Professional Documents
Culture Documents
Alaa El-Ghobashy
Thomas Ind
Jan Persson
Javier F. Magrina
Editors
123
Textbook of Gynecologic Robotic Surgery
Alaa El-Ghobashy • Thomas Ind
Jan Persson • Javier F. Magrina
Editors
Textbook of Gynecologic
Robotic Surgery
Editors
Alaa El-Ghobashy Thomas Ind
Department of Gynaecological Oncology Department of Gynaecological Oncology
Royal Wolverhampton Hospitals NHS Trust Royal Marsden and St George’s Hospitals
Wolverhampton, West Midlands London
UK UK
Surgical practice has undergone significant evolution over the past few decades from open
access through to laparoscopy approach to most recently robotic techniques. Since the first
description of robotic hysterectomy in 2005, the technique has gained popularity and its indi-
cations have broadened. Therefore, it was timely to offer a comprehensive review of the pres-
ent status of robotic surgery in gynecology using the Da Vinci system.
This book is not only a compilation of the knowledge and experiences of the world renowned
robotic surgeons, but it has also incorporated the recent advances and updates in gynecological
surgery.
The textbook is aimed at practicing gynecologists, urogynecologists, and gynecological
oncologists and is designed to provide a detailed guide to common robotic gynecologic proce-
dures for the purpose of helping novice surgeons in their transition to robotic surgery and
seasoned robotic surgeons to refine their surgical technique and expand their repertoire of
robotic procedures.
The descriptive, step-by-step, text is complemented by figures, intraoperative photographs,
and videos detailing the nuances of each procedure. Emphasis is placed on the operative setup,
instrument and equipment needs, and surgical techniques for both the primary surgeon and the
operative assistant.
This edition will provide unique insights into robotic gynecologic surgery and reduce the
learning curve of accomplishing these increasingly popular procedures.
We would like to express our deepest thanks and gratitude to all the contributors, who so
graciously have given their time and effort, and without whom this book would not have been
born. There are many more people who have made this book possible specially Springer who
supported this project since its inception. To all, thank you for the advice and help and for
making this book a reality.
Alaa El-Ghobashy
Javier Magrina
vii
Contents
ix
x Contents
Index����������������������������������������������������������������������������������������������������������������������������������� 249
Contributors
xi
xii Contributors
San Soo Hoo Department of Gynaecological Oncology, The Royal Wolverhampton Hospitals
NHS Trust, West Midlands, UK
Delphine Hudry Department of Gynecologic Oncology, Cancer Center Oscar Lambret,
Lille Cedex, France
Elizabeth Y. Kang Center of Hope, University of Nevada School of Medicine, Reno, NV,
USA
John T. Kidwell Department of Surgery, Mayo Clinic College of Medicine, Phoenix, AZ,
USA
Sami Gokhan Kilic, M.D., F.A.C.O.G., F.A.C.S. Division of Minimally Invasive Gynecology
and Research, Department of Obstetrics and Gynecology, The University of Texas Medical
Branch, Galveston, TX, USA
Rainer Kimmig Department of Gynaecology and Obstetrics, West German Cancer Center,
University Hospital Essen, Essen, Germany
M. Faruk Kose Faculty of Medicine, Department of Obstetrics and Gynecology, Acıbadem
Mehmet Ali Aydınlar University, Istanbul, Turkey
Mertihan Kurdoglu, M.D. Division of Minimally Invasive Gynecology and Research,
Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston,
TX, USA
Sandra Madeuke Laveaux, M.D. Division of Gynecologic Specialty Surgery, Department of
OB/GYN, Columbia University Medical Center/New York-Presbyterian Hospital,
New York, NY, USA
Eric Leblanc Department of Gynecologic Oncology, Cancer Center Oscar Lambret,
Lille Cedex, France
Mario M. Leitao Jr, M.D. Memorial Sloan Kettering Cancer Center, New York, NY, USA
Anjie Li, M.D. Center for Special Minimally Invasive and Robotic Surgery,
Palo Alto, CA, USA
Stanford University Medical Center, Stanford, CA, USA
Peter C. Lim, M.D., F.A.C.O.G., F.A.C.S. Center of Hope, University of Nevada School of
Medicine, Reno, NV, USA
Celine Lönnerfors, M.D., Ph.D. Department of Obstetrics and Gynecology, Skane University
