CHAPTER 121

Robotic Gynecologic Surgery

The da Vinci surgical system (Fig. 121–1) is a minimally invasive robotic surgical platform approved by the FDA in 2005 for gynecologic surgeries. It is currently the only commercially available robotic surgical system. Utilization of robotic gynecologic surgery is rapidly increasing in the United States. Examples of gynecologic surgeries that can be performed with robot assistance include myomectomy, simple and radical hysterectomy, lymph node dissection, tubal reanastomosis, and sacral colpopexy. Robotic surgery was first conceived by the military, but it has evolved recently to enhance minimally invasive and laparoscopic surgery in the community.

Robotic surgery offers several advantages when compared with laparoscopic surgery. First, a magnified, three-dimensional, stereoscopic vision system is used (Fig. 121–2A, B). Second, EndoWrist instruments (designed with seven degrees of motion that mimic the human hand and wrist) provide hand movements with unparalleled precision, control, and dexterity (Fig. 121–3A through C). Last, the operating surgeon sits comfortably at an ergonomically designed surgeon console and controls the EndoWrist instruments and camera with hand controls and foot pedals (Fig. 121–4A, B).

The basic setup includes a robotic master console, a patient-side robot, and a vision tower with video screen. Once anesthetized, the patient is placed in dorsal lithotomy position in Allen stirrups and then is prepped and draped (Fig. 121–5). If a hysterectomy is to be performed, usually a uterine manipulator is placed (Fig. 121–6). Port placement varies, depending upon the surgeon and the operation to be performed. The da Vinci surgical system allows for two or three surgical arms and a camera port (all controlled by the operating surgeon at the console) (Fig. 121–7). Additionally, one or two assistant ports are placed. Once the ports are placed, the patient is placed in Trendelenburg’s position; the patient side cart (with robotic arms) is docked to the ports, and instruments are inserted through the robotic arms for console surgeon control at the bedside master console (Fig. 121–8). The surgery is then performed by the surgeon sitting at the master console with one or two assistants at the bedside (one for uterine manipulation and one for suction/irrigation, retraction, introducing suture, etc).

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