Robotically Assisted Hysterectomy
Habibeh Ladan Gitiforooz
General Principles
Definition
Robotic hysterectomy is a highly effective, minimally invasive approach to removing the uterus in patients with a variety of uterine conditions. Robotic approach can be very effective for morbidly obese patients and for large fibroids weighing more than 500 g. It can also be a very effective tool for patients with multiple pelvic surgeries and severe adhesions.
Differential Diagnosis
Sarcoma, leiomyosarcoma, large fibroid uterus, fibroma, endometrial stromal sarcoma, adenomyosis, and endometrial carcinoma.
Anatomic Considerations
A large, wide, uterus can be difficult to manipulate and this can limit visibility.
The blood supply to a wide cervix can be very close to the ureters.
Lifting the uterus to incise the uterosacral ligament posteriorly can be challenging.
The ureters can be closer to the uterosacral ligament than usual.
Nonoperative Management
Conservative, nonoperative management can be designed depending on the patient’s symptoms.
Heavy menstrual bleeding, bulk and pressure symptoms, and mild hydronephrosis may respond well to uterine artery embolization.
Heavy bleeding may respond to oral contraceptive pills, progestins, or an IUD.
Imaging and Other Diagnostics
See Figures 8.4.1 to 8.4.6.
Figure 8.4.1. MRI 3 large midline fibroids.
Figure 8.4.2. MRI-2 large midline mass of fibroids above umbilicus.
Preoperative Planning
Pap and HPV testing must be up-to-date in all cases.
An up-to-date, in office, endometrial biopsy is a very important part of evaluation. Some studies suggest that more than 50% of sarcoma can be diagnosed by an office endometrial biopsy.
Early evaluation of hemoglobin and bleeding.
Gonadotropin releasing hormone and IV or oral iron therapy can prevent unnecessary blood transfusions.
An examination under anesthesia is performed to assess the height and width of the uterus to plan the position of the midline port (Fig. 8.4.7).
Cystoscopy is indicated in all cases. Administer intraoperative fluorescein or use dextrose 10% as the distending hysteroscopic fluid to evaluate ureteral integrity.
Oral/nasal gastric tubes are important to avoid injury to a distended stomach.
Figure 8.4.3. MRI 1 bilobed fibroid.
Figure 8.4.4. 3D ultrasound picture of fibroid uterus.
Surgical Management
Indication of using the robotic approach may include:
patients with endometriosis and previous surgery with adhesions (Fig. 8.4.8),
other pelvic surgeries such as history of colon resection or multiple cesarean sections (see Fig. 8.4.8),
patients with a history of failed myomectomy and uterine artery embolization.
Positioning
Proper chest wrap is important to prevent obese patients from moving up the operating table in Trendelenburg position. Keeping in mind ventilation, IV lines, and the blood pressure cuff and pulse oximeter (Fig. 8.4.9).
Perineal access to the uterus is an important part of operative positioning for manipulation and morcellation (Fig. 8.4.10).
Figure 8.4.5. Degenerative fibroids.
Figure 8.4.6. SIS picture showing 4 cm fibroid. The majority of the fibroid is located within the muscularis and is not approachable through the endometrium.
Figure 8.4.7. EUA is performed to assess and plan the position of parts.
Figure 8.4.8. This patient had four cesarean sections. Note the bladder and uterine adhesions to the anterior abdominal wall.
Figure 8.4.9. Wrap the chest to the operating table to prevent patients from sliding when placed in Trendelenburg position.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
Get Clinical Tree app for offline access
