11.3.1.1 Simulation

Speed is the essence of this procedure; blood flows in the hourglass of myomectomy. Fortunately, top technical proficiency at the robotic console can be achieved outside of the operating room, through one of the many available digital simulation options. This is an ethical imperative for every aspiring robotic surgeon and surgical trainee [21]. Until a specific simulation protocol for myomectomy comes about, we recommend passing the validated protocol published by Culligan et al. [22] as a prerequisite for attempting robotic myomectomy. Moreover, the makers of the only currently available robotic console have developed specific simulator exercises combinations to hone one’s console skills in preparation for specific gynecologic operations, including myomectomy.

11.3.1.2 Case Selection

Reproductive surgeons transitioning to robotics should adhere to the recently published AAGL credentialing criteria to identify basic robotic myomectomy (a maximum myoma number of 4 and a maximum myoma size of 6 cm) [23]. This case selection should be in place for the first 15 cases, at a minimum. Expert surgeons will rapidly increase their comfort zone in terms of myoma size and number once they move beyond the robotic learning curve. Current top single myoma size at our institution lies between 15 and 20 cm. Current top myoma number is at 15. Final assessment is made on a case-by-case basis, and depends on the location and cumulative uterine size, among other general preoperative considerations.

11.3.1.3 Magnetic Resonance Imaging

When the goal is extraction of deeply situated tumors of uncertain nature that lie adjacent to irreplaceable anatomical structures, high-quality preoperative imaging is essential. One could say that this is particularly relevant when we operate in the absence of haptic feedback. However, the superiority of imaging over direct tactile feedback in myomectomy has been proven even for the open technique [24]. Hence, myoma mapping through imaging has more clinical impact than any degree of tactile feedback in myomectomy. The ability of MRI to detect and locate smaller (but potentially clinically significant) fibroids is superior to ultrasound, and so is its accuracy in ruling out adenomyosis, a condition that changes indications, counseling, and execution of surgery (see Section 11.3.1.9) [25,26]. Additionally, MRI has a developing role in the screening for leiomyosarcoma. In addition to morphological features (namely peripheral margins and necrosis), diffusion-weighted imaging (DWI) is a useful tool in defining the benign or malignant nature of large uterine lesions, particularly when high signal intensity is seen on T2-weighted images [27].

In our robotic operating rooms, a large video display is dedicated to the display of key MRI images at all time during our operations. The TilePro™ function of current robotic platforms allows the direct visualization of the MRI images through the robotic operator console. We have not found this technology to provide a real advantage though, because both the laparoscope feed and the MRI images become too small to be of real assistance.

11.3.1.4 Timing

The timing of surgery in relation to phases of the menstrual cycle has only been addressed at the level of expert opinion. In the absence of strong evidence, avoidance of surgery in the perimenstrual phase can be considered, but it is not strictly recommended.

11.3.1.5 GnRH Agonists

Known benefits of pretreatment with GnRH agonists (GnRHa) in myomectomy include a decrease in intraoperative blood loss and a lower risk for perioperative blood transfusion (largely based on better preoperative hematocrit). Indeed, the only Food and Drug Administration (FDA)-approved use of depot leuprolide in the treatment of uterine fibroids is preoperative. Patients with fibroid-induced anemia and large fibroids are ideal candidates for the use of these drugs. In these cases we administer a quarterly Depot dose and plan the surgery for 3 months later. The expected shrinking of most fibroids is between 30% and 40% of the original volume. Fibroids that are poorly vascularized or frankly necrotic at MRI may not shrink, and should probably be addressed with minimal delay. The preoperative use of GnRHa is ill-advised in cases where small myomata are present. A potential risk in such scenarios is that of missing fibroids in surgery because they have become too small; this can result in a rapid postoperative recurrence once the patient is off GnRHa.

11.3.1.6 Misoprostol

Misoprostol induces uterine contractions and vascular constriction. Preoperative administration of misoprostol (vaginal or rectal) has been shown to decrease intraoperative bleeding in abdominal myomectomy. We currently administer a single 400 mcg rectal dose of misoprostol at the time of patient positioning in the operating room, following induction of anesthesia. A double dose (400 mcg 3 hours before and 1 hour before surgery) has been shown to be more effective, but it is less practical in the setting of a day surgery protocol, because it can cause diarrhea and cramping by the time of patient admission [28,29].

