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Robotic Compared with Conventional Laproscopic Hysterectomy
Transcript of Robotic Compared with Conventional Laproscopic Hysterectomy
Surgeons Conclusions Treatment Arms Discussion Discussion Strengths Weaknesses Background Sarlos, Dimitri MD, et al. "Robotic Compared With Conventional Laparoscopic Hysterectomy: A Randomized Controlled Trial". Obstetrics & Gynecology: 2012 Sept;120(3):604–611.
EQ-50 Questionnaire. 2012. http://www.euroqol.org/
Jacoby VL, et al. "Nationwide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches." Obstetrics & Gynecology: 2009 Nov;114(5):1041-8.
The Medical Center of Plano. "Top Five Surprising Facts about Robotic Surgery". http://blog.themedicalcenterofplano.com/tag/da-vinci-si-surgical-system/
Mt Hood's Women's Health. "DaVinci Surgery". http://www.mthoodwomenshealth.com/daVinciRoboticSurgery.html
Neil, Peter. 2012. "Menstrual Disturbances". Prezi presentation format.
UKE Consultant and Management Group. "Kantonsspital Aarau" http://www.u-c-m.de/index.php/projects/project/aarau/
William Kondo. Advanced Gynecologic Endoscopy, "Chapter 17: Total Laparoscopic Hysterectomy: Surgical Technique and Results". 2011. References Conventional Laproscopic Hysterectomy Robotic Hyserectomy (daVinci) Aurau, Switzerland at the Kantonsspital Aarau (KSA)
Held from 2008 until 2011
The Department of Obstetrics and Gynecology
KSA consists of over 30 centers for diagnostics and treatment with over 3,000 employees.
Around 23,000 inpatients and 330,000 outpatients are treated yearly
576 acute care beds (2008). Kantonsspital Aarau (KSA) Location & Timing Despite these advances, abdominal hysterectomy is the most common approach worldwide Hysterectomy The term hysterectomy originates from two Greek words:
“hystero” = uterus
“ectomy” = resection/removal from the human body. In the United States among 518,828 hysterectomies performed in 2005: 64% abdominal, 22% vaginal, and 14% were laparoscopic.
In contrast to 2003, with 67% abdominal and 11% laparoscopic. Due to advances in endoscopic surgery, almost all gynecologic procedures can be done laparoscopically with little difficulty Historically,
1813: 1st vaginal hysterectomy was performed by Conrad Langenbeck
1863: 1st elective abdominal hysterectomy by Clay and Koeberle
1988, 1st laparoscopic hysterectomy by Harry Reich
1998: 1st robotic gynecologic procedure Hysterectomy approaches:
Laparoscopic assisted vaginal hysterectomy. Due to the lower perioperative morbidity over abdominal hysterectomies, laparoscopic hysterectomies are considered the gold standard for all cases in which vaginal hysterectomies are not feasible. Hysterectomies are one of the most common gynecological procedures performed worldwide. Previous Studies Research Question: Because operating room costs for robotic surgery are high, is there an additional benefit to the patient regarding outcome and quality of life compared to conventional laparoscoptic hysterctomy? Research Objective: Compare robotic with conventional laparoscopic surgery for benign indications in terms of perioperative outcome, morbidity and quality of life Low numbers
Comparison with ABDOMINAL hysterectomies All hysterectomies were performed by two senior gynecologic surgeons: Routinely performed an average of 50 total laparoscopic hysterectomies yearly for the last 10 years
Performed at least 30 robotic hysterectomies before study began Randomized Control Trial (n=100)
Benign Indications for Hysterectomy:
Vaginal hysterectomy was expected to be difficult because of myomas or nulliparity
The estimated uterus weight less than 500g
Conventional total laparoscopic hysterectomy
Robotic total laparoscopic hysterectomy (daVinci surgical system
Patients recruited from clinic
Unable to blind randomization due to logistics: robot was situated in different building and patients had to be informed of transportation Definitions Total Operating Time:
Time from skin incision to the last skin closure suture
Robot Docking Time:
Time robot brought to operating table until the surgeon starts the operation at the console (including attachment of robot to trocars)
Net Operating Time:
Total operating time less docking time in robotic arm
Total operating time in conventional arm
Surgeon, bedside assistant, and a surgical nurse End Points Primary Endpoints
Total Operating Time
Net Operating Time