Hospital and Lund University, Lund, Sweden
Javier F. Magrina, M.D. Department of Medical and Surgical Gynecology, Mayo Clinic,
Phoenix, AZ, USA
Paul M. Magtibay, M.D. Department of Medical and Surgical Gynecology, Mayo Clinic,
Phoenix, AZ, USA
Paul M. Magtibay III, M.S. Department of Administration, Mayo Clinic, Phoenix, AZ, USA
Nitin Mishra, M.D. Department of Surgery, Mayo Clinic College of Medicine, Phoenix,
AZ, USA
Esther Moss, M.R.C.O.G., M.Sc., Ph.D. Department of Gynaecological Oncology,
University Hospitals of Leicester, Leicester, UK
Damian Murphy Department of Gynaecological Oncology, The Royal Wolverhampton
Hospitals NHS Trust, West Midlands, UK
Contributors xiii
Surgical Developments
Fig. 1.3 St Bartholomews surgeons, London, in the 1900s. Archived Fig. 1.4 St Bartholomews surgeons in the 1940s. Archived photo from
photo from Medical Photography Department at St Bartholomews Medical Photography Department at St Bartholomews Hospital (from
Hospital (from Professor John Shepherd’s personal collection) Professor John Shepherd’s personal collection)
Fig. 1.7 Sentinel lymph node detection external iliac artery using
indocyanine green and Firefly filter (archive MA Nobbenhuis)
Fig. 1.6 Double console robotic surgery. The Royal Marsden Hospital The Future
(permission Press Office The Royal Marsden Hospital London)
The future is already here; we do not need to go back to it.
Smaller robots with artificial intelligence are being devel-
time the surgeon’s brain activity can be measured to assess oped with almost frightening possibilities for their use.
fatigue and even stress levels. The impact on patient safety is Nanotechnology will supersede today’s machinery. Research
quite clear. Newer models of robot equipment have dual con- will continue at an accelerating pace, and the place of new
trols which will allow tutoring and co-surgical techniques to techniques and technologies will need to be carefully evalu-
be performed (Fig. 1.6). ated in a critical way as they become available. This will be
at an inevitable cost, but this must be offset by an improve-
ment in efficiency and success of treatments available. A
reduction of morbidity and inevitable sequelae of treatment
Added Tools and Technology must be shown to be achieved with a reduction in hospitali-
sation and time away from home and work. Advances in
With further developments in imaging especially using MRI, medical care need to be supported and encouraged but their
three-dimensional images may be superimposed into the correct place carefully assessed. To quote Martin Luther
optics at the console of the robot to enable tumours and other King “Nothing in all the world is more dangerous than sin-
anatomical structures to be visualised prior to a surgical proce- cere ignorance and conscientious stupidity”. We just must
dure being carried out. This will be especially useful in cancer accept anything is possible although not always practical.
surgery for identifying tumours as well as other anatomical
features, such as with the development and incorporation of
fluorescent imaging identifying sentinel lymph nodes References
(Fig. 1.7).
Similarly, with developments in immunocytochemistry 1. Pasek A. Renaissance robotics: Leonardo da Vinci’s lost knight and
enlivened materiality. Grad J Vis Mater Cult. 2014;7:1–25.
and microscopy in histology, in vivo identification of pathol- 2. Descartes R.. Discours de la Méthode. Leiden; 1637.
ogy becomes a realistic possibility allowing intelligent 3. Asimov I. The complete robot. Garden City: Doubleday; 1982.
knives to excise malignant tissue with greater dexterity than 4. Turing A. Computing machinery and intelligence. Mind.
the surgeons’ hand. With developments with haptic feedback, 1950;LIX(236):433–60.
5. Von Neumann J. The general and logical theory of automata. In:
this will facilitate precision microsurgery. An alternative is Jefferies LA, editor. Cerebral mechanisms in behaviour—the Hixon
the use of robotic endoscope holders providing an alternative symposium. New York: Wiley; 1951. p. 1–31.
to telesurgery systems by offering a third arm to the surgeon 6. Adler John R Jr, et al. The Cyberknife: a frameless robotic system
during an operation. for radiosurgery. Stereotact Funct Neurosurg. 1997;69:124–8.
