3rd ANNUAL CONFERENCE
6 – 7th SEPTEMBER 2012, MANCHESTER
ABSTRACTS
Dr Mo’iad Alazzam
Consultant Surgeon & Oncologist, Galway Clinic, Ireland
The successful robotic programme - A guide to implementation.
Over the last few years, robotic surgery in gynaecology has increased significantly and surpassed urological robotic procedures. The experiences of different hospitals with the robotic programme have been fairly mixed especially in Europe.
The adoption of robotic programme institution requires a well-structure plan to ensure successful implementation. A thorough initial planning and designing with clear vision of the scope and volume services is paramount prior to implementing the programme. Once purchased, the focus should be on safely establishing the service. Implementing & maintaining robotic surgery service requires huge level of commitment and coordination.
Professor Sami Gokhan Kilic
Associate Professor, Director of Minimally Invasive Gynecology and Research, UTMB, Galveston, USA
Robotic sacrocolpopexy for the management of uterine and vaginal vault prolapse.
In this presentation we describe robotic-assisted approach to sacrocolpopexy, focusing on indications, technique, complications, and outcomes.
EVALUATION AND SURGICAL INDICATIONS: The clinical evaluation of the patient with apical prolapse includes a complete history and physical examination as well as a limited number of additional tests. Considerations such as symptomatology, associated organ prolapse, urinary incontinence, reproductive status, and sexual function all influence the choice of management. A careful examination with the patient sitting at a 45-degree angle or standing often produces the abdominal pressure needed to expose the apical defect.
TECHNIQUE AND CONCOMITANT PROCEDURE: Preoperative preparation: All patients should have a vaginal exam before the surgery and in case of bacterial vaginosis, it should be treated accordingly. Pretreatment atrophic vaginitis also should be treated with local estrogen treatment 6 weeks to 3 months before the surgery. Fasting starts at midnight before surgery.
Patient positioning and initial preparation: When the combined surgeries perform, trocar placements, positioning of the patient, the number of trocars, and placement of the trocars should be discussed beforehand the surgeon who is involved with the sacrocolpopexy part only after the hysterectomy is done.
Access and port placement: There are different approaches for robotic sacrocolpopexy and most of them are implemented from the laparoscopy sacrocolpopexy cases. The number of trocars, depending on the surgeon’s discretion, varies from 4 to 6 trocars including camera, robotic arms, and assistant port.
SURGICAL TECHNIQUE
Sacral Dissection: We prefer to start from sacral area dissection which is the most critical part of the dissection, since it would avoid wasting further time to abort the procedure when any problem occurs.
Anterior Dissection: Anterior dissection carry out usually based on the patient’s requirement’s for correction of pelvic prolapse.
Posterior Dissection:
The traction between the rectum and the vagina to create an optimum visualization before creating the posterior rectal vaginal plane. Both the initial of posterior and anterior dissections incision is made 1 cm away from the vaginal cuff closing area to decrease the risk of mesh exposure later on in case the hysterectomy is performed at the time surgery simultaneously.
Mesh Preparation: For sacrocolpopexy, wide- pore polypropylene mesh is most commonly used in RASC and this mesh commonly called Y- shaped mesh as pre- packaged. During mesh measurement should be careful to avoid any tension on the mesh. Redundant mesh at the promontorium site is removed.
Cystoscopy can be considered to assure the right ureter opening as well as ruling out bladder injuries during the dissection. The robot should be undone and the patient’s Trendelenburg position must be reversed for cystoscopy. Indigo carmine (5 cc) is given IV. Indigo carmen should be given free arm of blood pressure cuff or to be sure that blood pressure cuff is out of work at the time, otherwise given indigo carmen under pressure can cause local spread in the arm. During the cystoscopy, before indigo carmine reaches the bladder, the bladder should be examined under cystoscopy with 30° scope. Once the blue dye has reached the bladder, the right ureter should be examined to reassure good efflux
Follow- up: The patient should be seen in post op 6 weeks and 3 months again for to check vaginal cuff and mesh erosions. The patients who have atrophic vaginitis should continue to be treated with local vaginal estrogen treatment starting six weeks after surgery.
