Robot

Impact of Robotic Surgery in
Minimally Invasive
Management of Oncofertility
Patients
Farr R. Nezhat, MD, FACOG
Professor of Obstetrics and Gynecology
Director, Gynecologic Robotic and Minimally Invasive Surgery Fellowship
Division of Gynecologic Oncology
Department of Obstetrics and Gynecology
St. Luke's-Roosevelt Hospital Center
Mt. Sinai School of Medicine
Objectives

Historical back ground

Overview of Robotic Surgery and Indications

Surgical Techniques and potential Complications

Future Technology
th
18
Century
First successful laparotomy
performed longitudinally
Ephraim McDowell 1771 - 1830
President Polk’s Surgery


When Polk was a
teenager, he suffered
from urolithiasis
McDowell performed
a urolithotomy with a
gorget through his
prostate and bladder,
extracting the stones
19th Century
First transverse laparotomy
Johannes Pfannenstiel 1862-1909
ABDOMINAL WOUND
DEHISCENCE AFTER CSECTION
(vertical vs. Pfannenstiel)
No.
Dehiscence
Rate
Vertical
Transverse
1635
540
48
2
2.94 %
0.37 %
Mowat J, Bonnar J. Br Med J 1971; 2 (756): 256-257
20th Century Laparoscopy
Dr George
Kelling
Dr Raoul
Palmer
Dr Victor Gomel
Dr Kurt Semm
Beginning of Videosurgery
Nezhat et al, Advanced Operative Laparoscopy Principle & Techniques
McGraw Hill 1995
Advantages of Video
Laparoscopy
Video Laparoscopy
Advantages


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


Improved cosmesis
Quicker recovery time
Less blood loss
Shorter hospitalization
Decreased need for
analgesics
Less adhesions
Better results
Videolaparoscopy
Introduced to Literature
Nezhat C, Crowgey S, Garrison C. Surgical
treatment of endometriosis via laser
laparoscopy.
Fertil Steril 1985 as an abstract
1986 as a publication;25(6):778-83.
Even advanced (stage IV) endometriosis
was treated by this technique.
First Total Laparoscopic
Radical Hysterectomy with
Lymphadenectomy was
performed in June 1989
Nezhat CR, Burrell MO, Nezhat FR,
Benigno BB, Welander CE
February 12, 1990
"Wherever in the body a cavity exists or cavity
can be created, operative laparoscopy is
indicated and probably preferable. The limiting
factors are: skill and experience of the surgeon
and the availability of proper instrumentation”
Camran Nezhat
Journal of Gynecologic Surgery 1992
Fertility and Sterility 1986
Looking to the Future
One of the first cameras used for video-laparoscopic
surgery by Camran Nezhat, MD
Looking to the Future
Advantages of VideoEndoscopy
Smaller incisions
 Shorter hospital stay
 Lower blood loss
 Less need for analgesics
 Better Visualization
 More rapid recovery
 Less Adhesion formation
 Shorter interval to Chemo
and Radiationtherapy
(if indicated)

Advantages of VideoEndoscopy
Smaller incisions
 Shorter hospital stay
 Lower blood loss
 Less need for analgesics
 Better Visualization
 More rapid recovery
 Less Adhesion formation
 Shorter interval to Chemo
and Radiationtherapy
(if indicated)

Ovarian Cancer
Right Diaphragm
Metastases
Disadvantages of
VideoLaparoscopy

Long learning curve



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Two-dimensional field,
limited depth perception and
view
Limited dexterity
Counterintuitive motion
Ergonomic difficulty

8-12% of surgeons report pain
or numbness with laparoscopy
Improvements
Instrumentation
 Blood vessels sealing devices with cutting
capabilities
 Staplers
 Articulating tips
 3-dimensional imaging
 Robotics
 Simulators

Robotics

Computer enhanced telesurgery
Robot: The Console

The console has 3 dimensional
viewing

Intuitive motions

Improved ergonomics


Pedals control camera and
electrosurgical function
Motion scaling: reducing tremor
Tremor Filtration
Laparoscopic
Robotic
Dexterity and the Robot

7 degrees of motion
compared with the
traditional 4 with
laparoscopy
Robot in General Gynecology
Nezhat, C et al. feasability study: 15 patients undergoing
gynecologic surgeries using both laparoscopy and roboticassisted laparoscopic surgery
 Assembly time to switch from laparoscopy to robotic assisted
surgery was 18.9 minutes, disassembly time was 2.1 minutes
Conclusion:
 Advantages: 3 dimensional field, greater surgical precision,
decreased fatigue and tension tremor, and added wrist motion
for improved dexterity, cases of suturing
 Disadvantages: cost, added operating time for assembly and
disassembly