Training and Proctoring in Robotic
Gynaecological Surgery 2
René H.M. Verheijen
Introduction equally been validated. In this way trainees become well pre-
pared for surgery on life or cadaver models, which are more
Although laparoscopic surgery had been introduced in the late suitable for procedural training. Finally, performance during
1960s, it lasted until this century for regulatory authorities and real-life operations can now equally objectively be evaluated
professionals to realize that medical training following a mas- using validated assessment tools, such as objective struc-
ter-apprentice principle is insufficient to provide safe and tured assessment of technical skills (OSATS) [3].
adequate mastering and monitoring of competence and profi- Although curricula and criteria for training in conventional
ciency [1]. As a consequence, also the introduction of robot- laparoscopic surgery have now been well established in many
assisted surgery was viewed with scepticism and criticism on parts of Europe, this is as yet not the case in robot-assisted
the way surgeons were trained [2]. This has rightfully led to a surgery. No accredited training programmes or fellowships
call for (a) more structured, (b) more validated and (c) more exist that might be used to certify specialists to perform robot-
virtual training in specifically a field-like laparoscopic surgery assisted surgery. Nevertheless, already in 2007 the Society of
where more and more technology is being introduced. American Gastrointestinal and Endoscopic Surgeons (SAGES)
It has gradually been acknowledged that a long learning together with the Minimal Invasive Robotic Association
curve as well as the use of technical equipment put patients (MIRA) drafted a position paper with formal guidelines for
at risks during the apprenticeship. It was also recognized that training and credentialing [4]. The European Board and
these risks could easily be avoided by preparation through College of Obstetricians and Gynaecologists (EBCOG) has
e-learning, followed by practicing first in dry and wet labora- also issued ‘Robotic Surgery Standards’ as part of their
tory conditions, using virtual or physical models, and as a ‘Gynaecology Standards’ [5]. Although this latter document
next step using animal or cadaver models to prepare for sur- only describes training in broad terms, it does clearly define
gery in real patients. the learning curve of surgeons that should be ‘specifically
Curricula have been developed that have been incorpo- trained’ for robot-assisted procedures, including sufficient
rated into specialist training for most of the surgical special- systematic and validated system and procedural (didactic and
ties. Also, some professional societies have set criteria within skills) training, as well as proctor-assisted procedures.
the specialty training programmes, which need to be met for Not surprisingly, urologists have been first to propose a
a trainee to be allowed to start operating on a real patient as curriculum for proper training. Although several groups (e.g.
well as for established specialists continuing to do so. Florida Hospital Nicholson Center and Roswell Cancer
Both the training methods as well as methods of assess- Center) have developed surgical curricula, the curriculum
ment must be validated in order to objectively and accurately developed by the EAU Robotic Urology Section (ERUS) is
measure and monitor progress. E-learning modules have the only one that encompasses the whole learning path, from
been developed to prepare for hands-on training. Virtual technical instruction to patient procedures [6].
training modules have been developed for technical and pro- From their experience gynaecologists could learn that
cedural training. Box training for technical instruction as modular training of procedures is more efficient than non-
well as development of, e.g., eye-hand co-ordination has structured training [7]. This seems a quite obvious conclu-
sion, but in practice structured training is badly implemented.
The Society of European Robotic Gynaecological Surgery
R.H.M. Verheijen (SERGS) is developing guidelines and a gynaecological cur-
Professor Emeritus of Gynaecological Oncology, Formerly
riculum for safe introduction in robot-assisted gynaecologi-
University Medical Center Utrecht, Utrecht, Netherlands
e-mail: rene.h.m.verheijen@gmail.com cal surgery.
Structured Assessment
Fig. 2.2 CanMEDS roles describing a truly competent physician [15] If anything has changed in surgical training, it is surely the
systematic and structured way learning goals are being
tively, and the procedure is done more safely than in a case defined and assessed. The ‘see one, do one, teach one’ prin-
where the whole procedure is performed at once. ciple has long since been abandoned and assessment of sur-
gical performance is no longer a matter of a short observation
by a single tutor resulting in a brief and undocumented ver-
Competency Based Assessment dict. A regular, non-judgemental and objective evaluation of
progress is essential for effective learning. Also, or particu-
After the successful introduction of competence-based train- larly, training in robot-assisted surgery is not a matter of trial
ing in general gynaecology and of structural assessment and error.