OUTCOMES AND COMPLICATIONS
Anatomical and functional outcomes of RASC: The current literature is limited about compared to long term follow- up of RASC between open or laparoscopic sacrocolpopexy and mainly depend on cohort series. Within 10 days after surgery, women who underwent RASC did not return to their preoperative level of physical activity faster than women who underwent this procedure via laparotomy, and pain control was not improved after RASC compared to ASC.
Complications: Although the potential complications of laparoscopic approaches and open surgery already described , however, this complications are similar to robotic surgery, use of da Vinci robot have specific complications.
Disadvantages: One of the most argued against to robotic surgery is the cost. The cost of robotic surgery mainly depend on purchase of the surgical system, annual maintenance cost, robotic instrument costs which can be only used for a finite number of cases before disposal.
Conclusion: The primary advantages of robotic sacrocolpopexy are dexterity, three dimensional vision, certainty of wrist movement, easy suturing and knotting and decreased blood loss, length of hospital stay, and convalescence. It is necessary that more studies and long term follow- up is required to be known exact information of useful of robotic sacrocolpopexy compared to open surgery.
Mr Ahmed Sekotory Ahmed
Consultant Gynaecological Oncology Surgeon, The Christie NHS Foundation Trust, Manchester UK
ABSTRACT 1: Staging for Endometrial Cancer; Standard Technical steps and operative considerations
Experience is rapidly accumulating in the field of Robotic Staging in Gynaecological Oncology; particularly in Endometrial Cancer. The concept of staging for endometrial cancer varies across different Centres and countries. Many Centres would rely on preoperative imaging to assess nodal status and gauge the need for adjuvant therapy according to the uterine risk factors in the hysterectomy specimen. Staging in these Centres is merely a full hysterectomy and bilateral salpingo-oophorectomy procedure with thorough examination of the abdominal cavity and lymph nodes, dissecting only the pathological ones. Yet, the standard FIGO staging encompasses objective assessment of the pelvic and para-aortic lymph nodes by dissecting them with the hysterectomy procedure. This presentation would cover the full FIGO staging for endometrial cancer including Retroperitoneal Node Dissection. Patient selection, positioning, vaginal manipulation and trocar placement are all important factors not to be ignored. Hitherto, central docking between the patient’s legs remains the preferred ideal place for the patient cart for the complete staging of endometrial cancer. This docking approach mainly facilitates para-aortic node dissection. Trocars are placed at a higher position compared with the standard hysterectomy. Whether to perform the hysterectomy or nodal dissection first depends on the local policy and both are acceptable. Developing anatomical spaces prior to embarking on major steps is central to successful completion of the procedure. The essential steps of the full staging procedure will be highlighted and discussed in a hybrid combination of video clips and demonstration slides
Mr Ahmed Sekotory Ahmed
Consultant Gynaecological Oncology Surgeon, The Christie NHS Foundation Trust, Manchester UK
ABSTRACT 2: Radical Vaginal Trachelectomy; approaches and results of pooled data.
Vaginal radical trachelectomy and bilateral pelvic lymph node dissection for early T1b1N0M0 cervical cancer has become an established safe fertility preserving procedure with acceptable results. It is mainly reserved to tumours less than 2 cm maximum diameter but in certain selected patients larger tumours may be considered. Both squamous and adenocarcinoma sub-types are suitable for the procedures; this also applies to tumours exhibiting lymphovascular space invasion. The literature reports on just under a thousand cases. Survival is reassuringly in the region of 97% with an acceptable recurrence rate of <4% which is comparable to definitive surgery with the radical hysterectomy procedure. Approximately a quarter of patients fall pregnant; however this does not account for those who did not wish to embark on a pregnancy at the time of different reports. Out of all pregnancies, 47% were delivered at term and 17% were premature. Although this is an encouraging obstetric outcome, pregnancy remains to be a high risk one that is better managed in a multi-disciplinary team approach. This presentation aims to cover essential aspects of the procedure including patient selection, technical considerations
Christina Etén Bergqvist RN BscN
Theatre Nurse, Dept of Obstetrics and Gynaecology, Skåne University Hospital, Lund, Sweden
Safety aspects in robotic surgery; the nurse´s perspective
Background:
Robotic assisted laparoscopic surgery creates different challenges in perioperative nursing.