Change in Quality of Life (Comparison - before operation and 6 weeks after operation)
Quality of Life Assessment: EQ-50 Questionnaire Assessed @ baseline, 2-3 post-op, and 6-8 weeks post-op Overall Score: 0 - 100
Five Dimensions of Quality of Life:
Pain and Discomfort
Anxiety and Depression General Anesthesia
Perioperative antibiotic prophylaxis: 2g IV cephazolin
Clermont-Ferrand manipulator inserted in uterus Procedure Procedure Both procedures used same standard operating procedure: Transection of round ligament
Broad ligament dissected anteriorly and posteriorly
Bladder dissected from the proximal vagina
Ascending branches of the uterine vessels coagulated and transected
Transection of Mackenrodt's ligament
Colpotomy with monopolar cutting current
Uterus extracted vaginally Large Size Uteri
Cut into extractable pieces with knife (extracted vaginally)
Vaginal Cuff Closure
Robotic suturing using five interrupted sutures
Conventional laparoscopic intracorporal knotting Four Total Incisions:
Optic Port (1): 12 mm
Robotic Working Ports (2): 8 mm
Assistance/Suture Port (1): 10 mm
Fenestrated EndoWrist bipolar forceps in left port
Monopolar EndoWrist curved scissors in right port Four Total Incisions:
Optic Port (1): 10 mm
Working Trocar Ports (3): 5 mm
Standard Bipolar and Monopolar devices Results Total Operating Time: 106 (+/-29) 75 (+/- 21) Net Operating Time: 96 (+/-28) 75 (+/- 21) Even with correction for docking time, robotic surgery still took significantly longer Change in Quality of Life: 13 (+/-10) 5 (+/- 14) Results Mean (and median) change in quality of life is higher in the robotic arm No severe intraoperative complications occurred in either group.
No statistical difference in blood loss between groups Due to large uterus size, five cases required robot undocking.
Uterus was cut with knife into extractable pieces and removed vaginally
Colpotomy site was sutured through vaginal access No statistical significance between group in regards to complications *No significant difference in postoperative outcomes Three variables that effect operating time for endoscopic hysterectomies:
Other patient characteristics (e.g. adhesions, endometriosis) Mean uterine weight, BMI, and other patient related pathologies were similar in both treatment arms Operating surgeons were much more experienced in conventional laparoscopic hysterectomies than in robotic Despite this, the mean robotic operating times (106 mins) were relatively low compared to other studies which ranged 89 to 242 minutes Case load may be too small to properly detect any differences in complications. Low mean incidence. Due to surgeons' many years experience in laparoscopy, the operating times are more likely to be due to patient factors, like uterus size, and technical error than a steep learning curve for robotic laparoscopy Generalizability No inter-operator reliability testing The surgeon's experience was cited to be the main reason for the lower operating times compared with past studies
Mean uterine weights in both groups (robotic- 255g; conventional-247g) are larger than past studies which range from 122 to 347g.
This study had an increased mean hospital stay (3 days) compared with other studies that range from 1 to 1.6 days.
Differences may be due to difference in hospital systems and country norms across studies Conventional versus Robot? Quality of Life Despite the fact that postoperative use of analgesics, hospital stay, return to activity, and return to work were similar between the two groups, improvement in quality of life was better in the robotic arm
The questionnaire was a validated instrument but quality of life assessment is still very subjective
Careful interpretation because of inability of blinding in the study Robotic and conventional laparoscopic hysterectomy approaches compare well in most surgical aspects. Robotic procedure is associated with longer operating times but with a better post-operative quality of life index Conclusions Reasons:
Postoperative and intraoperative outcomes are similar
Operating room costs for the robotic procedure are significantly higher (~$2,600)
A considerable learning curve is needed to perform robotic hysterectomy even for experience laparoscopic surgeons. In experienced laparoscopic centers, patients with benign pathology should preferentially be treated by conventional laparoscopic hysterectomy