Roboti      

ic myomeectomy -  

tips & triicks 

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Technology Update

Robotic myomectomy e tips & tricks

Rooma Sinha a,*, Madhumati Sanjay b, B. Rupa c, Samita Kumari d

a Senior Consultant, Department of Minimally Invasive Gynecology, Apollo Health City, Hyderabad, Indiab Consultant, Department of Minimally Invasive Gynecology, Apollo Health City, Hyderabad, Indiac Senior Registrar, Department of Minimally Invasive Gynecology, Apollo Health City, Hyderabad, Indiad Resident (DNB), Department of Obstetrics & Gynecology, Department of Minimally Invasive Gynecology,

Apollo Health City, Hyderabad, India

a r t i c l e i n f o

Article history:

Received 25 July 2014

Accepted 5 August 2014

Available online xxx

Keywords:

Robotic

Myomectomy

MRI

Hybrid technique

Barbed suture

* Corresponding author.E-mail addresses: drsanjaysinha@hotmai

Please cite this article in press as: Sinha R10.1016/j.apme.2014.08.003

http://dx.doi.org/10.1016/j.apme.2014.08.0030976-0016/Copyright © 2014, Indraprastha M

a b s t r a c t

Fibroid is a common problem in women of reproductive age group. Myomectomy remains

the gold standard method in treating fibroids where uterine conservation is desired. With

advent of minimally invasive techniques, laparoscopic myomectomy becomes the obvious

method of choice. However it is not a very popular surgery because of technical challenges

especially the need for extensive suturing. Introduction of robotic technology helps the

surgeon to follow open surgical steps and addresses the technical challenges of conven-

tional laparoscopic suturing and knot tying. Myomectomy is a suture-intensive surgery and

assistance with robotic arms makes suturing simple and easy. This article discusses some

of the tips and tricks of performing robotic myomectomy in the areas of pre operative

assessment & MRI, port placement & docking, hybrid procedure, dealing with associated

sub mucous fibroids and variations in suturing techniques. Pre operative MRI of the pelvis

is helps in identifying the number and location of all the fibroids. The primary port is

placed in the midline. The rest of the ports are placed 10 cms apart in an inverted “W”

fashion. Hybrid technique is a variation in robotic myomectomy where a conventional

laparoscopic enucleation of the myoma is followed by reconstruction with the da Vinci

robot. Assosciated submucous fibroids can be removed by hysteroscopy myomectomy,

however large type 2-sub mucous fibroid has been removed with robotic approach. Use of

unidirectional knotless barbed suture substantially facilitates closure of uterine defects

during minimally invasive myomectomy and may offer additional advantages such as

minimizing operative time.

Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

Fibroid is a common problem in women of reproductive age

group. Myomectomy remains an important option for fertility

& uterine preservation in young women. While uterine artery

embolization and MRI-guided focused ultrasound are also

methods that are becoming popular in managing fibroid

uterus, myomectomy remains the gold standard method.

l.com, drroomasinha@ho

, et al., Robotic myomec

edical Corporation Ltd. A

Myomectomy has being a part of medical management for

decades and we have long term data of good reproductive

outcome following it. With advent of minimally invasive

techniques, laparoscopic myomectomy becomes the obvious

method of choice. But the question remains e why still so

many open myomectomies are being performed all over the

tmail.com (R. Sinha).

tomy e tips & tricks, Apollo Medicine (2014), http://dx.doi.org/

ll rights reserved.

Fig. 1 e MRI T2 WEIGHTED IMAGE e sagittal image of

multiple fibroids.

