Didactic: Robotic Gynecologic Surgery from Start to … · Course chairs, planning committee ... Robotic Training Network RTN Curriculum ... Basics of Electricity

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AAGLAdvancing Minimally Invasive Gynecology Worldwide

Didactic:Robotic Gynecologic Surgery from Start to Finish:

Strategies for Optimizing Outcomes

PROGRAM CHAIR

Arleen H. Song, MD

Devin M. Garza, MD Kathy Huang, MD Mario M. Leitao, MDGaby N. Moawad, MD Erinn Myers, MD Kristin E. Patzkowsky, MD

Nazema Y. Siddiqui, MD, MHS

Professional Education Information Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

Table of Contents

Course Description ........................................................................................................................................ 1

Disclosure ...................................................................................................................................................... 2

Setting Up for Success: Docking, Trocar Placement, and Troubleshooting K. Huang ........................................................................................................................................................ 4 Simulation: Safely Surfing the Learning Curve N.Y. Siddiqui .................................................................................................................................................. 7 Understanding Energy A.H. Song ..................................................................................................................................................... 14

Multi Port to Single Site Approaches to Robotic Hysterectomy D.M. Garza .................................................................................................................................................. 21

Myomectomy: Surgical Management for Optimal Fertility Outcomes K.E. Patzkowsky ........................................................................................................................................... 27

Robotic Sacrocolpexy E. Myers ...................................................................................................................................................... 36

Prevention and Management of Robotic Complications M.M. Leitao ................................................................................................................................................. 42 Approaching Advanced Endometriosis and Tissue Containment and Extraction Techniques G.N. Moawad .............................................................................................................................................. 50

Cultural and Linguistics Competency ......................................................................................................... 56

ROBO-603: Didactic:

Robotic Gynecologic Surgery from Start to Finish:

Strategies for Optimizing Outcomes

Presented in cooperation with the AAGL Special Interest Group on Robotics

Arleen H. Song, Chair

Faculty: Devin M. Garza, Kathy Huang, Mario M. Leitao, Gaby N. Moawad, Erinn Myers, Kristin E. Patzkowsky, Nazema Y. Siddiqui

This course is a comprehensive review of current robotic surgical techniques to ensure successful

surgical outcomes of even the most complex gynecologic cases. Surgical techniques to perform

hysterectomy, myomectomy, endometriosis, and sacrocolpopexy will be covered. This course is

designed to provide a starting point for the novice and to advance the skill set of the experienced

robotic surgeon from patient selection, docking and operating room setup to strategies to successfully

perform common and more complex robotic procedures. Participants will learn to prevent, recognize

and manage complications, and learn about new tissue extraction methods and advances in robotic

technology.

Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Demonstrate

knowledge of robotic gynecologic surgeries, including hysterectomy, myomectomy, resection of

advanced endometriosis, and sacrocolpopexy; 2) identify strategies to both prevent, recognize, and

manage problems common in robotic surgery; and 3) discuss tissue containment and extraction

techniques.

Course Outline

7:00 Welcome, Introductions and Course Overview A.H. Song

7:05 Setting Up for Success: Docking, Trocar Placement, and Troubleshooting K. Huang 7:25 Simulation: Safely Surfing the Learning Curve N.Y. Siddiqui

7:50 Understanding Energy A.H. Song

8:10 Multi Port to Single Site Approaches to Robotic Hysterectomy D.M. Garza

8:50 Questions & Answers All Faculty

9:00 Break

9:15 Myomectomy: Surgical Management for Optimal Fertility Outcomes K.E. Patzkowsky

9:40 Robotic Sacrocolpexy E. Myers

9:50 Prevention and Management of Robotic Complications M.M. Leitao

10:20 Approaching Advanced Endometriosis and Tissue Containment and

Extraction Techniques G.N. Moawad

10:50 Questions & Answers All Faculty

11:00 Adjourn

1

PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop (listed in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* R. Edward Betcher* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Sarah L. Cohen Consultant: Olympus Erica Dun* Joseph (Jay) L. Hudgens Contracted Research: Gynesonics Frank D. Loffer, Medical Director, AAGL* Suketu Mansuria Speakers Bureau: Covidien Linda Michels, Executive Director, AAGL* Arleen H. Song* Karen C. Wang* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Sawsan As-Sanie Consultant: Myriad Genetics Lab Jubilee Brown* Aarathi Cholkeri-Singh Consultant: Smith & Nephew Endoscopy Speakers Bureau: Bayer Healthcare Corp., DySIS Medical, Hologic Other: Advisory Board: Bayer Healthcare Corp., Hologic Jon I. Einarsson* Suketu Mansuria Speakers Bureau: Covidien Andrew I. Sokol* Kevin J.E. Stepp Consultant: CONMED Corporation, Teleflex Stock ownership: Titan Medical Karen C. Wang* FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Devin M. Garza Consultant: Applied Medical, Boston Scientific Corp., Inc. Speakers Bureau: Intuitive Surgical Kathy Huang Consultant: Intuitive Surgical Mario M. Leitao Other: Ad Hoc Speaker and Lab Proctor: Intuitive Surgical Other: Ad Hoc Speaker: Novadaq

2

Gaby N. Moawad Speakers Bureau: Applied Medical, Intuitive Surgical Erinn Myers* Kristin E. Patzkowsky* Nazema Y. Siddiqui Contracted Research: Medtronic Arleen H. Song* Content Reviewer has no relationships. Asterisk (*) denotes no financial relationships to disclose.

3

Setting Up for Success: Docking, Trocar Placement, and

Troubleshooting

Setting Up for Success: Docking, Trocar Placement, and

Troubleshooting

KATHY HUANG, M.D.DIRECTOR of Gynecologic Robotic Surgery

NYU LANGONE MEDICAL CENTERASSISTANT PROFESSOR

NYU SCHOOL OF MEDICINE

KATHY HUANG, M.D.DIRECTOR of Gynecologic Robotic Surgery

NYU LANGONE MEDICAL CENTERASSISTANT PROFESSOR

NYU SCHOOL OF MEDICINE

Disclosure

• Consultant: Intuitive Surgical

Patient Positioning

Patient - Foam -OR Table

Steep Trendelenburg

Uterine Manipulators

Port Placement Veres needle

Pressure setting: 20mmHg

First port: 5mm LUQ: noncommittal

90 degrees to the fascia

Avoiding collision

Docking

4

Robotic Instruments

Robotic Instruments

monopolar instruments

Bipolarinstruments

Needle Drivers

Large vs Mega

Suture Cut ?

Other Instruments

Hysterectomy Colpotomy

5

Unedited Cuff ClosureAAGL Annual

MeetingNovember 14-18,

2016

AAGL Annual Meeting

November 14-18, 2016

6

Simulation: Safely Surfing the Learning Curve

Nazema Y. Siddiqui, MD MHScAssistant Professor, Department of Obstetrics and Gynecology

Division of Urogynecology and Reconstructive Pelvic Surgery

Director, Duke Robotic Training Program

Disclosure

Contracted Research: Medtronic

Objectives

✓ Discuss ways to optimize the training experience

✓ Where to focus dry lab practice

✓ Review web-based and simulation curricula; training tools

Why do we need simulation?