Safety aspects, hygiene and communication are always of utmost importance in surgery. With “a robot” as a member of the surgical team these subjects must be even more highlighted (1).
Safety can be achieved by good team work and an adequate training program including trouble shooting and emergency exercises (2, 3). A well organized OR suite with enough space for the robot system contributes to a safe working environment. Other useful tools for safety are guidelines, checklists and standardization of the perioperative work and the technical equipment (4).
Focus of interest:
This presentation will focus on important factors that make robotic surgery safe both for the patient and the robotic team.
References:
1. Lingard, L., Espin, S., Whyte, S., Regehr, G., Baker, GR., Reznick, R., Bohnen, J., Orser, B., Doran, D., Grober, E. (2004). Communication failures in the operating room: an observational classification of recurrent types and effects. Quality and Safety in Health Care, 13, 330-334.
2. Wiley Nifong, L., Randolph Chitwood, Jr, W. (2004). Building a surgical robotics program. The American Journal of Surgery, 188, (suppl October), 165-185.
3. Sullivan, Michael J., Frost, Elizabeth A M., Lew, Michael W. ( 2008). Anaesthetic Care of The Patient for Robotic Surgery. Middle East Journal of Anaesthesia 19 (5), 967-982. 4.Francis, P. (2008). New technology and patient safety go hand in hand. OR Nurse, January, 41-46.
Keywords:
Communication, hygiene, perioperative nursing, robotic surgery, safety
Mr Simon Butler-Manuel
Consultant in Gynaecological Oncology, St Luke’s Cancer Centre, Royal Surrey County Hospital, Guildford, Surrey
Robotic Surgery in Cervical Cancer: management options and outcome data
Abstract:
The management of early-stage cervical cancer is essentially surgical and consists of excision of the central tumour +/- pelvic lymphadenectomy. Excision may be simple or radical if the parametria are excised, and/or fertility-sparing. Sentinel node assessment is being evaluated as an alternative to lymphadenectomy, while autonomic nerve-sparing approaches to radical hysterectomy are increasingly used to reduce the morbidity of parametrectomy.
Robotics enhances the benefits of laparoscopic surgery including reduced blood loss, short hospital stay and faster recovery, with 3-D HD visualization, autonomy of camera control and wristed instrumentation resulting in fine instrument control. These facilitate complex procedures and lead to a better appreciation of surgical anatomy.
Complex laparoscopic oncology surgery is still not widely available. Learning and maintaining the necessary surgical skills is faster and more intuitive with robotics than with ‘traditional’ laparoscopy. Our initial experience performing robotic surgery for early-stage cervical cancer including node dissection, radical trachelectomy, parametrectomy, simple and radical hysterectomy suggests a further reduction in blood loss and in-hospital stay compared with laparoscopy. Standard approaches have yet to be defined, but robotics allows difficult procedures to be performed to the surgeon’s satisfaction, suggesting an improvement in quality and reproducibility.
The relative infrequency of cervical cancer and the development of individualized treatments for early-stage disease have lead to smaller numbers of a wider variety of surgical procedures being offered. Centres treating cervical cancer, and those involved in training Gynae-oncologists, should be able to offer patients a full range of treatment options including advanced laparoscopic surgery or preferably robotics.
Mr Raj Naik
Consultant Gynaecological Oncologist, Northern Gynaecological Oncology Centre, Gateshead
The total laparoscopic radical trachelectomy video demonstrates the anatomical spaces that need to be developed when performing a radical surgical procedure for treatment of cervical cancer. Demonstrating these spaces is more readily achievable and demonstrable laparoscopically than via an open or vaginal approach. It is only after exposing these anatomical spaces satisfactorily that it is then possible to tailor the radicality of the surgical procedure to the tumour and the patient. Whilst there is good evidence that a vaginal trachelectomy is less radical than an open approach therefore making it unsuitable for larger tumours, we will demonstrate that the radicality of the procedure compared to an open approach is not compromised using the laparoscopic approach. Nerve sparing procedures are also more easily performed laparoscopically compared to open surgery. When combined with better visibility, easier assistance, reduced blood loss, swift post-op recovery, ease of training and arguably reduced complications, we would recommend total laparoscopic surgery rather than the open or vaginal routes for women with cervical cancer who are wanting to preserve fertility.