11.3.1.7 Tranexamic Acid

This antifibrinolytic agent is an excellent therapeutic option in patients with abnormal uterine bleeding. It is generally well tolerated and very safe (available over the counter in the European Union for the treatment of menorrhagia). Its role in the treatment of symptomatic fibroids is emerging. However, its role to decrease intraoperative blood loss in myomectomy is not established. The only randomized study employing intravenous tranexamic acid has not found a significant advantage in terms of blood loss during open myomectomy [30].

11.3.1.8 Informed Consent

There is no question that the recent controversy surrounding the use of electromechanical morcellation in laparoscopic myomectomy [2] has impacted the practice style of many surgeons in terms of the informed consent process. We recommend that a surgical consent for robot-assisted laparoscopic myomectomy should be delivered at a sixth-grade language level, and in the format of a detailed contract between the patient and the operator. It should always be stored in the electronic record and should contain (at a very minimum) the following sections:

1. 
   

   (a) self-explanatory name for the planned surgery (no acronyms)

   
   
2. 
   

   (b) indication(s) for surgery

   
   
3. 
   

   (c) alternatives discussed and declined (always including hysterectomy)

   
   
4. 
   

   (d) concise review of the preoperative testing performed, as well as the limitations of such preoperative testing in detecting all uterine cancer

   
   
5. 
   

   (e) conservative risk assessment of the prevalence of uterine cancer among patients undergoing myomectomy [31]

   
   
6. 
   

   (f) specific mention of the current limitations imposed by the FDA (or other regulatory agency or hospital administrative body) on the use of electromechanical morcellation

   
   
7. 
   

   (g) specific mention of the planned use of robotic devices in the upcoming surgery, and the specific level of FDA approval for their use.

11.3.1.9 Special Considerations for Adenomyomectomy

The modern reproductive surgeon must never face unexpected adenomyosis. Rather, he or she should take active steps to diagnose it radiologically and plan accordingly. High-quality imaging is the starting point of therapeutic success in adenomyosis. In the early days of robotic surgery, I agreed to proctor a very experienced reproductive surgeon on his first robotic myomectomy. An oblong 8 cm anterior intramural myoma had been identified by an expert sonographer. An MRI was ordered, per our protocol, which identified diffuse adenomyosis infiltrating the entire anterior myometrium, but no fibroid. The robotic case was canceled, and an alternative management was planned for this patient. The MRI saved the day on that occasion, as it has done for my patients many times before and since. Recent technological developments in three-dimensional high-definition ultrasonography have made it an acceptable alternative to MRI, provided that one understands the limitations of an operator-dependent modality such as ultrasound, as opposed to the operator-independent nature of MRI. There is an added value to the surgeon reading the preoperative MRI, or performing the three-dimensional ultrasonography: surgeons enjoy a unique visual feedback of the actual pathology during surgery, and therefore are in a unique position to build exceptional diagnostic imaging skills over time. Without exception, an expert reproductive surgeon should never operate without having studied the images; radiology reports should not be overlooked, but they should never guide our decisions.

Once adenomyosis is correctly diagnosed, a complex patient counseling follows, the scope of which is vastly beyond that of this chapter. A concise take-home message from the robotic surgeon’s standpoint is the following. There is no doubt that robotic platforms empower gynecologists to address adenomyosis laparoscopically as effectively as they would at laparotomy: this fact however does not broaden the surgical indications for adenomyomectomy, and restraint must be observed. With a few exceptions, surgery should be limited to focal adenomyosis, because adenomyomectomy implies loss of myometrium, whereas myomectomy, when performed with intracapsular technique (discussed later in section 11.3.2.1), does not result in any tissue loss [32]. High-complexity conservative surgical procedures for diffuse uterine adenomyosis have been described, and the long-term follow-up of these operations is reportedly good [33,34]. However, it should be stressed that these are open microsurgical procedures that have not been replicated laparoscopically or robotically and should not be performed outside of an experimental protocol for the foreseeable future.