Robotic surgery continues to increase

• Urology, GYN, General Surgery (thoracic, colorectal)

Steep learning curve exclusive to robotic surgery

Learning curve magnified in trainees

(learning robotic techniques + learning procedure)

Lenihan et al.; JMIG 2008Woelk et al; Obstet Gynecol 2013Geller et al; JMIG 2013

Operative Efficiency Suggestions

✓ Utilize a standard training program for initial practice

• Residents, new surgeons

✓ Provide opportunities for ongoing/advanced practice

• Upper level trainees, new surgeons

✓ Periodically review systems & implementation

7

All Rights Reserved, Duke Medicine 2007

Initial Training: Bedside Skills and Dry Lab Training

7

Robotic Training Network

www.robotictraining.org

RTN Curriculum

✓ Incorporates ACGME 6 core competencies

(important for trainees)

✓Milestones approach

✓Divides the learner into two phases

• Phase I - bedside assistant training

• Phase II - console training

Isabel C. Green, MDMayo ClinicRochester, MN

Martin A. Martino, MDLehigh Valley Med CtnrAllentown, PA

Phase I - Bedside Assistant

Phase II - Console Training Phase II - Console Training

8

Phase II - Console Test Robotic Training Network

Robotic Training Network Phase II - Console Training

✓To operate on console:

• Practice using RTN skill drills or VR simulators

• Attend a proctored testing session

• Score > 13/20 for each drill during testing session

(benchmark for trainees developed through RTN studies)


Ongoing Training: VR simulators

17

Ongoing Training

Skills degradation

o “Skills degrade significantly within 4 weeks of inactivity in newly

trained surgeons”

9

Ongoing Training – VR Simulation

Virtual Reality Simulators

o Intuitive Surgical “backpack”

o MIMIC DV Trainer

o 3D Systems – RobotiX Mentor

Ongoing drills/dry lab practice

Ongoing Training – VR Simulation

Simulation Training Level 1

Peg Board #1

Camera Targeting – Basic (Camera Targeting #1)

Ring Walk #1

Level 2

Peg Board #2

Camera Targeting #1(Camera Targeting #2)

Match Board #1

Energy Switching #1

Level 3

Camera Targeting #2 (no drill for DaVinci Simulator)

Energy Switching #2

Thread The Rings #1

Energy Dissection #1

Match Board #3

GYN ADVANCED Hysterectomy

Ring Walk #3 – Bladder flap manipulation

Rope Walk – Suture manipulation (no drill for DaVinci Simulator)

Energy Dissection #2 – Uterine vessel ligation

Suture Sponge #1 – Vaginal cuff closure

Myomectomy

Suture Sponge #2 – Myomectomy closure

Tubes #1 – Tissue manipulation

Thread the rings #2 – Needle manipulation

Sacrocolpopexy

Needle Targeting – Needle driving

Suture sponge #3 – Advanced needle manipulation Wound closure (vertical) ‐ Suturing

VR Simulation

Megan Bradley, MDFPMRS FellowDuke University

Laura Newcomb,MDOB/GYN ResidentDuke University

VR Simulation - Video

“Morristown” Protocol

Series of skills to allow novice surgeons to

train towards expertise

Average of 20 hours of simulation lab time

o Range 9.7-38.2 hours

Established predictive validity

(passing protocol predicts successful completion of

robotic hysterectomy in times comparable to experts)

Patrick Culligan, MDDept of UrologyWeill Cornell Medicine

“Morristown” Protocol

10


Procedure Specific Training

25

Hysterectomy

✓ Perform drills that simulate activities needed for hysterectomy

o List of drills (dry lab or VR trainer)

✓ Perform a simulated hysterectomy on VR trainer

VR Hysterectomy VR Hysterectomy

Content provided by Intuitive Surgical, Inc.

Simulation-based hysterectomy procedure training created by 3D Systems and developed in collaboration with the Fundamentals of Robotic Gynecologic Surgery (FRGS) group.

Advanced Procedures

✓ Drills that simulate activities needed for procedure

o E.g. for sacrocolpopexy, complete a list of relevant drills

(dry lab or VR trainer)

✓ Perform a simulated procedure on a model

Sacrocolpopexy – VR Drills

✓ Drills that simulate activities needed for sacrocolpopexy

o List of drills (dry lab or VR trainer)

11

Sacrocolpopexy – VR Drills Sacrocolpopexy - Model

Sacrocolpopexy - Model Sacrocolpopexy - Model Creation

Jason S. Yeh, MD, FACOG

Reproductive Endocrinologist & Fertility SpecialistDirector of Patient EducationHouston Fertility Institute

https://www.youtube.com/watch?v=YwPdwI1wE5U&feature=youtu.be

Sacrocolpopexy – Suturing mesh Sacrocolpopexy – Sacrum

12

Summary

✓ Robotic training program should involve bedside, dry lab, and

other simulation activities

✓ For new surgeons, skills degrade after 4 weeks of inactivity

✓ Simulation curricula available

• RTN, Morristown Protocol

✓ Procedure Specific simulation is more difficult to obtain, but still available

13

Undestanding Energy in Robotic Surgery

ARLEEN H. SONG, MD MPH

ASSISTANT PROFESSORDIVISION OF MINIMALLY INVASIVE GYNECOLOGIC SURGERY

DUKE UNIVERSITY

I have no financial relationships to disclose.

At the conclusion of this lecture, you should:

Review the basic principles of electricity

Identify and understand the different energy sources used in robotic surgery

Discuss potential advantages and risks of these energy sources

Identify strategies to reduce thermal injury in robotic surgery

Basics of Electricity

Always seeks ground

Always moves through least path of resistance

Requires a complete circuit to do work

In patient: Current originates from generator, enters patient and seeks path of least resistance and returns to generator

Conception of electrosurgery

19th Century

French physicist Becqueral

Passed direct current through wire to heat it and cauterize tissue

French biophysicist D’Arsonoval

Pioneered use of alternating current in human body

Demonstrated that low frequency was safe in humans

Use AC to prevent neuromuscular stimulation

Refinement of ElectrosurgeryHarvey Cushing, MDNeurosurgeon

William T. Bovie, PhDPhysicist

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Current: Electrons (measured in amperes) moving in a circuit

Circuit: Uninterrupted pathway for flow of electrons

Impedance: obstacle to the flow of current (measured in ohms)

Voltage: Force pushing current through resistance (measured in volts)

Ohm’s law: Voltage = Current x Resistance

Foundation of Electrosurgery Types of Energy in Robotic Surgery

Monopolar (hook, spatula and shears) Bipolar (Maryland, fenestrated, curved, precise, and micro forceps) Advanced bipolar (PK, Endowrist One Vessel Sealer) Ultrasonic (Harmonic Ace)

Laser

Monopolar Electrosurgery

Dessication, vaporization, fulgaration and coaptation

Effects achieved by current power settings, contact or noncontact technique, current waveform, duration of current waveform activity, electrode size/configuration, and tissue conductivity.

Cut versus Coagulation

Monopolar energy

Generator produces current which travels through the active electrode (Bovie) into the patient tissue, through the return electrode and back into the generator.

Monopolar Energy: Cutting Mode

Continuous, low voltage current concentrating energy at small area.

Rapid tissue heating

Vaporization Hold tip of electrode close, but not in direct contact with tissue

Monopolar: Coagulation Mode

Interrupted, high voltage current dispersed over large surface area

Modulated current: Tissue heated more slowly leading to dehydration effect

Ideal for sealing vessels More tissue damage and thermal spread

15

Optimal use of Monopolar

Lowest power setting

Low voltage waveform Brief intermittent activation Do not use in close proximity to vital structures Useful on “cut” mode to dissect near vital structures

Useful on “cut” mode to cause deeper effect (removal of deep endometriotic lesion)

Useful on “coag” on tissue with high resistance (adipose, fibrous tissue)

Useful on “coag” for large surface area with superficial bleeder

Bipolar

Energy confined to tissue between two electrodes

Forceps, blades of scissors or graspers No dispersion pad needed

Bipolar energy

Effective for hemostasis

Dessication results in coaptation and thermal welding of blood vessels

“Enhanced bipolar” Tissue feedback from generator measuring impedance

Lowest possible power setting is utilized to achieve desired tissue effect

16

Bipolar Electrosurgical Thermal Effects

time

Resistance

Heat

Tissue Response Technology

Senses tissue impedance at active electrode site

Adjusts current and output voltage in cut and blend modes to maintain consistent surgical effect

Uses lower power settings and voltages in cut and blend modes Reduces lateral thermal spread Minimizes sparking Reduces need to adjust power settings

Vessel sealing technology “Enhanced Bipolar”

Ligasure Seals vessels up to 7mm

Minimal sticking/charring

Unable to cut; cut with blade

Gyrus Greater thermal spread (3.6mm)

Mechanical blade for cutting

Significant smoke production

Pulsed Bipolar Coagulation

• Low voltage

• Delivered as a series of pulses

Retroactive generator responses

• Impedance monitoring by generator

Tone changes pitch when impedence meets pre-

determined level

Energy flows until foot pedal released

Plasmakinetics System

Harmonic scalpel MECHANICAL energy (vibrations at tip of active blade – 55,000

times per second) – NOT electrocautery Leads to denaturation of proteins and separation of tissue

Produces significant steam from vaporization Blade remains “hot” Active blade is black “move towards the white” No risk for electrical injury

Coagulate vessels between 3-5mm Blade can break off – avoid excessive traction

Light Amplification and Stimulated Emission of Radiation (LASER)

Laser energy generated when electrons jump from higher to lower energy levels during their circuits around the nucleus.