[14], these should also be the basis of advanced training in Modular set-up of the curriculum allows safe introduction
robot-assisted surgery. This provides a framework for train- of new skills and at the same time guarantees adequate prep-
ees to assess regularly and systematically their progress. aration for each next step in the training. This should be
Thus necessary adjustments in the training and focus on spe- monitored by assessments after each of the modules or parts
cific needs can be made early on in the training. thereof. This may be built in an e-learning module, but
The Royal College of Physicians and Surgeons of Canada should be undertaken by a tutor in other parts. Following a
were the first to recognize and use seven roles of a physician, structured assessment avoids forgetting important issues to
each requiring specific competencies: professional, commu- assess and also forces the tutor to systematically review the
nicator, collaborator, leader, health advocate, scholar and various skills and competencies that need to be evaluated.
medical expert as the central role [15] (Fig. 2.2). The perfor- Numerical scoring as in Global Evaluative Assessment of
mance in each of these roles determines the level of training Robotic Skills (GEARS) and OSATS facilitates a quick eval-
in any field of medicine. Such evaluation of the various roles uation, which allows also quick reference to earlier perfor-
and the defined competencies is now an integrated part of mance to measure progress. Various instruments have been
assessment in general training in obstetrics and gynaecology, developed and validated (Table 2.2). Such brief and stan-
as reflected by compulsory national programmes such as in dardized assessment should be followed by the identification
the United Kingdom and the Netherlands. It is important to of specific positive elements (‘what went well’) and issues
realize that even in a technical field as robot-assisted surgery, that might need some more attention (‘what can be
these roles and competencies are essential for the future improved’). In this way the trainee is stimulated to set new
expert to develop and to assess. Robot-assisted surgery, e.g. goals for the next phase of the training.
requires good co-operation between the surgeon and the bed- GEARS is the only instrument specifically designed and
side team, including scrub nurses, surgical assistants and validated for robot-assisted surgery [16, 17]. In order to inte-
anaesthesiologists. grate also non-technical competencies, a brief instrument, Non-
8 R.H.M. Verheijen
strategies may be needed employed, such as the use of posi- clearance of CO2, but studies suggesting this link have been
tive end expiratory pressure (PEEP). In addition intravenous underpowered due to the small numbers involved.
fluid should be restricted, at least until the patient is levelled Post-operative pain relief is usually achieved through a
off near the end of surgery. multimodal analgesia technique. Intravenous or oral opiates,
paracetamol and non-steroidal anti-inflammatory drugs are
commonly used at our institution. The use of transverses
Ocular abdominis plane (TAP) bocks and wound infiltration with
local anaesthesia has also been described. Neuraxial block-
Raised intraocular pressure and corneal abrasions are more ade is generally not required for the post-operative pain relief
likely, again due to patient position, and the potential reflux and thus is rarely used.
of gastric acid. Eyes should be taped shut and padded for Nausea and vomiting may persist in the post-operative,
extra precaution. principally due to ileus, and anti-emetic medication should
be given.
Haematological
The Future
Pelvic surgery is associated with deep venous thrombosis
(DVT), and in lithotomy position this risk is even greater as Minimally invasive robotic surgery has a future potential in
the return of blood from the legs is impaired. Another com- providing cancer treatment to people who are unable to with-
plication of lithotomy position for a prolonged period is the stand the stress of a major laparotomy. As with other laparo-
potential for rhabdomyolysis [9]. scopic techniques, those that undergo surgery have an
improved functional outcome, reduced length of hospital
stay and faster recovery.
Musculoskeletal Due to the extreme positions involved and the effect on a
patient’s physiology, innovative monitoring and safety
There is a risk of brachial plexus nerve injury with shoulder devices will no doubt be developed to reduce risks of injury
bolsters in place, but this needs to be balanced with the risk and aid anaesthetists in controlling physiological parameters.
of patient sliding off the table in such a steep position. Also with the advent of remote site access (so that the opera-
Normally shoulder bolsters are positioned 4–5 cm away tor might be in a different city), communication aids between
from the patient’s shoulders when supine—once team members will also be vital to the continued success of
Trendelenburg position is established the anaesthetist needs this type of surgery.
to check the bolsters are not exerting traction onto the
shoulders.