11.3.2.1 General Technical Considerations

Hemostasis is, obviously, paramount. A Trendelenburg angle of 20–25º and an intraabdominal pressure of 15 mmHg will help decrease uterine arterial pressure, but judicious use of dilute vasopressin causes a very effective vasoconstriction. We infiltrate 5 IU of vasopressin in the myometrium (note that no untoward events have ever been reported with doses under 5 IU) and repeat the injection every 30–60 minutes, if needed. A recent randomized study has demonstrated with finality that the degree of dilution has no effect on the efficacy of vasopressin [35]. We dilute a standard 20 IU ampoule of vasopressin in 40 cc or 100 cc of normal saline; a 5 IU infiltration would therefore employ 10 cc or 25 cc of the above solutions, respectively.

The choice of energy is important for hemostasis, also to limit the risk for adhesion formation and uterine rupture. Our energy tools of choice are the ultrasonic scalpel and the CO₂ laser. We do not employ monopolar electrocautery in women of reproductive age but have done so occasionally in postreproductive myomectomy cases. The dramatic reduction in collateral thermal damage obtained by avoiding monopolar energy is well documented. When monopolar cautery is used, it should exclusively be used in the cutting mode, as the coagulation mode results in even more significant uterine tissue damage [36]. To date, all reported uterine ruptures following laparoscopic and robotic myomectomy have occurred following monopolar or bipolar electrocautery use [14]. We are unaware of any reports implicating the use of ultrasonic scalpel or CO₂ laser in a subsequent uterine rupture.

Regardless of the type of energy chosen for the hysterotomy, one should always remember that the surface of the hysterotomy must be completely free of char and should ideally be oozing from transected myometrial vessels. Hemostasis in myomectomy is achieved with suturing.

The type of uterine incision for myomectomy remains a matter of personal preference, as arguments have been proposed in support of both transverse and sagittal incisions (relative to the axis of the uterus). In robot-assisted myomectomy, the type of incision can influence the speed and accuracy of myometrial repair. In general, the triangulation achieved by the most common robotic port placements (see earlier discussion in Section 11.2) facilitates the repair of transverse uterine incisions in particular. Elliptical incisions should be reserved for FIGO 7 myomata, and some FIGO 6 myomata covered by a very thin layer of uterine serosa, because these incisions cause loss of native uterine tissue. Elliptical incisions are also more technically difficult to repair compared to any linear incision. When addressing FIGO 7 myomas, it is important that the elliptical incision be performed at the equator of the mass, lest the tissue should retract and result in a more challenging closure of the defect. Also with FIGO 7 myomas, vasopressin should be injected away from the tumor pedicle, to avoid intravascular injection (which is both ineffective and dangerous).

Effective myoma enucleation is based on three cardinal principles:

1. 
   

   (a) planning the location of the incision(s) and the vector(s) of the enucleation based on preoperative imaging

   
   
2. 
   

   (b) entering the pericapsular space

   
   
3. 
   

   (c) applying steady traction to the myoma(s) with a tenaculum, while proceeding with gentle detachment of the pseudocapsule (and its all-important neurovascular bundle) using mechanical counter-traction and minimal thermal energy application [32].

Chromopertubation with methylene blue or indigo carmine (depending on availability) is performed in most of our myomectomies to identify any breach into the uterine cavity in a timely fashion. Early identification of a breached endometrial cavity is very helpful in limiting further damage and guiding repair (see discussion later in this section). Even though it can be reassuring to observe tubal fill and spill at the time of such chromopertubation, one should remain cognizant of the fact that the fallopian tubes may scar after myomectomy and that failures of the tubes to fill and spill during myomectomies can be for reasons independent of the actual anatomical compartment (tissue edema, low injection pressure from points of leak, etc.). Hence, chromotubation at the time of myomectomy is done to recognize endometrial entry.

