Robotic Extrafascial Hysterectomy
Ali Bassi
Susie Lau
Shannon Salvador
GENERAL PRINCIPLES
It is well-established that traditional laparoscopic surgery for endometrial cancer has less blood loss, less postoperative pain, shorter hospital stay, and faster recovery than abdominal hysterectomy. Despite this, the majority of gynecologic oncologists did not adopt it into their treatment of endometrial cancer because of the long and steep learning curve associated with limited range of movement, rigid instruments, and two-dimensional (2D) imaging.
The introduction of robotic surgical technology has overcome most of the laparoscopic limitations and has led to a rapid increase in the use of minimally invasive surgery in gynecologic oncology.
The learning curve in robotic hysterectomy is more rapid than with traditional laparoscopy. Surgeons found significant improvement in operative time, complications, and lymph node counts after 20 cases. There was additional limited improvement over the next 20 cases.
Definition
Robotics refers to the use of a computer interface and mechanical arms controlled by the surgeon to perform operations. The 3D optics, increased instrument range of motion, and wristed action of the instruments lead to a much shorter learning curve than for traditional laparoscopy.
Anatomic Considerations
See Chapters 9, Open Surgery for Apparent Early-Stage Endometrial Cancer, and 11, Laparoscopic Hysterectomy With Pelvic and Paraaortic Node Dissection.
IMAGING AND OTHER DIAGNOSTICS
See Chapter 9, Open Surgery for Apparent Early-Stage Endometrial Cancer.
PREOPERATIVE PLANNING
Preoperative biopsies showing endometrial cancer should be reviewed by a pathologist specializing in gynecologic cancer for confirmation of grade and type of cancer as this may affect your surgical planning to perform an extrafascial hysterectomy.
Pregnancy test is mandatory in all patients of reproductive age.
Although the risk of surgical site infection (SSI) is low in MIS compared to laparotomy (2% vs. 4%), preoperative prophylactic antibiotics are still indicated to decrease the risk of infection. The recommended regimen is in Chapter 9.
Prophylaxis for venous thrombosis using intermittent pneumatic compression device is recommended. Prophylactic Lovenox or heparin may be added in high-risk women.
A randomized clinical trial comparing patients with mechanical bowel preparation to no mechanical bowel preparation before laparoscopic hysterectomy showed no difference in surgical field visualization. If a mechanical bowel preparation is not used, a clear liquid diet for 24 hours should be considered.
SURGICAL MANAGEMENT
Endometrial cancer is usually treated with extrafascial hysterectomy with bilateral salpingo-oophorectomy. Radical hysterectomy is preformed if cancer is invading the cervix or the parametrial tissues. Complete surgical staging with evaluation of lymph nodes either with complete pelvic and paraaortic lymph node dissection or sentinel lymph node evaluation is addressed in other chapters.
Positioning
The patient is placed in a dorsal lithotomy position. To prevent slippage of the patient during steep Trendelenburg, the patient can be placed on a gel mat. Other products are available and have been used successfully.
Both arms are tucked to the patients’ side and wrapped with a gel padding to prevent injury.
The legs are placed in adjustable stirrups to avoid nerve injury. Adequate foam or gel padding can be placed between the legs and the stirrups to prevent leg pressure. Pneumatic compression stockings are placed on the legs for DVT prophylaxis.
Shoulder braces and chest straps are used to secure the patient to the bed.
A Foley catheter is placed to drain the bladder.
A figure-of-eight stitch is placed on the anterior and posterior cervical lips to occlude the cervical canal and to allow traction on the cervix. The suture is then pulled through the HOHL uterine manipulator and secured with a hemostat to ensure the placement of the cervix in the vaginal cup that helps to delineate the vaginal fornices. We do not place any device in the endometrial cavity as it may increase the risk of endometrial cancer cell spillage, although studies have not shown if it affects outcome.
Approach
The hysterectomy is preformed via a transperitoneal approach with the patient in a dorsal lithotomy position to allow vaginal and rectal access if required.
The procedure is started laparoscopically to evaluate the peritoneal cavity and perform any required lysis of adhesions to enable placement of the trocars.
The surgical ports are placed in an arc across the abdomen with the camera port between 5 and 15 cm above the umbilicus to allow for paraaortic lymph node dissection if required. The assistant port is placed first at Palmer’s point in the left upper abdomen. Robotic ports for arms 1 and 3 are placed on the patient’s right mid and lower abdomen and the port for arm 2 is placed at the same level as the lower right port (Fig. 12.1).
 Figure 12.1. Port placement for the da Vinci Si robot. |
PROCEDURES AND TECHNIQUES
Procedures and Techniques (Video 12.1) 
The da Vinci Surgical System is docked at a 45-degree angle to the operating table for best docking position to attach the robotic arms 1 and 3 on the right side of the table and arm 2 on the left side (Tech Fig. 12.1).
 Tech Figure 12.1. The da Vinci Si robot docked at a 45-degree angle to the operating table with the patient in steep Trendelenburg position. |
Mobilizing the Bowel
After placing the trocars and before docking, the patient is placed in the Trendelenburg position to mobilize the bowel cephalad. Two fenestrated nontraumatic laparoscopic graspers can be used to gently manipulate the bowel. Physiologic adhesions of the sigmoid colon to the left pelvic sidewall are common and need to be lysed to gain access to the retroperitoneal space on the left side.
Placing the Instruments
Four instruments are usually inserted during robotic-assisted hysterectomy: a high-definition 3D camera is inserted in the supraumbilical camera port, a monopolar curved scissors in the right upper quadrant (arm 1), a fenestrated bipolar forceps in the left lower quadrant (arm 2), and a ProGrasp forceps in the right lower quadrant (arm 3). Placing the forceps in this manner will help in handling and grasping the tissues from both sides during surgery.
Opening the Retroperitoneal Space
The ProGrasp forceps (arm 3) is used to grasp the cornua of the uterus and mobilize the uterus medially and anterior to create tension on the broad ligament. The retroperitoneal space is then entered by tenting the peritoneum and making an incision using the monopolar curved scissors just lateral to the infundibulopelvic ligament and extending the incision parallel and lateral to the infundibulopelvic and utero-ovarian ligaments.
Identifying the Ureter
The areolar connective tissues are then separated to identify the ureter on the medial leaf of the broad ligament close to the bifurcation of the common iliac artery. The internal iliac artery, superior vesical artery, and uterine artery are identified. The pararectal space is developed between the internal iliac vessels laterally and the ureter and rectum medially. The paravesical space is developed lateral to the umbilical ligament (obliterated umbilical artery) and medial to the external iliac vessels.
Dissection of the Infundibulopelvic Ligament
A fenestration is performed between the infundibulopelvic ligament and the ureter. The infundibulopelvic ligament is then electrocauterized using the bipolar forceps and cut 2 cm proximal to the ovary.
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