Objective
This article describes the simulation of robotically assisted hysterectomy utilizing the porcine model.
Study Design
Utilizing 3 domestic pigs, a technique for robotically assisted hysterectomy was developed. An edited video clip of the model was assessed by 6 gynecological surgeons.
Results
The steps of the operation are described in detail and are shown in a video clip. Overall the procedure simulated that done in the human both anatomically and surgically. Some of the evaluators rated the identification of the cervicovesical junction to be more difficult and division of the paracervical ligaments to be relatively easier in the model.
Conclusion
Reported here is a technique for robotically assisted hysterectomy in the domestic pig that may be useful for training purposes.
Hysterectomy is a technically complex pelvic operation that requires careful vascular control and separation of the lower urinary tract. In many centers this operation is performed with minimally invasive surgery. Adapting da Vinci robotic technology to this operation requires skill in both pelvic and robotically assisted surgery. The process of learning to do a robotically assisted hysterectomy is not well defined but likely includes residency training, proctoring, attending advanced courses, observation of cases, and/or observation of video .
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Medical training is becoming increasingly complex and yet increasingly time restricted. In efforts to partially compensate for this and an often otherwise reduced volume of surgical training material, as well as to improve outcomes, increasing emphasis is being placed on simulation.
This article describes simulation of robotically assisted hysterectomy utilizing the porcine model.
Material and Methods
Under approval of the University of South Florida Institutional Animal Care and Use Committee at our da Vinci training center, we developed a model for hysterectomy utilizing the domestic pig. The pigs are properly kept and cared for under the close supervision of a veterinarian. To refine the technique, 3 pigs whose weight ranged from 30 to 40 kg were utilized. All surgeries were done under a carefully monitored general anesthesia protocol in conjunction with other aspects of training labs and all labs were terminal. The approximate total cost of each laboratory procedure was $3000.
Video from these operations ( Video clip ) was shown independently to 6 board-certified gynecologic surgeons with 3, 10, 10, 11, 27, and 30 years of experience (2 have extensive robotic surgical experience). One of the evaluators was a senior gynecologic oncology fellow and 2 were urogynecologists. Adequacy of the model (relative to the human) was rated as good, fair, or bad by each individual for each of the following steps: division of gonadal vessels, identification of the ureter, division of the round ligament, dissection of the vesicocervical space, division of the paracervical tissues, and identification and transection of the vaginal cuff.
Results
No intraoperative complications occurred during the three hysterectomies. The operative time for the second and third cases was approximately 30 minutes each (for the hysterectomy only). Overall the procedure simulated that done in the human both anatomically and surgically. The model was rated as good in all categories with the exception that 2 evaluators rated the vaginal cuff identification and transaction as fair. Criticisms included the substantial difference in gross normal anatomy, a less clearly defined cervicovaginal junction, and a very small round ligament. All commented that the model was very good for the purpose of training in robotic hysterectomy. From the authors’ perspective (with the hands-on vantage point vs observation of video ), an additional criticism of this model is that the paracervical tissues are relatively flimsy, hypovascular, and less intimately associated with the urinary tract compared to the human.
Basic steps of the operation in the pig are as follows:
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The ureter on each side is identified in the upper pelvis.
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The round ligament is divided.
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The gonadal vessels are then isolated and hemostatically divided with electrosurgery.
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The uterine horns are hemostatically divided from the fundus, completely separated, and placed outside the operative field.
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The uterine artery is divided medially.
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The posterior cul-de-sac peritoneum is divided and the rectovaginal space is developed.
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The uterosacral ligaments are hemostatically divided.
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The vesicovaginal space is developed.
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The uterovesical ligaments are hemostatically divided.
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The paracervical ligaments are hemostatically divided against the cervix.
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The vagina is transected caudally, completing the procedure.
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Closure of the vagina may be done.
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