Repair in layers is an essential feature of myomectomy. This is where the increased dexterity offered by robotic assistance has been shown to generally improve the operators’ ability to proceed with an uncompromised technique. A recent study reports that a single-layer suturing represents the prevailing type of repair in conventional laparoscopic myomectomy, in contrast to a two- and three-layer suturing in robotic myomectomy [37]. The number of layers depends on the size and depth of the incision; we use between one and five layers. When the endometrial cavity is breached, we carefully approximate the edges of the endometrial tear, and proceed with a running closure of the layer of myometrium immediately above it, so that no suture comes close to the endometrium itself. Reapproximation of an endometrial tear is the only situation in which we occasionally use a nonbarbed suture in myomectomy. Other than that, a delayed absorbable 2.0 barbed suture is considered the optimal choice in the modern approach to minimally invasive myomectomy [38]. A barbed suture can be used all the way to the serosal layer (be it a subserosal closure or a classic imbricating “baseball stitch”). Because of case reports of postoperative bowel obstruction associated with the use of barbed sutures, it is important to avoid leaving exposed barbs on the serosal surface; a simple running suture on the outermost layer of the uterine repair is never acceptable.

The choice of adhesion-prevention barriers is a personal one, and a review of the vast literature on this aspect of reproductive surgery is not immediately relevant to this chapter. We universally apply oxidized regenerated cellulose to cover all of the uterine incisions and all deperitonealized areas. Some surgeons suture the mesh in place. Although this can easily be accomplished robotically with a 4.0 or 6.0 Vicryl suture, we have noticed that suturing the mesh in pace can result in its staining with blood from the suture points. Because this is known to increase the chance of postoperative adhesions in studies employing this type of barrier, we do not suture this barrier in place. We take particular care in suctioning all blood and irrigation fluid from the abdominal cavity before the end of the case, in order to avoid a postoperative flooding of the pelvis which is likely to wash away the barrier.

11.3.2.2 Techniques for Small Myomas (<7 cm Diameter)

Please refer to Section 11.2 on port placement for a general explanation of the positioning described here. Myomas of this size are universally addressed with fully cosmetic approach, which means that they can either be completed through single-site surgery or through a cosmetic multiport approach.

Our single-site approach has been recently published in full detail [39,40]. The main steps can be summarized as follows. Please refer to Figure 11.2 for illustrations of the following operative steps:

1. 
   

   1. The patient is anesthetized in supine position on a disposable memory foam pad and then positioned in dorsal lithotomy on Allen stirrups with both arms tucked along her sides in clear plastic toboggans. Foam padding is placed to protect the arms, thighs, and face. Standard surgical preparation is performed following the exam under anesthesia and the placement of rectal misoprostol (see Section 11.4.1.6).

   
   
2. 
   

   2. A uterine manipulator with chromopertubation capacity and without cervical delineator is placed. A standard Foley catheter is placed. An 8.5 mm primary cannula of the da Vinci Surgical System is placed in the umbilicus. The 8 mm robotic laparoscope is inserted to confirm an atraumatic entry before Trendelenburg position (20–25º angle) is obtained. A full inspection of the pelvis, facilitated by the use of the uterine manipulator, is made to confirm that the patient is a candidate for single-site surgery. If not a candidate, then a cosmetic multiport technique is chosen (see later in this section).

   
   
3. 
   

   3. While keeping the primary steel cannula in the umbilicus, the primary skin incision is extended cephalad and caudad to a final length of 2.5 cm. The cannula is a backstop to the knife so that the widening of the umbilical incision is safe and fast. The skin incision is then carried down to the fascia with a knife and with curved Mayo scissors (similar to the classic technique for open laparoscopy). The index finger is used to perform a 360º palpation around the inner margin of the incision to rule out the presence of bowel or omental adhesions. Sutures are introduced in the abdominal cavity within a closed endoscopic specimen bag connected to a lifeline. Between three and five sutures (20 cm long, 2.0 barbed) are placed in the bag. Alternatively, a Gelpoint Mini (single-incision-laparoscopy port) is placed at this point; this is particularly useful when the abdominal wall is unusually thick (obese patients), or if there are upper abdominal adhesions that need to be removed with single-incision conventional laparoscopy technique.

   
   
4. 
   