Induces molecular vibration and thermal energy

Laser consists of an energy source, focusing mechanism, and radiating mechanism.

Type of medium determines wavelength Carbon dioxide, Argon,Potassium-titanium-phosphate (KTP),

neodynium:yttrium aluminum garnet (NdYag).

17

Monopolar Tissue Effects Dessication: Hemostasis < 1mm vessel

Direct contact of electrode

Typically use “cutting” current

Pronounced lateral spread

Vaporization

Non-touch

Use “cutting” current

Explosion of cells, low voltage sparks, minimal smoke

Results in cutting effect

Coaptation: Sealing of < 2 mm vessel

Cutting current

Contact and compression of vessel wall

Similar to bipolar; pronounced lateral spread

Fulguration: Hemostasis < 1mm vessel

Non-touch

Use “coagulation” current

Need higher voltage compared to cutting due to impedance of air

Chars tissue over large area, high voltage sparks, smoke

Variables Affecting Tissue Effects Waveform: Coag vs Cut Power setting (=current x voltage) Electrode size

Smaller electrodehigher current concentration Time

Longer time of activationproduce more heatgreater thermal spread Electrode manipulation

Sparking versus direct contact to control vaporization or dessication Tissue type

Fat, bone, and fibrous tissue have high resistance Muscle, skin, and vessels have low resistance

Eschar High resistance to currentless effective

Results

Complications of MonopolarElectrosurgery

Prevalence of 2-5 per 1000 procedures

Most commonly unrecognized thermal injuries Bowel, ureteral

Delayed injury: 4-10 days

Insulation Failure

Occurs with breaks in insulation of instrument Compromise of insulation sheath

Visual inspection

Caused by resterilization and use of high voltage

18

Direct coupling

Occurs when an activated instrument touches another conductor in contact with vital structure (bowel)

Capacitive coupling

When capacitor created (two conductors separated by insulator) and forms stored energy

Electrostatic field is created between the two conductors and current transmits once net charge exceeded

AC induces unintended stray current to adjacent conductor

High Current Density

Unpeeled Return Electrode!

High Current Density

Burn = Heat x Time / Surface Area

Active electrode monitoring

“Contact quality monitoring systems”

Utilized to avoid complications of monopolar electrosurgery

Utilized to avoid alternate site burns

Continuously checks for appropriate placement of grounding pad, insulation failures and capacitive coupling

Will discontinue current if those problems arise

Injuries Specific to LASER

Ignition of flammable materials

Inadvertent reflection by surgical instruments leading to injury in nontargeted tissue

Thermal Spread

Traditional bipolar device: 2 – 22 mm Ultrasonic (Harmonic): 0 – 3 mm

Dependent on application time and setting Thermal spread of up to 25 mm in animal models with continuous

dissection for 10-15 sec

Vessel sealers: Ligasure:

10 mm Ligasure: 1.8 mm spread 5 mm Ligasure: 4.4 mm spread

Gyrus PK: 6.3 mm spread

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Avoiding Complications

Use of monopolar energy necessitates return electrode pad (“grounding pad”)

Use intermittent bursts of energy

Avoid activation without being in contact with tissue unless intent is for sparking

Use lowest power settings

Avoid touching instruments during surgery Maintain panoramic view of surgical field during application of

energy Observe tissue changes

Important to have a fundamental understanding of energy source in order to:

Know the limitations of the energy source chosen Select appropriate instrument Prevent and recognize thermal complications

References

Lamberton GR,Hsi RS, Jin DH et al. Prospective comparison of four laparoscopic vessel ligation devices. Journal of Endourology.2008;22:2307-2312.

Sutton C, Abbott J. History of power sources in endoscopic surgery. J of Minimally Invasive Gynecology 2013;20:271-278.

Teoh, D, Lowery WJ,Jiang X, Ehrisman J,Halvorson P, Broadwater G, Bentley R, Secord AA, Sobolewski C, Berchuck A, Havrilevsky LJ, Valea FA, Lee PS. Vaginal cuff thermal injury by mode of colpotomyat a total laparoscopic hysterectomy:a randomized controlled trial. J of Minimally Invasive Gynecology.2015;22(2):227-33.

Vancaillie TG. Active electrode monitoring. How to prevent unintentional thermal injury associated with monopolarelectrosurgery at laparoscopy. Surgical Endoscopy 1998;12:1009.

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Single Site to Multiport Approaches

To Robotic Hysterectomy

Disclosures

• Consultant: Applied Medical, Boston Scientific Corp., Inc.

• Speakers Bureau: Intuitive Surgical

Goals

• Review systematic approach to hysterectomy on robotic platform

• Compare and Contrast Single Site vs Multisite

• “See and Select” approach

Systematic Approach to Hysterectomy

• Pathology• Uterine size and shape

• Prior surgery

• Endometriosis

• Adhesions

• Ports• Number

• Placement

Multi Site Approach To Hysterectomy Port Placement: <14w

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Port Placement

Assist

Placement

Docking – “Not too close”

Right handed surgeon = RIGHT side docking

Functional Wristed RetractorPrograspSingle Tooth Tenaculum

Successful Complex RoboticsMaximizing “4th Arm”

Video Docking: Maximizing 4th Arm Port Placement: SI/XI

10cm10cm 10cm 10cm

Assist

Port Placement: Large Complex Systematic Approach to Hysterectomy

• Port Placement

• Normalize anatomy

• Identify ureters

• Exposure• Maximize mobility

22

Video edited Large Uterus SINGLE SITE!

Single Site vs Multi Site

Non‐wristed semi rigid instruments

Wristed rigid instruments

Camera port: umbillicus Camera port placement: flexible

Virtually “scarless” Visible scars

• Gel port x 1

• Umbilical Incision x 1 = 2.5 cm

• Hysterectomy and adnexa

Single Site Robotics

WHAT?

Single‐Site™ Instruments

da Vinci® Si™ System

8.5 mm Si Scope

Curved instrument cannulae

5 mm, non‐wristed (YET!)semi‐rigid instruments

Single‐Site Port

• Aesthetics & Cosmesis

• See & Select Protocol

• Extraction Site


WHY?

23

Post Op Cosmesis

Laparoscopic Single Port vs Robotic Single‐Site

Laparoscopic Single Port

Unstable, in‐line optics

Instrument crowding

Lack of triangulation

Single‐Site™ for Robotics

• Stable, 3D HD visualization

• Precise, ergonomic control

• Maintains triangulation

Patient Selection

Surgeon Selection


WHO?

SS: Patient Selection

NO!

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SS Hysterectomy: Patient Selection

• Initial Cases

• BMI < 35 (Alexis)

• Minimal Pathology

• <12wk size uterus

• Add “+ 1 “

23

• Post Learning Curve• BMI >35 *Alexis• Moderate Pathology• <16wk size• Add “+1”

Yes.. Single‐Site

24

Learning Curve Data For Single‐Site

• Lenihan et al, What is the Learning Curve for Robotic Assisted Gynecologic Surgery?

