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Robotic-Assisted Surgery in Robotic-Assisted Surgery in Urogynecology: Passing Urogynecology: Passing
Fad or Here to StayFad or Here to Stay
Marie Fidela R. Paraiso, M.D.Marie Fidela R. Paraiso, M.D.
Professor of SurgeryProfessor of Surgery
Head, Division of Urogynecology Head, Division of Urogynecology and Reconstructive Pelvic and Reconstructive Pelvic
SurgerySurgery
Cleveland, OHCleveland, OH
DisclosuresDisclosures
Coloplast CorporationColoplast Corporation
ObjectiveObjective
To discuss indications for To discuss indications for robotic-assisted laparoscopic robotic-assisted laparoscopic surgery for pelvic floor disorderssurgery for pelvic floor disorders
To demonstrate various surgical To demonstrate various surgical procedures and techniques that procedures and techniques that are robot-enabledare robot-enabled
My VoteMy Vote
Passing FadPassing FadHere to stayHere to stay
Reasons to Utilize Robotic Reasons to Utilize Robotic Assistance in Gynecologic Assistance in Gynecologic
LaparoscopyLaparoscopy Sacrocolpoperineopexy +/- ventral Sacrocolpoperineopexy +/- ventral
rectopexyrectopexy Also with posterior rectopexy depending on the Also with posterior rectopexy depending on the
indications and surgeon preferenceindications and surgeon preference Sacral HysterocervicocolpoperineopexySacral Hysterocervicocolpoperineopexy
Including other modificationsIncluding other modifications Supracervical hysterectomy and Supracervical hysterectomy and
concomitant sacrocolpopexyconcomitant sacrocolpopexy Especially with lesser skilled assistantsEspecially with lesser skilled assistants
Case #1Case #1 58 year old s/p previous laparoscopic 58 year old s/p previous laparoscopic
enterocele repair with uterosacral enterocele repair with uterosacral vaginal vault suspension and rectocele vaginal vault suspension and rectocele repair with cadaveric fascia lata who repair with cadaveric fascia lata who complains of outlet dysfunction complains of outlet dysfunction constipation. constipation.
She splints perineum to defecateShe splints perineum to defecate Examination shows Stage 2 vaginal Examination shows Stage 2 vaginal
apex prolapse with recurrent anterior apex prolapse with recurrent anterior rectocele and perineal descentrectocele and perineal descent
Defocography confirms exam and Defocography confirms exam and demonstrates no intussusceptiondemonstrates no intussusception
Robotic Robotic SacrocolpoperineopexySacrocolpoperineopexy
Video shown with ventral rectopexy Video shown with ventral rectopexy based on time constraintsbased on time constraints
Surgical techniqueSurgical technique
Difficult to access perineum with laparotomy, perfect for LSC and Robot
Especially with 30 degree up or down scope
Combined Rectal Prolapse Combined Rectal Prolapse SurgerySurgery
VideoVideo Surgical techniqueSurgical technique 24% of women have pelvic floor 24% of women have pelvic floor
disordersdisorders Combined rectal and uterine/vaginal Combined rectal and uterine/vaginal
apex prolapse is uncommonapex prolapse is uncommon Mucosal prolapse/Intussusception Mucosal prolapse/Intussusception
above anus: Ventral rectopexyabove anus: Ventral rectopexy Full thickness prolapse: Posterior Full thickness prolapse: Posterior
dissection and direct attachment of dissection and direct attachment of rectosigmoid mesentary to sacrumrectosigmoid mesentary to sacrum
Side-docking the Robot is Optimal
Case #2Case #2
59 year old female with CREST 59 year old female with CREST syndrome and chronic Stage IV syndrome and chronic Stage IV uterovaginal and full thickness uterovaginal and full thickness rectal prolapse ( 9 cm beyond anal rectal prolapse ( 9 cm beyond anal verge)verge)
Plan Robotic-assisted laparoscopic Plan Robotic-assisted laparoscopic SCH, sacralcolpopexy, and ventral SCH, sacralcolpopexy, and ventral rectopexyrectopexy
Segment shows dissectionSegment shows dissection
HysterosacrocolpopexyHysterosacrocolpopexy
VideoVideo Surgical techniqueSurgical technique Cure rates for open procedure are Cure rates for open procedure are
91-100%91-100% Improved quality of life and sexual Improved quality of life and sexual
functionfunction No data regarding laparoscopic or No data regarding laparoscopic or
robotic sacro-hysterocolpopexyrobotic sacro-hysterocolpopexyE Barranger et al, AJOG 2003
E Constantini et al, European Urol 2005
Dissection of RV and VV spaces, formation of broad ligament windows
Graft measurement and formation
Graft attachment and tunneling
Graft attachment to the sacrum
Hysterosacral Colpopexy Hysterosacral Colpopexy PearlsPearls
Understand the contraindicationsUnderstand the contraindications Negative uterine pathology must be confirmedNegative uterine pathology must be confirmed This particular technique is not recommended in This particular technique is not recommended in
women desiring future childbearingwomen desiring future childbearing Option is biologic graft or tunneling arms underneath Option is biologic graft or tunneling arms underneath
Cardinal ligament and ureterCardinal ligament and ureter Review the risks and benefits thoroughly with the Review the risks and benefits thoroughly with the
patientpatient Future hysterectomy may be more difficultFuture hysterectomy may be more difficult
The procedure leads to improved anatomical The procedure leads to improved anatomical outcomes and resolution of anterior apical outcomes and resolution of anterior apical vaginal wall and uterine prolapsevaginal wall and uterine prolapse
Supracervical Hysterectomy Supracervical Hysterectomy with Sacrocolpopexywith Sacrocolpopexy
Surgical technique and rationaleSurgical technique and rationale A combination of both procedures butA combination of both procedures but
I use bipolar to cauterize the endocervical canalI use bipolar to cauterize the endocervical canal I stitch the canal closed I stitch the canal closed
Combine TVH or TLH with ASC butCombine TVH or TLH with ASC but Recommend 2 layered closure of cuffRecommend 2 layered closure of cuff If mesh is sewn on vaginally to save time, counsel If mesh is sewn on vaginally to save time, counsel
your patients regarding increased risk of mesh your patients regarding increased risk of mesh erosion (Menefee et al, SGS 2010)erosion (Menefee et al, SGS 2010)
Make sure that the patient has negative Paps Make sure that the patient has negative Paps and HPV testingand HPV testing
ConclusionConclusion Robotic-assisted laparoscopic sacrocolpopexy Robotic-assisted laparoscopic sacrocolpopexy
continues with widespread adoption despite lack continues with widespread adoption despite lack of supporting data of supporting data
This technology has enabled many surgeons to This technology has enabled many surgeons to become minimally invasive surgeonsbecome minimally invasive surgeons
Suture labor, difficult dissection, difficult access Suture labor, difficult dissection, difficult access of surgical sites, and ease of manipulation are of surgical sites, and ease of manipulation are reasons to utilize this technology compared to reasons to utilize this technology compared to conventional laparoscopic surgeryconventional laparoscopic surgery
Sacral colpoperineopexy, sacral hysteropexy, Sacral colpoperineopexy, sacral hysteropexy, concomitant rectopexy, and combined SCH and concomitant rectopexy, and combined SCH and ASC are facilitated with robotic assistanceASC are facilitated with robotic assistance
When My Vote No Longer When My Vote No Longer CountsCounts
Here to stayHere to stayPassing FadPassing Fad
Obama HealthcareObama Healthcare