Magrina slides reformatted for printing

Robotic Surgery in Gynecologic Oncology and Advanced Benign

Gynecology

Javier F. Magrina, MD

Professor of Gynecology

Mayo Clinic Scottsdale

Scottsdale, Arizona

JFM101603

Objectives

• Robotic results • Ovarian cancer• Advanced endometriosis

Robotic Surgery at Mayo Clinic Arizona 2003-2011

• Hysterectomy Kho RM, Hilger WS, Hentz JG, Magtibay PM, Magrina JF. Robotic hysterectomy: technique and initial outcomes. Am J Obstet Gynecol 2007 Jul; 197(1):113

• Adnexectomy**Magrina JF, Espada M, Munoz R, Noble BN, Kho RM. Robotic adnexectomy compared with laparoscopy for adnexal mass. Obstet Gynecol 2009 Sep; 114(3):581-4

• Myomectomy**Bedient CE, Magrina JF, Noble BN, Kho RM. Comparison of robotic and laparoscopic myomectomy. Am J Obstet Gynecol 2009 Dec; 201(6):566

• Presacral neurectomy. Int J Med Robot. 2011 Oct 07 • Appendectomy Akl MN, Magrina JF, Kho RM, Magtibay PM.

Robotic appendectomy in gynaecological surgery: technique and pathological findings. Int J Med Robot 2008 Sep; 4(3):210-3

Robotic Surgery at Mayo Clinic Arizona 2003-2011

• Cervical cancer**Magrina JF, Kho RM, Weaver AL, Montero RP, Magtibay PM. Robotic radical hysterectomy: comparison with laparoscopy and laparotomy. Gynecol Oncol 2008 Apr; 109(1):86-91

• Ovarian cancer** Magrina JF, Zanagnolo V, Noble BN, Kho RM, Magtibay P. Robotic approach for ovarian cancer: Perioperative and survival results and comparison with laparoscopy and laparotomy. Gynecol Oncol. 2011 Apr; 121(1):100-5

• Endometrial cancer**Magrina JF, Zanagnolo V, Giles D, Kho RM, Noble B, Magtibay PM. Robotic surgery for endometrial cancer: comparison with laparoscopy, vaginal/laparoscopy, laparotomy. Eur J Gynaecol Oncol. 2011; 32(5):476-80

Robotic Surgery at Mayo Clinic Arizona 2003-2011

• Robotic transperitoneal aortic lymphadenectomy Int J Gynecol Cancer. 2010 Jan; 20(1):184-7

• Robotic extraperitoneal aortic lymphadenectomy Gynecol Oncol. 2009 Apr; 113(1):32-5

• Robotic radical hysterectomy: Technical aspects. Gynecol Oncol. 2009 Apr; 113(1):28-31

• Robotic radical parametrectomy Acta Obstet Gynecol Scand. 2010 Aug; 89(8):1108-10

• Robotic transperitoneal infrarenal aortic lymphadenectomy for gynecologic malignancy: a left lateral approach. J Laparoendosc Adv Surg Tech A. 2011 Oct; 21(8):733-6

Robotic Surgery at Mayo Clinic Arizona 2003-2011

• Robotic extraperitoneal aortic lymphadenectomy: Development of a technique. Gynecol Oncol. 2009 Apr; 113(1):32-5

• Robotic nerve-sparing radical hysterectomy: feasibility and technique. Gynecol Oncol. 2011 Jun 1; 121(3):605-9

• Robotic nerve-sparing radical parametrectomy. Int J Med Robotics Computer-assisted Surg 2012