J.Minim Invasive Gynecol Received: November 12, 2007; Accepted: June 27, 2008;

• A Comparison of Outcomes between Robotic‐Assisted Single Site Laparoscopy versus Laparoendoscopic Single Site (LESS) for Benign HysterectomySandra Lopez, MD, Zuber D. Mulla, PhD, Loretta Hernandez, MPH, Devin M. Garza, MD, Thomas N. Payne, MD, Richard W. Farnam, MD

Received: June 9, 2015; Received in revised form: August 13, 2015; Accepted: August 21, 2015; Published Online: August 27, 2015 Publication stage:

In Press Accepted Manuscript JMIG

26

Multi‐center retrospective cohort study: SS Robotic vs. SILS

See & Select Approach

Review History and bimanual exam

If unsure: Place routine daVinci Camera Port: assess difficulty

Select approach: (4A, 4B, 4C).

Tip:

• Mark 3rd arm lateral >15cm

27

Assess3

Simple (4A) Complex (4C)Unsure (4B)

Single-Site Single-Site + 1 Multi-Port

Select

8‐10 cm

4

Video Single Site Entry

Assistant Center Docking Video Single Site Hysterectomy

25

Video Single Site Cuff Closure Summary

• Plan Ports based on Pathology ‐ One size does NOT fit all!

• Work towards mastering 4th arm use

• Single Site 16w or less and moderate pathology

• Single Site incision useful as an extraction site

• Multi Site for high complexity and a large uterus

• Be Flexible – choose number of ports ”on the fly”

Thanks!

Devin Martin Garza, M.D., FACOGClinical Assistant Professor, University of Texas Dell Medical SchoolDirector Minimally Invasive SurgeryRennaissanceWomens GroupTexas Institute for Robotic Surgery, Austin, Texas

26

Myomectomy: Surgical Management for Optimal Fertility Outcomes

Kristin Patzkowsky, MD

Assistant Professor

Minimally Invasive Gynecologic Surgery

Johns Hopkins Hospital

November 14, 2016 1Gynecology and Obstetrics


2

Gynecology and Obstetrics

Objectives

• To better define the impact of fibroids on infertility and potential fertility

• Describe pre-op and operative interventions to optimize patient outcomes

• Suggest recommendations for post op surveillance and management

3 Gynecology and Obstetrics

History of myomectomy

• 1845: 1st abdominal myomectomy in US, John Atlee– Case series, 14 abdominal myomectomies, 5 deaths

• Mortality rate: – Early 1900s: 40%

– Mortality at Johns Hopkins:• 1889-1906: 6%

• 1906-1909: <1%

4Rock et al, TeLindes Operative Gynecology, 2003.


History of Myomectomy

Abdominal myomectomy was “so dangerous and difficult as not to be thought

of except in desperate conditions.”

- 1875, W.H. Byford, MD. Chairman’s address to the AMA


History of myomectomy

TeLinde’s Operative Gynecology, 2003:

“This procedure (laparoscopic myomectomy) is appropriate in very few patients for several

reasons…

…In both circumstances, the myomata are likely to be large and laparoscopic myomectomy is rarely the

most appropriate procedure for removal”

6

27

Gynecology and Obstetrics 7 Gynecology and Obstetrics 8

Fibroids and Fertility


Effect of fibroids on fertility: all locations.

Outcome Number of studies/substudi

es

Relative risk 95% CI Significance

Clinical pregnancy rate 18 0.849 0.734-0.983 p=.029

Implantation rate 14 0.821 0.722-0.932 p=.002

Ongoing pregnancy/live birth rate

17 0.697 0.589-0.826 p<.001

Spontaneous abortion rate

18 1.678 1.373-2.051 p<.001

Preterm delivery rate 3 1.357 0.607-3.036 NS

9Pritts et al. Fertil Steril, 2009. Gynecology and Obstetrics

Fibroids and Fertility

• Embryo implantation

• Miscarriage

• Pregnancy complications

• Mode of delivery

• Fetal/Neonatal morbidity

• PP complications

10Klatsky et al. AJOG, 2008.


Location, location, location

• SubmucosalIn an ART population:– Detrimental effect on fertility outcomes

– Improved outcomes with fibroid removal

• Intramural– Gray zone

• Subserosal– Do not appear to effect fertility outcomes

– Removal does not confer benefit

11Pritts et al. Fertil Steril, 2009.


Submucosal Fibroids & Infertility

• Submucosal fibroids are associated with decreased fertility:– Decreased implantation rates from 11.5% to 3.0%

– Decrease in ongoing pregnancy rate from 30% to 14%

– Increased risk of miscarriage 22% to 47%

• Benefit of myomectomy in women with infertility:• 40% pregnancy rate/1yr in women who underwent

myomectomy vs 21% in the cohort who declined myomectomy

12Klatsky et al, AJOG, 2008. Pritts et al, Fertil Steril, 2009.

28


Intramural fibroids & Infertility

• Intramural fibroids appear to be associated with decreased fertility & increased pregnancy loss– Cavity distortion

– Size

– Proximity to endometrium

– Location within the uterus (& how defined)

• Benefits of myomectomy unclear

13Pritts et al, Fertil Steril, 2009 Gynecology and Obstetrics

Fibroids in Pregnancy & Delivery

• Higher rate of c-section– Malpresentation

– No difference in labor curve

• Increased risk post partum hemorrhage & emergency hysterectomy

• Inconsistent data:– PPROM / PTD

– Previa

– Growth restriction

– Abruption14

Klatsky et al, AJOG, 2008.


When to intervene?


When to intervene…

16

34yo G2P0 with AUB, anemia & SAB.

28yo G1P1 bulk symptoms, desires future childbearing.

39yo G0 AUB, anemia, planned IVF transfer.

36yo G0 with AUB, anemia, desires future childbearing


The “art” of medicine

43yo G0 untested fertility, AMH 0.2, desires future childbearing.

32yo G1P1 s/p SVD 6 months ago. Asymptomatic. Concerned about impact of surgery on future pregnancy & delivery.

41yo G0, recently married, desires pregnancy.


PRE-OP CONSIDERATIONS

18

29


PreOp Considerations

• MRI pelvis w/wo gadolinium contrast– Mapping; size, #, location.

– Eval for other pathology adenomyosis/oma, leiomyosarcoma

– Critical for counseling


PreOp Considerations

• Severe anemia– GnRH agonist

– IV iron

– Cell salvage

– PreOp UAE with gelfoam

20


Deciding on Surgical Route

21

• Laparoscopic vs Robotic myomectomy– No RCTs exist

– 8 restrospective studies (large heterogeneity)

• Iavazzo et al, Meta-analysis, 2016. – No difference in:

• Operative time

• Blood loss

• Transfusion

• Length of stay

• Post operative pain

• Complications

• Post operative fertility

Iavazzo et al, Arch Gynecol Obstet, 2016.


Deciding on Surgical Route

• Barakat et al, 2011

• Retrospective review, 575 myomectomies, Jan 1995-Dec 2009– 393 (68.3%) abdominal

– 93 (16.2%) laparoscopic

– 89 (15.5.%) robotic

• Outcomes: OR time, EBL, ∆Hgb, intra-op & post-op complications, length of stay, myoma weight

22Barakat et al, Obstet Gynecol, 2011.


Surgical outcomes by approach

Abdominal(390)

Laparoscopic(93)

Robotic(25)

p- value

Surgical time (min)

126.00(95.00, 177.00)

155.00(98.00, 200.000

181.00(151.00, 265.00)

<.001

Blood loss(mL)

200.00(100.00, 437.50)

150.00(100.00, 200.00)

100.00(50.00, 212.50)

<.001

Hemoglobindrop (g/dL)

2.00(1.40, 2.90)

1.55(1.20, 2.40)

1.30(0.80, 2.28)

<.001

Hospital Stay (d)

3.00(2.00, 3.00)

1.00(0.00, 1.00)

1.00(1.00, 1.00)

<.001

Myoma weight(g)

263.00]90.50, 449.00]

96.65[49.50, 227.25]

223.00[85.25, 391.50]

.002

Barakat et al, Obstet Gynecol, 2011.Gynecology and Obstetrics

OPERATIVE CONSIDERATIONS

24

30


Myomectomy

Basic tenets of surgery:

• Meticulous tissue dissection

• Minimal blood loss

• Minimal damage to reproductive tissues

• Multilayer closure


Minimizing blood loss

• Misoprostol / cytotec– Prostaglandin E1 analog

– 400mcg 1hr prior to surgery

– Reduced EBL, decreased transfusion rate

26Celik et al, Fertil Steril 2003. Kalogiannidis. Clin Exp Obstet Gynecol 2011.