Peter Barton-Smith; Nikolaos Akrivos
Consultant Gynaecologist/Senior Clinical Fellow, The Royal Surrey County Hospital, Egerton Road, Guildford, Surrey
Cost of robotic gynaecological surgery in a U.K. setting
Aim: To evaluate the cost of benign robotic gynaecological surgery in a District General Hospital in U.K. and to examine if the National Health Service (NHS) and economic situation encourage the use of robotic technology.
Methods: A Retrospective financial analysis of strategic costs, specific robotic equipment costs, and full absorption costing for open, laparoscopic and robotic surgery for a variety of benign procedures judged against the National Tariffs that the hospital receives for each case.
Results: The robot incurs a cost to the hospital whether it is used or not of £199,000 per annum due to depreciation and maintenance contract. This cost can be spread if the robot is used more frequently (£1,990 per case for 100 cases per year or £265 per case for 750 cases). The cost of a robotic hysterectomy for theatre equipment and sterilization is £1930,29 per case versus £79.94 for open. Full absorption costing increased this amount to £4.354,31 making it more expensive than either open (£2926.50) surgery even compensating for reduced stay and other factors. The National Elective Tariff for the same procedure was £2480.04 suggesting a loss to the hospital of £1.874,27 per case. The fact that open hysterectomy is the cheapest approach for the NHS is a perverse incentive to continue to let open surgery be the main approach in benign gynaecology. Conclusions: In order to get robotics closer to cost neutral at hospital level other strategies need to be employed to reduce the deficit.
Peter Barton-Smith; Nikolaos Akrivos
Consultant Gynaecologist/Senior Clinical Fellow, The Royal Surrey County Hospital, Guildford, Surrey
ViKY Uterine Positioner in gynaecological robotic surgery
Aim: A pilot study of uterine manipulation with a new surgical robot for gynaecological surgery.
Methods: A prospective cohort study of the ViKY Uterine Positioner in combination with the V-Care manipulator. Data was recorded relating to set up, operating time, usability and complications.
Results: 36 cases were performed between July 2010 and February 2012 including 31 hysterectomies, 2 myomectomies, 2 sacrocolpopexies and 1 severe endometriosis. Mean was age 48, BMI 25.7, uterine weight 231g. 9 cases were foot controlled and 27 by Bluetooth voice control. Mean procedure (skin to skin) duration was 142min whilst mean ViKY docking time once V-Care inserted, was 4.3min. No perioperative complications were observed. Adequate mobilization, visualization and range of movements was possible in 81, 78 and 61% of cases respectively with most of the problems arising in cases with uterine weight > 350g. ViKY positioner was detached and an assistant was required in 3 cases, whilst V-Care came out of the uterus in 1 case. The learning curve led to various adjustments including optimizing patient position, increasing the device range of movement and adjusting device sensitivity. As a result problems were minimised in our last 9 cases.
Conclusions: Adding robotic uterine manipulation is the obvious next step to give the gynaecologist the ultimate control and stability of the uterus during MIS without having to lift their head from the viewfinder. ViKY Uterine Positioner is the first device to deliver this. Pilot study results show it to be very safe, effective and easy to learn.
Nikolaos Akrivos;Kavitha Madhuri; Anil Tailor; SimonButler-Manuel; Peter Barton-Smith
Department of Gynaecology & Gynaecological Oncology, The Royal Surrey County Hospital, Guildford, Surrey
Fellowship in Robotic Gynaecological Surgery. Reflections of a trainee’s experience.
I am the first trainee in a post certificate completion training fellowship in robotic gynaecological surgery at Royal Surrey County Hospital in Guildford. I have received training in complex benign and oncological surgery from 3 consultants-mentors. Data on my operative experience will be presented together with reflections on the learning process and the future of training in robotic surgery in U.K.
Gokhan S Kilic, M.D.; Omer L Tapisiz, M.D.; Ana M Rodriguez, M.D.; Daniel H Freeman, Jr. PhD; and Mostafa Borahay, M.D.
Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas USA
Comparison of perioperative outcomes of total robotically assisted, laparoscopic and open abdominal hysterectomy cases in obese patient population
Design: In this cohort study minimally invasive surgeries collected prospectively, control groupdeveloped retrospectively until target case numbers matched.