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e52

world? There is no doubt that a laparoscopic approach ismore

advantageous than laparotomy, however laparoscopic sutur-

ing is more demanding. This can be overcome by robotic-

assisted laparoscopic myomectomy.1 A retrospective case

study from the Cleveland Clinic confirmed these findings

when investigators compared surgical outcomes between the

robot-assisted laparoscopic approach, standard laparoscopy,

and open myomectomy. In an assessment of 575 cases (393

open, 93 laparoscopic, and 89 robot-assisted laparoscopic),

they found the robot-assisted laparoscopic approach to be

associatedwith the removal of significantly largermyomas (as

compared to standard laparoscopy), as well as lower blood

loss and shorter hospitalization when compared to open

myomectomy.2

It is accepted beyond doubt that minimally invasive gy-

necological surgeries have distinct advantages for the patient

for its minimal access and comfort. However laparoscopic

myomectomy is a technically challenging surgery and good

outcomes are possible only by high volume surgeons who

have exceptional skills. The need for extensive suturing in

myomectomy is the main limitation in its wide spread

acceptance by surgeons. Post operative implications in a myo-

mectomy surgery is also due to the fact that poor closure of in-

cisions or excessive use of diathermy can lead to uterine

rupture in future pregnancies.3,4 Robotic surgery is a natural

progress in the field of minimally invasive surgery. As robotic

surgery allows surgeon to perform detailed surgery due to

magnified 3D vision and deep reach into the pelvis that a ro-

botic telescope can achieve. There fore a new technology of

robotic assistance is slowly gaining ground. The da Vinci has

EndoWrist technology with increased instrument range of

motion (7�) enabling the surgeon to mimic open surgical

techniques. Other advantages of robotic technology over

conventional laparoscopy are absence of tremor, superior in-

strument articulation, downscaling of movements, and com-

fort for the surgeon.5 The fact that robotic arms helps the

surgeon to follow open surgical steps, addresses the technical

challenges of conventional laparoscopic suturing and knot-

tying. But the robotic technology cannot just simplify the

challenges that leiomyoma's can pose, including enucleation

of large myomas and suturing. Although it has facilitated the

adoption of endoscopic myomectomy, the da Vinci system

requires an experienced gynecologic endoscopic surgeonwith

good knowledge of surgical anatomy. Compared with open

abdominal myomectomy, the robot-assisted laparoscopic

approach is associated with less blood loss, lower complica-

tion rates, and shorter hospitalization.6 Reproductive out-

comes in pregnancies and deliveries are similar to open

myomectomy. Pitter et al studied these outcomes, reporting

92 deliveries out of 107 patients studied with only 1 uterine

rupture.7 After robotic myomectomy successful term preg-

nancy has also been reported by Bocca et al., in 2007.8

Having being exposed to robotic technology for the last 2

years, today Robotic assisted myomectomy is one of our fa-

vorite surgeries. The reasons for this are that myomectomy is a

suture-intensive surgery and assistance with robotic arms makes

suturing simple and easy. Robotic myomectomy guarantees a pro-

cedure that is as effective as a classic open myomectomy. Robotic

assisted surgery is as safe and acceptable as a laparoscopic opera-

tion. This article discusses the tricks & tips of doing robotic

Please cite this article in press as: Sinha R, et al., Robotic myomec10.1016/j.apme.2014.08.003

assisted myomectomy in a systematic, safe, and efficient

manner.

We shall discus these in the following areas-

1. Pre operative assessment & MRI

2. Port placement & docking

3. Hybrid procedure

4. Dealing with associated sub mucous fibroids

5. Variations in suturing techniques

1. Pre operative assessment

Careful patient selection and a good preoperative assessment

are vital for the success of the minimally invasive myomec-

tomy procedures. It gives details of size, location & number of

fibroids. It is difficult to assess this on a 2D scan and even on

3D scan if the fibroids are multiple and large volume, one can

miss locating them preoperatively. Pre operative MRI of the

pelvis is suggested before Robotic myomectomy. In fact we

would suggest reviewing the MRI scan at the console with an

experienced radiology collogue gives details that may other-

wise get missed by the surgeon. During surgery it becomes

difficult to remove all fibroids if the locations are not known

from before. This information also helps in the counseling

session before surgery, as womenwith solitary fibroid or a few

large fibroids, or pedunculated fibroids are good candidates

and full clearance is possible Fig. 1. Diffuse fibromas, adeno-

myoma, adenomyosis with very little normal myometrium,

are poor surgical candidates and these should be identified

preoperatively Fig. 2. Although there are no limits on the

number of fibroids that can be removed (maximum of 9 fi-

broids in our series), multiple seedlings disseminated

throughout the uterus are not the right candidates for myo-

mectomy. Adenomyomectomy is also possible with

tomy e tips& tricks, Apollo Medicine (2014), http://dx.doi.org/

Fig. 2 e MRI T2 WEIGHTED IMAGE e extensive

adenomyosis of anterior wall of uterus.

Fig. 4 e MRI depicting intramural and a separate

submucous myoma.

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e5 3

symptomatic women with the help of robotic assistance.

Preopertaive MRI gives an opportunity to take a decision for

HYBRID PROCEDURE. Thus helps in planning the port place-

ment and better instrument selection.

2. Port placement & docking

The primary port is placed in the midline. The initial port can

be at the umbilicus or above (2e5 cms), depending on the size

of the fibroid. As shown in the figure the primary port is 5 cms

above the umbilicus as the upper border of the fibroid is 5 cms

above the pubic symphysis (Fig. 3). The rest of the ports are

placed as shown in the figure, in an inverted “W” so that there

is about 10 cms space between the ports. This is important as

when port placements are not selected well the robotic arms

Fig. 3 e Diagramatic representation of surface anatomy of

port locations in robotic myomectomy.

Please cite this article in press as: Sinha R, et al., Robotic myomec10.1016/j.apme.2014.08.003

tend to clash and the movements are hindered. The next step

is the selection of instruments in each port. We recommend

the hot shears in arm 1, bipolar forceps in arm 2 and tenacu-

lum in arm 3. Once the myoma enucleation is complete we

change the hot shears in arm 1 to needle driver. The tenacu-

lum can be changed to a prograsp in arm 3 for the myoma bed

suturing. The assistant port can be used for suction-irrigation,

passage of needle and for morcellation in the end.

