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Robotic Surgery in Gynecologic Oncology and Advanced Benign Gynecology Javier F. Magrina, MD Professor of Gynecology Mayo Clinic Scottsdale Scottsdale, Arizona JFM101603

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Robotic Applications in Gynecologic Oncology

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Robotic Surgery in Gynecologic Oncology and Advanced Benign

Gynecology

Javier F. Magrina, MD

Professor of Gynecology

Mayo Clinic Scottsdale

Scottsdale, Arizona

JFM101603

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Objectives

• Robotic results • Ovarian cancer• Advanced endometriosis

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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

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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

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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

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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

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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

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Robotics vs. LaparoscopyHysterectomy

Complications, %

Robotics Laparoscopy p

Intraop 0 0 NS

Postop 5.1 0 NS

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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

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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

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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

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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

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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

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Robotics vs. Laparoscopy for Endometriosis

Robotics Laparoscopy p

Complications

Intraop 0.1 0 NS

Postop 6 8 NS

Conversion 2 0 NS

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Mayo Clinic Arizona

Robotics vs. Laparoscopy

No major differences in perioperative results

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Conclusion

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

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Robotics for Ovarian Cancer

• Primary debulking• Interval debulking • Recurrent cancer

Disease localized to pelvis and one or two other areas

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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

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Types of Debulking

Type

I Hyst + staging + 1 major

procedure

II Hyst + staging + 2 major

procedures

III Hyst + staging + 3 or more

major procedures

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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

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Type I Debulking in Ovarian CancerMayo Clinic Arizona

Robotics Laparoscopy Laparotomy p

Complications,%

Intraop 20 10 10 NS

Postop 20 5 17 NS

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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

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Type II Debulking in Ovarian CancerMayo Clinic Arizona

Robotics Laparoscopy Laparotomy p

Complications,%

Intraop 0 14 11 NS

Postop 25 0 54 0.01

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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

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Type III Debulking in Ovarian CancerMayo Clinic Arizona

Robotics Laparotomy

Complications,%

Intraop 0 22

Postop 100 56

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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

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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

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Turning OR Table 180

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Head Docking

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Head Docking

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R Upper Docking

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R Upper Docking

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assistantassistant

Pubis

camera

Cameraumbilicus

assistant

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Infrahepatic and Anterior Diaphragm

Right ribs

Right ribs

AssistantAssistant

AssistantAssistant

22ndnd assistant assistant

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Posterior Diaphragm

xyphoidxyphoid

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Need for Incision

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Neoadjuvant Chemotherapy

Increases % MIS for debulking

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Sigmoid and Left Ovary

Before After

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Infracolic OmentumBefore After

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OmentumBefore After

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StomachBefore After

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Right DiaphragmBefore After

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Splenic OmentumBefore After

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PelvisBefore After

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Right PelvisBefore After

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Ascending ColonBefore After

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Hepatic OmentumBefore After

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Right Diaphragm and LiverBefore After

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Liver After

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Left Diaphragm and LiverAfter After

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Robotic Excision Liver Metastasis

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Excision Diaphragm Peritoneum

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Robotic Full-thickness Diaphragm Resection

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Robotic Excision Diaphragm Endometriosis

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Robotic Resection L Diaphragm Recurrence

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Infracolonic Omentectomy

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Thank you