Nezhat,C et al ASRM 2005
Conclusions


Robotic procedures are useful teaching tools
and facilitators for transition from open
abdominal to laparoscopic approach
Use of the robot may bridge the gap between
laparotomy and laparoscopy, which is limited
by a long learning curve
Indications
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
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Myomectomy
Total Hysterectomy
Sacrocolpopexy
Sever Endometriosis and Adhesions
Tubal Reanastomosis
Difficult Adenaxal Masses
Indications

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Staging for Endometrial Cancer(Hysterectomy
and Pelvic and Para-Aortic Lympadenectomy)
Radical Hysterectomy
Radical Trachelectomy
Staging for Ovarian cancer
Limited Debulking primary and recurrent
Ovarian cancer
First Total Laparoscopic
Radical Hysterectomy with
Lymphadenectomy was
performed in June 1989
Nezhat CR, Burrell MO, Nezhat FR,
Benigno BB, Welander CE
Case Report



Patient: 39 yo, Para 3
Diagnosis: . Stage IA2 SCC CX
Procedure: Laparoscopic radical hysterectomy with
paraaortic and pelvic node dissection
–Instruments
Bipolar
–Operative
7 hours
time
–EBL
Cautery
CO2 laser
30 cc
–Total
paraaortic LNs
5
–Total
pelvic LNs
14
–Hospital
stay
2 days
Evolution of Total Laparoscopic
Radical Hysterectomy

Over 900 cases have been reported to date

No prospective randomized trials available

Retrospective analysis shows comparable to
laparotomy progression free and overall survival
in cancer patients
Robotic Radical Hysterectomy: Review
Comparisons of Robotic Radical Hysterectomies
Author
N
Sert and Abeler
Nezhat et al.
Kim et al .
Magrina et al.
Boggess et al.
Fanning et al.
Ko et al.
Persson et al. *
Estape et al.
Lowe et al.
Maggioni et al.
7
13
10
27
51
20
16
80
32
42
40
Total
338
OR Time LOS
(mins)
(days)
Nodes
(Avg)
EBL
Recurrence
(mL)
(mos)____
241
323
207
190
211
390
290
355
135
215
272
4
2.7
7.9
1.7
1
1
1.7
NR
2.6
1
3.7
13
25
28
26
34
18
16
26
32
25
20
71
157
355
133
96
300
82
150
180
50
78
257
2.7
24
150
0% (14)
0% (24)
0% (9)
0% (31)
NR
10% (24)
NR
4%
3%
NR
8%
Robotic Radical Hysterectomy
Robotic Assisted Gynecological
Surgery: Technical aspects


Semi-lithotomy position
Four trocars are used:
12-mm transumbilical optical trocar
 two 8-mm robotic trocars,
 10-mm assistant trocar.

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Trendelenburg to a maximum of 30 degrees
Uterine manipulator
Port Placement
Results
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Operating Time
Blood Lost
Hospital Stay
Complications
Recurrence
Quality of life( Recovery time and
Post operative pain)
Cost
Considerations

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Tissue margin and radicality
Complications
Recurrence
Survival
Quality of life
Cost
New technologies for reproductive
medicine:laparoscopy,endoscopy,r
obotic surgery and gynecology. A
review of the literature
J.E. CHO,A Shamshirsaz,C.Nezhat,C.Nezhat,F.Nezhat
Minerva gynecologica,2010
Robotic Radical Hysterectomy Versus Total laparoscopic
Radical Hysterectomy With Pelvic Lymphadenectomy for
Treatment of Early Cervical Cancer
Nezhat F et al,2008
To compare intraoperative,pathologic and
postoperative outcomes of robotic radical
hysterectomy (RRH) to total laparoscopic radical
hysterectomy (TLRH) in patients with early
stage cervical carcinoma
Farr R. Nezhat,, M. Shoma Datta, Connie Liu, Linus Chuang,,Konstantin Zakashansky,. Robotic Radical Hysterectomy Versus total laparoscopic Radical Hysterectomy
With Pelvic Lymphadenectomy for Treatment of Early Cervical Cancer. JSLS (2008)12:227–237
Methods
Prospective analyses
Cases of TLRH or RRH
with pelvic
lymphadenectomy performed
for treatment of early cervical
cancer between 2000 and
2008
No differences
between groups for
age, tumor histology,
stage, lymphovascular
space involvement or
nodal status
30 TLRH + pelvic
lymphadenectomy
for cervical cancer
13 RRH and pelvic
lymphadenectomy
for cervical cancer
Robotic Radical Hysterectomy Versus Radical Hysterectomy
With Pelvic Lymphadenectomy for Treatment of Early
Cervical Cancer
Nezhat F et al,2008
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
No significant difference in major intra and post
operative complications
All patients in both groups are alive and free of
disease at the time of last follow up(mean time
12 months for RRH and 29 months for TLRH)
Robotic Radical Hysterectomy Versus Radical Hysterectomy
With Pelvic Lymphadenectomy for Treatment of Early
Cervical Cancer
Nezhat F et al,2008
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