Another site for nerve injury is the common peroneal References
nerve, that can easily been compromised by the leg supports
used for lithotomy position. 1. Chang CH, Lee HK, Nam SH. The displacement of the tracheal tube
Monitoring of neuromuscular function must be in place as during robot-assisted radical prostatectomy. Eur J Anaesthesiol.
any coughing during surgery could be catastrophic once the 2010;27(5):478–80.
2. Danic MJ, Chow M, Gayload A, Bhandari A, Menon M, Brown
robot is engaged. M. Anesthesia consideration for robotic-assisted laparoscopic pros-
tatectomy: a review of 1500 cases. J Robot Surg. 2007;1:119–23.
3. Suh MK, Seong KW, Jung SH, Kim SS. The effect of pneumoperi-
Post-operative Management toneum and Trendelenburg position on respiratory mechanics dur-
ing pelviscopic surgery. Korean J Anesthesiol. 2010;59(5):329–34.
Epub 2010 Nov 25.
Patients should be recovered by appropriately trained staff in 4. Murdock CM, Wolff AJ, Van Geem T. Risk factors for hypercarbia,
a suitable environment. Those deemed high risk owing to subcutaneous emphysema, pneumothorax, and pneumomediasti-
their comorbidities or a turbulent perioperative phase should num during laparoscopy. Obstet Gynecol. 2000;95(5):704–9.
5. Lestar M, Gunnarsson L, Lagerstrand L, Wiklund P, Odeberg-
be managed in a high dependency environment. Wernerman S. Hemodynamic perturbations during robot-assisted
The prolonged steep Trendelenburg position can result in laparoscopic radical prostatectomy in 45° Trendelenburg posi-
complications in the recovery period that must be antici- tion. Anesth Analg. 2011;113(5):1069–75. DOI 10.1213/
pated. Laryngeal oedema resulting in stridor and airway ANE.0b013e3182075d1f. Epub 2011 Jan 13.
6. Falabella A, Moore-Jeffries E, Sullivan MJ, Nelson R, Lew
obstruction can occur, necessitating re-intubation. Post- M. Cardiac function during steep Trendelenburg position and CO2
operative confusion and delirium had also been reported, pneumoperitoneum for robotic-assisted prostatectomy: a trans-
presumably secondary to cerebral oedema and inadequate oesophageal Doppler probe study. Int J Med Robot. 2007;3:312–5.
12 S. White et al.
7. Meininger D, Westphal K, Bremerich DH, Runkel H, Probst M, 9. Biswas S, Gnanasekaran I, Ivatury RR, Simon R, Patel
Zwissler B, Byhahn C. Effects of posture and prolonged pneumo- AN. Exaggerated lithotomy position-related rhabdomyolysis. Am
peritoneum on hemodynamic parameters during laparoscopy. World Surg. 1997;63(4):361–4.
J Surg. 2008;32(7):1400–5. DOI 10.1007/s00268-007-9424-5. 10. Neudecker J, Sauerland S, Neugebauer E, Bergamaschi R, Bonjer
8. Kikuno N, Urakami S, Shigeno K, Kishi H, Shiina H, Igawa HJ, Cuschieri A, et al. The European Association for Endoscopic
M. Traumatic rhabdomyolysis resulting from continuous compres- Surgery clinical practice guideline on pneumoperitoneum for lapa-
sion in the exaggerated lithotomy position for radical perineal pros- roscopic surgery. Surg Endosc. 2002;16:1121–43.
tatectomy. Int J Urol. 2002;9(9):521–4.
Robotic Machine and Instruments
4
Alaa El-Ghobashy and Damian Murphy
Surgeon Console
Patient Cart
Language: English
Personified:
OR
BY
MR. STOPS.
LONDON:
JOHN HARRIS,
CORNER OF ST. PAUL’S CHURCH-YARD.
LONDON:
PRINTED BY S. AND R. BENTLEY, DORSET STREET.
ROBERT’S first interview with MR.
STOPS.