3. Hybrid technique

It is a technique in which conventional laparoscopic enucle-

ation of the myoma is followed by reconstruction with the

Fig. 5 e MRI picture showing large sub mucous fibroid

which was removed by robotic assistance.

tomy e tips & tricks, Apollo Medicine (2014), http://dx.doi.org/

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e54

da Vinci robot. This is a technique used in situations where

myomas are more than 10 cms as such myomas are often

beyond pelvis. Deep intramural myomas or highly vascular

myomas can also be tackled by this technique. Additionally

with large myomas inadequate countertraction due to insuf-

ficient torque during enucleation can be a significant chal-

lenge.6,7,9,10 The advantage of this technique is that it

preserves tactile sensation as large myomas are heavy and

surrounded by delicate reproductive structures like the tubes,

and every attempt should be made to preserve the tubal

function. Rigid (not articulated) Myoma screw & Suction can-

nula exerts significant pull at every angle with the benefit of

haptic feedback (without risk of equipment damage). It is also

effective inmanipulation outside the pelvis and into the upper

abdominal quadrants.11 We use arm 2 & assistant port for

hybrid procedure as laparoscopic procedurewhile standing on

the left side of the patient using ipsi-lateral ports is easier to

handle and operate. The initial ports are all robotic ports. Once

myomectomy is done, the robot is swiftly docked and suturing

of the uterus undertaken. It is important to keep this quickly

as the raw edges continue to ooze a little. This technique

Fig. 6 e Showing the relevant steps in robotic myomectomy. (A

the fibroid capsule. (C) Enucleation of the fibroid. (D) Putting the

multiple layers with V Loc suture. (F) The final view after sutur

Please cite this article in press as: Sinha R, et al., Robotic myomec10.1016/j.apme.2014.08.003

entails a variable time lag between the completion of the

conventional laparoscopic myoma enucleation and the time

when the operator sits at the console to start the next step.

This “docking time” should be as minimal as possible and

depends on the team's coordination & efficiency. Hybrid ro-

botic myomectomy is regarded as an advanced robotic

technique.

4. Dealing with associated submucousfibroids

Some women have intramural fibroids associated with sub-

mucous fibroids. Hysteroscopy myomectomy is needed to

remove the submucous fibroids either in the same sitting or as

a two-stage procedure. The size of the sub mucous myoma as

well as the hemoglobin status of the patient determines

whether it should be one stage or two stages. Fig. 4 depicts the

MRI of a case with 3 � 2 cms sub mucous myoma associated

with large intramural myoma with 6 gms % of hemoglobin

which was operated as two stage procedure. However we also

) The initial incision at the fibroid capsule. (B) Dissection of

fibroid in a bag for morcellation & retrieval. (E) Suturing in

ing.

tomy e tips& tricks, Apollo Medicine (2014), http://dx.doi.org/

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e5 5

have experience of approaching large type 2-sub mucous

fibroid with robotic approach. Reasons for choosing Robotic

approach in the case illustrated by Fig. 5 was that type 2 sub

mucous fibroids are difficult to remove completely by hyster-

oscopy. The intramural component often remains partially

resected necessitating a second procedure. Hysteroscopic

resection takes longer operative time with little control on

bleeding and many of these women are already anemic.

5. Suturing techniques

The use of unidirectional knotless barbed suture substantially

facilitates closure of uterine defects during minimally inva-

sive myomectomy and may offer additional advantages such

asminimizing operative time.12 Barbed sutures are easy to use

for myoma bed repair as they can hold the two edges of

myometrial tissue in adequate tension for suturing. We use

30 cm No 1 V loc suture. This length although long at the

beginning, we find that one suture is often sufficient for

multilayer closure. There are fewer needle passes and cost is

also less. Curve of the needle helps to take good deep bites for proper

approximation. With arm 1 & 2 actively used for suturing, arm

three with prograsp forceps can be used to keep adequate

tension on the suture. Hence skillful use of all the 3 arms helps in

quick and effective suturing. After taking 2e3 multiple layers, we

finally take an inverted (baseball) suture to invert the raw edges as

well as the barbed suture (Fig. 6).

6. Conclusion

Ultimately openmyomectomywill be replaced byminimally invasive

myomectomy. Due to its ease in performance of myomectomy, ro-

botic technology will slowly replace the laparoscopic method. Ro-

botic approach helps surgeons to extend their boundaries in

terms of the size and number of myomas that can be removed

in minimally invasive way.2,13 This also helps to remove my-

omas in odd locations as well. Improvements in robotic

technology are also expected in near future. Affordability and

miniaturization of the equipment will increase its acceptance

widely. Presence of haptic feedback and assisted docking will

enable the surgeon to include this in day to day practice.

Single incision applications are already in use atmany centers

and will further add to the benefits of robotic technology in

gynecological surgeries.

Please cite this article in press as: Sinha R, et al., Robotic myomec10.1016/j.apme.2014.08.003

Conflicts of interest

All authors have none to declare.

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