• Vasopressin– Synthetic derivative of ADH

– Potent vasoconstrictor

– Plasma ½ life 10-20 min

– Possible side effects; hypotension, bradycardia, cardiac arrest, pulmonary edema

– Recommended dilution .05-.3 units/mL

– Reduced EBL, decreased transfusion rate

27Frederick et al, Fertil Steril 2013, Hobo et al Obstet Gynecol 2009. Gynecology and Obstetrics


• Tranexamic acid

• GnRH agonist

• PreOp UAE

• Tourniquet

• Oxytocin

• Hemostatic agents; Floseal, Tisseal

28

Shaaban et al, Reprod Sci, 2016. Caglar et al. Eur J Obstet Gynecol Reprod Biol, 2008. Chen et al, J Min Inv Gynecol 2011. Taylor et al, Br J obstet Gynecol 2006. Wang et al, J Minim Invasive Gynecol, 2007.


Myometrial Incision and Closure

• Uterine incision; vertical vs transverse

• CO2 laser

• Barbed suture for closure



• Uterine incision– Vertical vs Transverse

– No studies to compare EBL, adhesion formation, uterine strength or rupture rate

– Determine based on size and location & surgeon preference

30

31



• Benefit of the CO2 laser?– Least thermal damage to surrounding

tissue

– Choussein et al, 2015• Retrospective comparison of myomectomy

using laser vs ultrasonic energy

• No difference in EBL or operative time

– Benefit?... tbd

31Choussein et al, JMIG 2015. Gynecology and Obstetrics

Myometrial incision and closure

• Barbed suture

• Reduced suturing time

• Reduced EBL

• Conflicting data re: adhesion formation

32

Zhang et al, JMIG, 2016. Tinelli et al, Int J Gynecol Obstet, 2016. Einarsson et al, JMIG, 2015. Api et al, Eur J Obstet Gynecol Repro Bio, 2015.


Operative Tips and Tricks

• Minimize number of incisions

• Don’t dig holes

• Ok to trim excess myometrium (but only the excess)

• Multi-layer closure

• Close cavity in event of entry

• Minimize exposed suture


video

34


video


video

36

32


video


video

38


video


POST-OP CONSIDERATIONS

40


Post-Op Adhesions

• Pelvic Adhesions

• Intra-uterine adhesions


Adhesion Formation & Prevention

• Pelvic Adhesions– 30-90% after open, 20-40% after

laparoscopy

– Pelvic pain, ileus/SBO, tubal sterility, future surgical morbidity

42Takeuchi H et al, Fertil Steril, 2008.

33


Adhesion Formation & Prevention

• Factors influencing the risk of adhesions– Increasing myoma size

– Increasing number of myomas

– Myoma location, posterior > anterior

– Use of adhesion barrier

43Takeuchi H et al, Fertil Steril, 2008. Gynecology and Obstetrics

Role of Adhesion Barriers

• Mechanical Barriers– Liquid Barriers

• Polyethylene glycol (Spraygel), Icodextrin solution (Adept), Hyaluronic acid solution (sepraspray)

– Solid Barriers• Hyaluronic acid sheets (sepra film)

• Oxidized regenerated cellulose (interceed)– Reduced effectiveness in the presence of blood or excess

peritoneal fluid

• Fibrin Glue– Fibrin sealant

• Human fibrinogen and thrombin (tisseal, evicel), mimics last step of coagulation cascade 44


Adhesion Formation and Prevention

• Intra-uterine Adhesions– 20-50% incidence

– No association with:• Fibroid size or number

• Cavity entry

• Blood loss

45

Conforti et al. Eur J Obstet Gynecol Repro Biol, 2013. Bhandari S et al. J Human Repro Sciences, 2016. Gynecology and Obstetrics

Prevention of Intra-uterine Adhesions

• Physical barriers– Estrogen

– Intrauterine Foley Catheter

– IUD

– Intrauterine hyaluronic acid

• Repeat hysteroscopy with adhesiolysis

46

Healy et al, AJOG, 2016.


Fibroid Recurrence

47

Time since Myomectomy

Recurrence Rate ReOperation Rate

5 years 53% 7%

8 years 84% 16%

Factors influencing recurrence:- Increasing number of fibroids- Young age- Larger uterine size

Yoo et al, JMIG, 2007. Buckley et al, JMIG, 2015.Gynecology and Obstetrics

Subsequent Conception and Pregnancy

• Time to conception– 3-6 months?

• Uterine rupture– <1% Risk of rupture

• Multi-layer closure

• Minimize use of electrocautery

48

Seracchioli et al, Fertil Steril, 2006. Buckley et al, JMIG, 2015.

34


Pregnancy Outcomes following Robotic Myomectomy

• Pitter et al, 2013.– 872 women undergoing robotic myomectomy

between 10/2005 – 11/2010• 107 women conceived

• 127 pregnancies

• 92 deliveries

– Results:• Mean age at myomectomy 34.8 ± 4.5yrs

• Mean # of myomas removed 3.9 ± 3.2

• Mean myoma size 7.5 ± 3.0cm

• Mean myoma weight 191.7 ± 144.8g

49Pitter, et al, Human Repro, 2013. Gynecology and Obstetrics

Pregnancy outcomes following Robotic Myomectomy

Pregnancy / Delivery Characteristics

%N = 127

95% CI

ART 39.4 32.6, 46.7

Multiples 9.8 5.0, 17.8

Spontaneous AB 18.9 13.0, 26.6

Preterm delivery (<35wks) 17.4* 10.9, 26.5

Uterine rupture 1.1* 0.3, 4.7

50

Pitter, et al, Human Repro, 2013.

- 20% entry into cavity- Time to conception 12.9 ±11.5 months- Avg GA at delivery 36.6 ± 2.6 weeks- <5% vaginal delivery

* N = 92


Conclusions

• The impact of fibroids and myomectomy on infertility is dependent upon fibroid location

• PreOp MRI necessary for characterization of disease and optimal patient counseling

• To optimize patient outcomes and to preserve fertility, minimize blood loss, preserve myometrium, perform multilayer closure and minimize adhesions

• PLENTY of research opportunities


References1. Rock, JA, Jones HW. 2003. TeLinde’s operative gynecology. Philadelphia, PA: Lippincott Williams and

Wilkins.

2. Barakat E, Bedaiway M, Zimberg S et al. Robotic-assisted, laparoscopic and abdominal myomectomy: a comparison of surgical outcomes. Obstet Gynecol. 2011; 117 (2): 256-65.

3. Iavazzo C, Mamais I, Gkedges I. Robotic assisted versus laparoscopic and/or open myomectomy: systematic review and meta-analysis of the clinical evidence. Arch Gynecol Obstet. 2016; 294(1): 5-17.

4. Celik H, Sapmaz E. Use of single preoperative dose of misoprostol is efficacious for patients who undergo abdominal myomectomy. Fertil Steril. D003; 79: 1207-1210.

5. Kalogiannidis I, Xiromeritis P, Prapas N, et al. Intravaginal misoprostol reduces intraoperative blood loss in minimally invasive myomectomy: a randomized clinical trial. Clin Exp Obstet Gynecol. 2011; 38: 46-49.

