampling Video courtesy of Labib Riachi, M.D. Vaginal cuff closure
  Video courtesy of Labib Riachi, M.D. Robo$c adhesiolysis
▪  Dexterity for complex dissec4ons (e.g endometriosis) ▪  Great precision in dissec4ng bowel adhesions ▪  Improved visualiza4on and access around structures ▪  Ability to address complex adhesions with greater safety Video courtesy of Labib Riachi, M.D. Adhesions Video courtesy of Labib Riachi, M.D. Endometriosis
Video courtesy of Labib Riachi, M.D. Ovarian cystectomy
Vesico-­‐vaginal Fistula Robo$c Hysterectomy Minimizes TAH and Conversion Rates
Data from Drs. Thomas Payne and Ralph Dauterive Ochsner Clinic, Baton Rouge, LA Retrospec?ve Review of Hysterectomy: Pre-­‐Robo?c versus da Vinci Last 25
da Vinci
Pre-robotic (n=100)
da Vinci (n=100)
Age (years)
43.5
43.2
BMI
28.8
28.8
Estimated blood loss (ml)
113
61
Hospital stay (days)
1.6
1.1
TAH rate
20%
4%
0%
Conversions (subset of TAH)
9%
4%
0%
Avg uterine weight of conversions
359.5
1387.5
TAH due to adhesions
8%
0%
Operative times (skin-to-skin)
92.4
Source:
Oral presentation by Dr. Thomas Payne
at AAGL 2007.
119
78.7
Benefits of Robo$c Hysterectomy
▪  Enables GYNs to treat complex pathology endoscopically ▪  Unsurpassed precision, dexterity and control offer poten4al for: ▪  More precise and efficient dissec4ons ▪  Ureters, vesico-­‐uterine reflec4on, colpotomy ▪  Quicker, easier vaginal cuff closure ▪  Greater ability to perform MIS on more pa4ent types ▪  Compromised anatomy and 4ssue planes, e.g., due to endometriosis and adhesive disease from prior pelvic surgeries ▪  Larger pathology ▪  Obese pa4ents Robo$c Myomectomy
da Vinci Myomectomy
▪  High-­‐defini4on 3D visualiza4on of 4ssue planes for a more precise dissec4on and enuclea4on ▪  Enhanced dexterity facilitates enuclea4on of larger myomas ▪  Precise, 3-­‐layer suture reconstruc4on of uterus Video courtesy of Labib Riachi, M.D. Myomectomy
  Video courtesy of Labib Riachi, M.D. Benefits of Robo?c Myomectomy   Enables an MIS approach for myomectomy ◦  Open is standard; laparoscopy is very difficult to learn/perform ◦  An effec4ve 3-­‐layer suture reconstruc4on is difficult ◦  Concern over conversions and uterine rupture ◦  Most GYNs perform open or opt for hysterectomy instead   Advantages over laparoscopy ◦  BeXer suture reconstruc4on and faster more precise dissec4on   Advantages over laparotomy ◦  Poten4al pa4ent benefits associated with MIS ◦  Longer procedure 4mes outweighed by improved outcomes ✓ Short LOS, minimum EBL, minimum comps or conversions, quick recovery, beXer cosmesis RASC Video courtesy of Labib Riachi, M.D. da Vinci Sacrocolpopexy
RASC
▪  Easier, quicker and more precise suturing ▪  Complete control of the camera and all three opera4ve arms ▪  A reproducible approach ▪  RASC is safe and effec4ve for POP Double-­‐click to view video Benefits of da Vinci Sacrocolpopexy
  da Vinci Sacrocolpopexy is considered the gold standard for vaginal vault prolapse ◦  <5% are performed with laparoscopy ◦  This procedure typically requires difficult dissec4ons and extensive suturing   Robo?cs enables an endoscopic approach for sacrocolpopexy   The unsurpassed visualiza4on, depth percep4on, dexterity and control offered by the Robo4c System provide: ◦  Improved access to the pelvis compared to open and conven4onal laparoscopic approaches ◦  Easier, more precise rectovaginal and presacral dissec4ons ◦  Improved handling of suture and mesh for more accurate grak placement and aXachment dVH vs. TLH: Five Meta-­‐analyses
Data from: Scandola M, Grespan L, Vicen4ni M, Fiorini P. Robot-­‐Assisted Laparoscopic Hysterectomy vs Tradi4onal Laparoscopic Hysterectomy: Five Metaanalyses. J Minim Invasive Gynecol. 2011 Nov-­‐Dec;18(6):705-­‐15. # of Studies Odds Ra4o 95% Confidence Interval p value EBL 14 -­‐0.61 (-­‐47.42; 46.20) NS Opera4ve Time 20 0.66 (-­‐15.72; 17.04) NS LOS 17 -­‐0.43 (-­‐0.68; -­‐0.17) 0.05 Conversion to laparotomy 15 0.49 (0.31; 0.77) 0.05 Postopera4ve complica4ons 14 0.68 (0.49; 0.94) 0.05 A total of 1,280 robo4c and 1,386 laparoscopic hysterectomies included in the analyses, covering both malignant and benign condi4ons. No sta4s4cally significant differences were found when comparing malignant and benign cases with respect to the measured indices except opera4ve 4me and postopera4ve complica4ons. Forest Plots: Significant Difference vs. Non
Data from: Scandola M, Grespan L, Vicen4ni M, Fiorini P. Robot-­‐Assisted Laparoscopic Hysterectomy vs Tradi4onal Laparoscopic Hysterectomy: Five Metaanalyses. J Minim Invasive Gynecol. 2011 Nov/Dec; 18(6):705-­‐15 Opera4ve 4me (no significant difference) Conversions (significant difference) “Thus, we conclude that, compared with tradi4onal laparoscopic hysterectomy, robo4c-­‐assisted hysterectomy might have an overall smaller effect on hospital, societal, and psycho-­‐physiologic stress factors, with a shorter hospital LOS, a smaller number of conversions to open surgery, and fewer postopera4ve complica4ons.” Is it Safe ?
The Future
Ques?ons ??????????