Conclusion.
With respect to operative time, blood
loss, hospital stay, and oncological outcome
RRH=TLRH
Robotic Radical Hysterectomy Versus Radical Hysterectomy
With Pelvic Lymphadenectomy for Treatment of Early
Cervical Cancer
Nezhat F et al,2008

Advantages of Robotic approach:
Better magnification
 Dexterity
 Flexibility
 Significant reduction in surgeon’s fatigue

152 patients meeting criteria of inclusion
110 patients consented
Exclusion of:
- 9 patients converted to minilaparotomy
- 10 patients who withdrew from the study
Total enrolled N =91
Laparoscopic n=52
Robotic n=39
2-week follow-up n=51
6-week follow-up n=43
2-week follow-up n=37
6-week follow-up n=25
Figure 1: Flow of enrolled subjects through the study
Table 1: Demographic Data
Laparoscopic
n=52
Robotic
n=39
P
Age , years, mean (SD)
46.08 (13.58)
52.69 (12.31)
.019
BMI, Kg/m2, mean (SD)
26.03 (6.07)
32.01 (8.87)
<.001
Race, n (%)
Caucasian
AA
Hispanic
Asian
Indian
27 (52%)
9 (17%)
11 (21%)
4 (8%)
1 (2%)
14 (36%)
14 (36%)
9 (23%)
2 (5%)
0 (0%)
.239
Prior abdomino-pelvic surgeries, n
(%)
41 (79%)
26 (67%)
.192
Psychiatric history, n (%)
13 (25%)
8 (21%)
.662
Preoperative narcotic use, n (%)
3 (6%)
2 (5%)
1.000
Drug use, n (%)
2 (4%)
1 (3%)
1.000
Data shown as mean (SD), median (range)or n (%)
Table 2: Surgical Data
Laparoscopy
n= 52
Robotic
n= 39
P
Operating time, min, mean (SD)
156.10(75.84)
297.31(83.75)
<.001
Blood loss, mL, mean (SD)
100.67 (81.56)
203.08 (384.61)
.065
Complex procedures, n (%)
28 (54%)
23 (59%)
.626
Concurrent hysterectomy, n (%)
22 (42%)
25 (64%)
.040
Cumulative incision length, cm, mean
(SD)
2.40 (0.76)
3.96 (0.54)
<.001
IOP complications, n (%)¹
0 (0%)
3 (8%)
.075
Postoperative complications, n (%)
Minor²
Major³
8 (15%)
3 (6%)
6 (15%)
4 (10%)
1.000
.456
2 [1,5]
3 [1, 26]
<.001
Length of hospital stay in days,
median [range]
Data shown as mean (SD), median [range] or n (%)
Figure 2: Postoperative mean NRS pain scores over time
There is a trend for a higher level of postoperative pain in robotic patients compared to laparoscopy patients,
but the difference is not statistically significant p=0.4991
Error bars indicate standard error
Postoperative Narcotic Requirements
Figure 3: Postoperative narcotic doses in MSE
There is no significant difference over time between laparoscopic and robotic
procedures, p=0.393
Table 3: Pain and Recovery Time Outcomes
Peak pain scores, mean (SD)
Days to being off narcotics,
median [range]
Days to return to baseline activities,
median [range]
Laparoscopi
c
n= 52
Robotic
n= 39
P
6.75 (2.37)
7.46 (1.64)
.480
4 [0,15]
4.5 [0, 49]
.336
13 [3, 42]
21 [3, 56]
.021
Data shown as mean (SD) or n (%) or median [range]
Robotic approach confers the same amount of post-operative pain
over time and need for analgesia and sheds a doubt on the
presumption that robotic surgery decreases postoperative pain when
compared with laparoscopy.
Robotically assisted laparoscopy has significantly longer operating
time, hospital stay, and return to baseline activities compared with
conventional .
In the hands of an experience laparoscopic surgeon, roboticallyassisted laparoscopy does not seem to offer any advantages to
conventional laparoscopy in terms of postoperative pain and
recovery.
El Hachem et al, Obstet Gynecol 2013;121:547
Cost
da Vinci® HD S Surgical
System
da Vinci® Si Surgical
System
April 2009:
da Vinci® Si System
released (dual console)
da Vinci® Standard Surgical
System
January 2006:
da Vinci® HD S System released
April 2005:FDA Clears
da Vinci® System for
Gynecologic Procedures
July 2000: FDA Clears da Vinci® System for Laparoscopic Surgery
Robotic Timeline
Intuitive Surgical Simulator
nd
2 Console
da Vinci Surgical System U.S.
®
Installed Base 1999 – 2011
Alaska
Hawaii
1999
2000
2001
2002
2003
2004
2005
2006
2007
Puerto Rico
2008
2009
2010
2011
Complications
Loss of Heptic
Tunnel View
Robotic-Assisted Laparoscopic Transection and Repair of an Obturator
Nerve During Pelvic Lymphadenectomy for Endometrial Cancer
F Nezhat et al,2012
Case report