6. Hobo R, Netsu S Koyasu Y et al. Bradycardia and cardiac arrest casued by intramyometrial injection of vasopressin during a laparoscopially assisted myomectomy. Obstet Gynecol. 2009; 113: 484-486

7. Frederick S, Frederick J, Fletcher H, et al. A trial comparing the use of rectal misoprostol plus perivascular vasopressin with perivascular vasopressin alone to decrease myometrial bleeding at the time of abdominal myomectomy. Fertil Steril. 2013; 100: 1044-1049.

8. Shaaban MM, Ahmed MR, Farhan RE, Dardeer HH. Efficacy of tranexamic acid on myomectomy associated blood loss in patients with multiple myomas: a randomized controlled clinical trial. Reprod Sci. 2016; 23(7): 908-12.

9. Caglar GS, Tasci Y, Kayikcioglu F, Haberal A. Intravenous tranexamic acid use in myomectomy: a prospective randomized double-blind placebo controlled study. Eur J Obstet Gynaecol Obstet. 2008; 137: 227-231.

10. Chen I, Motan T, Kiddoo D. Gonadotropin-releasing hormone agonist in laparoscopic myomectomy ; systematic review and meta-analysis of randomized controlled trials J Minim Invasive Gynecol. 2011; 18:303-309. 52


References11. Taylor A, Magos A. Reducing blood loss at open myomectomy using triple tourniquet: a randomized controled trial. Br J Obstet Gynaecol. 2006; 113:618-19.

12. Wang CJ, Lee CL, Yuen LT, et al. Oxytoxin infusino in laparoscopic myomecomty may decrease operative blood loss. J Minim Invasive Gynecol. 2007; 14: 184-188.

13. Choussein S, Srouji S, Farland L, Gargiuo A. Flexible carbon dioxide laser fibrer versus ultrasonic scalpel in robot-assisted laparoscopic myomectomy. JMIG. 2015; 22(7): 1183-90.

14. Zhange Y, Ma D, Li X, et al. Role of barbed sutures in repairing urterine wall defects in laparoscopic myomectomy: a systemic review and meta-analysis.

15. Tinelli R, Litta P, Angioni S, et al. A multicenter study comparing surgical outcomes and ultrasonographicevaluation of scarring after laparoscopic myomectomy with conventional versus barbed sutures. Int J Gynecol Obstet. 2016; 134: 18-21.

16. Einarsson J, Grazul-Bilska A, Vonnahme A. Barbed vs standard suture: randomized single blinded comparison of adhesion formation and ease of use in an animal model. JMIG. 2011; 18(6): 716-719.

17. Api M, Boza A, Cikman MS, et al. Comparison of barbed and conventional sutures in adhesion formation and histological features in a rat myomectomy model: randomized single blind controlled trial. Eur J ObstetGynecol Repro Bio. 2015; 185: 121-125.

18. Takeuchi H, Kitade M, Kikuchi I, et al. Influencing factors of adhesion development and the efficacy of adhesion-preventing agents in patients undergoing laparoscopic myomectomy as evaluated by a second-look laparoscopy. Fertil Steril. 2008; 89(5): 1247-1253.

19. Pitter MC, Gargiulo AR, Bonaventura LM, et al. Pregnancy outcomes following robot-assisted myomectomy. Human Reproduction. 2013; 28(1) 99-108.

20. Bhandari S, Ganguly I, Agarwal P, Singh A, Gupta N. Effect of myomectomy on endometrial cavity: A prospective study of 51 cases. Journal of Human Reproductive Sciences. 2016;9(2):107-111.


References

21. Healy MW, Schexnayder B, Connell MT, et al. Intrauterine adhesions prevention after hysteroscopy: a systematic review and meta-analysis. AJOG. 2016: Sept; 267-275.e7.

22. Yoo EH, Lee PI, Huh CY, et al. Predictors of leiomyoma recurrence after laparoscopic myomecotmy. J Minim Invasive Gynecol. 2007; 14: 690-697.

23. Buckley VA, Nesbitt-Hawes EM, Atkinson P, et al. Laparoscopic myomectomy: clinical outcomes and comparative evidence. J Minim Invasive Gynecol. 2015: 22(1); 11-25.

24. Seracchioli R, Manuzzi L, Vianello F, et al. Obstetric and delivery outcome of pregnancies achieved after laparoscopic myomectomy.

54

35

Robotic Sacrocolpopexy:Appropriate Technique and

Common Complications

Erinn M. Myers, MDAssistant Professor

Female Pelvic Medicine and Reconstructive Surgery

Carolinas HealthCare System

Charlotte, NC10/11/2016 2

Disclosures


10/11/2016 3

Objectives

• Review procedural steps for sacrocolpopexy

• Discuss common sites of injury

• Discuss management of intraoperative complications

10/11/2016 4

You don’t have to operate

• Remember this is ELECTIVE

• Appropriate patient selection

• Use caution

– Extensive prior abdominal surgery

– Extreme weight

10/11/2016 5

Technique and Complications

• Improper positioning: Nerve injury

• Robotic arm interference: can’t complete the case

• Abdominal access: Avoiding bowel and vascular injury

• Can’t find the promontory: Injury to iliac vein

• Difficulty with dissection avascular spaces: Bladder and bowel injury

• Absence of haptic feedback: using visual not tactile clues for dissection

• Mesh complications

10/11/2016 6

Positioning

Clark‐Pearson, et al. Obstet Gynecol. 2013.

36

10/11/2016 7 10/11/2016 8

10/11/2016 9

Docking to Avoid Arm Interference

10/11/2016 10

Safe abdominal entry: Palmer’s point

X

10/11/2016 11

Promontory is 3 cm medial to right ureter at pelvic brim

McCullough M, et al. FPMRS. 2012. 10/11/2016 12

Good M, et al. AJOG. 2013.

37

10/11/2016 13


10/11/2016 14


10/11/2016 15

Tips for finding sacral promontory

• Finding the promontory: Retrorectal dissection can solve this in obese patients

10/11/2016 16

video

10/11/2016 17

video

10/11/2016 18

video

38

10/11/2016 19

Presacral Hemorrhage

• It shouldn’t happen if you’re at the promontory

• Proper visualization, use 30° down scope if needed

• Floseal™hemostatic matrix works for both venous and arterial bleeding

• Use a raytec sponge for initial compression

• Don’t panic

10/11/2016 20

10/11/2016 21

Bladder injury

• Follow the rule of the FAT

• Retrograde fill the bladder to identify boundaries

– Cystosufflation

– Retrograde fill with fluid

O’Hanlan, KA. JMIG. 2009 10/11/2016 22

video

10/11/2016 23

video

10/11/2016 24

video

39

10/11/2016 25

RCT Mesh Attachment Techniques

Tan‐Kim J. Et al, IUJ. 2014 10/11/2016 26

Anatomic outcomes one year after minimally invasive sacrocolpopexy: a comparison between

permanent and barbed delayed absorbable suture

• Retrospective cohort analysis

• Included women who underwent a minimally invasive

sacrocolpopexy over 36 month period

– 0 Ethibond (95%) and CV2 Gortex (5%)

– 2-0 Vloc 180

• Objective: To compare recurrent prolapse ≥ hymen

and mesh exposure rates at 12 months

10/11/2016 27

Results

Permanentn=140

BDAn=73

P Value

Recurrent Prolapse

6 weeks 9/122 (7.4) 1/49 (2.0) 0.28

1 year 10/64 (15.6) 5/30 (16.7) 1.0

Mesh Exposure

6 weeks 0/139 (0) 0/68 (0) 1.0

1 year 0/72 (0) 0/37 (0) 1.0

10/11/2016 28

Mesh Complications

10/11/2016 29

Mesh complication

• Light-weight mesh

• Avoid braided permanent suture

• +/- concomitant hysterectomy

Shepherd JP, et al. FPMRS. 2010.Myers EM, et al. IUJ. 2015 10/11/2016 30

Summary• Proper positioning:

– prevent nerve injury and avoid robotic arm interference

• Abdominal access: – Remember Palmer’s point

• Sacral Promontory: – 3 cm medial to ureter at pelvic brim and Retrorectal dissection

• Anterior and posterior vaginal dissection:– Fat goes with the viscera

– Retrograde fill bladder, EEA sizer in rectum

• Mesh complications:– Consider supracervical hysterectomy

40

10/11/2016 31

References• Clark-Pearson DL, Geller EJ. Complications of Hysterectomy. Obstet Gynecol. 2013;

121(3):654-73.