   4. The da Vinci Surgical System’s multilumen silicone port is set within the umbilical incision (or within the mini Alexis retractor of the GelPoint Mini, if used as described in the previous paragraph, for obese patients) and the abdominal cavity is insufflated again. A camera cannula is placed through the dedicated lumen of the silicon port, the robotic patient-side cart is docked in a central position, and the camera arm secured to cannula. The robotic laparoscope is inserted. Two 250 mm instrument curved cannulas inserted under continuous laparoscopic guidance and connected to robotic arms #1 and #2. We have found the 5 mm and 10 mm assistant ports provided in this instrument kit to be of limited use in this particular operation. The 5 mm port is too small and the 10 mm port does not allow for a smooth use of arm #2. Hence, an 8 mm bariatric (long) robotic instrument cannula is placed through the dedicated assistant cannula lumen of the silicon port.

   
   
5. 
   

   5. Two semirigid 5 mm wristed robotic needle drivers are loaded through the curved cannulas. A flexible laser fiber is inserted through the 8 mm assistant port. The tip of the fiber (in its armored guide) is grasped and operated with either of the wristed needle drivers.

   
   
6. 
   

   6. Dilute vasopressin is injected with a spinal needle inserted suprapubically. CO₂ laser is set at 20 W. A nonwristed monopolar cautery hook can be used for this technique, with all the limitations implicit in monopolar energy and nonwristed instrumentation. Incision of the myometrium is made to reach the intracapsular space. The free avascular surface of the myoma is then grasped by the surgical assistant with 5 mm laparoscopic tenaculum to provide traction. The main operator pushes the muscle fibers away from the exposed area of the tumor using the wristed needle drivers and the tip of the laser guide. A known limitation of current single-site technology is that the operator is restricted to a range of distance above which the cannulae restrict movement, and below which the semirigid instruments are too flimsy to operate. Several tricks can be adopted to circumvent this limitation: (1) cannulae can be pushed in or retracted for up to a couple of centimeters, without affecting instrument function; (2) the patient’s Trendelenburg angle can be changed with the robot docked (steeper Trendelenburg brings the target closer to port and less Trendelenburg brings the target farther from port). This is the only case in robotics where it is safe to change the Trendelenburg angle without undocking and redocking (unless one uses the synchronized robotic bed available for the da Vinci Xi system).

   
   
7. 
   

   7. The enucleated myomas are placed in posterior cul de sac for later retrieval. In case of multiple myomas, a formal “myoma count” is kept by the surgical technologist at bedside. Using one of the 20 mm barbed sutures introduced originally, all enucleated fibroids are placed onto a single “safety line.” Suturing of each incision is performed after each myoma enucleation to limit blood loss. Suturing follows standard microsurgical technique (see Section 11.3.2.1).

   
   
8. 
   

   8. There are two modalities of specimen extraction for this technique, depending on the specimen size. For smaller specimens, all enucleated fibroids and all needles are placed in the original endoscopic specimen bag. Oxidized regenerated cellulose is placed to cover uterine incisions. The multilumen port is removed from the umbilical incision and the specimen bag is pulled to the incision by its lifeline. Needles and fibroids are carefully removed and counted. A number 10 blade is used to cut larger myomata and to allow their passage in strips through the 2.5 cm umbilical incision. Towel clips or Kocher clamps are used for traction on the specimen to be extracted. The endoscopic bag is extracted and confirmed to be intact. For larger specimens, needles used in the case are placed back into the endoscopic pouch and retrieved separately with the pouch upon removing the multilumen port. A Mini Alexis self-retaining wound retractor (part of the Gelpoint Mini single-incision-laparoscopy port) is set in the umbilical incision, if not already set at the beginning of the case. A separate, larger endoscopic specimen bag is placed in the abdominal cavity through the umbilical incision. Myomas are loaded into the endoscopic bag with conventional single-incision laparoscopy technique. The bag is retrieved through the Alexis retractor. The same sharp tissue extraction technique as described earlier in Section 11.3.2.2 is employed.

   
   
9. 
   

   9. The single incision is closed with mass closure (peritoneum and fascia together in a running fashion) using 0 Vicryl on UR-6 needles. The dead space in the dermis is closed with running 3-0 Monocryl and the closure is completed with interrupted subcuticular skin sutures of 4-0 Monocryl.