Robotics vs. Laparoscopy PRT Total Hysterectomy

Laparoscopy Robotics p

n=36 n=39

Uterus, gm 158.3 157.3 NS

OR, min 160.5 130.3 NS

EBL, ml 73.3 73.8 NS

LOS, hr 24.3 21.2 NS

Robotics vs. LaparoscopyHysterectomy

Complications, %

Robotics Laparoscopy p

Intraop 0 0 NS

Postop 5.1 0 NS

Robotic vs. Laparoscopic Adnexectomy for the Adnexal Mass

Robotic Laparoscopy p n=85 n=91

OR, min 83 71 0.01 EBL, ml 39 41 NS Hospital, >2 d, % 0 3 NS

Obstet Gynecol 2009, 114:581-4

Robotic vs. Laparoscopic Adnexectomy for the Adnexal Mass

Complications,%

Robotic Laparoscopy P

Intraop 1 2 NS

Postop ≤ 6 wk 12 11 NS

Obstet Gynecol 2009, 114:581-4

Robotic vs. Laparoscopic MyomectomyMayo Clinic Arizona

Robotic Laparoscopy p

OR, min 141 166 NS

EBL, ml 100 250 0.02

Hospital > 2d,% 5 9 NS

Am J Obstet Gynecol 2009, 201:566

Robotic vs. Laparoscopic MyomectomyMayo Clinic Arizona

Complications,% Robotic Laparoscopy p

n=40 n=41

Intraop 2 15 NS

Postop 12 10 NS

Conversion 0 5 NS

Readmissions 5 3 NS

Am J Obstet Gynecol 2009, 201:566

Robotics vs. Laparoscopy for Endometriosis

Robotics Laparoscopy p

OR time, min 159 179 NS

EBL, ml l88 103 NS

Hospital, d 1 1.1 NS

Robotics vs. Laparoscopy for Endometriosis

Robotics Laparoscopy p

Complications

Intraop 0.1 0 NS

Postop 6 8 NS

Conversion 2 0 NS

Mayo Clinic Arizona

Robotics vs. Laparoscopy

No major differences in perioperative results

Conclusion

Robotics is preferable to laparoscopy for:• Areas of difficult access• Extensive suturing• Complex dissection • Precision• Bleeding• Obesity

Robotics for Ovarian Cancer

• Primary debulking• Interval debulking • Recurrent cancer

Disease localized to pelvis and one or two other areas

Patient Selection for Robotics in Ovarian Cancer

Primary tumor excision (Hyst + BSO + omentectomy + lymphadenectomy) + 1 or 2 major procedures

• Modified posterior pelvic exenteration • Diaphragm resection• Small bowel resection • Other

Types of Debulking

Type

I Hyst + staging + 1 major

procedure

II Hyst + staging + 2 major

procedures

III Hyst + staging + 3 or more

major procedures

Type I Debulking in Ovarian CancerMayo Clinic Arizona

Robotics Laparoscopy Laparotomy p n=15 n=20 n=41

OR, min 282 249 230 NS

EBL, ml 152 222 1005 <0.001

Hosp, d 3 3 7 <0.001Gynecol Oncol; 121:100, 2011

Type I Debulking in Ovarian CancerMayo Clinic Arizona

Robotics Laparoscopy Laparotomy p

Complications,%

Intraop 20 10 10 NS

Postop 20 5 17 NS

Type II Debulking in Ovarian CancerMayo Clinic Arizona

Robotics Laparoscopy Laparotomy p n=8 n=7 n=46

OR,min 345 267 259 0.02

EBL,ml 191 389 1261 <0.001

Hosp,d 5 5 11 <0.001Gynecol Oncol; 121:100, 2011

Type II Debulking in Ovarian CancerMayo Clinic Arizona

Robotics Laparoscopy Laparotomy p

Complications,%

Intraop 0 14 11 NS

Postop 25 0 54 0.01

Type III Debulking in Ovarian CancerMayo Clinic Arizona

Robotics Laparotomy n=2 n=32

OR, min 443 305

EBL, ml 150 1775

Hosp, d 11 10 Gynecol Oncol; 121:100, 2011

Type III Debulking in Ovarian CancerMayo Clinic Arizona

Robotics Laparotomy

Complications,%

Intraop 0 22

Postop 100 56

Survival in Ovarian CancerMayo Clinic Arizona

Robotics Laparoscopy Laparotomy p n=25 n=27 n=119

OS 3-yr,% 67 76 66 NS OS vs. debulking Complete 71 78 82 NS Incomplete 50 50 45 NS Gynecol Oncol; 121:100, 2011

Robotic Disadvantages for Ovarian Cancer

• OR table rotation • Additional trocars• Increased OR time with increased number of procedures

• Incision for anastomosis or removal of large specimens

Turning OR Table 180

Head Docking

Head Docking

R Upper Docking

R Upper Docking

assistantassistant

Pubis

camera

Cameraumbilicus

assistant

Infrahepatic and Anterior Diaphragm

Right ribs

Right ribs

AssistantAssistant

AssistantAssistant

22ndnd assistant assistant

Posterior Diaphragm

xyphoidxyphoid

Need for Incision

Neoadjuvant Chemotherapy

Increases % MIS for debulking

Sigmoid and Left Ovary

Before After

Infracolic OmentumBefore After

OmentumBefore After

StomachBefore After

Right DiaphragmBefore After

Splenic OmentumBefore After

PelvisBefore After

Right PelvisBefore After

Ascending ColonBefore After

Hepatic OmentumBefore After

Right Diaphragm and LiverBefore After

Liver After

Left Diaphragm and LiverAfter After

Robotic Excision Liver Metastasis

Excision Diaphragm Peritoneum

Robotic Full-thickness Diaphragm Resection

Robotic Excision Diaphragm Endometriosis

Robotic Resection L Diaphragm Recurrence

Infracolonic Omentectomy

Thank you