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Reapproximated left obturator nerve with 4.0
polyglactin suture
76-year-old woman with stage IA
endometrial adenocarcinoma
sustained a left obturator nerve
transection during pelvic
lymphadenectomy , was recognized
immediately
Robotic-assisted laparoscopic
repair was performed successfully
No residual neuropathy 6 months
postoperatively
Nezhat F, Chang JS,Acholonu U,Vetere P.Robotic-Assisted Laparoscopic Transection nd Repair of an Obturator Nerve During Pelvic Lymphadenectomy for
Endometrial Cancer. Obstet Gynecol 2012;119:462–4
ElectrocauteryAssociated
Injury During
Robotic-Assisted
Surgery
Electrocautery-AssociatedVascular Injury During RoboticAssisted Surgery
Cormier B,Nezhat F,Sternchos J,Sonada Y,Leito M,2012
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3 vascular injuries during robotic pelvic lymphadenectomy reported in 2012
Case1:
Injury to external iliac vein while using cutting mode with scissors ,by a spark through the intact
protective sheath of the monopolar scissors onto an adjacent metallic suction irrigator that was
retracting the external iliac vein;required laparotomy for repair
Case 2:
Injury to external iliac artery by accidental activation of monopolar coagulation scissor rather
then bipolar forceps ;repaired robotically.

Case 3:
Injury to the right external iliac artery caused by a spark spreading through the scissors insulating
plastic sheath while applying monopolar coagulation type current;repaired robotically

In all cases the scissor insulating sheet was intact

All patient post op follow up was uneventfull

Cormier B,Nezhat F,Sternchos J,Sonada Y,Leito M. Electrocautery-AssociatedVascular Injury DuringRobotic-Assisted Surgery.Obst & gyn:12;2,2012
Risk factors increasing monopolar
injury





Defects in insulation
Direct coupling with another
Instrument
Probe activation at a distance
from tissue ( “open circuit”)
Overheating of the active electrode tip
(when covered with dried blood or
debris)
The use of coagulation-type current to
achieve the same effect achievable with
cutting current
Insulation sheet defect
Future
Beginning of Videosurgery
Nezhat et al, Advanced Operative Laparoscopy Principle & Techniques
McGraw Hill 1995
Robotics

Computer-Enhanced Telesurgery
Improvements
Instrumentation
 Blood vessels sealing devices with cutting
capabilities
 Staplers
 Articulating tips
 3-dimensional imaging
 Robotics
 Simulators

Mimic Simulator
Mimic Simulator
The Future of Surgery
Peoria
Frankfurt
Istanbul
Boston
Hopkins
Tokyo
Mayo
Paris
New York
Boise
Little Rock
CCF
Fresno
San
Francisco
Barcelona
6
th
annual seminar on
Minimally Invasive Gynecologic Surgery
with hands-on workshop on laparoscopic suturing and knot-tying
HIGHLIGHTS
BEST Comprehensive Overview on
Prevention and Management of
Complications
Save the Date
DECEMBER
11 12
• Laparoscopic & Robotic Hysterectomy: Step-by-Step
• Enhance Performance and Achieve Proficiency in Suturing and
Knot-Tying Techniques
• Improve Surgical Efficiency, Patient Outcomes and Satisfaction,
Decrease Risks of Complications, and Cut Costs
• Safe n’ Simple: Create Bladder Flap, Remove Cervix, Repair
Bladder, Bowel & Ureter Injury
• Advances in Gynecologic Surgery: Technology and Instruments in
Robotic Surgery
• Open Forum Discussions with Experts: Tips & Tricks, Pearls &
Pitfalls of Suturing
• Live Surgery Telecasts and Video Sessions
• da Vinci Robot Test Drive & Mimic Simulation Training
General Chair:
Scientific Program Co-Chairs:
The Roosevelt Hotel New York, New York
For more information, please visit:
Farr R. Nezhat, MD
Camran Nezhat, MD
Ceana Nezhat, MD
http://nezhat.org/camran/6th-Annual-seminar-on-Minimally-Invasive-Gynecologic-Surgery.php