Figure 11.2 Single-site robotic myomectomy. (A) Specimen extraction has to be planned in advance; for small pathology we drop a specimen bag (containing needles) on a lifeline at the beginning of the case. (B) Two wristed needle drivers are the only robotic instruments needed in our technique; a flexible CO₂ laser fiber is used as the only energy device. (C) A skilled bedside assistant will be able to manage the very limited instrument movements allowed by the setup; it is the assistant’s tenaculum that actually makes the enucleation possible. (D) We recommend 20 cm long barbed sutures for this technique, given the small range of movement allowed by the single-site port and cannulas. (E) A complete, uncompromised uterine reconstruction is always possible with the single-site setup. (F) Cosmetic outcome at 4 weeks makes every technical effort worthwhile; in well-selected patients, this procedure results in a completely hidden scar.

Our cosmetic multiport procedure has been recently described [41]. The main steps can be summarized as follows (all steps already mentioned for other robotic myomectomy techniques will be omitted). Please refer to Figure 11.3 for illustrations of the following operative steps.:

1. 
   

   1. See port placement in Figure 11.1. A primary disposable 12 mm camera port is placed in the umbilicus. Two 8 mm robotic cannulas are placed 3 cm medial and 3 cm cephalad to the left and right ASIS. A 5 mm port is placed in the suprapubic area (this can be omitted in easier cases). Camera arm and robotic arms #1 and #2 are used in this setup; occasionally using arm #3 instead of #2 will allow a more functional angle. The patient-side cart docked at a 45º angle from either right or left side.

   
   
2. 
   

   2. An 8 mm robotic needle driver is loaded on arm #1 and an 8 mm robotic tenaculum on arm #2. A flexible laser fiber within its metal guide is inserted alongside the 8 mm laparoscope through the 12 mm primary port. The tip of the armored guide is grasped and operated by the robotic needle driver. Alternative energy instrument choices are also allowed by this configuration: robotic monopolar curved shears or robotic ultrasonic scalpel can be used, though each present unique disadvantages (the monopolar shears have more thermal spread, while the current ultrasonic scalpel does not allow wrist movements).

   
   
3. 
   

   3. Barbed sutures (2-0 Stratafix, 20 cm length) are introduced through the 12 mm primary port by temporarily removing the laparoscope and pushing the suture in with a laparoscopic needle driver. Alternatively, they can be inserted and retrieved with conventional technique through the suprapubic incision.

   
   
4. 
   

   4. There are two modalities of specimen extraction, depending on the specimen size.

   
   

   For smaller specimens: A standard 10 cm laparoscopic specimen bag is introduced through the 12 mm primary port. In some cases the best choice is a 15 cm endoscopic bag, in which case the primary port is removed and the 15 cm bag introducer is placed directly through the umbilical incision. Myomas are introduced into the deployed endoscopic bag. While keeping the 12 mm trocar (or the 15 cm bag introducer) in place through the umbilicus, umbilical skin incision is extended cephalad and caudad to a final length of 2.5 cm. This skin incision was then carried down to the fascia with a knife and with curved Mayo scissors, in a fashion similar to the classic Hasson technique for open laparoscopy. The specimen bag is pulled to the incision. The same tissue extraction technique described for single-site myomectomy is employed.

   
   

   For larger specimens: While keeping the primary trocar in place through the umbilicus, the umbilical skin incision is extended cephalad and caudad to a final length of 2.5 cm. A Mini Alexis self-retaining wound retractor (part of the Gelpoint Mini single incision laparoscopy port) is set in the umbilical incision. An endoscopic specimen bag is placed in the abdominal cavity through the umbilical incision. Myomas are loaded into endoscopic bag with conventional laparoscopic technique. The bag is retrieved through the Alexis retractor. The same tissue extraction technique as above is employed.

Figure 11.3 Multiport robotic myomectomy, cosmetic approach, solo (no assistant port). (A) Only two ports are placed, medial to the ASIS on each side. Note the obtuse angle of triangulation of the instruments. An oblique incision is made over the two myomata. (B) Intracapsular location is reached and the plane developed. (C) The myoma is enucleated. The endometrium is peeled off the large FIGO 2–5 myoma and not entered. (D) Repair in layers is achieved. Needles are loaded through the 12 mm primary port. The last layer is always imbricating so that no suture is exposed. (E) Irrigation and other assistant functions can be performed through one of the robotic ports. (F) The three incisions as they appear at the end of surgery (note: umbilical tissue extraction performed in containment system).