• Good MM, Abele TA, Balgobin S, et al. Vascular and ureteral anatomy relative to the midsacral promontory. Am J Obstet Gynecol. 2013; 208(6):468.

• Llarena NC, Shah AB, Milad MP. Bowel injury in gynecologic laparoscopy: a systematic review. Obstet Gynecol. 2015; 125(6):1407-17.

• McCullough M, Valceus J, Downes K, et al. The Ureter as a Landmark for Robotic Sacrocolpopexy. Female Pelvic Med Reconstr Surg. 2012; 18:162-164.

• Myers EM, Siff L, Osmundsen B, et al. Differences in recurrent prolapse at 1 year after total vs supracervical hysterectomy and robotic sacrocolpopexy. Int UrogynecolJ. 2015; 26:585-589.

• O’Hanlan KA. Cystosufflation to prevent bladder injury. J Minim Invasive Gynecol. 2009; 16(2):195-7.

• Shepherd JP, Higdon HL, Standord EJ, et al. Effect of sutures selection on the rate of suture or mesh exposure and surgical failure in abdominal sacrocolpopexy. Female Pelvic Med Reconstr Surg. 2010; 16:229-233.

• Tan-Kim J, Nager C, Grimes C, et al. A randomized trial of vaginal mesh attachment techniques for minimally invasive sacrocolpopexy. Int Urogynecol J. 2015; 26:649-56.

• Tijdink MM, Vierhout ME, Heesakkers JP, et al. Surgical management of mesh related complications after prior pelvic floor reconstructive surgery with mesh. Int UrogynecolJ. 2011; 22:1395-1404 10/11/2016 32

Questions?

10/11/2016 33

Which of the following is true regarding the sacral promontory?

A. It is located 3 cm medial to the right ureter at the pelvic brim

B. It is located above the L5-S1 disc

C. It is located 1 cm below the bifurcation of the aorta

D. Visualization is improved with a 30 degree up scope

E. Bleeding can occur if the dissection is too close to the inferior sacral artery

10/11/2016 34

Which of the following is true regarding the sacral promontory?

A. It is located 3 cm medial to the right ureter at the pelvic brim

B. It is located above the L5-S1 disc

C. It is located 1 cm below the bifurcation of the aorta

D. Visualization is improved with a 30 degree up scope

E. Bleeding can occur if the dissection is too close to the inferior sacral artery

41

Preventing and recognizing complications in robotic gynecologic surgery

Mario M. Leitao, Jr., MDProfessor, Weill Cornell Medical CollegeMember, Gynecology ServiceDirector, Gynecologic Oncology Fellowship ProgramDirector, Minimal Access and Robotic Surgery (MARS) ProgramDepartment of Surgery

@leitaomd

Disclosure

Other: Ad Hoc Speaker and Lab Proctor: Intuitive SurgicalOther: Ad Hoc Speaker: Novadaq

• Anatomy ‐master anatomy

• Principles – master surgical principles

• Tools – master your tools

• Exposure – maximize exposure

• Structures – maximize identification of structures

• Standardize – techniques across all surgeons

Essential Basic Tips in Avoiding Complications

“APTESS”

Courtesy of Yukio Sonoda, MD

Robotic PlatformGeneral thoughts

• A tool • Not new surgery or procedure• A tool that makes minimally invasive surgery easier• Very rare to have “robotic” complication if used

properly• Surgeon who is using the robot has a complication as

with any other tool• A complication is inevitable• Many are avoidable

DOES NOT INCREASE COMPLICATIONSLess than laparotomy

Rosero EB, et al. ObstetGynecol 2013;122:778‐786Wright JD, et al. JAMA 2013;309:689‐698

Wright JD, et al. J ClinOncol 2012;30:783‐791

Series Robotic LaparoscopicP‐

value

Rosero 2013NAny complication

41,2418.8%

165,3818.9% 0.9

Wright 2013 (JAMA)NAny complication

10,7975.5%

75,7615.3% 0.8

Wright 2012 (JCO)NAny complication

1,4378.1%

1,0279.8% 0.1

42

Nerve injuries

Improper positioning during surgery is a cause of post‐operative morbidity

Spectrum of injury, often transient

Joint pain

Muscle ache

Paresthesia

Weakness

Complications associated with improper patient positioning are poorly described and rarely reported

Patient Positioning Injury

Borrowed from Dr. Jonathan Coleman, Urology Service, MSKCC

Compartment Syndromes

Prolonged abnormal positioning Direct soft tissue pressure, typically over boneMuscle hypoxia/ischemia and reperfusion

Tissue swelling within closed fascia compartmentProgressive vascular tamponadeNerve injury

Limb Injuries –Most commonAnatomical isolationFascial compartments

Patient Positioning Injury

Borrowed from Dr. Jonathan Coleman, Urology Service, MSKCC

Risk factors: obesity, male, long case (>4 hours)

RoboticsPatient positioning



43

Patient Positioning

http://www.xodusmedical.com/downloads/Instructions/The‐Pink‐Pad‐IFU‐Rev8.pdf (accessed 8/15/16)

Positioning for robotic proceduresKey points

• Low lithotomy – avoid unnatural and/or excessive flexions/extensions

• Arms tucked, thumbs up, hands padded• Patient cannot move during procedure• Avoid medial pressure on neck• Strap tight around chest• Alert at 4 hours – check patient, limbs, consider break

from Trendelenburg

Vascular injury

MIS: 2 categories of injury

At insertion= laparoscopy

• About 10‐2 to 10‐3

• 83% of injuries reported L‐scopy– 44% Veress Needle, 39% trocar (half disposable)

During MIS

Chapron et al. J Am Coll Surg 1997; 185: 461Sandadi et al. J Min InvGyn 2010; 17: 692

Gas embolusO2 sat, arryth., hypoT, mill wheelRt sided failure

Remove Veress, 100% O2, Trend, RtAtrium. Cath.

ExsanguinationImmediate Hemoperitoneum 88%

Delayed retroperitoneal hematoma 12%

About 10% mortality

Borrowed: P.Escobar, MD

Robotic Trocar PlacementAvoids inferior epigastrics

15‐18 cm

10 cm

8 cm2 cm

8 cm

8 cm8 cm

Minimum distances

44

InstrumentationVascular clamps

Borrowed and modified: P.Escobar, MD

Avulsion Injury

Borrowed: P.Escobar, MD

Renal vein avulsion injury and repair

Burn Injury

Right external iliac artery injury and repair

Major Vascular InjuryBasic tips & common sense approach• Have a “timeout” process in place for each case

• Have vascular instruments handy for each case

• DO NOT start randomly moving or removing instruments

• Grasp bleeding vessel with robotic grasper

• Throw in sponge

• Relax, take charge, and plot out next steps (robot won’t move)

• Call for laparotomy set up

• Call for laparoscopic bulldog clamps, 5‐0 prolene sutures, hemostatic agents

• Find out who is around who can truly help

• Convert to laparotomy any time uncomfortable and before too late

• Obtain best exposure surrounding site of injury

• Assess extent of injury

• Attempt repair if possible

• If not, call for help if none there yet and convert

Major Vascular InjuryConverting considerations

• Robot can be undocked very quickly if needed

• Put all instruments in view

• Pull them all out with trocars still attached to robotic arms

• Can leave one arm attached that is grasping vessel, remove all others, pull them as far away as possible and convert

• Apply bulldog clamps over site, proximal/distal, whatever works and then undock and convert

45

Emergent Conversion for Major Complication

Who What

Attending Surgeon 1. Call for emergent conversion to open procedure, designate person in charge of maintaining tamponade.