11.3.2.3 Techniques for Larger Myomas (7–10 cm Diameter)

Myomas in this size range can be easily addressed with a completely robotic approach, though port location is different than for the smaller ones. The main steps can be summarized as follows (all applicable steps already mentioned above will be omitted). Please refer to Figure 11.4 for illustrations of the following operative steps.

1. 
   

   1. See port placement in Figure 11.1. A disposable 12 mm primary camera port is placed in the umbilicus. Two 8 mm robotic cannulas are placed 8–10 cm to the right and to the left of the camera port, or slightly caudal to it. A 5 or 12 mm assistant port is placed in the right lower quadrant. The camera arm and robotic arms #1 and #2 are used in this setup. Arm #3 is usually not necessary. Patient-side cart is docked at a 45º angle from either the right or left side.

   
   
2. 
   

   2. An 8 mm robotic needle driver is set on arm #1 and an 8 mm robotic tenaculum on arm #2. A flexible laser fiber within its steel-armored guide is inserted alongside an 8 mm laparoscope through the 12 mm primary port. Alternatively, the laser fiber can be introduced through the 12 mm lower-quadrant assistant port. The tip of the laser guide is grasped and operated by the robotic needle driver. Alternative energy instrument choices are allowed by this configuration; robotic monopolar curved shears or robotic ultrasonic scalpel can be used, though each present unique disadvantages (monopolar has more thermal spread, while the ultrasonic scalpel allows no wrist movement).

   
   
3. 
   

   3. Barbed sutures (2-0 Stratafix, 20 cm length) are introduced and removed through the lower-quadrant assistant port with a laparoscopic needle driver. Alternatively, the sutures are inserted through the primary 12 mm port, while temporarily removing the camera.

   
   
4. 
   

   4. The best current modality of specimen extraction for large uterine masses is the Alexis Contained Extraction System (Applied Medical, Rancho Santa Margarita, CA, USA). At the time of this publication, this is the only specimen extraction system specifically approved by the FDA for extracorporeal uterine tissue extraction. While keeping the primary 12 mm trocar in place through the umbilicus to act as a guide and to protect the underlying tissues, the original umbilical skin incision is extended cephalad and caudal to a final length of 2.5 cm. This incision is then carried down to the fascia with curved Mayo scissors, in a fashion similar to the classic Hasson technique for open laparoscopy.

   
   

   The Alexis Specimen Containment Bag (a dedicated large specimen bag for extracorporeal tissue extraction) is introduced in the abdomen through this umbilical incision. A dedicated Hasson Cannula (Applied Medical, Rancho Santa Margarita, CA, USA) is secured in place to cover the umbilical incision, and the pneumoperitoneum is again created.

   
   

   The enucleated myomas are placed in the bag and the upper rim of the bag is carefully exteriorized. At this point, a dedicated guard is placed inside the opening to the bag to allow for the safer use of sharp instruments in the removal of the myomas. The specimen is grasped with towel clips and lifted at the level of the umbilical incision. A number 10 blade is used to undermine the specimen to allow for passage through the 2.5 cm umbilical incision, with great care as to not damage the bag. It is essential to always aim for the myoma edge and proceed with either U-shaped or V-shaped cuts while applying traction with the towel clip; the goal is to attempt to roll the myoma while excising a long strip of its outer layer. Allowing some space for the tumors to roll within the bag is essential for the success of this technique. After the entire specimen is removed, the bag itself is extracted and confirmed to be intact. The dedicated Hasson cannula is again secured in place and the pneumoperitoneum is created. Copious irrigation with sterile Ringers lactate is performed and hemostasis is confirmed. Adhesion barrier is placed to cover the uterine incision(s). At this point the dedicated Hasson cannula is removed for the last time and the umbilical fascia is identified and closed with mass closure (see in Section 11.3.2.2). Please note: the extraction technique is the same for very large myomas (see later).

Figure 11.4 Multiport robotic myomectomy, standard approach. (A) Recurrent anterior lower segment myoma following a prior open myomectomy; the entire anterior uterine wall is densely adherent to the abdominal wall and bladder. Continuous low-wattage CO₂ laser energy, delivered through a flexible device driven by a robotic needle driver, is used to perform a complete adhesiolysis. (B) Maryland bipolar graspers act as a safe backstop for the laser beam, and maintain tissue tension, essential for safe and effective adhesiolysis. (C). Repair of the anterior bladder peritoneum at the end of the extensive adhesiolysis. (D) A large FIGO 2–5 myoma is eventually identified, distending the anterior lower segment. (E) Once the intracapsular space is entered, the myoma is immobilized with a robotic tenaculum (lower left) while a blunt instrument pushes away myometrial fibers surrounding the tumor. (F) Repair of the deep incision in layers in this deep pelvic location is made possible by the coordinated work of three instruments, with the robotic tenaculum continuously exposing the correct planes for the needle drivers to suture.

11.3.2.4 Techniques for Very Large Myomas (>10 cm in Diameter)

Current teleoperators are less-than-ideal instruments to tackle very large myomectomies. First, the robotic tenaculum is quite delicate, to the point of not allowing substantial traction on a heavy tumor. Second, the patient-side carts of current robotic platforms (both da Vinci Si and Xi) are designed to work as two-quadrant operators. A laparoscopic myomectomy where the uterine size reaches or surpasses the umbilicus (i.e., the abdominal midpoint) is a four-quadrant operation. Differently from the more common hysterectomy, where most of the surgical targets are fixed (the uterine vessels in the deep pelvis, the round ligaments at the inguinal rings and the ovarian vessels, usually at the pelvic brim), in myomectomy there is a “hourglass effect” of the enucleated myoma that rises over the bulky uterus, which once contained it.

This is not to say that the robot cannot be used to tackle very large myomata. Most expert robotic surgeons can manage to reliably complete these operations, even with the aforementioned limitations. Three fundamental intraoperative steps are essential for success in these scenarios.

1. 
   

   1. The primary port must be supraumbilical; the fastest way to “shrink” a large myoma is to move the laparoscope in the upper abdomen. See our considerations in Section 11.2 and refer to Figure 11.1 for our port placement for very large myomata.

   
   
2. 
   

   2. The only practical energy source in these cases is the robotic monopolar curved shears (always in cutting mode, never in coagulation mode, to limit delayed myometrial thermal injury). The robotic ultrasonic scalpel and the laser are absolutely impractical when dealing with these very large myomas.

   
   
3. 
   

   3. The bedside surgical assistant must be very well trained with the concomitant use of the uterine manipulator and the laparoscopic tenaculum, in order to provide optimal exposure and to keep the cleavage plane low enough in the abdomen to allow the robotic arms to function properly. This is achieved mainly by lateralizing the uterus so that it lies at a right or left angle in the abdomen, which keeps the operative focus more caudal.

   
   
4. 
   

   4. The third instrument arm provides a definite advantage during the reconstruction stage of the myomectomy. The robotic tenaculum is an ideal instrument in this part of the operation, allowing positioning of the delicate structures for repair.

As pointed out earlier in Section 11.3.2.3, our team prefers to avoid the use of monopolar energy in myomectomy. Because of this, and because of the limitations discussed at the beginning of this section, we perform our robotic myomectomies for very large myomas with a hybrid technique that entails a first step of conventional laparoscopic myoma enucleation with handheld ultrasonic scalpel, followed by rapid docking of the robotic patient-side cart to proceed with microsurgical reconstruction in multiple layers as described in Section 11.3.2.1. In our hands, this technique allows the best results, because both techniques (conventional laparoscopy and robot-assisted laparoscopy) are used for the steps where they confer an actual advantage. Conventional laparoscopy provides a sturdy tenaculum and an unobstructed four-quadrant technique; robot-assisted laparoscopy provides better visualization and unrestricted intuitive wrist movement for pristine reconstruction in layers [42].

Tissue extraction, also in these cases, occurs through an umbilical incision. Our current preference in terms of equipment goes to the Alexis Contained Extraction System, described earlier in Section 11.3.2.3 in full detail.