Circ RN 2. Push Code “blue” button / or call central desk. Turn on OR lights.

Circ RN 3. Open Robotic Emergency Tray

Anesthesia team 4. Notify anesthesia attending via Vocera

Anesthesia team 5. Initiate IV fluid resuscitation. Confirm adequacy of IV access.

Anesthesia team 6. Request blood products. Request confirmation when sent.

Bedside assistant 7. Maintain tamponade, may initiate removal of some robotic instruments at the direction of attending surgeon

Attending Surgeon 8. Undock Robot at direction of Attending Surgeon

Attending Surgeon 9. Proceed to open

Circ RN 10. Notify all available service attendings for additional help

• Mostly vascular emergencies

• Gowns and gloves always open and available for all console surgeons

• Robot emergency “team timeout” done during “Contingency Plan” section of active timeout for each case

GU injury

Ureteral injuryHow to avoid

• SIMPLE

• OPEN RP SPACE AND IDENTIFY IT!

• Master anatomy

• Upward traction of uterus is helpful

• Lateral extension of cautery, inadvertent clamping, and/or kinking greatest if you aren’t aware of ureter’s location

• Avoid excessive devascularization

• Avoid placement of wide sutures at vaginal cuff angles

• If difficult case, dissect and follow ureter to ensure no injury or kinking

• Ureteral stent use??

• Cystoscopy DOES NOT AVOID injury

Ureteral Anatomy

Effect of Traction

Courtesy of Yukio Sonoda, MD

Best way to avoid ureteral injury

46

Gilmour DT, et al. ObstetGynecol 2006;107:1366‐1372.

Rates of lower GU tract injury in GYNMeta‐analysis of retrospective series

VH=vag hyst; SAH=subtotal hyst; LH=LRS hyst; OGUS=other gynecologic/urogyn procedure (or type of hyst not specified)

Sandberg EM, et al. Obstet Gynecol 2012;120:1363-1370.

Use of cystoscopy during hysterectomy

Ureteral injury and repair

GI injury

Bowel preparation

Mechanical Bowel Prep in CRSRCT meta‐analysis

OutcomePrep

(N)

No prep

(N)Peto OR 95%CI

Anastomotic leak

Peritonitis

Wound infection

Re‐op rates

Mortality

2275

1999

2305

2171

2094

2258

1984

2290

2148

2072

0.99

0.74

1.16

1.04

0.93

0.74 – 1.31

0.50 – 1.08

0.95 – 1.42

0.81 – 1.34

0.58 – 1.47

Guenaga KF, et al. Cochrane Database of Systematic Reviews 2011;Issue 9. Art No,:CD001544. DOI: 10.1002/14651858.CD001544.pub4.

47

Mechanical Bowel PrepLaparoscopy

Won H, et al. Obstet Gynecol 2013;121:538‐546.

Mechanical Bowel PrepLaparoscopy view


Mechanical Bowel PrepLaparoscopy view

Siedhoff MT, et al. Obstet Gynecol 2014;123:562‐567.

Mechanical Bowel PrepLaparoscopy


Injury management

Traumatic Colon InjuryUnprepped bowel

Cleary RK, et al. Dis Colon Rectum 2006;49:1203‐1222.

48

Traumatic Rectal InjuryUnprepped bowel

Cleary RK, et al. Dis Colon Rectum 2006;49:1203‐1222.

Unrecognized injury

•Patients get better fast after MIS

•Low threshold for assessing for injury

•Abdominal pain, significant distention, fever, increased WBC, bandemia

•Do not be fooled if abdominal exam “benign”

•Delayed diagnosis – 4‐5% mortality

Platform fault or malfunction

ENSURE PATIENT IS SAFE

YES NO

No

YES

NO SUDDEN MOVEMENTS OF INSTRUMENTS OR PLATFORM

Press "FAULT OVERRIDE"

Fault overridden?RESUME CASE

Contact Intuitive Customer Support

Institutional process for tracking all events1. Notify robotic coordinators and/or director

2. Maintain log3. RISQ reporting

Contact Intuitive Customer Support and/or Robotic Coordinator

REMOVE ALL INSTRUMENTS IF SAFE AND UNDER DIRECT VISUALIZATION

TURN PLATFORM OFF AND BACK ON SYSTEM REBOOT

90 seconds

DO NOT UNDOCK ARMS FROM TROCARS

Platform functioning properly?

1. UNDOCK PLATFORM2. CONSIDER BRINGING IN ANOTHER PLATFORM

3. COMPLETE CASE WITHOUT ROBOT

THANK YOU!

@leitaomd

Special Thanks to all the wonderful strong women that I have the privilege of being a part of their life

49

Approaches to Advanced Endometriosis and Tissue Containment and Extraction Techniques

GABY MOAWAD, MD, FACOG

Assistant Professor of Obstetrics and Gynecology

AAGL Fellowship Co-Director

Director of GYN Robotic Surgery

The George Washington University

DISCLOSURES

Speakers Bureau: Applied Medical, Intuitive Surgical

OBJECTIVES MRI CORRELATION TO INTRAOPERATIVE FINDINGS OF DEEPLY INFILTRATIVE ENDOMETRIOSIS (DIE)

FIREFLY TECHNOLOGY

REVIEW OPERATIVE TIPS AND TRICKS IN DIE

REVIEW OPERATIVE TIPS AND TRICKS IN TISSUE CONTAINMENT

MRI CORRELATION TO INTRAOPERATIVE FINDINGS OF DIE

BLADDER ENDOMETRIOSIS


50



RECTOVAGINAL ENDOMETRIOSIS



UTERSOSACRAL LIGAMENT ENDOMETRIOSIS

51



SIGMOID ENDOMETRIOSIS SIGMOID ENDOMETRIOSIS:MRI

SIGMOID ENDOMETRIOSIS

LAUNCHED 2011

FDA CLEARANCE : LAP CHOLE

SYSTEM

INDOCYANINE GREEN (ICG)

INFRARED 803nm LASER ILLUMINATOR

IR CAMERA

ICG IDENTIFIES VASCULARITY USING FIRELFY TM CAMERA

FIREFLY TM TECHNOLOGY

52

MINIMAL ENDOMETRIOSIS

Robotic Single-Site Endometriosis Resection Using Firefly Technology Guan, Xiaoming et al.Journal of Minimally InvasiveGynecology , Volume 23 , Issue 1 , 10 - 11

MINIMAL ENDOMETRIOSIS

Robotic Single-Site Endometriosis Resection Using Firefly Technology Guan, Xiaoming et al.Journal of Minimally InvasiveGynecology , Volume 23 , Issue 1 , 10 - 11

OPERATIVE TRICKS FOR DIE

Robotic Cerclage in Advanced-stage Endometriosis Moawad, Gaby N. et al.Journal of Minimally Invasive Gynecology in press

CHALLENGES

INCISION RETRACTOR

53

TISSUE CONTAINMENT TISSUE CONTAINMENT

TISSUE CONTAINMENT TISSUE CONTAINMENT

TISSUE CONTAINMENT TISSUE EXTRACTION

54

CLOSURE

Robotic Single-Site Endometriosis Resection Using Firefly TechnologyGuan, Xiaoming et al.Journal of Minimally Invasive Gynecology ,Volume 23 , Issue 1 , 10 – 11

Robotic Cerclage in Advanced-stage Endometriosis Moawad, Gaby N. et al.Journal of Minimally Invasive Gynecology in press

Novel Use of Indocyanine Green for Intraoperative, Real-timeLocalization of Ureter During Robot-Assisted Excision ofEndometriosis. Park, H et al.Journal of Minimally Invasive Gynecology ,Volume 22 , Issue 6 , S69

Abdominal Approaches to Tissue Containment and Extraction.Moawad, Gaby N. et al.Journal of Minimally Invasive Gynecology inpress

REFERENCES

Thank youAug 5 Issue No. 99

Aug 5 Issue No. 99

55

CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsian

Indo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

56

http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

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